VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan)

Transcription

1 H9345_MBR16_03 CMS Approved VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This formulary was updated on 10/01/2016. For more recent information or other questions, please contact VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit Formulary ID: , Version 19

2 VillageCareMAX Full Advantage FIDA Plan 2016 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in VillageCareMAX Full Advantage FIDA Plan. VillageCareMAX Full Advantage FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check VillageCareMAX Full Advantage FIDA Plan s up-to-date List of Covered Drugs online at or by calling VillageCareMAX Full Advantage FIDA Plan Participant Services at TTY users should call 711. Limitations and restrictions may apply. For more information, call VillageCareMAX Full Advantage FIDA Plan Participant Services or read the VillageCareMAX Full Advantage FIDA Plan Participant Handbook. There are no copays for any covered drugs. You can get this information for free in other formats, such as large print, braille, or audio. Call and 711 during hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. You can get this information for free in other languages. Call and TTY users should call 711 during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español. Llame a Servicios del Participante al durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 711. La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 711. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a pou gratis nan kreyòl ayisyen. Rele sèvis patisipan nan les heures de 8:00 je pou 8:00 pm, 7 jou nan semenn nan. Utilisateurs TTY ta dwe rele 711. Apèl gratis. Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону с 8:00 утра до 8 вечера, 7 дней в неделю. Пользователи TTY звоните по телефону 711. Звонок бесплатный. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit ii

3 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 , 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽力語言殘障服務專線 (TTY) 用戶請撥打 711 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7일오전 8시에서오후 8시사이에 번 (TTY 사용자는 711번 ) 으로문의해주십시오. 통화는무료입니다. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VillageCareMAX Full Advantage FIDA Plan. ICAN may be reached toll-free at or online at icannys.org. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit iii

4 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by VillageCareMAX Full Advantage FIDA Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. VillageCareMAX Full Advantage FIDA Plan will cover all drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a VillageCareMAX Full Advantage FIDA Plan network pharmacy. VillageCareMAX Full Advantage FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at or call Participant Services at TTY users should call Does the Drug List ever change? Yes. VillageCareMAX Full Advantage FIDA Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit iv

5 Decide to require or not require prior approval for a drug. (Prior approval is permission from VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page vi). We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check VillageCareMAX Full Advantage FIDA Plan s up to date Drug List online at You can also call Participant Services to check the current Drug List at TTY users should call What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. VillageCareMAX Full Advantage FIDA Plan may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. VillageCareMAX Full Advantage FIDA Plan will send you a letter when a drug you are taking is removed from the Drug List. Our web site includes the most up-to-date information about our Drug List. You can always check or call Participant Services if you have any questions. Our phone number is TTY users should call 711. We are open 7 days a week from 8:00 am to 8:00 pm. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit v

6 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Please talk to your doctor if you are taking a medication that the FDA determines to be unsafe. Your doctor can prescribe a different medication to replace the one that is no longer available. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, VillageCareMAX Full Advantage FIDA Plan may not cover the drug. Quantity limits: Sometimes VillageCareMAX Full Advantage FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes VillageCareMAX Full Advantage FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 1. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new VillageCareMAX Full Advantage FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit vi

7 is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page I-1. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Participant Services at and ask about it. If you learn that VillageCareMAX Full Advantage FIDA Plan will not cover the drug, you can do one of these things: If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit vii

8 Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new VillageCareMAX Full Advantage FIDA Plan Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of VillageCareMAX Full Advantage FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. VillageCareMAX Full Advantage FIDA Plan has a transition process and ensures that continued drug coverage is provided to new and current Part D members. There are times when you may experience a change in your level of care, such as a discharge or admission to a Long Term Care facility or a discharge or admission to a hospital. In these cases, VillageCareMAX Full Advantage FIDA plan will provide you with a one-time emergency supply of a non-formulary medication. Non-formulary drugs include both Part D drugs that are not on a plan s formulary and Part D drugs that are on a plan s formulary but require prior authorization or step therapy under the plan s utilization management rules. Please call Participant Services if you have any questions. You can call from 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit viii

9 11. Can you ask for an exception to cover your drug? Yes. You can ask VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask VillageCareMAX Full Advantage FIDA Plan or your IDT to change the rules on your drug. For example, VillageCareMAX Full Advantage FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). VillageCareMAX Full Advantage FIDA Plan covers both brand name drugs and generic drugs. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit ix

10 15. What are OTC drugs? OTC stands for over-the-counter. VillageCareMAX Full Advantage FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC drugs are covered. OTC drugs are included in Tier Does VillageCareMAX Full Advantage FIDA Plan cover OTC nondrug products? VillageCareMAX Full Advantage FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider. Examples include: OTC diabetic supplies such as gauze pads, alcohol swabs/pads, insulin syringes and needles. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC drugs are covered. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC nondrug products are covered. 17. What is your copay? You will not be charged a copay for drugs on the Drug List. 18. What are drug tiers? In the VillageCareMAX Full Advantage FIDA Plan Formulary, you will see 4 drug tiers included in the formulary list. Tier 1 drugs are generic drugs covered by Medicare Tier 2 drugs are brand name and specialty drugs covered by Medicare Tier 3 drugs are non-part D generic and brand name drugs covered by Medicaid Tier 4 drugs are Over-the-Counter (OTC) drugs covered by Medicaid As a member of our plan, you will pay $0 copayment for drugs in any of these 4 tiers. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit x

11 List of Covered Drugs The list of covered drugs that begins below on page 1 gives you information about the drugs covered by VillageCareMAX Full Advantage FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., LIPITOR and generic drugs are listed in lower-case italics (e.g., ibuprofen). The information in the necessary actions, restrictions, or limits on use column tells you if VillageCareMAX Full Advantage FIDA Plan has any rules for covering your drug. ABBREVIATION/SYMBOL DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA-HRM Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications You (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Participants age 65 yrs or older are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xi

12 ABBREVIATION/SYMBOL DESCRIPTION EXPLANATION PA NSO QL ST Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction If you are a new participant or if you have not taken this drug before, you (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. VillageCareMAX Full Advantage FIDA Plan limits the amount of this drug that is covered per prescription, or within a specific time frame. Before VillageCareMAX Full Advantage FIDA Plan can provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. OTHER SPECIAL REQUIREMENTS FOR COVERAGE LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Participant Services at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. * Not a Part D Drug This drug is a non-part D drug, or an OTC drug or product covered by Medicaid. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xii

13 Note: The * next to a drug means the drug is not a Part D drug and are included in tiers 3 and 4. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at or the Independent Consumer Advocacy Network (ICAN) at You can also read the Participant Handbook to learn how to appeal a decision. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xiii

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15 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01,

16 Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01,

17 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg rapid tab 160 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 3

18 BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain-fever 160 mg/5 ml a/f,gluten/f,cherry 160 mg/5 ml * (Acetaminophen) (Infants' Tylenol) ST; QL (60 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) QL (240 per 30 days) 4

19 child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) (Codeine Sulfate) mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet mg, 2.5- QL (360 per 30 days) (Xolox) 325 mg, mg, mg endodan oral tablet mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml (Hycet) hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) 5

20 hydrocodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Norco) mg, mg hydrocodone-ibuprofen oral tablet QL (150 per 30 days) mg, mg, mg, mg (Ibudone) hydromorphone (pf) injection solution 10 mg/ml (Dilaudid-HP) hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution 2 (Hydromorphone mg/ml HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml elixir 160 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) 6

21 mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Tylenol Arthritis) mg * margesic oral capsule mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) 7

22 morphine in dextrose 5 % injection pt controlled analgesia syring 100 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG 8

23 NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral QL (120 per 30 days) (Oxycontin) only,ext.rel.12 hr 80 mg (Oxycodone QL (1800 per 30 days) oxycodone-acetaminophen oral HCl/Acetaminophe solution mg/5 ml n) oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg 9

24 oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet mg, mg, mg roxicet oral solution mg/5 ml (Ibudone) (Oxycodone HCl/Acetaminophe n) QL (150 per 30 days) QL (1800 per 30 days) silapap infant's drops infant 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * 10

25 tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (180 per tencon oral tablet mg (Tencon) 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg (includes Vicodin, vicodin es oral tablet mg (Norco) Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) zebutal oral capsule mg (Esgic) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 11

26 aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 100 mg diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral diclofenac potassium oral tablet 50 (Aspirin/Calcium (Choline Sal/Mag (Diclofenac mg * liquid 500 mg/5 ml mg Carbonate/Mag) Salicylate) Potassium) QL (60 per 30 days) 12

27 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Etodolac) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) mg fenoprofen oral capsule 200 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) 13

28 INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) QL (20 per 30 days) 14

29 tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) 15

30 bupropion hcl sr 150 mg tablet f/c 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) 16

31 nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) PA; QL (90 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml 17

32 diazepam oral solution 5 mg/5 ml (1 mg/ml) (Diazepam) diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan) ONFI ORAL SUSPENSION 2.5 MG/ML Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 (Gentamicin In ml, 100 mg/50 ml, 60 mg/50 ml, 70 Nacl, Iso-Osm) mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 (Gentamicin mg/ml Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization (Tobi) 300 mg/5 ml QL (1200 per 30 days) QL (120 per 30 days) QL (90 per 30 days) PA NSO; QL (480 per 30 days) QL (224 per 28 days) 18

33 tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) (Cleocin HCl) (Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) (Zyvox) linezolid oral tablet 600 mg (Zyvox) 19

34 methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrodantin) (Macrobid) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) 20

35 polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl gram/200 ml In Dextrose 5 %) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 1 gram/50 Sodium/Dextrose, ml, 2 gram/50 ml Iso) PA; QL (9 per 30 days) PA 21

36 cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram (Maxipime) cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg (Claforan) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) 22

37 ceftibuten oral suspension for reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback 50ml galaxycontainer 1 gram/50 ml ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram ceftriaxone 2 gm piggyback 50ml galaxycontainer 2 gram/50 ml ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg, 750 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Cedax) (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Ceftin) (Zinacef) (Zinacef) (Keflex) (Cephalexin) (Cephalexin) (Fortaz) 23

38 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet (Erythromycin 250 mg Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (Erythromycin tablet 400 mg Ethylsuccinate) 24

39 erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Augmentin) LA 25

40 amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Dicloxacillin Sodium) (Nafcillin Sodium) 26

41 nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) (Zosyn) 27

42 Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml (Cipro) (Cipro I.V.) (Ciprofloxacin Lactate) (Cipro) ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 (Levaquin) mg/150 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) levofloxacin oral solution 250 mg/10 ml (Levaquin) levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous solution mg/5 Trimethoprim) ml sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet mg, mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) 28

43 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines doxy-100 intravenous recon soln 100 mg doxycycline hyclate 100 mg cap 100 mg doxycycline hyclate 100 mg tab 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline mono 100 mg cap 100 mg doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg (Azulfidine) (Sulfamethoxazole/ Trimethoprim) (Doxycycline Hyclate) (Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy) (Doryx) (Adoxa) (Avidoxy) (Avidoxy) (Adoxa) (Vibramycin) (Avidoxy) 29

44 minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 10 mg, 20 mg, 50 mg adriamycin intravenous solution 10 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Minocin) (Minocycline HCl) (Tetracycline HCl) (Doxorubicin HCl) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet 1 mg (Arimidex) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) 30

45 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML (Vidaza) bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 30 (Bleomycin unit Sulfate) bleomycin sulfate 15 unit vial latexfree 15 unit Sulfate) (Bleomycin BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) 31

46 COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG (Cyclophosphamid e) (Cyclophosphamid e) (Dactinomycin) (Dacogen) (Doxil) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) 32

47 EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) mg/10 ml flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO PA NSO; QL (30 per 30 days) PA NSO 33

48 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial suv 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) (Ifex) (Ifosfamide/Mesna ) imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 15 MG KIT WITH DILUENT 15 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) 34

49 JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 (Leuprolide mg/0.2 ml Acetate) lipodox 50 intravenous suspension 2 mg/ml (Doxil) lipodox intravenous suspension 2 mg/ml (Doxil) lomustine oral capsule 10 mg, 100 mg, 40 mg (Lomustine) LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) 35

50 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml Sodium) (Methotrexate methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) ; ST 36

51 NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) 37

52 STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) TREANDA 25 MG VIAL 25 MG PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO; (vial only) 38

53 TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 180 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) (capsule: 10mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA PA NSO; QL (120 per 30 days) 39

54 XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION (Atropine Sulfate) (Atropine Sulfate) (Propantheline Bromide) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) QL (4 per 28 days) 40

55 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 41

56 divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin 500 mg pe/10 ml 10's,sdv,latex-free 500 mg pe/10 ml (Cerebyx) fosphenytoin injection solution 100 mg pe/2 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg ST ST 42

57 lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution 130 mg/ml, 65 mg/ml Sodium) 43

58 phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION 1,000 MG days) SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiragen oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) ST; QL (120 per 30 days) 44

59 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, ST QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG 45

60 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG buproban oral tablet extended release 150 mg bupropion hcl (smoking deter) oral tablet extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg (Exelon) (Exelon) (Amitriptyline HCl) (Amoxapine) (Wellbutrin SR) (Wellbutrin SR) (Wellbutrin) (Wellbutrin SR) (Wellbutrin XL) (Citalopram Hydrobromide) (Celexa) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA NSO-HRM ST QL (30 per 30 days) 46

