Comprehensive Formulary

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1 Comprehensive Formulary 2016 List of covered drugs Updated December 1, 2016 Live Healthy! Choose HEALTH CHOICE HealthChoiceEssential.com

2 2016 Comprehensive Formulary Introduction Health Choice Insurance Co. utilizes a Pharmacy and Therapeutics Committee (P & T Committee), made up of practicing physicians, pharmacists, and nurses to help ensure that our formulary drug list is medically sound and that it supports patient health. This committee reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapy categories. Prescription medicines covered by Health Choice Insurance Co. must be prescribed for you by your doctor and must be FDA approved products. Formulary Drug List The Health Choice Insurance Co formulary is closed. This means that if the drug is not on the formulary (List of Covered Drugs) it will not be covered unless your doctor explains why no other drugs on the formulary will work for your medical condition. The formulary is very comprehensive and has many brand and generic drugs that treat many medical conditions. The drugs are placed in tiers that determine your medication cost. Drugs in higher tiers usually have higher costs. : Generic drugs : Preferred brand drugs : Non preferred drugs Tier 4: Specialty drugs Tier 5: Oral Cancer Specialty Drugs : Zero cost share, Preventive Health Drugs Within each drug category and class, drugs are listed in alphabetical order by drug product name. Drugs in lower case italics are generic drugs products (e.g. glipizide), and drugs listed in upper case letters (e.g. JANUVIA) are brand drug products. Brand drug products are listed as either preferred brand name products (), nonpreferred brand products (), specialty drugs (Tier 4), and oral cancer specialty drugs, generic and brand drug (Tier 5). Preventive Health medications for men, women and children which are located in are covered as a requirement of The Affordable Care Act of These medications are covered at no cost, without a copayment or having to meet the plan deductible when specific criteria are met. I

3 For prescriptions medicines for which a generic product exists, the generic product will be on the formulary and the brand name product will not be on the formulary. To avoid additional costs members should ask their doctor to prescribe available generic equivalent medications. Most drugs on the formulary will have a copayment or co insurance. Copayment or co insurance is a portion of the cost of a covered formulary drug that a member must pay. For information about prescription drug copayments please see your Health Choice Insurance Schedule of Benefits document. Common Prescription Drug Terms Generic Drug Drugs marketed without brand names are generally less expensive than brand name drugs. They are chemically identical to brandname drugs and meet the same standards of the FDA (US Food and Drug Administration) for safety, purity and effectiveness. Preferred Brand Drug Drugs on the formulary that have a trade name and are protected by a patent. These drugs meet the standards of the FDA for safety, purity and effectiveness. These brand drugs are preferred over other brand drugs because of better efficacy or lower cost. These drugs are used when there is not a generic drug available to treat your medical condition. Non Preferred Brand Drug Drugs on the formulary that have a trade name and are protected by a patent. These drugs meet the standards of the FDA for safety, purity and effectiveness. The drugs are commonly used when a preferred brand or generic drug is not available to treat your medical condition. The cost of these drugs is usually higher than generic or preferred brand drugs that can be used to treat your condition. Specialty Drug Drugs that are unique and/or very high cost drugs used to treat rare and/or complex medical conditions. Oral Cancer drugs are specialty drugs. Preventive Health Medication Drugs that are covered per the Affordable Care Act. The Affordable Care Act of 2010 requires the coverage of certain preventive medications for men, women and children. These medications are included on the formulary and are covered at no cost, without a copayment or having to meet the plan deductible when specific criteria are met. These preventive medications include products like aspirin, folic acid, iron and fluoride supplements, certain contraceptives, and vaccines. ii

4 Medication Management Some of the formulary drugs are subject to medication management restrictions. These restrictions promote the safe and effective use of medicines. Restrictions include age (AL), gender (GL) and/or quantity (QL) limits, step therapy (ST) and prior authorization (PA). Medication management restrictions are subject to change as medical evidence requires. Our formulary notes if a drug needs PA, ST, QL, GL, or AL. Common medication management restrictions are noted below. Prior Authorization: This requires you or your doctor to get approval before you fill your prescription. If you don t get approval, Health Choice may not cover the drug. Prior authorization criteria are based on nationally recognized guidelines; FDA approved indications and accepted standards of practice. Prior Authorization is common for specialty medications. Step Therapy: This requires that you must first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your condition, Health Choice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Quantity Limits: This limits the amount of the drug covered per 30 day fill. For detailed information on drugs that require prior authorization, step therapy, or have a quantity limit please visit our website, Specialty Medication Management Certain medications used for treating complex health conditions are handled through our Specialty Pharmacy, Orchard Specialty. The purpose of the Specialty Pharmacy is to assist you with monitoring your medication needs for conditions such as Multiple Sclerosis, Rheumatoid Arthritis, Cancer, Hepatitis, Psoriasis and transplant, and providing patient education. The program assists members with the use of drugs requiring complex administration methods, special storage, and handling as well as requiring close patient monitoring to make sure the drug works properly for the member. Medications may only be obtained through Orchard Specialty pharmacy and are only dispensed in 30 day supplies. A specialty pharmacy representative may contact you to facilitate your enrollment in the specialty program. Trained specialty pharmacy staff is available 24 hours a day, 7 days a week to assist you. iii

5 Health Choice Insurance Company 2016 Formulary Table of Contents Analgesics (Pain, Inflammation, Muscle, Joint Condition Drugs)... 3 Anesthetics (Numbing Drugs)... 5 Anti-Addiction/Substance Abuse Treatment Agents... 5 Antibacterials (Infection Fighting Drugs)... 6 Anticonvulsants (Nerve Condition Drugs) Antidementia Agents (Nerve Condition Drugs) Antidepressants Antidepressants (Nerve Condition Drugs) Antiemetics (Bowel, Instestine, And Stomach Condition Drugs) Antifungals (Infection Fighting Drugs) Antigout Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) Anti-Inflammatory Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) Antimigraine Agents (Nerve Condition Drugs) Antimyasthenic Agents (Nerve Condition Drugs) Antimycobacterials (Infection Fighting Drugs) Antineoplastics (Cancer Drugs) Antiparasitics (Infection Fighting Drugs) Antiparkinson Agents (Nerve Condition Drugs) Antipsychotics (Nerve Condition Drugs) Antispasticity Agents (Muscle And Joint Drugs) Antivirals (Infection Fighting Drugs) Anxiolytics (Nerve Condition Drugs) Bipolar Agents (Nerve Condition Drugs) Blood Glucose Regulators (Hormone And Diabetic Drugs) Blood Products/Modifiers/ Volume Expanders (Blood Disorder Drugs) Cardiovascular Agents (Heart And Circulation Condition Drugs) Central Nervous System Agents (Nerve Condition Drugs) Contraceptives Cough/Cold/Allergy Dental And Oral Agents Dental And Oral Agents (Drugs For The Mouth) Dermatological Agents (Drugs Affecting Skin) Enzyme Replacement/ Modifiers (Hormone And Enzyme Drugs) Gastrointestinal Agents (Bowel, Instestine, And Stomach Condition Drugs) Genitourinary Agents (Bladder, Genital, And Kidney Condition Drugs) Hematopoietic Agents Hereditary Orotic Aciduria Treatment Agents Hormonal Agents Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) (Hormone And Diabetic Drugs) Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) (Hormone And Diabetic Drugs) Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) (Hormone And Diabetic Drugs) Hormonal Agents, Stimulant/Replacement/Modifying (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) (Hormone And Diabetic Drugs) Hormonal Agents, Suppressant (Pituitary) (Hormone And Diabetic Drugs)

6 Hormonal Agents, Suppressant (Thyroid) (Hormone And Diabetic Drugs) Immunological Agents (Drugs Affecting The Immune System) Inflammatory Bowel Disease Agents (Bowel, Instestine, And Stomach Condition Drugs) Metabolic Bone Disease Agents (Hormone And Bone Drugs) Miscellaneous (Misc) Ophthalmic Agents (Eye Medications) Otic Agents (Ear Drugs) Respiratory Tract Agents (Allergies, Cough, Cold, And Lung Condition Drugs) Respiratory Tract/Pulmonary Agents Respiratory Tract/Pulmonary Agents (Allergies, Cough, Cold, And Lung Condition Drugs) Skeletal Muscle Relaxants (Muscle And Joint Drugs) Sleep Disorder Agents (Sleep Condition Drugs) Therapeutic Nutrients/ Minerals/ Electrolytes (Multivitamins And Replacement Solutions)

7 Health Choice Insurance Company 2016 Formulary Drug Name Tier Status Requirements/Limits Analgesics (Pain, Inflammation, Muscle, Joint Condition Drugs) Analgesic Combinations butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet mg butalbital-asa-caffeine oral capsule Opioid Analgesics, Long-Acting (Narcotic Pain Relievers) fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr methadone hcl injection solution methadone hcl oral concentrate methadone hcl oral solution methadone hcl oral tablet methadone hcl oral tablet soluble morphine sulfate er beads oral capsule extended release 24 hour morphine sulfate er oral capsule extended release 24 hour morphine sulfate er oral tablet extendedrelease* morphine sulfate suppository 30 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR* OPANA ER ORAL 10 MG, 20 MG, 30 MG, 40 MG, 5 MG ST; QL (10 EA per 30 days) OPANA ER ORAL 15 MG, 7.5 MG QL (60 EA per 30 days) oxymorphone hcl er oral tablet extended release 12 hr* 10 mg, 20 mg, 30 mg, 5 mg QL (60 EA per 30 days) 3

8 oxymorphone hcl er oral tablet extended release 12 hr* 15 mg, 7.5 mg oxymorphone hcl er oral tablet extended release 12 hr* 40 mg oxymorphone hcl oral tablet 5 mg Opioid Analgesics, Short-Acting (Narcotic Pain Relievers) QL (120 EA per 30 days) acetaminophen-codeine #3 oral tablet QL (390 EA per 30 days) acetaminophen-codeine #4 oral tablet QL (390 EA per 30 days) acetaminophen-codeine oral solution QL (980 ML per 30 days) acetaminophen-codeine oral tablet mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule FENTORA BUCCAL TABLET 200 MCG, 400 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet hydromorphone hcl oral tablet hydromorphone hcl pf injection solution 500 mg/50ml isometheptene-caffeine-apap oral tablet mg isometheptene-dichloral-apap oral capsule morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine sulfate oral solution morphine sulfate oral tablet nalbuphine hcl injection solution NUCYNTA ORAL TABLET oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml 4 QL (390 EA per 30 days) QL (360 EA per 30 days) PA; QL (120 EA per 30 days) QL (400 ML per 30 days) QL (360 EA per 30 days)

9 oxycodone hcl oral solution oxycodone hcl oral tablet oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet mg oxycodone-ibuprofen oral tablet oxymorphone hcl oral tablet 10 mg pentazocine-naloxone hcl oral tablet REPREXAIN ORAL TABLET MG tramadol hcl er (biphasic) oral tablet extended release 24 hr* tramadol hcl er oral tablet extended release 24 hr* tramadol hcl oral tablet tramadol-acetaminophen oral tablet Opioid Antagonists BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR Salicylate Combinations choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate oral liquid Anesthetics (Numbing Drugs) Local Anesthetics - Parenteral lidocaine hcl (pf) injection solution 0.5 %, 1 % lidocaine hcl injection solution 0.5 %, 1 % Local Anesthetics (Local Numbing Drugs) lidocaine viscous mouth/throat solution Topical Anesthetic Combinations lidocaine-prilocaine external cream lidocaine-prilocaine external kit Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving disulfiram oral tablet naltrexone hcl oral tablet QL (360 EA per 30 days) 5

10 Opioid Antagonists buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG QL (240 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG Opioid Reversal Agents naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml Smoking Cessation Agents bupropion hcl er (smoking det) oral tablet extended release 12 hr* CHANTIX CONTINUING MONTH PAK ORAL TABLET CHANTIX ORAL TABLET CHANTIX STARTING MONTH PAK ORAL TABLET nicotine mini mouth/throat lozenge OTC nicotine polacrilex mouth/throat gum OTC nicotine polacrilex mouth/throat lozenge OTC nicotine transdermal patch 24 hr OTC Antibacterials (Infection Fighting Drugs) Aminoglycosides (Bacterial Infection Drugs (Antibiotics) amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml gentamicin sulfate injection solution neomycin sulfate oral tablet paromomycin sulfate oral capsule streptomycin sulfate intramuscular* solution reconstituted QL (90 EA per 30 days) tobramycin inhalation nebulization solution QL (280 ML per 30 days) 6

11 tobramycin sulfate injection solution 1.2 gm/30ml, 2 gm/50ml, 80 mg/2ml tobramycin sulfate injection solution 10 mg/ml tobramycin sulfate injection solution reconstituted Antibacterial (Injections) aztreonam injection solution reconstituted bacitracin intramuscular* solution reconstituted chloramphenicol sod succinate intravenous* solution reconstituted clindamycin palmitate hcl oral solution reconstituted clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml, 9000 mg/60ml colistimethate sodium injection solution reconstituted Tier 4 lincomycin hcl injection solution linezolid intravenous* solution 600 mg/300ml meropenem intravenous* solution reconstituted metronidazole in nacl intravenous* solution mg/100ml-% vancomycin hcl intravenous* solution reconstituted Antibacterials, Other clindamycin hcl oral capsule linezolid oral suspension reconstituted linezolid oral tablet methenamine hippurate oral tablet methenamine mandelate oral tablet 1 gm metronidazole oral capsule metronidazole oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd macro oral capsule tinidazole oral tablet 7 QL (10 ML per 5 days) QL (240 ML per 365 days) QL (10 EA per 5 days)

12 trimethoprim oral tablet vancomycin hcl oral capsule XIFAXAN ORAL TABLET 550 MG Anti-Infective, Other CAYSTON INHALATION SOLUTION INVANZ INJECTION SOLUTION Cephalosporin (Injection) cefazolin sodium injection solution reconstituted Tier 4 cefepime hcl injection solution reconstituted cefoxitin sodium injection solution reconstituted cefoxitin sodium intravenous* solution reconstituted cefpodoxime proxetil oral tablet 200 mg ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium intravenous* solution reconstituted 1.5 gm Cephalosporin Antibiotics cefaclor er oral tablet extended release 12 hr* cefaclor oral capsule cefadroxil oral capsule cefadroxil oral suspension reconstituted cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension reconstituted cefditoren pivoxil oral tablet cefixime oral suspension reconstituted 200 mg/5ml cefpodoxime proxetil oral suspension reconstituted 8

13 cefpodoxime proxetil oral tablet 100 mg cefprozil oral suspension reconstituted cefprozil oral tablet cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension reconstituted cephalexin oral tablet SUPRAX ORAL CAPSULE Cephalosporin Combinations (Injection) AVYCAZ INTRAVENOUS* SOLUTION Macrolides azithromycin oral packet azithromycin oral suspension reconstituted azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin er oral tablet extended release 24 hr* clarithromycin oral suspension reconstituted clarithromycin oral tablet DIFICID ORAL TABLET Tier 4 ST ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin ethylsuccinate oral tablet KETEK ORAL TABLET Macrolides (Injection) azithromycin intravenous* solution reconstituted 500 mg ERYTHROCIN LACTOBIONATE INTRAVENOUS* SOLUTION 500 MG Penicillin Combination Antibiotics amoxicillin-pot clavulanate er oral tablet extended release 12 hr* amoxicillin-pot clavulanate oral suspension reconstituted amoxicillin-pot clavulanate oral tablet 9

14 amoxicillin-pot clavulanate oral tablet chewable Penicillin Combinations (Injection) ampicillin-sulbactam sodium injection solution reconstituted 15 (10-5) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm piperacillin sod-tazobactam so intravenous* solution reconstituted Penicillins amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule ampicillin oral suspension reconstituted dicloxacillin sodium oral capsule penicillin v potassium oral tablet Penicillins (Injection) ampicillin sodium injection solution reconstituted ampicillin sodium intravenous* solution reconstituted 2 gm nafcillin sodium injection solution reconstituted oxacillin sodium injection solution reconstituted 1 gm, 2 gm penicillin g potassium injection solution reconstituted penicillin g sodium injection solution reconstituted penicillin v potassium oral solution reconstituted Quinolones ciprofloxacin hcl oral tablet ciprofloxacin oral suspension reconstituted ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* levofloxacin oral solution 10

15 levofloxacin oral tablet ofloxacin oral tablet Quinolones (Injection) ciprofloxacin intravenous* solution 200 mg/20ml, 400 mg/40ml levofloxacin intravenous* solution Sulfonamides sulfadiazine oral tablet QL (30 EA per 30 days) sulfamethoxazole-trimethoprim intravenous* solution sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet Tetracyclines demeclocycline hcl oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension reconstituted doxycycline monohydrate oral tablet minocycline hcl er oral tablet extended release 24 hr* minocycline hcl oral capsule minocycline hcl oral tablet tetracycline hcl oral capsule 250 mg Tetracyclines (Injection) DOXY 100 INTRAVENOUS* SOLUTION Anticonvulsants (Nerve Condition Drugs) Anticonvulsants Other (Seizure Control Drugs) levetiracetam er oral tablet extended release 24 hr* levetiracetam intravenous* solution 11

16 levetiracetam oral solution levetiracetam oral tablet POTIGA ORAL TABLET tiagabine hcl oral tablet Barbiturates (Seizure Control Drugs) BUTISOL SODIUM ORAL TABLET 30 MG phenobarbital oral solution phenobarbital oral tablet Benzodiazepines (Seizure Control Drugs) clonazepam oral tablet clonazepam oral tablet dispersible DIASTAT PEDIATRIC GEL PA diazepam gel 10 mg, 20 mg PA ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG Calcium Channel Modifying Agents (Seizure Control Drugs) CELONTIN ORAL CAPSULE ethosuximide oral capsule ethosuximide oral solution zonisamide oral capsule Gamma-Aminobutyric Acid (Gaba) Augmenting Agents (Seizure Control Drugs) divalproex sodium er oral tablet extended release 24 hr* divalproex sodium oral divalproex sodium oral tablet delayed release FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule gabapentin oral solution 250 mg/5ml gabapentin oral tablet GABITRIL ORAL TABLET 12 MG, 16 MG primidone oral tablet 12

17 SABRIL ORAL PACKET Tier 4 SABRIL ORAL TABLET Tier 4 valproate sodium intravenous* solution 100 mg/ml valproic acid oral capsule valproic acid oral syrup Glutamate Reducing Agents (Seizure Control Drugs) felbamate oral suspension felbamate oral tablet lamotrigine er oral tablet extended release 24 hr* lamotrigine oral tablet lamotrigine oral tablet chewable topiramate oral capsule sprinkle topiramate oral tablet TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR Sodium Channel Agents (Seizure Control Drugs) BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hr* carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet chewable fosphenytoin sodium injection solution oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* PEGANONE ORAL TABLET phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable phenytoin sodium extended oral capsule 13

