VNS MMP formulary

Transcription

1 2017 年 給付藥品清單 ( 處方集 ) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) 處方集 ID: , 版本 : 13 請撥打 CHOICE 免付費電話 : TTY: 711 每週 7 天, 早上 8:00 至晚上 8: Broadway, New York, NY vnsnychoice.org H8490_CY2017_LOCD_16702_TC AF

2 H8490_CY2017_LOCD_16702_TC AF Multi-Language Insert Multi-language Interpreter Services ATTENTION: Language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (711) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 711) লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711).

3 ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください

4 VNSNY CHOICE FIDA Complete 2017 年給付藥品清單 ( 處方集 ) 這是參與者可以透過 VNSNY CHOICE FIDA Complete 領取的藥品清單 VNSNY CHOICE FIDA Complete 是一項與 Medicare 和紐約州衛生署 (Medicaid) 簽約的管理式照護計畫, 其透過完全整合式雙優惠 (Fully Integrated Duals Advantage, FIDA) 示範, 將兩個計畫的好處提供給參與者 投保 VNSNY CHOICE FIDA Complete 取決於合約續訂 給付藥品和 / 或藥局清單及提供者網路可能在一年當中發生變更 在進行對您有影響的變更之前, 我們會向您發送通知 福利可能於每年的 1 月 1 日變更 您隨時可以透過網站 vnsnychoice.org 在線查閱 VNSNY CHOICE FIDA Complete 的最新給付藥品清單, 或致電 VNSNY CHOICE FIDA Complete 參與者服務中心 ( ) 索取清單 可能會有一些限制 如需詳細資訊, 請致電 VNSNY CHOICE FIDA Complete 參與者服務中心或閱讀 VNSNY CHOICE FIDA Complete 參與者手冊 不需要為任何給付藥品支付共同負擔費用 您可以透過其他格式 ( 例如大字版 點字版或錄音版 ) 免費取得此資訊 請致電 (TTY 使用者請撥打 711), 服務時間為每週 7 天, 早上 8:00 至晚上 8:00 此為免付費電話 您可以免費取得其他語言版本的此資訊 請致電 ( 聽障人士專線為 711), 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 此電話為免付費電話 若您需要索取英文版或任何其他語言或格式的任何參與者資料副本, 請撥打以下電話聯絡參與者服務部 : ,TTY 使用者請撥打 711; 服務時間為每週 7 天, 早上 8:00 至晚上 8:00 紐約州已建立一項參與者申訴計劃 (Participant Ombudsman Program), 該計劃名為獨立消費者倡權網路 (Independent Consumer Advocacy Network, ICAN), 其針對 VNSNY CHOICE FIDA Complete 所提供的任何服務, 免費 保密地向參與者提供相關的協助 可撥打免付費電話 聯絡 ICAN, 或透過 icannys.org 線上聯絡 (TTY 使用者請撥打 711, 然後按照提示撥打 )? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org I

5 常見問答集 (FAQ) 在這裡尋找有關此給付藥品清單的相關問題解答 您可以閱讀所有 FAQ 來瞭解更多資訊, 或尋找問題和答案 1. 給付藥品清單中有哪些處方藥? ( 我們將給付藥品清單簡稱為 藥品清單 ) 第 11 頁開始列出的給付藥品清單中的藥品是 VNSNY CHOICE FIDA Complete 給付的藥品 這些藥品可在我們網絡中的藥局取得 如果某藥局與我們簽訂合作及服務合約, 就會被納入我們的網絡 我們將這些藥局稱為 網絡藥局 在下列情況下,VNSNY CHOICE FIDA Complete 將給付藥品清單中的所有藥品 : 您的醫師或其他網絡開立處方者說明您需要這些藥品才能好轉或維持健康, 此藥品對您的病症具有醫療必要性和 您在 VNSNY CHOICE FIDA Complete 網絡藥局領取處方藥 VNSNY CHOICE FIDA Complete 可能要求您執行其他步驟才能取得特定藥品 ( 請參閱下面的問題 #5) 在某些情況下, 您可能必須進行其他流程才能領取藥品, 如先嘗試其他藥品 您也可以造訪我們的網站 vnsnychoice.org 或致電參與者服務中心 ( ), 瞭解我們給付的最新藥品清單 2. 藥品清單是否會變更? 會 在一年中,VNSNY CHOICE FIDA Complete 可能會增加或移除藥品清單中的藥品 通常, 只有在下列情況才會更改藥品清單 : 新藥品與目前藥品清單中的藥品具有相同的效用, 或者 我們發現某種藥品不安全? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org II

6 我們也可能會變更我們的藥品相關規則 例如, 我們可能 : 決定在領取藥品前是否需要事先核淮 ( 事先核准是 VNSNY CHOICE FIDA Complete 或您的跨學科小組 (Interdisciplinary Team, IDT) 核淮您是否能領取藥品的權限 ) 增加或變更您可領取的藥品量 ( 稱為 數量限制 ) 增加或變更藥品的分階段療法限制 ( 分階段療法表示您必須先嘗試一種藥品, 我們才會給付另一種藥品 ) ( 如需這些藥品規則的詳細資訊, 請參閱第 5 頁 ) 當我們從藥品清單移除您正在服用的藥品時, 我們會通知您 當我們變更藥品的給付規則時, 我們也會通知您 下面的問題 3 4 和 7 提供了當藥品清單變更時, 會發生哪些狀況的詳細資訊 您隨時可以從線上查閱 VNSNY CHOICE FIDA Complete 的最新藥品清單, 網址為 vnsnychoice.org 您也可以致電 聯絡參與者服務中心, 以查閱當前的藥品清單 3. 當更便宜的藥品與目前藥品清單中的藥品具有相同的效用時, 會出現什麼 情況? 若有更便宜的可用藥品與目前藥品清單中的藥品具有相同的效用時 : 當您下一次領取處方藥時, 您的藥劑師可能會向您提供更便宜的藥品 如果您和您的提供者判斷您不適合更便宜的藥品, 則提供者會通知藥劑師繼續向您提供目前服用的藥品 VNSNY CHOICE FIDA Complete 可能會決定從藥品清單中移除更昂貴的藥品 如果我們因較便宜的藥品具有相同的效用, 而從藥品清單移除您正在服用的藥品, 我們至少會在移除前 60 天通知您, 或當您申請續配時通知您 接著您可以在藥品清單變更生效前領取 60 天份的藥品 如果您所服藥品的給付狀況發生變化, 計畫通常會提前 60 天寄通知函給您? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org III