61 clomipramine oral capsule 25 mg, PA NSO-HRM (Anafranil) 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 PA NSO-HRM (Doxepin HCl) mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 47

62 fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML (Fluvoxamine Maleate) (Fluvoxamine Maleate) (Tofranil) (Tofranil-Pm) (Maprotiline HCl) (Remeron) (Remeron) (Nefazodone HCl) (Pamelor) (Nortriptyline HCl) (Symbyax) (Paxil) (Paxil CR) PA NSO-HRM PA NSO-HRM 48

63 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg (Perphenazine/Ami triptyline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg (Trazodone HCl) trimipramine oral capsule 100 mg, (Trimipramine 25 mg, 50 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 (Effexor XR) mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (Venlafaxine HCl) (Venlafaxine HCl) PA NSO-HRM ST; QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST 49

64 VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG (Precose) QL (90 per 30 days) QL (180 per 30 days) ST ST ST ST ST 50

65 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG KORLYM ORAL TABLET 300 MG PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr 1,000 mg metformin oral tablet extended QL (150 per 30 days) (Fortamet) release 24hr 500 mg miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg pioglitazone-glimepiride oral tablet QL (30 per 30 days) (Duetact) 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet QL (90 per 30 days) (Actoplus Met) mg, mg repaglinide oral tablet 0.5 mg, 1 mg, QL (240 per 30 days) (Prandin) 2 mg repaglinide-metformin oral tablet 1- QL (150 per 30 days) (Prandimet) 500 mg, mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML PA; QL (10.8 per 28 days) 51

66 SYMLINPEN 60 PA; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ST 1,000 MG, MG, 5-1,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) QL (24 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 QL (40 per 28 days) (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 52

67 NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) 250 mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (120 per 30 days) 500 mg, mg in HCl) glyburide micronized oral tablet 1.5 PA-HRM; AGE (Max (Glynase) mg, 3 mg, 6 mg 64 Years) glyburide oral tablet 1.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) mg, mg, mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) 53

68 tolbutamide oral tablet 500 mg (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln (Miconazole Nitrate) (Amphotericin B) 50 mg anti-fungal 1% powder 1 % * (Tolnaftate) antifungal 2% cream 2 % * (Nuzole) baza antifungal 2% cream 12's 2 % * (Nuzole) blis-to-sol 1% liquid 1 % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) ciclopirox topical gel 0.77 % (Loprox) ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Ciclopirox % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) topical solution 8 % clotrim 1% vaginal cream 1 % * (Gyne-Lotrimin) clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) clotrimazole 1% solution (otc) 1 % (Clotrimazole) * clotrimazole insert 100 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) troche 10 mg 54

69 clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Clotrimazole) clotrimazole-7 cream 1 % * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream % (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion % methasone Dip) critic-aid clear af 2% oint 12's, w/ (Miconazole antifungal 2 % * Nitrate) cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af 1% spray powder 1 % * (Tinactin) cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) * (Miconazole Nitrate) dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream 1 % (Econazole Nitrate) elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml (Fluconazole In Nacl,Iso-Osm) fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) fluconazole-nacl 400 mg/200 ml (Fluconazole In 10's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * (Clotrimazole) FUNGI-NAIL TINCTURE * 55

70 fungoid-d 1% cream 1 % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet (Grifulvin V) 500 mg inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % (Tinactin) * lamisil af defense 1% powder 1 % * (Tolnaftate) LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole mg vag supp 100 (Miconazole mg * Nitrate) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole 200 mg Nitrate) MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) 56

71 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 (Nystatin) unit/gram nystatin oral suspension 100,000 (Nystatin) unit/ml nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 100,000 (Nystatin) unit/gram nystatin topical ointment 100,000 (Nystatin) unit/gram nystatin topical powder 100,000 (Nystatin) unit/gram nystatin-triamcinolone topical (Nystatin/Triamcin cream 100, unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin ointment 100, unit/gram-% ) nystop topical powder 100,000 (Nystatin) unit/gram pv foot odor control 1% powder 1 % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal 1% liquid spray liquid (Tolnaftate) spray 1 % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine 1% cream 1 % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Tolnaftate) 57

72 triple paste af 2% ointment 2 % * (Miconazole Nitrate) voriconazole intravenous solution 200 mg (Vfend IV) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint 10 mg * (Claritin) alavert d-12 allergy-sinus tab (Claritin-D 12 mg * Hour) ALLEGRA ALLERGY 180 MG TABLET 180 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-12hr tablet mg * (Claritin-D 12 Hour) allerclear d-24hr er tablet nondrowsy mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d mg tablet mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet mg * (Triprolidine/Pseud oephedrine) 58

73 banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl 1 mg/1 ml soln children, s/f, grape (otc) 1 mg/ml * (Children'S Zyrtec) cetirizine hcl 10 mg tablet indoor & outdoor 10 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er mg tab mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * child triaminic cold & allergy mg/5 ml * (Dimetapp) child wal-tap cold-allergy elx mg/5 ml * (Dimetapp) CHILD ZYRTEC 1 MG/ML SOLUTION D/F,S/F,GRAPE 1 MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * (Children'S Zyrtec) CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * 59

74 child's wal-dryl 12.5 mg/5 ml a/f,s/f,d/f,bubb gum 12.5 mg/5 ml * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 10 MG REDITABS 10 MG * CLARITIN 10 MG TABLET (OTC) 10 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs child allergy 10 mg chw tb 24 hr,indoor/outdoor 10 mg * cvs cold & cough nighttime liq mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f mg/5 ml * (Zzzquil) (Zyrtec) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) (Zyrtec) (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) (Dimetapp) 60

75 dimetapp cold & congest liquid mg/5 ml * (Triaminic Nighttime Cold- Cough) diphenhist 12.5 mg/5 ml soln 12.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/ * Phenylephrine) fexofenadine hcl 180 mg tablet (Allegra Allergy) 24hr,original str (otc) 180 mg * fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) ml levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Claritin) fexofenadine hcl 30 mg/5 ml 30 loratadine allergy 5 mg/5 ml d/f, a/f, loratadine-d 12 hour tablet nondrowsy mg * (Fexofenadine (Children'S (Claritin-D 12 mg/5 ml * s/f 5 mg/5 ml * HCl) Claritin) Hour) 61

76 loratadine-d 24hr tablet mg * promethazine oral syrup 6.25 mg/5 ml pv nyt-time sleep 25 mg caplet 25 mg * q-dryl 12.5 mg/5 ml liquid a/f 12.5 mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * simply sleep 25 mg caplet caplet 25 mg * sleep aid 25 mg tablet 25 mg * sm allergy relief 1.34 mg tab 1.34 mg * sm sinus and allergy tablet maximum strength 4-60 mg * sm z-sleep 50 mg/30 ml liquid berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 mg * TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE MG/5 ML * unisom 50 mg sleepgels softgel 50 mg * wal-act d cold & allergy tab mg * wal-dryl allergy 25 mg capsule 25 mg * wal-dryl allergy 25 mg minitab minitab, coated 25 mg * (Claritin-D 24 Hour) (Promethazine HCl) (Diphenhydramine HCl) (Zzzquil) (Zzzquil) (Zzzquil) (Diphenhydramine HCl) (Doxylamine Succinate) (Clemastine Fumarate) (Chlorpheniramine/ Pseudoephed) (Zzzquil) (Chlorpheniramine/ Pseudoephed) (Zzzquil) (Triprolidine/Pseud oephedrine) (Zzzquil) (Diphenhydramine HCl) PA-HRM; AGE (Max 64 Years) 62

77 wal-fex allergy 180 mg tablet 180 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 10 mg odt non-drowsy 10 (Claritin) mg * wal-itin 10 mg tablet non-drowsy 10 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 12 wal-itin d 12 hour tablet mg * Hour) wal-itin d 24 hour tablet mg (Claritin-D 24 * Hour) (Unisom wal-sleep z 25 mg odt 25 mg * Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid (Zzzquil) berry, a/f, d/f, s/f 50 mg/30 ml * (Doxylamine wal-som 25 mg tablet 25 mg * Succinate) wal-som 50 mg softgel softgel 50 mg (Zzzquil) * wal-tap elixir mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr mg * (Zyrtec-D) wal-zyr solution children's, a/f 1 (Children'S Zyrtec) mg/ml * wal-phed pe sinus-allergy tab 4-10 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 63

78 ZYRTEC 10 MG LIQUID GELS 10 MG * ZYRTEC 10 MG ODT 10 MG * ZYRTEC 10 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt Mlt) 10 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng (Sumatriptan QL (4 per 28 days) p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) 64

79 sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM (Imitrex) (Imitrex) (Sumatriptan Succinate) (Imitrex) (Sumatriptan Succinate) (Sumatriptan Succinate) (Imitrex) (Zomig) (Zomig Zmt) QL (12 per 28 days) QL (18 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (12 per 28 days) QL (12 per 28 days) dapsone oral tablet 100 mg, 25 mg (Dapsone) ethambutol oral tablet 100 mg, 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 100 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 150 mg (Mycobutin) 65

80 rifampin intravenous recon soln 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE MG (Rifadin) (Rifadin) PA; QL (188 per 168 days) compro rectal suppository 25 mg (Compazine) cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg (Marinol) EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) 66

81 granisetron (pf) intravenous (Granisetron solution 100 mcg/ml HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) granisetron hcl oral tablet 1 mg (Granisetron HCl) meclizine 12.5 mg caplet caplet (otc) 12.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Meclizine HCl) motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) ondansetron hcl oral solution 4 (Zofran) mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) mg, 8 mg ondansetron oral (Zofran Odt) tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 PA-HRM; AGE (Max (Phenergan) mg, 25 mg 64 Years) prochlorperazine edisylate injection (Prochlorperazine solution 10 mg/2 ml (5 mg/ml) Edisylate) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) prochlorperazine rectal suppository 25 mg (Compazine) promethazine oral tablet 12.5 mg, (Promethazine PA-HRM; AGE (Max 25 mg, 50 mg HCl) 64 Years) promethazine rectal suppository PA-HRM; AGE (Max (Phenergan) 12.5 mg, 25 mg, 50 mg 64 Years) promethegan rectal suppository PA-HRM; AGE (Max (Phenergan) 12.5 mg, 25 mg, 50 mg 64 Years) 67

82 TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg, mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) QL (10 per 30 days) QL (6 per 21 days) 68

83 PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 100 mg (Amantadine HCl) APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine oral tablet 0.5 mg, 1 (Benztropine mg, 2 mg Mesylate) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet mg, mg, mg (Sinemet CR) carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, (Stalevo 50) mg, mg, mg entacapone oral tablet 200 mg (Comtan) QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 69

84 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl trihexyphenidyl oral tablet 2 mg, 5 mg Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG HCl) (Trihexyphenidyl HCl) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml (Abilify) QL (900 per 30 days) 70

85 aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) chlorpromazine oral tablet 10 mg, (Chlorpromazine 100 mg, 200 mg, 25 mg, 50 mg HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating ST 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg (Fazaclo) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 ST; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- ST; QL (8 per 28 days) 6MG(2) fluphenazine decanoate injection solution 25 mg/ml (Fluphenazine Decanoate) 71

86 fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) (Haloperidol) QL (6 per 28 days) 72

87 loxapine succinate oral capsule 10 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) molindone oral tablet 10 mg (Molindone HCl) QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating QL (31 per 30 days) (Zyprexa Zydis) 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg (Perphenazine) pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (120 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) 73

88 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG (Risperdal) (Risperdal M-Tab) (Risperdal M-Tab) (Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl) (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) ST; QL (60 per 30 days) PA NSO-HRM ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 74

89 abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG (Trizivir) (Videx EC) 75

90 INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG 76

91 PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG 77

92 VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS 100 MG/1 ML VIAL 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG QL (84 per 180 days) 78

93 TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG ZEPATIER ORAL TABLET MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 10 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) QL (48 per 180 days) QL (42 per 180 days) QL (540 per 180 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO 79

94 INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg (Famvir) ganciclovir sodium intravenous recon soln 500 mg (Cytovene) PA NSO PA NSO PA PA PA PA PA NSO; QL (4 per 28 days) 80

95 ribasphere oral capsule 200 mg (Rebetol) ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) 81

96 heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container 25,000 unit/250 ml(100 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) (Coumadin) (Coumadin) PA; QL (24 per 28 days) ST; QL (60 per 30 days) 82

97 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 83

98 NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 10,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet 1,000 mg, 500 mg anagrelide oral capsule 0.5 mg, 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) (Aminocaproic Acid) (Aminocaproic Acid) (Agrylin) (Protamine Sulfate) (Tranexamic Acid) PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors 84

99 aspirin-dipyridamole oral capsule, er multiphase 12 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg (Pletal) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % QL (30 per 30 days) 85

100 AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % 86

101 CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % 87

102 CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * dextrose 10 % in water (d10w) intravenous parenteral solution 10 % (Cysteine HCl) (Dextrose) (Dextrose 10 % in Water) 88

103 dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous solution Water) dextrose 20 % in water (d20w) (Dextrose 20 % in intravenous parenteral solution 20 Water) % dextrose 25 % in water (d25w) (Dextrose 25 % in intravenous syringe Water) dextrose 40 % in water (d40w) (Dextrose 40 % in intravenous parenteral solution 40 Water) % dextrose 5 % in ringers intravenous (Dextrose 5 % In parenteral solution 5 % Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous syringe Water) dextrose 70 % in water (d70w) (Dextrose 70 % in intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, caffeine free 4 gram * (Dextrose) glucose 40% gel tropical fruit 40 % * (Dextrose) glutose 15 gel 3 pak, outer, u-d 40 % * (Dextrose) 89