18 phenytoin sodium injection solution VIMPAT INTRAVENOUS* SOLUTION VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET Antidementia Agents (Nerve Condition Drugs) Antidementia Agents, Other (Alzeimer's And Dementia Drugs) ergoloid mesylates oral tablet Cholinesterase Inhibitors (Alzeimer's And Dementia Drugs) donepezil hcl oral tablet donepezil hcl oral tablet dispersible galantamine hydrobromide er oral capsule extended release 24 hour galantamine hydrobromide oral solution galantamine hydrobromide oral tablet rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hr N-Methyl-D-Aspartate (Nmda) Receptor Antagonist (Alzeimer's And Dementia Drugs) NAMENDA ORAL SOLUTION NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR Antidepressants Antidepressants, Other nefazodone hcl oral tablet trazodone hcl oral tablet VIIBRYD ORAL TABLET VIIBRYD STARTER PACK ORAL KIT Antidepressants (Nerve Condition Drugs) APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 174 MG, 348 MG 14

19 BUDEPRION SR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG bupropion hcl er (sr) oral tablet extended release 12 hr* bupropion hcl er (xl) oral tablet extended release 24 hr* bupropion hcl oral tablet FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR* maprotiline hcl oral tablet mirtazapine oral tablet mirtazapine oral tablet dispersible TRINTELLIX ORAL TABLET ST Monoamine Oxidase Inhibitor Antidepressants EMSAM TRANSDERMAL PATCH 24 HR MARPLAN ORAL TABLET phenelzine sulfate oral tablet tranylcypromine sulfate oral tablet Selective Serotonin Reuptake Inhibitors (Ssris) citalopram hydrobromide oral solution citalopram hydrobromide oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet fluoxetine hcl oral capsule fluoxetine hcl oral capsule delayed release fluoxetine hcl oral solution fluoxetine hcl oral tablet 10 mg, 20 mg fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er oral capsule extended release 24 hour fluvoxamine maleate oral tablet paroxetine hcl er oral tablet extended release 24 hr* paroxetine hcl oral tablet PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET 15

20 sertraline hcl oral concentrate sertraline hcl oral tablet Serotonin/Norepinephrine Reuptake Inhibitors (Depression Drugs) BRISDELLE ORAL CAPSULE fluoxetine hcl (pmdd) oral capsule olanzapine-fluoxetine hcl oral capsule TRINTELLIX ORAL TABLET ST Serotonin/Norepinephrine Reuptake Inhibitors (Snris) desvenlafaxine er oral tablet extended release 24 hr* desvenlafaxine fumarate er oral tablet extended release 24 hr* duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR FETZIMA TITRATION ORAL KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HR* PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hr* venlafaxine hcl oral tablet Tricyclic Antidepressants amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl oral capsule desipramine hcl oral tablet doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet imipramine pamoate oral capsule nortriptyline hcl oral capsule nortriptyline hcl oral solution 16

21 protriptyline hcl oral tablet trimipramine maleate oral capsule Tricyclics (Depression Drugs) chlordiazepoxide-amitriptyline oral tablet Antiemetics (Bowel, Instestine, And Stomach Condition Drugs) Antiemetics Other (Nausea And Vomiting Drugs) meclizine hcl oral tablet OTC promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl suppository 12.5 mg, 25 mg trimethobenzamide hcl oral capsule Emetogenic Therapy Adjuncts (Nausea And Vomiting Drugs) dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG EMEND ORAL CAPSULE 80 & 125 MG Tier 4 granisetron hcl intravenous* solution granisetron hcl oral tablet QL (30 EA per 30 days) ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml Tier 4 QL (50 ML per 30 days) ondansetron hcl oral solution QL (50 ML per 30 days) ondansetron hcl oral tablet QL (30 EA per 30 days) ondansetron oral tablet dispersible QL (30 EA per 30 days) SANCUSO TRANSDERMAL PATCH VARUBI ORAL TABLET Antifungals (Infection Fighting Drugs) Antifungals (Fungus Infection Drugs) ABELCET INTRAVENOUS* SUSPENSION QL (60 ML per 30 days) amphotericin b injection solution reconstituted QL (60 EA per 30 days) 17

22 CANCIDAS INTRAVENOUS* SOLUTION 50 MG CANCIDAS INTRAVENOUS* SOLUTION 70 MG clotrimazole mouth/throat troche CRESEMBA INTRAVENOUS* SOLUTION CRESEMBA ORAL CAPSULE ERAXIS INTRAVENOUS* SOLUTION fluconazole in dextrose intravenous* solution fluconazole in sodium chloride intravenous* solution fluconazole oral suspension reconstituted 10 mg/ml fluconazole oral suspension reconstituted 40 mg/ml QL (21 EA per 30 days) QL (50 EA per 30 days) QL (150 ML per 30 days) QL (60 ML per 30 days) fluconazole oral tablet 100 mg QL (22 EA per 30 days) fluconazole oral tablet 150 mg, 200 mg QL (24 EA per 30 days) fluconazole oral tablet 50 mg QL (60 EA per 30 days) flucytosine oral capsule 250 mg QL (60 EA per 30 days) flucytosine oral capsule 500 mg QL (15 EA per 30 days) griseofulvin microsize oral suspension QL (150 ML per 30 days) griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule QL (240 EA per 365 days) ketoconazole oral tablet QL (60 EA per 30 days) MYCAMINE INTRAVENOUS* SOLUTION 100 MG MYCAMINE INTRAVENOUS* SOLUTION 50 MG QL (30 EA per 30 days) QL (50 EA per 30 days) NOXAFIL ORAL SUSPENSION QL (21 ML per 30 days) NOXAFIL ORAL TABLET DELAYED RELEASE nystatin mouth/throat suspension nystatin oral powder QL (21 EA per 30 days) nystatin oral tablet QL (60 EA per 30 days) terbinafine hcl oral tablet voriconazole oral suspension reconstituted Tier 4 QL (21 ML per 30 days) 18

23 voriconazole oral tablet 200 mg Tier 4 QL (21 EA per 30 days) voriconazole oral tablet 50 mg Antigout Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) Antigout Agents (Gout Drugs) allopurinol oral tablet COLCRYS ORAL TABLET probenecid oral tablet ULORIC ORAL TABLET ST Anti-Inflammatory Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) Nonsteroidal Anti-Inflammatory Drugs (Pain, Anti-Inflammatory Drugs) celecoxib oral capsule diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hr* diclofenac sodium oral tablet delayed release diclofenac-misoprostol oral tablet delayed release etodolac er oral tablet extended release 24 hr* etodolac oral capsule etodolac oral tablet fenoprofen calcium oral tablet flurbiprofen oral tablet ibuprofen childrens oral suspension OTC ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release* indomethacin oral capsule ketoprofen er oral capsule extended release 24 hour ketoprofen oral capsule ketorolac tromethamine injection solution 19

24 ketorolac tromethamine intramuscular* solution 60 mg/2ml ketorolac tromethamine oral tablet QL (20 EA per 5 days) meclofenamate sodium oral capsule mefenamic acid oral capsule meloxicam oral tablet nabumetone oral tablet naproxen dr oral tablet delayed release naproxen oral suspension naproxen oral tablet naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet 600 mg Salicylates adult aspirin low strength oral tablet dispersible aspirin adult low dose oral tablet delayed release OTC OTC aspirin ec oral tablet delayed release 325 mg OTC aspirin low dose oral tablet chewable OTC aspirin oral tablet 325 mg OTC BAYER ASPIRIN EXTRA STRENGTH ORAL TABLET diflunisal oral tablet OTC tri-buffered aspirin oral tablet 325 mg OTC Antimigraine Agents (Nerve Condition Drugs) Ergot Alkaloids (Migraine Drugs) dihydroergotamine mesylate injection solution ERGOMAR SUBLINGUAL TABLET SUBLINGUAL XELJANZ ORAL TABLET Tier 4 ST 20

25 Serotonin (5-Ht) 1B/1D Receptor Agonists (Migraine Drugs) naratriptan hcl oral tablet RELPAX ORAL TABLET QL (9 EA per 30 days) rizatriptan benzoate oral tablet rizatriptan benzoate oral tablet dispersible sumatriptan nasal solution sumatriptan succinate oral tablet QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* 6 mg/0.5ml sumatriptan succinate subcutaneous* 6 mg/0.5ml sumatriptan succinate subcutaneous* solution 6 mg/0.5ml zolmitriptan oral tablet zolmitriptan oral tablet dispersible 2.5 mg Antimyasthenic Agents (Nerve Condition Drugs) Parasympathomimetics (Miscellaneous Nerve Condition Drugs) guanidine hcl oral tablet MESTINON ORAL SYRUP pyridostigmine bromide oral tablet Antimycobacterials (Infection Fighting Drugs) Antimycobacterials Other (Miscellaneous Infection Fighting Drugs) dapsone oral tablet QL (3 ML per 30 days) QL (3 ML per 30 days) QL (3 ML per 30 days) MYCOBUTIN ORAL CAPSULE QL (4 EA per 30 days) rifabutin oral capsule Antituberculars (Tuberculosis Drugs) CAPASTAT SULFATE INJECTION SOLUTION cycloserine oral capsule QL (30 EA per 30 days) ethambutol hcl oral tablet 100 mg QL (4 EA per 28 days) 21

26 ethambutol hcl oral tablet 400 mg QL (90 EA per 30 days) isoniazid injection solution QL (60 ML per 30 days) isoniazid oral syrup QL (30 ML per 30 days) isoniazid oral tablet 100 mg QL (30 EA per 30 days) isoniazid oral tablet 300 mg QL (13 EA per 30 days) PASER ORAL PACKET QL (30 EA per 30 days) PRIFTIN ORAL TABLET QL (12 EA per 30 days) pyrazinamide oral tablet RIFAMATE ORAL CAPSULE rifampin intravenous* solution reconstituted QL (12 EA per 30 days) rifampin oral capsule QL (11 EA per 30 days) RIFATER ORAL TABLET QL (12 EA per 30 days) SIRTURO ORAL TABLET QL (8 EA per 28 days) TRECATOR ORAL TABLET QL (30 EA per 30 days) Antineoplastics (Cancer Drugs) Alkylating Agents (Chemotherapy Drugs) BICNU INTRAVENOUS* SOLUTION Tier 5 BUSULFEX INTRAVENOUS* SOLUTION Tier 5 carboplatin intravenous* solution carboplatin intravenous* solution reconstituted 150 mg cisplatin intravenous* solution cyclophosphamide oral tablet Tier 5 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Tier 5 HEXALEN ORAL CAPSULE Tier 5 IFEX INTRAVENOUS* SOLUTION Tier 5 ifosfamide intravenous* solution reconstituted Tier 5 LEUKERAN ORAL TABLET Tier 5 melphalan hcl intravenous* solution reconstituted MUSTARGEN INJECTION SOLUTION Tier 5 Tier 5 oxaliplatin intravenous* solution thiotepa injection solution reconstituted 22

27 TREANDA INTRAVENOUS* SOLUTION Antiangiogenic Agents (Chemotherapy Drugs) Tier 5 AVASTIN INTRAVENOUS* SOLUTION Tier 5 REVLIMID ORAL CAPSULE Tier 5 THALOMID ORAL CAPSULE Tier 5 Antimetabolites (Chemotherapy Drugs) ALIMTA INTRAVENOUS* SOLUTION Tier 5 ARRANON INTRAVENOUS* SOLUTION Tier 5 azacitidine injection suspension reconstituted Tier 5 capecitabine oral tablet Tier 5 cladribine intravenous* solution 10 mg/10ml CLOLAR INTRAVENOUS* SOLUTION Tier 5 cytarabine (pf) injection solution cytarabine injection solution DACOGEN INTRAVENOUS* SOLUTION Tier 5 daunorubicin hcl intravenous* injectable decitabine intravenous* solution reconstituted doxorubicin hcl intravenous* solution doxorubicin hcl intravenous* solution reconstituted ELLENCE INTRAVENOUS* SOLUTION Tier 5 epirubicin hcl intravenous* solution 200 mg/100ml, 50 mg/25ml epirubicin hcl intravenous* solution reconstituted ERWINAZE INJECTION SOLUTION Tier 5 fludarabine phosphate intravenous* solution fludarabine phosphate intravenous* solution reconstituted fluorouracil intravenous* solution FOLOTYN INTRAVENOUS* SOLUTION Tier 5 gemcitabine hcl intravenous* solution reconstituted 23 Tier 5 PA

28 IDAMYCIN PFS INTRAVENOUS* SOLUTION 10 MG/10ML, 5 MG/5ML idarubicin hcl intravenous* solution 10 mg/10ml, 5 mg/5ml Tier 5 mercaptopurine oral tablet Tier 5 methotrexate oral tablet Tier 5 methotrexate sodium (pf) injection solution 50 mg/2ml methotrexate sodium injection solution 50 mg/2ml methotrexate sodium injection solution reconstituted Tier 5 Tier 5 mitomycin intravenous* solution reconstituted mitoxantrone hcl intravenous* concentrate TABLOID ORAL TABLET Tier 5 TREXALL ORAL TABLET Tier 5 UVADEX INJECTION SOLUTION Tier 5 Antineoplastics (Miscellaneous Chemotherapy Drugs) ABRAXANE INTRAVENOUS* SUSPENSION ACTIMMUNE SUBCUTANEOUS* SOLUTION AFINITOR DISPERZ ORAL TABLET SOLUBLE Tier 5 Tier 5 Tier 5 AFINITOR ORAL TABLET Tier 5 ALECENSA ORAL CAPSULE Tier 5 PA amifostine intravenous* solution reconstituted Tier 5 ARZERRA INTRAVENOUS* CONCENTRATE Tier 5 bexarotene oral capsule Tier 5 bicalutamide oral tablet Tier 5 bleomycin sulfate injection solution reconstituted BLINCYTO INTRAVENOUS* SOLUTION Tier 5 BOSULIF ORAL TABLET Tier 5 PA CAPRELSA ORAL TABLET Tier 5 COMETRIQ (100 MG DAILY DOSE) ORAL KIT 24 Tier 5 PA

29 COMETRIQ (140 MG DAILY DOSE) ORAL KIT COMETRIQ (60 MG DAILY DOSE) ORAL KIT COSMEGEN INTRAVENOUS* SOLUTION Tier 5 Tier 5 Tier 5 COTELLIC ORAL TABLET Tier 5 PA dacarbazine intravenous* solution reconstituted DARZALEX INTRAVENOUS* SOLUTION Tier 5 PA dexrazoxane intravenous* solution reconstituted DOCEFREZ INTRAVENOUS* SOLUTION docetaxel intravenous* concentrate 140 mg/7ml, 160 mg/8ml, 20 mg/ml, 80 mg/4ml Tier 5 Tier 5 Tier 5 docetaxel intravenous* solution Tier 5 ELIGARD SUBCUTANEOUS* KIT Tier 5 ELITEK INTRAVENOUS* SOLUTION Tier 5 EMCYT ORAL CAPSULE Tier 5 EMPLICITI INTRAVENOUS* SOLUTION Tier 5 ERBITUX INTRAVENOUS* SOLUTION Tier 5 ERIVEDGE ORAL CAPSULE Tier 5 ETOPOPHOS INTRAVENOUS* SOLUTION etoposide intravenous* solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml Tier 5 etoposide oral capsule Tier 5 FARESTON ORAL TABLET Tier 5 FARYDAK ORAL CAPSULE Tier 5 PA FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS* SOLUTION Tier 5 Tier 5 flutamide oral capsule Tier 5 FUSILEV INTRAVENOUS* SOLUTION Tier 5 GILOTRIF ORAL TABLET Tier 5 PA PA 25

30 HALAVEN INTRAVENOUS* SOLUTION Tier 5 HERCEPTIN INTRAVENOUS* SOLUTION Tier 5 hydroxyurea oral capsule Tier 5 IBRANCE ORAL CAPSULE Tier 5 PA IDAMYCIN PFS INTRAVENOUS* SOLUTION 20 MG/20ML idarubicin hcl intravenous* solution 20 mg/20ml Tier 5 imatinib mesylate oral tablet Tier 5 IMBRUVICA ORAL CAPSULE Tier 5 PA INLYTA ORAL TABLET Tier 5 INTRON A INJECTION SOLUTION Tier 5 INTRON A INJECTION SOLUTION UNIT Tier 5 irinotecan hcl intravenous* solution Tier 5 ISTODAX INTRAVENOUS* SOLUTION IXEMPRA KIT INTRAVENOUS* SOLUTION Tier 5 Tier 5 JAKAFI ORAL TABLET Tier 5 JEVTANA INTRAVENOUS* SOLUTION Tier 5 KADCYLA INTRAVENOUS* SOLUTION KEPIVANCE INTRAVENOUS* SOLUTION Tier 5 Tier 5 LENVIMA 10 MG DAILY DOSE ORAL Tier 5 LENVIMA 14 MG DAILY DOSE ORAL Tier 5 LENVIMA 18 MG DAILY DOSE ORAL Tier 5 LENVIMA 20 MG DAILY DOSE ORAL Tier 5 LENVIMA 24 MG DAILY DOSE ORAL Tier 5 LENVIMA 8 MG DAILY DOSE ORAL Tier 5 leucovorin calcium injection solution reconstituted leucovorin calcium oral tablet Tier 5 leuprolide acetate injection kit LONSURF ORAL TABLET Tier 4 PA LUPRON DEPOT INTRAMUSCULAR* KIT Tier 5 LYNPARZA ORAL CAPSULE Tier 5 PA 26

31 LYSODREN ORAL TABLET Tier 5 MATULANE ORAL CAPSULE Tier 5 megestrol acetate oral suspension 40 mg/ml megestrol acetate oral tablet MEKINIST ORAL TABLET Tier 5 mesna intravenous* solution MESNEX ORAL TABLET Tier 5 NEXAVAR ORAL TABLET Tier 5 NILANDRON ORAL TABLET Tier 5 NINLARO ORAL CAPSULE Tier 5 PA ODOMZO ORAL CAPSULE Tier 5 PA ONCASPAR INJECTION SOLUTION Tier 5 OPDIVO INTRAVENOUS* SOLUTION Tier 5 PA paclitaxel intravenous* concentrate PERJETA INTRAVENOUS* SOLUTION Tier 5 POMALYST ORAL CAPSULE Tier 5 PORTRAZZA INTRAVENOUS* SOLUTION Tier 5 PA PROLEUKIN INTRAVENOUS* SOLUTION Tier 5 RITUXAN INTRAVENOUS* SOLUTION Tier 5 SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET Tier 5 STIVARGA ORAL TABLET Tier 5 PA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* SOLUTION Tier 5 Tier 5 Tier 5 TAFINLAR ORAL CAPSULE Tier 5 TAGRISSO ORAL TABLET Tier 5 PA TARCEVA ORAL TABLET Tier 5 TARGRETIN ORAL CAPSULE Tier 5 TASIGNA ORAL CAPSULE Tier 5 TAXOTERE INTRAVENOUS* CONCENTRATE 20 MG/ML, 80 MG/4ML Tier 5 temozolomide oral capsule Tier 5 27