7 4. 當我們發現藥品不安全時會發生什麼事? 如果美國食品和藥品管理局 (Food and Drug Administration, FDA) 表示您正在服用的藥品不安全, 我們會立即從藥品清單中移除該藥品 我們也會以書信通知您, 並透過電話告知您我們從藥品清單中移除不安全藥品的消息 您的提供者也會知道這項變更, 而且可以和您一起尋找適合您所患病症的其他藥品 5. 藥品給付是否有任何限制? 或者在領取特定藥品時, 是否需要採取任何必要的 行動? 是的, 部分藥品具有給付規則, 或具有領取量限制 在某些情況下, 您必須先採取一些措施才能領取藥品 例如 : 事先核淮 ( 或事先授權 ): 對於某些藥品, 您或您的醫師或其他開立處方者必須先獲得 VNSNY CHOICE FIDA Complete 或跨學科小組 (IDT) 的核淮, 之後才能領取處方藥 若未經核淮,VNSNY CHOICE FIDA Complete 可能無法給付藥品 數量限制 : VNSNY CHOICE FIDA Complete 有時會限制您可以領取的藥品量 分階段療法 :VNSNY CHOICE FIDA Complete 有時會要求您進行分階段療法 這表示您必須根據您的醫療情況, 按特定順序嘗試藥品 您可能必須先嘗試某種藥品, 接著我們將給付另一種藥品 如果醫師認為第一種藥品不適合您, 則我們將給付第二種藥品 您可以查看第 14 頁開始的表格, 瞭解您的藥品是否有任何其他需求或限制 您也可以造訪我們的網站 vnsnychoice.org 來取得詳細資訊 我們已張貼線上文件來說明事先授權和分階段療法限制 您也可以要求我們寄給您副本 您可以申請這些限制的 例外處理 如需例外處理的詳細資訊, 請參閱問題 11 如果您在護理機構或長期照護機構接受照護, 並且需要藥品清單中不包含的藥品, 或如果您無法輕易取得所需藥品, 我們可提供協助 不論您是否為新的 VNSNY CHOICE FIDA Complete 參與者, 我們都會提供您所需的 31 天份藥品緊急供應 ( 除非您需要天數較短的處方藥 ) 如此您就有時間與您的醫師或其他? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org IV

8 開立處方者進行溝通 他 / 她能協助您判斷是否能改服藥品清單中的類似藥品, 或是否需要申請例外處理 如需例外處理的詳細資訊, 請參閱問題 您如何得知所需藥品是否有限制, 或是否需要採取一些必要的行動才能領取藥 品? 第 14 頁的給付藥品清單有一個標示為 必要的行動 限制或使用限制 的欄 7. 如果我們變更部分藥品的給付方式規則, 會發生什麼事? 例如, 如果我們針對 藥品增加事先授權 ( 核淮 ) 數量限制和 / 或分階段療法限制 如果我們針對藥品增加事先核淮 數量限制和 / 或分階段療法限制, 我們將通知您 我們至少會在增加限制前 60 天, 或在您下一次申請續配時通知您 接著您可以在藥品清單變更生效前領取 60 天份的藥品 如此您就有時間與您的醫師或其他開立處方者談論接下來的作法 8. 如何在藥品清單中尋找藥品? 有兩種尋找藥品的方法 : 您可以按字母順序搜尋 ( 如果您知道藥品的拼字 ), 或者 您可以按醫療情況搜尋 若要按字母順序搜尋, 請移至第 I-1 頁的 按字母排列的藥品清單 部分 接著在清單中尋找您的藥品名稱 若要按醫療情況搜尋, 請在第 14 頁尋找標題為 按醫療情況排列的藥品清單 部分 此部分的藥品是依它們用於治療的醫療情況類型分門別類 例如, 如果您有心臟疾病, 您就應該尋找 心血管藥劑 (Cardiovascular Agents) 類別 您會在那裡找到治療心臟疾病的藥品? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org V

9 9. 如果藥品清單中沒有您要服用的藥品, 該如何處理? 如果您在藥品清單中沒有找到所需的藥品, 請致電 並告知參與者服務中心這一情況 如果您得知 VNSNY CHOICE FIDA Complete 不會給付該藥品, 您可以採取下列其中一種作法 : 向參與者服務中心索取與您要服用的藥品類似的藥品清單 然後向您的醫師或其他開立處方者出示清單 他 / 她會根據藥品清單開立與您要服用的藥品類似的藥品 或是 您可以要求計畫或您的跨學科小組 (IDT) 為您進行例外處理以給付藥品 如需例外處理的詳細資訊, 請參閱問題 如果您是新的 VNSNY CHOICE FIDA Complete 參與者, 而且在藥品清單中 找不 到所需藥品, 或在取得藥品過程中遇到問題, 您該怎麼辦? 我們會助您一臂之力 在您成為 VNSNY CHOICE FIDA Complete 參與者的前 90 天內, 我們必須視需要給付最多 90 天的藥品臨時供應 如此您就有時間與您的醫師或其他開立處方者進行溝通 他 / 她能協助您判斷是否能改服藥品清單中的類似藥品, 或是否需要申請例外處理 在下列情況下, 我們會給付最多 90 天的藥品臨時供應 : 您正在服用未列於我們藥品清單中的藥品, 或 健康計畫規則使您無法領取開立處方者所訂購的藥品量, 或 藥品需要事先經過 VNSNY CHOICE FIDA Complete 或您的跨學科小組 (IDT) 核淮, 或 您正在服用分階段療法限制藥品中的藥品之一? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org VI

10 如果您在護理機構或長期照護機構中生活, 您可以續配長達 98 天的處方藥 在您計畫的前 90 天期間, 您可以多次領藥 這能讓您的開立處方者有時間將您的藥品變更為藥品清單中的藥品, 或者申請例外處理 如果您的照護等級發生變化 ( 例如從醫院轉為居家照護 ), 而且您需要的藥品未列於我們的處方集或您無法取得藥品, 但您已成為本計劃會員超過 90 天, 只要您前往合作網路內藥房領藥, 我們便會給付一次暫時供應藥品 ( 最多 30 天, 或者如果您是長期照護居民則為 31 天 ) 如您希望暫時供應藥品用完後仍然繼續享有藥品給付, 則應於這段期間進行本計劃的例外處理流程 若要申請暫時供應藥品, 請致電參與者服務中心 11. 您是否可以申請藥品給付例外處理? 是 您可以向 VNSNY CHOICE FIDA Complete 或您的跨學科小組 (IDT) 申請例外處理, 以給付未列於藥品清單中的藥品 您也可以要求 VNSNY CHOICE FIDA Complete 或您的 IDT 變更您的藥品規則 例如,VNSNY CHOICE FIDA Complete 可能會限制我們將給付的藥品量 如果您的藥品有限制, 您可以要求我們或您的 IDT 變更限制及給付更多藥品 其他範例 : 您可以要求我們或您的 IDT 取消分階段療法限制或事先核淮要求 12. 需要多久時間才能獲得例外處理? 首先,VNSNY CHOICE FIDA Complete 或您的跨學科小組 (IDT) 必須從您的開立處方者那裡取得您的例外處理申請之佐證聲明 我們會在收到聲明後, 於 72 小時內通知您有關例外處理要求的決定 如果您或您的開立處方者認為在 72 小時等待決定的過程中, 您的健康可能會受到損害, 您可以申請緊急例外處理 這是較快速的決策過程 如果您的開立處方者支持您的要求, 您將在我們收到開立處方者佐證聲明後的 24 小時內收到決策通知? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org VII

