HealthSelect MedicareRx Effective August, Drug Name Drug Requirements/ Tier Limits ANALGESICS GOUT allopurinol tab 1 ALOPRIM 3 colchicine w/ pr

Transcription

1 HealthSelect MedicareRx Effective August, 205 ANALGESICS GOUT allopurinol tab ALOPRIM 3 colchicine w/ probenecid COLCRYS 2 probenecid ULORIC 2 MISCELLANEOUS diclofenac w/ misoprostol DUEXIS 3 PRIALT 00mcg/ml, 3 PA 500mcg/20ml VIMOVO 2 NSAIDS celecoxib CAPS diclofenac potassium diclofenac sodium TB24; TBEC diflunisal etodolac etodolac er fenoprofen calcium TABS flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS; CP24 mefenamic acid CAPS MELOXICAM SUSP meloxicam tabs nabumetone TABS NAPRELAN 3 naproxen SUSP; TABS; TBEC NAPROXEN SOD TAB 500MG CR naproxen sodium TABS 275mg, 550mg oxaprozin piroxicam CAPS sulindac TABS tolmetin sodium ZIPSOR 3 ZORVOLEX 3 OPIOID ANALGESICS acetaminophen w/ codeine QL SOLN QL (5000 ml / 30 days) acetaminophen w/ codeine QL TABS QL (400 tabs / 30 days) ASPIRIN-CAFFEINE-DIHYDR OCODEINE BITARTRATE butorphanol nasal spray QL QL (0 ml / 30 days) butorphanol tartrate SOLN BUTRANS 2 capital and codeine 3 QL QL (5000 ml / 30 days) CONZIP 3 hydrocodone-acetaminophen QL mg QL (360 tabs / 30 days) hydrocodone-acetaminophen QL 5-300mg QL (400 tabs / 30 days) hydrocodone-acetaminophen QL 5-325mg QL (360 tabs / 30 days) hydrocodone-acetaminophen QL mg QL (400 tabs / 30 days) hydrocodone-acetaminophen QL mg/5ml QL (5400 ml / 30 days) hydrocodone-acetaminophen QL mg QL (360 tabs / 30 days) hydrocodone-acetaminophen QL 0-300mg QL (400 tabs / 30 days) hydrocodone-acetaminophen QL tab 0-325mg QL (360 tabs / 30 days) hydrocodone-ibuprofen mg hydrocodone-ibuprofen tab mg ibudone mg ibudone tab 0-200mg lorcet hd tab 0-325mg QL (360 tabs / 30 days) QL

2 lorcet plus tab QL QL (360 tabs / 30 days) lorcet tab 5-325mg QL QL (360 tabs / 30 days) LORTAB ELIX 3 QL QL (6000 ml / 30 days) lortab tab 5-325mg QL QL (360 tabs / 30 days) lortab tab QL QL (360 tabs / 30 days) lortab tab 0-325mg QL QL (360 tabs / 30 days) reprexain 0/200 TRAMADOL HCL TB24 tramadol hcl er TB24 tramadol hcl er (biphasic) 00mg tramadol hcl er (biphasic) 200mg tramadol hcl er (biphasic) 300mg tramadol hcl tab 50 mg tramadol-acetaminophen QL QL (240 tabs / 30 days) trezix 3 QL QL (360 caps / 30 days) vicodin QL QL (400 tabs / 30 days) vicodin es QL QL (400 tabs / 30 days) vicodin hp QL (400 tabs / 30 days) QL OPIOID ANALGESICS, CII ABSTRAL QL (20 tabs / 30 days) 3 QL PA CODEINE SULFATE DILAUDID-HP INJ 250MG 3 B/D DURAMORPH B/D EMBEDA CAPS MG 3 EMBEDA CAPS 30-.2MG 3 EMBEDA CAPS 50-2MG 3 EMBEDA CAPS MG 3 EMBEDA CAPS MG 3 EMBEDA CAPS 00-4MG 3 endocet QL QL (360 tabs / 30 days) ENDODAN TAB fentanyl citrate LPOP QL (20 lozenges / 30 days) QL PA fentanyl td patch 72hr 2 mcg/hr fentanyl td patch 72hr 25 mcg/hr fentanyl td patch 72hr 50 mcg/hr fentanyl td patch 72hr 75 mcg/hr fentanyl td patch 72hr 00 mcg/hr FENTORA 2 QL PA QL (20 tabs / 30 days) hydromorphone hcl LIQD HYDROMORPHONE HCL SOLN mg/ml, 2mg/ml, 4mg/ml B/D hydromorphone hcl SOLN 500mg/50ml hydromorphone hcl TABS hydromorphone tab 8mg er hydromorphone tab 2mg er hydromorphone tab 6mg er B/D HYDROMORPHONE TABS 32MG HYSINGLA ER 20mg, 30mg, 3 QL 40mg, 60mg QL (60 tabs / 30 days) HYSINGLA ER 80mg, 3 QL 00mg, 20mg QL (30 tabs / 30 days) INFUMORPH B/D INFUMORPH B/D KADIAN 40mg, 200mg 3 LAZANDA 2 QL PA QL (30 bottles / 30 days) levorphanol tartrate TABS methadone hcl CONC; SOLN; TABS METHADONE INJ 0MG/ML 3 MORPHINE SUL 20MG/ML ORAL SOL morphine sulfate CP24 MORPHINE SULFATE SOLN mg/ml, 0mg/ml, 5mg/ml B/D 2

3 MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE SOLN 0mg/5ml, 20mg/5ml morphine sulfate SOLN.5mg/ml, mg/ml MORPHINE SULFATE TABS morphine sulfate beads morphine sulfate ext-rel tab NUCYNTA 2 NUCYNTA ER 2 3 B/D B/D OPANA ER (CRUSH 2 RESISTANT OXECTA 3 OXYCODONE HCL CAPS; CONC oxycodone hcl SOLN; TABS oxycodone w/ acetaminophen QL mg QL (360 tabs / 30 days) oxycodone w/ acetaminophen QL 5-325mg QL (360 tabs / 30 days) oxycodone w/ acetaminophen QL mg QL (360 tabs / 30 days) oxycodone w/ acetaminophen QL 0-325mg QL (360 tabs / 30 days) oxycodone-aspirin oxycodone-ibuprofen OXYCONTIN 0mg, 5mg, 2 20mg, 30mg OXYCONTIN 40mg, 60mg, 2 QL 80mg QL (20 tabs / 30 days) oxymorphone hcl TABS roxicet soln 2 QL QL (800 ml / 30 days) roxicet tabs QL QL (360 tabs / 30 days) SUBSYS 3 QL PA QL (4 boxes / 30 days) XARTEMIS XR 3 QL QL (20 tabs / 30 days) ZOHYDRO ER (ABUSE DETERRENT) 3 LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D lidocaine inj 0.5% B/D lidocaine inj % B/D lidocaine inj.5% B/D lidocaine inj 2% B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN BETHKIS 3 B/D gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj mg/ml gentamicin in saline inj mg/ml gentamicin in saline inj.2 mg/ml gentamicin in saline inj.4 3 mg/ml gentamicin in saline inj.6 mg/ml gentamicin in saline inj 2 mg/ml gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS 3 TOBI PODHALER 3 PA tobramycin NEBU B/D tobramycin sulfate SOLN; SOLR tobramycin sulfate in saline 3 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2 ALINIA 2 atovaquone SUSP AZACTAM 3 AZACTAM/DEX INJ GM 3 AZACTAM/DEX INJ 2GM 3 aztreonam BILTRICIDE 2 CAYSTON 2 LA PA clindamycin hcl CAPS clindamycin palmitate hydrochloride ANESTHETICS 3

4 clindamycin phosphate SOLN clindamycin phosphate in d5w colistimethate sodium SOLR CUBICIN 3 DALVANCE 3 dapsone TABS DARAPRIM 3 DORIBAX 3 FLAGYL ER 3 imipenem-cilastatin INVANZ 3 ivermectin TABS linezolid SOLN MACRODANTIN 25mg 2 PA 90 day limit if > 64 yr meropenem methenamine hippurate METRO IV 3 metronidazole CAPS; TABS metronidazole inj NEBUPENT 3 B/D nitrofurantoin SUSP PA 90 day limit if > 64 yr nitrofurantoin macrocrystal PA 50mg 90 day limit if > 64 yr nitrofurantoin macrocrystal PA 00mg 90 day limit if >64 yr nitrofurantoin monohyd macro PA 90 day limit if > 64 yr PENTAM polymyxin b sulfate SOLR PRIMSOL SOL 50MG/5ML 3 SIVEXTRO 3 sulfamethoxazole-trimethop sulfamethoxazole-trimethopri m inj SYNERCID 3 trimethoprim TABS TYGACIL 3 vancomycin hcl CAPS vancomycin hcl SOLR 0gm, 500mg, 000mg, 5000mg vancomycin hcl SOLR 750mg 3 XIFAXAN TAB 200MG 3 ZYVOX SUSR; TABS 2 ANTIFUNGALS ABELCET 3 B/D AMBISOME 3 B/D AMPHOTEC 3 B/D amphotericin b SOLR B/D CANCIDAS 3 CRESEMBA 3 ERAXIS 3 fluconazole SUSR; TABS fluconazole in dextrose fluconazole inj nacl 00 3 fluconazole inj nacl 200 fluconazole inj nacl 400 flucytosine CAPS griseofulvin microsize griseofulvin ultramicrosize itraconazole CAPS ketoconazole TABS LAMISIL PACK 3 MYCAMINE 3 NOXAFIL 3 nystatin TABS ONMEL 3 SPORANOX SOL 0MG/ML 3 terbinafine hcl TABS voriconazole SUSR; TABS voriconazole inj 200mg ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB MG atovaquone-proguanil hcl tab mg chloroquine phosphate TABS COARTEM 2 mefloquine hcl PRIMAQUINE PHOSPHATE 3 quinine sulfate CAPS ANTIRETROVIRAL AGENTS abacavir sulfate APTIVUS 3 CRIXIVAN 3 didanosine EDURANT 2 4

