ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5, 300-30, 300-60 ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 PA PA PA butalbital-acetaminophen oral tablet 50-325 PA butalbital-acetaminophen-caff oral capsule 50-325-40 butalbital-acetaminophen-caff oral tablet 50-325- 40 butalbital-aspirin-caffeine oral capsule 50-325-40 carisoprodol-asa-codeine oral tablet 200-325-6 PA PA PA PA carisoprodol-aspirin oral tablet 200-325 PA hydrocodone-acetaminophen oral tablet 0-325, 2.5-325, 5-325, 7.5-325 hydrocodone-ibuprofen oral tablet 0-200, 7.5-200 IBU ORAL TABLET 600 MG, 800 MG MO ibuprofen-oxycodone oral tablet 400-5 oxycodone-acetaminophen oral tablet 0-325, 2.5-325, 5-325, 7.5-325 oxycodone-aspirin oral tablet 4.8355-325 pentazocine-naloxone oral tablet 50-0.5 PA

tramadol-acetaminophen oral tablet 37.5-325 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 00, 200, 400, 50 MO diclofenac potassium oral tablet 50 MO diclofenac sodium oral tablet extended release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 MO MO diflunisal oral tablet 500 MO etodolac oral capsule 200, 300 MO etodolac oral tablet 400, 500 MO etodolac oral tablet extended release 24 hr 400, 500, 600 MO flurbiprofen oral tablet 00, 50 MO hydrocodone-ibuprofen oral tablet 5-200 ibuprofen oral suspension 00 /5 ml MO ibuprofen oral tablet 400, 600, 800 MO indomethacin oral capsule 25, 50 PA; MO indomethacin oral capsule, extended release 75 PA; MO ketorolac oral tablet 0 PA; MO; QL (20 EA per 30 days) meclofenamate oral capsule 00, 50 MO meloxicam oral tablet 5, 7.5 MO nabumetone oral tablet 500, 750 MO naproxen oral suspension 25 /5 ml MO naproxen oral tablet 250, 375, 500 MO naproxen oral tablet,delayed release (dr/ec) 375, 500 MO naproxen sodium oral tablet 275, 550 MO piroxicam oral capsule 0, 20 MO sulindac oral tablet 50, 200 MO OPIOID ANALGESICS, LONG-ACTING 2

buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 20 mcg/hour, 5 mcg/hour fentanyl transdermal patch 72 hour 00 mcg/hr PA fentanyl transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (4 EA per 28 days) QL (0 EA per 30 days) methadone oral solution 0 /5 ml QL (200 ML per 30 days) methadone oral solution 5 /5 ml QL (2400 ML per 30 days) methadone oral tablet 0 PA methadone oral tablet 5 QL (80 EA per 30 days) morphine oral tablet extended release 00, 200 morphine oral tablet extended release 5, 30, 60 oxycodone oral tablet,oral only,ext.rel.2 hr 0, 5, 20, 30, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate nasal spray,non-aerosol 0 /ml DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection syringe 2 /ml PA QL (60 EA per 30 days) PA QL (5 ML per 30 days) B/D PA; QL (20 EA per 30 days) hydromorphone oral tablet 2, 4, 8 QL (20 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY ; QL (600 EA per 30 days) ; QL (50 EA per 30 days) meperidine oral solution 50 /5 ml PA; QL (900 ML per 30 days) 3

meperidine oral tablet 00, 50 PA; QL (80 EA per 30 days) morphine oral tablet 5, 30 QL (20 EA per 30 days) oxycodone oral solution 5 /5 ml QL (5400 ML per 30 days) oxycodone oral tablet 0, 5, 20, 30, 5 QL (20 EA per 30 days) tramadol oral tablet 50 QL (240 EA per 30 days) ANESTHETICS LOCAL TREATMENT OF PAIN LOCAL ANESTHETICS diclofenac sodium topical gel % MO lidocaine hcl mucous membrane jelly 2 % MO lidocaine hcl mucous membrane solution 4 % (40 /ml) MO lidocaine topical adhesive patch,medicated 5 % PA; MO; QL (90 EA per 30 days) lidocaine topical ointment 5 % MO lidocaine-prilocaine topical cream 2.5-2.5 % MO ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS TREATMENT OF SUBSTANCE ABUSE DISORDERS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 MO disulfiram oral tablet 250, 500 MO OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet 2, 8 MO buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 MO LUCEMYRA ORAL TABLET 0.8 MG ; MO; QL (224 EA per 4 days) naltrexone oral tablet 50 MO OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml MO naloxone injection syringe 0.4 /ml, /ml MO NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION SMOKING CESSATION AGENTS 2 4

bupropion hcl (smoking deter) oral tablet extended release 2 hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG MO ; QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, MG ; QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML ; QL (06 EA per 365 days) ANTIBACTERIALS TREATMENT OF BACTERIAL INFECTIONS AMINOGLYCOSIDES amikacin injection solution 500 /2 ml GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 80 /00 ml, 80 /50 ml gentamicin injection solution 40 /ml MO gentamicin ophthalmic (eye) drops 0.3 % MO gentamicin topical cream 0. % MO gentamicin topical ointment 0. % MO neomycin oral tablet 500 MO paromomycin oral capsule 250 MO streptomycin intramuscular recon soln gram TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0. % tobramycin ophthalmic (eye) drops 0.3 % MO tobramycin sulfate injection solution 0 /ml, 40 /ml 5

