/ Connecticut: Florida: Georgia: Illinois: Louisiana: Missouri: New Jersey: New York: Ohio: Texas: WellCare Access (HMO SNP)

Transcription

1 完整的處方藥目錄 ( 承保藥物列表 ) 協調性護理計劃 Choice Select Value Essential Dividend Rx // 上次更新於 08/2012 處方藥目錄檔案文件 # 處方藥目錄版本編號 # 15 Y0070_NA015555_WCM_FOR_CHI_FINAL_05 CMS Approved WellCare 2011 NA_08_12 NAV02FORC39270C_0812

2 / Connecticut: Florida: Georgia: Illinois: Louisiana: Missouri: New Jersey: New York: Ohio: Texas: WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Select (HMO SNP/HMO-POS SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) WellCare Access (HMO SNP) 所有州的 TTY

3 什麼是 WellCare 處方藥目錄? WellCare WellCare WellCare 處方藥目錄會變更嗎? / /2011 WellCare / I

4 我如何使用處方藥目錄? 醫療病況 1 1 按字母排列的列表 52 什麼是副廠藥? WellCare (FDA) 我的承保有任何限制嗎? WellCare WellCare WellCare WellCare WellCare sumatriptan 25mg 31 9 WellCare A B A WellCare B A WellCare B 1 WellCare WellCare 2012 II

5 如果我的藥不在處方藥目錄裡怎麼辦? WellCare WellCare WellCare WellCare 我如何要求 WellCare 例外處理處方藥目錄? WellCare WellCare /WellCare 2012 III

6 在我跟我的醫生討論有關換藥或要求例外處理之前, 我要怎麼做? 進一步詳情 WellCare WellCare / IV

7 Medicare Medicare MEDICARE ( ) 7 24 TTY WellCare 處方藥目錄 1 WellCare 52 COUMADIN simvastatin / WellCare MO 3 WellCare ½ PA II QL II LA WellCare / ST II 2012 V

8 藥物層級共付款 / 共付保險金額 WellCare / 如何閱讀處方藥目錄列表 : / / / B PLAVIX 2 QL MO G ticlopidine hcl 1 MO LA = MO = PA = QL = ST = 2012 VI

9 (08/2012) / G salsalate 1 MO G acetaminophen/codeine #3 1 QL MO G acetaminophen/codeine #4 1 QL MO G acetaminophen/codeine solution 1 MO G acetaminophen/codeine tablet 300mg; 15mg 1 QL MO G butalbital/acetaminophen/caffeine/codeine 1 QL MO G co-gesic 1 QL MO G codeine sulfate 1 QL MO G duramorph 1 MO G endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 7.5mg 1 QL MO G endocet tablet 650mg; 10mg 1 QL MO G fentanyl citrate oral transmucosal 1 PA MO G fentanyl patch 1 QL MO G hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg 1 QL MO G hydrocodone/acetaminophen solution 1 MO G hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg 1 QL MO G hydrocodone/acetaminophen tablet 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg 1 QL MO G hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL MO G hydrocodone/ibuprofen 1 QL MO G hydromorphone hcl injection 1 MO G hydromorphone hcl tablet 1 QL MO G methadone hcl tablet 1 QL MO G methadose 1 QL MO G morphine sulfate er 1 QL MO G morphine sulfate injection, oral solution 1 MO G morphine sulfate tablet 1 QL MO G oxycodone hcl tablet 1 QL MO B G PA 1 LA QL MO ST

10 (08/2012) / G oxycodone/acetaminophen capsule 1 QL MO G oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 7.5mg 1 QL MO G oxycodone/acetaminophen tablet 650mg; 10mg 1 QL MO G reprexain tablet 10mg; 200mg 1 QL MO G tramadol hcl 1 QL MO G tramadol hydrochloride/acetaminophen 1 QL MO G lidocaine hcl injection 1 MO G lidocaine hcl jelly 1 MO G lidocaine ointment 1 MO G lidocaine viscous 1 MO G lidocaine/prilocaine cream 1 MO B LIDODERM 3 QL MO G phenazopyridine hcl 1 MO G diclofenac potassium 1 MO G diclofenac sodium ec tablet delayed release 50mg 1 MO G diclofenac sodium tablet 1 MO G diclofenac sodium xr 1 MO G diflunisal 1 MO G etodolac 1 MO G etodolac er 1 MO G fenoprofen calcium 1 MO G flurbiprofen tablet 1 MO G ibuprofen 1 MO G indomethacin 1 MO G ketoprofen 1 MO LA MO B G PA QL ST 2

11 (08/2012) / G ketoprofen er 1 QL MO G meloxicam tablet 1 MO G nabumetone 1 MO G naproxen 1 MO G naproxen sodium 1 MO G oxaprozin 1 MO G piroxicam 1 MO G sulindac 1 MO B VOLTAREN GEL 2 MO G amikacin sulfate injection 1 MO G gentak ointment 1 MO G gentamicin sulfate cream, ointment, ophthalmic solution, injection 1 MO G neomycin sulfate 1 MO G paromomycin sulfate 1 MO B TOBI 4 PA MO G tobramycin sulfate 1 MO G tobrasol ophthalmic solution 1 MO G bacitracin 1 MO G bacitracin/polymyxin b 1 MO G clindamycin hcl capsule 1 MO G clindamycin phosphate injection 1 MO G colistimethate sodium injection 1 MO B CUBICIN 4 PA MO G methenamine hippurate 1 MO G metronidazole cream, tablet 1 MO G mupirocin 1 MO G neomycin/bacitracin/polymyxin 1 MO G nitrofurantoin macrocrystalline 1 MO G nitrofurantoin monohydrate 1 MO LA MO B G PA QL ST 3

12 (08/2012) / G polycin b 1 MO G silver sulfadiazine 1 MO G thermazene 1 MO G trimethoprim tablet 1 MO B TYGACIL 4 MO B VANCOCIN HCL CAPSULE 4 PA MO G vancomycin hcl capsules 1 PA MO G vancomycin hcl injection 1gm, 10gm 1 PA MO G vandazole 1 MO B ZYVOX 4 PA MO 酰 G cefaclor 1 MO G cefadroxil 1 MO G cefazolin sodium 1 MO G cefdinir capsule, suspension reconstituted 1 MO G cefepime 1 MO G cefotaxime sodium 1 MO G cefoxitin sodium injection 10gm, 1gm, 2gm 1 MO G cefpodoxime proxetil 1 MO G cefprozil suspension reconstituted, tablet 1 MO G ceftazidime 1 MO G ceftriaxone sodium 1 MO G cefuroxime axetil 1 MO G cefuroxime sodium injection 1.5gm, 750mg 1 MO G cephalexin 1 MO B SUPRAX 3 MO 酰 G imipenem/cilastatin injection 1 MO B INVANZ 3 MO B PRIMAXIN I.M. 2 MO B PRIMAXIN IV 2 MO LA MO B G PA QL ST 4

13 (08/2012) / 酰 G amoxicillin 1 MO G amoxicillin/clavulanate potassium 1 MO G amoxicillin/potassium clavulanate 1 MO G ampicillin 1 MO G ampicillin sodium injection 125mg, 1gm, 250mg, 2gm, 500mg 1 MO G ampicillin-sulbactam 1 MO B BICILLIN C-R 2 MO B BICILLIN L-A 2 MO G dicloxacillin sodium 1 MO G oxacillin sodium 1 MO G penicillin g potassium 1 MO B PENICILLIN G PROCAINE 2 MO G penicillin v potassium 1 MO G pfizerpen-g 1 MO G piperacillin sodium 1 MO G piperacillin sodium/ tazobactam sodium 1 MO B TIMENTIN 2 MO B AZASITE 2 MO G azithromycin injection, suspension reconstituted, tablet 1 MO G clarithromycin suspension reconstituted, tablet 1 MO G e.e.s MO G e.e.s. granules 1 MO G ery-tab 1 MO G erythrocin lactobionate injection 1 MO G erythrocin stearate tablet 1 MO G erythromycin base tablet 1 MO G erythromycin ethylsuccinate tablet 1 MO G erythromycin ointment 1 MO G erythromycin/sulfisoxazole suspension 1 MO LA MO B G PA QL ST 5

14 (08/2012) B BESIVANCE SUSPENSION 3 MO G ciprofloxacin hcl ophthalmic solution 1 MO G ciprofloxacin hcl tablet 250mg, 500mg, 750mg 1 MO G ciprofloxacin injection 1 MO G levofloxacin injection 1 MO G levofloxacin solution 1 MO G levofloxacin tablet 1 MO B MOXEZA 2 MO G ofloxacin ophthalmic solution, otic solution, tablet 1 MO B VIGAMOX 2 MO B ZYMAXID 3 MO G sodium sulfacetamide solution 1 MO G sulfacetamide sodium 1 MO G sulfadiazine 1 MO G sulfamethoxazole/trimethoprim 1 MO G sulfamethoxazole/trimethoprim ds 1 MO G trimethoprim sulfate/polymyxin b sulfate solution 1 MO G demeclocycline hcl 1 MO G doxycycline hyclate capsule, injection 1 MO G doxycycline hyclate tablet 100mg 1 MO G minocycline hcl capsule 1 MO G ocudox 1 MO G tetracycline hcl 1 MO / B BANZEL SUSPENSION 3 PA MO B BANZEL TABLET 200MG 3 PA MO B BANZEL TABLET 400MG 4 PA MO G levetiracetam injection, oral solution, tablet 1 MO LA MO B G PA QL ST 6