11 13. 如何申請例外處理? 若要申請例外處理, 請致電您的照護管理師 您的照護管理師將與您及您的提供者一起, 協助申請例外處理 14. 什麼是仿製藥? 仿製藥的成分與專利藥的成分相同 仿製藥的價格通常低於專利藥, 且一般沒有為人熟知的名稱 仿製藥皆經過美國食品和藥品管理局 (FDA) 核准 VNSNY CHOICE FIDA Complete 同時給付專利藥和仿製藥 15. 什麼是 OTC 藥品? OTC 代表 成藥 (Over-the-counter, OTC) VNSNY CHOICE FIDA Complete 給付部分 OTC 藥品, 但前提是您的提供者將這些藥品開立為處方藥 您可以閱讀 VNSNY CHOICE FIDA Complete 藥品清單來查看其給付的 OTC 藥品 16. VNSNY CHOICE FIDA Complete 是否給付 OTC 非藥品產品? VNSNY CHOICE FIDA Complete 給付部分 OTC 非藥品產品, 但前提是您的提供者將這些產品開立為處方藥 非藥物的 OTC 產品範例是酒精棉片 您可以閱讀 VNSNY CHOICE FIDA Complete 藥品清單來查看其給付的 OTC 非藥品產品 17. 您的共同負擔費用是多少? 您不必支付藥品清單中藥品的共同負擔費用? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org VIII

12 18. 什麼是藥品層級? 層級是指藥品分組 計畫的藥品清單上的每一種藥品均屬於 4 種層級的其中一種 您不必支付任何層級的藥品費用 第 1 層藥品是仿製藥 第 2 層藥品是專利藥 第 3 層藥品是非 Medicare 處方藥 第 4 層藥品是非 Medicare OTC 藥品? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org IX

13 給付藥品清單 從下一頁開始的給付藥品清單為您提供了 VNSNY CHOICE FIDA Complete 所給付藥品的相關資訊 如果您在清單中找不到所需的藥品, 請參考從第 I-1 頁開始的 索引 圖表的第一欄會列出藥品的名稱 原廠藥為大寫 ( 例如 ROZEREM), 而學名藥則是小寫的斜體字 ( 例如 zaleplon) 使用欄中的必要行動或限制資訊旨在說明 VNSNY CHOICE FIDA Complete 對您的藥品是否有任何給付規則 注意 : 藥品旁的 * 表示該藥品不是 Part D 藥品 這些藥品具有不同的上訴規則 上訴是一種正式管道, 當您認為決策錯誤時, 可要求審查及更改所做出的給付決定 例如,VNSNY CHOICE FIDA Complete 或您的跨學科小組 (IDT) 可能決定不給付您所需的藥品, 或 Medicare 或 Medicaid 不再給付該藥品 如果您本人 您的醫師或其他開立處方者不同意這項決定, 您可以上訴 若要取得有關上訴方式的指示, 請致電 聯絡參與者服務中心, 或致電 聯絡獨立消費者倡權網路 (Independent Consumer Advocacy Network,ICAN) (TTY 使用者請撥打 711, 然後按照提示撥打 ) 您也可以閱讀 參與者手冊 來瞭解如何針對決策提出上訴? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org X

14 以下的使用管理縮寫可能出現於本文件的正文 保險給付注意事項縮寫 縮寫說明解釋 使用管理限制 PA PA-HRM PA NSO QL ST 事先授權限制 Part B 與 Part D 裁決的事先授權限制 高風險藥物的事先授權限制 僅限新會員的事先授權限制 數量限制 分階段療法限制 在按此處方領取藥品之前, 您 ( 或您的醫生 ) 必須先從 VNSNY CHOICE FIDA Complete 取得事先授權 如未事先核准,VNSNY CHOICE FIDA Complete 可能無法給付此藥品 此藥品可能符合 Medicare Part B 或 Part D 的給付資格 在按此處方領取藥品之前, 您 ( 或您的醫生 ) 必須先從 VNSNY CHOICE FIDA Complete 取得事先授權, 以判定是否根據 Medicare Part D 給付此藥品 如未事先核准,VNSNY CHOICE FIDA Complete 可能無法給付此藥品 CMS 認為此藥品具有潛在的傷害性, 因此是年滿 65 歲之 Medicare 受益人的高風險藥物 在按此處方領取藥品之前, 年滿 65 歲的參與者必須取得 VNSNY CHOICE FIDA Complete 的事先授權 如未事先核准,VNSNY CHOICE FIDA Complete 可能無法給付此藥品 如果您是新的參與者或是之前尚未服用過此藥, 在按此處方領取藥品之前, 您 ( 或您的醫生 ) 必須取得 VNSNY CHOICE FIDA Complete 的事先授權 如未事先核准,VNSNY CHOICE FIDA Complete 可能無法給付此藥品 VNSNY CHOICE FIDA Complete 限制每張處方籤或是在特定時間內, 給付此藥品的數量 在 VNSNY CHOICE FIDA Complete 提供此藥品的給付之前, 您必須先嘗試其他藥品以治療您的病症 如果其他藥品對您沒有功效, 才會給付此藥品? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org XI

15 以下的其他給付注意事項縮寫可能出現於本文件的正文 保險給付的其他特殊要求 縮寫說明解釋 LA NM 取得受限的藥品 非郵購藥品 此處方可能只提供於特定的藥局 如需更多資訊, 請查閱您的 提供者及藥局目錄 或致電會員服務部, 電話 : , 每週 7 天, 早上 8:00 至晚上 8:00 TTY/TDD 使用者請撥打 711 透過郵購, 您可能以降低的分攤費用領取處方集大部分藥品 1 個月以上的藥量 無法透過郵購福利提供的藥品, 在處方集的 要求 / 限制 (Requirements/Limits) 欄標示為 "NM" * 非 Part D 藥品此藥品為非 Part D 藥品或是 OTC 藥品或產品? 如果您有疑問, 請致電 聯絡 VNSNY CHOICE FIDA Complete, 此專線每週 7 天的上午 8 點到晚上 8 點提供服務 ( 聽障人士專線為 711) 此電話為免付費電話 如需詳細資訊, 請造訪 vnsnychoice.org XII

