Standard Six-Tier Prescription Drug Formulary

Standard Six-Tier Prescription Drug Formulary The Multi-Tier Formulary Tier Description Preferred Generic Drugs Non-Preferred Generic Drugs Preferred Brand-Name Drugs Non-Preferred Brand-Name Drugs Preferred Specialty Drugs Non-Preferred Specialty Drugs Affordable Care Act Drugs

Reading the Formulary Column Name What you will find in each column: Drug Mandatory Generic Substitution Drug Mandatory Generic Substitution Reference Drug This formulary is subject to change as new products and information become available.

Abbreviation Dictionary PA - Prior authorization members.bcidaho.com PREV - Preventive Drugs for HSA Plans QL - Quantity Limits SP - Specialty Drug Program ST - Step Therapy AL - Age Limitation

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 1 hour guanfacine hcl er oral tablet extended release hour Kapvay Intuniv *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release hour amphetamine-dextroamphetamine oral tablet *Amphetamines*** ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE Adderall XR Adderall DEXEDRINE ORAL TABLET Zenzedi dextroamphetamine sulfate er oral capsule extended release hour dextroamphetamine sulfate oral solution Dexedrine ProCentra dextroamphetamine sulfate oral tablet Zenzedi DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE methamphetamine hcl oral tablet Desoxyn VYVANSE ORAL CAPSULE 3 VYVANSE ORAL TABLET CHEWABLE QL 3 1

*Stimulants - Misc.*** armodafinil oral tablet Nuvigil QL DAYTRANA TRANSDERMAL PATCH dexmethylphenidate hcl er oral capsule extended release hour Focalin XR dexmethylphenidate hcl oral tablet Focalin METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er (la) oral capsule extended release hour methylphenidate hcl er oral tablet extended release 10 mg methylphenidate hcl er oral tablet extended release 18 mg, 7 mg, 36 mg, 5 mg methylphenidate hcl er oral tablet extended release 0 mg methylphenidate hcl er oral tablet extended release hour Metadate ER Ritalin LA Concerta Metadate ER methylphenidate hcl oral solution Methylin methylphenidate hcl oral tablet Ritalin methylphenidate hcl oral tablet chewable modafinil oral tablet Provigil QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *Alternative Medicines* *Alternative Medicine - Eu*** ISCAR MALI SUBCUTANEOUS INJECTABLE 5 MG/ML *Amebicides* *Amebicides*** QL SOLOSEC ORAL PACKET PA 3

*Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet paromomycin sulfate oral capsule TOBI PODHALER INHALATION CAPSULE tobramycin inhalation nebulization solution *Analgesics - Anti-Inflammatory* *Antirheumatic Antimetabolites*** RHEUMATREX ORAL TABLET.5 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 0MG/0.ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 0MG/0.ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 SP; QL Kitabis Pak 5 SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 3

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT *Cyclooxygenase (Cox-) Inhibitors*** 5 PA; SP celecoxib oral capsule CeleBREX QL *Gold Compounds*** RIDAURA ORAL CAPSULE 3 *Interleukin-1 Blockers*** ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-1Beta Blockers*** 6 PA; SP ILARIS SUBCUTANEOUS SOLUTION 6 PA; SP ILARIS SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-6 Receptor Inhibitors*** KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release Arthrotec *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release hour diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release hour etodolac oral capsule etodolac oral tablet Lodine fenoprofen calcium oral tablet ProFeno flurbiprofen oral tablet ibuprofen oral tablet 00 mg, 600 mg, 800 mg IBU 6 PA; SP 5 PA; SP 5 PA; SP

indomethacin er oral capsule extended release indomethacin oral capsule ketoprofen er oral capsule extended release hour ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet QL meclofenamate sodium oral capsule mefenamic acid oral capsule Ponstel meloxicam oral suspension meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release EC-Naprosyn naproxen oral suspension Naprosyn naproxen oral tablet naproxen sodium oral tablet 75 mg naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin oral tablet Daypro piroxicam oral capsule Feldene sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava QL *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5

*Analgesics - Nonnarcotic* *Analgesic Combinations*** duraxin oral capsule LEVACET ORAL TABLET *Analgesics-Sedatives*** BUPAP ORAL TABLET 50-300 MG butalbital-acetaminophen oral tablet 50-35 mg Tencon butalbital-apap-caffeine oral capsule Fioricet butalbital-apap-caffeine oral tablet 50-35-0 mg Esgic butalbital-aspirin-caffeine oral capsule Fiorinal CAPACET ORAL CAPSULE Esgic ESGIC ORAL CAPSULE Esgic margesic oral capsule Esgic marten-tab oral tablet Tencon TENCON ORAL TABLET 50-35 MG Tencon ZEBUTAL ORAL CAPSULE 50-35-0 MG *Salicylate Combinations*** Esgic choline-mag trisalicylate oral liquid *Salicylates*** adult aspirin ec low strength oral tablet delayed release Aspir-Low ACA AL; QL aspir-81 oral tablet delayed release Aspir-Low ACA AL; QL aspirin adult low dose oral tablet delayed release aspirin adult low strength oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL aspirin childrens oral tablet chewable Bayer Low Dose ACA AL; QL aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL aspirin oral tablet delayed release 81 mg ASPIR-LOW ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL 6