32 topotecan hcl intravenous* solution reconstituted TORISEL INTRAVENOUS* SOLUTION Tier 5 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION Tier 5 tretinoin oral capsule Tier 5 TRISENOX INTRAVENOUS* SOLUTION Tier 5 TYKERB ORAL TABLET Tier 5 UNITUXIN INTRAVENOUS* SOLUTION Tier 5 PA VECTIBIX INTRAVENOUS* SOLUTION 100 MG/5ML, 400 MG/20ML VELCADE INJECTION SOLUTION Tier 5 Tier 5 vinblastine sulfate intravenous* solution vinblastine sulfate intravenous* solution reconstituted VINCASAR PFS INTRAVENOUS* SOLUTION vinorelbine tartrate intravenous* solution VOTRIENT ORAL TABLET Tier 5 VRAYLAR ORAL ST; QL (7 EA per 7 days) VRAYLAR ORAL CAPSULE 1.5 MG ST; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG ST; QL (30 EA per 30 days) VRAYLAR ORAL CAPSULE 6 MG XALKORI ORAL CAPSULE Tier 5 PA XTANDI ORAL CAPSULE Tier 5 PA YERVOY INTRAVENOUS* SOLUTION Tier 5 YONDELIS INTRAVENOUS* SOLUTION Tier 5 ZALTRAP INTRAVENOUS* SOLUTION Tier 5 ZELBORAF ORAL TABLET Tier 5 ZOLINZA ORAL CAPSULE Tier 5 ZYTIGA ORAL TABLET Tier 5 Aromatase Inhibitors 3Rd Generation (Hormonal Chemotherapy Drugs) anastrozole oral tablet Tier 5 exemestane oral tablet Tier 5 letrozole oral tablet Tier 5 28 PA

33 Ppaca Prev Breast Ca (Cancer Drugs) tamoxifen citrate oral tablet Antiparasitics (Infection Fighting Drugs) Anthelmintics (Miscellaneous Infection Fighting Drugs) ALBENZA ORAL TABLET ivermectin oral tablet SKLICE EXTERNAL LOTION Antiprotozoals (Malaria Drugs) ALINIA ORAL SUSPENSION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil hcl oral tablet chloroquine phosphate oral tablet DARAPRIM ORAL TABLET Tier 4 hydroxychloroquine sulfate oral tablet mefloquine hcl oral tablet MEPRON ORAL SUSPENSION NEBUPENT INHALATION SOLUTION PENTAM INJECTION SOLUTION primaquine phosphate oral tablet Antiparkinson Agents (Nerve Condition Drugs) Anticholinergics (Parkinson's Disease Drugs) benztropine mesylate injection solution benztropine mesylate oral tablet trihexyphenidyl hcl oral elixir trihexyphenidyl hcl oral tablet Antiparkinson Agents Other (Parkinson's Disease Drugs) amantadine hcl oral capsule 29

34 amantadine hcl oral syrup amantadine hcl oral tablet entacapone oral tablet Dopamine Agonists (Parkinson's Disease Drugs) APOKYN SUBCUTANEOUS* SOLUTION Tier 4 bromocriptine mesylate oral capsule bromocriptine mesylate oral tablet pramipexole dihydrochloride oral tablet ropinirole hcl er oral tablet extended release 24 hr* ropinirole hcl oral tablet Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors (Parkinson's Disease Drugs) carbidopa-levodopa er oral tablet extendedrelease* mg, mg carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet dispersible carbidopa-levodopa-entacapone oral tablet Monoamine Oxidase B (Mao-B) Inhibitors (Parkinson's Disease Drugs) AZILECT ORAL TABLET selegiline hcl oral capsule selegiline hcl oral tablet Antipsychotics (Nerve Condition Drugs) 1St Generation/Typical (Mood Disorder Drugs) chlorpromazine hcl injection solution chlorpromazine hcl oral tablet fluphenazine decanoate injection solution fluphenazine hcl injection solution fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet 30

35 haloperidol decanoate intramuscular* solution haloperidol lactate injection solution haloperidol lactate oral concentrate haloperidol oral tablet loxapine succinate oral capsule ORAP ORAL TABLET perphenazine oral tablet perphenazine-amitriptyline oral tablet prochlorperazine edisylate injection solution prochlorperazine maleate oral tablet prochlorperazine suppository thioridazine hcl oral tablet thiothixene oral capsule trifluoperazine hcl oral tablet 2Nd Generation/Atypical (Mood Disorder Drugs) ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION 300 MG, 400 MG aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet dispersible ARISTADA INTRAMUSCULAR* 441 MG/1.6ML ARISTADA INTRAMUSCULAR* 662 MG/2.4ML ARISTADA INTRAMUSCULAR* 882 MG/3.2ML FANAPT ORAL TABLET FANAPT TITRATION PACK ORAL TABLET GEODON INTRAMUSCULAR* SOLUTION INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION LATUDA ORAL TABLET ST; QL (1.8 ML per 28 days) ST; QL (2.4 ML per 28 days) ST; QL (3.2 ML per 28 days) 31

36 olanzapine intramuscular* solution reconstituted olanzapine oral tablet olanzapine oral tablet dispersible quetiapine fumarate er oral tablet extended release 24 hr* quetiapine fumarate oral tablet RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 2 MG risperidone oral solution risperidone oral tablet risperidone oral tablet dispersible 0.25 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG ziprasidone hcl oral capsule Treatment-Resistant (Mood Disorder Drugs) clozapine oral tablet FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 25 MG Antispasticity Agents (Muscle And Joint Drugs) Antispasticity Agents (Muscle And Joint Drugs) GABLOFEN INTRATHECAL* SOLUTION 50 MCG/ML Antivirals (Infection Fighting Drugs) Anti-Cytomegalovirus (Cmv) Agents (Virus Infection Drugs) FOSCAVIR INTRAVENOUS* SOLUTION 6000 MG/250ML ganciclovir sodium intravenous* solution reconstituted VALCYTE ORAL SOLUTION 32

37 valganciclovir hcl oral tablet Antihepatitis Agents (Virus Infection Drugs) adefovir dipivoxil oral tablet Tier 4 BARACLUDE ORAL SOLUTION entecavir oral tablet HARVONI ORAL TABLET Tier 4 PA lamivudine oral tablet 100 mg QL (20 EA per 5 days) PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML Tier 4 PEGASYS SUBCUTANEOUS* SOLUTION Tier 4 RIBASPHERE ORAL TABLET 400 MG RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG Tier 4 ribavirin oral capsule ribavirin oral tablet 200 mg SOVALDI ORAL TABLET Tier 4 PA TYZEKA ORAL TABLET VICTRELIS ORAL CAPSULE Tier 4 PA Antiherpetic Agents (Virus Infection Drugs) acyclovir oral capsule acyclovir oral suspension acyclovir oral tablet acyclovir sodium intravenous* solution acyclovir sodium intravenous* solution reconstituted famciclovir oral tablet valacyclovir hcl oral tablet Anti-Hiv Agents Other (Retrovirus Infection Drugs) ATRIPLA ORAL TABLET COMPLERA ORAL TABLET FUZEON SUBCUTANEOUS* SOLUTION Tier 4 GENVOYA ORAL TABLET Tier 4 QL (60 EA per 30 days) ISENTRESS ORAL TABLET QL (10 EA per 30 days) 33

38 ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 25 MG QL (180 EA per 30 days) QL (10 EA per 30 days) SELZENTRY ORAL TABLET 150 MG Tier 4 QL (30 EA per 30 days) SELZENTRY ORAL TABLET 300 MG Tier 4 QL (10 EA per 30 days) STRIBILD ORAL TABLET Anti-Hiv Agents Protease Inhibitors (Retrovirus Infection Drugs) APTIVUS ORAL CAPSULE QL (360 EA per 30 days) APTIVUS ORAL SOLUTION QL (360 ML per 30 days) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG QL (90 EA per 30 days) INVIRASE ORAL CAPSULE QL (360 EA per 30 days) INVIRASE ORAL TABLET QL (360 EA per 30 days) KALETRA ORAL SOLUTION KALETRA ORAL TABLET LEXIVA ORAL SUSPENSION QL (90 ML per 30 days) LEXIVA ORAL TABLET QL (90 EA per 30 days) NORVIR ORAL CAPSULE QL (360 EA per 30 days) NORVIR ORAL SOLUTION QL (360 ML per 30 days) NORVIR ORAL TABLET QL (360 EA per 30 days) PREZISTA ORAL SUSPENSION QL (120 ML per 30 days) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG QL (60 EA per 30 days) QL (120 EA per 30 days) TIVICAY ORAL TABLET 50 MG QL (10 EA per 30 days) VIRACEPT ORAL TABLET 250 MG QL (240 EA per 30 days) VIRACEPT ORAL TABLET 625 MG QL (90 EA per 30 days) Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Retrovirus Infection Drugs) EDURANT ORAL TABLET INTELENCE ORAL TABLET nevirapine er oral tablet extended release 24 hr* nevirapine oral suspension 34

39 nevirapine oral tablet RESCRIPTOR ORAL TABLET SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET VIRAMUNE ORAL SUSPENSION Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Retrovirus Infection Drugs) abacavir sulfate oral tablet QL (390 EA per 30 days) abacavir sulfate-lamivudine oral tablet Tier 4 abacavir-lamivudine-zidovudine oral tablet didanosine oral capsule delayed release 125 mg didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg QL (980 EA per 30 days) QL (360 EA per 30 days) EMTRIVA ORAL CAPSULE QL (360 EA per 30 days) EMTRIVA ORAL SOLUTION QL (400 ML per 30 days) EPIVIR HBV ORAL SOLUTION QL (9 ML per 30 days) lamivudine oral solution lamivudine oral tablet 150 mg, 300 mg QL (9 EA per 30 days) lamivudine-zidovudine oral tablet RETROVIR INTRAVENOUS* SOLUTION stavudine oral capsule 15 mg QL (9 EA per 30 days) stavudine oral capsule 20 mg, 30 mg QL (3 EA per 30 days) stavudine oral capsule 40 mg QL (60 EA per 30 days) stavudine oral solution reconstituted QL (60 ML per 30 days) TRUVADA ORAL TABLET MG VIDEX ORAL SOLUTION VIREAD ORAL POWDER VIREAD ORAL TABLET QL (390 ML per 30 days) ZIAGEN ORAL SOLUTION QL (390 ML per 30 days) zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet 35

40 Anti-Influenza Agents (Virus Infection Drugs) rimantadine hcl oral tablet TAMIFLU ORAL CAPSULE 30 MG, 45 MG TAMIFLU ORAL CAPSULE 75 MG QL (10 EA per 5 days) TAMIFLU ORAL SUSPENSION 6 MG/ML Anxiolytics (Nerve Condition Drugs) Anxiolytics Other (Anxiety Drugs) buspirone hcl oral tablet hydroxyzine hcl intramuscular* solution hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet Benzodiazepines (Anxiety Drugs) alprazolam er oral tablet extended release 24 hr* 0.5 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet alprazolam oral tablet dispersible alprazolam xr oral tablet extended release 24 hr* 1 mg, 2 mg chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet diazepam oral concentrate diazepam oral solution 1 mg/ml diazepam oral tablet lorazepam oral concentrate lorazepam oral tablet oxazepam oral capsule Bipolar Agents (Nerve Condition Drugs) Mood Stabilizers (Miscellaneous Nerve Condition Drugs) lithium carbonate er oral tablet extendedrelease* 36

41 lithium carbonate oral capsule lithium carbonate oral tablet Blood Glucose Regulators (Hormone And Diabetic Drugs) *Alpha-Glucosidase Inhibitors*** acarbose oral tablet *Diabetic Other*** GLUCAGEN DIAGNOSTIC INJECTION SOLUTION GLUCAGEN HYPOKIT INJECTION SOLUTION GLUCAGON EMERGENCY INJECTION KIT glucose oral tablet chewable 4-6 gm-mg OTC PROGLYCEM ORAL SUSPENSION Tier 4 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** NESINA ORAL TABLET ONGLYZA ORAL TABLET Antidiabetic Agents (Injectable Diabetes, Blood Sugar Drugs) BYETTA 10 MCG PEN SUBCUTANEOUS* BYETTA 5 MCG PEN SUBCUTANEOUS* SYMLINPEN 120 SUBCUTANEOUS* SYMLINPEN 60 SUBCUTANEOUS* Antidiabetic Agents (Oral Diabetes, Blood Sugar Drugs) glipizide-metformin hcl oral tablet glyburide oral tablet 2.5 mg, 5 mg glyburide-metformin oral tablet OSENI ORAL TABLET pioglitazone hcl-glimepiride oral tablet PRANDIMET ORAL TABLET PRANDIN ORAL TABLET tolazamide oral tablet tolbutamide oral tablet Antidiabetics, Other CYCLOSET ORAL TABLET 37

42 nateglinide oral tablet repaglinide oral tablet Biguanide Antidiabetics metformin hcl er (mod) oral tablet extended release 24 hr* metformin hcl er (osm) oral tablet extended release 24 hr* metformin hcl er oral tablet extended release 24 hr* metformin hcl oral tablet RIOMET ORAL SOLUTION Dipeptidyl Peptidase-4 (Dpp-4) Inhibitor Combinations JANUMET ORAL TABLET JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* KAZANO ORAL TABLET KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors JANUVIA ORAL TABLET Insulins (Injectable Diabetes, Blood Sugar Drugs) APIDRA INJECTION SOLUTION APIDRA SOLOSTAR SUBCUTANEOUS* LANTUS SOLOSTAR SUBCUTANEOUS* LANTUS SUBCUTANEOUS* SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS* LEVEMIR SUBCUTANEOUS* SOLUTION NOVOLIN 70/30 RELION SUBCUTANEOUS* SUSPENSION NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION NOVOLIN N RELION SUBCUTANEOUS* SUSPENSION NOVOLIN N SUBCUTANEOUS* SUSPENSION OTC OTC OTC OTC NOVOLIN R INJECTION SOLUTION OTC 38

43 NOVOLIN R RELION INJECTION SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS* NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS* NOVOLOG SUBCUTANEOUS* SOLUTION OTC TOUJEO SOLOSTAR SUBCUTANEOUS* QL (21 ML per 30 days) TRESIBA FLEXTOUCH SUBCUTANEOUS* Sodium-Glucose Co-Transport 2 (Sglt2) Inhibitors (Antidiabetic) FARXIGA ORAL TABLET INVOKANA ORAL TABLET Sulfonylureas (Antidiabetic) chlorpropamide oral tablet DIABETA ORAL TABLET glimepiride oral tablet glipizide er oral tablet extended release 24 hr* glipizide oral tablet glipizide xl oral tablet extended release 24 hr* glyburide micronized oral tablet glyburide oral tablet 1.25 mg Thiazolidinediones (Tzds) AVANDIA ORAL TABLET pioglitazone hcl oral tablet Thiazolindinedione (Tzd) Combinations ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HR* AVANDAMET ORAL TABLET pioglitazone hcl-metformin hcl oral tablet 39

44 Blood Products/Modifiers/ Volume Expanders (Blood Disorder Drugs) Anticoagulants (Blood Thinners) ELIQUIS ORAL TABLET enoxaparin sodium injection solution enoxaparin sodium subcutaneous* solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 60 mg/0.6ml, 80 mg/0.8ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml Tier 4 fondaparinux sodium subcutaneous* solution Tier 4 heparin (porcine) in d5w intravenous* solution heparin (porcine) in nacl injection solution heparin lock flush intravenous* solution heparin sod (porcine) in d5w intravenous* solution heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution PRADAXA ORAL CAPSULE 150 MG, 75 MG sash kit intravenous* kit unit/ml-% SAVAYSA ORAL TABLET warfarin sodium oral tablet XARELTO ORAL TABLET XARELTO STARTER PACK ORAL Blood Formation Modifiers (Blood Formation Drugs) tranexamic acid intravenous* solution 1000 mg/10ml Erythropoietins PROCRIT INJECTION SOLUTION UNIT/ML Hematopoietic Agents, Other Tier 4 PROMACTA ORAL TABLET Tier 4 PA 40

45 Platelet Modifying Agents (Blood Thinners) AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR anagrelide hcl oral capsule aspirin-dipyridamole er oral capsule extended release 12 hour cilostazol oral tablet clopidogrel bisulfate oral tablet dipyridamole oral tablet EFFIENT ORAL TABLET ticlopidine hcl oral tablet Cardiovascular Agents (Heart And Circulation Condition Drugs) Alpha-Adrenergic Blocking Agents (Blood Pressure Drugs) clonidine hcl oral tablet clonidine hcl transdermal patch weekly doxazosin mesylate oral tablet guanfacine hcl oral tablet methyldopa oral tablet methyldopate hcl intravenous* solution prazosin hcl oral capsule terazosin hcl oral capsule Angiotensin Ii Receptor Antagonists (Blood Pressure Drugs) ATACAND ORAL TABLET 16 MG, 32 MG candesartan cilexetil oral tablet candesartan cilexetil-hctz oral tablet EDARBI ORAL TABLET ST eprosartan mesylate oral tablet irbesartan oral tablet losartan potassium oral tablet olmesartan medoxomil oral tablet telmisartan oral tablet valsartan oral tablet 41

46 Angiotensin-Converting Enzyme (Ace) Inhibitors (Blood Pressure Drugs) benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet fosinopril sodium oral tablet lisinopril oral tablet moexipril hcl oral tablet perindopril erbumine oral tablet quinapril hcl oral tablet ramipril oral capsule trandolapril oral tablet Antiarrhythmics (Heart Regulation Drugs) amiodarone hcl intravenous* solution amiodarone hcl oral tablet disopyramide phosphate oral capsule dofetilide oral capsule flecainide acetate oral tablet mexiletine hcl oral capsule MULTAQ ORAL TABLET PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG procainamide hcl injection solution 100 mg/ml propafenone hcl er oral capsule extended release 12 hour propafenone hcl oral tablet quinidine gluconate er oral tablet extendedrelease* quinidine sulfate er oral tablet extendedrelease* quinidine sulfate oral tablet Antihypertensive Combinations (Blood Pressure Drugs) amiloride-hydrochlorothiazide oral tablet amlodipine besy-benazepril hcl oral capsule 42