15 (08/2012) / B POTIGA TABLETS 200MG, 300MG, 400MG 4 PA MO B POTIGA TABLETS 50MG 3 PA MO B VIMPAT INJECTION, TABLET 3 MO B VIMPAT ORAL SOLUTION 3 MO B CELONTIN 2 MO G ethosuximide 1 MO B LYRICA 3 PA MO G zonisamide 1 MO (GABA) G gabapentin capsule 100mg, 300mg 1 QL MO G gabapentin capsule 400mg 1 QL MO G gabapentin solution 1 MO G gabapentin tablet 600mg 1 QL MO G gabapentin tablet 800mg 1 QL MO B GABITRIL 3 MO G primidone 1 MO B SABRIL PACKET 4 PA LA B SABRIL TABLET 4 PA LA G valproate sodium 1 MO G valproic acid 1 MO G felbamate suspension 1 MO G felbamate tablet 400mg 1 MO G felbamate tablet 600mg 1 MO B FELBATOL SUSPENSION 4 MO B FELBATOL TABLET 400MG 3 MO B FELBATOL TABLET 600MG 4 MO G lamotrigine 1 MO G topiramate capsule sprinkle, tablet 1 MO LA MO B G PA QL ST 7

16 (08/2012) / G carbamazepine suspension, tablet chewable, tablet 1 MO B DILANTIN CAPSULE 30MG 2 MO B DILANTIN INFATABS 2 MO G epitol 1 MO G fosphenytoin sodium 1 MO G oxcarbazepine 1 MO B PEGANONE 3 MO G phenytoin sodium extended capsule 1 MO G phenytoin sodium injection 1 MO G phenytoin suspension 1 MO G ergoloid mesylates 1 MO G donepezil hcl 1 MO B EXELON PATCH 24 HOUR, SOLUTION 2 MO G galantamine hydrobromide 1 MO G rivastigmine tartrate 1 MO B NAMENDA 2 MO B NAMENDA TITRATION PAK 2 MO G budeprion sr 1 MO G budeprion xl 1 MO G buproban 1 MO G bupropion hcl 1 MO G bupropion hcl sr 1 MO G bupropion hcl xl 1 QL MO G mirtazapine 1 MO G mirtazapine odt 1 MO G nefazodone hcl 1 MO B G PA 8 LA QL MO ST

17 (08/2012) / G trazodone hcl 1 MO B EMSAM 3 PA MO B MARPLAN 3 MO B NARDIL 3 MO G phenelzine sulfate 1 MO G tranylcypromine sulfate 1 MO / G citalopram hydrobromide 1 MO B CYMBALTA 3 PA MO G escitalopram oxalate solution 1 MO G escitalopram oxalate tablet 1 QL MO G fluoxetine hcl capsule, solution 1 MO G fluvoxamine maleate 1 MO B LEXAPRO SOLUTION 3 MO B LEXAPRO TABLET 3 QL MO G paroxetine hcl 1 MO B PAXIL SUSPENSION 3 MO B PRISTIQ 3 PA MO B SAVELLA 3 MO B SAVELLA TITRATION PACK 3 MO G sertraline hcl concentrate, tablet 1 MO G venlafaxine hcl 1 MO G venlafaxine hcl er capsule extended release 24 hour 1 QL MO G venlafaxine hcl er tablet extended release 24 hour 150mg, 37.5mg, 75mg 1 QL MO B VIIBRYD 3 ST MO G amitriptyline hcl 1 MO G amoxapine 1 MO G chlordiazepoxide/amitriptyline 1 MO G clomipramine hcl 1 MO LA MO B G PA QL ST 9

18 (08/2012) / G desipramine hcl 1 MO G doxepin hcl 1 MO G imipramine hcl 1 MO G imipramine pamoate 1 MO G maprotiline hcl 1 MO G nortriptyline hcl capsule, solution 1 MO G perphenazine/amitriptyline 1 MO G protriptyline hcl 1 MO B SURMONTIL 3 MO G trimipramine 1 MO B EXJADE 4 PA LA G fomepizole 1 MO G kionex 1 MO B RELISTOR 3 PA MO G sodium polystyrene sulfonate 1 MO G sps 1 MO B SYPRINE 3 MO B ANTABUSE 2 MO B CAMPRAL 3 MO B CHANTIX STARTER PACK 3 QL MO B CHANTIX TABLET 0.5MG, 1MG 3 QL MO G disulfiram 1 MO B NICOTROL NS 3 MO G buprenorphine hcl injection 1 PA MO G buprenorphine hcl tablet sublingual 1 PA MO G naloxone hcl injection 1mg/ml 1 MO G naltrexone hcl 1 MO B SUBOXONE FILM 3 PA MO LA MO B G PA QL ST 10

19 (08/2012) / G compro 1 MO G dronabinol 1 QL PA MO B EMEND COMBO PACK, CAPSULE 3 PA MO G granisetron hcl injection 1 QL PA MO G granisetron hcl tablet 1 QL PA MO G meclizine hcl 1 MO G ondansetron hcl injection 1 PA MO G ondansetron hcl oral solution 1 PA MO G ondansetron hcl tablet 1 MO G ondansetron odt 1 MO G phenadoz 1 MO G prochlorperazine edisylate injection 1 MO G prochlorperazine maleate tablet 1 MO G prochlorperazine suppository 1 MO G promethazine hcl 1 MO G promethegan 1 MO G amphotericin b 1 MO B ANCOBON 3 MO G ciclopirox 1 MO G ciclopirox nail lacquer 1 MO G ciclopirox olamine 1 MO G clotrimazole cream, troche 1 MO G clotrimazole/betamethasone dipropionate 1 MO G econazole nitrate 1 MO G fluconazole in dextrose 1 MO G fluconazole in nacl 1 MO G fluconazole suspension reconstituted, tablet 1 MO G flucytosine 1 MO B GRIFULVIN V 3 MO G griseofulvin microsize suspension 1 MO LA MO B G PA QL ST 11

20 (08/2012) / G itraconazole 1 PA MO G ketoconazole 1 MO B MYCAMINE 4 PA MO B NAFTIN 2 MO B NATACYN 2 MO G nyamyc 1 MO G nystatin cream, powder, ointment, suspension, tablet 1 MO G nystatin vaginal 1 MO G nystatin/triamcinolone 1 MO G nystop 1 MO G pedi-dri 1 MO G selenium sulfide 1 MO G terbinafine hcl 1 MO G terconazole cream, suppository 1 MO G voriconazole 1 PA MO G voriconazole solution 200mg 1 PA MO G zazole 1 MO G allopurinol 1 MO B COLCRYS 3 MO G probenecid 1 MO B ULORIC TABLETS 3 ST MO G dihydroergotamine mesylate 1 MO G ergotamine tartrate/caffeine 1 MO G sumatriptan nasal spray 1 QL MO G sumatriptan succinate injection 1 QL 31 8 MO G sumatriptan succinate injection refill 1 QL 31 8 MO G sumatriptan succinate tablet 1 QL 31 9 MO LA MO B G PA QL ST 12

21 (08/2012) / G bethanechol chloride 1 MO B GUANIDINE HCL 2 MO B MESTINON SYRUP 2 MO B MESTINON TIMESPAN 2 MO G pyridostigmine bromide 1 MO B DAPSONE 2 MO B MYCOBUTIN 3 MO B CAPASTAT SULFATE 3 MO G ethambutol hcl 1 MO G isoniazid syrup, tablet 1 MO B PASER 3 MO B PRIFTIN 3 MO G pyrazinamide 1 MO G rifampin capsule, injection 1 MO B SEROMYCIN 2 MO B TRECATOR 3 MO B CEENU 2 MO G cyclophosphamide 1 PA MO B HEXALEN 3 PA MO B LEUKERAN 2 MO B MATULANE 4 MO B TREANDA 4 PA MO B CAPRELSA 4 PA MO B REVLIMID 4 PA LA B THALOMID 4 QL PA MO B VANDETANIB 4 PA MO LA MO B G PA QL ST 13

22 (08/2012) / / B EMCYT 3 PA MO B FARESTON 4 MO B FASLODEX 4 PA MO G tamoxifen citrate 1 MO B DROXIA 2 MO B ELITEK 4 PA MO G hydroxyurea 1 MO G mercaptopurine 1 MO B OFORTA 4 PA MO B TABLOID 3 PA MO B ALIMTA 4 PA MO G amifostine 1 PA MO G bleomycin sulfate 1 PA MO B ERIVEDGE 4 QL PA MO G ifosfamide 1 MO B IXEMPRA KIT 4 PA MO B JAKAFI TABLET 4 PA MO G leucovorin calcium 1 MO G mesna solution 1 MO B MESNEX TABLET 4 MO G mitoxantrone hcl 1 PA MO B ONTAK 4 PA MO G pentostatin 1 PA MO B PROLEUKIN 4 PA MO B SYLATRON 4 PA MO B TRISENOX 3 PA MO B TYKERB 4 PA LA B VELCADE 4 PA MO B VIDAZA 4 PA MO B ZOLINZA 4 PA MO B G PA 14 LA QL MO ST