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0. % ANTIBACTERIALS, OTHER MO acetic acid otic (ear) solution 2 % MO bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % clindamycin hcl oral capsule 50, 300, 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml), 50 /ml clindamycin phosphate intravenous solution 600 /4 ml MO MO MO 6 MO clindamycin phosphate topical gel % MO clindamycin phosphate topical lotion % MO clindamycin phosphate topical solution % MO clindamycin phosphate topical swab % MO clindamycin phosphate vaginal cream 2 % MO colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 500 PA linezolid in dextrose 5% intravenous piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml B/D MO linezolid oral tablet 600 MO methenamine hippurate oral tablet gram MO metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml

metronidazole oral capsule 375 MO metronidazole oral tablet 250, 500 MO metronidazole topical cream 0.75 % MO metronidazole topical gel 0.75 %, % MO metronidazole topical lotion 0.75 % MO metronidazole vaginal gel 0.75 % MO mupirocin topical ointment 2 % MO neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-0,000 -unit/g-% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-0,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0,000-0 -unit-/ml nitrofurantoin macrocrystal oral capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- /ml tinidazole oral tablet 250, 500 MO MO MO MO MO MO MO; QL (360 EA per 365 days) MO; QL (80 EA per 365 days) MO trimethoprim oral tablet 00 MO vancomycin intravenous recon soln,000, 0 gram, 500 B/D vancomycin oral capsule 25, 250 MO BETA-LACTAM, CEPHALOSPORINS 7

cefaclor oral capsule 250, 500 MO cefaclor oral tablet extended release 2 hr 500 MO cefadroxil oral capsule 500 MO cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml MO cefadroxil oral tablet gram MO cefazolin injection recon soln gram, 500 cefdinir oral capsule 300 MO cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefepime injection recon soln gram, 2 gram cefotaxime injection recon soln gram, 2 gram, 500 cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml MO 8 MO cefpodoxime oral tablet 00, 200 MO cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml MO cefprozil oral tablet 250, 500 MO ceftazidime injection recon soln gram, 2 gram, 6 gram ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 MO cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 MO cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml MO cephalexin oral tablet 250, 500 MO SUPRAX ORAL CAPSULE 400 MG TAZICEF INJECTION RECON SOLN GRAM, 2 GRAM, 6 GRAM

TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection recon soln gram doripenem intravenous recon soln 500 PA imipenem-cilastatin intravenous recon soln 250, 500 B/D INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln gram, 500 VABOMERE INTRAVENOUS RECON SOLN 2 GRAM BETA-LACTAM, PENICILLINS ; MO amoxicillin oral capsule 250, 500 MO amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml MO amoxicillin oral tablet 500, 875 MO amoxicillin oral tablet,chewable 25, 250 MO amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 /5 ml, 250-62.5 /5 ml, 400-57 /5 ml, 600-42.9 /5 ml amoxicillin-pot clavulanate oral tablet 250-25, 500-25, 875-25 amoxicillin-pot clavulanate oral tablet extended release 2 hr,000-62.5 amoxicillin-pot clavulanate oral tablet,chewable 200-28.5, 400-57 MO MO MO MO ampicillin oral capsule 500 MO ampicillin sodium injection recon soln gram, 0 gram, 25 ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram 9

BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 MO nafcillin injection recon soln gram penicillin g procaine intramuscular syringe.2 million unit/2 ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml 0 MO penicillin v potassium oral tablet 250, 500 MO piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram MACROLIDES azithromycin intravenous recon soln 500 MO azithromycin oral packet gram MO azithromycin oral suspension for reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack), 600 clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml MO MO MO clarithromycin oral tablet 250, 500 MO clarithromycin oral tablet extended release 24 hr 500 MO DIFICID ORAL TABLET 200 MG ; MO ERY PADS TOPICAL SWAB 2 % MO ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml MO MO erythromycin ethylsuccinate oral tablet 400 MO erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) MO

erythromycin oral tablet 250, 500 MO erythromycin with ethanol topical gel 2 % MO erythromycin with ethanol topical solution 2 % MO QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr,000, 500 MO ciprofloxacin hcl ophthalmic (eye) drops 0.3 % MO ciprofloxacin hcl oral tablet 00, 250, 500, 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml MO levofloxacin oral solution 250 /0 ml MO levofloxacin oral tablet 250, 500, 750 MO moxifloxacin in nacl (iso-osm) intravenous piggyback 400 /250 ml MO moxifloxacin ophthalmic (eye) drops 0.5 % MO moxifloxacin oral tablet 400 MO ofloxacin ophthalmic (eye) drops 0.3 % MO ofloxacin oral tablet 300, 400 MO SULFONAMIDES silver sulfadiazine topical cream % MO SSD TOPICAL CREAM % MO sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic (eye) drops 0 % MO MO

sulfacetamide sodium ophthalmic (eye) ointment 0 % MO sulfadiazine oral tablet 500 MO sulfamethoxazole-trimethoprim oral suspension 200-40 /5 ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-60 TETRACYCLINES DOXY-00 INTRAVENOUS RECON SOLN 00 MG MO MO doxycycline hyclate oral capsule 00, 50 MO doxycycline hyclate oral tablet 00, 20 MO doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral tablet 00, 50, 50, 75 2 MO MO minocycline oral capsule 00, 50, 75 MO minocycline oral tablet 00, 50, 75 MO MORGIDOX ORAL CAPSULE 50 MG MO tetracycline oral capsule 250, 500 ANTICONVULSANTS TREATMENT OF SEIZURES ANTICONVULSANTS, OTHER BRIVIACT ORAL SOLUTION 0 MG/ML 2 ST; MO BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG 2 ST; MO levetiracetam oral solution 00 /ml MO levetiracetam oral tablet,000, 250, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 250 MG, 500 MG MO MO MO MO 2 ST; MO; QL (60 EA per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG 2 ST; MO; QL (20 EA per 30 days) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 MO ethosuximide oral solution 250 /5 ml MO LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 00, 25, 50 MO GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT ACUDIAL RECTAL KIT 2.5-5- 7.5-20 MG, 5-7.5-0 MG DIASTAT RECTAL KIT 2.5 MG divalproex oral capsule, delayed rel sprinkle 25 divalproex oral tablet extended release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 25, 250, 500 MO MO MO gabapentin oral capsule 00, 300, 400 MO gabapentin oral solution 250 /5 ml MO gabapentin oral tablet 600, 800 MO ONFI ORAL SUSPENSION 2.5 MG/ML ; MO; QL (480 ML per 30 days) ONFI ORAL TABLET 0 MG, 20 MG ; MO; QL (60 EA per 30 days) phenobarbital oral elixir 20 /5 ml (4 /ml) PA; MO phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 PA; MO primidone oral tablet 250, 50 MO SABRIL ORAL TABLET 500 MG ; QL (80 EA per 30 days) tiagabine oral tablet 2, 6, 2, 4 MO 3