104 HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/31 gram * insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % (Dextrose/Dextrin/ Maltose) (Fat Emul/Soy/Mct/Oli v/fish Oil) 90

105 TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-Tts 1) (Catapres-Tts 1) (Clonidine HCl/Chlorthalidon e) (Cardura) guanfacine oral tablet 1 mg, 2 mg (Tenex) midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists (Midodrine HCl) (Vazculep) (Minipress) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (180 per 30 days) 91

106 BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg ENTRESTO ORAL TABLET MG, MG, MG irbesartan oral tablet 150 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet mg, mg, mg TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) (Diovan) (Diovan HCT) PA; QL (60 per 30 days) ST 92

107 Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet mg, mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg (Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydroch lorothiazide) (Vasotec) (Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) (Zestril) (Zestoretic) moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet mg, mg, 7.5- hlorothiazide) 12.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Aceon) (Accupril) 93

108 quinapril-hydrochlorothiazide oral tablet mg, mg, mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg (Accuretic) (Altace) (Mavik) (Cordarone) (Norpace) (Tikosyn) (Tambocor) (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) (Mexiletine HCl) (Cordarone) (Procainamide HCl) (Rythmol SR) (Rythmol) 94

109 quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet mg, mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg (Betaxolol HCl) bisoprolol fumarate oral tablet 10 mg, 5 mg (Zebeta) bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 100 mg, 200 mg, 300 mg (Trandate) metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 (Toprol XL) mg, 25 mg, 50 mg 95

110 metoprolol ta-hydrochlorothiaz oral tablet mg, mg, mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Lopressor HCT) (Metoprolol Tartrate) (Metoprolol Tartrate) (Lopressor) (Corgard) pindolol oral tablet 10 mg, 5 mg (Pindolol) propranolol intravenous solution 1 mg/ml (Propranolol HCl) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg (Inderal LA) propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet mg, mg chlorothiazid) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg (Betapace) sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 10 mg, (Timolol Maleate) 20 mg, 5 mg Calcium-Channel Blocking Agents 96

111 cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg diltiazem 24hr er 360 mg cap 360 mg diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem LA) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Verapamil HCl) (Verelan Pm) 97

112 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Verelan) (Calan) (Calan SR) digitek oral tablet 125 mcg (Lanoxin) digitek oral tablet 250 mcg (Lanoxin) digox 125 mcg tablet 125 mcg (Lanoxin) ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) 98

113 digox 250 mcg tablet 250 mcg (Lanoxin) digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) (Digoxin) digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Lanoxin) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml) (Dobutamine HCl/D5W) (Dobutamine HCl) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 99

114 dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg (Dopamine HCl/D5W) (Dopamine HCl) (Ephedrine Sulfate) (Epinephrine HCl/PF) (Adrenaclick) (Epinephrine) (Epinephrine) (Ethanolamine Oleate) (Hydralazine HCl) (Hydralazine HCl) 100

115 LANOXIN ORAL TABLET MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 150 mg RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg (Milrinone Lactate/D5W) (Milrinone Lactate) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl) (Adalat CC) (Norvasc) (Lotrel) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA PA 101

116 amlodipine-valsartan oral tablet mg, mg, mg, 5- (Exforge) 320 mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) mg AZOR ORAL TABLET MG, MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg (Felodipine) isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, 1 mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) ST 102

117 chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG furosemide injection solution 10 mg/ml (Furosemide) furosemide injection syringe 10 mg/ml (Furosemide) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) indapamide oral tablet 1.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 10 mg, 2.5 mg, 5 mg (Zaroxolyn) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule mg, mg (Dyazide) triamterene-hydrochlorothiazid oral tablet mg, mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, (Caduet) mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) 103

118 cholestyramine light oral powder 4 (Cholestyramine/A gram spartame) cholestyramine light oral powder in packet 4 gram (Questran) cholestyramine packet 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 (Lofibra) mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg (Lofibra) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor) niacin 50 mg tablet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) PA PA; QL (4 per 28 days) QL (30 per 30 days) 104

119 niacin 500 mg tablet 500 mg * (Slo-Niacin) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg (Niaspan) niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram (Cholestyramine/A spartame) prevalite packet outer 4 gram (Cholestyramine/A spartame) REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Crestor) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Zocor) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) 105

120 simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg (Isochron) isosorbide dinitrate oral tablet extended release 40 mg (Isochron) isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) isosorbide mononitrate oral tablet (Isosorbide 10 mg, 20 mg Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg (Imdur) minitran transdermal patch 24 hour QL (30 per 30 days) (Nitro-Dur) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 days) (Nitro-Dur) 0.4 mg/hr minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil) 106

121 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (125 mg/ml caffeine) (Nitroglycerin/D5 W) (Nitroglycerin) (Nitrostat) (Nitro-Dur) (Nitro-Dur) (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) 107

122 clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0.1 mg/ml guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg (Kapvay) (Focalin) (Dexedrine) (Dexedrine) (Adderall XR) (Adderall XR) (Adderall) (Romazicon) (Intuniv) (Lithium Carbonate) (Lithobid) (Lithobid) (Lithium Citrate) (Metadate Cd) (Metadate Cd) QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 108

123 methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg (Metadate Cd) methylphenidate oral capsule, er biphasic mg (Metadate Cd) methylphenidate oral capsule,er biphasic mg, 40 mg (Metadate Cd) methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml (Methylin) methylphenidate oral tablet 10 mg, 20 mg, 5 mg (Ritalin) methylphenidate oral tablet (Methylphenidate extended release 10 mg, 20 mg HCl) methylphenidate oral tablet extended release 24hr 18 mg, 27 (Concerta) mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) NUEDEXTA ORAL CAPSULE MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Contraceptives QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) 109

124 Contraceptives AFTERA 1.5 MG TABLET 1.5 MG * 3 $0 altavera (28) oral tablet mg (Amethyst) alyacen 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (Seasonique) (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) apri oral tablet mg (Desogen) aranelle (28) oral tablet 0.5/1/ mg-mcg (Modicon) ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet mg-mcg (Amethyst) aviane oral tablet mg-mcg (Amethyst) azurette (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet mgmcg (Modicon) bekyree (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) blisovi fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) 110

125 briellyn oral tablet mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) (Seasonique) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) caziant (28) oral tablet 0.1/.125/ mg-mcg (Desogen) cryselle (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl cyclafem 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) cyred oral tablet mg (Desogen) dasetta 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet mg (Desogen) drospirenone-ethinyl estradiol oral tablet mg, mg (Yaz) econtra ez 1.5 mg tablet inner 1.5 mg * (Aftera) QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) 111

126 elinest oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg (Desogen) enpresse oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet mg (Desogen) errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet mg-mcg (Ortho-Cyclen) fallback solo 1.5 mg tablet inner 1.5 QL (6 per 365 days) (Aftera) mg * falmina (28) oral tablet mgmcg (Amethyst) gianvi (28) oral tablet mg (Yaz) gildagia oral tablet mg-mcg (Modicon) gildess 1.5/30 (21) oral tablet (Loestrin) mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) heather oral tablet 0.35 mg (Nor-Q-D) introvale oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet mg (Desogen) junel 1.5/30 (21) oral tablet mg-mcg (Loestrin) 112

127 junel 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen ) kimidess (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kurvelo oral tablet mg (Amethyst) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) larin 1.5/30 (21) oral tablet mg-mcg (Loestrin) larin 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) larissia oral tablet mg-mcg (Amethyst) leena 28 oral tablet 0.5/1/ mg-mcg (Modicon) lessina oral tablet mg-mcg (Amethyst) levonest (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) QL (91 per 84 days) 113

128 levonor-eth estrad outer QL (91 per 84 days) (Amethyst) mg levonorgestrel 1.5 mg tablet (otc) QL (6 per 365 days) (Aftera) 1.5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (12 per 365 days) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Amethyst) levonorgestrel-ethinyl estrad oral QL (91 per 84 days) tablets,dose pack,3 month 0.15 mg- 30 mcg (Amethyst) levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet mg (Yaz) low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet mg (Amethyst) microgestin 1.5/30 (21) oral tablet mg-mcg (Loestrin) microgestin 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) (Loestrin Fe) mono-linyah oral tablet mgmcg (Ortho-Cyclen) 114

129 mononessa (28) oral tablet mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet mg-mcg (Modicon) necon 1/35 (28) oral tablet 1-35 mgmcg (Modicon) necon 1/50 (28) oral tablet 1-50 mgmcg (Norinyl 1+50) necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg (Modicon) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) next choice one dose 1.5 mg tb (otc) QL (6 per 365 days) (Aftera) 1.5 mg * next choice one dose oral tablet 1.5 QL (6 per 365 days) (Plan B One-Step) mg nikki (28) oral tablet mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) norg-ee / x28 day regimen 0.18/0.215/0.25 mg-35 (Ortho-Cyclen) mcg (28) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, (Ortho-Cyclen) mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) 115

130 nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg (Modicon) nortrel 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) NUVARING VAGINAL RING ST; QL (1 per 28 days) MG/24 HR ocella oral tablet mg (Yaz) ogestrel (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * option mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) orsythia oral tablet mg-mcg (Amethyst) philith oral tablet mg-mcg (Modicon) pimtrea (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg (Modicon) PLAN B ONE-STEP 1.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC) 1.5 MG * portia oral tablet mg (Amethyst) previfem oral tablet mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) react 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet mg (Desogen) setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) 116

131 sprintec (28) oral tablet mgmcg (Ortho-Cyclen) sronyx oral tablet mg-mcg (Amethyst) syeda oral tablet mg (Yaz) tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg (Desogen) vestura (28) oral tablet mg (Yaz) vienva oral tablet mg-mcg (Amethyst) viorele (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) 117

132 vyfemla (28) oral tablet mgmcg (Modicon) wera (28) oral tablet mg-mcg (Modicon) xulane transdermal patch weekly mcg/24 hr (Ortho Evra) zarah oral tablet mg (Yaz) zenchent (28) oral tablet mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen ) zovia 1/50e (28) oral tablet 1-50 mg-mcg (Demulen ) Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-150gfn-15dm liquid mg/5 ml * 30pse-3brm-15dm oral liquid mg/5 ml * 3brm-15dm-30pse liquid mg/5 ml * 3brm-30dm-50pse liquid (otc) mg/5 ml * 50pse-3brm-30dm oral liquid mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin linger cold syr 15 mg/5 ml * adt robitussin peak cld dm max mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) (Neo Dm) (Neo Dm) (Neo Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) QL (3 per 28 days) 118

133 adult robitussin peak cold liq nondrowsy mg/5 ml * (G-Zyncof) adult wal-tussin dm max liq (G-Zyncof) a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup (Cough Formula a/f,cherry,adult mg/5 ml * Dm) (Robitussin adult wal-tussin liquid 100 mg/5 ml Mucus-Chest * Congest) alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 10peh-4cpm-20dm tablet (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 100 mg capsule 100 mg * (Zonatuss) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid mg/5 ml * (Neo Dm) bionel pediatric liquid mg/5 ml * (Trispec Pse) biospec dmx liquid mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (otc) mg/5 ml * (Neo Dm) bromfed dm cough syrup (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 119

134 bromphenir-pseudoephed-dm syr (rx) mg/5 ml * brom-pse-dm cough syrup butter scotch (otc) mg/5 ml * centergy dm pediatric drops mg/ml * cheracol d cough formula mg/5 ml * cheratussin dac syrup mg/5 ml * child sudafed pe cough-cold lq mg/5 ml * child triaminic cgh-congst syr mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f mg/5 ml * children's silfedrine liq 15 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * chl mucinex chest congest liq a/f 100 mg/5 ml * chld triaminic cgh-sor thr sus mg/5 ml * codituss dm syrup mg/5 ml * cold multi-symptom day-night pseudoephedrine-free mg * cold relief multi-symp caplet cplt,12 day,12 night mg * (Brompheniramine/ Pseudoephed/Dm) (Brompheniramine/ Pseudoephed/Dm) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Tusnel C) (Dextromethorphan /Phenylephrine) (Cough Formula Dm) (Dextromethorphan Hbr) (G-Zyncof) (Pseudoephedrine HCl) (Pseudoephedrine HCl) (Robitussin Mucus-Chest Congest) (Child Tylenol Plus Cough-Sore) (Pyrilamine/Pe/De xtromethorphan) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pe/Acetaminop hen/chlorph) 120

135 cold-flu relief d/n softgel (Vicks Dayquil- 325mg(d)/ mg * Nyquil) (Dcold-flu relief liquid ,000 Methorphan/Aceta mg/30 ml * min/doxylamn) congestac tablet mg * (Poly-Vent Ir) congest-eze mg caplet mg * (Poly-Vent Ir) (Dcoricidin hbp cold-multi sympt Methorphan/Aceta mg/15 ml * min/doxylamn) coricidin hbp softgel mg * (Guaifenesin/Dextr omethorphan) cough & cold syrup mg/5 ml * (Maxiphen Dmx) cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab mg * (Maxiphen) cvs chest congest relief dm tb mg * (Allfen Dm) cvs child cold-cough day liq mg/5 ml * cvs child's chest congest liq 100 mg/5 ml * cvs cough & sore throat susp mg/5 ml * cvs daytime-nighttime cold-flu multi-symp,twin pack mg/15 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq mg/5 ml * (Dextromethorphan /Phenylephrine) (Robitussin Mucus-Chest Congest) (Child Tylenol Plus Cough-Sore) (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) 121