16 禁止歧視聲明 歧視係違法行為 紐約探訪護士服務及其所有子公司與關係企業 * ( VNSNY ) 一律遵守聯邦民權法, 不因種族 膚色 國籍 年齡 殘障或性別而歧視任何人 VNSNY 不因種族 膚色 國籍 年齡 殘障或性別而排擠任何人或給予差別待遇 為讓殘障人士能夠與 VNSNY 充分溝通, 我們提供免費的援助和服務, 例如合格的手語翻譯人員 其他格式 ( 大字印刷版 錄音版 方便易用的電子格式 其他格式 ) 的書面資訊 ; 同時也為母語非英語的人士提供免費的語言服務, 例如合格的口譯人員或其他語言版本的書面資訊 如需以上服務, 請聯絡 VNSNY 的民權協調員 (Civil Rights Coordinator): VNSNY CHOICE 健康計劃 :Susan Underwood 若您認為 VNSNY 並未提供以上服務, 或在其他方面因種族 膚色 國籍 年齡 殘障或性別而歧視您, 您可以向前述民權協調員提出申訴 : 郵寄或親自送到 :1250 Broadway 11 th Floor, New York, New York 致電 : VNSNY CHOICE 健康計劃 : TTY 服務專線 :711 傳真 : 電子郵件 :CivilRightsCoordinator@vnsny.org 網站 : 如在提出申訴方面需要任何協助, 民權協調員可以為您服務 您也可以向美國聯邦衛生和人類服務部 (U.S. Department of Health and Human Services) 的民權辦事處 (Office for Civil Rights) 提出投訴, 如欲透過電子方式提出投訴, 請利用民權辦事處投訴入口網站 (Office for Civil Rights Complaint Portal), 網址是 : 或者如需郵寄或致電, 請利用下列資訊 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C (TDD 服務專線 ) 如需投訴表, 請至 下載 * 子公司與關係企業係指 :Visiting Nurse Service of New York Home Care VNSNY Hospice and Palliative Care 和 Partners in Care ( 統稱 VNSNY 提供者 ), 以及 VNSNY CHOICE 和 VNS Continuing Care Development Corporation ( 統稱 VNSNY CHOICE ) VNSNY 提供者和 VNSNY CHOICE 統稱 VNSNY

17 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders

18 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

19 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 500 mg softgel 500 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg (Non-Aspirin Child) (Non-Aspirin) (Pain Relief) (Tylophen) (Acephen) (Children's Acetaminophen) (Tylenol-Codeine #3) (Tylenol-Codeine #4) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (360 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 3

20 BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenex) (Fioricet with Codeine) (Tencon) (Zebutal) (Esgic) (Fiorinal) QL (60 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) 4

21 capacet oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) child non-aspirin 160 mg/5 ml QL (240 per 30 days) children's 160 mg/5 ml * child pain-fever 160 mg/5 ml a/f, QL (240 per 30 days) asa/f, ibu/f 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) * children's mapap 80 mg rapid 80 QL (30 per 30 days) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) mg, 60 mg cvs acetaminophen 8-hr 650 mg QL (180 per 30 days) (Pain Relief) caplet 650 mg * cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) * cvs pain relief 325 mg liq gel 325 QL (360 per 30 days) mg * cvs pain relief adult liquid 500 QL (120 per 30 days) mg/15 ml * endocet oral tablet mg QL (240 per 30 days) endocet oral tablet mg, 5- QL (360 per 30 days) 325 mg endocet oral tablet mg QL (300 per 30 days) endodan oral tablet mg QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr (Duragesic) QL (10 per 30 days) 5

22 fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour feverall 120 mg suppository children's, outer 120 mg * feverall 325 mg suppository junior str, outer 325 mg * feverall 650 mg suppository adult, inner 650 mg * hydrocodone-acetaminophen oral solution mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml (Hycet) (Vicodin HP) (Norco) (Verdrocet) (Vicodin) (Vicodin ES) (Lorcet Plus) (Reprexain) QL (10 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (390 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) QL (150 per 30 days) 6

23 hydromorphone 10 mg/ml vial p/f,sdv,latex-f 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml, 4 mg/ml hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg, 8 mg HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG infant pain relv 80 mg/0.8 ml a/f, QL (30 per 30 days) gluten-free 80 mg/0.8 ml * jr pain-fever 160 mg rapid tab QL (30 per 30 days) junior,bubblegum 160 mg * junior mapap 160 mg rapid tab 160 QL (30 per 30 days) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) 325 mg lorcet hd oral tablet mg QL (360 per 30 days) lorcet plus oral tablet mg QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 QL (240 per 30 days) ml * mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) mg/5 ml * mapap 325 mg tablet 325 mg * QL (360 per 30 days) mapap 500 mg capsule 500 mg * QL (240 per 30 days) mapap 500 mg tablet 500 mg * QL (240 per 30 days) 7

24 mapap 500 mg/15 ml liquid 500 QL (120 per 30 days) mg/15 ml * mapap 80 mg tablet chew 80 mg * QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) mg * margesic oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml methadone oral solution 10 mg/5 QL (1800 per 30 days) ml, 5 mg/5 ml methadone oral tablet 10 mg (Dolophine) QL (360 per 30 days) methadone oral tablet 5 mg (Dolophine) QL (180 per 30 days) methadose oral tablet,soluble 40 mg QL (90 per 30 days) morphine 10 mg/ml carpuject outer, p/f, l/f, suv 10 mg/ml morphine 2 mg/ml carpuject outer, l/f, p/f, sdv 2 mg/ml morphine 4 mg/ml syringe p/f, latexfree,suv 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml morphine concentrate oral solution QL (180 per 30 days) 100 mg/5 ml (20 mg/ml) morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG 8

25 MORPHINE ORAL TABLET 30 QL (120 per 30 days) MG morphine oral tablet extended QL (60 per 30 days) (MS Contin) release 100 mg, 200 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 30 mg non-aspirin x-str 167 mg/5 ml 500 QL (120 per 30 days) mg/15 ml * nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (120 per 30 days) mg/ml oxycodone oral solution 5 mg/5 ml QL (1300 per 30 days) oxycodone oral tablet 10 mg QL (180 per 30 days) oxycodone oral tablet 15 mg, 30 mg (Roxicodone) QL (120 per 30 days) oxycodone oral tablet 20 mg QL (120 per 30 days) oxycodone oral tablet 5 mg (Roxicodone) QL (180 per 30 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (OxyContin) QL (60 per 30 days) oxycodone oral tablet,oral QL (120 per 30 days) (OxyContin) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral QL (1800 per 30 days) solution mg/5 ml oxycodone-acetaminophen oral QL (240 per 30 days) (Endocet) tablet mg 9