23 (08/2012) / B ZYTIGA 4 PA MO 3 G anastrozole 1 QL MO G exemestane 1 MO B FEMARA 3 MO G letrozole 1 MO B AFINITOR 4 PA MO B GLEEVEC 4 PA MO B INLYTA 4 PA MO B IRESSA 4 LA B NEXAVAR 4 QL PA LA B SPRYCEL 4 QL PA MO B SUTENT 4 QL PA MO B TARCEVA 4 PA MO B TASIGNA 4 PA MO B VOTRIENT 4 PA MO B XALKORI CAPSULE 4 QL PA MO B ZELBORAF TABLET 4 QL PA MO B AVASTIN 4 PA MO B CAMPATH 4 PA LA B RITUXAN 4 PA LA B PANRETIN 4 MO B TARGRETIN 4 PA MO G tretinoin capsule 1 MO B ALBENZA 2 MO G mebendazole 1 MO LA MO B G PA QL ST 15

24 (08/2012) / B ALINIA 3 PA MO G chloroquine phosphate 1 MO B DARAPRIM 2 MO G hydroxychloroquine sulfate 1 MO G mefloquine hcl 1 MO B MEPRON 4 MO B PENTAM PA MO / G acticin 1 MO G malathion 1 MO G permethrin 1 MO B APOKYN 4 PA MO B AZILECT 3 MO G benztropine mesylate tablet 1 MO G bromocriptine mesylate 1 MO G carbidopa/levodopa cr 1 MO G carbidopa/levodopa sr 1 MO G carbidopa/levodopa tablet 1 MO B COMTAN 2 MO B LODOSYN 3 MO G pramipexole dihydrochloride 1 MO G ropinirole hcl 1 MO G selegiline hcl 1 MO B TASMAR 3 MO G trihexyphenidyl hcl 1 MO B ZELAPAR 3 MO B ABILIFY DISCMELT TABLET DISPERSIBLE 10MG 3 QL PA MO B ABILIFY DISCMELT TABLET DISPERSIBLE 15MG 3 QL PA MO LA MO B G PA QL ST 16

25 (08/2012) / B ABILIFY INJECTION 3 PA MO B ABILIFY ORAL SOLUTION 3 QL PA MO B ABILIFY TABLET 3 QL PA MO G clozapine 1 MO B FANAPT 3 QL PA MO B FANAPT TITRATION PACK 3 PA MO B FAZACLO TABLET DISPERSIBLE 12.5MG 3 PA MO B GEODON CAPSULE 3 QL PA MO B GEODON INJECTION 3 QL MO B INVEGA SUSTENNA INJECTION 117MG/0.75ML, 156MG/ML, 234MG/1.5ML 4 PA MO B INVEGA SUSTENNA INJECTION 39MG/0.25ML, 78MG/0.5ML 3 PA MO B INVEGA TABLET EXTENDED RELEASE 24 HOUR 1.5MG, 3MG, 9MG 3 QL PA MO B INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG 3 QL PA MO B LATUDA 3 PA MO G olanzapine injection 1 QL 31 6 MO G olanzapine tablet, oral disintegrating tablet 1 QL PA MO G quetiapine tablet 1 QL MO B RISPERDAL CONSTA INJECTION 12.5MG, 25MG 3 QL 28 4 PA MO B RISPERDAL CONSTA INJECTION 37.5MG, 50MG 4 QL 28 4 PA MO G risperidone m-tab 1 QL MO G risperidone odt 1 QL MO G risperidone solution 1 QL MO G risperidone tablet 1 QL MO B SAPHRIS 3 PA MO B SEROQUEL 3 QL MO G ziprasidone hcl 1 QL PA MO B ZYPREXA INJECTION 3 QL 31 6 MO B ZYPREXA RELPREVV 4 PA MO LA MO B G PA QL ST 17

26 (08/2012) / B ZYPREXA TABLET 3 QL PA MO B ZYPREXA ZYDIS 3 QL PA MO G chlorpromazine hcl 1 MO G fluphenazine decanoate 1 MO G fluphenazine hcl 1 MO B HALDOL DECANOATE MO B HALDOL DECANOATE 50 2 MO G haloperidol 1 MO G haloperidol decanoate 1 MO G haloperidol lactate 1 MO G loxapine succinate 1 MO B NAVANE CAPSULE 20MG 3 MO B ORAP 2 MO G perphenazine 1 MO G thioridazine hcl 1 MO G thiothixene 1 MO G trifluoperazine hcl 1 MO G baclofen tablet 1 MO G tizanidine hcl 1 MO (CMV) G foscarnet sodium 1 PA MO G ganciclovir capsule 1 MO B VALCYTE 4 PA MO HIV B COMPLERA 3 MO B EDURANT 4 QL MO G nevirapine suspension, tablets 1 MO B RESCRIPTOR 2 MO LA MO B G PA QL ST 18

27 (08/2012) HIV B SUSTIVA 2 MO B VIRAMUNE 2 MO B VIRAMUNE XR 3 MO / HIV B ATRIPLA 4 MO B COMBIVIR 2 MO G didanosine 1 MO B EMTRIVA 2 MO B EPIVIR 3 MO B EPIVIR HBV 3 MO B EPZICOM 2 MO B INTELENCE 4 QL MO G lamivudine tablets 1 MO G lamivudine/zidovudine tablet 1 MO B RETROVIR IV INFUSION 3 MO G stavudine 1 MO B TRIZIVIR 4 MO B TRUVADA 4 MO B VIDEX PEDIATRIC 3 MO B VIREAD 3 MO B ZERIT SOLUTION RECONSTITUTED 3 MO B ZIAGEN 2 MO G zidovudine syrup, tablet 1 MO HIV B FUZEON 4 MO B ISENTRESS 4 QL MO B SELZENTRY 4 QL MO HIV B APTIVUS 4 MO B CRIXIVAN 2 MO LA MO B G PA QL ST 19

28 (08/2012) / HIV B INCIVEK TABLET 4 QL PA MO B INVIRASE 4 MO B KALETRA 3 MO B LEXIVA 3 MO B NORVIR 3 MO B PREZISTA TABLET 150MG, 75MG 2 MO B PREZISTA TABLET 400MG, 600MG 4 MO B REYATAZ 2 MO B VICTRELIS CAPSULE 4 QL PA MO B VIRACEPT 2 MO G amantadine hcl capsule, syrup 1 MO B RELENZA DISKHALER 2 MO G rimantadine hcl 1 MO B TAMIFLU 2 MO B BARACLUDE SOLUTION 3 MO B BARACLUDE TABLET 4 MO B HEPSERA 4 MO G ribasphere tablet 200mg 1 MO G ribavirin tablet 200mg 1 MO B TYZEKA 3 PA MO G acyclovir capsule, suspension, tablet 1 MO G acyclovir sodium injection 1 MO B DENAVIR CREAM 2 MO G famciclovir 1 MO G trifluridine 1 MO G valacyclovir hcl 1 QL MO B ZIRGAN GEL 3 MO B ZOVIRAX CREAM, OINTMENT 3 MO LA MO B G PA QL ST 20

29 (08/2012) / G buspirone hcl 1 MO G meprobamate 1 PA MO G divalproex sodium 1 MO G divalproex sodium er 1 MO G lithium carbonate 1 MO G lithium carbonate er 1 MO G lithium citrate syrup 1 MO G quetiapine fumarate 1 QL MO B SEROQUEL XR TABLET 150MG, 200MG 3 QL MO B SEROQUEL XR TABLET 50MG, 300MG, 400MG 3 QL MO G acarbose 1 MO B ACTOPLUS MET 3 QL MO B ACTOS 3 QL MO B AVANDAMET 3 QL MO B AVANDARYL 3 QL MO B AVANDIA 3 QL MO B BYDUREON SUSPENSION 3 MO B BYETTA 3 MO B DUETACT 3 QL MO G glimepiride 1 QL MO G glipizide 1 QL MO G glipizide er 1 QL MO G glipizide xl 1 QL MO G glipizide/metformin hcl 1 QL MO G glyburide 1 QL MO G glyburide micronized 1 QL MO G glyburide/metformin hcl 1 QL MO G glycron 1 MO LA MO B G PA QL ST 21

30 (08/2012) / B JANUMET 3 QL MO B JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 100 MG 3 QL MO B JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 50MG, 500MG; 50MG 3 QL MO B JANUVIA TABLET 100MG 3 QL MO B JANUVIA TABLET 25MG, 50MG 3 QL MO B JUVISYNC 3 QL MO G metformin hcl er tablet extended release 24 hour 1000mg 1 QL MO G metformin hcl er tablet extended release 24 hour 500mg 1 QL MO G metformin hcl er tablet extended release 24 hour 750mg 1 QL MO G metformin hcl tablet 1000mg 1 QL MO G metformin hcl tablet 500mg 1 QL MO G metformin hcl tablet 850mg 1 QL MO G nateglinide 1 MO B PRANDIMET 3 MO B PRANDIN 3 MO B SYMLIN 3 PA MO B SYMLINPEN PA MO B SYMLINPEN 60 3 PA MO G tolazamide 1 QL MO G tolbutamide 1 QL MO B GLUCAGON EMERGENCY KIT 2 QL 31 4 MO B PROGLYCEM 3 MO B HUMALOG 2 QL MO B HUMALOG KWIKPEN 2 QL MO B HUMALOG MIX 50/50 2 QL MO B HUMALOG MIX 50/50 KWIKPEN 2 QL MO B HUMALOG MIX 75/25 2 QL MO LA MO B G PA QL ST 22