136 daytime cold & cough liquid 1, mg/30 ml * daytime cold-flu liquid a/f, glutenfree mg/15 ml * (Triaminic) (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan daytime cough liquid a/f, gluten-free 5 mg/5 ml * Hbr) daytime-nighttime cough liquid (Dextromethorphan 15mg/15ml(d)/ mg/30ml * Hb/Doxylamine) delsym cough+chest cngst dm lq mg/5 ml * (G-Zyncof) despec-dm tablet mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq mg/5 ml * (G-Zyncof) ed bron gp liquid mg/5 ml * (Despec) entre-cough liquid mg/5 ml * (Trispec Pse) expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold mg/5 ml * geri-tussin dm syrup mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution mg/5 ml * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) 122

137 guaifenesin er 600 mg tablet 600 mg * head congestion day-night pack mg * (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) hydrocodone-chlorphen er susp 10- (Tussionex) 3 $0 8 mg/5 ml * hydrocodone-homatropine mg (Tussigon) 3 $0 tablet mg * (Hydrocodone hydromet syrup mg/5 ml * Bit/Homatrop Me- 3 $0 Br) liquibid d-r tablet mg * (Maxiphen) lohist-dm syrup mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid mg/5 ml (Tusnel C) * mar-cof bp liquid mg/5 ml (Bromphenira/Pseu 3 $0 * doephed/codein) mar-cof cg liquid mg/5 ml * (M-Clear Wc) 3 $0 M-END DM SYRUP MG/5 ML * mucus dm mg tablet (Mucinex Dm) mg * mucus dm max tablet 60-1,200 mg * (Mucinex Dm) mucus relief 400 mg tablet d/f 400 (Allfen) mg * nasal-sinus decongest tab 30 mg * (Sudafed 12-Hour) NEO DM SYRUP MG/5 ML * neo-tuss liquid mg/5 ml * (G-Zyncof) mesehist dm oral syrup nasohist dm pediatric drops (Chlorpheniramin/ (Chlorpheniramine/ mg/5 ml * mg/ml * Pseudoephed/Dm) Phenyleph/Dm) 123

138 NEXAFED 30 MG TABLET 30 MG * night time cold med liquid mg/15 ml * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM MG * night time cough & sore throat ,000 mg/30 ml * nighttime cough liquid gluten-free, cherry mg/15 ml * nohist-dm liquid mg/5 ml * pecgen dmx mg/5 ml liq mg/5 ml * pedia relief cough-cold liquid a/f, cherry mg/5 ml * pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * poly-tussin liquid mg/5 ml * promethazine vc-codeine syrup mg/5 ml * promethazine-codeine syrup mg/5 ml * promethazine-dm syrup mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * (Dm/P- Ephed/Acetaminop h/doxylam) (D- Methorphan/Aceta min/doxylamn) (Dextromethorphan Hb/Doxylamine) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 124

139 pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime mg/15 ml * pv night-time softgel multisympt.,softgel mg * (Sudafed 12-Hour) (Sudafed 12-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid mg/5 ml * (Despec) q-tapp dm elixir mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 100 mg/5 ml solution a/f, Mucus-Chest non-drowsy 100 mg/5 ml * Congest) q-tussin dm syrup mg/5 ml * (Cough Formula Dm) ra child plus cough-runny nose pseudoephedrine free mg/5 ml * ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra maximum strength flu tablet mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * ra tussin dm syrup a/f mg/5 ml * (Dextromethorphn/ Acetaminoph/Cp) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) 125

140 ra tussin max strn cough syrup 15 (Dextromethorphan mg/5 ml * Hbr) refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet mg * (Maxiphen) relcof c liquid mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * 3 $0 robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid mg/5 ml * rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * (Robitussin Mucus-Chest Congest) (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) 126

141 sm adult nasal decongestant lq 15 mg/5 ml * sm childrens plus cold susp grape,multi-symptom mg/5 ml * sm cold-cough child elixir mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm mucus relief cough liquid childrens, a/f mg/5 ml * sm nite time cold-flu liquid ,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * sm pedia relief liquid mg/5 ml * sm severe cold m-s caplet mg * sm tussin cf syrup mg/5 ml * sudafed 30 mg tablet nondrowsy,max-str 30 mg * sudogest 30 mg tablet boxed 30 mg * (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) (Chlorpheniramin/ Pseudoephed/Dm) (Dm/Pseudoephed/ Acetaminophen) (Guaifenesin/Dm/P seudoephedrine) (Sudafed 12-Hour) (Sudafed 12-Hour) 127

142 sudogest 60 mg tablet 60 mg * (Sudafed 12-Hour) suphedrin liquid 15 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER MG * THERAFLU MULTI-SYMP COLD CPLT MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry mg/5 ml * /Phenylephrine) tri-dex pe oral syrup mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * TUSNEL PEDIATRIC LIQUID (RX) MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * tussin cf cough-cold syrup a/f mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap mg * seudoephedrine) tussin dm syrup mg/5 ml * (Cough Formula Dm) VANACOF LIQUID MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) 128

143 vicks dayquil liquicaps cold & flu mg * vicks nature fusion cough liq 5 mg/5 ml * vicks nyquil severe cold-flu mg/15 ml * virdec dm drops mg/ml * (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (Dm/Pe/Acetamino phen/doxylamine) (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp (Dm/Pseudoephed/ mg/1.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free mg * Dm/Acetamin/Gg) wal-tussin cough 15 mg softgel 15 mg * (Robitussin) wal-tussin cough 15 mg/5 ml 15 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 12-Hour) ZONATUSS 150 MG CAPSULE 150 MG * 3 $0 129

144 zyncof mg/5 ml liquid mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane mouthwash 0.12 % oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE % triamcinolone acetonide dental paste 0.1 % (Peridex) (Triamcinolone Acetonide) (Peridex) (Salagen) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% lotion 10 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acneclear gel 10 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * (Ammonium Lactate) 130

145 ammonium lactate 12% cream (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate 12% lotion (otc) (Ammonium 12 % * Lactate) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (otc) 10 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % (Calcipotriene) calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcipotriene) calcitrene topical ointment % (Calcipotriene) calcitriol topical ointment 3 mcg/gram (Vectical) CASTELLANI PAINT MODIFIED 1.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML PA PA PA 131

146 COSENTYX SUBCUTANEOUS PA SYRINGE 150 MG/ML cvs skin treatment body lotion 12 % (Ammonium * Lactate) fluorouracil topical cream 0.5 %, 5 (Carac) % fluorouracil topical solution 2 %, 5 (Fluorouracil) % (Ammonium geri-hydrolac 12% lotion 12 % * Lactate) (Ammonium geri-hydrolac 5% lotion 5 % * Lactate) imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 10 (Oxsoralen-Ultra) mg PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 (Benzoyl Peroxide) % * PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) (Podophyllum podocon topical liquid 25 % Resin) podofilox topical solution 0.5 % (Condylox) pv acne pimple 10% gel 10 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML potassium hydroxide topical (Potassium solution 5 % Hydroxide) 132

147 TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (15 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Cleocin T) cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) (Erygel) (Erythromycin Base/Ethanol) (Erythromycin Base/Ethanol) 133

148 gentamicin topical cream 0.1 % (Gentamicin Sulfate) gentamicin topical ointment 0.1 % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, 1 % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) silver nitrate topical ointment 10 % (Silver Nitrate) silver nitrate topical solution 0.5 %, 10 %, 25 %, 50 % (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % (Silvadene) sulfacetamide sodium (acne) topical suspension 10 % triple antibiotic ointment carton 3.5mg-400 unit- 5,000 unit/gram * (Klaron) (Neomycin Su/Bacitrac Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream 1 % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) 134

149 (Alclometasone alclometasone topical cream 0.05 % Dipropionate) alclometasone topical ointment 0.05 (Alclometasone % Dipropionate) aquanil hc 1% lotion 1 % * (Cortizone-10) beta hc 1% lotion 1 % * (Cortizone-10) betamethasone valerate topical (Luxiq) foam 0.12 % betamethasone, augmented topical (Diprolene AF) cream 0.05 % betamethasone, augmented topical (Diprolene) lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) (Clobetasol clobetasol scalp solution 0.05 % Propionate) clobetasol topical foam 0.05 % (Olux) (Clobetasol clobetasol topical gel 0.05 % Propionate) clobetasol topical lotion 0.05 % (Clobex) betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0.1 % lotion 0.1 % ointment 0.1 % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 135

150 clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0.1 % (Cloderm) colocort rectal enema 100 mg/60 ml (Cortenema) cormax scalp solution 0.05 % (Clobetasol Propionate) cortizone-10 1% creme maximum strength 1 % * (Hydrocortisone) CORTIZONE-10 1% LOTION 1 % * cortizone-10 1% ointment 1 % * (Hydrocortisone) dermarest eczema 1% lotion 1 % * (Cortizone-10) desonide topical cream 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 % (Ultravate) 136

151 halobetasol propionate topical (Ultravate) ointment 0.05 % hydro skin 1% lotion 1 % * (Cortizone-10) hydrocortisone 0.5% cream (otc) (Hydrocortisone) 0.5 % * hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone 1% cream maximum (Hydrocortisone) strength (otc) 1 % * hydrocortisone 1% cream maximum (Hydrocortisone strength 1 % * Acetate) hydrocortisone 1% lotion (otc) 1 % (Cortizone-10) 3 $0 * hydrocortisone 1% ointment carton (Hydrocortisone) (otc) 1 % * hydrocortisone acet-aloe vera (Hydrocortisone topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.1% cream 0.1 (Hydrocortisone % Butyrate) hydrocortisone butyrate topical (Locoid) ointment 0.1 % hydrocortisone butyrate topical (Locoid) solution 0.1 % hydrocortisone rectal enema 100 (Cortenema) mg/60 ml hydrocortisone topical cream 1 %, (Anusol-HC) 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment 1 (Hydrocortisone) %, 2.5 % hydrocortisone butyr-emollient hydrocortisone valerate topical (Hydrocortisone (Hydrocortisone topical cream 0.1 % cream 0.2 % Butyrate) Valerate) 137

152 hydrocortisone valerate topical ointment 0.2 % (Westcort) mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % (Elocon) neosporin 1% anti-itch cream 1 % * (Hydrocortisone) ONFI ORAL TABLET 10 MG, 20 MG prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) procto-pak topical cream with perineal applicator 1 % (Anusol-HC) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) recort plus 1% cream 1 % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical (Triamcinolone cream %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion %, 0.1 % Acetonide) triamcinolone acetonide topical (Triamcinolone ointment %, 0.1 %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone Acetonide) u-cort topical cream 1-10 % (Hydrocortisone Acetate/Urea) Dermatological Retinoids PA NSO; QL (60 per 30 days) adapalene topical cream 0.1 % (Differin) 138

153 adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel PA (Retin-A Micro) with pump 0.04 %, 0.1 % tretinoin topical cream %, PA (Retin-A) 0.05 %, 0.1 % tretinoin topical gel 0.01 %, PA (Retin-A) %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * (Piperonyl Butoxide/Pyrethrin s) cvs permethrin 1% lotion 1 % * (Nix) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * (Nix) sm lice treatment permethrin 2's 1 % * (Nix) v-r lice cream rinse 1 % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 31GX5/ ML 31 GAUGE X 5/16 139

154 BD INSULIN SYR 0.5 ML 31GX5/16" 0.5 ML 31 GAUGE X 5/16 BD INSULIN SYR 1 ML 31GX5/16" 1 ML 31 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 140

155 CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000-27,000 unit PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML (Zenpep) PA PA; LA 141

156 VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetravisc) altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % artificial tears 1.4 % drops 1.4 % * artificial tears drops p/f, sterile % * artificial tears eye drops strl % * (Iopidine) (Polyvinyl Alcohol) (Dextran 70/Hypromellose/P F) (Tears Naturale) PA QL (90 per 30 days) 142

157 artificial tears eye ointment % (Genteal Pm) * atropine ophthalmic drops 1 % (Isopto Atropine) atropine ophthalmic ointment 1 % (Atropine Sulfate) atropine-care ophthalmic drops 1 % (Isopto Atropine) ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 137 mcg (0.1 %) (Astepro) azelastine ophthalmic drops 0.05 % (Azelastine HCl) (Dextran bion tears eye drops % * 70/Hypromellose/P F) carteolol ophthalmic drops 1 % (Carteolol HCl) cromolyn ophthalmic drops 4 % (Cromolyn Sodium) cvs artificial tears drops sterile 1- (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf 1% 1 % * (Carboxymethylcel lulose Sodium) cvs lubricant eye ointment p/f (Genteal Pm) 42.5 % * cvs lubricant gel eye drops % * cvs lubricating eye drops dry eye soln % * cvs natural tears drops % * cyclopentolate ophthalmic drops 0.5 %, 1 %, 2 % (Carboxymethylcel l/hypromellose) (Refresh Optive) (Dextran 70/Hypromellose/P F) (Cyclogyl) QL (30 per 25 days) 143