26 oxycodone-acetaminophen oral QL (360 per 30 days) (Percocet) tablet mg oxycodone-acetaminophen oral QL (360 per 30 days) (Endocet) tablet mg oxycodone-acetaminophen oral QL (300 per 30 days) (Percocet) tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) QL (120 per 30 days) oxymorphone oral tablet 5 mg (Opana) QL (180 per 30 days) oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pain relief 500 mg capsule 500 mg * QL (240 per 30 days) pharbetol 325 mg tablet regular QL (360 per 30 days) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) q-pap 160 mg/5 ml solution a/f, QL (240 per 30 days) cherry 160 mg/5 ml * q-pap 325 mg tablet 325 mg * QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) free 500 mg * 10

27 reprexain oral tablet mg, QL (150 per 30 days) mg, mg sm pain rel jr str tab chew 160 mg * QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) children's 80 mg * tactinal 325 mg tablet 325 mg * QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) 500 mg * PA-HRM; QL (180 per tencon oral tablet mg 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg vicodin es oral tablet mg QL (390 per 30 days) vicodin hp oral tablet mg QL (390 per 30 days) vicodin oral tablet mg QL (390 per 30 days) XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG xylon 10 oral tablet mg QL (150 per 30 days) zebutal oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * 11

28 ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg * aspirin 325 mg tablet 325 mg * (Lite Coat Aspirin) aspirin 600 mg suppository 600 mg * aspirin 81 mg chewable tablet 81 mg * (St Joseph Aspirin) aspirin buffered 325 mg tab 325 mg * (Buffered Aspirin) aspirin ec 325 mg tablet 325 mg * (Aspir-Trin) aspirin ec 500 mg tablet 500 mg * aspirin ec 81 mg tablet low dose 81 mg * (Aspir-81) aspir-low ec 81 mg tablet 81 mg * bufferin 325 mg tablet coated 325 mg * CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg (Celebrex) CHILDREN'S ADVIL 100 MG/5 ML (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid filled,softge 200 mg * (Advil Liqui-Gel) diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg (Voltaren-XR) QL (60 per 30 days) 12

29 diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 75) mg-mcg diflunisal oral tablet 500 mg ecotrin ec 325 mg tablet saftey coated 325 mg * ecpirin ec 325 mg tablet 325 mg * etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg gnp ibuprofen jr str 100 mg tb 100 mg * ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children's Advil) ibuprofen 200 mg tablet 200 mg * (Motrin IB) ibuprofen oral suspension 100 mg/5 ml (Children's Advil) ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg QL (240 per 30 days) 13

30 indomethacin oral capsule 50 mg QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) release 75 mg indomethacin sodium intravenous recon soln 1 mg infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * infants' advil 50 mg/1.25 ml 50 mg/1.25 ml * ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral tablet 10 mg QL (20 per 30 days) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg (Anaprox DS) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * 14

31 st. joseph aspirin 81 mg chew orange 81 mg * st. joseph aspirin ec 81 mg tb enteric coated 81 mg * sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 15 mg/ml (1.5 %), 20 mg/ml (2 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 (Xylocaine) mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % PA 15

32 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg buproban oral tablet extended release 12 hr 150 mg bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG (Zyban) CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg (Revia) QL (30 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) 16

33 NARCAN NASAL SPRAY,NON- AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION nicorelief 2 mg gum 2 mg * nicorelief 4 mg gum 4 mg * NICORETTE 2 MG CHEWING GUM WHITE ICE MINT 2 MG * nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr * (Nicoderm CQ) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch outer, clear, step 1 (otc) 21 mg/24 hr * (Nicoderm CQ) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24 hr * (Nicoderm CQ) NICOTROL INHALATION CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents QL (4 per 30 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) 17

34 Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (120 per 30 days) (Xanax) mg, 1 mg alprazolam oral tablet 2 mg (Xanax) QL (150 per 30 days) chlordiazepoxide hcl oral capsule QL (120 per 30 days) 10 mg, 25 mg, 5 mg clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg QL (90 per 30 days) clonazepam oral QL (300 per 30 days) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (180 per 30 days) 15 mg, 3.75 mg clorazepate dipotassium oral tablet QL (180 per 30 days) (Tranxene T-Tab) 7.5 mg diazepam injection solution 5 mg/ml QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, mg (Diastat AcuDial) diazepam rectal kit 2.5 mg (Diastat) lorazepam injection solution 2 QL (2 per 30 days) (Ativan) mg/ml lorazepam oral tablet 0.5 mg, 1 mg (Ativan) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) QL (150 per 30 days) ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) ONFI ORAL TABLET 10 MG, 20 PA NSO; QL (60 per MG 30 days) 18

35 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization (Tobi) 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (BACiiM) chloramphenicol sod succinate intravenous recon soln 1 gram QL (224 per 28 days) 19

36 clindamycin 75 mg/5 ml soln 75 (Clindamycin mg/5 ml Pediatric) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin in 5 % intravenous piggyback 300 mg/50 dextrose) ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution 150 mg/ml (Cleocin) clindamycin phosphate intravenous solution 600 mg/4 ml (Cleocin) colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 (Metro I.V.) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) 20

37 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrodantin) (Macrobid) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg vancomycin hcl 1g/200 ml bag 1 gram/200 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg vancomycin oral capsule 125 mg, 250 mg (Vancocin) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Cephalosporins PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) PA; QL (9 per 30 days) PA 21

38 cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Maxipime) cefepime hcl 2 gram vial latex/f, sdv, (Maxipime) outer 2 gram CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM (Maxipime) CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 gram, 2 gram (Claforan) cefotaxime injection recon soln 500 mg 22

39 cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial l/f, outer, sdv 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg 23

40 cefuroxime sodium injection recon soln 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg (6 pack), 500 mg (3 pack) azithromycin oral tablet 250 mg, 600 mg (Zithromax) 24

41 azithromycin oral tablet 500 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Zithromax TRI- PAK) clarithromycin oral tablet 250 mg clarithromycin oral tablet 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg e.e.s. granules oral suspension for reconstitution 200 mg/5 ml ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 (E.E.S. Granules) mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg (E.E.S. 400) erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram (Azactam) 25

42 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg (Primaxin IV) (Merrem) (Augmentin) (Augmentin ES- 600) (Augmentin) (Augmentin XR) LA 26

43 amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial 10's, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml (Unasyn) 27

44 oxacillin injection recon soln 10 gram, 2 gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 ml (Pfizerpen-G) (Pfizerpen-G) (Zosyn) (Cipro) (Cipro in D5W) 28