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE BAYER LOW DOSE ORAL TABLET CHEWABLE BAYER LOW DOSE ORAL TABLET DELAYED RELEASE childrens aspirin low strength oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL childrens aspirin oral tablet chewable Bayer Low Dose ACA AL; QL cvs aspirin child oral tablet chewable Bayer Low Dose ACA QL cvs childrens aspirin oral tablet chewable Bayer Low Dose ACA QL diflunisal oral tablet ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE eq childrens aspirin oral tablet chewable gnp adult aspirin low strength oral tablet chewable gnp aspirin oral tablet delayed release 81 mg Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL goodsense aspirin oral tablet chewable Bayer Low Dose ACA AL; QL kls aspirin low dose oral tablet delayed release Aspir-Low ACA AL; QL kp aspirin oral tablet delayed release Aspir-Low ACA AL; QL MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL px aspirin oral tablet chewable Bayer Low Dose ACA AL; QL px enteric aspirin oral tablet delayed release 81 mg qc childrens aspirin oral tablet chewable ra aspirin adult low strength oral tablet chewable ra aspirin ec adult low st oral tablet delayed release ra aspirin ec oral tablet delayed release 81 mg Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL 7

ra childrens aspirin oral tablet chewable Bayer Low Dose ACA AL; QL salsalate oral tablet sb childrens aspirin oral tablet chewable ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE tgt aspirin low dose oral tablet delayed release Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL tgt aspirin oral tablet chewable Bayer Low Dose ACA AL; QL tgt aspirin oral tablet delayed release Aspir-Low ACA AL; QL tgt childrens aspirin oral tablet chewable *Analgesics - Opioid* *Codeine Combinations*** Bayer Low Dose ACA AL; QL acetaminophen-codeine # oral tablet QL acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QL acetaminophen-codeine # oral tablet Tylenol with Codeine # QL acetaminophen-codeine oral solution QL ASCOMP-CODEINE ORAL CAPSULE Ascomp-Codeine butalbital-apap-caff-cod oral capsule Fioricet/Codeine butalbital-asa-caff-codeine oral capsule Ascomp-Codeine CAPITAL/CODEINE ORAL SUSPENSION *Dihydrocodeine Combinations*** aspirin-caff-dihydrocodeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 10-35 mg/15ml, 7.5-35 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg hydrocodone-acetaminophen oral tablet 10-35 mg hydrocodone-acetaminophen oral tablet.5-35 mg QL QL QL Vicodin HP QL Lorcet HD QL Verdrocet QL 8

hydrocodone-acetaminophen oral tablet 5-300 mg hydrocodone-acetaminophen oral tablet 5-35 mg hydrocodone-acetaminophen oral tablet 7.5-300 mg hydrocodone-acetaminophen oral tablet 7.5-35 mg Vicodin QL Lorcet QL Vicodin ES QL Lorcet Plus QL hydrocodone-ibuprofen oral tablet Ibudone QL IBUDONE ORAL TABLET Ibudone QL LORCET HD ORAL TABLET Lorcet HD QL LORCET ORAL TABLET Lorcet QL LORCET PLUS ORAL TABLET 7.5-35 MG LORTAB ORAL ELIXIR 10-300 MG/15ML Lorcet Plus QL QL LORTAB ORAL TABLET 10-35 MG Lorcet HD QL LORTAB ORAL TABLET 5-35 MG Lorcet QL LORTAB ORAL TABLET 7.5-35 MG Lorcet Plus QL REPREXAIN ORAL TABLET 10-00 MG Ibudone QL VERDROCET ORAL TABLET Verdrocet QL VICODIN ES ORAL TABLET 7.5-300 MG VICODIN HP ORAL TABLET 10-300 MG Vicodin ES QL Vicodin HP QL VICODIN ORAL TABLET 5-300 MG Vicodin QL XYLON ORAL TABLET Ibudone QL ZAMICET ORAL SOLUTION QL *Opioid Agonists*** ABSTRAL SUBLINGUAL TABLET SUBLINGUAL ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE- DETERRENT PA QL codeine sulfate oral tablet QL 9

EMBEDA ORAL CAPSULE EXTENDED RELEASE fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 7 hour 100 mcg/hr fentanyl transdermal patch 7 hour 1 mcg/hr fentanyl transdermal patch 7 hour 5 mcg/hr fentanyl transdermal patch 7 hour 50 mcg/hr fentanyl transdermal patch 7 hour 75 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydromorphone hcl er oral tablet er hour abuse-deterrent hydromorphone hcl injection solution mg/ml QL Actiq PA Duragesic-100 QL Duragesic-1 QL Duragesic-5 QL Duragesic-50 QL Duragesic-75 QL PA Exalgo QL Dilaudid hydromorphone hcl oral liquid Dilaudid QL hydromorphone hcl oral tablet Dilaudid QL hydromorphone hcl rectal suppository QL KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 0 MG QL levorphanol tartrate oral tablet QL meperidine hcl oral solution QL meperidine hcl oral tablet Demerol QL methadone hcl oral concentrate Methadone HCl Intensol 1 QL methadone hcl oral solution 1 QL methadone hcl oral tablet Dolophine 1 QL methadone hcl oral tablet soluble Methadose 1 METHADOSE ORAL TABLET SOLUBLE MORPHABOND ER ORAL TABLET ER 1 HOUR ABUSE-DETERRENT Methadose 1 QL 10

morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er beads oral capsule extended release hour morphine sulfate er oral capsule extended release hour morphine sulfate er oral tablet extended release QL QL Kadian QL MS Contin QL morphine sulfate oral solution QL morphine sulfate oral tablet QL morphine sulfate rectal suppository 10 mg, 0 mg, 5 mg morphine sulfate rectal suppository 30 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR QL QL QL NUCYNTA ORAL TABLET QL OPANA ER ORAL TABLET ER 1 HOUR ABUSE-DETERRENT OXAYDO ORAL TABLET ABUSE- DETERRENT oxycodone hcl er oral tablet er 1 hour abuse-deterrent QL QL OxyCONTIN QL oxycodone hcl oral capsule QL oxycodone hcl oral concentrate 100 mg/5ml QL oxycodone hcl oral solution QL oxycodone hcl oral tablet QL OXYCONTIN ORAL TABLET ER 1 HOUR ABUSE-DETERRENT oxymorphone hcl er oral tablet extended release 1 hour OxyCONTIN 3 QL QL oxymorphone hcl oral tablet Opana QL tramadol hcl er oral tablet extended release hour QL tramadol hcl oral tablet Ultram QL XTAMPZA ER ORAL CAPSULE ER 1 HOUR ABUSE-DETERRENT QL 11