5 EMTRIVA 2 EPIVIR SOL 0MG/ML 2 FUZEON 2 INTELENCE 2 INVIRASE 3 ISENTRESS 2 lamivudine LEXIVA 3 NEVIRAPINE SUSP nevirapine TABS; TB24 NORVIR 2 PREZISTA 2 RESCRIPTOR 2 RETROVIR IV INFUSION 3 REYATAZ 2 SELZENTRY 3 stavudine SUSTIVA 2 TIVICAY 3 TYBOST 3 VIDEX PEDIATRIC 3 VIRACEPT 3 VIRAMUNE XR 00mg 2 VIREAD 2 VITEKTA 3 ZIAGEN SOLN 3 zidovudine ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine ATRIPLA 2 COMPLERA 3 EPZICOM 3 EVOTAZ 3 KALETRA SOL 2 KALETRA TAB 00-25MG 2 KALETRA TAB MG 2 lamivudine-zidovudine PREZCOBIX 3 STRIBILD 2 TRIUMEQ 3 TRUVADA 2 ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3 cycloserine CAPS ethambutol hcl TABS isoniazid SOLN; SYRP isoniazid tabs paser d/r 3 PRIFTIN 3 pyrazinamide rifabutin rifamate 3 rifampin CAPS; SOLR RIFATER 3 SIRTURO 3 LA TRECATOR 3 ANTIVIRALS acyclovir CAPS; SUSP; TABS acyclovir sodium B/D adefovir dipivoxil BARACLUDE SOLN 2 cidofovir entecavir EPIVIR HBV SOLN 2 famciclovir TABS foscarnet sodium ganciclovir inj 500mg B/D HARVONI 2 PA lamivudine (hbv) moderiba pak 3 PA moderiba tab 200mg PA OLYSIO 3 PA REBETOL SOLN 2 PA RELENZA DISKHALER 2 ribapak mis 600/day 3 PA ribasphere PA ribasphere ribapak PA ribasphere ribapak PA ribasphere ribapak PA ribavirin 200mg PA rimantadine hydrochloride SOVALDI 2 PA TAMIFLU 2 TYZEKA 3 valacyclovir hcl TABS VALCYTE SOLR 2 valganciclovir hcl VICTRELIS 2 PA CEPHALOSPORINS CEDAX SUSR 90mg/5ml 3 5

6 cefaclor cefaclor er tab 500mg 3 cefadroxil cefazolin inj cefazolin sodium gm, 20gm cefazolin/dextrose 3 cefdinir CEFEPIME GM SOLN 3 CEFEPIME 2GM SOLN 3 cefepime inj gm cefepime inj 2gm cefixime cefotaxime sodium gm, 2gm, 500mg cefotetan disodium 3 cefoxitin sodium CEFOXITIN SODIUM IN 3 DEXTROSE cefpodoxime proxetil cefprozil ceftazidime gm, 2gm, 6gm CEFTAZIDIME/DEXTROSE 3 ceftibuten CEFTIN SUSR 3 ceftriaxone sodium SOLR gm, 2gm, 0gm, 250mg, 500mg cefuroxime axetil cefuroxime sodium.5gm, 7.5gm, 750mg cefuroxime sodium soln iv gm cephalexin claforan gm, 2gm 3 FORTAZ SOLN 3 FORTAZ SOLR 500mg 3 MAXIPIME 3 SUPRAX CAPS 2 suprax CHEW 2 suprax SUSR 00mg/5ml, 2 200mg/5ml SUPRAX SUSR 500mg/5ml 2 tazicef SOLR tazicef vial TEFLARO 3 ZERBAXA 3 ZINACEF SOLR 750mg 3 ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK azithromycin SOLR 500mg azithromycin SUSR azithromycin TABS clarithromycin SUSR; TABS; TB24 DIFICID 2 e.e.s. 400 mg tab E.E.S. GRANULES 3 ery-tab 3 ERYPED ERYPED erythrocin lactobionate 3 500mg erythrocin stearate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate PCE 3 ZMAX 3 FLUOROQUINOLONES AVELOX SOLN 3 ciprofloxacin SOLN 200mg/20ml ciprofloxacin SUSR ciprofloxacin er ciprofloxacin hcl TABS ciprofloxacin in d5w ciprofloxacn inj FACTIVE 3 levofloxacin SOLN; TABS levofloxacin in d5w moxifloxacin hcl TABS PENICILLINS amoxicillin amoxicillin & pot clavulanate ampicillin & sulbactam sodium ampicillin cap 250mg ampicillin cap 500 mg ampicillin inj ampicillin sodium ampicillin susp AUGMENTIN SUSR 3 BACTOCILL INJ DEX GM 3 BACTOCILL INJ DEX 2GM 3 6

7 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium nafcillin sodium NALLPEN ISO-OSMOTIC IN 3 DE NALLPEN/DEXTROSE 3 oxacillin sodium PENICILLIN G POT IN 3 DEXTROSE penicillin g potassium penicillin g procaine 3 penicillin g sodium penicillin v potassium pfizerpen piperacillin sodium-tazobactam sodium ZOSYN SOLN 3 TETRACYCLINES demeclocycline hcl DORYX 200mg 3 doxy inj doxycycline (monohydrate) doxycycline hyclate CAPS; SOLR; TABS; TBEC minocycline hcl CAPS; TABS; TB24 SOLODYN 3 TETRACYCLINE HCL CAPS VIBRAMYCIN SYRP 2 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D BUSULFEX 3 B/D CYCLOPHOSPHAMIDE 2 B/D CAPS cyclophosphamide SOLR B/D dacarbazine 200mg B/D EMCYT 2 GLEOSTINE 3 HEXALEN 2 IFEX 3gm 3 B/D ifosfamide B/D ifosfamide for inj gm B/D IFOSFAMIDE FOR INJ 3 GM 3 B/D LEUKERAN 2 LOMUSTINE melphalan hcl B/D MUSTARGEN 3 B/D TREANDA 3 B/D ZANOSAR 3 B/D ANTHRACYCLINES daunorubicin inj 5mg/ml B/D doxorubicin hcl 50mg B/D doxorubicin hcl liposomal inj B/D (for iv infusion) 2 mg/ml doxorubicin inj 50mg B/D EPIRUBICIN INJ 50MG 3 B/D epirubicin inj 50mg/25ml B/D epirubicin inj 200mg B/D idarubicin hcl B/D VALSTAR 3 PA ANTIBIOTICS bleomycin sulfate B/D COSMEGEN 3 B/D mitomycin SOLR B/D ANTIMETABOLITES adrucil B/D ALIMTA 3 B/D ARRANON 3 B/D azacitidine B/D cladribine B/D CLOLAR 3 B/D cytarabine inj B/D decitabine B/D fludarabine phosphate B/D fluorouracil SOLN B/D FOLOTYN 3 PA GEMCITABINE INJ GM 3 B/D SOLN gemcitabine inj gm SOLR B/D GEMCITABINE INJ 2GM 3 B/D SOLN gemcitabine inj 2gm SOLR B/D GEMCITABINE INJ 200MG 3 B/D SOLN gemcitabine inj 200mg B/D SOLR mercaptopurine TABS methotrexate sodium inj B/D NIPENT 3 B/D PURIXAN 3 TABLOID 2 ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D 7

8 DOCETAXEL CONC 20mg/ml, 80mg/4ml B/D docetaxel CONC 40mg/7ml 3 B/D DOCETAXEL SOLN 3 B/D 80mg/8ml, 200mg/20ml paclitaxel B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar B/D vincristine sulfate B/D vinorelbine tartrate B/D BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 B/D AVASTIN 3 B/D ERBITUX 3 B/D ERIVEDGE 3 LA PA FARYDAK 3 LA PA HERCEPTIN 3 B/D IBRANCE 3 LA PA ISTODAX 3 B/D KADCYLA 3 B/D LYNPARZA 3 PA PERJETA 3 PA PROLEUKIN 3 B/D RITUXAN 2 PA TORISEL 3 B/D VECTIBIX 3 B/D VELCADE 3 B/D YERVOY 3 PA ZALTRAP 3 PA ZOLINZA 2 PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS bicalutamide DEPO-PROVERA INJ 400/ML 3 B/D ELIGARD INJ 7.5MG 3 B/D ELIGARD INJ 22.5MG 3 B/D ELIGARD INJ 30MG 3 B/D ELIGARD INJ 45MG 3 B/D exemestane FARESTON 2 FASLODEX 2 B/D FIRMAGON 3 B/D flutamide letrozole TABS leuprolide acetate KIT PA LUPR DEP-PED INJ 5MG 2 PA LUPR DEP-PED INJ 30MG 2 PA LUPRON DEP INJ.25MG 2 PA LUPRON DEPOT 2 PA LUPRON DEPOT INJ 2 PA 22.5MG (3-MONTH) LUPRON DEPOT INJ 30MG 2 PA (3-MONTH) LUPRON DEPOT INJ 45MG 2 PA LUPRON DEPOT-PED 2 PA LYSODREN 2 MEGACE ES 2 megestrol acetate SUSP; TABS PA NILANDRON 2 SOLTAMOX 3 tamoxifen citrate TABS TRELSTAR MIXJECT 2 PA VANTAS 3 PA XTANDI 3 LA PA ZOLADEX 2 PA ZYTIGA 3 PA KINASE INHIBITORS AFINITOR 2 PA AFINITOR DISPERZ 2 PA BOSULIF 2 PA CAPRELSA 3 LA PA COMETRIQ 3 PA GILOTRIF TAB 20MG 3 LA PA GILOTRIF TAB 30MG 3 LA PA GILOTRIF TAB 40MG 3 LA PA GLEEVEC 2 PA ICLUSIG 2 LA PA IMBRUVICA CAP 40MG 3 LA PA INLYTA 3 LA PA JAKAFI 3 LA PA LENVIMA 0MG DAILY 3 LA PA DOSE LENVIMA 4MG DAILY 3 LA PA DOSE LENVIMA 20MG DAILY 3 LA PA DOSE LENVIMA 24MG DAILY 3 LA PA DOSE MEKINIST 3 PA NEXAVAR 2 LA PA SPRYCEL 2 PA STIVARGA 3 LA PA SUTENT 2 PA TAFINLAR 3 PA TARCEVA 2 PA (3-MONTH) 8