45 ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml (Sulfatrim) sulfamethoxazole-trimethoprim oral tablet mg (Bactrim) sulfamethoxazole-trimethoprim oral tablet mg (Bactrim DS) sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed (Azulfidine ENtabs) release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines 29

46 doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg doxycycline monohydrate oral capsule 150 mg doxycycline monohydrate oral capsule 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg Anticancer Agents Anticancer Agents (Doxy-100) (Vibramycin) (Morgidox) (Monodox) (Mondoxyne NL) (Vibramycin) (Avidoxy) (Minocin) (Tygacil) 30

47 ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution 2 mg/ml, 20 mg/10 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALUNBRIG ORAL TABLET 30 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO; QL (180 per 30 days) PA NSO PA NSO PA NSO 31

48 BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 unit (Bleo 15K) bleomycin injection recon soln 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST 32

49 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin 200 mg/100 ml vial latex-free 2 mg/ml doxorubicin intravenous solution 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG (Dacogen) (Adriamycin) (Adriamycin) (Doxil) PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) 33

50 etoposide intravenous solution 20 mg/ml (Toposar) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Adrucil) fluorouracil intravenous solution 1 gram/20 ml fluorouracil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml (Adrucil) flutamide oral capsule 125 mg GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG PA NSO PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) 34

51 ifosfamide 1 gm/20 ml vial sdv,p/f,latex-free 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO 35

52 KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG PA NSO; QL (49 per 28 days) PA NSO; QL (70 per 28 days) PA NSO; QL (91 per 28 days) PA NSO; QL (63 per 28 days) PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO; LA PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) 36

53 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mitoxantrone intravenous concentrate 2 mg/ml QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) ; ST 37

54 NEXAVAR ORAL TABLET 200 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 200 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (120 per 30 days) PA NSO; QL (224 per 28 days) 38

55 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Tepadina) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO 39

56 toposar intravenous solution 20 mg/ml TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR MG VIAL INNER, SDV MG TRELSTAR 22.5 MG SYRINGE OUTER, L/F, SDV 22.5 MG/2 ML TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG QL (1 per 84 days) QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) ; ST PA NSO PA NSO PA NSO; LA; QL (60 per 30 days) PA NSO; LA; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) 40

57 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG (Navelbine) XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics PA NSO; LA; QL (42 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (90 per 30 days) PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) 41

58 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Epitol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote sprinkle 125 mg Sprinkles) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 42

59 divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) ST ST ST 43

60 lamotrigine oral tablets,dose pack (Lamictal Starter 25 mg (35) (Blue) Kit) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg (Roweepra) levetiracetam oral tablet 250 mg, 500 mg, 750 mg (Keppra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg QL (200 per 30 days) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) 44

61 phenytoin sodium extended oral capsule 100 mg phenytoin sodium extended oral capsule 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG (Dilantin Extended) (Phenytek) POTIGA ORAL TABLET 50 MG primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG ST; QL (90 per 30 days) ST; QL (270 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST 45

62 valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg (Zonegran) zonisamide oral capsule 50 mg Antidementia Agents Antidementia Agents ST; QL (200 per 5 days) ST; QL (1200 per 30 days) ST; QL (60 per 30 days) donepezil oral tablet 10 mg, 23 mg, QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- (Namenda Titration QL (49 per 28 days) 10 mg Pak) NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG 46

63 NAMZARIC ORAL QL (56 per 365 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule QL (60 per 30 days) 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 QL (30 per 30 days) hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr (Exelon) Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 ST MG, 20 MG, 5 MG bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 (Wellbutrin SR) mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg (Wellbutrin XL) citalopram oral solution 10 mg/5 ml QL (600 per 30 days) citalopram oral tablet 10 mg, 20 QL (30 per 30 days) (Celexa) mg, 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg (Anafranil) desipramine oral tablet 10 mg, 25 mg (Norpramin) 47

64 desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg (Pristiq) doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Cymbalta) duloxetine oral capsule,delayed release(dr/ec) 30 mg (Cymbalta) duloxetine oral capsule,delayed release(dr/ec) 40 mg (Irenka) EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Sarafem) ST; QL (30 per 30 days) (Cymbalta); QL (60 per 30 days) (Cymbalta); QL (30 per 30 days) (Irenka); QL (30 per 30 days) QL (30 per 30 days) ST ST 48

65 fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 (Tofranil) mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg (Remeron) mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, (Remeron SolTab) 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 (Symbyax) mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg (Paxil) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 (Paxil CR) mg PAXIL ORAL SUSPENSION 10 MG/5 ML 49

66 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg trimipramine oral capsule 100 mg, 25 mg, 50 mg (Surmontil) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 (Effexor XR) mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous ST; QL (30 per 30 days) ST 50

67 acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG (Precose) QL (90 per 30 days) QL (180 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (60 per 30 days) ST; QL (30 per 30 days) ST; QL (30 per 30 days) 51

68 KORLYM ORAL TABLET 300 PA; QL (112 per 28 MG days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended ST; QL (60 per 30 (Fortamet) release 24hr 1,000 mg days) metformin oral tablet extended ST; QL (120 per 30 (Fortamet) release 24hr 500 mg days) miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg pioglitazone-glimepiride oral tablet QL (30 per 30 days) (DUETACT) 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet QL (90 per 30 days) (Actoplus MET) mg, mg repaglinide oral tablet 0.5 mg QL (240 per 30 days) repaglinide oral tablet 1 mg, 2 mg (Prandin) QL (240 per 30 days) repaglinide-metformin oral tablet 1- QL (150 per 30 days) 500 mg, mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) 52

69 SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR ,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML ST; QL (60 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days) QL (24 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) 53

70 NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- QL (240 per 30 days) 250 mg glipizide-metformin oral tablet 2.5- QL (120 per 30 days) 500 mg, mg glyburide micronized oral tablet 1.5 (Glynase) PA-HRM; AGE (Max mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 64 Years) PA-HRM; AGE (Max 64 Years) 54

71 glyburide-metformin oral tablet PA-HRM; AGE (Max mg 64 Years) glyburide-metformin oral tablet 2.5- PA-HRM; AGE (Max (Glucovance) 500 mg, mg 64 Years) tolazamide oral tablet 250 mg QL (120 per 30 days) tolazamide oral tablet 500 mg QL (60 per 30 days) tolbutamide oral tablet 500 mg QL (180 per 30 days) Antifungals Antifungals 3-day vaginal cream 2 % * ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 12's 2 % * AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg anti-fungal 1% powder 1 % * antifungal 2% cream 2 % * baza antifungal 2% cream 12's 2 % * blis-to-sol 1% liquid 1 % * CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG (Loprox (as ciclopirox topical cream 0.77 % olamine)) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Loprox (as % olamine)) clotrim 1% vaginal cream 1 % * (Clotrimazole-7) 55