47 amlodipine besylate-valsartan oral tablet amlodipine-atorvastatin oral tablet mg amlodipine-olmesartan oral tablet amlodipine-valsartan-hctz oral tablet AMTURNIDE ORAL TABLET atenolol-chlorthalidone oral tablet benazepril-hydrochlorothiazide oral tablet bisoprolol-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet EDARBYCLOR ORAL TABLET ST enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet irbesartan-hydrochlorothiazide oral tablet lisinopril-hydrochlorothiazide oral tablet losartan potassium-hctz oral tablet methyldopa-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet nadolol-bendroflumethiazide oral tablet olmesartan medoxomil-hctz oral tablet olmesartan-amlodipine-hctz oral tablet propranolol-hctz oral tablet quinapril-hydrochlorothiazide oral tablet spironolactone-hctz oral tablet TEKAMLO ORAL TABLET TEKTURNA HCT ORAL TABLET telmisartan-amlodipine oral tablet telmisartan-hctz oral tablet TEVETEN HCT ORAL TABLET trandolapril-verapamil hcl er oral tablet extendedrelease* triamterene-hctz oral capsule triamterene-hctz oral tablet valsartan-hydrochlorothiazide oral tablet Beta-Adrenergic Blocking Agents (Blood Pressure Drugs) acebutolol hcl oral capsule 43

48 atenolol oral tablet betaxolol hcl oral tablet bisoprolol fumarate oral tablet carvedilol oral tablet INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR labetalol hcl intravenous* solution labetalol hcl oral tablet metoprolol succinate er oral tablet extended release 24 hr* metoprolol tartrate intravenous* solution 1 mg/ml metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet propranolol hcl er oral capsule extended release 24 hour propranolol hcl intravenous* solution propranolol hcl oral solution propranolol hcl oral tablet sotalol hcl (af) oral tablet sotalol hcl oral tablet timolol maleate oral tablet Calcium Channel Blocking Agents (Blood Pressure Drugs) amlodipine besylate oral tablet diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl er beads oral capsule extended release 24 hour diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 hr* diltiazem hcl er oral capsule extended release 12 hour diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl intravenous* solution 44

49 diltiazem hcl oral tablet felodipine er oral tablet extended release 24 hr* isradipine oral capsule nicardipine hcl oral capsule NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 90 MG nifedipine er oral tablet extended release 24 hr* 30 mg, 60 mg nifedipine er osmotic release oral tablet extended release 24 hr* nifedipine oral capsule nimodipine oral capsule Tier 4 nisoldipine er oral tablet extended release 24 hr* verapamil hcl er oral capsule extended release 24 hour verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg verapamil hcl intravenous* solution verapamil hcl oral tablet Cardiovascular Agents, Other digoxin injection solution digoxin oral solution digoxin oral tablet PA epinephrine hcl pf intravenous* solution midodrine hcl oral tablet pentoxifylline er oral tablet extendedrelease* RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* TEKTURNA ORAL TABLET Diuretics Carbonic Anhydrase Inhibitors [Blood Pressure Drugs (Water Pills)] acetazolamide er oral capsule extended release 12 hour acetazolamide oral tablet methazolamide oral tablet NEPTAZANE ORAL TABLET 45

50 Diuretics Loop [Blood Pressure Drugs (Water Pills)] bumetanide injection solution bumetanide oral tablet furosemide injection solution 10 mg/ml furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet torsemide oral tablet Diuretics Potassium-Sparing [Blood Pressure Drugs (Water Pills)] amiloride hcl oral tablet DYRENIUM ORAL CAPSULE eplerenone oral tablet spironolactone oral tablet Diuretics Thiazide [Blood Pressure Drugs (Water Pills)] chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet methyclothiazide oral tablet metolazone oral tablet Dyslipidemics Fibric Acid Derivatives (Cholesterol Drugs) fenofibrate micronized oral capsule fenofibrate oral capsule fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg fenofibric acid oral capsule delayed release gemfibrozil oral tablet LIPOFEN ORAL CAPSULE Dyslipidemics Hmg Coa Reductase Inhibitors (Cholesterol Drugs) ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR* 46

51 atorvastatin calcium oral tablet fluvastatin sodium er oral tablet extended release 24 hr* fluvastatin sodium oral capsule LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR* LIVALO ORAL TABLET lovastatin oral tablet pravastatin sodium oral tablet rosuvastatin calcium oral tablet simvastatin oral tablet Dyslipidemics Other (Cholesterol Drugs) cholestyramine light oral packet cholestyramine light oral powder cholestyramine oral packet cholestyramine oral powder colestipol hcl oral granules colestipol hcl oral packet colestipol hcl oral tablet JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG Tier 4 LOVAZA ORAL CAPSULE niacin er (antihyperlipidemic) oral tablet extendedrelease* NIACOR ORAL TABLET omega-3-acid ethyl esters oral capsule VYTORIN ORAL TABLET WELCHOL ORAL PACKET WELCHOL ORAL TABLET ZETIA ORAL TABLET Vasodilators Direct-Acting Arterial (Miscellaneous Heart And Circulation Drugs) hydralazine hcl injection solution hydralazine hcl oral tablet minoxidil oral tablet 47

52 Vasodilators Direct-Acting Arterial/Venous (Chest Pain Drugs) isosorbide dinitrate er oral tablet extendedrelease* isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hr* isosorbide mononitrate oral tablet nitroglycerin intravenous* solution nitroglycerin transdermal patch 24 hr nitroglycerin translingual aerosol, solution nitroglycerin translingual solution NITROLINGUAL TRANSLINGUAL SOLUTION NITROSTAT SUBLINGUAL TABLET SUBLINGUAL Central Nervous System Agents (Nerve Condition Drugs) Attention Deficit Hyperactivity Disorder Agents, Amphetamines (Adhd Drugs) amphetamine-dextroamphet er oral capsule extended release 24 hour amphetamine-dextroamphetamine oral tablet dextroamphetamine sulfate er oral capsule extended release 24 hour dextroamphetamine sulfate oral tablet Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines (Adhd Drugs) CONCERTA ORAL TABLET EXTENDEDRELEASE* dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg dexmethylphenidate hcl oral tablet guanfacine hcl er oral tablet extended release 24 hr* methylphenidate hcl er (cd) oral capsule extended release* 48 PA

53 methylphenidate hcl er (la) oral capsule extended release 24 hour methylphenidate hcl er oral tablet extendedrelease* methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable STRATTERA ORAL CAPSULE Central Nervous System, Other NUEDEXTA ORAL CAPSULE riluzole oral tablet tetrabenazine oral tablet Tier 4 XENAZINE ORAL TABLET Tier 4 Fibromyalgia Agents LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION SAVELLA ORAL TABLET SAVELLA TITRATION PACK ORAL Multiple Sclerosis Agents (Multiple Sclerosis Drugs) AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* Tier 4 AUBAGIO ORAL TABLET Tier 4 ST BETASERON SUBCUTANEOUS* KIT Tier 4 COPAXONE SUBCUTANEOUS* 20 MG/ML Tier 4 EXTAVIA SUBCUTANEOUS* KIT Tier 4 GILENYA ORAL CAPSULE Tier 4 LEMTRADA INTRAVENOUS* SOLUTION Tier 4 PA REBIF REBIDOSE SUBCUTANEOUS* Tier 4 REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* Tier 4 REBIF SUBCUTANEOUS* Tier 4 REBIF TITRATION PACK SUBCUTANEOUS* Tier 4 TYSABRI INTRAVENOUS* CONCENTRATE Tier 4 49

54 Contraceptives *Combination Contraceptives - Transdermal*** XULANE TRANSDERMAL PATCH WEEKLY *Emergency Contraceptives*** ELLA ORAL TABLET levonorgestrel oral tablet 1.5 mg OTC Condoms, Female FC2 FEMALE CONDOM OTC Contraceptives Implant NEXPLANON SUBCUTANEOUS* IMPLANT Contraceptives Injectable DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION medroxyprogesterone acetate intramuscular* suspension Contraceptives Intrauterine MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE SKYLA INTRAUTERINE INTRAUTERINE DEVICE Contraceptives Intravaginal CAYA VAGINAL DIAPHRAGM NUVARING VAGINAL RING OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM OPTIONS CONCEPTROL VAGINAL GEL OTC OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL PRENTIF FITTING SET VAGINAL OTC TODAY SPONGE VAGINAL OTC VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM VCF VAGINAL CONTRACEPTIVE VAGINAL GEL OTC OTC 50

55 Contraceptives Oral ALTAVERA ORAL TABLET alyacen 1/35 oral tablet alyacen 7/7/7 oral tablet AMETHIA LO ORAL TABLET AMETHIA ORAL TABLET AMETHYST ORAL TABLET APRI ORAL TABLET ARANELLE ORAL TABLET ASHLYNA ORAL TABLET AUBRA ORAL TABLET AVIANE ORAL TABLET AZURETTE ORAL TABLET BEKYREE ORAL TABLET BEYAZ ORAL TABLET BLISOVI 24 FE ORAL TABLET BLISOVI FE 1.5/30 ORAL TABLET BLISOVI FE 1/20 ORAL TABLET briellyn oral tablet CAMRESE LO ORAL TABLET CAMRESE ORAL TABLET CAZIANT ORAL TABLET CESIA ORAL TABLET CHATEAL ORAL TABLET CRYSELLE-28 ORAL TABLET CYCLAFEM 1/35 ORAL TABLET CYCLAFEM 7/7/7 ORAL TABLET CYRED ORAL TABLET DASETTA 1/35 ORAL TABLET DASETTA 7/7/7 ORAL TABLET DAYSEE ORAL TABLET DEBLITANE ORAL TABLET DELYLA ORAL TABLET desogestrel-ethinyl estradiol oral tablet drospirenone-ethinyl estradiol oral tablet ELINEST ORAL TABLET EMOQUETTE ORAL TABLET 51

56 ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET ESTARYLLA ORAL TABLET estradiol-norethindrone acet oral tablet FALMINA ORAL TABLET GIANVI ORAL TABLET GILDAGIA ORAL TABLET GILDESS 1.5/30 ORAL TABLET GILDESS 1/20 ORAL TABLET GILDESS FE 1.5/30 ORAL TABLET GILDESS FE 1/20 ORAL TABLET HEATHER ORAL TABLET INTROVALE ORAL TABLET JENCYCLA ORAL TABLET jevantique lo oral tablet JINTELI ORAL TABLET JOLESSA ORAL TABLET JOLIVETTE ORAL TABLET JULEBER ORAL TABLET JUNEL 1.5/30 ORAL TABLET JUNEL FE 1.5/30 ORAL TABLET JUNEL FE 1/20 ORAL TABLET JUNEL FE 24 ORAL TABLET KAITLIB FE ORAL TABLET CHEWABLE KARIVA ORAL TABLET KELNOR 1/35 ORAL TABLET KIMIDESS ORAL TABLET KURVELO ORAL TABLET LARIN 1.5/30 ORAL TABLET LARIN 1/20 ORAL TABLET LARIN 24 FE ORAL TABLET LARIN FE 1.5/30 ORAL TABLET LARIN FE 1/20 ORAL TABLET LAYOLIS FE ORAL TABLET CHEWABLE LEENA ORAL TABLET LESSINA ORAL TABLET LEVONEST ORAL TABLET 52

57 levonorgest-eth estrad 91-day oral tablet levonorgestrel-ethinyl estrad oral tablet levonorg-eth estrad triphasic oral tablet LEVORA 0.15/30 (28) ORAL TABLET LO LOESTRIN FE ORAL TABLET LOMEDIA 24 FE ORAL TABLET LORYNA ORAL TABLET LOW-OGESTREL ORAL TABLET LUTERA ORAL TABLET LYZA ORAL TABLET marlissa oral tablet MICROGESTIN 1.5/30 ORAL TABLET MICROGESTIN 1/20 ORAL TABLET MICROGESTIN 24 FE ORAL TABLET MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET MINASTRIN 24 FE ORAL TABLET CHEWABLE MONO-LINYAH ORAL TABLET MONONESSA ORAL TABLET MYZILRA ORAL TABLET NATAZIA ORAL TABLET NECON 0.5/35 (28) ORAL TABLET NECON 1/35 (28) ORAL TABLET NECON 1/50 (28) ORAL TABLET NECON 10/11 (28) ORAL TABLET NECON 7/7/7 ORAL TABLET NIKKI ORAL TABLET NORA-BE ORAL TABLET norethin ace-eth estrad-fe oral tablet norethindrone acet-ethinyl est oral tablet norethindrone oral tablet norethindrone-eth estradiol oral tablet mg-mcg norethin-eth estradiol-fe oral tablet chewable mg-mcg norgestimate-eth estradiol oral tablet mg-mcg 53

58 norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg NORLYROC ORAL TABLET NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET NORTREL 1/35 (28) ORAL TABLET NORTREL 7/7/7 ORAL TABLET OCELLA ORAL TABLET OGESTREL ORAL TABLET ORSYTHIA ORAL TABLET ORTHO TRI-CYCLEN LO ORAL TABLET PHILITH ORAL TABLET PIMTREA ORAL TABLET PIRMELLA 1/35 ORAL TABLET PIRMELLA 7/7/7 ORAL TABLET PORTIA-28 ORAL TABLET PREVIFEM ORAL TABLET QUARTETTE ORAL TABLET QUASENSE ORAL TABLET RECLIPSEN ORAL TABLET SAFYRAL ORAL TABLET SETLAKIN ORAL TABLET SHAROBEL ORAL TABLET SOLIA ORAL TABLET SPRINTEC 28 ORAL TABLET SRONYX ORAL TABLET SYEDA ORAL TABLET TARINA FE 1/20 ORAL TABLET TILIA FE ORAL TABLET TRI-ESTARYLLA ORAL TABLET TRI-LEGEST FE ORAL TABLET TRI-LINYAH ORAL TABLET TRINESSA (28) ORAL TABLET TRI-PREVIFEM ORAL TABLET TRI-SPRINTEC ORAL TABLET TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 54

59 VESTURA ORAL TABLET VIENVA ORAL TABLET viorele oral tablet VYFEMLA ORAL TABLET WERA ORAL TABLET WYMZYA FE ORAL TABLET CHEWABLE ZARAH ORAL TABLET ZENCHENT FE ORAL TABLET CHEWABLE ZENCHENT ORAL TABLET ZOVIA 1/50E (28) ORAL TABLET Cough/Cold/Allergy Antitussive (Narcotic) hydrocodone-homatropine oral syrup hydrocodone-homatropine oral tablet Antitussive Combination (Narcotic) hydrocod polst-cpm polst er oral promethazine vc/codeine oral syrup promethazine-codeine oral syrup pseudoeph-chlorphen-hydrocod oral solution Antitussive Combination (Non-Narcotic) DESGEN PEDIATRIC ORAL LIQUID OTC promethazine-dm oral syrup pseudoeph-bromphen-dm oral syrup mg/5ml OTC TUSSLIN PEDIATRIC ORAL LIQUID OTC Antitussives (Non-Narcotic) benzonatate oral capsule 100 mg, 200 mg Decongestant-Antihistamine cold & allergy oral elixir OTC promethazine vc plain oral syrup Dental And Oral Agents Fluoride fluoritab oral tablet chewable FLURA-DROPS ORAL SOLUTION LUDENT ORAL TABLET CHEWABLE 55

60 sodium fluoride oral solution sodium fluoride oral tablet 1.1 (0.5 f) mg sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg Fluoride Dental Products ACT ANTICAVITY FLUORIDE RINSE MOUTH/THROAT SOLUTION CAVIRINSE MOUTH/THROAT SOLUTION CLINPRO 5000 DENTAL PASTE DENTA 5000 PLUS DENTAL CREAM DENTAGEL DENTAL GEL FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE Dental And Oral Agents (Drugs For The Mouth) Dental And Oral Agents (Mouth/Throat/Dental Drugs) chlorhexidine gluconate mouth/throat solution OTC cold sore treatment external liquid OTC pilocarpine hcl oral tablet triamcinolone acetonide mouth/throat paste Dermatological Agents (Drugs Affecting Skin) *Local Anesthetics - Topical*** lidocaine external ointment lidocaine external patch 5 % lidocaine hcl external gel 2 % lidocaine hcl external solution LIDODERM EXTERNAL PATCH Dermatological Agents (Drugs Affecting Skin) 8-MOP ORAL CAPSULE acitretin oral capsule acyclovir external ointment adapalene external cream adapalene external gel alclometasone dipropionate external cream 56

61 alclometasone dipropionate external ointment amcinonide external cream amcinonide external lotion amcinonide external ointment ammonium lactate external lotion OTC benzoyl peroxide-erythromycin external gel betamethasone dipropionate aug external cream betamethasone dipropionate aug external lotion betamethasone dipropionate aug external ointment betamethasone dipropionate external cream betamethasone dipropionate external lotion betamethasone dipropionate external ointment betamethasone valerate external cream betamethasone valerate external foam betamethasone valerate external lotion betamethasone valerate external ointment bp wash external liquid 2.5 %, 7 % calcipotriene external cream calcipotriene external ointment calcipotriene external solution CICLODAN CREAM EXTERNAL KIT CICLODAN SOLUTION EXTERNAL KIT ciclopirox external gel ciclopirox external shampoo ciclopirox external solution ciclopirox olamine external cream ciclopirox olamine external suspension ciclopirox treatment external kit ciclopirox-vitamin e external kit CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG CLARAVIS ORAL CAPSULE 30 MG CLINDACIN PAC EXTERNAL KIT 57

62 clindamycin phos-benzoyl perox external gel clindamycin phosphate external gel clindamycin phosphate external lotion clindamycin phosphate external solution clindamycin phosphate external swab clobetasol propionate e external cream clobetasol propionate emulsion external foam clobetasol propionate external cream clobetasol propionate external foam clobetasol propionate external gel clobetasol propionate external lotion clobetasol propionate external ointment clobetasol propionate external shampoo CLODERM PUMP EXTERNAL CREAM clotrimazole external cream OTC clotrimazole external solution OTC clotrimazole-betamethasone external cream clotrimazole-betamethasone external lotion CONDYLOX EXTERNAL GEL CORMAX SCALP APPLICATION EXTERNAL SOLUTION DERMAZENE EXTERNAL CREAM desonide external cream desonide external lotion desonide external ointment desoximetasone external cream desoximetasone external gel desoximetasone external ointment 0.25 % diclofenac sodium transdermal gel 3 % diclofenac sodium transdermal solution diflorasone diacetate external cream diflorasone diacetate external ointment econazole nitrate external cream ELIDEL EXTERNAL CREAM erythromycin external gel erythromycin external pad erythromycin external solution 58