9 TASIGNA 2 PA TYKERB 2 LA PA VOTRIENT 2 PA XALKORI 3 LA PA ZELBORAF 3 LA PA ZYDELIG 3 LA PA ZYKADIA 3 LA PA MISCELLANEOUS BLINCYTO 3 PA CYRAMZA 00mg/0ml 3 PA DROXIA 3 ERWINAZE 3 LA PA GAZYVA 3 PA HALAVEN 3 B/D hydroxyurea CAPS IXEMPRA KIT 3 B/D JEVTANA 3 PA KEYTRUDA SOLR 3 PA MATULANE 2 mitoxantrone hcl B/D ONCASPAR 3 PA OPDIVO 40mg/4ml 3 PA POMALYST 2 LA PA SYLATRON KIT 296MCG 2 PA SYLATRON KIT 444MCG 2 PA SYLATRON KIT 888MCG 2 PA SYNRIBO 3 PA TARGRETIN 2 PA tretinoin CAPS TRISENOX 3 B/D UVADEX 3 B/D PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D ELOXATIN 3 B/D oxaliplatin B/D PROTECTIVE AGENTS amifostine crystalline B/D dexrazoxane 250mg B/D ELITEK 3 B/D FUSILEV 3 PA KEPIVANCE 3 B/D leucovor ca inj B/D leucovorin calcium SOLR B/D leucovorin calcium TABS leucovorin calcium 500 mg 3 B/D mesna B/D MESNEX TABS 3 TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/5ml 3 B/D ETOPOPHOS 3 B/D etoposide SOLN B/D 500mg/25ml irinotecan B/D irinotecan hcl B/D toposar gm/50ml B/D topotecan hcl SOLR B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl benazepril & hydrochlorothiazide captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide TARKA 2 trandolapril-verapamil hcl ACE INHIBITORS benazepril hcl TABS captopril TABS enalapril maleate TABS fosinopril sodium lisinopril TABS moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone TABS ALPHA BLOCKERS doxazosin mesylate prazosin hcl terazosin hcl 9

10 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-60 mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab 0-60 mg amlodipine besylate-valsartan tab mg amlodipine-valsartan-hydrochl orothiazide mg amlodipine-valsartan-hydrochl orothiazide mg amlodipine-valsartan-hydrochl orothiazide mg amlodipine-valsartan-hydrochl orothiazide mg amlodipine-valsartan-hydrochl orothiazide mg AZOR 2 BENICAR HCT 2 candesartan cilexetil-hydrochlorothiazide EDARBYCLOR 3 irbesartan-hydrochlorothiazide losartan potassium & hydrochlorothiazide telmisartan-amlodipine telmisartan-hydrochlorothiazid e TEVETEN HCT 3 TRIBENZOR 2 valsartan-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2 candesartan cilexetil EDARBI 3 eprosartan mesylate irbesartan losartan potassium TELMISARTAN valsartan ANTIARRHYTHMICS amiodarone hcl amiodarone inj 50mg/ml disopyramide phosphate PA flecainide acetate mexiletine hcl MULTAQ 3 NORPACE CR 2 PA pacerone propafenone hcl quinidine gluconate er quinidine sulfate TABS sorine sotalol hcl sotalol hcl (afib/afl) TIKOSYN 2 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3 atorvastatin calcium TABS CRESTOR 2 fluvastatin sodium LESCOL XL 3 LIVALO 3 lovastatin pravastatin sodium simvastatin TABS ANTILIPEMICS, MISCELLANEOUS ADVICOR 3 ANTARA 3 cholestyramine cholestyramine light choline fenofibrate colestipol hcl FENOFIBRATE CAPS fenofibrate TABS 48mg, 54mg, 45mg, 60mg fenofibrate micronized FENOFIBRIC ACID FENOGLIDE 3 gemfibrozil TABS JUXTAPID 5mg, 0mg, 3 PA 20mg KYNAMRO 3 PA LIPTRUZET 3 niacin (antihyperlipidemic) niacor omega-3-acid ethyl esters prevalite SIMCOR 2 0

11 TRIGLIDE 3 VASCEPA 3 VYTORIN 2 WELCHOL 2 ZETIA TAB 0MG 2 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide DUTOPROL 3 metoprolol & hctz tab 50-25mg metoprolol & hctz tab 00-25mg metoprolol & hctz tab 00-50mg nadolol & bendroflumethiazide propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol TABS betaxolol hcl bisoprolol fumarate BYSTOLIC 2 carvedilol COREG CR 2 labetalol hcl SOLN; TABS metoprolol succinate metoprolol tartrate SOLN; TABS nadolol TABS pindolol propranolol hcl er propranolol inj mg/ml propranolol sol propranolol tab SOTYLIZE 3 timolol maleate TABS CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV CALCIUM CHANNEL BLOCKERS afeditab cr amlodipine besylate TABS CARDIZEM LA 20mg 3 cartia xt dilt-cd cap dilt-xr cap diltiazem cap 20mg/24hr diltiazem cap er/2hr diltiazem hcl TABS diltiazem hcl coated beads diltiazem hcl er diltiazem hcl extended release beads diltiazem inj 25mg/5ml diltiazem inj 50/0ml diltiazem inj 00mg 3 diltiazem inj 25/25ml diltzac felodipine isradipine matzim la nicardipine hcl CAPS nifedical nifedipine TB24 nifedipine er nimodipine CAPS nisoldipine NYMALIZE 3 taztia xt verapamil hcl CP24 00mg, 20mg, 80mg, 200mg, 240mg, 300mg VERAPAMIL HCL CP24 360mg verapamil hcl SOLN verapamil hcl TABS verapamil hcl TBCR DIGITALIS GLYCOSIDES digitek digoxin digoxin inj DIGOXIN SOL 50MCG/ML LANOXIN PEDIATRIC 3 LANOXIN TAB 2 DIRECT RENIN INHIBITORS/COMBINATIONS TEKAMLO 2 TEKTURNA 2

12 TEKTURNA HCT 2 DIURETICS acetazolamide CP2; TABS acetazolamide sodium ALDACTAZIDE TAB 50/50 3 amiloride & hydrochlorothiazide amiloride hcl bumetanide chlorothiazide chlorthalidone 25mg, 50mg DIURIL SUS 250/5ML 3 DYRENIUM 3 EDECRIN 3 furosemide SOLN; TABS furosemide inj furosemide oral soln 8 mg/ml 2 hydrochlorothiazide CAPS; TABS indapamide methazolamide TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide torsemide inj 20mg/2ml 3 torsemide inj 50mg/5ml 3 torsemide tabs triamt/hctz cap triamt/hctz cap 50-25mg triamt/hctz tab triamt/hctz tab 75-50mg MISCELLANEOUS BIDIL 2 clonidine hcl PTWK; TABS clorpres DEMSER 3 DIBENZYLINE 3 hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS RANEXA 2 NITRATES DILATRATE SR 3 ISORDIL TITRADOSE 40mg 2 isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er minitran nitro-bid 3 NITRO-DUR.3mg/hr, 2.8mg/hr NITROGLYCERIN.4mg/spray NITROGLYCERIN LINGUAL nitroglycerin patches NITROLINGUAL SPR 2 PUMPSPRA NITROMIST 3 NITROSTAT 2 PULMONARY ARTERIAL HYPERTENSION ADCIRCA 2 PA ADEMPAS 3 PA FLOLAN 2 LA PA LETAIRIS 2 LA PA OPSUMIT 3 PA ORENITRAM TAB 0.25MG 3 PA ORENITRAM TAB 0.25MG 3 PA ORENITRAM TAB MG 3 PA ORENITRAM TAB 2.5MG 3 PA REMODULIN 2 B/D LA REVATIO SOLN 3 PA REVATIO SUSR 2 PA sildenafil citrate (pulmonary PA hypertension) TRACLEER 2 LA PA TYVASO 2 B/D VELETRI 3 LA PA VENTAVIS 2 B/D CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC 3 alprazolam TABS buspirone hcl TABS fluvoxamine maleate fluvoxamine maleate er lorazepam CONC; SOLN; TABS ANTICONVULSANTS APTIOM 3 BANZEL SUS 40MG/ML 3 BANZEL TAB 200MG 3 BANZEL TAB 400MG 3 2