31 (08/2012) / B HUMALOG MIX 75/25 KWIKPEN 2 QL MO B HUMULIN 70/30 2 QL MO B HUMULIN 70/30 PEN 2 QL MO B HUMULIN N 2 QL MO B HUMULIN N U-100 PEN 2 QL MO B HUMULIN R 2 QL MO B HUMULIN R U-500 (CONCENTRATED) 2 QL PA MO B LANTUS 2 QL MO B LANTUS SOLOSTAR 2 QL MO B LEVEMIR 3 QL MO B LEVEMIR FLEXPEN 3 QL MO / / B ARIXTRA INJECTION 10MG/0.8ML 4 QL MO B ARIXTRA INJECTION 2.5MG/0.5ML 2 QL MO B ARIXTRA INJECTION 5MG/0.4ML 4 QL MO B ARIXTRA INJECTION 7.5MG/0.6ML 4 QL MO B COUMADIN 2 MO G enoxaparin sodium injection 100mg/ml, 150mg/ml 1 QL MO G enoxaparin sodium injection 120mg/0.8ml, 80mg/0.8ml 1 QL MO G enoxaparin sodium injection 30mg/0.3ml, 40mg/0.4ml 1 QL MO G enoxaparin sodium injection 60mg/0.6ml 1 QL MO G enoxaparin sodium solution 300mg/3ml 1 QL MO G fondaparinux sodium soln 10mg/0.8ml 1 QL MO G fondaparinux sodium soln 2.5mg/0.5ml 1 QL MO G fondaparinux sodium soln 5mg/0.4ml 1 QL MO G fondaparinux sodium soln 7.5mg/0.6ml 1 QL MO G heparin sodium 1 MO G heparin sodium/d5w 1 MO G heparin sodium/nacl 0.45% 1 MO LA MO B G PA QL ST 23

32 (08/2012) / / / G heparin sodium/sodium chloride 0.9% premix 1 MO G jantoven 1 MO B PRADAXA 3 MO G warfarin sodium 1 MO B XARELTO TABLETS 10MG 2 QL MO G anagrelide hydrochloride 1 MO B LEUKINE 3 PA MO B NEUMEGA 4 PA MO B NEUPOGEN 4 PA MO B PROCRIT INJECTION 10000UNIT/ML, 2000UNIT/ ML, 3000UNIT/ML, 4000UNIT/ML 2 PA MO B PROCRIT INJECTION 20000UNIT/ML, 40000UNIT/ML 4 PA MO / / B PROMACTA 4 PA LA B CYKLOKAPRON 2 MO G tranexamic acid solution 100mg/ml 1 MO B AGGRENOX 3 MO G cilostazol 1 MO G clopidogrel tablets 1 QL MO G dipyridamole 1 MO G pentoxifylline er 1 MO B PLAVIX 2 QL MO G ticlopidine hcl 1 MO G clonidine hcl tablet 1 MO G clorpres 1 MO G guanabenz acetate 1 MO G guanfacine hcl 1 MO LA MO B G PA QL ST 24

33 (08/2012) / G methyldopa 1 MO G methyldopa/hydrochlorothiazide 1 MO G midodrine hcl 1 MO G doxazosin mesylate 1 MO G prazosin hcl 1 MO G terazosin hcl 1 MO G amiodarone hcl tablet 1 MO G disopyramide phosphate 1 MO G flecainide acetate 1 MO G mexiletine hcl 1 MO B MULTAQ 3 MO B NORPACE CR 3 MO G pacerone tablet 200mg 1 MO G procainamide hcl 1 MO G propafenone hcl 1 MO G quinidine gluconate er 1 MO G quinidine sulfate 1 MO G quinidine sulfate er 1 MO G sorine 1 MO G sotalol hcl 1 MO G sotalol hcl (af) 1 MO B TIKOSYN 3 MO G acebutolol hcl 1 MO G atenolol 1 MO G atenolol/chlorthalidone 1 MO G betaxolol hcl 1 MO G bisoprolol fumarate 1 MO G bisoprolol fumarate/hydrochlorothiazide 1 MO G carvedilol 1 MO LA MO B G PA QL ST 25

34 (08/2012) / B COREG CR 2 QL MO G labetalol hcl 1 MO G metoprolol succinate er 1 MO G metoprolol tartrate 1 MO G metoprolol/hydrochlorothiazide 1 MO G nadolol 1 MO G pindolol 1 MO G propranolol hcl 1 MO G propranolol hcl er 1 MO G propranolol/hydrochlorothiazide 1 MO G timolol maleate tablet 1 MO G amlodipine besylate 1 MO G cartia xt 1 MO G dilt-cd 1 MO G dilt-xr 1 MO G diltiazem cd 1 MO G diltiazem hcl 1 MO G diltiazem hcl er 1 MO G diltzac 1 MO G felodipine er 1 QL MO G matzim la 1 MO G nicardipine hcl capsule 1 MO G nifediac cc 1 QL MO G nifedical xl 1 QL MO G nifedipine 1 MO G nifedipine er 1 QL MO G nimodipine 1 MO G taztia xt 1 MO G verapamil hcl er 1 MO G verapamil hcl sr 1 MO G verapamil hcl tablet 1 MO LA MO B G PA QL ST 26

35 (08/2012) / G digoxin 1 MO B LANOXIN 2 MO B RANEXA 3 QL MO G reserpine 1 MO G acetazolamide capsule extended release 12 hour, tablet 1 MO G amiloride hcl 1 MO G amiloride/hydrochlorothiazide 1 MO G bumetanide injection, tablet 1 MO G chlorothiazide sodium injection 1 MO G chlorothiazide tablet 1 MO G chlorthalidone 1 MO G furosemide solution, tablet 1 MO G hydrochlorothiazide capsule 1 MO G hydrochlorothiazide tablet 25mg, 50mg 1 MO G indapamide 1 MO G methyclothiazide 1 MO G metolazone 1 MO G spironolactone 1 MO G spironolactone/hydrochlorothiazide 1 MO G torsemide tablet 1 MO G triamterene/hydrochlorothiazide 1 MO B ANTARA CAPSULE 2 MO G atorvastatin calcium tablets 1 MO G cholestyramine 1 MO G cholestyramine light 1 MO G colestipol hcl granules, tablet 1 MO G fenofibrate 1 MO G fenofibrate micronized 1 MO G gemfibrozil 1 MO B LIPITOR 1 MO LA MO B G PA QL ST 27

36 (08/2012) / B LIVALO TABLET 3 MO G lovastatin 1 MO B LOVAZA 3 MO G micronized colestipol hcl 1 MO B NIACOR 2 MO B NIASPAN TABLETS 3 MO G pravastatin sodium 1 MO G prevalite 1 MO G simvastatin 1 MO B ZETIA 3 QL MO - - G amlodipine besylate/benazepril hcl 1 QL MO G benazepril hcl 1 MO G benazepril hcl/hydrochlorothiazide 1 MO G captopril 1 MO G captopril/hydrochlorothiazide 1 MO B DIOVAN HCT TABLET 12.5MG; 160MG, 12.5MG; 80MG 3 QL MO B DIOVAN HCT TABLET 12.5MG; 320MG, 25MG; 160MG, 25MG; 320MG 3 QL MO B DIOVAN TABLET 160MG, 40MG, 80MG 3 QL MO B DIOVAN TABLET 320MG 3 QL MO G enalapril maleate 1 MO G enalapril maleate/hydrochlorothiazide 1 MO G fosinopril sodium 1 MO G fosinopril sodium/hydrochlorothiazide 1 MO G lisinopril 1 MO G lisinopril/hydrochlorothiazide 1 MO G losartan potassium tablet 100mg 1 QL MO G losartan potassium tablet 25mg, 50mg 1 QL MO G losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg, 25mg; 100mg 1 QL MO LA MO B G PA QL ST 28

37 (08/2012) / - - G losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg 1 QL MO G moexipril hcl 1 MO G moexipril/hydrochlorothiazide 1 MO G quinapril hcl 1 MO G quinapril/hydrochlorothiazide 1 MO G ramipril 1 MO B TEKTURNA 2 QL ST MO B TEKTURNA HCT 2 QL ST MO G trandolapril 1 MO G hydralazine hcl 1 MO G isosorbide dinitrate 1 MO G isosorbide mononitrate 1 MO G isosorbide mononitrate er 1 MO G minoxidil 1 MO B NITRO-BID 2 MO G nitroglycerin injection, patch 1 MO G nitroglycerin transdermal 1 MO B NITROSTAT 2 MO ADHD G amphetamine/dextroamphetamine 1 PA MO G dextroamphetamine sulfate 1 PA MO G dextroamphetamine sulfate er 1 PA MO ADHD G dexmethylphenidate hcl 1 MO G metadate er 1 MO G methylin er 1 MO G methylin tablet 1 MO G methylphenidate hcl 1 MO G methylphenidate hcl sr 1 MO B STRATTERA 3 PA MO LA MO B G PA QL ST 29