*Opioid Combinations*** ENDOCET ORAL TABLET 10-35 MG,.5-35 MG, 5-35 MG, 7.5-35 MG Endocet QL oxycodone-acetaminophen oral solution QL oxycodone-acetaminophen oral tablet 10-35 mg,.5-35 mg, 5-35 mg, 7.5-35 mg oxycodone-aspirin oral tablet.8355-35 mg Endocet QL QL oxycodone-ibuprofen oral tablet QL *Opioid Partial Agonists*** BUNAVAIL BUCCAL FILM 3 buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 0 mcg/hr, 5 mcg/hr Butrans 1 QL butorphanol tartrate nasal solution BUTRANS TRANSDERMAL PATCH WEEKLY Butrans QL pentazocine-naloxone hcl oral tablet QL SUBOXONE SUBLINGUAL FILM 3 *Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet QL *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 ORAL TABLET oxandrolone oral tablet Oxandrin *Androgens*** ANDRODERM TRANSDERMAL PATCH HOUR ANDROXY ORAL TABLET 3 danazol oral capsule methitest oral tablet 1 1 3 1

methyltestosterone oral capsule STRIANT BUCCAL testosterone cypionate intramuscular solution 100 mg/ml, 00 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (%) testosterone transdermal gel 1.5 mg/act (1%) testosterone transdermal gel 5 mg/.5gm (1%), 50 mg/5gm (1%) Depo-Testosterone Fortesta Vogelxo Pump AndroGel testosterone transdermal solution *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA Colocort CORTIFOAM RECTAL FOAM 3 hydrocortisone rectal enema Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT *Rectal Anesthetic/Steroids*** ANALPRAM-HC RECTAL LOTION 1-.5 % hydrocortisone ace-pramoxine rectal cream 1-1 % Analpram-HC pramcort rectal cream Analpram-HC PROCTOFOAM HC RECTAL FOAM *Rectal Steroids*** hydrocortisone rectal cream Anusol-HC PROCTO-MED HC RECTAL CREAM Anusol-HC PROCTO-PAK RECTAL CREAM Procto-Pak PROCTOSOL HC RECTAL CREAM Anusol-HC PROCTOZONE-HC RECTAL CREAM Anusol-HC 13

*Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET QL benznidazole oral tablet PA EMVERM ORAL TABLET CHEWABLE ivermectin oral tablet Stromectol QL praziquantel oral tablet Biltricide QL *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 1 HOUR *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE ISORDIL TITRADOSE ORAL TABLET 0 MG isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet Isordil Titradose 1 isosorbide mononitrate er oral tablet extended release hour isosorbide mononitrate oral tablet 1 MINITRAN TRANSDERMAL PATCH HOUR NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch hour nitroglycerin translingual aerosol solution Minitran Nitro-Time Nitrostat Minitran NitroMist 1 1 1

nitroglycerin translingual solution Nitrolingual NITRO-TIME ORAL CAPSULE EXTENDED RELEASE *Antianxiety Agents* *Antianxiety Agents - Misc.*** Nitro-Time buspirone hcl oral tablet hydroxyzine hcl oral syrup 1 hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet *Benzodiazepines*** ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet Xanax alprazolam oral tablet dispersible chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet DIAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral solution 5 mg/5ml diazepam oral tablet Valium LORAZEPAM INTENSOL ORAL CONCENTRATE lorazepam oral tablet Ativan oxazepam oral capsule *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace NORPACE CR ORAL CAPSULE EXTENDED RELEASE 1 HOUR quinidine gluconate er oral tablet extended release quinidine sulfate er oral tablet extended release quinidine sulfate oral tablet 1 3 1 15

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl er oral capsule extended release 1 hour Rythmol SR propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone dofetilide oral capsule Tikosyn 5 SP MULTAQ ORAL TABLET PACERONE ORAL TABLET 00 MG, 00 MG *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 1 hour *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Pacerone Zyflo CR DULERA INHALATION AEROSOL fluticasone-salmeterol inhalation aerosol powder breath activated ipratropium-albuterol inhalation solution AirDuo RespiClick 3/1 3 PREV 3 PREV 3 3 3 PREV PREV PREV 16

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION SYMBICORT INHALATION AEROSOL 3 PREV TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 1 hour albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet BROVANA INHALATION NEBULIZATION SOLUTION levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.5 mg/3ml levalbuterol hcl inhalation nebulization solution 1.5 mg/0.5ml ST 5 PA; SP PREV Xopenex PREV Xopenex Concentrate PREV levalbuterol tartrate inhalation aerosol Xopenex HFA metaproterenol sulfate oral syrup PREV metaproterenol sulfate oral tablet PREV PERFOROMIST INHALATION NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED PROVENTIL HFA INHALATION AEROSOL SOLUTION 3 3 3 17

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 3 PREV terbutaline sulfate oral tablet PREV VENTOLIN HFA INHALATION AEROSOL SOLUTION *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION ipratropium bromide inhalation solution LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *Leukotriene Receptor Antagonists*** 3 3 PREV PA 3 PREV 3 PREV montelukast sodium oral packet Singulair PREV montelukast sodium oral tablet Singulair PREV montelukast sodium oral tablet chewable Singulair PREV zafirlukast oral tablet Accolate PREV *Selective Phosphodiesterase (Pde) Inhibitors*** DALIRESP ORAL TABLET *Steroid Inhalants*** ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 1 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH 3 PREV 3 3 PREV 18

ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL 3 3 3 3 PREV budesonide inhalation suspension Pulmicort PREV FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED QVAR INHALATION AEROSOL SOLUTION QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED *Xanthine-Expectorants*** DIFIL-G FORTE ORAL LIQUID *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR THEO- ORAL CAPSULE EXTENDED RELEASE HOUR THEOCHRON ORAL TABLET EXTENDED RELEASE 1 HOUR 100 MG, 00 MG, 300 MG theophylline er oral tablet extended release 1 hour theophylline er oral tablet extended release hour 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV Theochron PREV Theochron PREV 3 PREV theophylline oral solution PREV 19