valproic acid (as sodium salt) oral solution 250 /5 ml MO valproic acid oral capsule 250 MO vigabatrin oral powder in packet 500 PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5 ml MO felbamate oral tablet 400, 600 MO FYCOMPA ORAL SUSPENSION 0.5 MG/ML 2 ST; MO FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet extended release 24hr 00, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 2 ST; MO; QL (30 EA per 30 days) MO MO topiramate oral capsule, sprinkle 5, 25 MO topiramate oral tablet 00, 200, 25, 50 SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG MO 2 ST; MO; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG 2 ST; MO; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML ; MO; QL (2400 ML per 30 days) BANZEL ORAL TABLET 200 MG, 400 MG ; MO; QL (240 EA per 30 days) carbamazepine oral suspension 00 /5 ml MO carbamazepine oral tablet 200 MO carbamazepine oral tablet extended release 2 hr 00, 200, 400 MO carbamazepine oral tablet,chewable 00 MO DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 200 MG MO oxcarbazepine oral suspension 300 /5 ml (60 /ml) MO oxcarbazepine oral tablet 50, 300, 600 MO PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG 4

phenytoin oral suspension 25 /5 ml MO phenytoin oral tablet,chewable 50 MO phenytoin sodium extended oral capsule 00, 200, 300 MO VIMPAT ORAL SOLUTION 0 MG/ML 2 ST; MO; QL (200 ML per 30 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS MANAGEMENT OF DEMENTIA ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet PA; MO CHOLINESTERASE INHIBITORS donepezil oral tablet 0, 23, 5 MO donepezil oral tablet,disintegrating 0, 5 MO galantamine oral capsule,ext rel. pellets 24 hr 6, 24, 8 galantamine oral tablet 2, 4, 8 rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 3.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr 2 ST; MO; QL (60 EA per 30 days) MO MO N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 24hr 4, 2, 28, 7 memantine oral tablet 0, 5 MO memantine oral tablets,dose pack 5-0 MO NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-4-2-28 MG ANTIDEPRESSANTS TREATMENT OF DEPRESSION ANTIDEPRESSANTS, OTHER MO; QL (30 EA per 30 days) bupropion hcl oral tablet 00, 75 MO 5

bupropion hcl oral tablet extended release 24 hr 50, 300 bupropion hcl oral tablet sustained-release 2 hr 00, 50, 200 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 30, 45 nefazodone oral tablet 00, 50, 200, 250, 50 perphenazine-amitriptyline oral tablet 2-0, 2-25, 4-0, 4-25, 4-50 trazodone oral tablet 00, 50, 300, 50 MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR MO MO MO MO MO PA; MO MO MARPLAN ORAL TABLET 0 MG phenelzine oral tablet 5 MO tranylcypromine oral tablet 0 MO SSRIS/ SNRIS citalopram oral solution 0 /5 ml MO citalopram oral tablet 0, 20, 40 MO desvenlafaxine succinate oral tablet extended release 24 hr 00, 25, 50 MO escitalopram oxalate oral solution 5 /5 ml MO escitalopram oxalate oral tablet 0, 20, 5 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG MO 2 ST; MO 2 ST; MO fluoxetine oral capsule 0, 20, 40 MO 6

fluoxetine oral capsule,delayed release(dr/ec) 90 MO fluoxetine oral solution 20 /5 ml (4 /ml) MO fluoxetine oral tablet 0, 20 MO fluvoxamine oral tablet 00, 25, 50 MO maprotiline oral tablet 25, 50, 75 MO paroxetine hcl oral tablet 0, 20, 30, 40 paroxetine hcl oral tablet extended release 24 hr 2.5, 25, 37.5 MO MO PAXIL ORAL SUSPENSION 0 MG/5 ML sertraline oral concentrate 20 /ml MO sertraline oral tablet 00, 25, 50 MO TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 50, 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 venlafaxine oral tablet extended release 24hr 50, 225, 37.5, 75 VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) TRICYCLICS amitriptyline oral tablet 0, 00, 50, 25, 50, 75 amoxapine oral tablet 00, 50, 25, 50 2 ST; MO MO MO MO 2 ST; MO 2 ST; MO PA; MO MO clomipramine oral capsule 25, 50, 75 PA; MO desipramine oral tablet 0, 00, 50, 25, 50, 75 MO 7

doxepin oral capsule 0, 00, 50, 25, 50, 75 PA; MO doxepin oral concentrate 0 /ml PA; MO imipramine hcl oral tablet 0, 25, 50 PA; MO imipramine pamoate oral capsule 00, 25, 50, 75 nortriptyline oral capsule 0, 25, 50, 75 PA; MO MO nortriptyline oral solution 0 /5 ml MO protriptyline oral tablet 0, 5 MO trimipramine oral capsule 00, 25, 50 PA; MO ANTIEMETICS TREATMENT OF VOMITING OR NAUSEA ANTIEMETICS, OTHER chlorpromazine oral tablet 0, 00, 200, 25, 50 MO meclizine oral tablet 2.5, 25 MO metoclopramide hcl oral solution 5 /5 ml MO metoclopramide hcl oral tablet 0, 5 MO perphenazine oral tablet 6, 2, 4, 8 MO prochlorperazine maleate oral tablet 0, 5 MO prochlorperazine rectal suppository 25 MO promethazine oral tablet 2.5, 25, 50 PA; MO promethazine rectal suppository 2.5, 25 PA; MO promethazine rectal suppository 50 PROMETHEGAN RECTAL SUPPOSITORY 50 MG scopolamine base transdermal patch 3 day over 3 days PA; MO MO trimethobenzamide oral capsule 300 PA; MO EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 25, 40, 80 B/D; MO aprepitant oral capsule,dose pack 25 ()- 80 (2) B/D; MO dronabinol oral capsule 0, 2.5, 5 B/D; MO 8

EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 MG (25 MG/ ML FINAL CONC.) 2 B/D; MO granisetron hcl oral tablet B/D; MO ondansetron hcl oral solution 4 /5 ml B/D; MO ondansetron hcl oral tablet 24, 4, 8 B/D; MO ondansetron oral tablet,disintegrating 4, 8 B/D; MO SYNDROS ORAL SOLUTION 5 MG/ML ; MO ANTIFUNGALS TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 2 B/D 2 B/D amphotericin b injection recon soln 50 B/D caspofungin intravenous recon soln 50, 70 PA ciclopirox topical cream 0.77 % MO ciclopirox topical solution 8 % MO ciclopirox topical suspension 0.77 % MO clotrimazole mucous membrane troche 0 MO clotrimazole topical cream % MO clotrimazole topical solution % MO econazole topical cream % MO ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole in nacl (iso-osm) intravenous piggyback 200 /00 ml, 400 /200 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 200, 50 MO MO flucytosine oral capsule 250 9

flucytosine oral capsule 500 MO griseofulvin microsize oral suspension 25 /5 ml MO itraconazole oral capsule 00 MO ketoconazole oral tablet 200 MO ketoconazole topical cream 2 % MO ketoconazole topical shampoo 2 % MO MENTAX TOPICAL CREAM % MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG NYAMYC TOPICAL POWDER 00,000 UNIT/GRAM ; MO ; MO MO nystatin oral suspension 00,000 unit/ml MO nystatin oral tablet 500,000 unit MO nystatin topical cream 00,000 unit/gram MO nystatin topical ointment 00,000 unit/gram MO nystatin topical powder 00,000 unit/gram MO NYSTOP TOPICAL POWDER 00,000 UNIT/GRAM MO terbinafine hcl oral tablet 250 MO terconazole vaginal cream 0.4 %, 0.8 % MO terconazole vaginal suppository 80 MO voriconazole intravenous solution 200 voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) MO voriconazole oral tablet 200, 50 MO ANTIGOUT AGENTS TREATMENT OF PREVENTION OF GOUTY ARTHRITIS ANTIGOUT AGENTS allopurinol oral tablet 00, 300 MO colchicine oral capsule 0.6 MO 20

colchicine oral tablet 0.6 MO probenecid oral tablet 500 MO probenecid-colchicine oral tablet 500-0.5 MO ULORIC ORAL TABLET 40 MG, 80 MG 2 ST; MO ANTI-INFLAMMATORY AGENTS TREATMENT OF INFLAMMATION GLUCOCORTICOIDS ALA-CORT TOPICAL CREAM %, 2.5 % MO alclometasone topical cream 0.05 % MO alclometasone topical ointment 0.05 % MO betamethasone dipropionate topical cream 0.05 % MO betamethasone dipropionate topical lotion 0.05 % MO betamethasone dipropionate topical ointment 0.05 % MO betamethasone valerate topical cream 0. % MO betamethasone valerate topical lotion 0. % MO betamethasone valerate topical ointment 0. % MO betamethasone, augmented topical cream 0.05 % MO betamethasone, augmented topical gel 0.05 % MO betamethasone, augmented topical lotion 0.05 % MO betamethasone, augmented topical ointment 0.05 % MO clobetasol scalp solution 0.05 % MO clobetasol topical cream 0.05 % MO clobetasol topical gel 0.05 % MO clobetasol topical ointment 0.05 % MO clobetasol-emollient topical cream 0.05 % MO desonide topical cream 0.05 % MO desonide topical lotion 0.05 % MO desonide topical ointment 0.05 % MO desoximetasone topical cream 0.05 %, 0.25 % MO 2

desoximetasone topical gel 0.05 % MO desoximetasone topical ointment 0.05 %, 0.25 % MO DEXAMETHASONE INTENSOL ORAL DROPS MG/ML MO dexamethasone oral elixir 0.5 /5 ml MO dexamethasone oral tablet 0.5, 0.75,,.5, 2, 4, 6 MO fluocinolone topical cream 0.0 %, 0.025 % MO fluocinolone topical ointment 0.025 % MO fluocinolone topical solution 0.0 % MO fluocinonide topical gel 0.05 % MO fluocinonide topical ointment 0.05 % MO fluocinonide topical solution 0.05 % MO FLUOCINONIDE-E TOPICAL CREAM 0.05 % MO fluticasone topical cream 0.05 % MO fluticasone topical lotion 0.05 % MO fluticasone topical ointment 0.005 % MO halobetasol propionate topical cream 0.05 % MO halobetasol propionate topical ointment 0.05 % MO hydrocortisone butyrate topical cream 0. % MO hydrocortisone butyrate topical ointment 0. % MO hydrocortisone butyrate topical solution 0. % MO hydrocortisone topical cream %, 2.5 % MO hydrocortisone topical lotion 2.5 % MO hydrocortisone topical ointment %, 2.5 % MO hydrocortisone valerate topical cream 0.2 % MO hydrocortisone valerate topical ointment 0.2 % MO methylprednisolone oral tablets,dose pack 4 MO mometasone topical cream 0. % MO mometasone topical ointment 0. % MO mometasone topical solution 0. % MO prednisolone oral solution 5 /5 ml MO 22

prednisolone sodium phosphate oral solution 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) MO prednisone oral solution 5 /5 ml MO prednisone oral tablet, 0, 2.5, 20, 5, 50 prednisone oral tablets,dose pack 0, 0 (48 pack), 5, 5 (48 pack) triamcinolone acetonide topical cream 0.025 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.025 %, 0. % triamcinolone acetonide topical ointment 0.025 %, 0. %, 0.5 % MO MO MO MO MO TRIDERM TOPICAL CREAM 0. % MO ANTIMIGRAINE AGENTS TREATMENT OF MIGRAINE HEADACHES ERGOT ALKALOIDS dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. (4 /ml) ergotamine-caffeine oral tablet -00 MO PROPHYLACTIC AIMOVIG AUTOINJECTOR (CK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML SEROTONIN (5-HT) B/D RECEPTOR AGONISTS MO; QL (8 ML per 30 days) ; MO rizatriptan oral tablet 0, 5 MO; QL (2 EA per 30 days) rizatriptan oral tablet,disintegrating 0, 5 MO; QL (2 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 /actuation, 5 /actuation sumatriptan succinate oral tablet 00, 25, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml MO; QL (2 EA per 30 days) MO; QL (9 EA per 30 days) MO; QL (4 ML per 30 days) 23

sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 /0.5 ml MO; QL (4 ML per 30 days) MO; QL (4 ML per 30 days) ANTIMYASTHENIC AGENTS TREATMENT OF MYASTHENIA PARASYMPATHOMIMETICS guanidine oral tablet 25 MO pyridostigmine bromide oral tablet 60 MO pyridostigmine bromide oral tablet extended release 80 ANTIMYCOBACTERIALS TREATMENT FOR INFECTIONS BY TUBERCULOSIS- TYPE ORGANISMS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00, 25 rifabutin oral capsule 50 MO ANTITUBERCULARS ethambutol oral tablet 00, 400 MO isoniazid oral tablet 00, 300 MO PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 MO rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 MO RIFATER ORAL TABLET 50-20-300 MG SIRTURO ORAL TABLET 00 MG ; MO TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS TREATMENT OF CANCER ALKYLATING AGENTS cyclophosphamide oral capsule 25, 50 B/D; MO GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG 24