63 EURAX EXTERNAL CREAM EXODERM EXTERNAL LOTION fluocinolone acetonide body external oil fluocinolone acetonide external cream fluocinolone acetonide external ointment fluocinolone acetonide external solution fluocinolone acetonide scalp external oil fluocinonide external cream fluocinonide external gel fluocinonide external ointment fluocinonide external solution fluocinonide-e external cream fluorouracil external cream 5 % fluorouracil external solution fluticasone propionate external cream fluticasone propionate external lotion fluticasone propionate external ointment gentamicin sulfate external cream gentamicin sulfate external ointment halobetasol propionate external cream halobetasol propionate external ointment HEMMOREX-HC SUPPOSITORY 30 MG hydrocortisone ace-pramoxine cream hydrocortisone ace-pramoxine kit hydrocortisone acetate external cream OTC hydrocortisone acetate suppository 30 mg hydrocortisone butyr lipo base external cream hydrocortisone butyrate external cream hydrocortisone butyrate external ointment hydrocortisone butyrate external solution hydrocortisone cream 2.5 % hydrocortisone enema hydrocortisone external cream 1 % OTC hydrocortisone external cream 2.5 % hydrocortisone external lotion 1 % OTC hydrocortisone external lotion 2.5 % 59

64 hydrocortisone external ointment 1 % OTC hydrocortisone external ointment 2.5 % hydrocortisone valerate external cream hydrocortisone valerate external ointment hydrocortisone-aloe external cream 1 % OTC hydroquinone external cream hydroquinone time release external cream imiquimod external cream isopropyl alcohol wipes external OTC iv prep wipes external pad 70 % OTC ketoconazole external cream ketoconazole external foam ketoconazole external shampoo KETODAN EXTERNAL KIT lindane external shampoo LUZU EXTERNAL CREAM mafenide acetate external packet malathion external lotion methoxsalen rapid oral capsule metronidazole external cream metronidazole external gel metronidazole external lotion mometasone furoate external cream mometasone furoate external ointment mometasone furoate external solution mupirocin calcium external cream mupirocin external ointment NEUAC EXTERNAL GEL NEUAC EXTERNAL KIT nystatin external cream nystatin external ointment nystatin external powder nystatin-triamcinolone external cream nystatin-triamcinolone external ointment OXSORALEN ULTRA ORAL CAPSULE Tier 4 PANRETIN EXTERNAL GEL permethrin external cream 60

65 PICATO EXTERNAL GEL podofilox external solution prednicarbate external ointment PROCTO-PAK CREAM PROCTOZONE-HC CREAM RECTIV OINTMENT REGRANEX EXTERNAL GEL PA ROSADAN EXTERNAL KIT 0.75 % (CREAM) ROSULA EXTERNAL PAD salicylic acid external cream salicylic acid external foam salicylic acid external lotion salicylic acid-cleanser external kit SANTYL EXTERNAL OINTMENT scalacort external lotion selenium sulfide external lotion selenium sulfide external shampoo silver sulfadiazine external cream sodium chloride irrigation solution 0.9 % sodium sulfacetamide external shampoo sodium sulfacetamide wash external liquid SOLARAZE TRANSDERMAL GEL SORIATANE ORAL CAPSULE 10 MG, 17.5 MG spinosad external suspension sss 10-5 external foam sulfacetamide sodium (acne) external lotion sulfacetamide sodium external gel sulfacetamide sodium external liquid sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 % sulfacetamide sodium-sulfur external emulsion sulfacetamide sodium-sulfur external liquid % sulfacetamide sodium-sulfur external lotion 10-5 % 61

66 sulfacetamide sodium-sulfur external pad 10-4 % sulfacetamide sodium-sulfur external suspension sulfacetamide sod-sulfur wash external kit sulfacetamide-sulfur in urea external emulsion sulfacetamide-sulfur-sunscreen external kit TARGRETIN EXTERNAL GEL TAZORAC EXTERNAL CREAM TAZORAC EXTERNAL GEL terbinafine hcl external cream OTC tretinoin (emollient) external cream tretinoin external cream tretinoin external gel 0.01 %, % tretinoin microsphere external gel triamcinolone acetonide external cream %, 0.5 % triamcinolone acetonide external lotion triamcinolone acetonide external ointment TRIDERM EXTERNAL CREAM U-CORT EXTERNAL CREAM ULESFIA EXTERNAL LOTION urea external cream 40 % urea external lotion 40 % urea nail film external suspension WOUND WASH SALINE EXTERNAL SOLUTION Enzyme Replacement/ Modifiers (Hormone And Enzyme Drugs) Enzyme Replacement/ Modifiers (Enzyme Deficiency Drugs) ADAGEN INTRAMUSCULAR* SOLUTION Tier 4 ALDURAZYME INTRAVENOUS* SOLUTION Tier 4 CEREZYME INTRAVENOUS* SOLUTION 400 UNIT Tier 4 CYSTADANE ORAL POWDER Tier 4 ELAPRASE INTRAVENOUS* SOLUTION Tier 4 OTC 62

67 FABRAZYME INTRAVENOUS* SOLUTION Tier 4 KANUMA INTRAVENOUS* SOLUTION Tier 4 PA KUVAN ORAL PACKET 100 MG Tier 4 KUVAN ORAL TABLET SOLUBLE Tier 4 levocarnitine intravenous* solution levocarnitine oral solution OTC levocarnitine oral tablet LUMIZYME INTRAVENOUS* SOLUTION Tier 4 NAGLAZYME INTRAVENOUS* SOLUTION Tier 4 ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ZAVESCA ORAL CAPSULE Tier 4 Gastrointestinal Agents (Bowel, Instestine, And Stomach Condition Drugs) Antispasmodics Gastrointestinal (Bowel Treatment Drugs) atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml belladonna alkaloids-opium suppository dicyclomine hcl oral capsule dicyclomine hcl oral solution dicyclomine hcl oral tablet glycopyrrolate oral tablet hyoscyamine sulfate er oral tablet extended release 12 hr* hyoscyamine sulfate oral elixir hyoscyamine sulfate oral solution hyoscyamine sulfate oral tablet hyoscyamine sulfate oral tablet dispersible hyoscyamine sulfate sublingual tablet sublingual methscopolamine bromide oral tablet 2.5 mg SYMAX DUOTAB ORAL TABLET EXTENDEDRELEASE* SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HR* 63

68 Digestive Enzymes (Miscellaneous Digestive System Drugs) CREON ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT Gastrointestinal Agents Other (Miscellaneous Digestive System Drugs) CHOLBAM ORAL CAPSULE Tier 4 diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet FULYZAQ ORAL TABLET DELAYED RELEASE loperamide hcl oral capsule metoclopramide hcl injection solution metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet MOVANTIK ORAL TABLET RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML ursodiol oral capsule ursodiol oral tablet Histamine2 (H2) Receptor Antagonists (Ulcer And Stomach Acid Drugs) cimetidine 200 oral tablet OTC cimetidine hcl oral solution cimetidine oral tablet 300 mg, 400 mg, 800 mg famotidine intravenous* solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml, 500 mg/50ml famotidine oral suspension reconstituted famotidine oral tablet 20 mg, 40 mg ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml ranitidine hcl oral capsule PA 64

69 ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg OTC ranitidine hcl oral tablet 300 mg Irritable Bowel Syndrome Agents (Bowel Treatment Drugs) alosetron hcl oral tablet AMITIZA ORAL CAPSULE Laxatives (Constipation Drugs) lactulose encephalopathy oral solution lactulose oral solution 10 gm/15ml peg 3350 oral powder OTC polyethylene glycol 3350 oral packet OTC Ppaca Bowel Prep (Bowel Treatment Drugs) COLYTE WITH FLAVOR PACKS ORAL SOLUTION 240 GM GAVILYTE-C ORAL SOLUTION GAVILYTE-G ORAL SOLUTION GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION GOLYTELY ORAL SOLUTION MOVIPREP ORAL SOLUTION NULYTELY WITH FLAVOR PACKS ORAL SOLUTION peg 3350/electrolytes oral solution reconstituted peg 3350-kcl-na bicarb-nacl oral solution reconstituted peg-3350/electrolytes oral solution reconstituted PREPOPIK ORAL PACKET SUPREP BOWEL PREP ORAL SOLUTION PA TRILYTE ORAL SOLUTION PA PA PA PA PA PA 65

70 Protectants (Miscellaneous Digestive System Drugs) CARAFATE ORAL SUSPENSION misoprostol oral tablet sucralfate oral tablet Proton Pump Inhibitors (Ulcer And Stomach Acid Drugs) amoxicill-clarithro-lansopraz oral DEXILANT ORAL CAPSULE DELAYED RELEASE esomeprazole magnesium oral capsule delayed release 40 mg lansoprazole oral capsule delayed release 15 mg lansoprazole oral capsule delayed release 30 mg omeprazole magnesium oral capsule delayed release OTC OTC; QL (60 EA per 30 days) omeprazole oral capsule delayed release QL (60 EA per 30 days) omeprazole-sodium bicarbonate oral capsule mg omeprazole-sodium bicarbonate oral capsule mg pantoprazole sodium intravenous* solution reconstituted pantoprazole sodium oral tablet delayed release rabeprazole sodium oral tablet delayed release Genitourinary Agents (Bladder, Genital, And Kidney Condition Drugs) Antispasmodics Urinary (Bladder Muscle Relaxants) bethanechol chloride oral tablet 10 mg darifenacin hydrobromide er oral tablet extended release 24 hr* HYOPHEN ORAL TABLET MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 66 OTC ST ST

71 oxybutynin chloride er oral tablet extended release 24 hr* oxybutynin chloride oral syrup oxybutynin chloride oral tablet tolterodine tartrate er oral capsule extended release 24 hour tolterodine tartrate oral tablet trospium chloride er oral capsule extended release 24 hour trospium chloride oral tablet URECHOLINE ORAL TABLET 10 MG UTA ORAL CAPSULE UTIRA-C ORAL TABLET VESICARE ORAL TABLET Benign Prostatic Hypertrophy Agents (Prostate Drugs) AVODART ORAL CAPSULE CIALIS ORAL TABLET 2.5 MG, 5 MG PA; QL (30 EA per 30 days) dutasteride-tamsulosin hcl oral capsule finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE tamsulosin hcl oral capsule Genitourinary Agents Other (Miscellaneous Bladder, Genital, And Kidney Condition Drugs) CYSTAGON ORAL CAPSULE ELMIRON ORAL CAPSULE neomycin-polymyxin b gu irrigation solution phenazopyridine hcl oral tablet 100 mg, 200 mg potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 5 meq (540 mg) Phosphate Binders (Phosphate Removing Drugs) calcium acetate (phos binder) oral capsule FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG Tier 4 RENVELA ORAL PACKET Tier 4 67

72 RENVELA ORAL TABLET Tier 4 Vaginal Products (Hormone Replacement/Modifying Drugs) PREMARIN VAGINAL CREAM Vaginal Products (Vaginal Infection Drugs) clindamycin phosphate vaginal cream metronidazole vaginal gel miconazole 3 combo pack vaginal kit OTC miconazole 3 vaginal suppository terconazole vaginal cream terconazole vaginal suppository Hematopoietic Agents *Granulocyte Colony-Stimulating Factors (G-Csf)*** NEUPOGEN INJECTION Tier 4 NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML *Granulocyte/Macrophage Colony-Stimulating Factor LEUKINE INTRAVENOUS* SOLUTION Erythropoietins PROCRIT INJECTION SOLUTION UNIT/ML, UNIT/ML, 3000 UNIT/ML, UNIT/ML PROCRIT INJECTION SOLUTION 2000 UNIT/ML, 4000 UNIT/ML Hematopoietic Agents, Other NEUMEGA SUBCUTANEOUS* SOLUTION Hereditary Orotic Aciduria Treatment Agents *Hereditary Orotic Aciduria Treatment - Agents** Tier 4 Tier 4 Tier 4 Tier 4 XURIDEN ORAL PACKET PA PA 68

73 Hormonal Agents Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids (Anti-Inflammatory Drugs) budesonide oral capsule delayed release particles cortisone acetate oral tablet dexamethasone oral solution dexamethasone oral tablet dexamethasone sodium phosphate injection solution 120 mg/30ml, 20 mg/5ml, 4 mg/ml hydrocortisone oral tablet methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg prednisolone oral solution prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisone oral 10 mg (48), 5 mg (21), 5 mg (48) prednisone oral tablet 10 mg UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Tier 4 fludrocortisone acetate oral tablet prednisone oral 10 mg (21) prednisone oral solution prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 50 mg ST 69

74 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) (Hormone And Diabetic Drugs) Anabolic Steroids (Male Hormone Drugs) oxandrolone oral tablet 10 mg Tier 4 oxandrolone oral tablet 2.5 mg Androgens (Male Hormone Drugs) ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%) ANDROID ORAL CAPSULE Tier 4 PA ANDROXY ORAL TABLET danazol oral capsule testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution testosterone transdermal gel 50 mg/5gm (1%) Estrogens (Hormone Replacement/Modifying Drugs) estradiol oral tablet estradiol transdermal patch weekly estropipate oral tablet MENEST ORAL TABLET PREMARIN INJECTION SOLUTION PREMARIN ORAL TABLET PREMPHASE ORAL TABLET PREMPRO ORAL TABLET Ppaca Oral Contraceptives (Birth Control Drugs) norethindrone-eth estradiol oral tablet 1-5 mg-mcg 70

75 Progestins (Hormone Replacement/Modifying Drugs) DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML Tier 5 medroxyprogesterone acetate oral tablet MEGACE ES ORAL SUSPENSION megestrol acetate oral suspension 625 mg/5ml norethindrone acetate oral tablet progesterone micronized oral capsule Selective Estrogen Receptor Modifying Agents raloxifene hcl oral tablet PA Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) (Hormone And Diabetic Drugs) *Growth Hormones*** HUMATROPE INJECTION SOLUTION 12 MG, 24 MG NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS* SOLUTION NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS* SOLUTION NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS* SOLUTION NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION SAIZEN CLICK.EASY INJECTION SOLUTION SAIZEN INJECTION SOLUTION *Insulin-Like Growth Factors (Somatomedins)*** Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 INCRELEX SUBCUTANEOUS* SOLUTION Tier 4 *Progesterone Receptor Antagonists*** KORLYM ORAL TABLET Tier 4 PA PA PA PA PA PA PA PA 71

76 Hormonal Agents, Stimulant/Replacement/ Modifying [(Pituitary) Hormone Replacement/Modifying Drugs] chorionic gonadotropin intramuscular* solution reconstituted desmopressin ace rhinal tube nasal solution desmopressin ace spray refrig nasal solution desmopressin acetate injection solution desmopressin acetate oral tablet desmopressin acetate spray nasal solution SIGNIFOR SUBCUTANEOUS* SOLUTION Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) (Hormone And Diabetic Drugs) Thyroid Replacement LEVO-T ORAL TABLET 88 MCG LEVOTHROID ORAL TABLET 125 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg SYNTHROID ORAL TABLET Hormonal Agents, Stimulant/Replacement/Modifying (Parathyroid) Hormonal Agents, Stimulant/Replacement/ Modifying [(Parathyroid) Hormone Replacement/Modifying Drugs] NATPARA SUBCUTANEOUS* PA Hormonal Agents, Suppressant (Parathyroid) (Hormone And Diabetic Drugs) Hormonal Agents, Suppressant [(Parathyroid) Drugs To Treat High Calcium] SENSIPAR ORAL TABLET 30 MG 72

77 SENSIPAR ORAL TABLET 60 MG, 90 MG Tier 4 Hormonal Agents, Suppressant (Pituitary) (Hormone And Diabetic Drugs) Hormonal Agents, Suppressant [(Pituitary) Miscellaneous Hormone And Diabetic Drugs] LUPRON DEPOT-PED INTRAMUSCULAR* KIT MG (PED), 30 MG (PED), 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR* KIT MG, 15 MG octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 200 mcg/ml, 50 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION SOMAVERT SUBCUTANEOUS* SOLUTION 10 MG, 15 MG, 20 MG Tier 5 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 SYNAREL NASAL SOLUTION Tier 4 Hormonal Agents, Suppressant (Thyroid) (Hormone And Diabetic Drugs) *Antithyroid Agents*** methimazole oral tablet propylthiouracil oral tablet Thyroid Replacement levothyroxine sodium oral tablet 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium oral tablet NATURE-THROID ORAL TABLET MG np thyroid oral tablet 30 mg, 60 mg, 90 mg UNITHROID ORAL TABLET 73

78 Immunological Agents (Drugs Affecting The Immune System) *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML Tier 4 HUMIRA PEN SUBCUTANEOUS* Tier 4 HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* HUMIRA SUBCUTANEOUS* 20 MG/0.4ML, 40 MG/0.8ML Tier 4 Tier 4 Tier 4 KINERET SUBCUTANEOUS* Tier 4 ST SIMPONI ARIA INTRAVENOUS* SOLUTION Tier 4 SIMPONI SUBCUTANEOUS* Tier 4 *Interleukin-6 Receptor Inhibitors*** ACTEMRA INTRAVENOUS* SOLUTION Tier 4 ST ACTEMRA SUBCUTANEOUS* Tier 4 ST *Selective Costimulation Modulators*** ORENCIA INTRAVENOUS* SOLUTION Tier 4 ORENCIA SUBCUTANEOUS* Tier 4 ST *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS* Tier 4 ENBREL SURECLICK SUBCUTANEOUS* Tier 4 Angioedema (Hae) Agents (Immune System Drugs) FIRAZYR SUBCUTANEOUS* SOLUTION Tier 4 Antipsoratics--Systemic COSENTYX SENSOREADY PEN SUBCUTANEOUS* 150 MG/ML Tier 4 COSENTYX SUBCUTANEOUS* Tier 4 ST ST 74

79 Immune Suppressants (Immune System Drugs) ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR AZASAN ORAL TABLET azathioprine oral tablet BENLYSTA INTRAVENOUS* SOLUTION CELLCEPT INTRAVENOUS INTRAVENOUS* SOLUTION Tier 4 cyclosporine intravenous* solution cyclosporine modified oral capsule cyclosporine modified oral solution ENBREL SUBCUTANEOUS* SOLUTION Tier 4 GENGRAF ORAL CAPSULE GENGRAF ORAL SOLUTION ILARIS SUBCUTANEOUS* SOLUTION mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension reconstituted mycophenolate mofetil oral tablet mycophenolic acid oral tablet delayed release MYFORTIC ORAL TABLET DELAYED RELEASE NULOJIX INTRAVENOUS* SOLUTION Tier 4 PROGRAF INTRAVENOUS* SOLUTION RAPAMUNE ORAL SOLUTION RHEUMATREX ORAL TABLET 2.5 MG SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SIMPONI ARIA INTRAVENOUS* SOLUTION Tier 4 sirolimus oral tablet tacrolimus oral capsule 0.5 mg, 1 mg tacrolimus oral capsule 5 mg 75