*Anticoagulants* *Coumarin Anticoagulants*** COUMADIN ORAL TABLET Coumadin 3 PREV JANTOVEN ORAL TABLET Coumadin PREV warfarin sodium oral tablet Coumadin PREV *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 3 XARELTO ORAL TABLET 3 XARELTO STARTER PACK ORAL TABLET THERAPY PACK *Heparins And Heparinoid-Like Agents*** heparin (porcine) in nacl injection solution 100-0.5 unit/ml-%, 50-0.5 unit/ml-% heparin (porcine) in nacl injection solution -0.9 unit/ml-% *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox enoxaparin sodium subcutaneous solution FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 1500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/0.ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** Lovenox Arixtra FYCOMPA ORAL SUSPENSION PA FYCOMPA ORAL TABLET PA *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet KlonoPIN clonazepam oral tablet dispersible 3 0

diazepam rectal gel Diastat AcuDial ONFI ORAL SUSPENSION PA ONFI ORAL TABLET 10 MG, 0 MG PA *Anticonvulsants - Misc.*** APTIOM ORAL TABLET PA BANZEL ORAL SUSPENSION 3 BANZEL ORAL TABLET 3 BRIVIACT ORAL SOLUTION PA BRIVIACT ORAL TABLET PA carbamazepine er oral capsule extended release 1 hour carbamazepine er oral tablet extended release 1 hour Carbatrol TEGretol-XR carbamazepine oral suspension TEGretol carbamazepine oral tablet Epitol carbamazepine oral tablet chewable CARBATROL ORAL CAPSULE EXTENDED RELEASE 1 HOUR Carbatrol 3 EPITOL ORAL TABLET Epitol gabapentin oral capsule Neurontin gabapentin oral solution Neurontin gabapentin oral tablet Neurontin LAMICTAL ODT ORAL KIT LaMICtal ODT 3 LAMICTAL ODT ORAL TABLET DISPERSIBLE LaMICtal ODT 3 LAMICTAL ORAL TABLET LaMICtal 3 LAMICTAL ORAL TABLET CHEWABLE 5 MG, 5 MG LaMICtal 3 LAMICTAL XR ORAL KIT 3 LAMICTAL XR ORAL TABLET EXTENDED RELEASE HOUR lamotrigine er oral tablet extended release hour lamotrigine oral kit 5 & 50 & 100 mg, 5 (1)-50 (7) mg, 50 ()-100(1) mg LaMICtal XR 3 LaMICtal XR LaMICtal ODT lamotrigine oral tablet LaMICtal 1

lamotrigine oral tablet chewable LaMICtal lamotrigine oral tablet dispersible LaMICtal ODT lamotrigine starter kit-blue oral kit LaMICtal Starter lamotrigine starter kit-green oral kit LaMICtal Starter lamotrigine starter kit-orange oral kit LaMICtal Starter levetiracetam er oral tablet extended release hour Keppra XR levetiracetam oral solution Keppra levetiracetam oral tablet Keppra LYRICA ORAL CAPSULE 3 LYRICA ORAL SOLUTION 3 oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR POTIGA ORAL TABLET primidone oral tablet Mysoline ROWEEPRA ORAL TABLET 500 MG Keppra SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE TEGRETOL ORAL SUSPENSION TEGretol 3 TEGRETOL ORAL TABLET Epitol 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 1 HOUR 00 MG, 00 MG TEGretol-XR 3 TOPAMAX ORAL TABLET Topamax 3 TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE Topamax Sprinkle 3 topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax TRILEPTAL ORAL SUSPENSION Trileptal 3 TRILEPTAL ORAL TABLET Trileptal 3 VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZONEGRAN ORAL CAPSULE Zonegran 3 zonisamide oral capsule Zonegran

*Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol *Gaba Modulators*** SABRIL ORAL TABLET 5 PA; SP tiagabine hcl oral tablet Gabitril vigabatrin oral packet Sabril 5 PA; SP *Hydantoins*** DILANTIN INFATABS ORAL TABLET CHEWABLE Dilantin Infatabs 3 DILANTIN ORAL CAPSULE Dilantin 3 DILANTIN ORAL SUSPENSION Dilantin 3 PEGANONE ORAL TABLET PHENYTEK ORAL CAPSULE Phenytek 3 phenytoin oral suspension 15 mg/5ml Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended oral capsule Dilantin *Succinimides*** CELONTIN ORAL CAPSULE ethosuximide oral capsule Zarontin ethosuximide oral solution Zarontin ZARONTIN ORAL CAPSULE Zarontin 3 ZARONTIN ORAL SOLUTION Zarontin 3 *Valproic Acid*** DEPAKENE ORAL CAPSULE Depakene 3 DEPAKENE ORAL SOLUTION Depakene 3 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HOUR DEPAKOTE ORAL TABLET DELAYED RELEASE DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE divalproex sodium er oral tablet extended release hour Depakote ER 3 Depakote 3 Depakote Sprinkles 3 Depakote ER 3

divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release Depakote Sprinkles Depakote valproate sodium oral solution Depakene valproic acid oral capsule Depakene valproic acid oral solution Depakene *Antidepressants* *Alpha- Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 1 mirtazapine oral tablet dispersible Remeron SolTab 1 *Antidepressants - Misc.*** APLENZIN ORAL TABLET EXTENDED RELEASE HOUR bupropion hcl er (sr) oral tablet extended release 1 hour bupropion hcl er (xl) oral tablet extended release hour Wellbutrin SR 1 Wellbutrin XL 1 bupropion hcl oral tablet 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE HOUR maprotiline hcl oral tablet 1 *Modified Cyclics*** nefazodone hcl oral tablet 1 trazodone hcl oral tablet 1 TRINTELLIX ORAL TABLET PA VIIBRYD ORAL KIT PA; ST; QL VIIBRYD ORAL TABLET PA; ST; QL *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH HOUR MARPLAN ORAL TABLET phenelzine sulfate oral tablet Nardil 1 tranylcypromine sulfate oral tablet Parnate 1