13 carbamazepine CHEW; CP2; SUSP; TABS; TB2 CELONTIN 3 clonazepam TABS; TBDP clorazepate dipotassium diazepam CONC; SOLN; TABS DIAZEPAM GEL (ANTICONVULSANT) dilantin 3 DILANTIN-25 3 divalproex sodium epitol ethosuximide CAPS; SOLN felbamate FYCOMPA 3 gabapentin CAPS; SOLN; TABS GABITRIL 2mg, 6mg 2 LAMICTAL ODT 2 LAMICTAL STARTER 3 LAMICTAL XR KIT 2 lamotrigine CHEW; TABS; TB24; TBDP levetiracetam SOLN; TABS; TB24 LEVETIRACETAM IN NACL 3 LYRICA 2 ONFI SUS 2.5MG/ML 3 ONFI TAB 0MG 3 oxcarbazepine OXTELLAR XR 3 PEGANONE 3 phenobarbital ELIX; TABS PA PHENOBARBITAL SODIUM 3 PA 65mg/ml phenobarbital sodium PA 30mg/ml phenytek 3 phenytoin CHEW; SUSP phenytoin inj 50mg/ml phenytoin sodium extended POTIGA 3 primidone TABS QUDEXY XR 3 SABRIL 3 LA PA TEGRETOL 3 TEGRETOL-XR 3 tiagabine hcl topiramate CPSP; TABS TOPIRAMATE CS24 TROKENDI XR 3 valproate sodium SOLN; SYRP valproic acid CAPS VIMPAT 2 zonisamide CAPS ANTIDEMENTIA donepezil odt 5mg donepezil odt 0mg donepezil tab hcl 23mg donepezil tabs 5mg donepezil tabs 0mg EXELON PATCHES 2 galantamine hydrobromide NAMENDA SOL 0MG/5ML 2 PA PA if <30 yr NAMENDA TAB 2 PA PA if <30 yr NAMENDA XR 2 PA PA if <30 yr NAMENDA XR TITRATION 2 PA PACK PA if <30 yr NAMZARIC 3 rivastigmine tartrate ANTIDEPRESSANTS amitriptyline hcl TABS PA amoxapine APLENZIN 3 BRINTELLIX 2 bupropion hcl TABS; TB2; TB24 citalopram hydrobromide clomipramine hcl CAPS PA desipramine hcl TABS doxepin hcl CAPS; CONC PA duloxetine hcl CPEP 20mg, 30mg, 60mg EMSAM 3 escitalopram oxalate FETZIMA 3 FETZIMA TITRATION PACK 3 fluoxetine hcl CAPS 3

14 fluoxetine hcl CPDR fluoxetine hcl SOLN fluoxetine hcl TABS 0mg, 20mg FLUOXETINE HCL TABS 2 60mg FORFIVO XL 3 imipramine hcl TABS PA imipramine pamoate PA maprotiline hcl MARPLAN 2 mirtazapine nefazodone hcl nortriptyline hcl CAPS; SOLN paroxetine er tab paroxetine hcl PAXIL SUSP 3 PEXEVA 3 phenelzine sulfate TABS PRISTIQ 2 protriptyline hcl sertraline hcl CONC; TABS SURMONTIL 3 PA tranylcypromine sulfate trazodone hcl TABS venlafaxine cap er venlafaxine hcl venlafaxine tab VENLAFAXINE TAB 225MG ER venlafaxine tab er VIIBRYD 2 ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS APOKYN 3 LA PA AZILECT 2 benztropine mesylate SOLN benztropine mesylate TABS PA bromocriptine mesylate CAPS; TABS carbidopa TABS carbidopa-levodopa CARBIDOPA/LEVODOPA/EN TACAPONE DUOPA 3 B/D entacapone MIRAPEX.75mg 3 MIRAPEX ER 2 NEUPRO 2 pramipexole dihydrochloride pramipexole dihydrochloride tab sr 24hr 0.75 mg pramipexole dihydrochloride tab sr 24hr mg pramipexole dihydrochloride tab sr 24hr.5 mg ropinirole hydrochloride RYTARY 3 selegiline hcl CAPS; TABS trihexyphenidyl hcl PA ZELAPAR 2 ANTIPSYCHOTICS ABILIFY 2 ABILIFY DISCMELT 2 ABILIFY INJ 9.75MG 2 ABILIFY MAINTENA 3 aripiprazole chlorpromaz inj 25mg/ml 3 chlorpromazine hcl TABS clozapine CLOZAPINE ODT CLOZAPINE ODT 50MG CLOZAPINE ODT 200MG FANAPT 3 FANAPT TITRATION PACK 3 FAZACLO 3 fluphenazine decanoate SOLN fluphenazine hcl GEODON INJ 3 haloperidol TABS haloperidol decanoate SOLN haloperidol lactate INVEGA 3 INVEGA SUST INJ 39 3 MG/0.25 ML INVEGA SUST INJ 78 MG/0.5 3 ML INVEGA SUST INJ 7 3 MG/0.75 ML INVEGA SUST INJ 3 56MG/ML 4

15 3 INVEGA SUST INJ 234 MG/.5 ML INVEGA TRINZA 3 LATUDA 2 loxapine succinate olanzapine olanzapine odt ORAP 3 perphenazine TABS quetiapine fumarate RISPERDAL INJ 2.5MG 2 RISPERDAL INJ 25MG 2 RISPERDAL INJ 37.5MG 2 RISPERDAL INJ 50MG 2 risperidone risperidone odt SAPHRIS 3 SEROQUEL XR 2 thioridazine hcl TABS PA thiothixene trifluoperazine hcl VERSACLOZ 3 ziprasidone hcl ZYPREXA RELPREVV 3 B/D ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 0mg er amphetamine cap 5mg er amphetamine cap 20mg er amphetamine cap 25mg er amphetamine cap 30mg er amphetamine-dextroampheta mine cap sr 24hr 5 mg APTENSIO XR 3 DAYTRANA 2 guanfacine hcl (adhd) metadate tab er 20 mg METHYLIN CHEW TAB 2 rizatriptan benzoate amphetamine-dextroampheta SUMATRIPTAN SUCCINATE mine tab 5 mg SOAJ amphetamine-dextroampheta SUMATRIPTAN SUCCINATE mine tab 7.5 mg SOCT amphetamine-dextroampheta SUMATRIPTAN SUCCINATE mine tab 0 mg SOLN 5mg/act, 20mg/act amphetamine-dextroampheta sumatriptan succinate SOSY mine tab 2.5 mg amphetamine-dextroampheta sumatriptan succinate TABS mine tab 5 mg sumatriptan succinate inj amphetamine-dextroampheta SOAJ; SOLN mine tab 20 mg SUMATRIPTAN SUCCINATE amphetamine-dextroampheta INJ SOCT mine tab 30 mg SUMAVEL DOSEPRO 2 TREXIMET 2 methylphenidate hcl CHEW; CP24; CPCR; SOLN; TABS; TBCR methylphenidate hcl er QUILLIVANT XR 2 RITALIN LA 0mg, 60mg 3 STRATTERA 2 VYVANSE 2 HYPNOTICS ROZEREM 3 SILENOR 2 temazepam 7.5mg, 5mg 90 day limit if >64 yr zolpidem tartrate TABS PA 90 day limit if >64 yr MIGRAINE ALSUMA 3 AXERT 3 cafergot tab -00mg 2 dihydroergotamine mesylate mg/ml DIHYDROERGOTAMINE MESYLATE 4mg/ml ergomar 3 FROVA TAB 2.5MG 3 migergot naratriptan hcl RELPAX 2 5

16 zolmitriptan TABS zolmitriptan odt ZOMIG NASAL SPRAY 2 MISCELLANEOUS BRISDELLE 2 EQUETRO 3 GRALISE 2 GRALISE STARTER 2 HETLIOZ 3 PA HORIZANT 3 lithium carbonate CAPS; TABS; TBCR LITHIUM CITRATE 3 MESTINON SYRUP 2 MESTINON TIMESPAN 2 NUEDEXTA 2 pyridostigmine bromide TABS riluzole SAVELLA 2 SAVELLA TITRATION PACK 2 XENAZINE 2 LA PA MULTIPLE SCLEROSIS AGENTS AMPYRA 3 LA PA AUBAGIO 3 PA AVONEX 2 PA AVONEX PEN 2 PA BETASERON 3 PA COPAXONE INJ 40MG/ML 2 PA COPAXONE KIT 20MG/ML 2 PA EXTAVIA 2 PA GILENYA CAP 0.5MG 2 PA LEMTRADA 3 LA PA PLEGRIDY 2 PA PLEGRIDY STARTER PACK 2 PA REBIF 3 PA REBIF REBIDOSE 3 PA REBIF REBIDOSE 3 PA TITRATION REBIF TITRATION PACK 3 PA TECFIDERA CAP 20MG 2 PA TECFIDERA CAP 240MG 2 PA TECFIDERA MIS STARTER 2 PA TYSABRI 3 LA PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS cyclobenzaprine hcl TABS 5mg, 0mg PA dantrolene sodium CAPS tizanidine NARCOLEPSY/CATAPLEXY modafinil NUVIGIL 2 XYREM 2 LA PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium BUNAVAIL MIS BUNAVAIL MIS BUNAVAIL MIS 6.3-MG 3 buprenorphine hcl SUBL buprenorphine hcl-naloxone hcl sl buproban CHANTIX 2 PA CHANTIX CONTINUING 2 PA MONTH CHANTIX STARTER PACK 2 PA disulfiram TABS naloxone hcl SOLN naltrexone hcl TABS NICOTROL INHALER 3 NICOTROL NS 3 SARAFEM 3 SUBOXONE MIS 2-0.5MG 3 SUBOXONE MIS 4-MG 3 SUBOXONE MIS 8-2MG 3 SUBOXONE MIS 2-3MG 3 VIVITROL 3 PA ZUBSOLV 2 ZUBSOLV SUB ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2 PA ANDROGEL 3 PA ANDROGEL % 3 PA ANDROGEL.62% 3 PA ANDROGEL GEL PUMP % 3 PA ANDROGEL PUMP 3 PA AVEED 3 PA AXIRON 2 PA depo-testosterone 00mg/ml 3 FORTESTA 2 PA oxandrolone TABS PA STRIANT 3 PA TESTIM 3 PA 6