80 ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG Immunizing Agents, Passive (Immune System Drugs) Tier 4 ATGAM INTRAVENOUS* INJECTABLE Tier 4 CARIMUNE NF INTRAVENOUS* SOLUTION Tier 4 GAMMAGARD INJECTION SOLUTION Tier 4 GAMMAGARD S/D INTRAVENOUS* SOLUTION 2.5 GM GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION Tier 4 Tier 4 GAMMAPLEX INTRAVENOUS* SOLUTION Tier 4 THYMOGLOBULIN INTRAVENOUS* SOLUTION Immunomodulators (Immune System Drugs) Tier 4 ARAVA ORAL TABLET ARCALYST SUBCUTANEOUS* SOLUTION Tier 4 leflunomide oral tablet RIDAURA ORAL CAPSULE Ppaca Adult Vac (Vaccines) ZOSTAVAX SUBCUTANEOUS* SOLUTION Ppaca Child Vac (Vaccines) ACTHIB INTRAMUSCULAR* SOLUTION CERVARIX INTRAMUSCULAR* SUSPENSION COMVAX INTRAMUSCULAR* SUSPENSION ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML GARDASIL INTRAMUSCULAR* SUSPENSION HAVRIX INTRAMUSCULAR* SUSPENSION IPOL INJECTION INJECTABLE 76

81 MENACTRA INTRAMUSCULAR* INJECTABLE MENOMUNE SUBCUTANEOUS* INJECTABLE MENVEO INTRAMUSCULAR* SOLUTION M-M-R II SUBCUTANEOUS* INJECTABLE PEDVAX HIB INTRAMUSCULAR* SUSPENSION PROQUAD SUBCUTANEOUS* INJECTABLE RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION ROTATEQ ORAL SOLUTION tetanus toxoid adsorbed intramuscular* solution TWINRIX INTRAMUSCULAR* SUSPENSION VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE Tumor Necrosis Factor Alpha Blockers CIMZIA PREFILLED SUBCUTANEOUS* KIT Tier 4 ST CIMZIA STARTER KIT SUBCUTANEOUS* KIT Tier 4 CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG Tier 4 ST REMICADE INTRAVENOUS* SOLUTION Vaccines (Vaccines) Tier 4 ADACEL INTRAMUSCULAR* SUSPENSION AFLURIA INTRAMUSCULAR* SUSPENSION AFLURIA PRESERVATIVE FREE INTRAMUSCULAR* bcg vaccine injection injectable BOOSTRIX INTRAMUSCULAR* SUSPENSION ST

82 DAPTACEL INTRAMUSCULAR* SUSPENSION EZ FLU SHOT-FLUCELVAX INTRAMUSCULAR* FLUARIX INTRAMUSCULAR* FLUARIX QUADRIVALENT INTRAMUSCULAR* FLUBLOK INTRAMUSCULAR* SOLUTION FLUCELVAX INTRAMUSCULAR* FLULAVAL QUADRIVALENT INTRAMUSCULAR* FLULAVAL QUADRIVALENT INTRAMUSCULAR* SUSPENSION FLUMIST QUADRIVALENT NASAL SUSPENSION FLUVIRIN INTRAMUSCULAR* FLUVIRIN INTRAMUSCULAR* SUSPENSION FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR* FLUZONE HIGH-DOSE INTRAMUSCULAR* FLUZONE PRESERVATIVE FREE INTRAMUSCULAR* SUSPENSION FLUZONE QUADRIVALENT INTRADERMAL* FLUZONE QUADRIVALENT INTRAMUSCULAR* FLUZONE QUADRIVALENT INTRAMUSCULAR* SUSPENSION, 0.5 ML IMOVAX RABIES INTRAMUSCULAR* INJECTABLE INFANRIX INTRAMUSCULAR* SUSPENSION IXIARO INTRAMUSCULAR* SUSPENSION PNEUMOVAX 23 INJECTION INJECTABLE PREVNAR 13 INTRAMUSCULAR* SUSPENSION RABAVERT INTRAMUSCULAR* SUSPENSION tetanus-diphtheria toxoids td intramuscular* suspension 78

83 TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML YF-VAX SUBCUTANEOUS* INJECTABLE Inflammatory Bowel Disease Agents (Bowel, Instestine, And Stomach Condition Drugs) Aminosalicylates (Bowel Treatment Drugs) APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR ASACOL HD ORAL TABLET DELAYED RELEASE balsalazide disodium oral capsule mesalamine enema mesalamine-cleanser kit ROWASA KIT SFROWASA ENEMA Sulfonamides (Bowel Treatment Drugs) DIPENTUM ORAL CAPSULE sulfasalazine oral tablet sulfasalazine oral tablet delayed release Metabolic Bone Disease Agents (Hormone And Bone Drugs) *Bisphosphonates*** alendronate sodium oral tablet 10 mg, 40 mg, 5 mg QL (30 EA per 30 days) alendronate sodium oral tablet 35 mg QL (8 EA per 28 days) alendronate sodium oral tablet 70 mg QL (4 EA per 28 days) FOSAMAX PLUS D ORAL TABLET ibandronate sodium oral tablet pamidronate disodium intravenous* solution Metabolic Bone Disease Agents (Osteoporosis Drugs) calcitonin (salmon) nasal solution calcitriol intravenous* solution 1 mcg/ml calcitriol oral capsule calcitriol oral solution 79

84 doxercalciferol oral capsule FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML pamidronate disodium intravenous* solution reconstituted Tier 4 paricalcitol intravenous* solution paricalcitol oral capsule PROLIA SUBCUTANEOUS* SOLUTION Tier 4 RECLAST INTRAVENOUS* SOLUTION Tier 4 risedronate sodium oral tablet 150 mg risedronate sodium oral tablet delayed release XGEVA SUBCUTANEOUS* SOLUTION Tier 4 ZEMPLAR INTRAVENOUS* SOLUTION zoledronic acid intravenous* concentrate zoledronic acid intravenous* solution 5 mg/100ml zoledronic acid intravenous* solution reconstituted Miscellaneous (Misc) *Applicators,Cotton Balls,Etc*** alcohol pads pad OTC alcohol swabs pad 70 % OTC *Needles & Syringes*** insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml OTC insulin syringe/needle OTC pen needles 1/2" OTC pen needles 29g x 12mm, 31g x 5 mm, 31g x 6 mm, 32g x 4 mm OTC pen needles 3/16" OTC pen needles 5/16" OTC ULTRA-THIN II PEN NEEDLES OTC Antidotes PRAXBIND INTRAVENOUS* SOLUTION 80

85 Diagnostic Products BAYER BREEZE 2 TEST IN VITRO DISK OTC; QL (300 EA per 30 days) BAYER CONTOUR NEXT TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) BAYER CONTOUR TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) EXACTECH R-S-G TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) EXACTECH TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) FREESTYLE INSULINX TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) FREESTYLE LITE TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) FREESTYLE PRECISION NEO TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) FREESTYLE TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) PRECISION PCX IN VITRO STRIP OTC; QL (300 EA per 30 days) PRECISION PCX PLUS TEST IN VITRO STRIP PRECISION POINT OF CARE TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) OTC; QL (300 EA per 30 days) PRECISION QID TEST IN VITRO STRIP OTC; QL (300 EA per 30 days) PRECISION SOF-TACT TEST IN VITRO STRIP PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP PRECISION XTRA KETONE IN VITRO STRIP Miscellaneous (Miscellaneous Wound Care Drugs) lactated ringers irrigation solution PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution Ophthalmic Agents (Eye Medications) Ophthalmic Agents Other (Miscellaneous Eye Medications) atropine sulfate ophthalmic ointment atropine sulfate ophthalmic solution cyclopentolate hcl ophthalmic solution 1 %, 2 % OTC; QL (30 EA per 300 days) OTC; QL (300 EA per 30 days) OTC; QL (300 EA per 30 days) 81

86 HOMATROPAIRE OPHTHALMIC SOLUTION LACRISERT OPHTHALMIC INSERT naphazoline hcl ophthalmic solution phenylephrine hcl ophthalmic solution 10 %, 2.5 % proparacaine hcl ophthalmic solution RESTASIS OPHTHALMIC EMULSION tropicamide ophthalmic solution Ophthalmic Anti Infectives (Infection Eye Medications) bacitracin ophthalmic ointment bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION ciprofloxacin hcl ophthalmic solution erythromycin ophthalmic ointment gatifloxacin ophthalmic solution GENTAK OPHTHALMIC OINTMENT gentamicin sulfate ophthalmic ointment gentamicin sulfate ophthalmic solution levofloxacin ophthalmic solution MOXEZA OPHTHALMIC SOLUTION neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution POLYCIN OPHTHALMIC OINTMENT polymyxin b-trimethoprim ophthalmic solution sulfacetamide sodium ophthalmic solution tobramycin ophthalmic solution trifluridine ophthalmic solution VIGAMOX OPHTHALMIC SOLUTION ZIRGAN OPHTHALMIC GEL ZYMAXID OPHTHALMIC SOLUTION 82

87 Ophthalmic Anti-Allergy Agents (Allergy Eye Medications) azelastine hcl ophthalmic solution BEPREVE OPHTHALMIC SOLUTION cromolyn sodium ophthalmic solution ELESTAT OPHTHALMIC SOLUTION EMADINE OPHTHALMIC SOLUTION epinastine hcl ophthalmic solution PATADAY OPHTHALMIC SOLUTION PATANOL OPHTHALMIC SOLUTION Ophthalmic Antiglaucoma Agents (Glaucoma Medications) ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl ophthalmic solution AZOPT OPHTHALMIC SUSPENSION betaxolol hcl ophthalmic solution brimonidine tartrate ophthalmic solution carteolol hcl ophthalmic solution COMBIGAN OPHTHALMIC SOLUTION dorzolamide hcl ophthalmic solution dorzolamide hcl-timolol mal ophthalmic solution levobunolol hcl ophthalmic solution 0.5 % metipranolol ophthalmic solution PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % PROLENSA OPHTHALMIC SOLUTION timolol maleate ophthalmic gel forming solution timolol maleate ophthalmic solution Ophthalmic Anti-Inflammatories (Inflammation Eye Medications) BROMDAY OPHTHALMIC SOLUTION bromfenac sodium (once-daily) ophthalmic solution 83

88 bromfenac sodium ophthalmic solution dexamethasone sodium phosphate ophthalmic solution diclofenac sodium ophthalmic solution DUREZOL OPHTHALMIC EMULSION eye wash ophthalmic solution OTC fluorometholone ophthalmic suspension flurbiprofen sodium ophthalmic solution ketorolac tromethamine ophthalmic solution neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension NEO-POLYCIN HC OPHTHALMIC OINTMENT NEVANAC OPHTHALMIC SUSPENSION prednisolone acetate ophthalmic suspension prednisolone sodium phosphate ophthalmic solution sulfacetamide-prednisolone ophthalmic solution TOBRADEX OPHTHALMIC OINTMENT tobramycin-dexamethasone ophthalmic suspension VEXOL OPHTHALMIC SUSPENSION Ophthalmic Prostaglandin And Prostamide Analogs (Glaucoma Medications) latanoprost ophthalmic solution LUMIGAN OPHTHALMIC SOLUTION 0.01 % TRAVATAN Z OPHTHALMIC SOLUTION travoprost ophthalmic solution Otic Agents (Ear Drugs) Otic Agents (Ear Drugs) acetic acid otic solution acetic acid-aluminum acetate otic solution 84

89 antipyrine-benzocaine otic solution mg/ml CIPRODEX OTIC SUSPENSION CORTANE-B AQUEOUS OTIC SOLUTION fluocinolone acetonide otic oil hydrocortisone-acetic acid otic solution neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution otomax-hc otic solution PRAMOTIC OTIC LIQUID Respiratory Tract Agents (Allergies, Cough, Cold, And Lung Condition Drugs) Antihistamines (Allergies/Lung Drugs) ARBINOXA ORAL SOLUTION PA carbinoxamine maleate oral solution cetirizine hcl oral solution clemastine fumarate oral syrup clemastine fumarate oral tablet 2.68 mg cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet desloratadine oral tablet desloratadine oral tablet dispersible diphenhydramine hcl injection solution diphenhydramine hcl oral capsule 25 mg OTC diphenhydramine hcl oral capsule 50 mg OTC diphenhydramine hcl oral elixir OTC diphenhydramine hcl oral liquid OTC levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet WAL-DRYL ALLERGY CHILDRENS ORAL LIQUID OTC 85

90 Anti-Inflammatories Inhaled Corticosteroids (Asthma/Lung Drugs) AEROSPAN INHALATION AEROSOL, SOLUTION budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT Antileukotrienes (Asthma/Lung Drugs) montelukast sodium oral packet montelukast sodium oral tablet montelukast sodium oral tablet chewable zafirlukast oral tablet ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR* ZYFLO ORAL TABLET Bronchodilators Anticholinergic (Asthma/Lung Drugs) ATROVENT HFA INHALATION AEROSOL, SOLUTION INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE Bronchodilators Phosphodiesterase Inhibitors [Xanthines (Asthma/Lung Drugs)] aminophylline intravenous* solution QL (60 EA per 30 days) QL (24 GM per 30 days) QL (22 GM per 30 days) QL (15 GM per 30 days) QL (13 GM per 30 days) QL (30 EA per 30 days) 86

91 theophylline er oral tablet extended release 12 hr* theophylline er oral tablet extended release 24 hr* 600 mg Bronchodilators Sympathomimetic (Asthma/Lung Drugs) ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED QL (60 EA per 30 days) ADVAIR HFA INHALATION AEROSOL QL (12 GM per 30 days) albuterol sulfate er oral tablet extended release 12 hr* albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION DULERA INHALATION AEROSOL epinephrine hcl injection solution 1 mg/ml ipratropium-albuterol inhalation solution levalbuterol hcl inhalation nebulization solution metaproterenol sulfate oral syrup PROAIR HFA INHALATION AEROSOL, SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION QL (4 GM per 30 days) QL (17 GM per 30 days) QL (60 EA per 30 days) SYMBICORT INHALATION AEROSOL QL (11 GM per 30 days) terbutaline sulfate injection solution VENTOLIN HFA INHALATION AEROSOL, SOLUTION Mast Cell Stabilizers (Asthma/Lung Drugs) cromolyn sodium inhalation nebulization solution QL (36 GM per 30 days) 87

92 Nasal Agents (Nasal Allergy Drugs) ASTEPRO NASAL SOLUTION 0.15 % azelastine hcl nasal solution budesonide nasal suspension OTC flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension OTC ipratropium bromide nasal solution olopatadine hcl nasal solution triamcinolone acetonide nasal aerosol OTC TYZINE NASAL SOLUTION 0.05 % Pulmonary Antihypertensives (Pulmonary Drugs) LETAIRIS ORAL TABLET Tier 4 OPSUMIT ORAL TABLET Tier 4 TRACLEER ORAL TABLET Tier 4 VENTAVIS INHALATION SOLUTION Respiratory Tract Agents Other (Miscellaneous Respiratory Drugs) acetylcysteine inhalation solution ARALAST NP INTRAVENOUS* SOLUTION 1000 MG, 500 MG cromolyn sodium oral concentrate DALIRESP ORAL TABLET ESBRIET ORAL CAPSULE Tier 4 PA KALYDECO ORAL TABLET Tier 4 PA NUCALA SUBCUTANEOUS* SOLUTION Tier 4 ORKAMBI ORAL TABLET MG Tier 4 PA PROLASTIN-C INTRAVENOUS* SOLUTION 1000 MG Tier 4 PULMOZYME INHALATION SOLUTION Tier 4 QL (150 ML per 30 days) sildenafil citrate oral tablet PA; QL (90 EA per 30 days) sodium chloride inhalation nebulization solution 0.9 % XOLAIR SUBCUTANEOUS* SOLUTION Tier 4 PA 88

93 Respiratory Tract/Pulmonary Agents Anapylaxis Treatment ADRENALIN INJECTION SOLUTION 1 MG/ML epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml EPIPEN 2-PAK INJECTION EPIPEN JR 2-PAK INJECTION Respiratory Tract/Pulmonary Agents (Allergies, Cough, Cold, And Lung Condition Drugs) Pulmonary Antihypertensives (Pulmonary Drug) sildenafil citrate intravenous* solution PA Skeletal Muscle Relaxants (Muscle And Joint Drugs) Skeletal Muscle Relaxants (Muscle And Joint Drugs) baclofen oral tablet chlorzoxazone oral tablet 500 mg cyclobenzaprine hcl oral tablet dantrolene sodium oral capsule metaxalone oral tablet 800 mg methocarbamol oral tablet orphenadrine citrate er oral tablet extended release 12 hr* orphenadrine citrate injection solution tizanidine hcl oral capsule tizanidine hcl oral tablet Sleep Disorder Agents (Sleep Condition Drugs) Barbiturates (Sedation And Sleep Drugs) SECONAL ORAL CAPSULE 89

94 Benzodiazepines (Sedation And Sleep Drugs) estazolam oral tablet flurazepam hcl oral capsule temazepam oral capsule triazolam oral tablet Gaba Receptor Modulators (Sedation And Sleep Drugs) eszopiclone oral tablet zaleplon oral capsule zolpidem tartrate oral tablet QL (30 EA per 30 days) Sleep Disorders Other (Sedation And Sleep Drugs) modafinil oral tablet PA NUVIGIL ORAL TABLET 250 MG, 50 MG sleep-aid maximum strength oral capsule OTC XYREM ORAL SOLUTION Tier 4 Therapeutic Nutrients/ Minerals/ Electrolytes (Multivitamins And Replacement Solutions) *Prenatal Mv & Min W/Fe-Fa*** prenatal low iron oral tablet mg OTC prenatal one daily oral tablet OTC prenatal vitamin oral tablet OTC RIGHT STEP PRENATAL ORAL TABLET OTC Electrolyte/Mineral Modifiers (Antidotes/Protectants) CHEMET ORAL CAPSULE EXJADE ORAL TABLET SOLUBLE Tier 4 KIONEX ORAL POWDER KIONEX ORAL SUSPENSION sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate suspension 50 gm/200ml 90