*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 1 citalopram hydrobromide oral tablet CeleXA 1 escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet Lexapro 1 fluoxetine hcl oral capsule PROzac 1 fluoxetine hcl oral capsule delayed release fluoxetine hcl oral solution 1 fluoxetine hcl oral tablet 10 mg, 0 mg 1 fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er oral capsule extended release hour fluvoxamine maleate oral tablet 1 paroxetine hcl er oral tablet extended release hour Paxil CR 1 paroxetine hcl oral tablet Paxil 1 PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET sertraline hcl oral concentrate Zoloft 1 sertraline hcl oral tablet Zoloft 1 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine fumarate er oral tablet extended release hour desvenlafaxine succinate er oral tablet extended release hour duloxetine hcl oral capsule delayed release particles venlafaxine hcl er oral capsule extended release hour venlafaxine hcl er oral tablet extended release hour Pristiq 1 Cymbalta 1 Effexor XR 1 venlafaxine hcl oral tablet 1 *Tricyclic Agents*** amitriptyline hcl oral tablet 1 amoxapine oral tablet 1 1 QL 1 1 5

clomipramine hcl oral capsule Anafranil 1 desipramine hcl oral tablet 1 doxepin hcl oral capsule 1 doxepin hcl oral concentrate 1 imipramine hcl oral tablet Tofranil 1 imipramine pamoate oral capsule 1 nortriptyline hcl oral capsule Pamelor 1 nortriptyline hcl oral solution 1 protriptyline hcl oral tablet 1 trimipramine maleate oral capsule Surmontil 1 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose PREV miglitol oral tablet Glyset *Antidiabetic - Amylin Analogs*** SYMLINPEN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR *Biguanides*** metformin hcl er oral tablet extended release hour PREV PREV Glucophage XR 1 PREV metformin hcl oral tablet Glucophage 1 PREV RIOMET ORAL SOLUTION *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION 3 *Dipeptidyl Peptidase- (Dpp-) Inhibitors*** JANUVIA ORAL TABLET 3 TRADJENTA ORAL TABLET 3 *Dipeptidyl Peptidase- Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 3 3 3 6

JANUMET XR ORAL TABLET EXTENDED RELEASE HOUR JENTADUETO ORAL TABLET 3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE HOUR *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET *Human Insulin*** FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 3 3 3 PREV FIASP SUBCUTANEOUS SOLUTION 3 PREV HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR SUBCUTANEOUS SOLUTION NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV NOVOLIN R INJECTION SOLUTION 3 PREV NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 3 PREV 3 PREV 7

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** 3 PREV 3 PREV 3 PREV 3 PREV 3 PREV 3 ST; PREV; QL 3 ST; PREV; QL 3 ST; PREV; QL nateglinide oral tablet Starlix 1 PREV repaglinide oral tablet Prandin 1 PREV *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1 *Progesterone Receptor Antagonists*** KORLYM ORAL TABLET 6 PA; SP *Sodium-Glucose Co-Transporter (Sglt) Inhibitors*** FARXIGA ORAL TABLET 3 PA JARDIANCE ORAL TABLET 3 PA *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 1 PREV glyburide-metformin oral tablet 1 PREV *Sulfonylureas*** chlorpropamide oral tablet PREV glimepiride oral tablet Amaryl 1 PREV 8

glipizide er oral tablet extended release hour Glucotrol XL 1 PREV glipizide oral tablet Glucotrol 1 PREV glipizide xl oral tablet extended release hour Glucotrol XL 1 PREV glyburide micronized oral tablet Glynase 1 PREV glyburide oral tablet 1 PREV tolazamide oral tablet PREV tolbutamide oral tablet *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet Duetact 1 PREV *Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE HOUR pioglitazone hcl-metformin hcl oral tablet *Thiazolidinediones*** Actoplus Met 1 PREV AVANDIA ORAL TABLET 3 pioglitazone hcl oral tablet Actos 1 PREV *Antidiarrheal/Probiotic Agents* *Antidiarrheal/Probiotic Combinations*** RESTORA RX ORAL CAPSULE *Antidiarrheals* *Antidiarrheal Combinations*** RESTORA RX ORAL CAPSULE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet Lomotil opium oral tincture paregoric oral tincture *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** VISTOGARD ORAL PACKET 5 SP 3 9

*Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE PA EXJADE ORAL TABLET SOLUBLE 6 PA; SP FERRIPROX ORAL SOLUTION 6 PA; SP FERRIPROX ORAL TABLET 6 PA; SP JADENU ORAL TABLET 6 PA; SP JADENU SPRINKLE ORAL PACKET 6 PA; SP *Antidotes*** VISTOGARD ORAL PACKET 5 SP *Opioid Antagonists*** EVZIO INJECTION SOLUTION AUTO- INJECTOR naloxone hcl injection solution 0. mg/ml, mg/10ml naloxone hcl injection solution cartridge naloxone hcl injection solution prefilled syringe naltrexone hcl oral tablet 1 PA; ST; QL 1 QL 1 QL NARCAN NASAL LIQUID 3 QL VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED *Antiemetics* *5-Ht3 Receptor Antagonists*** 1 6 SP; QL ANZEMET ORAL TABLET QL granisetron hcl oral tablet QL ondansetron hcl oral solution Zofran ondansetron hcl oral tablet QL ondansetron oral tablet dispersible Zofran ODT QL SANCUSO TRANSDERMAL PATCH QL ZUPLENZ ORAL FILM QL *Antiemetics - Anticholinergic*** meclizine hcl oral tablet Dramamine Less Drowsy 30

scopolamine transdermal patch 7 hour Transderm-Scop (1.5 MG) trimethobenzamide hcl oral capsule Tigan *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE QL dronabinol oral capsule Marinol QL SYNDROS ORAL SOLUTION QL *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule Emend QL EMEND ORAL SUSPENSION RECONSTITUTED 1 QL VARUBI ORAL TABLET PA; QL *Antifungals* *Antifungals*** bio-statin oral capsule bio-statin oral powder griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet LAMISIL ORAL PACKET nystatin oral tablet terbinafine hcl oral tablet LamISIL *Imidazoles*** ketoconazole oral tablet *Triazoles*** CRESEMBA ORAL CAPSULE PA fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan itraconazole oral capsule Sporanox NOXAFIL ORAL SUSPENSION PA NOXAFIL ORAL TABLET DELAYED RELEASE ONMEL ORAL TABLET SPORANOX ORAL SOLUTION PA 31