LEUKERAN ORAL TABLET 2 MG 2 MATULANE ORAL CAPSULE 50 MG 2 VALCHLOR TOPICAL GEL 0.06 % ANTIANDROGENS bicalutamide oral tablet 50 MO ERLEADA ORAL TABLET 60 MG flutamide oral capsule 25 MO nilutamide oral tablet 50 XTANDI ORAL CAPSULE 40 MG YONSA ORAL TABLET 25 MG ZYTIGA ORAL TABLET 250 MG, 500 MG ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG ANTIESTROGENS/MODIFIERS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML ; LA 2 ; MO EMCYT ORAL CAPSULE 40 MG FARESTON ORAL TABLET 60 MG ; MO SOLTAMOX ORAL SOLUTION 0 MG/5 ML 2 tamoxifen oral tablet 0, 20 MO ANTIMETABOLITES DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG fluorouracil topical cream 0.5 %, 5 % MO fluorouracil topical solution 2 %, 5 % MO 25

hydroxyurea oral capsule 500 MO mercaptopurine oral tablet 50 MO PURIXAN ORAL SUSPENSION 20 MG/ML TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS, OTHER diclofenac sodium topical gel 3 % MO leucovorin calcium oral tablet 0, 5, 25, 5 LONSURF ORAL TABLET 5-6.4 MG, 20-8.9 MG 26 LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 00 MG, 50 MG MESNEX ORAL TABLET 400 MG 2 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet MO exemestane oral tablet 25 letrozole oral tablet 2.5 MO MOLECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG

ALECENSA ORAL CAPSULE 50 MG ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (23) BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG CAPRELSA ORAL TABLET 00 MG, 300 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG ERIVEDGE ORAL CAPSULE 50 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG ICLUSIG ORAL TABLET 5 MG, 45 MG IDHIFA ORAL TABLET 00 MG, 50 MG imatinib oral tablet 00, 400 PA IMBRUVICA ORAL CAPSULE 40 MG, 70 MG IMBRUVICA ORAL TABLET 40 MG, 280 MG, 420 MG, 560 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 250 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG 27

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) MEKINIST ORAL TABLET 0.5 MG, 2 MG NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG TASIGNA ORAL CAPSULE 50 MG, 200 MG, 50 MG TYKERB ORAL TABLET 250 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG ZEJULA ORAL CAPSULE 00 MG ZELBORAF ORAL TABLET 240 MG ZYKADIA ORAL CAPSULE 50 MG 28

RETINOIDS bexarotene oral capsule 75 PANRETIN TOPICAL GEL 0. % ; MO TARGRETIN TOPICAL GEL % tretinoin (chemotherapy) oral capsule 0 TREATMENT ADJUNCTS LYSODREN ORAL TABLET 500 MG 2 ANTIPARASITICS TREATMENT OF INFECTIONS FROM PARASITES ANTHELMINTICS ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 MO ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml MO atovaquone-proguanil oral tablet 250-00, 62.5-25 MO benznidazole oral tablet 00, 2.5 PA; MO chloroquine phosphate oral tablet 250, 500 MO COARTEM ORAL TABLET 20-20 MG DARAPRIM ORAL TABLET 25 MG 2 hydroxychloroquine oral tablet 200 MO mefloquine oral tablet 250 MO NEBUPENT INHALATION RECON SOLN 300 MG 2 B/D PENTAM INJECTION RECON SOLN 300 MG primaquine oral tablet 26.3 MO quinine sulfate oral capsule 324 MO 29

PEDICULICIDES/ SCABICIDES lindane topical shampoo % MO malathion topical lotion 0.5 % MO permethrin topical cream 5 % MO ANTIPARKINSON AGENTS TREATMENT OF PARKINSON S DISEASE ANTICHOLINERGICS benztropine oral tablet 0.5,, 2 PA; MO trihexyphenidyl oral elixir 0.4 /ml PA; MO trihexyphenidyl oral tablet 2, 5 PA; MO ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 00 MO amantadine hcl oral solution 50 /5 ml MO amantadine hcl oral tablet 00 MO entacapone oral tablet 200 MO GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 37 MG, 68.5 MG ; MO tolcapone oral tablet 00 MO DOPAMINE AGONISTS APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML bromocriptine oral capsule 5 MO bromocriptine oral tablet 2.5 MO NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25, 0.25, 0.5, 0.75,,.5 pramipexole oral tablet extended release 24 hr 0.375, 0.75,.5, 2.25, 3, 3.75, 4.5 ropinirole oral tablet 0.25, 0.5,, 2, 3, 4, 5 ropinirole oral tablet extended release 24 hr 2, 2, 4, 6, 8 MO 30 MO

DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa oral tablet 0-00, 25-00, 25-250 carbidopa-levodopa oral tablet extended release 25-00, 50-200 carbidopa-levodopa oral tablet,disintegrating 0-00, 25-00, 25-250 carbidopa-levodopa-entacapone oral tablet 2.5-50-200, 8.75-75-200, 25-00-200, 3.25-25-200, 37.5-50-200, 50-200-200 MONOAMINE OXIDASE B (MAO-B) INHIBITORS MO MO rasagiline oral tablet 0.5, MO selegiline hcl oral capsule 5 MO selegiline hcl oral tablet 5 MO ANTIPSYCHOTICS TREATMENT OF BEHAVIORAL AND EMOTIONAL DISORDERS ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 25 /ml MO fluphenazine hcl injection solution 2.5 /ml MO fluphenazine hcl oral concentrate 5 /ml MO fluphenazine hcl oral elixir 2.5 /5 ml MO fluphenazine hcl oral tablet, 0, 2.5, 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml MO MO haloperidol lactate injection solution 5 /ml MO haloperidol lactate intramuscular syringe 5 /ml MO haloperidol lactate oral concentrate 2 /ml MO haloperidol oral tablet 0.5,, 0, 2, 20, 5 MO 3

loxapine succinate oral capsule 0, 25, 5, 50 MO pimozide oral tablet, 2 MO thioridazine oral tablet 0, 00, 25, 50 PA; MO thiothixene oral capsule, 0, 2, 5 MO trifluoperazine oral tablet, 0, 2, 5 2ND GENERATION/ ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG MO ; QL ( EA per 28 days) ; QL ( EA per 28 days) aripiprazole oral solution /ml MO; QL (900 ML per 30 days) aripiprazole oral tablet 0, 5, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 0, 5 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)-6MG(2) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) MO; QL (30 EA per 30 days) MO; QL (60 EA per 30 days) ; QL (3.9 ML per 56 days) ; QL (.6 ML per 28 days) ; QL (2.4 ML per 28 days) ; QL (3.2 ML per 28 days) ; MO; QL (60 EA per 30 days) ; MO 2 B/D; QL (6 EA per 3 days) 32

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 40 MG/.35 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG ; QL (0.75 ML per 28 days) ; QL ( ML per 28 days) ; QL (.5 ML per 28 days) ; QL (0.25 ML per 28 days) ; QL (0.5 ML per 28 days) ; QL (0.875 ML per 84 days) ; QL (.35 ML per 84 days) ; QL (.75 ML per 84 days) ; QL (2.625 ML per 84 days) ; MO; QL (30 EA per 30 days) LATUDA ORAL TABLET 80 MG ; MO; QL (60 EA per 30 days) NUPLAZID ORAL TABLET 7 MG ; MO; QL (60 EA per 30 days) olanzapine intramuscular recon soln 0 QL (90 EA per 30 days) olanzapine oral tablet 0, 5, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 0, 5, 20, 5 paliperidone oral tablet extended release 24hr.5, 3, 9 paliperidone oral tablet extended release 24hr 6 quetiapine oral tablet 00, 200, 300, 400 MO; QL (30 EA per 30 days) MO; QL (30 EA per 30 days) PA; MO; QL (30 EA per 30 days) PA; MO; QL (60 EA per 30 days) MO; QL (60 EA per 30 days) quetiapine oral tablet 25, 50 MO; QL (90 EA per 30 days) 33

quetiapine oral tablet extended release 24 hr 50, 200 quetiapine oral tablet extended release 24 hr 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML MO; QL (30 EA per 30 days) MO; QL (60 EA per 30 days) ; MO; QL (30 EA per 30 days) ; QL (2 EA per 28 days) risperidone oral solution /ml MO; QL (240 ML per 30 days) risperidone oral tablet 0.25, 0.5,, 2, 3 MO; QL (60 EA per 30 days) risperidone oral tablet 4 MO; QL (20 EA per 30 days) risperidone oral tablet,disintegrating 0.25, 0.5,, 2, 3 MO; QL (60 EA per 30 days) risperidone oral tablet,disintegrating 4 MO; QL (20 EA per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 5 MG ; QL (60 EA per 30 days) SAPHRIS SUBLINGUAL TABLET 2.5 MG ; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG TREATMENT-RESISTANT ; MO; QL (30 EA per 30 days) ; MO; QL (28 EA per 28 days) MO; QL (60 EA per 30 days) ; QL (2 EA per 28 days) clozapine oral tablet 00 MO; QL (270 EA per 30 days) clozapine oral tablet 200 MO; QL (20 EA per 30 days) clozapine oral tablet 25, 50 MO; QL (90 EA per 30 days) clozapine oral tablet,disintegrating 00 MO; QL (270 EA per 30 days) clozapine oral tablet,disintegrating 2.5, 25 MO clozapine oral tablet,disintegrating 50 MO; QL (80 EA per 30 days) clozapine oral tablet,disintegrating 200 MO; QL (20 EA per 30 days) 34

VERSACLOZ ORAL SUSPENSION 50 MG/ML ; QL (540 ML per 30 days) ANTISPASTICITY AGENTS TREATMENT OF MUSCLE SPASMS ANTISPASTICITY AGENTS baclofen oral tablet 0, 20, 5 MO dantrolene oral capsule 00, 25, 50 MO tizanidine oral tablet 2, 4 MO ANTIVIRALS TREATMENT OF INFECTIONS BY VIRUSES ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PREVYMIS ORAL TABLET 240 MG, 480 MG valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % 2 ST; MO ANTI-HEPATITIS B (HBV) AGENTS adefovir oral tablet 0 PA BARACLUDE ORAL SOLUTION 0.05 MG/ML 2 entecavir oral tablet 0.5, EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) lamivudine oral solution 0 /ml MO lamivudine oral tablet 00 QL (30 EA per 30 days) lamivudine oral tablet 50 MO; QL (60 EA per 30 days) lamivudine oral tablet 300 MO; QL (30 EA per 30 days) PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML 2 tenofovir disoproxil fumarate oral tablet 300 MO VEMLIDY ORAL TABLET 25 MG 35

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS MAVYRET ORAL TABLET 00-40 MG VOSEVI ORAL TABLET 400-00-00 MG ANTI-HEPATITIS C (HCV) AGENTS, OTHER INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML ribavirin oral capsule 200 ribavirin oral tablet 200 ANTIHERPETIC AGENTS acyclovir oral capsule 200 MO acyclovir oral suspension 200 /5 ml MO acyclovir oral tablet 400, 800 MO acyclovir sodium intravenous solution 50 /ml B/D acyclovir topical ointment 5 % MO DENAVIR TOPICAL CREAM % famciclovir oral tablet 25, 250, 500 MO trifluridine ophthalmic (eye) drops % MO valacyclovir oral tablet gram, 500 MO ZOVIRAX TOPICAL CREAM 5 % ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) GENVOYA ORAL TABLET 50-50-200-0 MG ; QL (30 EA per 30 days) ISENTRESS HD ORAL TABLET 600 MG ; QL (60 EA per 30 days) ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ; QL (20 EA per 30 days) 36

ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG ; QL (80 EA per 30 days) JULUCA ORAL TABLET 50-25 MG ; QL (30 EA per 30 days) STRIBILD ORAL TABLET 50-50-200-300 MG ; QL (30 EA per 30 days) TIVICAY ORAL TABLET 0 MG ; QL (300 EA per 30 days) TIVICAY ORAL TABLET 25 MG ; QL (20 EA per 30 days) TIVICAY ORAL TABLET 50 MG ; QL (60 EA per 30 days) TRIUMEQ ORAL TABLET 600-50-300 MG ; QL (30 EA per 30 days) ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA ORAL TABLET 600-200-300 MG ; QL (30 EA per 30 days) COMPLERA ORAL TABLET 200-25-300 MG ; QL (30 EA per 30 days) EDURANT ORAL TABLET 25 MG ; QL (30 EA per 30 days) efavirenz oral capsule 200 MO; QL (20 EA per 30 days) efavirenz oral capsule 50 MO; QL (360 EA per 30 days) efavirenz oral tablet 600 MO; QL (30 EA per 30 days) INTELENCE ORAL TABLET 00 MG, 25 MG ; QL (20 EA per 30 days) INTELENCE ORAL TABLET 200 MG ; QL (60 EA per 30 days) nevirapine oral tablet 200 MO; QL (60 EA per 30 days) nevirapine oral tablet extended release 24 hr 00 nevirapine oral tablet extended release 24 hr 400 MO; QL (20 EA per 30 days) MO; QL (30 EA per 30 days) ODEFSEY ORAL TABLET 200-25-25 MG ; QL (30 EA per 30 days) RESCRIPTOR ORAL TABLET 200 MG ; QL (80 EA per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG ; QL (360 EA per 30 days) SYMFI LO ORAL TABLET 400-300-300 MG ; QL (30 EA per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 37

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir oral solution 20 /ml MO abacavir oral tablet 300 MO; QL (60 EA per 30 days) abacavir-lamivudine oral tablet 600-300 MO; QL (30 EA per 30 days) abacavir-lamivudine-zidovudine oral tablet 300-50-300 MO; QL (60 EA per 30 days) CIMDUO ORAL TABLET 300-300 MG ; QL (30 EA per 30 days) DESCOVY ORAL TABLET 200-25 MG ; QL (30 EA per 30 days) didanosine oral capsule,delayed release(dr/ec) 200 didanosine oral capsule,delayed release(dr/ec) 250, 400 MO; QL (60 EA per 30 days) MO; QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 200 MG ; QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 0 MG/ML lamivudine-zidovudine oral tablet 50-300 MO; QL (60 EA per 30 days) stavudine oral capsule 5, 20 MO; QL (20 EA per 30 days) stavudine oral capsule 30, 40 MO; QL (60 EA per 30 days) TRUVADA ORAL TABLET 00-50 MG, 33-200 MG, 67-250 MG, 200-300 MG VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 25 MG ; QL (30 EA per 30 days) ZERIT ORAL RECON SOLN MG/ML ; QL (90 EA per 30 days) zidovudine oral capsule 00 MO; QL (80 EA per 30 days) zidovudine oral syrup 0 /ml MO zidovudine oral tablet 300 MO; QL (60 EA per 30 days) ANTI-HIV AGENTS, OTHER BIKTARVY ORAL TABLET 50-200-25 MG ; QL (30 EA per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 90 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 75 MG ; QL (60 EA per 30 days) SELZENTRY ORAL TABLET 25 MG, 300 MG ; QL (20 EA per 30 days) 38 2

SYMFI ORAL TABLET 600-300-300 MG ; QL (30 EA per 30 days) TYBOST ORAL TABLET 50 MG ; QL (30 EA per 30 days) ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG ; QL (20 EA per 30 days) APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 300 MO; QL (30 EA per 30 days) atazanavir oral capsule 200 MO; QL (60 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG ; QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG ; QL (80 EA per 30 days) EVOTAZ ORAL TABLET 300-50 MG ; QL (30 EA per 30 days) fosamprenavir oral tablet 700 MO; QL (20 EA per 30 days) INVIRASE ORAL CAPSULE 200 MG ; QL (300 EA per 30 days) INVIRASE ORAL TABLET 500 MG ; QL (20 EA per 30 days) KALETRA ORAL TABLET 00-25 MG ; QL (240 EA per 30 days) KALETRA ORAL TABLET 200-50 MG ; QL (20 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution 400-00 /5 ml MO NORVIR ORAL POWDER IN PACKET 00 MG ; QL (360 EA per 30 days) NORVIR ORAL SOLUTION 80 MG/ML PREZCOBIX ORAL TABLET 800-50 MG-MG ; QL (30 EA per 30 days) PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG ; QL (80 EA per 30 days) PREZISTA ORAL TABLET 600 MG ; QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG ; QL (300 EA per 30 days) PREZISTA ORAL TABLET 800 MG ; QL (30 EA per 30 days) REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 00 MO; QL (360 EA per 30 days) VIRACEPT ORAL TABLET 250 MG ; QL (300 EA per 30 days) 39

VIRACEPT ORAL TABLET 625 MG ; QL (20 EA per 30 days) ANTI-INFLUENZA AGENTS oseltamivir oral capsule 30 MO; QL (84 EA per 80 days) oseltamivir oral capsule 45, 75 MO; QL (42 EA per 80 days) oseltamivir oral suspension for reconstitution 6 /ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 MO MO; QL (540 ML per 80 days) ; QL (60 EA per 80 days) ANXIOLYTICS TREATMENT OF ANXIETY OR NERVOUSNESS ANXIOLYTICS, OTHER buspirone oral tablet 0, 5, 30, 5, 7.5 hydroxyzine pamoate oral capsule 00, 25, 50 BENZODIAZEPINES MO PA; MO alprazolam oral tablet 0.25, 0.5, MO; QL (20 EA per 30 days) alprazolam oral tablet 2 MO; QL (50 EA per 30 days) clonazepam oral tablet 0.5, PA; MO; QL (90 EA per 30 days) clonazepam oral tablet 2 PA; MO; QL (300 EA per 30 days) clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5, PA; MO; QL (90 EA per 30 days) clonazepam oral tablet,disintegrating 2 PA; MO; QL (300 EA per 30 days) clorazepate dipotassium oral tablet 5 PA; MO; QL (80 EA per 30 days) clorazepate dipotassium oral tablet 3.75, 7.5 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML PA; MO; QL (90 EA per 30 days) PA; MO; QL (240 ML per 30 days) diazepam oral solution 5 /5 ml ( /ml) PA; MO; QL (200 ML per 30 days) diazepam oral tablet 0, 2, 5 PA; MO; QL (20 EA per 30 days) lorazepam oral concentrate 2 /ml MO; QL (50 ML per 30 days) lorazepam oral tablet 0.5, MO; QL (90 EA per 30 days) lorazepam oral tablet 2 MO; QL (50 EA per 30 days) BIPOLAR AGENTS TREATMENT OF BIPOLAR ILLNESSES 40