95 Electrolyte/Mineral Modifiers (Electrolytes Replacements) SAMSCA ORAL TABLET Tier 4 PA Electrolyte/Mineral Replacement (Electrolytes Replacements) CARBAGLU ORAL TABLET Tier 4 chromic chloride intravenous* solution effervescent pot chloride oral tablet effervescent gnp vitamin d-400 oral tablet OTC HYPERLYTE-CR INTRAVENOUS* SOLUTION kcl in dextrose-nacl intravenous* solution meq/l-%-%, meq/l-%-% k-effervescent oral tablet effervescent KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* KLOR-CON M15 ORAL TABLET EXTENDEDRELEASE* KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* KLOR-CON ORAL PACKET KLOR-CON ORAL TABLET EXTENDEDRELEASE* magnesium chloride injection solution magnesium sulfate injection solution 50 % nutrilyte intravenous* concentrate pot bicarb-pot chloride oral tablet effervescent potassium acetate intravenous* solution potassium bicarbonate oral tablet effervescent potassium chloride crys er oral tablet extendedrelease* potassium chloride er oral capsule extended release* potassium chloride er oral tablet extendedrelease* 91

96 potassium chloride in nacl intravenous* solution meq/l-% potassium chloride intravenous* solution potassium chloride oral packet potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) sodium chloride injection solution sodium chloride intravenous* solution 0.9 %, 4 meq/ml sodium lactate intravenous* solution 5 meq/ml virt-phos 250 neutral oral tablet zinc sulfate oral capsule OTC Electrolyte/Mineral Replacement (Fluid Replacements) dextrose in lactated ringers intravenous* solution dextrose-nacl intravenous* solution %, %, %, %, %, % ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION ISOLYTE-S INTRAVENOUS* SOLUTION ISOLYTE-S PH 7.4 INTRAVENOUS* SOLUTION kcl in d5w lactated ringers intravenous* solution kcl in dextrose-nacl intravenous* solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous* solution lactated ringers intravenous* solution NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R INTRAVENOUS* SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION 92

97 PLASMA-LYTE 148 INTRAVENOUS* SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous* solution meq/l-%, meq/l-% ringers intravenous* solution saline flush intravenous* solution sodium chloride bacteriostatic injection solution sodium chloride flush intravenous* solution sodium chloride intravenous* solution 0.45 %, 3 %, 5 % Nutrients (Fluid Replacements) AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 % AMINOSYN M INTRAVENOUS* SOLUTION AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % AMINOSYN-PF INTRAVENOUS* SOLUTION 7 % CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS* SOLUTION CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS* SOLUTION 93

98 CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (5/20) INTRAVENOUS* SOLUTION CLINIMIX/DEXTROSE (5/25) INTRAVENOUS* SOLUTION dextrose intravenous* solution 10 %, 5 % FER-IN-SOL ORAL SOLUTION OTC ferrous sulfate oral elixir OTC ferrous sulfate oral liquid OTC ferrous sulfate oral solution 75 (15 fe) mg/ml OTC folic acid oral tablet 1 mg OTC HEPATASOL INTRAVENOUS* SOLUTION INTRALIPID INTRAVENOUS* EMULSION 20 % iron chews pediatric oral tablet chewable OTC NEPHRAMINE INTRAVENOUS* SOLUTION PREMASOL INTRAVENOUS* SOLUTION 6 % PROCALAMINE INTRAVENOUS* SOLUTION PROSOL INTRAVENOUS* SOLUTION Ppaca Folic (Vitamins) calcium pnv oral capsule CITRANATAL B-CALM ORAL CONCEPT OB ORAL CAPSULE folcal dha oral capsule mg FOLIVANE-OB ORAL CAPSULE FOLIVANE-PRX DHA NF ORAL CAPSULE GESTICARE DHA ORAL 27-1 & 250 MG INATAL ADVANCE ORAL TABLET INATAL GT ORAL TABLET INATAL ULTRA ORAL TABLET 94

99 multi prenatal oral tablet OTC MYNATAL ADVANCE ORAL TABLET MYNATAL ORAL TABLET NATELLE ONE ORAL CAPSULE MG pnv fe fum/docusate/folic acid oral tablet pnv-dha oral capsule pnv-dha+docusate oral capsule prenaissance oral capsule prenatal 19 oral tablet rulavite dha oral capsule se-natal 19 oral tablet TARON-BC ORAL TARON-PREX ORAL CAPSULE thrivite 19 oral tablet tl-select oral capsule triadvance oral tablet trinatal gt oral tablet ultra tabs oral tablet VEMAVITE-PRX 2 ORAL CAPSULE VINACAL B ORAL virt-advance oral tablet virt-pn dha oral capsule virt-select oral capsule virt-vite gt oral tablet VITAFOL-ONE ORAL CAPSULE ZATEAN-PN DHA ORAL CAPSULE Vitamins (Vitamins) aqueous vitamin d oral liquid OTC bp folinatal plus b oral tablet multi-vit/fluoride oral solution 0.5 mg/ml multi-vitamin/fluoride oral solution multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG niacin er oral tablet extendedrelease* 500 mg, 750 mg 95 OTC

100 one-daily multi vitamins oral tablet OTC triple-vitamin/fluoride oral solution tri-vitamin/fluoride oral solution 0.5 mg/ml vitamin d (cholecalciferol) oral tablet 400 unit OTC vitamin d oral liquid OTC 96

101 Index 8-MOP abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE acarbose acebutolol hcl acetaminophen-codeine... 4 acetaminophen-codeine # acetaminophen-codeine # acetazolamide acetazolamide er acetic acid acetic acid-aluminum acetate acetylcysteine acitretin ACT ANTICAVITY FLUORIDE RINSE ACTEMRA ACTHIB ACTIMMUNE ACTOPLUS MET XR acyclovir... 33, 56 acyclovir sodium ADACEL ADAGEN adapalene adefovir dipivoxil ADRENALIN adult aspirin low strength ADVAIR DISKUS ADVAIR HFA ADVICOR AEROSPAN AFINITOR AFINITOR DISPERZ AFLURIA AFLURIA PRESERVATIVE FREE AGGRENOX ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate... 56, 57 alcohol pads alcohol swabs ALDURAZYME ALECENSA alendronate sodium ALIMTA ALINIA allopurinol alosetron hcl ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL alprazolam xr ALTAVERA ALTOPREV alyacen 1/ alyacen 7/7/ amantadine hcl... 29, 30 amcinonide AMETHIA AMETHIA LO AMETHYST amifostine amikacin sulfate... 6 amiloride hcl amiloride-hydrochlorothiazide aminophylline AMINOSYN AMINOSYN M AMINOSYN/ELECTROLYTES AMINOSYN-PF amiodarone hcl AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan-hctz ammonium lactate amoxapine amoxicill-clarithro-lansopraz amoxicillin amoxicillin-pot clavulanate... 9, 10 amoxicillin-pot clavulanate er... 9 amphetamine-dextroamphet er amphetamine-dextroamphetami ne amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam sodium AMPYRA AMTURNIDE anagrelide hcl anastrozole ANDRODERM ANDROGEL ANDROID ANDROXY antipyrine-benzocaine APIDRA APIDRA SOLOSTAR APLENZIN APOKYN apraclonidine hcl APRI APRISO APTIVUS aqueous vitamin d ARALAST NP ARANELLE ARAVA ARBINOXA ARCALYST aripiprazole ARISTADA ARRANON ARZERRA ASACOL HD ASHLYNA aspirin aspirin adult low dose aspirin ec aspirin low dose aspirin-dipyridamole er ASTAGRAF XL ASTEPRO ATACAND atenolol atenolol-chlorthalidone ATGAM atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate... 63, 81 ATROVENT HFA AUBAGIO AUBRA AVANDAMET AVANDIA... 39

102 AVASTIN AVIANE AVODART AVYCAZ... 9 azacitidine AZASAN azathioprine azelastine hcl... 83, 88 AZILECT azithromycin... 9 AZOPT aztreonam... 7 AZURETTE bacitracin... 7, 82 bacitracin-polymyxin b baclofen balsalazide disodium BANZEL BARACLUDE BAYER ASPIRIN EXTRA STRENGTH BAYER BREEZE 2 TEST BAYER CONTOUR NEXT TEST BAYER CONTOUR TEST bcg vaccine BEKYREE belladonna alkaloids-opium benazepril hcl benazepril-hydrochlorothiazide BENLYSTA benzonatate benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 44, 83 bethanechol chloride bexarotene BEYAZ bicalutamide BICNU bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin sulfate BLINCYTO BLISOVI 24 FE BLISOVI FE 1.5/ BLISOVI FE 1/ BOOSTRIX BOSULIF bp folinatal plus b bp wash BREO ELLIPTA briellyn brimonidine tartrate BRISDELLE BROMDAY bromfenac sodium bromfenac sodium (once-daily) bromocriptine mesylate BUDEPRION SR budesonide... 69, 86, 88 bumetanide buprenorphine hcl... 6 buprenorphine hcl-naloxone hcl... 6 bupropion hcl bupropion hcl er (smoking det)... 6 bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl BUSULFEX butalbital-acetaminophen... 3 butalbital-apap-caff-cod... 4 butalbital-apap-caffeine... 3 butalbital-asa-caff-codeine... 4 butalbital-asa-caffeine... 3 BUTISOL SODIUM BUTRANS... 5 BYETTA 10 MCG PEN BYETTA 5 MCG PEN calcipotriene calcitonin (salmon) calcitriol calcium acetate (phos binder) calcium pnv CAMRESE CAMRESE LO CANCIDAS candesartan cilexetil candesartan cilexetil-hctz CAPASTAT SULFATE capecitabine CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE CARBAGLU carbamazepine carbamazepine er carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapon e carbinoxamine maleate carboplatin CARIMUNE NF carteolol hcl carvedilol CAVIRINSE CAYA CAYSTON... 8 CAZIANT cefaclor... 8 cefaclor er... 8 cefadroxil... 8 cefazolin sodium... 8 cefdinir... 8 cefditoren pivoxil... 8 cefepime hcl... 8 cefixime... 8 cefoxitin sodium... 8 cefpodoxime proxetil... 8, 9 cefprozil... 9 ceftazidime... 8 ceftriaxone sodium... 8 cefuroxime axetil... 9 cefuroxime sodium... 8 celecoxib CELLCEPT INTRAVENOUS CELONTIN cephalexin... 9 CEREZYME CERVARIX CESIA cetirizine hcl CHANTIX... 6 CHANTIX CONTINUING MONTH PAK... 6 CHANTIX STARTING MONTH PAK... 6 CHATEAL CHEMET chloramphenicol sod succinate... 7 chlordiazepoxide hcl chlordiazepoxide-amitriptyline chlorhexidine gluconate chloroquine phosphate... 29

103 chlorothiazide chlorpromazine hcl chlorpropamide chlorthalidone chlorzoxazone CHOLBAM cholestyramine cholestyramine light choline & mag trisalicylate... 5 choline-mag trisalicylate... 5 chorionic gonadotropin chromic chloride CIALIS CICLODAN CREAM CICLODAN SOLUTION ciclopirox ciclopirox olamine ciclopirox treatment ciclopirox-vitamin e cilostazol cimetidine cimetidine cimetidine hcl CIMZIA CIMZIA PREFILLED CIMZIA STARTER KIT CIPRODEX ciprofloxacin... 10, 11 ciprofloxacin hcl... 10, 82 ciprofloxacin-ciproflox hcl er cisplatin citalopram hydrobromide CITRANATAL B-CALM cladribine CLARAVIS clarithromycin... 9 clarithromycin er... 9 clemastine fumarate CLINDACIN PAC clindamycin hcl... 7 clindamycin palmitate hcl... 7 clindamycin phos-benzoyl perox clindamycin phosphate... 7, 58, 68 CLINIMIX E/DEXTROSE (2.75/10) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/10) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) CLINPRO clobetasol propionate clobetasol propionate e clobetasol propionate emulsion CLODERM PUMP CLOLAR clomipramine hcl clonazepam clonidine hcl clopidogrel bisulfate clorazepate dipotassium clotrimazole... 18, 58 clotrimazole-betamethasone clozapine COLCRYS cold & allergy cold sore treatment colestipol hcl colistimethate sodium... 7 COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMPLERA COMVAX CONCEPT OB CONCERTA CONDYLOX COPAXONE CORMAX SCALP APPLICATION CORTANE-B AQUEOUS cortisone acetate COSENTYX COSENTYX SENSOREADY PEN COSMEGEN COTELLIC CREON CRESEMBA CRIXIVAN cromolyn sodium... 83, 87, 88 CRYSELLE CYCLAFEM 1/ CYCLAFEM 7/7/ cyclobenzaprine hcl cyclopentolate hcl cyclophosphamide cycloserine CYCLOSET cyclosporine cyclosporine modified cyproheptadine hcl CYRED CYSTADANE CYSTAGON cytarabine cytarabine (pf) dacarbazine DACOGEN DALIRESP danazol dantrolene sodium dapsone DAPTACEL DARAPRIM darifenacin hydrobromide er DARZALEX DASETTA 1/ DASETTA 7/7/ daunorubicin hcl DAYSEE DEBLITANE decitabine DELYLA demeclocycline hcl DENTA 5000 PLUS DENTAGEL DEPO-PROVERA... 71

104 DEPO-SUBQ PROVERA DERMAZENE DESGEN PEDIATRIC desipramine hcl desloratadine desmopressin ace rhinal tube desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine er desvenlafaxine fumarate er dexamethasone dexamethasone sodium phosphate... 69, 84 DEXILANT dexmethylphenidate hcl dexmethylphenidate hcl er dexrazoxane dextroamphetamine sulfate dextroamphetamine sulfate er dextrose dextrose in lactated ringers dextrose-nacl DIABETA DIASTAT PEDIATRIC diazepam... 12, 36 diclofenac potassium diclofenac sodium... 19, 58, 84 diclofenac sodium er diclofenac-misoprostol dicloxacillin sodium dicyclomine hcl didanosine DIFICID... 9 diflorasone diacetate diflunisal digoxin dihydroergotamine mesylate diltiazem cd diltiazem hcl... 44, 45 diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 5 divalproex sodium divalproex sodium er DOCEFREZ docetaxel dofetilide donepezil hcl dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate doxepin hcl doxercalciferol doxorubicin hcl DOXY doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol DULERA duloxetine hcl DUREZOL dutasteride-tamsulosin hcl DYRENIUM econazole nitrate EDARBI EDARBYCLOR EDURANT effervescent pot chloride EFFIENT ELAPRASE ELESTAT ELIDEL ELIGARD ELINEST ELIQUIS ELITEK ELLA ELLENCE ELMIRON EMADINE EMCYT EMEND EMOQUETTE EMPLICITI EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL... 74, ENBREL SURECLICK ENGERIX-B enoxaparin sodium ENPRESSE ENSKYCE entacapone entecavir epinastine hcl epinephrine epinephrine hcl epinephrine hcl pf EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin hcl EPIVIR HBV eplerenone eprosartan mesylate ERAXIS ERBITUX ergoloid mesylates ERGOMAR ERIVEDGE ERWINAZE ERYTHROCIN LACTOBIONATE... 9 ERYTHROCIN STEARATE... 9 erythromycin... 58, 82 erythromycin ethylsuccinate... 9 ESBRIET escitalopram oxalate esomeprazole magnesium ESTARYLLA estazolam estradiol estradiol-norethindrone acet estropipate eszopiclone ethambutol hcl... 21, 22 ethosuximide etodolac etodolac er ETOPOPHOS etoposide EURAX EXACTECH R-S-G TEST EXACTECH TEST exemestane EXJADE EXODERM EXTAVIA eye wash EZ FLU SHOT-FLUCELVAX FABRAZYME... 63

105 FALMINA famciclovir famotidine FANAPT FANAPT TITRATION PACK FARESTON FARXIGA FARYDAK FASLODEX FAZACLO FC2 FEMALE CONDOM felbamate felodipine er fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fentanyl... 3 FENTORA... 4 FER-IN-SOL ferrous sulfate FETZIMA FETZIMA TITRATION finasteride FIRAZYR FIRMAGON flecainide acetate FLOVENT DISKUS FLOVENT HFA FLUARIX FLUARIX QUADRIVALENT FLUBLOK FLUCELVAX fluconazole fluconazole in dextrose fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate FLULAVAL QUADRIVALENT FLUMIST QUADRIVALENT flunisolide fluocinolone acetonide... 59, 85 fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide-e FLUORIDEX SENSITIVITY RELIEF fluoritab fluorometholone fluorouracil... 23, 59 fluoxetine hcl fluoxetine hcl (pmdd) fluphenazine decanoate fluphenazine hcl FLURA-DROPS flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate... 59, 88 fluvastatin sodium fluvastatin sodium er FLUVIRIN FLUVIRIN PRESERVATIVE FREE fluvoxamine maleate fluvoxamine maleate er FLUZONE HIGH-DOSE FLUZONE PRESERVATIVE FREE FLUZONE QUADRIVALENT folcal dha folic acid FOLIVANE-OB FOLIVANE-PRX DHA NF FOLOTYN fondaparinux sodium FORFIVO XL FORTEO FOSAMAX PLUS D FOSCAVIR fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium FOSRENOL FREESTYLE INSULINX TEST FREESTYLE LITE TEST FREESTYLE PRECISION NEO TEST FREESTYLE TEST FULYZAQ furosemide FUSILEV FUZEON FYCOMPA gabapentin GABITRIL GABLOFEN galantamine hydrobromide galantamine hydrobromide er GAMMAGARD GAMMAGARD S/D GAMMAGARD S/D LESS IGA GAMMAPLEX ganciclovir sodium GARDASIL gatifloxacin GAVILYTE-C GAVILYTE-G GAVILYTE-N WITH FLAVOR PACK gemcitabine hcl gemfibrozil GENGRAF GENTAK gentamicin sulfate... 6, 59, 82 GENVOYA GEODON GESTICARE DHA GIANVI GILDAGIA GILDESS 1.5/ GILDESS 1/ GILDESS FE 1.5/ GILDESS FE 1/ GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide er glipizide xl glipizide-metformin hcl GLUCAGEN DIAGNOSTIC GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glucose glyburide... 37, 39 glyburide micronized glyburide-metformin glycopyrrolate gnp vitamin d GOLYTELY granisetron hcl griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er guanidine hcl HALAVEN... 26