72 clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) clotrimazole 1% solution (otc) 1 % * clotrimazole insert 100 mg * clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % (Lotrimin AF) clotrimazole topical solution 1 % clotrimazole-7 cream 1 % * clotrimazole-betamethasone topical cream % (Lotrisone) clotrimazole-betamethasone topical lotion % critic-aid clear af 2% oint 12's, w/ antifungal 2 % * cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (Monistat 3) (9 gram) * dermafungal 2% ointment 2 % * econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * fungoid-d 1% cream 1 % * griseofulvin microsize oral tablet 500 mg inzo antifungal 2% cream 2 % * itraconazole oral capsule 100 mg (Sporanox) 56

73 ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % * lamisil af defense 1% powder 1 % * LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * miconazole 3 combo pack 3 sup,9gm crm w/app 200 mg- 2 % (9 gram) * miconazole mg vag supp 100 mg * miconazole nitrate 2% cream 2 % * (Monistat 7) miconazole-3 vaginal suppository 200 mg MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % * NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nyata topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit 57

74 nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram (Nyamyc) nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram pv foot odor control 1% powder 1 % * qc 3 day vaginal 4% cream 200 mg/5 gram (4 %) * ra antifungal 1% liquid spray liquid spray 1 % * remedy phytplx antifungal oint 2 % * terbinafine 1% cream 1 % * (Jock Itch (terbinafine)) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Athlete's Foot (tolnaftate)) tolnaftate 1% solution 1 % * (Formula 3) tolnaftate 1% spray powder 1 % * (Tinactin) triple paste af 2% ointment 2 % * vagistat-3 combo pack 200 mg- 2 % (9 gram) * voriconazole intravenous solution 200 mg (Vfend IV) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) (Vfend) 58

75 voriconazole oral tablet 200 mg, 50 mg Antigout Agents Antigout Agents, Other allopurinol oral tablet 100 mg, 300 (Vfend) mg (Zyloprim) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG ZURAMPIC ORAL TABLET 200 MG Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint 10 mg * alavert d-12 allergy-sinus tab mg * aller-chlor 2 mg/5 ml syrup 2 mg/5 ml * aller-chlor 4 mg tablet 4 mg * allerclear d-12hr tablet mg * allerclear d-24hr er tablet nondrowsy mg * allergy 4 mg tablet 4 mg * aller-tec d mg tablet mg * ambi 60pse-4cpm tablet 4-60 mg * aprodine tablet mg * banophen 25 mg capsule 25 mg * banophen 25 mg tablet 25 mg * QL (30 per 30 days) ST; QL (30 per 30 days) 59

76 banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * benadryl allergy 25 mg ultratb ultratab 25 mg * cetirizine hcl 1 mg/ml soln children, (Children's Allers/f, grape (otc) 1 mg/ml * Tec) cetirizine hcl 10 mg chew tab (Child Allergy children's,outer,u-d 10 mg * Relf(cetirizine)) cetirizine hcl 10 mg tablet 10 mg * (Aller-Tec) cetirizine hcl 5 mg chew tab (Children's children's,outer,u-d 5 mg * Cetirizine) cetirizine-pse er mg tab mg * (Aller-Tec D) child allegra allergy 30 mg/5 ml suspension 30 mg/5 ml * child loratadine 5 mg/5 ml syr (Children's Allergy grape, s/f 5 mg/5 ml * Relief(lor)) child triaminic cold & allergy mg/5 ml * child wal-tap cold-allergy elx mg/5 ml * child wal-zyr 1 mg/ml solution cherry 1 mg/ml * children's wal-fex 30 mg/5 ml 30 mg/5 ml * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * 60

77 CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs cold & cough nighttime liq mg/5 ml * cvs loratadine-d 24hr tablet nondrowsy mg * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f mg/5 ml * dimetapp cold & congest liquid mg/5 ml * diphenhist 12.5 mg/5 ml soln 12.5 mg/5 ml * diphenhist 25 mg capsule 25 mg * diphenhist 25 mg captab captab 25 mg * diphenhydramine 25 mg capsule (otc) 25 mg * (Q-Dryl) diphenhydramine 50 mg capsule (otc) 50 mg * (Sleeping) diphenhydramine hcl injection solution 50 mg/ml ed chlorped jr syrup 2 mg/5 ml * ed-a-hist 4 mg-10 mg tablet 4-10 mg * 61

78 eq allergy relief 25 mg tablet 25 mg * fexofenadine hcl 180 mg tablet 24 hour, non-drowsy (otc) 180 mg * (Wal-Fex Allergy) fexofenadine hcl 30 mg/5 ml 30 (Children's Allergy mg/5 ml * Relief(fex)) fexofenadine hcl 60 mg tablet indoor/outdoor (otc) 60 mg * (Allegra Allergy) hm z-sleep 25 mg softgel 25 mg * hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg levocetirizine oral solution 2.5 mg/5 ml (Xyzal) levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Non-Drowsy Allergy) loratadine-d 12 hour tablet nondrowsy mg * promethazine oral syrup 6.25 mg/5 ml pv nyt-time sleep 25 mg caplet 25 mg * q-dryl 12.5 mg/5 ml liquid a/f,unboxed 12.5 mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * simply sleep 25 mg caplet caplet 25 mg * sleep aid 25 mg tablet 25 mg * PA-HRM; AGE (Max 64 Years) 62

79 sm allergy relief 1.34 mg tab 1.34 mg * sm sinus and allergy tablet maximum strength 4-60 mg * sm z-sleep 50 mg/30 ml liquid berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 mg * unisom 50 mg sleepgels softgel 50 mg * unisom 50 mg/30 ml liquid 50 mg/30 ml * unisom sleep aid 25 mg tablet 25 mg * vicks qlearquil night 25 mg 25 mg * wal-act d cold & allergy tab mg * wal-dryl allergy 12.5 mg/5 ml children,a/f,s/f,d/f 12.5 mg/5 ml * wal-dryl allergy 25 mg capsule 25 mg * wal-dryl allergy 25 mg minitab minitab, coated 25 mg * wal-fex allergy 180 mg tablet 180 mg * wal-fex allergy 60 mg tablet 60 mg * wal-finate 4 mg tablet 4 mg * wal-finate-d tablet 4-60 mg * wal-itin 10 mg odt non-drowsy 10 mg * wal-itin 10 mg tablet non-drowsy,24 hr rlf 10 mg * wal-itin 5 mg/5 ml syrup children's, grape 5 mg/5 ml * wal-itin d 12 hour tablet mg * 63