17 testosterone cypionate SOLN testosterone enanthate SOLN VOGELXO 3 PA VOGELXO PUMP 3 PA ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2 APIDRA 2 APIDRA SOLOSTAR 2 BYDUREON 2 BYETTA 3 GAUZE PADS 2X2 2 HUMALOG 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 3 KWIKPEN HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 3 KWIKPEN HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U B/D (CONCENTRATE) INSULIN PEN NEEDLES 2 INSULIN SAFETY NEEDLES 2 INSULIN SYRINGES 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXTOUCH 2 NOVOLIN 70/30 2 NOVOLIN 70/30 RELION 3 NOVOLIN N 2 NOVOLIN N RELION 3 NOVOLIN R 2 NOVOLIN R RELION 3 NOVOLOG 2 NOVOLOG MIX 70/30 2 NOVOLOG MIX 70/30 2 PREFILL NOVOLOG PENFILL 2 SYMLINPEN 60 2 SYMLINPEN 20 2 TANZEUM 3 TOUJEO SOLOSTAR 3 TRULICITY 3 PA VICTOZA 2 ANTIDIABETICS, ORAL acarbose ACTOPLUS MET XR MG ACTOPLUS MET XR MG FARXIGA 3 glimepiride glipizide TABS glipizide er glipizide-metformin mg glipizide-metformin mg glipizide-metformin 5-500mg GLUMETZA 3 GLYSET 3 GLYXAMBI 3 INVOKAMET TAB MG 2 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKANA TAB 00MG 2 INVOKANA TAB 300MG 2 JANUMET 2 JANUMET XR TAB MG JANUMET XR TAB JANUMET XR TAB JANUVIA 2 JARDIANCE 3 JENTADUETO 2 KAZANO 3 KOMBIGLYZE XR MG KOMBIGLYZE XR 5-500MG 3 KOMBIGLYZE XR 5-000MG 3 metformin er metformin hcl TABS; TB24 nateglinide NESINA 3 ONGLYZA 3 OSENI TAB 2.5-5MG 3 7

18 OSENI TAB MG 3 OSENI TAB MG 3 OSENI TAB 25-5MG 3 OSENI TAB 25-30MG 3 OSENI TAB 25-45MG 3 pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl PRANDIMET 3 repaglinide RIOMET 3 TRADJENTA 2 XIGDUO XR TAB 5-500MG 3 XIGDUO XR TAB 5-000MG 3 XIGDUO XR TAB 0-500MG 3 XIGDUO XR TAB BISPHOSPHONATES ACTONEL 5mg, 30mg, 2 35mg alendronate sodium ATELVIA 2 BINOSTO 3 FOSAMAX PLUS D 3 ibandronate sodium B/D pamidronate inj 6mg/ml 3 B/D pamidronate inj 30/0ml B/D pamidronate inj 90/0ml B/D risedronate sodium zoledronic inj 4mg/5ml B/D zoledronic inj 5/00ml B/D ZOMETA SOLN 3 B/D CALCIUM RECEPTOR AGONISTS SENSIPAR 2 CHELATING AGENTS CHEMET 3 DEPEN TITRATABS 3 EXJADE 3 LA PA FERRIPROX 3 PA kionex sodium polystyrene sulfonate SYPRINE 3 CONTRACEPTIVES altavera amethia 9 day amethyst 28 day apri 28 day aranelle 28 ashlyna 9 day aubra 28 day aviane 28 balziva 28 day BEYAZ 2 briellyn 28 day camila 28 day CAMRESE LO TAB cryselle 28 cyclafem /35 28 day cyclafem 7/7/7 28 day deblitane 28 day delyla 28 day DEPO-SUBQ PROVERA 04 2 desogestrel-ethinyl estradiol (biphasic) drospirenone-ethinyl estradiol ELLA 2 emoquette enpresse 28 day errin 28 day falmina 28 day GENERESS FE 3 GIANVI TAB MG gildagia gildess.5/30 2 day gildess 24 fe 28 day heather introvale 9 day JOLESSA TAB MG JOLIVETTE junel.5/30 2 day junel /20 2 day junel fe.5/30 28 day junel fe /20 28 day kariva 28 day kelnor /35 28 day larin.5/30 larin /20 larin fe.5/30 larin fe /20 LEENA TAB lessina 28 day levonest 28 day 8

19 levonorgestrel & eth estradiol levonorgestrel (emergency oc) levonorgestrel-ethinyl estradiol (9-day) levonorgestrel-ethinyl estradiol (continuous) levora 0.5/30 28 day LO LOESTRIN FE 2 lomedia 24 fe loryna 28 day low-ogestrel 28 day lutera 28 day lyza marlissa 28 day medroxyprogesterone acetate (contraceptive) microgestin.5/30 2 day microgestin /20 2 day microgestin fe.5/30 28 day microgestin fe /20 28 day MINASTRIN 24 FE 2 MONONESSA my way myzilra necon 0.5/35 28 day necon /35 28 day NECON 7/7/7 necon 0/ 28 day 3 NECON TAB /50-28 next choice tab.5mg nikki 28 day NORA-BE TAB norethin acet & estrad-fe norethindrone & ethinyl estradiol-fe norethindrone (contraceptive) norgestimate-ethinyl estradiol (triphasic) norlyroc 28 day nortrel 0.5/35 28 day nortrel /35 2 day nortrel /35 28 day nortrel 7/7/7 28 day NUVARING 2 OCELLA TAB MG ogestrel 28 day orsythia 28 day ORTHO TRI-CYCLEN LO 2 philith pimtrea pack pirmella /35 28 day portia 28 day previfem 28 day QUARTETTE 3 quasense 9 day reclipsen 28 day sharobel 28 day SOLIA sprintec 28 day sronyx 28 day syeda tarina fe tab /20 tri-legest 28 day tri-previfem 28 day tri-sprintec 28 day TRINESSA trivora 28 day velivet 28 day vestura viorele vyfemia 28 day WYMZYA FE xulane dis zarah zenchent fe 28 day zenchent tab zovia /35e 28 day zovia /50e 28 day ENDOMETRIOSIS danazol CAPS LUPANETA PACK 3 PA SYNAREL 2 ENZYME REPLACEMENTS ADAGEN 3 LA PA ALDURAZYME 3 LA PA CARBAGLU 3 LA PA CERDELGA 3 PA CEREZYME 3 PA CYSTADANE 3 CYSTAGON 3 PA ELAPRASE 3 PA ELELYSO 3 PA 9

20 FABRAZYME 3 PA KUVAN 2 PA levocarnitine (metabolic B/D modifiers) LUMIZYME 3 PA MYOZYME 3 PA NAGLAZYME 3 LA PA ORFADIN 3 PA PROCYSBI 3 LA PA sodium phenylbutyrate VIMIZIM 3 PA VPRIV 3 PA ZAVESCA 3 LA PA ESTROGENS ALORA 3 PA COMBIPATCH 3 PA depo-estradiol 3 DUAVEE 2 PA estrace CREA 2 estradiol PTTW; PTWK; PA TABS ESTRADIOL VALERATE OIL 0mg/ml, 40mg/ml estradiol valerate OIL 20mg/ml ESTRING 3 FEMRING 3 MENOSTAR 3 PA MINIVELLE 2 PA PREMARIN 2 PA PREMARIN CREAM 2 PREMARIN INJ 3 PREMPHASE 2 PA PREMPRO 2 PA VAGIFEM 2 GLUCOCORTICOIDS a-hydrocort cortisone acetate TABS DEPO-MEDROL INJ 3 B/D 20MG/ML dexamethasone CONC 3 dexamethasone ELIX; SOLN; TABS dexamethasone sodium phosphate dexpak taperpak 3 day 2 FLO-PRED SUS 3 B/D fludrocortisone acetate TABS hydrocortisone TABS MEDROL TAB 2MG 3 B/D methylpr ace inj 40mg/ml B/D methylpr ace inj 80mg/ml B/D methylpr ss inj gm B/D methylpr ss inj 40mg B/D methylpr ss inj 25mg B/D methylpred pak 4mg B/D methylpred tab 4mg B/D methylpred tab 8mg B/D methylpred tab 6mg B/D methylpred tab 32mg B/D millipred 3 B/D ORAPRED ODT TAB 0MG 2 B/D pred sod pho sol 5mg/5ml B/D prednisolone sodium B/D phosphate prednisolone sol 5mg/5ml B/D prednisolone sol 25mg/5ml B/D prednisolone syrup 5 mg/5ml B/D prednisone con 5mg/ml 3 B/D prednisone pak 5mg B/D prednisone pak 0mg B/D prednisone sol 5mg/5ml B/D prednisone tab mg B/D prednisone tab 2.5mg B/D prednisone tab 5mg B/D prednisone tab 0mg B/D prednisone tab 20mg B/D prednisone tab 50mg B/D RAYOS TAB MG 3 B/D RAYOS TAB 2MG 3 B/D RAYOS TAB 5MG 3 B/D SOLU-CORTEF 3 SOLU-MEDROL INJ 2GM 3 B/D veripred 3 B/D GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY 2 KIT PROGLYCEM SUS 50MG/ML 3 HUMAN GROWTH HORMONES GENOTROPIN 3 PA GENOTROPIN MINIQUICK 3 PA HUMATROPE 2 PA HUMATROPE COMBO PACK 2 PA NORDITROPIN FLEXPRO 2 PA 20