158 CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.1%-0.3% drop 0.1- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % Homatropine) ipratropium bromide nasal (Atrovent) spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) spray,non-aerosol 0.06 % (Genteal Mild To isopto tears 0.5% eye drops 0.5 % * Moderate) LACRISERT OPHTHALMIC INSERT 5 MG homatropine hbr ophthalmic drops (Isopto 5 % Homatropine) QL (30 per 28 days) QL (15 per 10 days) 144

159 lubricant % eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant % eye drops 0.5- (Refresh Optive) 0.9 % * lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment % (Genteal Pm) * muro-128 2% eye drops 2 % * (Sodium Chloride) muro-128 5% eye drops 5 % * (Sodium Chloride) muro-128 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0.1 % (Naphazoline HCl) nasal decongestant 0.05% spray (Afrin) 0.05 % * (Genteal Mild To natural balance tears drops 0.4 % * Moderate) (Genteal Mild To nature's tears drops 0.4 % * Moderate) neo-synephrine 12 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0.1 % (Patanol) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops (Mydfrin) 10 %, 2.5 % proparacaine ophthalmic drops 0.5 (Proparacaine HCl) % pure & gentle eye drops lubricant (Genteal Mild To 0.3 % * Moderate) (Genteal Mild To pv artificial tears 0.4 % * Moderate) pv lubricant 1.4 % eye drops 1.4 % (Polyvinyl * Alcohol) pv pure-gentle eye drops sterile 0.3 (Genteal Mild To % * Moderate) ST 145

160 REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * REFRESH OPTIVE EYE DROPS % * retaine cmc 0.5% eye drops 0.5 % * (Carboxymethylcel lulose Sodium) saline mist 0.65% nose spry 0.65 % * (Little Remedies) sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl % * (Systane) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE % EYE DROPS % * SYSTANE GEL EYE DROPS % * tears again 1.4 % drops 1.4 % * (Polyvinyl Alcohol) tears again eye ointment % * (Genteal Pm) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f % * F) tetracaine hcl (pf) ophthalmic drops (Tetracaine 0.5 % HCl/PF) ultra fresh pm ointment * (Lanolin/Mineral Oil/Petrolatum) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 12 hour spray 0.05 % * (Afrin) 146

161 Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment ,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) gentamicin ophthalmic drops 0.3 % (Garamycin) gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic drops 0.5 % (Levofloxacin) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment ,000 Zn/Poly/HC) mg-unit/g-1% 147

162 neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension , mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-1% (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) (Cortisporin) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy ,000 mg-unit-unit/g xin) ofloxacin ophthalmic drops 0.3 % (Floxin) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic drops 10 % (Polytrim) (Sulfacetamide Sodium) 148

163 sulfacetamide sodium ophthalmic (Sulfacetamide ointment 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre ophthalmic drops 10 %-0.23 % dnisolone Sp) (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) (Diclofenac Sodium) (Flunisolide) ST QL (50 per 25 days) 149

164 fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * cvs gas relief 125 mg chew tab extra strength 125 mg * (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) (Simethicone) (Gas-X) QL (60 per 30 days) PA; QL (60 per 30 days) 150

165 cvs gas relief 125 mg softgel softgel 125 mg * (Phazyme) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 125 mg chew tablet max str,lactose-free 125 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 180 mg * (Phazyme) inf gas rel 20 mg/0.3 ml drop (Simethicone) 20mg/0.3ml, dye free 40 mg/0.6 ml * mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 125 mg tab 125 mg * (Gas-X) simethicone 180 mg softgel 180 mg * (Phazyme) v-r anti-gas 166 mg softgel 166 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Cimetidine) cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) (Rx Product Only) 151

166 esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) gnp acid reducer 10 mg tablet 10 mg * (Pepcid Ac) lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 14-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg (Prilosec) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) oral capsule mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) 152

167 ra omeprazole-bicarb 20-1,100 3x14 day course (otc) mggram (Zegerid Otc) * ranitidine 150 mg tablet maximum strength (otc) 150 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl injection solution 50 (Rx Product Only) (Ranitidine HCl) mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 150 mg, (Rx Product Only) (Ranitidine HCl) 300 mg ranitidine hcl oral syrup 15 mg/ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg sucralfate oral suspension 100 mg/ml (Sucralfate) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 150 MG TABLET TWIN PACK(2X45TABS) (OTC) 150 MG * ZANTAC 150 MG TABLET TWIN PK, MAX STRGTH (OTC) 150 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid mg/15 ml * (Gaviscon) almacone liquid mg/5 (Maalox Maximum ml * almacone-2 liquid mg/5 ml * Strength) (Maalox Maximum Strength) 153

168 aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG antacid plus x-stren susp mg/5 ml * antacid ultra tablet chew 400 mg (1,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * antacid-antigas liquid mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) (Maalox Maximum Strength) (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) (Tums) (Tums) (Tums) QL (60 per 30 days) 154

169 children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * comfort gel suspension regular str, cherry mg/5 ml * constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml cvs antacid-antigas tab chew 1, mg * (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) (Gastrocrom) (Calcium Carbonate/Simethi cone) cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * (Pepto-Bismol) cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) flanax antacid liquid (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid mg/15 ml * (Gaviscon) 155

170 GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq mg/5 ml * gelusil tablet chewable cool mint mg * generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0.2 mg/ml glycopyrrolate oral tablet 1 mg, 2 mg imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/15 ml susp vanilla flavor 262 mg/15 ml * kionex 15 gm/60 ml suspension gram/60 ml kionex oral powder (Maalox Maximum Strength) (Almacone) (Lactulose) (Robinul) (Loperamide HCl) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) (Sodium Polystyrene Sulfon/Sorb) lactulose oral solution 10 gram/15 ml (Lactulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG loperamide 1 mg/5 ml liquid 1 mg/5 ml * (Loperamide HCl) loperamide oral capsule 2 mg (Loperamide HCl) LOTRONEX ORAL TABLET 0.5 MG, 1 MG PA PA QL (30 per 30 days) 156

171 maalox advanced suspension regular strength mg/5 ml * MAGNEBIND 300 TABLET MG * magnesium 500 mg capsule s/f,na/f 500 mg * magnesium oxide 250 mg tablet 250 mg * magnesium oxide 400 mg tablet s/f,p/f,gluten-free 400 mg * magnesium oxide 500 mg tablet p/f,s/f,lactose-free 500 mg * masanti liquid mg/5 ml * medi-first pep-t-med tab chew 262 mg * methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg (Maalox Maximum Strength) (Uromag) (Magox 400) (Magox 400) (Magox 400) (Maalox Maximum Strength) (Pepto-Bismol To- Go) (Methscopolamine Bromide) (Metoclopramide HCl) (Metoclopramide HCl) (Reglan) mgo 400 mg tablet 400 mg * (Magox 400) mi acid suspension (Maalox Maximum mg/5 ml, mg/5 ml * Strength) mi-acid ds tablet mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme mg/5 Strength) ml * mintox plus tablet chewable 200- (Almacone) mg * 157

172 mintox suspension mint creme 200- (Maalox Maximum mg/5 ml * Strength) MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide 1 mg/7.5 ml susp mint (Loperamide HCl) 1 mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension (Maalox Maximum mg/5 ml * Strength) ri-mox suspension mg/5 (Maalox Maximum ml * Strength) sm foaming antacid tablet chew mg * (Gaviscon) sm stomach relief caplet 262 mg * (Bismuth Subsalicylate) sodium bicarb 650 mg tablet 10 gr (Sodium 650 mg * Bicarbonate) QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 158

173 sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps (with sorbitol) oral suspension gram/60 ml (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 10 mg suppository 10 mg (Dulcolax) * bisacodyl 10 mg suppository 10 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 10 mg suppository 10 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 100 MG CAPSULE 100 MG * cvs enema disposable 19-7 gram/118 ml * cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * cvs kids 100 mg mini enema 100 mg/5 ml * (Enema) (Citrucel) (Docusate Sodium) ST; QL (60 per 30 days) 159

174 cvs purelax powder 14 once-daily (Gavilax) doses 17 gram/dose * cvs purelax powder packet s/f, 10 (Miralax) daily doses 17 gram * cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 (Surfak) mg * doc-q-lace 100 mg softgel 100 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml (Docusate Sodium) * docusate sodium 100 mg tablet (Docusate Sodium) crushable 100 mg * docusate sodium-senna tablet (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 100 mg softgel softgel 100 mg * (Colace) dok 100 mg tablet 100 mg * (Docusate Sodium) dulcolax ss 100 mg softgel 100 mg * (Colace) enema disposable 19-7 gram/118 ml (Enema) * enema ready to use latex-free 19-7 (Enema) gram/118 ml * enemeez mini enema 5cc tubes, (Docusate Sodium) outer 283 mg/5 ml * enemeez plus mini enema outer 283- (Docusol Plus) 20 mg/5 ml * (Psyllium Seed eq fiber therapy powder * (With Sugar)) equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy (psyllium) oral powder (Psyllium Seed) * 160

175 fiber therapy powder 2 gram/19 gram * (Citrucel) fiber-lax captabs 500mg polycarbophil 625 mg * (Fibercon) fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln gram (Golytely) gavilyte-g oral recon soln gram (Golytely) gavilyte-n oral recon soln 420 gram (Nulytely with Flavor Packs) gentlelax powder 30 once-daily doses 17 gram/dose * (Gavilax) glycolax powder 7 doses (otc) 17 gram/dose * (Gavilax) 3 $0 healthylax powder packet 14x17gm, outer 17 gram * (Miralax) hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * konsyl psyllium fiber packet orange, (Psyllium Husk gluten free 3.4 gram * (With Sugar)) magic bullet 10 mg suppos 10 mg * (Dulcolax) milk of magnesia suspension 400 (Milk Of mg/5 ml * Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) 161

176 oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon gram/15 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln gram, gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 100 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon gram/15 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 17 gram/dose Glycol 3350) polyethylene glycol 3350 oral (Polyethylene powder in packet 17 gram Glycol 3350) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (Gavilax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 17 gram * (Miralax) promolaxin 100 mg tablet 100 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * (Enema) ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) 162

177 senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/15 ml syrup 60 mg/15 ml * (Docusate Sodium) sm clearlax powder 14 once-daily doses 17 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 10 oncedaily doses 17 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) (Calcium magnebind 400 oral tablet Carbonate/Mag 1 mg Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG 163

178 Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Oxybutynin Chloride) (Oxybutynin Chloride) (Ditropan XL) (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg (Trospium Chloride) (Trospium Chloride) (Uroxatral) (Flomax) (Terazosin HCl) (Desferal) 164

179 DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) (Sodium Thiosulfate) androxy oral tablet 10 mg (Fluoxymesterone) danazol oral capsule 100 mg, 200 mg, 50 mg (Danazol) oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) 165

180 testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr (Depo- Testosterone) (Testosterone Enanthate) (Testim) (Vogelxo) (Androgel) (Testim) (Activella) (Estrace) (Vivelle-Dot) (Climara) PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) 166

181 estradiol valerate intramuscular oil 10 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG (Delestrogen) (Activella) (Estropipate) mimvey lo oral tablet mg (Activella) mimvey oral tablet mg (Activella) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 10 MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 100 (Hydrocortisone mg Sod Succinate) betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (18 per 28 days) 167

182 cortisone oral tablet 25 mg (Cortisone Acetate) dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone injection solution 10 mg/ml, 4 mg/ml Sod Phosphate) fludrocortisone oral tablet 0.1 mg (Fludrocortisone Acetate) hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (Solu-Medrol) methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml (Prednisone) prednisone oral tablet 1 mg, 2.5 mg, (Prednisone) 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg (Prednisone) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) 168

183 SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection suspension 10 mg/ml, 40 mg/ml Pituitary desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG, 7.5 MG (PED) (Triamcinolone Acetonide) (Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP) QL (15 per 30 days) QL (15 per 30 days) PA PA QL (1 per 84 days) 169

184 NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 10 MG KIT 10 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) PA PA PA PA QL (1 per 28 days) 170

185 SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg (Hydroxyprogester one Caproate) (Depo-Provera) (Medroxyprogester one Acetate) (Provera) (Megace Es) (Aygestin) (Progesterone) (Prometrium) (Levothyroxine Sodium) (Levoxyl) QL (1 per 360 days) QL (10 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) 171

186 liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG AUBAGIO ORAL TABLET 14 MG, 7 MG azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon (Azathioprine soln 100 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) 250 mg/5 ml cyclosporine modified oral capsule (Neoral) 100 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) 100 mg/ml PA; QL (28 per 28 days) 172

187 cyclosporine oral capsule 100 mg, (Sandimmune) 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 100 mg, 25 (Neoral) mg, 50 mg gengraf oral solution 100 mg/ml (Neoral) HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PA 173

188 HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil oral capsule 250 mg (Arava) (Cellcept) PA PA PA PA PA; QL (18.76 per 28 days) 174

189 mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines (Cellcept) (Cellcept) (Myfortic) (Rapamune) (Hecoria) PA PA PA; LA; QL (15 per 28 days) ; QL (120 per 30 days) 175

190 ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML 176

191 DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 10'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 177

192 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG 178

193 MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL) MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT QL (2 per 365 days) QL (2 per 365 days) 179

194 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) ; QL (3 per 365 days) 180

195 TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Alosetron HCl) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) QL (2 per 365 days) QL (1 per 365 days) 181

196 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet,delayed release (dr/ec) 800 mg Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 (Asacol Hd) % (Acetic Acid) LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution (Mannitol/Sorbitol g/100 ml Solution) water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation (Alendronate Sodium) (Fosamax) (Fosamax) (Miacalcin) ST QL (300 per 28 days) QL (4 per 28 days) QL (3.7 per 28 days) 182