106 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX HEATHER HEMMOREX-HC heparin (porcine) in d5w heparin (porcine) in nacl heparin lock flush heparin sod (porcine) in d5w heparin sodium (porcine) heparin sodium (porcine) pf HEPATASOL HERCEPTIN HEXALEN HOMATROPAIRE HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER hydralazine hcl hydrochlorothiazide hydrocod polst-cpm polst er hydrocodone-acetaminophen... 4 hydrocodone-homatropine hydrocodone-ibuprofen... 4 hydrocortisone... 59, 60, 69 hydrocortisone ace-pramoxine hydrocortisone acetate hydrocortisone butyr lipo base hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-aloe hydromorphone hcl... 4 hydromorphone hcl pf... 4 hydroquinone hydroquinone time release hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYOPHEN hyoscyamine sulfate hyoscyamine sulfate er HYPERLYTE-CR ibandronate sodium IBRANCE ibuprofen ibuprofen childrens IDAMYCIN PFS... 24, 26 idarubicin hcl... 24, 26 IFEX ifosfamide ILARIS imatinib mesylate IMBRUVICA imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES INATAL ADVANCE INATAL GT INATAL ULTRA INCRELEX INCRUSE ELLIPTA indapamide indomethacin indomethacin er INFANRIX INLYTA INNOPRAN XL insulin syringe insulin syringe/needle INTELENCE INTRALIPID INTRON A INTROVALE INVANZ... 8 INVEGA INVEGA SUSTENNA INVIRASE INVOKANA IPOL ipratropium bromide... 86, 88 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide irinotecan hcl iron chews pediatric ISENTRESS... 33, 34 ISOLYTE-P IN D5W ISOLYTE-S ISOLYTE-S PH isometheptene-caffeine-apap isometheptene-dichloral-apap... 4 isoniazid isopropyl alcohol wipes isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine ISTODAX itraconazole iv prep wipes ivermectin IXEMPRA KIT IXIARO JAKAFI JANUMET JANUMET XR JANUVIA JENCYCLA jevantique lo JEVTANA JINTELI JOLESSA JOLIVETTE JULEBER JUNEL 1.5/ JUNEL FE 1.5/ JUNEL FE 1/ JUNEL FE JUXTAPID KADCYLA KAITLIB FE KALETRA KALYDECO KANUMA KARIVA KAZANO kcl in d5w lactated ringers kcl in dextrose-nacl... 91, 92 kcl-lactated ringers-d5w k-effervescent KELNOR 1/ KEPIVANCE KETEK... 9 ketoconazole... 18, 60 KETODAN ketoprofen ketoprofen er ketorolac tromethamine... 19, 20, 84 KHEDEZLA KIMIDESS KINERET KIONEX... 90

107 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KOMBIGLYZE XR KORLYM KURVELO KUVAN labetalol hcl LACRISERT lactated ringers... 81, 92 lactulose lactulose encephalopathy lamivudine... 33, 35 lamivudine-zidovudine lamotrigine lamotrigine er lansoprazole LANTUS LANTUS SOLOSTAR LARIN 1.5/ LARIN 1/ LARIN 24 FE LARIN FE 1.5/ LARIN FE 1/ latanoprost LATUDA LAYOLIS FE LEENA leflunomide LEMTRADA LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LESCOL XL LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... 11, 12 levetiracetam er levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin... 10, 11, 82 LEVONEST levonorgest-eth estrad 91-day levonorgestrel levonorgestrel-ethinyl estrad levonorg-eth estrad triphasic LEVORA 0.15/30 (28) LEVO-T LEVOTHROID levothyroxine sodium... 72, 73 LEXIVA lidocaine lidocaine hcl... 5, 56 lidocaine hcl (pf)... 5 lidocaine viscous... 5 lidocaine-prilocaine... 5 LIDODERM lincomycin hcl... 7 lindane linezolid... 7 liothyronine sodium LIPOFEN lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium carbonate er LIVALO LO LOESTRIN FE LOMEDIA 24 FE LONSURF loperamide hcl lorazepam LORYNA losartan potassium losartan potassium-hctz lovastatin LOVAZA LOW-OGESTREL loxapine succinate LUDENT LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT-PED LUTERA LUZU LYNPARZA LYRICA LYSODREN LYZA mafenide acetate magnesium chloride magnesium sulfate malathion maprotiline hcl marlissa MARPLAN MATULANE meclizine hcl meclofenamate sodium medroxyprogesterone acetate... 50, 71 mefenamic acid mefloquine hcl MEGACE ES megestrol acetate... 27, 71 MEKINIST meloxicam melphalan hcl MENACTRA MENEST MENOMUNE MENVEO meprobamate MEPRON mercaptopurine meropenem... 7 mesalamine mesalamine-cleanser mesna MESNEX MESTINON metaproterenol sulfate metaxalone metformin hcl metformin hcl er metformin hcl er (mod) metformin hcl er (osm) methadone hcl... 3 methazolamide methenamine hippurate... 7 methenamine mandelate... 7 methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide... 46

108 methyldopa methyldopa-hydrochlorothiazide methyldopate hcl methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 7, 60, 68 metronidazole in nacl... 7 mexiletine hcl miconazole miconazole 3 combo pack MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN 24 FE MICROGESTIN FE 1.5/ MICROGESTIN FE 1/ midodrine hcl MINASTRIN 24 FE minocycline hcl minocycline hcl er minoxidil MIRENA (52 MG) mirtazapine misoprostol mitomycin mitoxantrone hcl M-M-R II modafinil moexipril hcl moexipril-hydrochlorothiazide mometasone furoate MONO-LINYAH MONONESSA montelukast sodium MONUROL... 7 morphine sulfate... 3, 4 morphine sulfate (concentrate)... 4 morphine sulfate (pf)... 4 morphine sulfate er... 3 morphine sulfate er beads... 3 MOVANTIK MOVIPREP MOXEZA MULTAQ multi prenatal multi-vit/fluoride multivitamin/fluoride multi-vitamin/fluoride mupirocin mupirocin calcium MUSTARGEN MVC-FLUORIDE MYCAMINE MYCOBUTIN mycophenolate mofetil mycophenolic acid MYFORTIC MYNATAL MYNATAL ADVANCE MYRBETRIQ MYZILRA nabumetone nadolol nadolol-bendroflumethiazide nafcillin sodium NAGLAZYME nalbuphine hcl... 4 naloxone hcl... 6 naltrexone hcl... 5 NAMENDA NAMENDA XR NAMENDA XR TITRATION PACK naphazoline hcl naproxen naproxen dr naproxen sodium naratriptan hcl NATAZIA nateglinide NATELLE ONE NATPARA NATURE-THROID NEBUPENT NECON 0.5/35 (28) NECON 1/35 (28) NECON 1/50 (28) NECON 10/11 (28) NECON 7/7/ nefazodone hcl neomycin sulfate... 6 neomycin-bacitracin zn-polymyx neomycin-polymyxin b gu neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc... 84, 85 NEO-POLYCIN HC NEPHRAMINE NEPTAZANE NESINA NEUAC NEUMEGA NEUPOGEN NEVANAC nevirapine... 34, 35 nevirapine er NEXAVAR NEXPLANON niacin er niacin er (antihyperlipidemic) NIACOR nicardipine hcl nicotine... 6 nicotine mini... 6 nicotine polacrilex... 6 NIFEDIAC CC nifedipine nifedipine er nifedipine er osmotic release NIKKI NILANDRON nimodipine NINLARO nisoldipine er nitrofurantoin macrocrystal... 7 nitrofurantoin monohyd macro... 7 nitroglycerin NITROLINGUAL NITROSTAT NORA-BE norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est norethindrone-eth estradiol... 53, 70 norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic NORLYROC NORMOSOL-M IN D5W... 92

109 NORMOSOL-R NORMOSOL-R IN D5W NORMOSOL-R PH NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/ nortriptyline hcl NORVIR NOVOLIN 70/ NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL np thyroid NUCALA NUCYNTA... 4 NUCYNTA ER... 3 NUEDEXTA NULOJIX NULYTELY WITH FLAVOR PACKS nutrilyte NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ PEN NUVARING NUVIGIL nystatin... 18, 60 nystatin-triamcinolone OCELLA octreotide acetate ODOMZO ofloxacin... 11, 82, 85 OGESTREL olanzapine olanzapine-fluoxetine hcl olmesartan medoxomil olmesartan medoxomil-hctz olmesartan-amlodipine-hctz olopatadine hcl omega-3-acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate OMNIFLEX DIAPHRAGM ONCASPAR ondansetron ondansetron hcl one-daily multi vitamins ONFI ONGLYZA OPANA ER... 3 OPDIVO OPSUMIT OPTIONS CONCEPTROL OPTIONS GYNOL II CONTRACEPTIVE ORAP ORENCIA ORFADIN ORKAMBI orphenadrine citrate orphenadrine citrate er ORSYTHIA ORTHO TRI-CYCLEN LO OSENI otomax-hc oxacillin sodium oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxybutynin chloride er oxycodone hcl... 4, 5 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 oxycodone-ibuprofen... 5 oxymorphone hcl... 4, 5 oxymorphone hcl er... 3, 4 PACERONE paclitaxel pamidronate disodium... 79, 80 PANRETIN pantoprazole sodium PARAGARD INTRAUTERINE COPPER paricalcitol paromomycin sulfate... 6 paroxetine hcl paroxetine hcl er PASER PATADAY PATANOL PAXIL PEDVAX HIB peg peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEGANONE PEGASYS PEGASYS PROCLICK pen needles pen needles 1/2" pen needles 3/16" pen needles 5/16" penicillin g potassium penicillin g sodium penicillin v potassium PENTAM pentazocine-naloxone hcl... 5 pentoxifylline er perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline PEXEVA phenazopyridine hcl phenelzine sulfate phenobarbital phenylephrine hcl phenytoin phenytoin sodium phenytoin sodium extended PHILITH PHOSPHOLINE IODIDE PHYSIOSOL IRRIGATION PICATO pilocarpine hcl... 56, 83 PIMTREA pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so PIRMELLA 1/ PIRMELLA 7/7/ piroxicam PLASMA-LYTE PLASMA-LYTE-56 IN D5W PNEUMOVAX pnv fe fum/docusate/folic acid... 95

110 pnv-dha pnv-dha+docusate podofilox POLYCIN polyethylene glycol polymyxin b-trimethoprim POMALYST PORTIA PORTRAZZA pot bicarb-pot chloride potassium acetate potassium bicarbonate potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl... 92, 93 potassium citrate er POTIGA PRADAXA pramipexole dihydrochloride PRAMOTIC PRANDIMET PRANDIN pravastatin sodium PRAXBIND prazosin hcl PRECISION PCX PRECISION PCX PLUS TEST PRECISION POINT OF CARE TEST PRECISION QID TEST PRECISION SOF-TACT TEST PRECISION XTRA BLOOD GLUCOSE PRECISION XTRA KETONE prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 69, 84 prednisone PREMARIN... 68, 70 PREMASOL PREMPHASE PREMPRO prenaissance prenatal prenatal low iron prenatal one daily prenatal vitamin PRENTIF FITTING SET PREPOPIK PREVIFEM PREVNAR PREZISTA PRIFTIN primaquine phosphate primidone PRISTIQ PROAIR HFA probenecid procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT... 40, 68 PROCTO-PAK PROCTOZONE-HC progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl promethazine vc plain promethazine vc/codeine promethazine-codeine promethazine-dm propafenone hcl propafenone hcl er proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl pseudoeph-bromphen-dm pseudoeph-chlorphen-hydrocod PULMICORT FLEXHALER PULMOZYME pyrazinamide pyridostigmine bromide QUARTETTE QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate er quinidine sulfate quinidine sulfate er QVAR RABAVERT rabeprazole sodium raloxifene hcl ramipril RANEXA ranitidine hcl... 64, 65 RAPAFLO RAPAMUNE REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK RECLAST RECLIPSEN RECOMBIVAX HB RECTIV REGRANEX RELISTOR RELPAX REMICADE RENVELA... 67, 68 repaglinide REPREXAIN... 5 RESCRIPTOR RESTASIS RETROVIR REVLIMID REYATAZ RHEUMATREX RIBASPHERE RIBASPHERE RIBAPAK ribavirin RIDAURA rifabutin RIFAMATE rifampin RIFATER RIGHT STEP PRENATAL riluzole rimantadine hcl ringers ringers irrigation RIOMET risedronate sodium RISPERDAL CONSTA risperidone RISPERIDONE M-TAB... 32

111 RITUXAN rivastigmine rivastigmine tartrate rizatriptan benzoate ropinirole hcl ropinirole hcl er ROSADAN ROSULA rosuvastatin calcium ROTARIX ROTATEQ ROWASA rulavite dha SABRIL SAFYRAL SAIZEN SAIZEN CLICK.EASY salicylic acid salicylic acid-cleanser saline flush SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS sash kit SAVAYSA SAVELLA SAVELLA TITRATION PACK scalacort SECONAL selegiline hcl selenium sulfide SELZENTRY se-natal SENSIPAR... 72, 73 SEREVENT DISKUS sertraline hcl SETLAKIN SFROWASA SHAROBEL SIGNIFOR sildenafil citrate... 88, 89 silver sulfadiazine SIMPONI SIMPONI ARIA... 74, 75 simvastatin sirolimus SIRTURO SKLICE SKYLA sleep-aid maximum strength sodium chloride... 61, 88, 92, 93 sodium chloride bacteriostatic sodium chloride flush sodium fluoride sodium lactate sodium polystyrene sulfonate sodium sulfacetamide sodium sulfacetamide wash SOLARAZE SOLIA SOLTAMOX SOMATULINE DEPOT SOMAVERT SORIATANE sotalol hcl sotalol hcl (af) SOVALDI spinosad SPIRIVA HANDIHALER spironolactone spironolactone-hctz SPRINTEC SPRYCEL SRONYX sss stavudine STIOLTO RESPIMAT STIVARGA STRATTERA streptomycin sulfate... 6 STRIBILD SUBOXONE... 6 sucralfate sulfacetamide sodium... 61, 82 sulfacetamide sodium (acne) sulfacetamide sodium-sulfur... 61, 62 sulfacetamide sod-sulfur wash sulfacetamide-prednisolone sulfacetamide-sulfur in urea sulfacetamide-sulfur-sunscreen sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulindac sumatriptan sumatriptan succinate sumatriptan succinate refill SUPRAX... 9 SUPREP BOWEL PREP SUSTIVA SUTENT SYEDA SYLATRON SYMAX DUOTAB SYMAX-SR SYMBICORT SYMLINPEN SYMLINPEN SYNAREL SYNRIBO SYNTHROID TABLOID tacrolimus TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN... 27, 62 TARINA FE 1/ TARON-BC TARON-PREX TASIGNA TAXOTERE TAZORAC TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hctz temazepam temozolomide terazosin hcl terbinafine hcl... 18, 62 terbutaline sulfate terconazole testosterone testosterone cypionate testosterone enanthate tetanus toxoid adsorbed tetanus-diphtheria toxoids td tetrabenazine tetracycline hcl TEVETEN HCT THALOMID theophylline er... 87

112 thioridazine hcl thiotepa thiothixene thrivite THYMOGLOBULIN tiagabine hcl ticlopidine hcl TILIA FE timolol maleate... 44, 83 tinidazole... 7 TIVICAY tizanidine hcl tl-select TOBRADEX tobramycin... 6, 82 tobramycin sulfate... 7 tobramycin-dexamethasone TODAY SPONGE tolazamide tolbutamide tolmetin sodium tolterodine tartrate tolterodine tartrate er topiramate topotecan hcl TORISEL torsemide TOUJEO SOLOSTAR TRACLEER tramadol hcl... 5 tramadol hcl er... 5 tramadol hcl er (biphasic)... 5 tramadol-acetaminophen... 5 trandolapril trandolapril-verapamil hcl er tranexamic acid tranylcypromine sulfate TRAVATAN Z travoprost trazodone hcl TREANDA TRECATOR TRELSTAR MIXJECT TRESIBA FLEXTOUCH tretinoin... 28, 62 tretinoin (emollient) tretinoin microsphere TREXALL triadvance triamcinolone acetonide... 56, 62, 88 triamterene-hctz triazolam tri-buffered aspirin TRIDERM TRI-ESTARYLLA trifluoperazine hcl trifluridine trihexyphenidyl hcl TRI-LEGEST FE TRI-LINYAH TRILYTE trimethobenzamide hcl trimethoprim... 8 trimipramine maleate trinatal gt TRINESSA (28) TRINTELLIX... 15, 16 triple-vitamin/fluoride TRI-PREVIFEM TRISENOX TRI-SPRINTEC tri-vitamin/fluoride TRIVORA (28) TROKENDI XR tropicamide trospium chloride trospium chloride er TRUVADA TUSSLIN PEDIATRIC TWINRIX TYKERB TYPHIM VI TYSABRI TYZEKA TYZINE UCERIS U-CORT ULESFIA ULORIC ultra tabs ULTRA-THIN II PEN NEEDLES UNITHROID UNITUXIN urea urea nail film URECHOLINE ursodiol UTA UTIRA-C UVADEX valacyclovir hcl VALCYTE valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide vancomycin hcl... 7, 8 VAQTA VARIVAX VARUBI VCF VAGINAL CONTRACEPTIVE VECTIBIX VELCADE VELIVET VEMAVITE-PRX venlafaxine hcl venlafaxine hcl er VENTAVIS VENTOLIN HFA verapamil hcl verapamil hcl er VESICARE VESTURA VEXOL VICTRELIS VIDEX VIENVA VIGAMOX VIIBRYD VIIBRYD STARTER PACK VIMPAT VINACAL B vinblastine sulfate VINCASAR PFS vinorelbine tartrate viorele VIRACEPT VIRAMUNE VIREAD virt-advance virt-phos 250 neutral virt-pn dha virt-select virt-vite gt VITAFOL-ONE vitamin d vitamin d (cholecalciferol) voriconazole... 18, 19 VOTRIENT VRAYLAR VYFEMLA VYTORIN WAL-DRYL ALLERGY CHILDRENS warfarin sodium WELCHOL WERA WOUND WASH SALINE... 62

113 WYMZYA FE XALKORI XARELTO XARELTO STARTER PACK XELJANZ XENAZINE XGEVA XIFAXAN... 8 XOLAIR XTANDI XULANE XURIDEN XYREM YERVOY YF-VAX YONDELIS zafirlukast zaleplon ZALTRAP ZARAH ZATEAN-PN DHA ZAVESCA ZELBORAF ZEMPLAR ZENCHENT ZENCHENT FE ZENPEP ZETIA ZIAGEN zidovudine zinc sulfate ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolmitriptan zolpidem tartrate zonisamide ZORTRESS ZOSTAVAX ZOVIA 1/50E (28) ZUBSOLV... 6 ZYFLO ZYFLO CR ZYMAXID ZYTIGA

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