MOOD STABILIZERS carbamazepine oral capsule, er multiphase 2 hr 00, 200, 300 EQUETRO ORAL CAPSULE, ER MULTIPHASE 2 HR 00 MG, 200 MG, 300 MG lamotrigine oral tablet 00, 50, 200, 25 lamotrigine oral tablets,dose pack 25 (35), 25 (42) -00 (7), 25 (84) -00 (4) lithium carbonate oral capsule 50, 300, 600 MO MO MO MO lithium carbonate oral tablet 300 MO lithium carbonate oral tablet extended release 300, 450 MO lithium citrate oral solution 8 meq/5 ml MO BLOOD GLUCOSE REGULATORS CONTROL OF DIABETES ANTIDIABETIC AGENTS acarbose oral tablet 00, 25, 50 ST; MO; QL (90 EA per 30 days) alogliptin oral tablet 2.5, 25, 6.25 ST; QL (30 EA per 30 days) alogliptin-metformin oral tablet 2.5-,000, 2.5-500 alogliptin-pioglitazone oral tablet 2.5-5, 2.5-30, 2.5-45, 25-5, 25-30, 25-45 ST; QL (60 EA per 30 days) ST; QL (30 EA per 30 days) AVANDIA ORAL TABLET 2 MG, 4 MG 2 ST; MO; QL (60 EA per 30 days) glimepiride oral tablet MO; QL (240 EA per 30 days) glimepiride oral tablet 2 MO; QL (20 EA per 30 days) glimepiride oral tablet 4 MO; QL (60 EA per 30 days) glipizide oral tablet 0 MO; QL (20 EA per 30 days) glipizide oral tablet 5 MO; QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 0 MO; QL (60 EA per 30 days) 4

glipizide oral tablet extended release 24hr 2.5 MO; QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 5 MO; QL (90 EA per 30 days) glipizide-metformin oral tablet 2.5-250 MO; QL (240 EA per 30 days) glipizide-metformin oral tablet 2.5-500, 5-500 MO; QL (20 EA per 30 days) glyburide micronized oral tablet.5, 3 PA; MO; QL (90 EA per 30 days) glyburide micronized oral tablet 6 PA; MO; QL (60 EA per 30 days) glyburide oral tablet.25, 2.5 PA; MO; QL (60 EA per 30 days) glyburide oral tablet 5 PA; MO glyburide-metformin oral tablet.25-250 PA; MO; QL (240 EA per 30 days) glyburide-metformin oral tablet 2.5-500, 5-500 INVOKAMET ORAL TABLET 50-,000 MG, 50-500 MG, 50-,000 MG PA; MO; QL (20 EA per 30 days) 2 ST; MO; QL (60 EA per 30 days) INVOKAMET ORAL TABLET 50-500 MG 2 ST; MO; QL (20 EA per 30 days) INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 50-,000 MG, 50-500 MG, 50-,000 MG, 50-500 MG 2 ST; MO; QL (60 EA per 30 days) INVOKANA ORAL TABLET 00 MG, 300 MG 2 ST; MO; QL (30 EA per 30 days) JANUMET ORAL TABLET 50-,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 MG, 50-500 MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JENTADUETO ORAL TABLET 2.5-,000 MG, 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-,000 MG KORLYM ORAL TABLET 300 MG ; MO 2 ST; MO; QL (60 EA per 30 days) 2 ST; MO; QL (30 EA per 30 days) 2 ST; MO; QL (60 EA per 30 days) 2 ST; MO; QL (30 EA per 30 days) 2 ST; MO; QL (60 EA per 30 days) 2 ST; MO; QL (60 EA per 30 days) 2 ST; MO; QL (30 EA per 30 days) metformin oral tablet,000 MO; QL (75 EA per 30 days) metformin oral tablet 500 MO; QL (50 EA per 30 days) 42

metformin oral tablet 850 MO; QL (90 EA per 30 days) metformin oral tablet extended release 24 hr 500 metformin oral tablet extended release 24 hr 750 MO; QL (20 EA per 30 days) MO; QL (60 EA per 30 days) nateglinide oral tablet 20, 60 ST; MO; QL (90 EA per 30 days) pioglitazone oral tablet 5, 30, 45 ST; MO; QL (30 EA per 30 days) pioglitazone-metformin oral tablet 5-500, 5-850 ST; MO; QL (90 EA per 30 days) repaglinide oral tablet 0.5, ST; MO; QL (20 EA per 30 days) repaglinide oral tablet 2 ST; MO SEGLUROMET ORAL TABLET 2.5-,000 MG, 7.5-,000 MG, 7.5-500 MG 2 ST; QL (60 EA per 30 days) SEGLUROMET ORAL TABLET 2.5-500 MG 2 ST; QL (20 EA per 30 days) STEGLATRO ORAL TABLET 5 MG, 5 MG 2 ST; QL (30 EA per 30 days) STEGLUJAN ORAL TABLET 5-00 MG, 5-00 MG SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML 2 ST; QL (30 EA per 30 days) ; MO ; MO TRADJENTA ORAL TABLET 5 MG 2 ST; MO; QL (30 EA per 30 days) TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) BLOOD GLUCOSE REGULATORS ALCOHOL PADS TOPICAL PADS, MEDICATED ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" 2 ST; MO; QL (2 ML per 28 days) 2 ST; MO; QL (9 ML per 30 days) MO MO GAUZE PAD TOPICAL BANDAGE 2 X 2 " MO 43