197 calcitriol intravenous solution 1 mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 (Ibandronate QL (3 per 84 days) mg/3 ml Sodium) ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 2 MCG/ML, 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg (Zemplar) PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) 183

198 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 28 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml (Zometa) zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML allopurinol oral tablet 100 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg anticoag citrate phos dextrose solution gram-mg/100ml AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG (Zoledronic Acid/Mannitol- Water) (Reclast) (Zyloprim) (Ethyol) (Citrate Phosphate Dextros Soln) QL (100 per 300 days) PA PA ST 184

199 AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg (Urecholine) buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg (Buspirone HCl) CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML (Ergoloid Mesylates) ST ST PA ST PA QL (30 per 30 days) PA; LA 185

200 EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) fomepizole intravenous solution 1 gram/ml (Fomepizole) FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg (Guanidine HCl) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg (Hydroxyzine HCl) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg (Vistaril) KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg (Leucovorin Calcium) (Leucovorin Calcium) (Leucovorin Calcium) ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA NSO; QL (120 per 30 days) PA 186

201 levocarnitine (with sugar) oral (Levocarnitine solution 100 mg/ml (With Sugar)) levocarnitine oral tablet 330 mg (Carnitor) levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORFADIN ORAL SUSPENSION 4 MG/ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 187

202 PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) probenecid-colchicine oral tablet (Colchicine/Proben mg ecid) PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 180 mg (Mestinon) qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) ST ST 188

203 REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 100 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " summer's eve dche-xtra clns 12's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 12's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG PA QL (60 per 30 days) PA PA PA PA QL (14 per 30 days) 189

204 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG topical light mineral oil * (Mineral Oil) QL (60 per 30 days) PA NSO; QL (60 per 30 days) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 125 mg, 250 mg (Acetazolamide) acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.15 %, 0.2 % (Alphagan P) PA; QL (60 per 30 days) PA; QL (30 per 30 days) ST (drops: 0.15%, 0.20%) 190

205 COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % (Metipranolol) PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) (Travoprost ophthalmic drops % (Benzalkonium)) Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * (Citracal-Vitamin D) (Calcium Citrate) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (2.5 per 25 days) 191

206 calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium vit d 400 caplet s/f, p/f, caplet 600 mg(1,500mg) -400 unit * calcium vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium vit d tablet mg-unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(1,500mg) -400 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated mg-unit * (Caltrate 600 Plus D3) (Calcium Vit D) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) (Calcium Chloride) (Citracal-Vitamin D) 192

207 calcium citrate-vit d3 caplet s/f, p/f mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 100 mg/ml (10%) calcium with vit d tablet mg-unit * CALTRATE D SOFT CHEW TAB VANILLA CREME 600 MG (1,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(1,500MG) -800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(1,500mg) -500 unit * cvs calcium vit d 200 tb 500 mg(1,250mg) -200 unit * cvs calcium vit d tablet oyster shell 500 mg(1,250mg) -125 unit * cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(1,500mg) unit * cvs magnesium 250 mg tablet 250 mg * (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) 193

208 d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 500-vit d3 600 tab 500mg (1,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * (Dextrose 10 % and 0.45 % NaCl) (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 10 % and 0.2 % NaCl) (Dextrose 5%- Lactated Ringers) (Dextrose 5 %-0.2 % NaCl) (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Potassium Chloride/D5-0.2%NaCl) (Klor-Con-Ef) (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) 194

209 hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * hm calcium citrate-vit d cplt caplet, gluten-free mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq KELP 150 MCG TABLET 150 MCG * KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Citracal-Vitamin D) (Klor-Con-Ef) (Potassium Chloride) (Potassium Chloride) 195

210 klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) klor-con sprinkle oral capsule, (Potassium extended release 10 meq, 8 meq Chloride) (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(1,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) (Magnesium magnesium 300 mg capsule 300 mg Oxide/Mag Aa * Chelate) magnesium chloride injection (Magnesium solution 200 mg/ml (20 %) Chloride) magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium sulf in 0.45% nacl intravenous solution 20 gram/500 ml (40 mg/ml) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) 196

211 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Calcium Carbonate) nu-mag 71.5 mg tablet 71.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oysco d tablet mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (1,250 mg) * Carbonate) oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 125 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (1,250 mg) * 197

212 oyster shell calcium tablet 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) oyster shell calcium-vit d tab (Caltrate 600 Plus p/f,s/f,gluten-free 500 mg(1,250mg) D3) -400 unit * oystercal-d 500 mg-400 unit tb 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) pediatric electrolyte solution * (Pedialyte) PHOS-NAK PACKET MG * phospha 250 neutral oral tablet 250 mg (K-Phos Neutral) PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous (Potassium solution 2 meq/ml, 4 meq/ml Acetate) potassium bicarb and chloride oral (Pot Chloride/Pot tablet, effervescent 25 meq Bicarb/Cit Ac) potassium bicarb-citric acid oral tablet, effervescent 25 meq (Klor-Con-Ef) potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l (Potassium Chloride In 0.9%NaCl) 198

213 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con) (Klor-Con 10) (Klor-Con 10) (Potassium Chloride) (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) 199

214 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 10 meq tablet 10 meq potassium cl er 10 meq tablet f/c 10 meq potassium cl er 20 meq tablet 20 meq (Potassium Chloride/D5-0.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con 10) (Potassium Chloride) (Potassium potassium phosphate m-/d-basic Phos,M-Basic-Dintravenous solution 3 mmol/ml Basic) (Ca/D3/Mag ra cal 600-vit d3-min chew tab 600 Ox/Zinc/Cop/Mang mg calcium- 400 unit-40 mg * /Bor) ra hi-cal plus vitamin d tab 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) (Calcium ra oyster shell-vitamin d tab s/f, p/f Carbonate/Vitamin 250 (625)-125 mg-unit * D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution sm calcium 600-vit d3 800 tab 600 mg(1,500mg) -800 unit * (Ringers Solution) (Caltrate 600 Plus D3) 200

215 sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) sodium bicarbonate intravenous (Sodium solution 1 meq/ml (8.4 %) Bicarbonate) sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution 0.45 % 0.45 %) sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) sodium chloride 3 % intravenous (Sodium Chloride parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 167 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg 3 %) (Sodium Chloride 5 %) (Sodium Chloride) (Sodium Lactate) (Sodium Lactate) (Sodium Phos,M- Basic-D-Basic) (K-Phos Neutral) 201

216 v-r calcium d 133 caplet mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION (Caltrate 600 Plus D3) QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) 202

217 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml (Albuterol Sulfate) (Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER) (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) QL (21.2 per 28 days) QL (17.4 per 25 days) QL (25.8 per 28 days) QL (8 per 30 days) 203

218 metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theochron oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg (Metaproterenol Sulfate) (Metaproterenol Sulfate) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) 204

219 theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) QL (2 per 28 days) acetylcysteine solution 100 mg/ml (Acetadote) (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS PA SOLUTION 10 MG/ML cromolyn inhalation solution for (Cromolyn nebulization 20 mg/2 ml Sodium) cromolyn sodium nasal spray 5.2 (Nasalcrom) mg/spray (4 %) * DALIRESP ORAL TABLET 500 QL (30 per 30 days) MCG ESBRIET ORAL CAPSULE 267 PA; QL (270 per 30 MG days) 205

220 KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg (Soma) (Parafon Forte DSC) (Fexmid) (Dantrium) metaxall oral tablet 800 mg (Skelaxin) metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg (Skelaxin) (Robaxin) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 206

221 revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Dantrium) (Zanaflex) tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Nuvigil) (Lunesta) HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) PA QL (30 per 30 days) PA-HRM; QL (30 per 30 days); AGE (Max 64 Years) PA LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) 207

222 zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) 208

223 ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (200 per 365 days) 209

224 a thru z advanced formula tab (Multivitamin/Iron/ gluten-free mg-mcg * Folic Acid) a thru z advanced formula tab new (Multivitamin with formula * Minerals/Lut) a thru z select 50+ formula tb advanced formula mgmcg-mcg (Biocel) * a thru z select men 50+ tablet mcg * (Biocel) a thru z select multivit tab mcg * (Biocel) a thru z select tablet adults 50+,iron-free mg-mcgmcg * (Biocel) a thru z select tablet new (Multivitamin with formulation * Minerals/Lut) a thru z select women's tablet * (Mv,Fe,Min/Lutein ) abc plus tablet mgmcg-mcg * (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet mg-mcg-mcg * (Biocel) adults' daily formula tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) 210

225 b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula #1 tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-100 tablet * (Vitamin B Complex) balanced b-100 tablet 100 mg * (Vit B Complex 100 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b12 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) biosupp liquid * (Multivitamin with Minerals) 211

226 biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) (Multivitcentram-care multivit-min liq 9 mg Minerals/Ferrous iron/15 ml * Gluc) centravites 50 plus tablet * (Multivit with Iron- Minerals) centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults mg-mcg-mcg * century adults 50+ tablet gluten free mg-mcg-mcg * century mature tablet * cerovite liquid 9 mg iron/15 ml * (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) 212

227 certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet mg-mcg * child chew + iron tab chew * (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet mcg * (Biocel) complete multivitamin tab * (Multivit,Th Iron,Other Min) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-100 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-150 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) 213

228 cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs mg-mcg-mcg * (Biocel) cvs spectravite advanced tab (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with cvs spectravite ultra women tb mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vision formula tablet 1,000 unit- 200 mg-60 unit-2 mg * cvs vitamin b-100 complx tb * Iron) (Multivitamin/Iron/ Folic Acid) (Vita-Bee with C) (Vits A,C,E/Lutein/Mine rals) (Vitamin B Complex) 214

229 cvs vitamin c 1,000 mg tb chw 1,000 (Ascorbic Acid) mg * cvs vitamin d3 1,000 unit sfgl softgel (D3-50) 1,000 unit * cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin 3 $0 1,000 mcg/ml * (Vitamin B-12)) d3 dots 2,000 unit tablet p/f 2,000 (Vitamin D3) unit * (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) (Multivitamin with daily vite with iron tablet * Iron) dino-life extra c tab chew * (Multivitamin) (Multivit with Irondino-life iron-zinc tb chew * Minerals) dino-life tablet chewable * (Multivitamin) daily multivitamin-iron tablet 18- daily vit formula + iron tab (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 215

230 eldertonic elixir mg * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 18 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet mcg * (Biocel) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet mg * (Tab A Vite) eql one daily men's tablet * (Multivitamin with Minerals) ergocalciferol 8,000 units/ml 8,000 unit/ml * (Drisdol) essentia tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) 216

231 essential balance tablet * essential daily tablet w/iron & calcium mg * ferocon capsule mg * ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule mg * (Mv,Fe,Min/Lutein ) (Tab A Vite) (Iron Fum/Vit C/B12-If/Fa) 3 $0 (Ferrous Fumarate) (Pic 200) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (106 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (106 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) 217

232 flintstones with iron tab chew 18 mg iron * (Pedi Mv No.79/Ferrous Fumarate) folic acid 1 mg tablet (rx) 1 mg * (Folic Acid) 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp century mature tablet gluten- (Biocel) free mg-mcg-mcg * gnp century tablet gluten-free 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet (Pnv133/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew (Multivitamin) multivit & minerals * hair vitamins * healthy eyes caplet caplet 1,000 unit-200 mg-60 unit-2 mg * hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * hi-b complex tablet * hm complete 50+ tablet mg-mcg-mcg * (Multivitamin with Iron) (Vits A,C,E/Lutein/Mine rals) (Ferrous Fumarate) (Vitamin B Complex) (Biocel) 218

233 hm one daily with iron tablet glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 150 capsule 150 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/15 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * MACUVITE TABLET 5, UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 219

234 milltrium senior multivit tab * (Multivitamin with Minerals/Lut) multi complete-iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-day plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 10 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) multivitamin-mineral liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.17 chewable, d/f, s/f 0.5 mg with Fluoride) multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * 3 $0 nephplex rx tablet mg-mg-mcg-mg * (Vit B Cmplx No3/Fa/C/Biot/Zin c) 3 $0 220

235 nephron fa tablet mg * (Iron Fum/Doss/Fa/Vit Bcomp,C) 3 $0 nephro-vite rx tablet mgmg-mcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 150 capsule 150 mg iron * (Pic 200) ocutabs tablet s/f, w/lutein * (Beta-Carotene(A)- Vits C,E/Mins) oncovite tablet * (Multivitamin,Ther apeutic) one daily complete tablet * (Multivitamin with Minerals) one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) 221

236 one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- 1 mg Ca,No.72/Iron/Fa) poly-iron 150 mg capsule 150 mg iron * (Pic 200) (Pediatric poly-vita drops 1, unitmg-unit/ml * Multivitamin No.20) poly-vita with iron drops 1,500 unit- (Ped Multivit 400 unit-10 mg/ml * #46/Iron Sulfate) poly-vitamin drops 1, unit-mg-unit/ml * (Pediatric Multivitamin No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops 1,500 (Ped Multivit unit-400 unit-10 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) mg * No.130/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg * prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg prenatal vitamin tablet 28 mg iron- 800 mcg * prenatal vitamins tablet phosphorus free 28 mg iron- 800 mcg * prosight tablet 5, unit-mgunit * pub multivitamin 50 plus tab * (Prenatal Vit/Iron Fumarate/Fa) (Pnv with Ca,No.72/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Prenatal) (A/C/E/Zinc/Sod Selenate/Copper) (Multivitamin with Minerals/Lut) (All Rx Prenatal Vitamins Covered) (All Rx Prenatal Vitamins Covered) 222