38 (08/2012) / G modafinil tablets 1 PA MO B PROVIGIL TABLET 100MG 2 PA MO B PROVIGIL TABLET 200MG 4 PA MO B RILUTEK 4 MO B XENAZINE 4 PA LA B XYREM 4 PA LA G chlorhexidine gluconate oral rinse 1 MO G dentagel 1 MO G karigel 1 MO G periogard 1 MO G pilocarpine hcl tablet 1 MO G sodium fluoride gel 1 MO G triamcinolone in orabase 1 MO B 8-MOP 2 MO G ammonium lactate 1 MO B AZELEX 2 MO G calcipotriene 1 MO B CARAC 3 MO G clindamycin phosphate cream, gel, lotion, solution 1 MO B CONDYLOX GEL 3 MO G erythromycin 1 MO G erythromycin/benzoyl peroxide 1 MO B FINACEA 2 MO B FLUOROPLEX 3 MO G fluorouracil 1 MO G imiquimod 1 PA MO G laclotion 1 MO G podofilox solution 1 MO LA MO B G PA QL ST 30

39 (08/2012) / B PROTOPIC 3 PA MO B REGRANEX 3 PA MO B SANTYL 3 MO B SORIATANE 4 MO B TAZORAC 3 MO G tretinoin cream, gel 1 MO G urea 40% cream 1 MO / / B ADAGEN 4 PA MO B ALDURAZYME 4 PA LA B BUPHENYL TABLET 4 PA MO B CEREDASE 4 PA LA B CEREZYME 4 PA LA B CREON 3 MO B CYSTADANE 2 PA MO B CYSTAGON 3 PA MO B ELAPRASE 4 PA MO B FABRAZYME 4 PA LA B KUVAN 4 PA MO B LUMIZYME 4 PA LA B MYOZYME 4 PA LA B NAGLAZYME 4 PA LA B ORFADIN 4 PA MO B SUCRAID 4 MO B VPRIV 4 PA MO B ZAVESCA 4 PA LA B ZENPEP 3 MO G atropine sulfate injection 1 MO G dicyclomine hcl 1 MO LA MO B G PA QL ST 31

40 (08/2012) G glycopyrrolate 1 MO G methscopolamine bromide 1 MO G propantheline bromide 1 MO / B AMITIZA 3 ST MO G cromolyn sodium oral concentrate 1 MO G diphenoxylate/atropine 1 MO G enulose 1 MO B GASTROCROM 3 MO G gavilyte-g 1 MO G generlac 1 MO B HALFLYTELY BOWEL PREP 3 MO G lactulose 1 MO G lonox 1 MO G loperamide hcl 1 MO G metoclopramide hcl 1 MO B MOVIPREP 3 MO B NULYTELY/FLAVOR PACKS 3 MO G peg 3350/electrolytes 1 MO G polyethylene glycol MO B SUPREP BOWEL PREP 3 MO G ursodiol capsule 300mg 1 MO 2 (H2) G cimetidine 1 MO G cimetidine hcl solution 1 MO G famotidine premixed solution 1 MO G famotidine tablet 1 MO G ranitidine hcl injection, syrup, tablet 1 MO B LOTRONEX TABLET 0.5MG 2 QL MO B LOTRONEX TABLET 1MG 4 QL MO LA MO B G PA QL ST 32

41 (08/2012) B CARAFATE SUSPENSION 3 MO G misoprostol 1 MO G sucralfate 1 MO B DEXILANT 3 MO G omeprazole 1 MO G pantoprazole sodium 1 MO B PROTONIX INJECTION 3 MO G oxybutynin chloride 1 MO G oxybutynin chloride er 1 MO G trospium chloride 1 MO B VESICARE 2 MO / B AVODART 2 QL MO G finasteride 1 MO B JALYN 2 QL MO B RAPAFLO 3 MO G tamsulosin hcl 1 MO B CIALIS TABLETS 2.5MG, 5MG 3 QL PA MO G calcium acetate 1 MO G eliphos 1 MO B RENVELA 3 MO // / G a-methapred 1 MO G alclometasone dipropionate 1 MO G amcinonide 1 MO G augmented betamethasone dipropionate 1 MO LA MO B G PA QL ST 33

42 (08/2012) // / G betamethasone dipropionate 1 MO G betamethasone valerate 1 MO G clobetasol propionate cream, gel, ointment, solution 1 MO G clobetasol propionate e cream 1 MO B CLODERM 3 MO B CORDRAN LOTION 3 MO G cormax 1 MO B CORTIFOAM 3 MO G cortisone acetate 1 MO B DERMA-SMOOTHE/FS BODY OIL 2 MO B DERMA-SMOOTHE/FS SCALP OIL 2 MO G desonide 1 MO G desoximetasone 1 MO G dexamethasone elixir, solution, tablet 1 MO G dexamethasone sodium phosphate injection 1 MO G diflorasone diacetate 1 MO G fludrocortisone acetate 1 MO G fluocinolone acetonide 1 MO G fluocinolone acetonide body oil, otic oil, scalp oil 1 MO G fluocinonide cream, gel, solution, ointment 1 MO G fluocinonide emollient base cream 1 MO G fluticasone propionate cream, ointment 1 MO G halobetasol propionate 1 MO G hydrocortisone butyrate 1 MO G hydrocortisone cream, ointment, tablet 1 MO G hydrocortisone lotion 2.5% 1 MO G hydrocortisone valerate 1 MO B MEDROL TABLET 2MG 3 MO G methylprednisolone acetate injection 1 MO G methylprednisolone sodium succinate injection 1 MO / LA MO B G PA QL ST 34

43 (08/2012) // / G methylprednisolone tablet, 4mg dose pack 1 MO G millipred tablet 1 MO G mometasone furoate 1 MO G prednisolone sodium phosphate solution 1 MO G prednisone 1 MO G procto-pak cream 1 MO G proctocream hc 1 MO G proctosol hc cream 1 MO G triamcinolone acetonide cream, lotion, ointment 1 MO // / // G chorionic gonadotropin 1 PA MO G desmopressin acetate injection, tablet 1 MO G desmopressin acetate nasal solution 1 QL MO B HUMATROPE 4 PA MO B HUMATROPE COMBO PACK 4 PA MO B INCRELEX 4 PA LA B TEV-TROPIN 3 PA MO // / B ANADROL-50 4 PA MO G oxandrolone tablet 10mg 1 QL PA MO G oxandrolone tablet 2.5mg 1 QL PA MO G androxy 1 MO G danazol 1 MO B METHITEST 2 PA MO B TESTIM 2 PA MO G testosterone cypionate 1 PA MO G testosterone enanthate 1 PA MO LA MO B G PA QL ST 35

44 (08/2012) / // / G briellyn 1 MO G caziant 1 MO G cesia 1 MO G emoquette 1 MO B ESTRACE CREAM 3 MO B ESTRADERM 2 MO G estradiol patch weekly, tablet 1 MO G estropipate 1 MO G gianvi tablets 3mg; 0.02mg 1 MO G jinteli 1 MO G leena 1 MO G loryna 1 MO B MENEST 3 MO G orsythia 1 MO B PREMARIN INJECTION 2 MO B PREMARIN TABLET 2 QL MO B PREMARIN W/APPLICATOR 2 MO G tri-legest fe 1 MO G vestura 1 MO B VIVELLE-DOT 2 MO G apri 1 MO G aranelle 1 MO G aviane 1 MO G balziva 1 MO G brevicon-28 1 MO G camila 1 MO B COMBIPATCH 2 MO G cryselle-28 1 MO G enpresse-28 1 MO G errin 1 MO G jolivette 1 MO LA MO B G PA QL ST 36

45 (08/2012) / // / G junel 1.5/30 1 MO G junel 1/20 1 MO G junel fe 1.5/30 1 MO G junel fe 1/20 1 MO G kelnor 1/35 1 MO G lessina-28 1 MO G levora 0.15/ MO G low-ogestrel 1 MO G lutera 1 MO G medroxyprogesterone acetate 1 MO G megestrol acetate suspension tablet 1 MO G microgestin 1/20 1 MO G microgestin fe 1 MO G microgestin fe 1.5/30 1 MO G mononessa 1 MO G necon 0.5/ MO G necon 1/ MO G necon 1/ MO G necon 10/ MO G necon 7/7/7 1 MO G next choice 1 MO G nora-be 1 MO G norethindrone acetate 1 MO G nortrel 0.5/35 (28) 1 MO G nortrel 1/35 (21) 1 MO G nortrel 1/35 (28) 1 MO G nortrel 7/7/7 1 MO G ocella 1 MO G portia-28 1 MO B PREMPHASE 2 MO B PREMPRO 2 MO B PREVIFEM 2 MO LA MO B G PA QL ST 37