voriconazole oral suspension reconstituted Vfend voriconazole oral tablet Vfend *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable RESPA-BR ORAL TABLET EXTENDED RELEASE 1 HOUR *Antihistamines - Ethanolamines*** ARBINOXA ORAL SOLUTION ARBINOXA ORAL TABLET carbinoxamine maleate oral solution carbinoxamine maleate oral tablet mg clemastine fumarate oral syrup clemastine fumarate oral tablet.68 mg diphenhydramine hcl oral elixir pharbedryl oral capsule 50 mg Banophen *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY Phenadoz PHENERGAN RECTAL SUPPOSITORY Promethegan promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Phenadoz PROMETHEGAN RECTAL SUPPOSITORY *Antihistamines - Piperidines*** Phenadoz cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite 1 PREV cholestyramine light oral powder Prevalite 1 PREV 3

cholestyramine oral packet Questran 1 PREV cholestyramine oral powder Questran 1 PREV colesevelam hcl oral packet Welchol colesevelam hcl oral tablet Welchol colestipol hcl oral granules Colestid PREV colestipol hcl oral packet Colestid PREV colestipol hcl oral tablet Colestid PREV PREVALITE ORAL PACKET Prevalite 1 PREV PREVALITE ORAL POWDER Prevalite 1 PREV *Fibric Acid Derivatives*** ANTARA ORAL CAPSULE 30 MG, 90 MG fenofibrate micronized oral capsule PREV fenofibrate oral capsule Lipofen PREV fenofibrate oral tablet PREV fenofibric acid oral capsule delayed release Trilipix PREV fenofibric acid oral tablet Fibricor PREV gemfibrozil oral tablet Lopid 1 PREV *Hmg Coa Reductase Inhibitors*** ALTOPREV ORAL TABLET EXTENDED RELEASE HOUR atorvastatin calcium oral tablet 10 mg, 0 mg atorvastatin calcium oral tablet 0 mg, 80 mg fluvastatin sodium er oral tablet extended release hour Lipitor ACA PREV Lipitor 1 PREV Lescol XL ACA fluvastatin sodium oral capsule ACA PREV lovastatin oral tablet ACA PREV pravastatin sodium oral tablet Pravachol ACA PREV rosuvastatin calcium oral tablet 10 mg, 5 mg rosuvastatin calcium oral tablet 0 mg, 0 mg Crestor ACA PREV Crestor 1 PREV 33

simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg Zocor ACA PREV simvastatin oral tablet 80 mg Zocor 1 PREV *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** ezetimibe-simvastatin oral tablet Vytorin PREV *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet Zetia PREV *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule trandolapril-verapamil hcl er oral tablet extended release *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet Lotrel 1 PREV Tarka 1 PREV Lotensin HCT 1 PREV 1 PREV 1 PREV fosinopril sodium-hctz oral tablet 1 PREV lisinopril-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet quinapril-hydrochlorothiazide oral tablet *Ace Inhibitors*** Zestoretic 1 PREV 1 PREV Accuretic 1 PREV benazepril hcl oral tablet 1 PREV captopril oral tablet 1 PREV enalapril maleate oral tablet Vasotec 1 PREV EPANED ORAL SOLUTION EPANED ORAL SOLUTION RECONSTITUTED 3

fosinopril sodium oral tablet 1 PREV lisinopril oral tablet Zestril 1 PREV moexipril hcl oral tablet 1 PREV perindopril erbumine oral tablet 1 PREV quinapril hcl oral tablet Accupril 1 PREV ramipril oral capsule Altace 1 PREV trandolapril oral tablet 1 PREV *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** CLORPRES ORAL TABLET PREV methyldopa-hydrochlorothiazide oral tablet *Agents For Pheochromocytoma*** DEMSER ORAL CAPSULE phenoxybenzamine hcl oral capsule Dibenzyline *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet PREV Exforge 1 PREV amlodipine-olmesartan oral tablet Azor 1 telmisartan-amlodipine oral tablet Twynsta 1 PREV *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet Atacand HCT 1 PREV EDARBYCLOR ORAL TABLET irbesartan-hydrochlorothiazide oral tablet Avalide 1 PREV losartan potassium-hctz oral tablet Hyzaar 1 PREV olmesartan medoxomil-hctz oral tablet Benicar HCT 1 PREV telmisartan-hctz oral tablet Micardis HCT 1 PREV valsartan-hydrochlorothiazide oral tablet *Angiotensin Ii Receptor Antagonists*** Diovan HCT 1 PREV candesartan cilexetil oral tablet Atacand 1 PREV EDARBI ORAL TABLET eprosartan mesylate oral tablet 1 PREV irbesartan oral tablet Avapro 1 PREV losartan potassium oral tablet Cozaar 1 PREV 35

olmesartan medoxomil oral tablet Benicar 1 PREV telmisartan oral tablet Micardis 1 PREV valsartan oral tablet Diovan 1 PREV *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet Exforge HCT 1 PREV olmesartan-amlodipine-hctz oral tablet Tribenzor *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet Catapres PREV clonidine hcl transdermal patch weekly Catapres-TTS- PREV guanfacine hcl oral tablet 1 PREV methyldopa oral tablet 1 PREV *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet Cardura 1 prazosin hcl oral capsule Minipress 1 terazosin hcl oral capsule 1 *Antihypertensives - Misc.*** VECAMYL ORAL TABLET *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 1 PREV bisoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet Ziac 1 PREV 1 PREV nadolol-bendroflumethiazide oral tablet Corzide PREV propranolol-hctz oral tablet 1 PREV *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** TEKTURNA HCT ORAL TABLET *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra PREV *Vasodilators*** hydralazine hcl oral tablet 1 PREV minoxidil oral tablet 1 PREV 36

*Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** FIRST-VANCOMYCIN 5 ORAL SOLUTION FIRST-VANCOMYCIN 50 ORAL SOLUTION FIRVANQ ORAL SOLUTION RECONSTITUTED metronidazole oral capsule Flagyl metronidazole oral tablet Flagyl NEBUPENT INHALATION SOLUTION RECONSTITUTED PRIMSOL ORAL SOLUTION tinidazole oral tablet trimethoprim oral tablet vancomycin hcl oral capsule Vancocin HCl XIFAXAN ORAL TABLET 3 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION RECONSTITUTED Sulfatrim Pediatric Bactrim Sulfatrim Pediatric ALINIA ORAL TABLET atovaquone oral suspension Mepron *Ketolides*** KETEK ORAL TABLET 3 *Leprostatics*** dapsone oral tablet *Lincosamides*** clindamycin hcl oral capsule Cleocin 3 3 3 3 37

clindamycin palmitate hcl oral solution reconstituted *Oxazolidinones*** Cleocin linezolid oral suspension reconstituted Zyvox linezolid oral tablet Zyvox *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet Malarone COARTEM ORAL TABLET *Antimalarials*** chloroquine phosphate oral tablet DARAPRIM ORAL TABLET 3 hydroxychloroquine sulfate oral tablet Plaquenil mefloquine hcl oral tablet QL primaquine phosphate oral tablet 3 quinine sulfate oral capsule Qualaquin *Antimyasthenic Agents* *Antimyasthenic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP 3 pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP 3 pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents* guanidine hcl oral tablet MESTINON ORAL SYRUP 3 pyridostigmine bromide er oral tablet extended release Mestinon 38

pyridostigmine bromide oral tablet Mestinon *Antimycobacterial Agents* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE RIFATER ORAL TABLET 3 *Antimycobacterial Agents*** cycloserine oral capsule Seromycin ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet PASER ORAL PACKET PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin oral capsule Rifadin TRECATOR ORAL TABLET *Antineoplastic - Bcl- Inhibitors*** *Antineoplastic - Bcl- Inhibitors*** VENCLEXTA ORAL TABLET 6 PA; SP VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 3 MYLERAN ORAL TABLET 3 *Androgen Biosynthesis Inhibitors*** 6 PA; SP YONSA ORAL TABLET 6 PA; SP ZYTIGA ORAL TABLET 6 PA; SP *Antiadrenals*** LYSODREN ORAL TABLET 3 *Antiandrogens*** bicalutamide oral tablet Casodex ERLEADA ORAL TABLET 6 PA; SP 39

flutamide oral capsule nilutamide oral tablet Nilandron XTANDI ORAL CAPSULE 6 PA; SP *Antiestrogens*** FARESTON ORAL TABLET 3 SOLTAMOX ORAL SOLUTION tamoxifen citrate oral tablet ACA AL; PREV *Antimetabolites*** capecitabine oral tablet Xeloda 5 PA; SP mercaptopurine oral tablet methotrexate oral tablet methotrexate sodium (pf) injection solution 50 mg/ml methotrexate sodium injection solution 50 mg/ml PURIXAN ORAL SUSPENSION 6 SP TABLOID ORAL TABLET 3 *Antineoplastic - Braf Kinase Inhibitors*** TAFINLAR ORAL CAPSULE 6 PA; SP ZELBORAF ORAL TABLET 6 PA; SP *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 6 PA; SP ODOMZO ORAL CAPSULE 6 PA; SP *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 6 PA; SP ZOLINZA ORAL CAPSULE 5 PA; SP *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 6 PA; SP *Antineoplastic - Mek Inhibitors*** COTELLIC ORAL TABLET 6 PA; SP MEKINIST ORAL TABLET 6 PA; SP *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 PA; SP 0

AFINITOR ORAL TABLET 5 PA; SP *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 5 PA; SP RYDAPT ORAL CAPSULE 6 PA; SP STIVARGA ORAL TABLET 6 PA; SP SUTENT ORAL CAPSULE 5 PA; SP *Antineoplastic - Proteasome Inhibitors*** NINLARO ORAL CAPSULE 6 PA; SP *Antineoplastic - Tyrosine Kinase Inhibitors*** ALECENSA ORAL CAPSULE 6 PA; SP ALUNBRIG ORAL TABLET 6 PA; SP ALUNBRIG ORAL TABLET THERAPY PACK 6 PA; SP BOSULIF ORAL TABLET 6 PA; SP CABOMETYX ORAL TABLET 5 PA; SP CALQUENCE ORAL CAPSULE 6 PA; SP CAPRELSA ORAL TABLET 6 PA; SP COMETRIQ (100 MG DAILY DOSE) ORAL KIT COMETRIQ (10 MG DAILY DOSE) ORAL KIT COMETRIQ (60 MG DAILY DOSE) ORAL KIT 6 PA; SP 6 PA; SP 6 PA; SP GILOTRIF ORAL TABLET 6 PA; SP ICLUSIG ORAL TABLET 6 PA; SP imatinib mesylate oral tablet Gleevec 5 PA; SP IMBRUVICA ORAL CAPSULE 6 PA; SP IMBRUVICA ORAL TABLET 6 PA; SP INLYTA ORAL TABLET 6 PA; SP IRESSA ORAL TABLET 6 PA; SP LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK LENVIMA 1 MG DAILY DOSE ORAL CAPSULE THERAPY PACK LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 6 PA; SP 6 PA; SP 6 PA; SP 1

LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 6 PA; SP 6 PA; SP 6 PA; SP NERLYNX ORAL TABLET 6 PA; SP SPRYCEL ORAL TABLET 5 PA; SP TAGRISSO ORAL TABLET 6 PA; SP TARCEVA ORAL TABLET 5 PA; SP TASIGNA ORAL CAPSULE 5 PA; SP TYKERB ORAL TABLET 5 PA; SP VOTRIENT ORAL TABLET 5 PA; SP XALKORI ORAL CAPSULE 6 PA; SP ZYKADIA ORAL CAPSULE 6 PA; SP *Antineoplastic Combinations*** KISQALI FEMARA 00 DOSE ORAL TABLET THERAPY PACK 5 PA; SP LONSURF ORAL TABLET 6 PA; SP *Antineoplastics Misc.*** ACTIMMUNE SUBCUTANEOUS SOLUTION hydroxyurea oral capsule Hydrea 6 SP INTRON A INJECTION SOLUTION 5 SP INTRON A INJECTION SOLUTION RECONSTITUTED MATULANE ORAL CAPSULE 3 SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED *Aromatase Inhibitors*** anastrozole oral tablet Arimidex exemestane oral tablet Aromasin letrozole oral tablet Femara 5 SP 6 PA; SP 6 PA; SP