237 pv b-100 complex * (Vitamin B Complex) pv b-50 complex * (Vitamin B Complex) pv kid's gummy bear tab chew chewable * (Multivitamin) pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) pv kids vitamins+iron tab chew 15 (Ped Multivit mg iron * #17/Iron Fumarate) pv multivital platinum tablet * (Multivitamin with Minerals/Lut) pv multivital platinum tablet w/lutein & lycopene (Biocel) mcg * pv prenatal formula tablet 28 mg (Prenatal Vit iron- 800 mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pyridoxine 100 mg/ml vial 25's 100 mg/ml * qc child complete vit chew tab 18 mg iron * No.131/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Multivitamin,Stres s Formula/Zn) (Pyridoxine HCl) 3 $0 (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab mg * (Tab A Vite) qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) 223

238 qc multi-vite tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab (Tab A Vite) mg * (Vitamin B ra balanced b-100 tablet 0.4 mg * Complex/Folic Acid) (Vitamin B ra b-complex tablet p/f * Complex) (Vitamin B ra b-complex tablet p/f * Complex) (Multivitamin with ra central vite select tab p/f * Minerals/Lut) (Multivit with Ironra central-vite select tab p/f * Minerals) ra central-vite senior tablet (Biocel) 250 mg-mcg-mcg * ra central-vite tablet (Biocel) mg-mcg-mcg * (Multivitamin with ra one daily energy tablet * Minerals) (Multivitamin with ra one daily plus iron tablet * Iron) ra one daily tablet p/f * (Multivitamin) ra therapeutic m multivit tab (Tab A Vite) mg * ra vitamin b-12 1,000 mcg tab (B-12) timed-release 1,000 mcg * ra central-vite tablet mgmcg * ra prenatal tablet 28 mg iron- 800 ra vit b-12 1,000 mcg/ml liq 1,000 (Multivitamin/Iron/ (Prenatal Vit/Iron (Cyanocobalamin mcg * mcg/ml * Folic Acid) Fumarate/Fa) (Vitamin B-12)) 224

239 ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 scooby-doo one a day tablet * (Multivit with Iron- Minerals) senior tabs mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f mcg * (Biocel) sentry senior tablet mgmcg-mcg * (Biocel) sentry tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) sm airshield effervescent tab 5,000- (Vit A,C,E/Dietary unit-mg-unit * Supp No.12) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) (Vits sm antioxidant vitamins tablet 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral (Multivitamin/Iron/ advanced formula mg-mcg * Folic Acid) sm complete senior formula tab * (Multivit with Iron- Minerals) 225

240 sm complete senior formula tab mg-mcg-mcg * sm hair, skin and nails caplet caplet, gluten-free * sm multivitamin w-iron tab * sm natural balanced b-100 tab 100 mg * sm opti-vitamin tablet 1,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet mg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet 1 mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * (Biocel) (Multivitamin with Minerals) (Multivitamin with Iron) (Vit B Complex 100 Cmb #2/Herbs) (Vits A,C,E/Lutein/Mine rals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi M.Vit No.17 with Fluoride) (Vitamin B Complex) (Multivitamin,Stres s Formula/Zn) (Multivitamin,Stres s Formula) 226

241 stress formula with iron tab * (Iron/Mv,Stress Form) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) stress formula with zinc tab * (Multivitamin,Stres s Formula/Zn) (Vit B stress-c with iron tablet 500 mg-400 Comp/C/Fa/Iron/Vi mcg- 18 mg iron * t E) (Mv-Min/Iron sunvite tablet 18 mg iron-400 mcg- Fum/Fa/K/Lyco/Lu 25 mcg * tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * (B Complex with Vitamin C) super b-50 complex capsule * (Vitamin B Complex) super b-50 complex plus tab * (Vitamin B Complex) super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) 227

242 superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 100 mg/ml * (Thiamine HCl) 3 $0 228

243 thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops 1, unit-mgunit/ml * tri-vitamin drops 1, unitmg-unit/ml * ultra b-100 complex tablet * v-c forte capsule 1 mg * vic-forte capsule 1 mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f 1,000 unit-200 mg-60 unit-2 mg * (Pedi Multivit A,C,And D3 No.21) (Pedi Multivit A,C,And D3 No.21) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) (Vits A,C,E/Lutein/Mine rals) 3 $0 3 $0 vit d mg (50,000 unit) 50,000 unit * (Drisdol) 3 $0 VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-200 MG vitalets tablet chewable child, (Multivitamin with orange,s/f * Iron) vitamin a 10,000 units capsule soluble 10,000 unit * (Vitamin A) 229

244 vitamin a 25,000 units capsule softgel 25,000 unit * (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b-12 1,000 mcg tablet 1,000 mcg * (B-12) vitamin b mcg tablet 100 mcg * (B-12) vitamin b mcg tablet 250 mcg * (B-12) vitamin b mcg tablet 500 mcg * (B-12) vitamin b-12 tr 1,000 mcg tab (Cyanocobalamin lactose free 1,000 mcg * (Vitamin B-12)) vitamin b12-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet p/f,no Cmplx C/Rice lactose,cplt mcg-mg * Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) 230

245 vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d 1,000 unit tablet 1,000 unit * (Vitamin D3) vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * (Vitamin D3) vitamin d3 1,000 units softgel softgel, p/f, s/f 1,000 unit * (D3-50) vitamin d3 10,000 unit softgel softgel 10,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 100 mcg tablet p/f, glutenfree 100 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-100 tablet * (Vitamin B Complex) yelets tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) 231

246 zoo chews gummie tablet * (Multivitamin) 232

247 INDEX 3 3 day vaginal pse-150gfn-15dm pse-3brm-15dm day vaginal pse-3brm-30dm MOP A a thru z advanced formula , 210 a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 182 acetylcysteine acid gone antacid acid reducer (famotidine) , 152 acid relief (cimetidine) acitretin acne medication , 132 ACNE MEDICATION acne-clear ACTEMRA ACTHIB (PF) , 176 ACTIMMUNE actinel pediatric acyclovir... 80, 130 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 176 ADAGEN adapalene , 139 ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max adult multivitamin gummies 210 adult nasal decongestant adult one daily gummies adult robitussin lingering cld 118 adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults 50 plus adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVIL af 55 afeditab cr AFINITOR AFINITOR DISPERZ AFTERA , 110 a-hydrocort airshield AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-12 allergy-sinus ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges ALLEGRA ALLERGY aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy (diphenhydramine) allergy relief (cetirizine) allergy relief (clemastine) allerhist aller-tec d allopurinol ALLZITAL... 3 almacone I-1 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

248 almacone aloe vesta antifungal (micon). 54 alophen alosetron ALPHAGAN P alprazolam ALREX altacaine altamist altavera (28) aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate... 25, 26 amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes plus iron antacid anti-gas antacid anti-gas (ca carb-sim) antacid extra-strength antacid plus extra strength anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide).. 154, 155 antifungal (tolnaftate)... 54, 57 antifungal cream anti-gas maximum strength antioxidant antioxidant vitamins apatate forte APOKYN apraclonidine apri APRISO aprodine APTIOM APTIVUS aquanil hc aranelle (28) ARCALYST aripiprazole... 70, 71 ARISTADA armodafinil arthritis pain relief (acetam) artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc) artificial tears(dext70-hypro) 142 artificial tears(glycerin-peg). 143 artificial tears(hypromellose) 145 ASACOL HD ascomp with codeine... 3 ascorbic acid (vitamin c) , 230 ashlyna aspirin aspirin, buffered aspirin-dipyridamole... 84, 85 aspir-low I-2 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

249 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 40, 143 atropine-care ATROVENT HFA AUBAGIO aubra AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 219, 227 b-100 complex b-12 dots b-50 complex bacitracin... 19, 133, 147 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 224 balanced b balanced b balanced b-50 complex balsalazide balziva (28) banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) 176 b-complex b-complex with vitamin c , 213, 225, 230 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE , 140 bekyree (28) BELBUCA... 4 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT... 91, 92 BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 167 betamethasone dipropionate. 135 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 95, 190 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF bp 8 cough BREO ELLIPTA briellyn I-3 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

250 BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm bromfenac bromocriptine brompheniramine-pseudoephdm , 119, 120 budesonide bufferin bumetanide BUPHENYL buprenorphine hcl... 4, 15 buprenorphine-naloxone buproban bupropion hcl bupropion hcl (smoking deter)... 16, 46 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC C c complex cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor , 195, 200 caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol , 183 calcium d calcium d (d3) calcium calcium d(3) calcium 600 with vitamin d3 196 calcium acetate calcium antacid calcium carbonate , 192 calcium carbonate-vitamin d calcium carbonate-vitamin d , 193, 194, 200 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d , 193, 195 calcium gluconate calcium+d CALDOLOR cal-gest antacid calphron CALTRATE D CALTRATE WITH VITAMIN D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 93 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt... 96, 97 carvedilol CASTELLANI PAINT MODIFIED CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 21 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 22 cefpodoxime cefprozil ceftazidime ceftibuten... 22, 23 ceftriaxone ceftriaxone in dextrose,iso-os. 23 cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT INTRAVENOUS CELONTIN centamin centergy dm central vite with lutein I-4 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

251 central-vite central-vite for seniors central-vite select , 224 central-vite senior centram-care centravites 50 plus centrum centrum complete centrum silver century century adults century mature , 216, 218 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula certavite senior-antioxidant certavite-antioxid (iron gluc) 213 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX cheracol d cheratussin dac chest congestion relief + dm 121 chest congestion relief pe chewable multi vitamin child allergy relf(cetirizine) child complete multivitamin 216 child cough and sore throat child mucinex chest congestion child plus cough and runnynose child triaminic cold-allergy child triaminic cough-congest child triaminic cough-sore thr child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 120 CHILDREN'S ADVIL children's allegra allergy children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 213 children's chewable w/minerals CHILDREN'S CLARITIN children's cold-cough daytime children's complete vitamin. 223 children's mapap... 5 children's mucinex cough children's multivit w/extra c. 216 children's non-aspirin... 4, 5 children's pain reliever children's pain-fever relief... 4 children's pepto childrens plus multi-symp cold children's silfedrine children's soothe children's sudafed children's sudafed pe cough. 120 children's tactinal... 5 children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 215, 231 cholestyramine (with sugar). 104 cholestyramine light choline,magnesium salicylate 12 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 28, 147 ciprofloxacin in 5 % dextrose 28 ciprofloxacin lactate citalopram I-5 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

252 citracal + d maximum citrus calcium clarithromycin CLARITIN CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 19 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate... 19, 64, 133 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W 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) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol , 136 clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 91, 108 clopidogrel clorazepate dipotassium clorpres clotrimazole... 54, 55 clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm COLACE colchicine cold and cough (diphenhydr-pe) cold multi-symptom day/night cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 203 COMETRIQ comfort gel comfort gel extra strength COMPLERA complete complete multi complete multivitamin. 213, 216 complete multivitamin-mineral , 225 complete senior , 225, 226 compoz compro COMVAX (PF) CONDYLOX congestac congest-eze constulose COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR cormax cortisone cortizone CORTIZONE COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 131 COTELLIC cough and cold cough and runny nose CREON critic-aid clear af CRIXIVAN cromolyn , 155, 205 cryselle (28) CUBICIN cyanocobalamin (vitamin b-12) , 215, 224, 230 cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine I-6 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

253 cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine , 173 cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin daily gummies daily multiple , 215 daily multi-vitamin daily multivitamin with iron 215 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 215 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough daytime cold-flu day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol. 111 desogestrel-ethinyl estradiol 111 desonide desoximetasone despec-dm (pseudoeph-dmguaif) dex4 glucose dexamethasone dexamethasone sodium phosphate , 168 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextromethorphan polistirex 122 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w)... 88, 89 dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 89 dextrose 5 %-lactated ringers194 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm diamode diazepam... 17, 18 diazepam intensol diclofenac potassium diclofenac sodium... 12, 149 diclofenac-misoprostol dicloxacillin dicyclomine didanosine I-7 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

254 DIFICID diflunisal digitek digox... 98, 99 digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex... 41, 42 dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) 160 DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM E e.c. prin e.e.s e.e.s. granules econazole econtra ez ed a-hist ed bron gp ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide 93 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin enema , 162 enema disposable , 160 enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir entre-cough ENTRESTO enulose ENVARSUS XR EPCLUSA ephedrine sulfate epinastine epinephrine I-8 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

255 epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epitol EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle equalactin ergocalciferol (vitamin d2). 216, 229 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 25, 147 erythromycin ethylsuccinate.. 24 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 217 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 167 estropipate eszopiclone ethambutol ethamolin ethosuximide etodolac ETOPOPHOS etoposide EVOTAZ exemestane EXJADE EXONDYS expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche eye health plus lutein F FABRAZYME fallback solo falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 152 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine feminine care douche FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 104 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 5 fentanyl citrate... 5 ferocon ferretts ferrex ferrex 150 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 219 ferrous sulfate , 217 FETZIMA feverall... 5 fexofenadine fiber (calcium polycarbophil) fiber laxative (methylcellulo)163 fiber smooth fiber therapy (m-cell/sugar) fiber therapy (m-cellulose) fiber therapy (psyllium) fiber therapy (psyllium/sugar) fiber-lax fibertab finasteride FIRAZYR flanax antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA , 203 floxuridine flu formula daytime-nighttime flu relief therapy daytime flu severe cold-congestion flucaine fluconazole fluconazole in dextrose(iso-o) 55 fluconazole in nacl (iso-osm). 55 flucytosine fludrocortisone I-9 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