46 (08/2012) / // / G reclipsen 1 MO G solia 1 MO G sprintec 28 1 MO G tri-previfem 1 MO G tri-sprintec 1 MO G trinessa 1 MO G trivora-28 1 MO G velivet 1 MO G zovia 1/35e 1 MO G zovia 1/50e 1 MO B EVISTA 2 QL MO // // B ARMOUR THYROID 2 MO B CYTOMEL TABLET 25MCG, 5MCG 3 MO G levothroid 1 MO G levothyroxine sodium 1 MO G levoxyl 1 MO G liothyronine sodium tablet 1 MO G np thyroid 30 1 MO G np thyroid 60 1 MO G np thyroid 90 1 MO B SYNTHROID 2 MO B THYROLAR-1 2 MO B THYROLAR-1/2 2 MO B THYROLAR-1/4 2 MO B THYROLAR-2 2 MO B THYROLAR-3 2 MO G unithroid 1 MO LA MO B G PA QL ST 38

47 (08/2012) / B LYSODREN 2 MO B SENSIPAR TABLET 30MG 2 QL MO B SENSIPAR TABLET 60MG, 90MG 4 MO B ELIGARD KIT 22.5MG, 30MG, 7.5 MG 3 PA MO B ELIGARD KIT 45MG 4 PA MO G leuprolide acetate 1 PA MO B LUPRON DEPOT 4 PA MO B LUPRON DEPOT-PED 4 PA MO G octreotide acetate 1 PA MO B SOMATULINE DEPOT 4 PA MO B SOMAVERT 4 PA MO B SYNAREL 4 MO B TRELSTAR DEPOT 4 QL 28 1 PA MO B TRELSTAR DEPOT MIXJECT 4 QL 28 1 PA MO B TRELSTAR LA 4 QL 84 1 PA MO B TRELSTAR LA MIXJECT 4 QL 84 1 PA MO B TRELSTAR MIXJECT 4 QL PA MO / G bicalutamide 1 MO G flutamide 1 MO B NILANDRON 3 MO G methimazole 1 MO G propylthiouracil 1 MO LA MO B G PA QL ST 39

48 (08/2012) / G azathioprine sodium injection 1 PA MO G azathioprine tablet 1 PA MO B CELLCEPT SUSPENSION RECONSTITUTED 3 PA MO B CIMZIA 4 PA MO B CIMZIA STARTER KIT 4 PA MO B CUPRIMINE 2 MO G cyclosporine 1 PA MO G cyclosporine modified 1 PA MO B ENBREL 4 PA MO B ENBREL SURECLICK 4 PA MO G gengraf 1 PA MO G hecoria capsule 1 PA MO B HUMIRA 4 PA MO B HUMIRA PEN 4 PA MO B HUMIRA PEN-CROHNS DISEASE STARTER 4 PA MO B HUMIRA PEN-PSORIASIS STARTER 4 PA MO G methotrexate sodium injection 1 PA MO G methotrexate tablet 1 MO G mycophenolate mofetil 1 PA MO B MYFORTIC 3 PA MO B NULOJIX INJECTION 4 PA MO B PROGRAF INJECTION 2 PA MO B RAPAMUNE 2 PA MO B REMICADE 4 PA MO B SANDIMMUNE INJECTION 3 PA MO B SIMPONI 4 PA MO G tacrolimus 1 PA MO B TREXALL 3 MO B ZORTRESS TABLET 0.25MG 3 QL PA MO B ZORTRESS TABLET 0.5MG, 0.75MG 4 PA MO LA MO B G PA QL ST 40

49 (08/2012) / B CARIMUNE NANOFILTERED 4 PA MO B GAMMAGARD LIQUID 4 PA MO B THYMOGLOBULIN 2 PA MO B ACTIMMUNE 4 PA LA B ARCALYST 4 PA MO B AVONEX 4 PA MO B COPAXONE 4 PA MO B EXTAVIA 4 PA MO B INTRON-A INJECTION 10MU/0.2ML, 5MU/ 0.2ML 4 PA MO B INTRON-A INJECTION 10MU/ML, 3MU/0.2ML, UNIT/ML 3 PA MO B INTRON-A W/DILUENT INJECTION 10MU, 18MU 3 PA MO B INTRON-A W/DILUENT INJECTION 50MU 4 PA MO G leflunomide 1 MO B PEGASYS 4 PA MO B PEGASYS PROCLICK 4 PA MO B REBIF 4 PA MO B REBIF TITRATION PACK 4 PA MO B RIDAURA 2 MO B ACTHIB 2 B ADACEL 2 B BIOTHRAX 3 B BOOSTRIX 2 B CERVARIX 2 PA B COMVAX 2 B DAPTACEL 2 B DECAVAC 2 B DIPHTHERIA/TETANUS TOXOID PEDIATRIC 2 B ENGERIX-B 2 PA LA MO B G PA QL ST 41

50 (08/2012) / B GARDASIL 2 PA B HAVRIX 2 B IMOVAX RABIES (H.D.C.V.) 2 B INFANRIX 2 B IPOL INACTIVATED IPV 2 B IXIARO 2 B JE-VAX 2 B KINRIX 3 B M-M-R II W/DILUENT 10 DOSE 2 B MENACTRA 2 B MENOMUNE-A/C/Y/W B MENVEO 3 B PEDIARIX 2 B PEDVAX HIB 2 B PENTACEL 3 B PROQUAD 2 B RABAVERT 2 B RECOMBIVAX HB 2 PA B ROTARIX 3 B ROTATEQ 2 B TENIVAC 2 B TETANUS TOXOID ADSORBED 2 B TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 2 B TRIHIBIT 2 B TRIPEDIA 2 B TWINRIX 2 B TYPHIM VI 2 B VAQTA 2 B VARIVAX 2 B YF-VAX 2 B ZOSTAVAX 3 LA MO B G PA QL ST 42

51 (08/2012) G budesonide capsule 3mg 1 MO G colocort 1 MO B ENTOCORT EC 3 MO G hydrocortisone enema 1 MO G prednisolone 1 MO B APRISO 3 MO B ASACOL 2 MO G balsalazide disodium 1 MO B CANASA 3 MO G mesalamine 1 MO / G sulfasalazine 1 MO G sulfazine ec 1 MO G alendronate sodium tablet 10mg, 40mg, 5mg 1 MO G alendronate sodium tablet 35mg, 70mg 1 QL 28 4 MO B BONIVA INJECTION 3 PA MO B BONIVA TABLET 150MG 3 QL 28 1 MO G calcitonin-salmon 1 MO G calcitriol capsule, injection, oral solution 1 PA MO G etidronate disodium 1 MO B FORTEO 4 QL PA MO G fortical 1 MO B HECTOROL 2 PA MO G ibandronate sodium 1 QL 28 1 MO B MIACALCIN INJECTION 3 PA MO G pamidronate disodium injection 30mg/10ml, 90mg/10ml 1 PA MO B PROLIA 3 PA MO B ZOMETA 3 PA MO LA MO B G PA QL ST 43

52 (08/2012) / G alcohol preps 1 MO B BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"'' 2 MO B BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"'' 2 MO B BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"'' 2 MO B BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"'' 2 MO B BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 MO B CURITY GAUZE PADS 2"''X2"'' 2 MO B HUMAPEN LUXURA HD 2 MO B HUMAPEN MEMOIR 2 MO G ak-con 1 MO G atropine sulfate ophthalmic solution, ointment 1 MO B LACRISERT 3 MO G phenylephrine hcl 1 MO B RESTASIS 3 MO B ALOCRIL 2 MO G cromolyn sodium ophthalmic solution 1 MO B PATADAY 3 MO B PATANOL 3 MO B ALREX SUSPENSION 3 MO B BROMDAY 3 QL MO G bromfenac 1 QL MO B CIPRODEX 3 MO G dexamethasone sodium phosphate ophthalmic solution 1 MO G diclofenac sodium ophthalmic solution 1 MO B DUREZOL 3 MO LA MO B G PA QL ST 44

53 (08/2012) / G fluor-op 1 MO G fluorometholone 1 MO G flurbiprofen sodium ophthalmic solution 1 MO B FML OINTMENT 2 MO G ketorolac tromethamine 1 MO B LOTEMAX OINTMENT 0.5% 3 MO B LOTEMAX SUSPENSION 0.5% 3 MO G neomycin/polymyxin/bacitracin/ hydrocortisone 1 MO G neomycin/polymyxin/dexamethasone 1 MO G neomycin/polymyxin/hydrocortisone 1 MO B NEVANAC 3 MO G prednisolone acetate 1 MO G prednisolone sodium phosphate ophthalmic solution 1 MO G sulfacetamide sodium/prednisolone sodium phosphate 1 MO B TOBRADEX OINTMENT 3 MO B TOBRADEX ST 3 MO G tobramycin/dexamethasone 1 MO B VEXOL 3 MO B ZYLET SUSPENSION 3 MO B ALPHAGAN P 0.1%, 0.15% 3 MO B AZOPT 2 MO G betaxolol hcl 1 MO B BETOPTIC-S 2 MO G brimonidine tartrate solution 0.15%, 0.2% 1 MO G carteolol hcl 1 MO G dorzolamide hcl 1 MO G dorzolamide hcl/timolol maleate 1 MO G levobunolol hcl 1 MO G methazolamide 1 MO LA MO B G PA QL ST 45