21 NORDITROPIN NORDIFLEX 2 PA PEN NUTROPIN AQ INJ 3 PA 20MG/2ML NUTROPIN AQ NUSPIN 5 3 PA NUTROPIN AQ PEN 3 PA OMNITROPE 5.8MG 3 PA OMNITROPE 5MG 3 PA OMNITROPE 0MG 3 PA SAIZEN 3 PA SAIZEN CLICK.EASY 3 PA SEROSTIM 3 PA TEV-TROPIN 3 PA ZOMACTON 3 PA ZORBTIVE 3 PA MISCELLANEOUS AFREZZA 3 cabergoline calcitonin (salmon) nasal spray CHORIONIC PA GONADOTROPIN SOLR EGRIFTA 3 PA FORTICAL SPR 200/ACT 3 H.P. ACTHAR 3 PA INCRELEX 3 LA PA KORLYM 3 LA PA methylergonovine maleate TABS MIACALCIN INJ 200U/ML 2 B/D MYALEPT 3 PA NOVAREL INJ 0000UNT PA octreotide acetate PA PREGNYL W/DILUENT BENZYL PA PROLIA 3 raloxifene hcl RAVICTI 3 LA PA SAMSCA 3 PA SANDOSTATIN LAR DEPOT 3 PA SIGNIFOR 3 PA SOMATULINE DEPOT 3 PA SOMAVERT 3 LA PA SUPPRELIN LA 3 PA XGEVA 3 PA PARATHYROID HORMONES FORTEO 2 PA PHOSPHATE BINDER AGENTS AURYXIA 3 calcium acetate (phosphate binder) FOSRENOL 3 PHOSLYRA 2 RENAGEL 3 RENVELA PAK 2 RENVELA TAB 800MG 2 VELPHORO 2 PROGESTINS CRINONE 2 MAKENA 3 PA medroxyprogesterone acetate norethindrone acetate TABS progesterone micronized CAPS THYROID AGENTS levothyroxine sodium TABS LEVOXYL liothyronine sodium SOLN; TABS methimazole TABS propylthiouracil TABS SYNTHROID 2 TIROSINT 3 UNITHROID VASOPRESSINS DESMOPRESSIN ACETATE SOLN desmopressin acetate TABS desmopressin acetate inj desmopressin acetate spray desmopressin acetate spray refrigerated STIMATE 3 PA GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D ALOXI 3 CESAMET 3 B/D compro supp dronabinol B/D EMEND CAP 40MG 3 B/D EMEND CAP 80MG 3 B/D EMEND CAP 25MG 3 B/D EMEND PAK 80 & 25 3 B/D granisetron hcl SOLN granisetron hcl TABS B/D 2

22 meclizine hcl TABS metoclopramide hcl SOLN; TABS; TBDP metoclopramide hcl inj 5 mg/ml METOZOLV ODT 3 ondansetron hcl SOLN ondansetron hcl TABS B/D ondansetron hcl inj ondansetron hcl oral soln B/D ondansetron odt B/D phenadoz PA phenadoz sup PA phenergan SUPP PA phenergan supp PA prochlorperazine inj 5 mg/ml prochlorperazine maleate TABS prochlorperazine supp promethazine hcl SOLN; PA SUPP; SYRP; TABS promethegan PA SANCUSO 2 TRANSDERM-SCOP 2 PA ZUPLENZ 3 B/D ANTISPASMODICS ATROPINE SULFATE SOLN.05mg/ml,.mg/ml BENTYL SOLN 3 CANTIL 3 CUVPOSA 3 dicyclomine hcl glycate 3 glycopyrrolate SOLN; TABS methscopolamine bromide TABS H2-RECEPTOR ANTAGONISTS cimetidine TABS cimetidine sol 300/5ml famotidine SOLN 20mg/2ml, 40mg/4ml, 200mg/20ml famotidine SUSR famotidine TABS 20mg, 40mg nizatidine ranitidine hcl CAPS ranitidine hcl SOLN ranitidine hcl SYRP ranitidine hcl TABS 50mg, 300mg INFLAMMATORY BOWEL DISEASE APRISO 2 ASACOL HD 3 balsalazide disodium budesonide CP24 CANASA 2 colocort DELZICOL 3 DIPENTUM 3 ENTYVIO 3 PA GIAZO 3 HYDROCORTISONE (INTRARECTAL) LIALDA 2 mesalamine enema PENTASA 2 SF-ROWASA 2 sulfasalazine dr sulfasalazine ir UCERIS 3 LAXATIVES COLYTE-FLAVOR PACKS 3 constulose enulose gaviltye-g gavilyte-c gavilyte-h gavilyte-n generlac GOLYTELY 3 kristalose 3 lactulose lactulose (encephalopathy) MOVIPREP 2 NULYTELY/FLAVOR PACKS 3 OSMOPREP 3 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350-potassium chloride-sod bicarbonate-sod chloride polyethylene glycol 3350 PACK; POWD PREPOPIK 3 RELISTOR 2 22

23 SUCLEAR 2 SUPREP BOWEL PREP 2 trilyte MISCELLANEOUS alosetron hcl AMITIZA 2 amoxicillin-clarithromycin w/ lansoprazole CARAFATE SUSP 2 cromolyn sodium (mastocytosis) diphenoxylate w/ atropine GATTEX 3 LA PA LINZESS 2 loperamide hcl CAPS LOTRONEX 2 misoprostol TABS MOVANTIK 3 OMECLAMOX-PAK 3 PYLERA 2 SUCRAID 3 sucralfate TABS ursodiol CAPS; TABS XIFAXAN TAB 550MG 2 PANCREATIC ENZYMES CREON 2 PANCREAZE 3 PERTZYE 3 ULTRESA 2 VIOKACE 0 2 VIOKACE 20 2 ZENPEP 2 PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3 ACIPHEX SPR CAP 0MG 3 DEXILANT 3 esomeprazole sodium lansoprazole CPDR NEXIUM 3 NEXIUM GRA 2.5MG DR 3 NEXIUM GRA 5MG DR 3 NEXIUM GRA 0MG DR 3 NEXIUM GRA 20MG DR 3 NEXIUM GRA 40MG DR 3 omeprazole CPDR OMEPRAZOLE-SODIUM BICARBONATE pantoprazole sodium PREVACID SOLUTAB 3 PRILOSEC PACK 3 PROTONIX PACK 3 rabeprazole sodium ZEGERID PACK 3 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl AVODART 2 CARDURA XL 3 finasteride TABS 5mg JALYN 3 RAPAFLO 2 tamsulosin hcl MISCELLANEOUS bethanechol chloride TABS ELMIRON 2 POTASSIUM CITRATE (ALKALINIZER) TAB URINARY ANTISPASMODICS ENABLEX 3 GELNIQUE 2 MYRBETRIQ 2 oxybutynin chloride OXYTROL 3 TOLTERODINE TARTRATE ER tolterodine tartrate tab mg tolterodine tartrate tab 2 mg TOVIAZ 3 trospium chloride trospium chloride er VESICARE 2 VAGINAL ANTI-INFECTIVES CLEOCIN VAG SUPP 00MG 2 clindamycin cre 2% vag metronidazole vaginal miconazole nitrate vaginal NUVESSA 3 terconazole vaginal VANDAZOLE zazole.4% ZAZOLE.8% 23

24 HEMATOLOGIC ANTICOAGULANTS COUMADIN 3 ELIQUIS TAB 2.5MG 2 ELIQUIS TAB 5MG 2 enoxaparin sodium fondaparinux sodium FRAGMIN 2 HEP SOD/NACL INJ HEPARIN (PORCINE) IN SODIUM CHLORIDE 00U/ML heparin sod inj 000u/ml B/D HEPARIN SOD INJ 3 B/D 2000U/ML HEPARIN SOD INJ 3 B/D 2500U/ML heparin sod inj 5000u/0.5ml B/D heparin sod inj 5000u/ml B/D heparin sod inj 0000u/ml B/D heparin sod inj 20000u/ml B/D HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL % jantoven PRADAXA 2 SAVAYSA 3 warfarin sodium XARELTO 2 XARELTO STARTER PACK 2 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 PA EPOGEN 2 PA GRANIX 3 PA LEUKINE 3 PA MIRCERA 3 PA MOZOBIL 2 PA NEULASTA 2 PA NEUMEGA 3 PA NEUPOGEN 2 PA PROCRIT 2 PA MISCELLANEOUS anagrelide hcl BERINERT 3 PA cilostazol CINRYZE 3 LA PA DESFERAL 2gm 3 PA FIRAZYR 2 PA KALBITOR 3 PA NPLATE 250mcg 3 PA pentoxifylline TBCR PROMACTA 2 LA PA RUCONEST 3 PA SOLIRIS 2 PA tranexamic acid SOLN; TABS PLATELET AGGREGATION INHIBITORS AGGRENOX 2 BRILINTA 2 clopidogrel bisulfate EFFIENT 2 ZONTIVITY 3 IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 PA CIMZIA 3 PA ENBREL 2 PA ENBREL SURECLICK 2 PA HUMIRA 2 PA HUMIRA PEN 2 PA HUMIRA PEN-CROHNS 2 PA STARTER KIT HUMIRA PEN-PSORIASIS 2 PA STARTER KIT hydroxychloroquine sulfate KINERET 3 PA leflunomide TABS methotrexate sodium tabs ORENCIA 3 PA OTEZLA 3 PA OTREXUP 3 PA REMICADE 3 PA RHEUMATREX 2 SIMPONI 3 PA SIMPONI ARIA 3 PA trexall 2 B/D XELJANZ 3 PA IMMUNOGLOBULINS BIVIGAM 3 PA CARIMUNE NANOFILTERED 3 PA CYTOGAM 3 PA FLEBOGAMMA 3 PA FLEBOGAMMA DIF 3 PA GAMASTAN S/D 2 B/D GAMMAGARD LIQUID 3 PA 24