*Estrogen Receptor Antagonist*** FASLODEX INTRAMUSCULAR SOLUTION 50 MG/5ML *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 3 *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet *Gonadotropin Releasing Hormone (Gnrh) Antagonists*** FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED *Imidazotetrazines*** PA 6 SP temozolomide oral capsule Temodar 5 PA; SP *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 6 PA; SP *Lhrh Analogs*** LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.5 MG *Mitotic Inhibitors*** etoposide oral capsule *Nitrogen Mustards*** cyclophosphamide oral capsule LEUKERAN ORAL TABLET 3 melphalan oral tablet Alkeran *Nitrosoureas*** GLEOSTINE ORAL CAPSULE lomustine oral capsule Gleostine *Progestins-Antineoplastic*** DEPO-PROVERA INTRAMUSCULAR SUSPENSION 00 MG/ML megestrol acetate oral suspension 0 mg/ml megestrol acetate oral tablet 5 PA; SP 5 PA; SP 3

*Retinoids*** tretinoin oral capsule *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule Targretin 5 PA; SP *Topoisomerase I Inhibitors*** HYCAMTIN ORAL CAPSULE 5 SP *Urinary Tract Protective Agents*** MESNEX ORAL TABLET *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet trihexyphenidyl hcl oral elixir trihexyphenidyl hcl oral tablet *Antiparkinson Dopaminergics*** amantadine hcl oral capsule amantadine hcl oral syrup amantadine hcl oral tablet bromocriptine mesylate oral capsule Parlodel bromocriptine mesylate oral tablet Parlodel GOCOVRI ORAL CAPSULE EXTENDED RELEASE HOUR OSMOLEX ER ORAL TABLET EXTENDED RELEASE HOUR *Antiparkinson Monoamine Oxidase Inhibitors*** rasagiline mesylate oral tablet Azilect selegiline hcl oral capsule Eldepryl selegiline hcl oral tablet ZELAPAR ORAL TABLET DISPERSIBLE *Central/Peripheral Comt Inhibitors*** tolcapone oral tablet Tasmar *Decarboxylase Inhibitors*** carbidopa oral tablet Lodosyn PA PA

*Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 5-100 mg, 50-00 mg Sinemet CR carbidopa-levodopa oral tablet Sinemet carbidopa-levodopa oral tablet dispersible carbidopa-levodopa-entacapone oral tablet *Nonergoline Dopamine Receptor Agonists*** APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NEUPRO TRANSDERMAL PATCH HOUR pramipexole dihydrochloride er oral tablet extended release hour Stalevo 75 Mirapex ER pramipexole dihydrochloride oral tablet Mirapex ropinirole hcl er oral tablet extended release hour Requip XL ropinirole hcl oral tablet Requip *Peripheral Comt Inhibitors*** entacapone oral tablet Comtan *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release lithium carbonate oral capsule 1 lithium carbonate oral tablet 1 lithium oral solution LITHOBID ORAL TABLET EXTENDED RELEASE *Antipsychotics - Misc.*** EQUETRO ORAL CAPSULE EXTENDED RELEASE 1 HOUR Lithobid 3 LATUDA ORAL TABLET 3 6 SP NUPLAZID ORAL CAPSULE 6 PA; SP NUPLAZID ORAL TABLET 6 PA; SP 3 1 5

VRAYLAR ORAL CAPSULE 3 QL VRAYLAR ORAL CAPSULE THERAPY PACK ziprasidone hcl oral capsule Geodon 1 *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION INVEGA TRINZA INTRAMUSCULAR SUSPENSION paliperidone er oral tablet extended release hour RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED Invega 1 risperidone oral solution RisperDAL 1 risperidone oral tablet RisperDAL 1 risperidone oral tablet dispersible 1 *Butyrophenones*** haloperidol lactate oral concentrate 1 haloperidol oral tablet 1 *Dibenzodiazepines*** clozapine oral tablet 1 clozapine oral tablet dispersible FazaClo 1 CLOZARIL ORAL TABLET Clozaril 3 VERSACLOZ ORAL SUSPENSION *Dibenzo-Oxepino Pyrroles*** SAPHRIS SUBLINGUAL TABLET SUBLINGUAL *Dibenzothiazepines*** quetiapine fumarate er oral tablet extended release hour SEROquel XR 1 quetiapine fumarate oral tablet SEROquel 1 *Dibenzoxazepines*** loxapine succinate oral capsule 1 3 QL PA PA PA 6

*Dihydroindolones*** molindone hcl oral tablet *Phenothiazines*** chlorpromazine hcl oral tablet 1 COMPRO RECTAL SUPPOSITORY Compro 1 fluphenazine hcl oral concentrate 1 fluphenazine hcl oral elixir 1 fluphenazine hcl oral tablet 1 perphenazine oral tablet 1 prochlorperazine maleate oral tablet 1 prochlorperazine rectal suppository Compro 1 thioridazine hcl oral tablet 1 trifluoperazine hcl oral tablet 1 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER aripiprazole oral solution 1 aripiprazole oral tablet Abilify 1 aripiprazole oral tablet dispersible 1 ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE ARISTADA INTRAMUSCULAR PREFILLED SYRINGE *Thienbenzodiazepines*** olanzapine oral tablet ZyPREXA 1 olanzapine oral tablet dispersible ZyPREXA Zydis 1 *Thioxanthenes*** thiothixene oral capsule 1 PA PA PA PA 7