54 (08/2012) / G metipranolol 1 MO G pilocarpine hcl 1 MO B PILOPINE HS 2 MO G timolol maleate ophthalmic gel forming 1 MO G timolol maleate ophthalmic solution 1 QL MO G latanoprost 1 MO B LUMIGAN 2 QL 31 5 MO B TRAVATAN Z 3 MO G acetic acid 1 MO G acetic acid/aluminum acetate 1 MO G cortomycin 1 MO B DERMOTIC 2 MO G neomycin/polymyxin/hc 1 MO B ADVAIR DISKUS 2 QL MO B ADVAIR HFA 2 QL MO B ASMANEX INHALER 2 MO B DULERA 2 QL MO B FLOVENT DISKUS 2 MO B FLOVENT HFA 2 MO G flunisolide 1 MO G fluticasone propionate nasal spray 1 MO B NASONEX 3 MO B QVAR 2 QL MO B SYMBICORT 3 MO G azelastine hcl nasal spray 1 MO G cyproheptadine hcl 1 MO LA MO B G PA QL ST 46

55 (08/2012) / G diphenhydramine hcl capsule 50mg 1 MO G diphenhydramine hcl elixir, injection 1 MO G hydroxyzine hcl 1 MO G hydroxyzine pamoate 1 MO G levocetirizine dihydrochloride oral solution 1 MO G levocetirizine dihydrochloride tablet 1 MO G promethazine vc 1 MO B SINGULAIR 2 QL MO G zafirlukast 1 QL MO B ATROVENT HFA 2 MO G ipratropium bromide inhalation solution 1 PA MO G ipratropium bromide nasal solution 1 MO B SPIRIVA HANDIHALER 3 QL MO G aminophylline 1 MO B THEO-24 2 MO G theochron 1 MO G theophylline er 1 MO G albuterol sulfate er 1 MO G albuterol sulfate nebulization solution 1 PA MO G albuterol sulfate syrup, tablet 1 MO B COMBIVENT 2 MO G epinephrine 1 MO B EPIPEN 2-PAK 3 MO G ipratropium bromide/albuterol sulfate 1 PA MO G metaproterenol sulfate syrup, tablet 1 MO B SEREVENT DISKUS 2 QL MO G terbutaline sulfate 1 MO B VENTOLIN HFA 2 MO LA MO B G PA QL ST 47

56 (08/2012) / G cromolyn sodium nebulization solution 1 PA MO B ADCIRCA 4 PA MO B LETAIRIS 4 QL PA LA B REMODULIN 4 PA MO B REVATIO TABLET 4 PA MO B TRACLEER 4 PA LA G acetylcysteine 1 PA MO B KALYDECO 4 QL PA MO B PROLASTIN 4 PA LA B PROLASTIN-C 4 PA LA B PULMOZYME 4 PA MO B TYZINE 2 MO B XOLAIR 4 PA LA / / G zaleplon 1 MO G zolpidem tartrate tablet 10mg 1 QL MO G zolpidem tartrate tablet 5mg 1 QL MO G carisoprodol tablet 350mg 1 QL PA MO G cyclobenzaprine hcl 1 QL PA MO G methocarbamol 1 PA MO / / / B AMINOSYN 2 MO B AMINOSYN 8.5%/ELECTROLYTES 2 MO B AMINOSYN II 2 MO B AMINOSYN II 3.5%/DEXTROSE25% 2 MO B AMINOSYN II 3.5%/DEXTROSE5% 2 MO LA MO B G PA QL ST 48

57 (08/2012) / / / / B AMINOSYN II 3.5/DEXTROSE 25% 2 MO B AMINOSYN II 4.25/DEXTROSE10% 2 MO B AMINOSYN II 4.25/DEXTROSE20% 2 MO B AMINOSYN II 4.25/DEXTROSE25% 2 MO B AMINOSYN II 5/DEXTROSE 25 2 MO B AMINOSYN II 8.5%/ELECTROLYTES 2 MO B AMINOSYN II M 3.5%/DEXTROSE 5% 2 MO B AMINOSYN M 2 MO B AMINOSYN-HBC 2 MO B AMINOSYN-HF 2 MO B AMINOSYN-PF 2 MO B AMINOSYN-PF 7% 2 MO B AMINOSYN-RF 2 MO G citric acid/sodium citrate 1 MO B CLINIMIX 2.75%/DEXTROSE 5% 3 MO B CLINIMIX 4.25%/DEXTROSE 10% 3 MO B CLINIMIX 4.25%/DEXTROSE 20% 3 MO B CLINIMIX 4.25%/DEXTROSE 25% 3 MO B CLINIMIX 4.25%/DEXTROSE 5% 3 MO B CLINIMIX 5%/DEXTROSE 15% 3 MO B CLINIMIX 5%/DEXTROSE 20% 3 MO B CLINIMIX 5%/DEXTROSE 25% 3 MO B CLINIMIX E 2.75%/DEXTROSE 10% 3 MO B CLINIMIX E 2.75%/DEXTROSE 5% 3 MO B CLINIMIX E 4.25%/DEXTROSE 25% 3 MO B CLINIMIX E 4.25%/DEXTROSE 5% 3 MO B CLINIMIX E 5%/DEXTROSE 15% 3 MO B CLINIMIX E 5%/DEXTROSE 20% 3 MO B CLINIMIX E 5%/DEXTROSE 25% 3 MO B CLINISOL SF 15% 2 MO G cytra-2 1 QL MO G cytra-3 1 QL MO LA MO B G PA QL ST 49

58 (08/2012) / / / B DEXTROSE 10%/NACL 0.45% 2 MO B DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX 2 MO B DEXTROSE 10% FLEX CONTAINER 2 MO B DEXTROSE 10%/NACL 0.2% 2 MO B DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% 2 MO B DEXTROSE 5% 2 MO B DEXTROSE 5%/NACL 0.2% 2 MO B DEXTROSE 5%/NACL 0.225% 2 MO B DEXTROSE 5%/NACL 0.33% 2 MO B DEXTROSE 5%/NACL 0.45% 2 MO B DEXTROSE 5%/NACL 0.9% 2 MO B DEXTROSE 5%/POTASSIUM CHLORIDE 0.075% 2 MO B FREAMINE III 3 MO B FREAMINE III 3% 3 MO B HEPATAMINE 3 MO B HEPATASOL 3 MO B INTRALIPID 2 MO B KCL 0.3%/D5W/LR IV LAC RING 2 MO G klor-con 10 1 MO G klor-con 25 1 MO G klor-con 8 1 MO G klor-con m10 1 MO G klor-con m15 1 MO G klor-con m20 1 MO G klor-con packet 1 MO B LACTATED RINGERS 2 MO B LACTATED RINGERS VIAFLEX 2 MO B LIPOSYN II 2 MO B LIPOSYN III 2 MO B NEPHRAMINE 3 MO B NORMOSOL-M IN D5W 2 MO B NORMOSOL-R 2 MO / LA MO B G PA QL ST 50

59 (08/2012) / / / B NORMOSOL-R IN D5W 2 MO B NOVAMINE 2 MO B PHYSIOLYTE 2 MO B POTASSIUM CHLORIDE 0.15%/D5W 2 MO G potassium chloride er capsule extended release 10meq 1 MO G potassium chloride er tablet extended release 1 MO G potassium chloride injection 2meq/ml 1 MO G potassium chloride liquid 1 MO G potassium chloride sr 1 MO G potassium citrate extended-release 1 MO B PROCALAMINE 3 MO G sodium bicarbonate 1 MO G sodium chloride 1 MO G sodium chloride 0.9% 1 MO G sodium chloride 0.45% viaflex 1 MO G tpn electrolytes ftv 1 MO B TRAVASOL 3 MO B TROPHAMINE 2 MO G prenatabs obn 1 MO G prenatal plus 1 MO G prenatal plus/iron tablet 1 MO / LA MO B G PA QL ST 51