25 GAMMAGARD S/D 3 PA GAMMAGARD S/D IGA LESS 3 PA TH GAMMAKED 3 PA GAMMAPLEX 2.5gm/50ml, 3 PA 5gm/00ml, 0gm/200ml GAMUNEX-C 3 PA GAMUNEX-C GM/0ML 3 PA HIZENTRA gm/5ml 3 PA HYQVIA 3 PA OCTAGAM gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/00ml, 0gm/200ml, 25gm/500ml 3 PA PRIVIGEN 3 PA IMMUNOMODULATORS ACTIMMUNE 3 LA PA ARCALYST 3 PA GRASTEK 2 ILARIS 2 PA INTRON-A INJ 0MU 2 B/D INTRON-A INJ 8MU 2 B/D INTRON-A INJ 25MU 2 B/D INTRON-A INJ 50MU 2 B/D PEG-INTRON 2 PA PEG-INTRON REDIPEN 2 PA PEGASYS 2 PA PEGASYS PROCLICK 2 PA PEGINTRON 80mcg/0.5ml, 2 PA 20mcg/0.5ml, 50mcg/0.5ml RAGWITEK 2 REVLIMID 2 LA PA THALOMID 2 PA IMMUNOSUPPRESSANTS ASTAGRAF XL 3 B/D ATGAM 3 B/D azasan 2 B/D azathioprine TABS B/D CELLCEPT INTRAVENOUS 3 B/D cyclosporine CAPS; SOLN B/D cyclosporine modified (for B/D microemulsion) gengraf B/D mycophenolate mofetil B/D mycophenolate sodium B/D NEORAL 2 B/D NULOJIX 3 B/D PROGRAF CAPS 2 B/D PROGRAF SOLN 3 B/D RAPAMUNE SOLN 2 B/D SANDIMMUNE CAPS 2 B/D SANDIMMUNE SOLN 2 B/D SIMULECT 3 B/D SIROLIMUS TABS B/D sirolimus tab 0.5 mg B/D tacrolimus CAPS B/D THYMOGLOBULIN 3 B/D ZORTRESS TAB 0.5MG 3 B/D ZORTRESS TAB 0.25MG 3 B/D ZORTRESS TAB 0.75MG 3 B/D MISCELLANEOUS BENLYSTA 3 PA SYLVANT 3 PA VACCINES ACTHIB 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 CERVARIX 3 COMVAX 3 DAPTACEL 3 DIPHTHERIA/TETANUS 3 B/D TOXOID ENGERIX-B SUSP 3 B/D GARDASIL 3 GARDASIL 9 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 2 IXIARO 3 M-M-R II W/DILUENT 0 3 DOS MENACTRA 3 MENOMUNE-A/C/Y/W-35 3 MENVEO 3 PEDVAX HIB 3 PROQUAD 3 RABAVERT 3 RECOMBIVAX HB 3 B/D ROTARIX 2 ROTATEQ 3 SYNAGIS 3 TENIVAC 3 B/D 25

26 TETANUS TOXOID ADSORBED TETANUS/DIPHTHERIA TOXOID TRUMENBA 3 TWINRIX INJ 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3 KLOR-CON 8 KLOR-CON 0 klor-con m5 3 klor-con m20 klor-con pow 20meq 3 B/D 3 B/D MAGNESIUM SULFATE 3 SOLN 40mg/ml, 80mg/ml magnesium sulfate SOLN 50% MAGNESIUM SULFATE SOLN 50% MAGNESIUM SULFATE IN 3 D5W potassium chloride LIQD POTASSIUM CHLORIDE TBCR potassium chloride caps er potassium chloride microencapsulated crystals cr SODIUM CHLORIDE SOLN 2.5meq/ml SODIUM FLUORIDE CHEW; TAB;. (0.5 F) MG/ML SOLN TPN ELECTROLYTES B/D IV NUTRITION AMINOSYN 3 B/D AMINOSYN 3 B/D 7%/ELECTROLYTES AMINOSYN II 3 B/D AMINOSYN II B/D 8.5%/ELECTROL AMINOSYN INJ 8.5/LYTE B/D AMINOSYN M 3 B/D AMINOSYN-HBC 3 B/D AMINOSYN-PF 3 B/D AMINOSYN-PF 7% 3 B/D AMINOSYN-RF 3 B/D CLINIMIX 2.75%/DEXTROSE 3 B/D 5% CLINIMIX 4.25%/DEXTROSE 3 B/D 5% CLINIMIX 4.25%/DEXTROSE 3 B/D 0% CLINIMIX 4.25%/DEXTROSE 3 B/D 20% CLINIMIX 4.25%/DEXTROSE 3 B/D 25% CLINIMIX 5%/DEXTROSE 3 B/D 5% CLINIMIX 5%/DEXTROSE 3 B/D 20% CLINIMIX 5%/DEXTROSE 3 B/D 25% CLINIMIX E 3 B/D 2.75%/DEXTROSE 5% CLINIMIX E 3 B/D 2.75%/DEXTROSE 0% CLINIMIX E 3 B/D 4.25%/DEXTROSE CLINIMIX E 3 B/D 4.25%/DEXTROSE 5% CLINIMIX E 3 B/D 4.25%/DEXTROSE 25% CLINIMIX E 5%/DEXTROSE 3 B/D 5% CLINIMIX E 5%/DEXTROSE 3 B/D 20% CLINIMIX E 5%/DEXTROSE 3 B/D 25% clinisol 5 B/D FREAMINE HBC 6.9% 3 B/D FREAMINE III 3 B/D HEPATAMINE B/D INTRALIPID INJ 20% B/D INTRALIPID INJ 30% 3 B/D LIPOSYN III INJ 0% 3 B/D NEPHRAMINE 3 B/D NUTRILIPID EMU 20% B/D premasol 6% B/D premasol 0% 3 B/D PROCALAMINE 3 B/D PROSOL 3 B/D travasol 0 3 B/D 26

27 TROPHAMINE INJ 0% 3 B/D IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% dextrose SOLN 70% DEXTROSE 2.5%/NACL 0.45% DEXTROSE 5% DEXTROSE 5% 3 /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.3% 3 DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 0% FLEX CONTAIN DEXTROSE 0% W/ 3 SODIUM CHLORIDE 0.2% DEXTROSE 0%/NACL 0.45% ELECTROLYTE-R IN 3 DEXTROSE IONOSOL-B/DEXTROSE 5% 3 IONOSOL-MB/DEXTROSE 3 5% ISOLYTE P 3 isolyte s 3 KCL0.5%/D5W/NACL0.2% KCL0.5%/D5W/NACL % kcl 0.3%/d5w/lr iv lac ri 3 KCL 0.3%/D5W/NACL 0.9% 3 KCL 0.3%/D5W/NACL 0.45% KCL 0.5%/D5W/LR 3 KCL 0.5%/D5W/NACL 0.9% KCL 0.075%/D5W/NACL 0.45% LACTATED RINGERS VIAFLEX normosol-m NORMOSOL-R 3 PLASMA-LYTE A 3 PLASMA-LYTE-56/D5W 3 PLASMA-LYTE-48 3 potassium chloride SOLN POTASSIUM CHLORIDE 0.3%/D POTASSIUM CHLORIDE 0.5% POTASSIUM CHLORIDE 0.22% potassium chloride in nacl POTASSIUM CHLORIDE IN NACL RINGER'S SODIUM CHLORIDE SOLN.9%, 3%, 5% SODIUM CHLORIDE 0.45% VIA VITAMINS calcitriol CAPS; SOLN B/D doxercalciferol B/D paricalcitol CAPS B/D PARICALCITOL SOLN 3 B/D PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ZEMPLAR SOLN 3 B/D OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc blephamide OINT 3 BLEPHAMIDE SUSP 3 neomycin-polymy-dexameth neomycin-polymyxin-hc (ophth) PRED-G 3 PRED-G S.O.P. 3 sulfacetamide sod-prednisolone TOBRADEX OINT 2 TOBRADEX ST 2 tobramycin-dexamethasone ZYLET 2 ANTI-INFECTIVES AZASITE 3 bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE 2 CILOXAN OIN 0.3% OP 3 ciprofloxacin hcl (ophth) 27

28 erythromycin (ophth) gatifloxacin (ophth) gentak gentamicin sulfate (ophth) ilotycin levofloxacin (ophth) MOXEZA 2 NATACYN 2 neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidi n ofloxacin (ophth) polymyxin b-trimethoprim sulfacetamide sodium (ophth) tobramycin (ophth) TOBREX OINT 0.3% 3 trifluridine SOLN VIGAMOX 2 ZIRGAN 3 ANTI-INFLAMMATORIES ACUVAIL 3 ALREX 2 bromfenac sodium (ophth) BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL 2 FLAREX 3 FLUOROMETHOLONE (OPHTH) flurbiprofen sodium FML 3 FML FORTE 3 ILEVRO 3 ketorolac tromethamine (ophth) LOTEMAX 2 MAXIDEX 3 NEVANAC 3 PRED MILD 3 PREDNISOLONE ACETATE (OPHTH) prednisolone sodium 3 phosphate (ophth) VEXOL 3 ANTIALLERGICS ALOCRIL 3 ALOMIDE 3 azelastine hcl (ophth) BEPREVE 3 cromolyn sodium (ophth) EMADINE 3 epinastine hcl (ophth) LASTACAFT 3 PATADAY 2 PATANOL 2 PAZEO 3 ANTIGLAUCOMA ALPHAGAN P 0.% 2 ALPHAGAN P 0.5% 2 AZOPT 2 betaxolol hcl (ophth) BETIMOL 2 BETOPTIC-S 2 brimonidine sol 0.2% BRIMONIDINE SOL 0.5% carteolol hcl (ophth) COMBIGAN 2 COSOPT PF 2 dorzolamide hcl dorzolamide hcl-timolol maleate ISTALOL 3 latanoprost SOLN levobunolol hcl.5% LEVOBUNOLOL HCL.25% LUMIGAN 3 metipranolol PHOSPHOLINE IODIDE 3 PILOCARPINE HCL SOLN SIMBRINZA SUS -0.2% 2 timolol maleate (ophth) TIMOLOL MALEATE GEL TIMOPTIC OCUDOSE 3 TRAVATAN Z 2 ZIOPTAN 2 MISCELLANEOUS BOTOX INJ 00UNIT 3 PA BOTOX INJ 200UNIT 3 PA CYSTARAN 3 PA 28