256 flumazenil flunisolide fluocinonide fluorometholone fluorouracil... 33, 132 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 150 fluvoxamine foaming antacid , 158 folic acid FOLIC ACID fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 18, 134, 147 gentamicin in nacl (iso-osm).. 18 gentamicin sulfate (ped) (pf).. 18 gentamicin sulfate (pf) GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-tussin dm gianvi (28) gildagia gildess 1.5/30 (21) gildess 1/20 (21) gildess 24 fe gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate glydo GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin , 123 guaifenesin dac guanfacine... 91, 108 guanidine gummi bear multivitamin , 223 gummy swirls H hair vitamins hair,skin and nails , 228 halobetasol propionate. 136, 137 haloperidol haloperidol decanoate I-10 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

257 haloperidol lactate HARVONI HAVRIX (PF) , 178 head congestion day-night healthy eyes healthylax heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex.. 82 heparin (porcine) in nacl (pf). 82 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN hi-b complex HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen... 6 hydrocortisone , 168 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate 137, 138 hydromet hydromorphone... 6 hydromorphone (pf)... 6 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 6 I ibandronate IBRANCE ibuprofen... 12, 13, 14 ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infants gas relief infant's ibuprofen INFANT'S MOTRIN infants' non-aspirin cold INLYTA insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A... 79, 80 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide , 203 ipratropium-albuterol I-11 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

258 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA iron high potency ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette jr. acetaminophen juleber junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe junior mapap... 6 JUXTAPID K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) k-effervescent kelnor 1/35 (28) KELP (IODINE) ketoconazole ketoprofen ketorolac... 14, 150 KEVEYIS KEYTRUDA kids mini enema kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad. 113 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine... 42, 43 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) larissia latanoprost LATUDA laxative peg LAZANDA... 6 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine I-12 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

259 levocarnitine (with sugar) levocetirizine levofloxacin... 28, 147 levofloxacin in d5w levoleucovorin levonest (28) levonorgestrel levonorgestrel-ethinyl estrad 114 levonorg-eth estrad triphasic 114 levora levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 15, 94 lidocaine hcl lidocaine in 5 % dextrose (pf) 94 lidocaine viscous lidocaine-prilocaine life-pack women's linezolid LINZESS liothyronine lipodox lipodox liquibid d-r liquid calcium with vitamin d LIQUI-E lisinopril lisinopril-hydrochlorothiazide 93 lithium carbonate lithium citrate little animals little animals-iron LIVALO lobana bath lohist-dm lomedia 24 fe lomustine LONSURF loperamide , 156, 158 loratadine loratadine-d... 61, 62 lorazepam lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex loryna (28) losartan losartan-hydrochlorothiazide. 92 LOTEMAX LOTRONEX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 145 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 145 lubricant eye (propyl glycol) 145 lubricant eye drops lubricant gel lubricating drops lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M maalox advanced MACUVITE MACUVITE EYE CARE mag mag-delay mag-g MAGNEBIND magnebind magnesium , 196 magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide , 158 magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water. 196, 197 malathion mapap (acetaminophen)... 6, 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline mar-cof bp mar-cof cg margesic... 7 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu I-13 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

260 meclizine medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol... 36, 171 MEKINIST meloxicam memantine MENACTRA (PF) M-END DM MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's one daily MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesalamine mesehist dm mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxall metaxalone metformin methadone... 7 methadose... 7 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate , 109 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 20, 64, 134 metronidazole in nacl (iso-os) 20 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 55, 56 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil , 190 MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 morphine concentrate... 7 morphine in dextrose 5 %... 8 morrhuate sodium motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL I-14 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

261 mucus dm mucus dm max mucus relief , 125 mucus relief cough MULTAQ multi complete with iron multi-day with iron multi-delyn with iron multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multivital platinum multivitamin 50 plus multi-vitamin hp/minerals multivitamin with fluoride multivitamin with iron. 220, 226 multivitamin with minerals multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way myco nail a mycophenolate mofetil. 174, 175 mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nafcillin... 26, 27 NAGLAZYME naloxone naltrexone NAMENDA XR... 45, 46 NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN nasal and sinus decongestant 123 nasal decongestant (oxymetazl) NASCOBAL nasohist dm NATACYN nateglinide NATPARA natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy 161 natural tears (pf) nature's tears (hypromellose) 145 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone NEO DM neomycin neomycin-bacitracin-poly-hc 147 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR next choice one dose niacin , 105 niacinamide , 221 niacor nicardipine NICODERM CQ nicorelief nicorette nicotine... 16, 17 nicotine (polacrilex)... 16, 17 NICOTROL nifedical xl nifedipine night time night time cold medicine night time cold-flu night time cold-flu relief night time cough-sore throat 124 nighttime cough nikki (28) NILANDRON nilutamide NINLARO I-15 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

262 NITE TIME COLD-FLU RELIEF NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose 107 NITROSTAT NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength.. 8, 10 non-aspirin flu non-aspirin jr strength... 5 nora-be NORDITROPIN FLEXPRO 170 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH nortemp... 8 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 9 NUCYNTA ER... 8 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING nyamyc nystatin nystatin-triamcinolone nystop nyt-time sleep O OCALIVA ocean nasal ocella OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV ofloxacin... 28, 148 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate , 153 ONCASPAR oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily , 224 one daily 50 plus one daily complete one daily energy one daily essential 216, 218, 221 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 221 one daily plus iron 219, 221, 224 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula221 one-a-day teen advantage , 222 ONFI... 18, 138 opcicon one-step OPDIVO OPSUMIT option opti-vitamins oral saline laxative oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN , 187 ORKAMBI I-16 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

263 orsythia OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 27 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9, 10 oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium-vit d oyster shell calcium-vit d , 198 oystercal-d P pacerone pain relief pain relief adult... 5 pain reliever jr strength paliperidone pancrelipase PANRETIN PANTILINERS pantoprazole papaverine paricalcitol PARICALCITOL paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx pedia relief pedia relief cough-cold pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte , 198, 200, 201 pediatric freezer pops pediatric multivitamin.. 220, 225 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 140 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline persa-gel pfizerpen-g pharbetol pharmacist favorite multi-vit 222 phenadoz phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 91, 145 phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended philith phillips phillips liqui-gels PHOSLYRA PHOS-NAK phospha 250 neutral phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k1) PICATO pilocarpine hcl , 191 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLAN B ONE-STEP PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podocon podofilox polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-tussin poly-vita poly-vita (iron) poly-vitamin I-17 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

264 poly-vitamin with iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 198 potassium chlorid-d5-0.45%nacl potassium chloride , 200 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 potassium citrate-citric acid. 200 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 168 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 222, 226 prenatal formula prenatal plus (calcium carb). 222 prenatal tablet prenatal vit#96-ferrous fum-fa prenatal vitamin , 222 prenatal vitamin plus low iron prenatal vitamin with minerals prenatal vit-iron fumarate-fa 222 preparation h hydrocortisone 138 PREVAIL BLADDER CONTROL PAD prevalite PREVIDENT 5000 SENSITIVE previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 62, 67 promethazine vc-codeine promethazine-codeine promethazine-dm promethegan promolaxin propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl , 125 PULMOZYME pure and gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q q-dryl I-18 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

265 q-pap q-pap extra strength q-tapp dm q-tussin q-tussin dm QUADRACEL (PF) quasense quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 94 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE RASUVO (PF) RAVICTI react REBIF (WITH ALBUMIN) 188 REBIF REBIDOSE REBIF TITRATION PACK 189 reclipsen (28) RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 57 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX 105 REPATHA SURECLICK REPATHA SYRINGE reprexain RESCRIPTOR RESTASIS retaine cmc RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA ribasphere RIDAURA rifabutin rifampin RIFATER ri-gel ii riluzole rimantadine ri-mox ringers , 200 risedronate , 184 RISPERDAL CONSTA risperidone... 73, 74 RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA roxicet ROZEREM rydex rynex dm S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline mist SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs senna , 163 senna lax senna laxative senna with docusate sodium. 160 senokot-s I-19 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

266 SENSIPAR sentry sentry senior SEREVENT DISKUS SEROSTIM sertraline setlakin sharobel SIGNIFOR silace siladryl sa silapap sildenafil SILENOR siltussin sa silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin , 106 sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 62 sleep aid (doxylamine) smoflipid smoothlax sodium acetate sodium bicarbonate , 201 sodium chloride , 182, 201, 206 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate sodium thiosulfate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe regular strength sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spectravite spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd st joseph aspirin st. joseph aspirin stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula plus iron stress formula with iron stress formula with zinc STRIBILD STRIVERDI RESPIMAT sucralfate sudafed sudogest , 128 sudogest sinus and allergy sulfacetamide sodium , 149 sulfacetamide sodium (acne) 134 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine... 28, 29 sulfatrim sulindac sumatriptan sumatriptan succinate... 64, 65 summer's eve disposable douche summers eve extra cleansing 189 sunvite super b complex-vitamin c.. 214, 226, 227 super b maxi complex super b/c super b-50 complex I-20 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

267 super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYPRINE SYSTANE (PROPYLENE GLYCOL) SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 175 tactinal tactinal extra strength TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ SYRINGE TAMIFLU... 78, 79 tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) TECENTRIQ TECFIDERA , 190 TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td 180 tetrabenazine tetracaine hcl (pf) tetracycline THALOMID the magic bullet theochron theophylline theophylline in dextrose 5 % 205 thera m plus (ferrous fumarat) thera vitamin thera-d theradex m THERAFLU DAYTIME COLD-COUGH THERAFLU MULTI- SYMPTOM COLD thera-m therapeutic liquid therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals thera-tabs theratrum complete 50 plus theratrum complete 50 plus/lut thiamine hcl (vitamin b1) , 229 thioridazine thiotepa thiothixene tiagabine TICE BCG tilia fe timolol maleate... 96, 191 TIVICAY tizanidine TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl I-21 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

268 tobramycin sulfate tobramycin-dexamethasone. 149 TOLAK tolazamide tolbutamide tolmetin... 14, 15 tolnaftate tolterodine topiragen topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA... 38, 39 TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting m-sym cold/cough. 129 triamcinolone acetonide , 138, 169 triaminic cold and cough (pe) TRIAMINIC COLD AND COUGHNT(PE) TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid trianex TRIBENZOR tri-buffered aspirin tri-dex pe tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRINTELLIX triple antibiotic , 134 triple paste af tri-previfem (28) tri-sprintec (28) TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28) TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL NEW FORMULA 128 TUSNEL PEDIATRIC TUSSI PRES-B tussin cf , 129 tussin cf cough-cold tussin cold-congestion tussin cough (dm only) tussin dm , 128 tussin dm cough and chest tussin maximum strength tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI , 181 TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U u-cort ULORIC ultra b-100 complex ultra fresh pm ultra strength antacid unisom sleepgels UNITUXIN UPTRAVI ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 45 I-22 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

269 valsartan valsartan-hydrochlorothiazide 92 VALSTAR valu-tapp dm VANACOF vancomycin vancomycin in dextrose 5 %.. 21 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28) VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil... 97, 98 VERSACLOZ vestura (28) VGO VIBERZI vic-forte vicks dayquil cold-flu relief. 129 vicks dayquil cough vicks nature fusion cough vicks nyquil severe cold-flu. 129 vicks qlearquil(oxymetazoline) vicks sinex 12-hour vicodin vicodin es vicodin hp VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva VIGAMOX VIIBRYD... 49, 50 VIMIZIM VIMPAT vinorelbine viorele (28) VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD virt-phos 250 neutral virtussin ac vision vision formula (with lutein) 214, 229 vision plus lutein vit b complex-folic acid VITAFOL FE+ (WITH DOCUSATE) vitalets vitamin a , 230 vitamin b complex , 224 vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 230, 231 vitamin d , 231 vitamins and minerals vitamins b complex , 230 vitamins for hair VITEKTA vitrum senior VOLTAREN voriconazole VOTRIENT VPRIV VRAYLAR vyfemla (28) W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 12 hour wal-phed... 63, 129 wal-phed pe day-night wal-phed pe sinus and allergy 63 wal-profen wal-sleep z wal-som (diphenhydramine).. 63 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin cough and cold cf 129 wal-tussin dm wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile WELCHOL wera (28) womens daily gummies women's daily multivitamin. 224 X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN XIIDRA XOLAIR XTANDI xulane xylon XYREM Y yelets I-23 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

270 YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon ZANTAC ZANTAC zarah ZARXIO ZAVESCA zebutal ZELBORAF ZEMPLAR zenatane zenchent (28) ZENPEP ZEPATIER zephrex-d ZETIA ZIAGEN zidovudine ZINBRYTA zinc oxide ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZOVIRAX z-sleep... 61, 62 ZUBSOLV ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA ZYVOX I-24 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID: Version: 19 Effective: November 01, 2016

271 This formulary was updated on 10/01/2016. For more recent information or other questions, please contact VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit Formulary ID: , Version 19