60 (08/2012) 8-MOP A ABILIFY DISCMELT TABLET DISPERSIBLE 10MG ABILIFY DISCMELT TABLET DISPERSIBLE 15MG ABILIFY INJECTION ABILIFY ORAL SOLUTION ABILIFY TABLET acarbose...21 acebutolol hcl...25 acetaminophen/codeine #3...1 acetaminophen/codeine #4...1 acetaminophen/codeine solution...1 acetaminophen/codeine tablet 300mg, 15mg...1 acetazolamide capsule extended release 12 hour, tablet...27 acetic acid acetic acid/aluminum acetate acetylcysteine ACTHIB acticin ACTIMMUNE ACTOPLUS MET ACTOS...21 acyclovir capsule, suspension, tablet acyclovir sodium injection ADACEL ADAGEN...31 ADCIRCA...48 ADVAIR DISKUS...46 ADVAIR HFA...46 AFINITOR AGGRENOX ak-con ALBENZA albuterol sulfate er...47 albuterol sulfate nebulization solution...47 albuterol sulfate syrup, tablet...47 alclometasone dipropionate...33 alcohol preps ALDURAZYME...31 alendronate sodium tablet 10mg, 40mg, 5mg...43 alendronate sodium tablet 35mg, 70mg...43 ALIMTA ALINIA allopurinol...12 ALOCRIL ALPHAGAN P 0.1%, 0.15% ALREX SUSPENSION amantadine hcl capsule, syrup amcinonide...33 a-methapred...33 amifostine...14 amikacin sulfate injection...3 amiloride hcl...27 amiloride/hydrochlorothiazide...27 aminophylline...47 AMINOSYN...48 AMINOSYN 8.5%/ELECTROLYTES...48 AMINOSYN II...48 AMINOSYN II 3.5%/DEXTROSE25%...48 AMINOSYN II 3.5%/DEXTROSE5%...48 AMINOSYN II 3.5/DEXTROSE 25%...49 AMINOSYN II 4.25/DEXTROSE10%...49 AMINOSYN II 4.25/DEXTROSE20%...49 AMINOSYN II 4.25/DEXTROSE25%...49 AMINOSYN II 5/DEXTROSE AMINOSYN II 8.5%/ELECTROLYTES...49 AMINOSYN II M 3.5%/DEXTROSE 5%...49 AMINOSYN M...49 AMINOSYN-HBC...49 AMINOSYN-HF...49 AMINOSYN-PF...49 AMINOSYN-PF 7%...49 AMINOSYN-RF...49 amiodarone hcl tablet...25 AMITIZA...32 amitriptyline hcl...9 amlodipine besylate amlodipine besylate/benazepril hcl ammonium lactate amoxapine...9 amoxicillin...5 amoxicillin/clavulanate potassium...5 amoxicillin/potassium clavulanate...5 amphetamine/dextroamphetamine amphotericin b...11 ampicillin...5 ampicillin sodium injection 125mg, 1gm, 250mg, 2gm, 500mg...5 ampicillin-sulbactam

61 (08/2012) A ANADROL bacitracin...3 anagrelide hydrochloride bacitracin/polymyxin b...3 anastrozole...15 baclofen tablet ANCOBON...11 balsalazide disodium androxy...35 balziva ANTABUSE BANZEL SUSPENSION...6 ANTARA CAPSULE BANZEL TABLET 200MG...6 APOKYN BANZEL TABLET 400MG...6 apri BARACLUDE SOLUTION...20 APRISO BARACLUDE TABLET...20 APTIVUS BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G aranelle X 1/ ARCALYST BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G ARIXTRA INJECTION 10MG/0.8ML...23 X 5/ ARIXTRA INJECTION 2.5MG/0.5ML...23 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G ARIXTRA INJECTION 5MG/0.4ML...23 X 1/ ARIXTRA INJECTION 7.5MG/0.6ML...23 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X ARMOUR THYROID / ASACOL BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM ASMANEX INHALER...46 benazepril hcl...28 atenolol benazepril hcl/hydrochlorothiazide...28 atenolol/chlorthalidone benztropine mesylate tablet atorvastatin calcium tablets BESIVANCE SUSPENSION...6 ATRIPLA betamethasone dipropionate atropine sulfate injection...31 betamethasone valerate atropine sulfate ophthalmic solution, ointment betaxolol hcl...25, 45 ATROVENT HFA bethanechol chloride...13 augmented betamethasone dipropionate...33 BETOPTIC-S AVANDAMET bicalutamide AVANDARYL BICILLIN C-R...5 AVANDIA BICILLIN L-A...5 AVASTIN BIOTHRAX aviane bisoprolol fumarate AVODART...33 bisoprolol fumarate/hydrochlorothiazide AVONEX bleomycin sulfate AZASITE...5 BONIVA INJECTION azathioprine sodium injection...40 BONIVA TABLET 150MG azathioprine tablet...40 BOOSTRIX azelastine hcl nasal spray...46 brevicon AZELEX briellyn AZILECT brimonidine tartrate solution 0.15%, 0.2% azithromycin injection, BROMDAY suspension reconstituted, tablet...5 bromfenac AZOPT bromocriptine mesylate budeprion sr...8 budeprion xl B

62 (08/2012) B budesonide capsule 3mg...43 bumetanide injection, tablet BUPHENYL TABLET...31 buprenorphine hcl injection buprenorphine hcl tablet sublingual buproban...8 bupropion hcl...8 bupropion hcl sr...8 bupropion hcl xl...8 buspirone hcl...21 butalbital/acetaminophen/caffeine/codeine...1 BYDUREON SUSPENSION BYETTA C calcipotriene calcitonin-salmon calcitriol capsule, injection, oral solution...43 calcium acetate...33 camila CAMPATH CAMPRAL CANASA CAPASTAT SULFATE...13 CAPRELSA...13 captopril captopril/hydrochlorothiazide CARAC CARAFATE SUSPENSION...33 carbamazepine suspension, tablet chewable, tablet...8 carbidopa/levodopa cr carbidopa/levodopa sr carbidopa/levodopa tablet CARIMUNE NANOFILTERED carisoprodol tablet 350mg carteolol hcl cartia xt carvedilol caziant CEENU...13 cefaclor...4 cefadroxil...4 cefazolin sodium...4 cefdinir capsule, suspension reconstituted...4 cefepime...4 cefotaxime sodium...4 cefoxitin sodium injection 10gm, 1gm, 2gm...4 cefpodoxime proxetil...4 cefprozil suspension reconstituted, tablet...4 ceftazidime...4 ceftriaxone sodium...4 cefuroxime axetil...4 cefuroxime sodium injection 1.5gm, 750mg...4 CELLCEPT SUSPENSION RECONSTITUTED...40 CELONTIN...7 cephalexin...4 CEREDASE...31 CEREZYME...31 CERVARIX cesia CHANTIX STARTER PACK CHANTIX TABLET 0.5MG, 1MG chlordiazepoxide/amitriptyline...9 chlorhexidine gluconate oral rinse chloroquine phosphate chlorothiazide sodium injection chlorothiazide tablet chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light chorionic gonadotropin...35 CIALIS TABLETS 2.5MG, 5MG...33 ciclopirox...11 ciclopirox nail lacquer...11 ciclopirox olamine...11 cilostazol cimetidine...32 cimetidine hcl solution...32 CIMZIA...40 CIMZIA STARTER KIT...40 CIPRODEX ciprofloxacin hcl ophthalmic solution...6 ciprofloxacin hcl tablet 250mg, 500mg, 750mg...6 ciprofloxacin injection...6 citalopram hydrobromide...9 citric acid/sodium citrate...49 clarithromycin suspension reconstituted, tablet...5 clindamycin hcl capsule

63 (08/2012) C clindamycin phosphate cream, gel, lotion, solution clindamycin phosphate injection...3 CLINIMIX 2.75%/DEXTROSE 5%...49 CLINIMIX 4.25%/DEXTROSE 10%...49 CLINIMIX 4.25%/DEXTROSE 20%...49 CLINIMIX 4.25%/DEXTROSE 25%...49 CLINIMIX 4.25%/DEXTROSE 5%...49 CLINIMIX 5%/DEXTROSE 15%...49 CLINIMIX 5%/DEXTROSE 20%...49 CLINIMIX 5%/DEXTROSE 25%...49 CLINIMIX E 2.75%/DEXTROSE 10%...49 CLINIMIX E 2.75%/DEXTROSE 5%...49 CLINIMIX E 4.25%/DEXTROSE 25%...49 CLINIMIX E 4.25%/DEXTROSE 5%...49 CLINIMIX E 5%/DEXTROSE 15%...49 CLINIMIX E 5%/DEXTROSE 20%...49 CLINIMIX E 5%/DEXTROSE 25%...49 CLINISOL SF 15%...49 clobetasol propionate cream, gel, ointment, solution clobetasol propionate e cream CLODERM clomipramine hcl...9 clonidine hcl tablet clopidogrel tablets clorpres clotrimazole cream, troche...11 clotrimazole/betamethasone dipropionate...11 clozapine codeine sulfate...1 co-gesic...1 COLCRYS colestipol hcl granules, tablet colistimethate sodium injection...3 colocort COMBIPATCH COMBIVENT COMBIVIR COMPLERA compro...11 COMTAN COMVAX CONDYLOX GEL COPAXONE CORDRAN LOTION COREG CR cormax CORTIFOAM cortisone acetate cortomycin...46 COUMADIN...23 CREON...31 CRIXIVAN cromolyn sodium nebulization solution...48 cromolyn sodium ophthalmic solution cromolyn sodium oral concentrate...32 cryselle CUBICIN...3 CUPRIMINE...40 CURITY GAUZE PADS 2 X cyclobenzaprine hcl...48 cyclophosphamide...13 cyclosporine...40 cyclosporine modified...40 CYKLOKAPRON CYMBALTA...9 cyproheptadine hcl CYSTADANE...31 CYSTAGON...31 CYTOMEL TABLET 25MCG, 5MCG cytra cytra D danazol...35 DAPSONE...13 DAPTACEL DARAPRIM DECAVAC demeclocycline hcl...6 DENAVIR CREAM...20 dentagel DERMA-SMOOTHE/FS BODY OIL DERMA-SMOOTHE/FS SCALP OIL DERMOTIC...46 desipramine hcl desmopressin acetate injection, tablet...35 desmopressin acetate nasal solution...35 desonide desoximetasone dexamethasone elixir, solution, tablet... 34