29 DYSPORT 3 PA EYLEA 3 PA LACRISERT 3 LUCENTIS 3 PA MYOBLOC 2500unit/0.5ml 3 PA naphazoline 0.% PROLENSA 2 proparacaine hcl SOLN RESTASIS 2 XEOMIN 3 PA RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER COMBIVENT RESPIMAT 2 ipratropium-albuterol B/D ANTICHOLINERGICS ATROVENT HFA 3 INCRUSE ELLIPTA 3 ipratropium bromide (nasal) ipratropium sol inhal B/D SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT 2 TUDORZA PRESSAIR 3 TUDORZA PRESSAIR 3 (INSTITUTIONAL PACK) 400MCG/ACT ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB DYMISTA SPR SEMPREX-D 3 ANTIHISTAMINES ASTEPRO 2 azelastine spr 0.% azelastine spr 0.5% cetirizine syrup CLARINEX SYRP 3 desloratadine diphenhydram inj 50mg/ml hydroxyzine hcl SOLN; PA TABS hydroxyzine hcl inj PA hydroxyzine pamoate CAPS PA levocetirizine soln 2.5mg/5ml levocetirizine tab 5 mg olopatadine hcl (nasal) BETA AGONISTS albuterol sulfate NEBU B/D albuterol sulfate SYRP; TABS albuterol sulfate er ARCAPTA NEOHALER 2 BROVANA 3 B/D FORADIL AEROLIZER 2 levalbuterol conc B/D.25mg/0.5ml LEVALBUTEROL HCL B/D NEBU.25mg/3ml levalbuterol hcl NEBU B/D.3mg/3ml,.63mg/3ml PERFOROMIST 2 B/D PROAIR HFA 2 PROAIR RESPICLICK 3 PROVENTIL HFA 2 SEREVENT DISKUS 2 STRIVERDI RESPIMAT 3 terbutaline sulfate SOLN; TABS VENTOLIN HFA 3 XOPENEX HFA 3 LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; PACK; TABS zafirlukast ZYFLO CR 3 MAST CELL STABILIZERS cromolyn sodium NEBU B/D MISCELLANEOUS acetylcysteine SOLN 0%, 20% B/D ARALAST NP 3 LA PA AUVI-Q 2 DALIRESP 2 EPINEPHRINE SOAJ EPIPEN 2-PAK 2 EPIPEN-JR 2-PAK 2 ESBRIET 3 PA GLASSIA 3 LA PA KALYDECO TABS 3 PA OFEV 3 PA PROLASTIN-C 3 LA PA PULMOZYME 2 B/D tyzine.05% 3 XOLAIR 2 LA PA 29

30 ZEMAIRA 3 LA PA NASAL STEROIDS BECONASE AQ 3 budesonide (nasal) flunisolide (nasal) fluticasone propionate (nasal) NASONEX 2 OMNARIS 3 QNASL 3 triamcinolone acetonide (nasal) VERAMYST 3 ZETONNA 3 STEROID INHALANTS AEROSPAN 3 ALVESCO 3 ARNUITY ELLIPTA 3 ASMANEX 2 ASMANEX HFA 2 ASMANEX TWISTHALER 4 2 MET budesonide (inhalation) B/D FLOVENT DISKUS 2 FLOVENT HFA 2 PULMICORT FLEXHALER 2 PULMICORT INH SUSP 3 B/D MG/2ML QVAR 2 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2 ADVAIR HFA 2 BREO ELLIPTA 3 DULERA 2 SYMBICORT 2 XANTHINES aminophylline inj elixophyllin 2 lufyllin 200mg 3 theo-24 2 theophylline TOPICAL DERMATOLOGY, ACNE ABSORICA 3 ACANYA 2 ACZONE 3 adapalene CREA adapalene GEL.% ADAPALENE GEL.3% amnesteem ATRALIN 2 AVITA AZELEX 3 benzoyl peroxide-erythromycin claravis CLINDAGEL 3 clindamax clindamycin phosphate (topical) clindamycin phosphate-benzoyl peroxide clindamycin phosphate-benzoyl peroxide (refrigerate) DIFFERIN LOTN 2 EPIDUO 2 ery pad 2% erythromycin (acne aid) FABIOR 3 myorisan neuac gel.2-5% ONEXTON 3 RETIN-A MICRO PUMP 2.08% sulfacetamide sodium (acne) tretin-x CREA 3 tretinoin CREA; GEL TRETINOIN MICROSPHERE VELTIN 3 zenatane ZIANA 3 DERMATOLOGY, ANTIBIOTICS ALTABAX 3 BACTROBAN NASAL 3 CENTANY 3 CORTISPORIN CREA; 3 OINT gentamicin sulfate (topical) mupirocin OINT mupirocin calcium (topical) SILVER SULFADIAZINE CREA 30

31 SSD SULFAMYLON CREA 3 DERMATOLOGY, ANTIFUNGALS ciclopirox GEL ciclopirox cre 0.77% ciclopirox shampoo % ciclopirox sus 0.77% clotrimazole (topical) econazole nitrate CREA ERTACZO 3 EXELDERM 3 ketoconazole (topical) ketodan aer 2% LUZU 2 MENTAX 2 NAFTIFINE HCL NAFTIN 2 nyamyc nystatin (topical) nystatin pow nystop OXISTAT 3 DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2 procto-pak proctosol hc 2.5 % proctozone hc PRUDOXIN CRE 5% DERMATOLOGY, ANTIPSORIATICS acitretin calcipotriene CREA; OINT; SOLN calcitrene oin 0.005% CALCITRIOL OINT COSENTYX 3 PA DESOXIMETASONE OINT COSENTYX SENSOREADY 3 PA.05% PEN desoximetasone OINT.25% methoxsalen rapid diflorasone diacetate 8-MOP 3 fluocinolone acetonide SORILUX 2 CREA; OIL; OINT; SOLN STELARA 3 PA fluocinonide CREA; GEL; TAZORAC 2 OINT; SOLN fluocinonide emulsified base DERMATOLOGY, ANTISEBORRHEICS fluticasone propionate ketoconazole shampoo CREA; LOTN; OINT selenium sulfide LOTN halobetasol propionate DERMATOLOGY, ANTIVIRALS HALOG 3 acyclovir topical DENAVIR 2 XERESE 3 ZOVIRAX CREA 3 DERMATOLOGY, CORTICOSTEROIDS ala-cort alclometasone dipropionate amcinonide CREA; LOTN amcinonide OINT 3 apexicon CREA 3 apexicon OINT betamethasone dipropionate (topical) betamethasone dipropionate augmented betamethasone valerate CREA; FOAM; LOTN; OINT calcipotrien oin betameth CAPEX 2 clobetasol propionate CREA; FOAM; GEL; LIQD; LOTN; OINT; SHAM; SOLN clobetasol propionate emollient base clobetasol propionate emulsion clocortolone pivalate clodan CORDRAN TAPE 3 cormax DESONATE 3 DESONIDE CREA desonide LOTN; OINT desoximetasone CREA desoximetasone GEL 3

32 hydrocortisone (topical) hydrocortisone butyrate hydrocortisone butyrate hydrophilic lipo base hydrocortisone valerate KENALOG 3 LOCOID LOTN 2 LOKARA LOTN 0.05% mometasone furoate CREA; OINT; SOLN PANDEL 3 PREDNICARBATE CREA prednicarbate OINT TACLONEX SUSP 3 texacort 2 TOPICORT LIQD 3 triamcinolone acetonide (topical) trianex 3 triderm u-cort DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT lidocaine PTCH PA lidocaine hcl GEL lidocaine hcl SOLN 4% lidocaine-prilocaine B/D SYNERA 3 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN CONDYLOX GEL 2 diclofenac gel 3% diclofenac sol.5% DOXYCYCLINE (ROSACEA) ELIDEL 2 FINACEA 2 fluorouracil (topical) CREA 5% FLUOROURACIL (TOPICAL) CREA.5% fluorouracil (topical) SOLN imiquimod CREA laclotion lot 2% metronidazole (topical) NORITATE 3 ORACEA 2 OXSORALEN 3 PANRETIN 3 PENNSAID 2 PICATO 2 podofilox SOLN RECTIV 3 rosadan cre 0.75% SOOLANTRA 3 tacrolimus (topical) PA TARGRETIN GEL 3 PA VALCHLOR 3 LA PA VOLTAREN GEL % 2 ZYCLARA 2 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3 malathion permethrin CREA SKLICE 3 DERMATOLOGY, WOUND CARE AGENTS acetic acid.25% neomycin/polymyxin b gu REGRANEX 3 SANTYL 3 SODIUM CHLORIDE 0.9% STERILE WATER IRRIGATION MOUTH/THROAT/DENTAL AGENTS cevimeline hcl chlorhexidine gluconate (mouth-throat) clotrimazole TROC lidocaine hcl (mouth-throat) nystatin (mouth-throat) periogard soln 0.2% pilocarpine hcl (oral) triamcinolone acetonide (mouth) OTIC acetasol hc acetic acid (otic) acetic acid sol/hc acetic acid-aluminum acetate CIPRO HC 3 CIPRODEX 2 32