80 wal-itin d 24 hour tablet mg * wal-phed pe sinus-allergy tab 4-10 mg * wal-phed sinus and allergy tab 4-60 mg * wal-sleep z 25 mg odt 25 mg * wal-sleep z 25 mg softgel 25 mg * wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * wal-som 25 mg odt 25 mg * wal-som 25 mg tablet 25 mg * wal-som 50 mg softgel softgel 50 mg * wal-tap elixir mg/5 ml * wal-zyr 10 mg tablet 10 mg * wal-zyr d tablet 12 hr relief mg * ZYRTEC 10 MG ODT 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Vandazole) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 mg Antimigraine Agents 64

81 Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt-MLT) 10 mg, 5 mg sumatriptan nasal spray,nonaerosol QL (12 per 28 days) 20 mg/actuation, 5 mg/actuation (Imitrex) sumatriptan succinate oral tablet QL (18 per 28 days) (Imitrex) 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous (Imitrex STATdose QL (4 per 28 days) cartridge 4 mg/0.5 ml, 6 mg/0.5 ml Kit Refill) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex STATdose pen injector 4 mg/0.5 ml, 6 mg/0.5 Pen) ml sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) solution 6 mg/0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) syringe 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 QL (12 per 28 days) (Zomig) mg zolmitriptan oral QL (12 per 28 days) (Zomig ZMT) tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg ethambutol oral tablet 100 mg 65

82 ethambutol oral tablet 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 150 mg, 300 mg (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE MG aprepitant oral capsule 125 mg, 40 mg, 80 mg (Emend) aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) (Emend) compro rectal suppository 25 mg cvs motion sickness 50 mg tab 50 mg * cvs motion sickness relief tab chewable tablet 25 mg * dimenhydrinate injection solution 50 mg/ml dramamine 50 mg tablet 50 mg * PA; QL (188 per 168 days) 66

83 dramamine less drowsy 25 mg tb 25 mg * driminate 50 mg tablet 50 mg * dronabinol oral capsule 10 mg, 2.5 PA (Marinol) mg, 5 mg EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 40 MG EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) granisetron hcl oral tablet 1 mg meclizine 12.5 mg caplet caplet (otc) 12.5 mg * meclizine 25 mg tablet (otc) 25 mg * (Motion Relief (meclizine)) meclizine oral tablet 12.5 mg meclizine oral tablet 25 mg (Motion Relief (meclizine)) medi-meclizine 25 mg tablet outer, f/c 25 mg * ondansetron hcl (pf) injection solution 4 mg/2 ml ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl oral solution 4 (Zofran (as mg/5 ml hydrochloride)) ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 (Zofran (as mg hydrochloride)) 67

84 ondansetron oral tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 mg, 25 mg prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral tablet 12.5 mg, 25 mg, 50 mg promethazine rectal suppository 12.5 mg promethazine rectal suppository 25 mg, 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 50 mg ra motion sickness rlf tb chew raspberry flavor 25 mg * TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Zofran ODT) (Compazine) (Compazine) (Phenadoz) (Phenergan) wal-dram 50 mg tablet 50 mg * Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (10 per 30 days) 68

85 atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg (Malarone) atovaquone-proguanil oral tablet (Malarone mg Pediatric) chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG mg/5 ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML benztropine oral tablet 0.5 mg, 1 mg, 2 mg bromocriptine oral capsule 5 mg (Parlodel) PA QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 69

86 bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet mg, mg, mg (Sinemet) carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet mg (Stalevo 50) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 75) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 100) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 125) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 150) carbidopa-levodopa-entacapone (Stalevo 200) oral tablet mg entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg (Mirapex) rasagiline oral tablet 0.5 mg, 1 mg (Azilect) ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg (Requip XL) QL (30 per 30 days) 70

87 selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg trihexyphenidyl oral elixir 0.4 mg/ml trihexyphenidyl oral tablet 2 mg, 5 mg Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 28 days) QL (1 per 28 days) aripiprazole oral solution 1 mg/ml QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution 25 mg/ml 71

88 chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg QL (135 per 30 days) clozapine oral tablet 25 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet 50 mg QL (90 per 30 days) clozapine oral tablet,disintegrating ST 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg (FazaClo) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 ST; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 days) PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR QL (6 per 28 days) RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol dec 50 mg/ml vial 50 mg/ml (Haldol Decanoate) haloperidol decanoate intramuscular solution 100 mg/ml (Haldol Decanoate) haloperidol decanoate intramuscular solution 50 mg/ml (Haldol Decanoate) 72

89 haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG (Haldol) QL (0.75 per 28 days) QL (1 per 28 days) QL (1.5 per 28 days) QL (0.25 per 28 days) QL (0.5 per 28 days) QL (0.875 per 84 days) QL (1.315 per 84 days) QL (1.75 per 84 days) QL (2.625 per 84 days) QL (30 per 30 days) 73

90 loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 10 mg QL (240 per 30 days) molindone oral tablet 25 mg QL (270 per 30 days) molindone oral tablet 5 mg QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 20 mg, 5 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 300 mg, 400 (Seroquel XR) ST; QL (60 per 30 days) mg, 50 mg quetiapine oral tablet extended (Seroquel XR) ST; QL (30 per 30 release 24 hr 200 mg REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (30 per 30 days) 74

91 RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg (Risperdal M- TAB) (Risperdal M- TAB) (Geodon) QL (60 per 30 days) QL (120 per 30 days) ST; QL (60 per 30 days) PA NSO-HRM; AGE (Max 64 Years) ST; QL (540 per 30 days) ST; QL (30 per 30 days) ST; QL (7 per 30 days) QL (60 per 30 days) 75

92 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG (Epzicom) (Trizivir) (Videx EC) QL (2 per 28 days) QL (1 per 28 days) 76

93 EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg (Epivir HBV) lamivudine oral tablet 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG 77

94 lopinavir-ritonavir oral solution mg/5 ml (Kaletra) nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) 78

95 stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZERIT ORAL RECON SOLN 1 MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) 79

96 oseltamivir oral capsule 30 mg (Tamiflu) QL (84 per 180 days) oseltamivir oral capsule 45 mg (Tamiflu) QL (48 per 180 days) oseltamivir oral capsule 75 mg (Tamiflu) QL (42 per 180 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS INTRAMUSCULAR PA SOLUTION 100 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION QL (540 per 180 days) FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 PA; QL (28 per 28 MG, 60 MG, 90 MG days) EPCLUSA ORAL TABLET 400- PA; QL (28 per MG days) HARVONI ORAL TABLET PA; QL (30 per 30 MG days) OLYSIO ORAL CAPSULE 150 PA; QL (28 per 28 MG days) SOVALDI ORAL TABLET 400 PA; QL (28 per 28 MG days) TECHNIVIE ORAL TABLET PA; QL (56 per MG days) VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG PA; QL (112 per 28 days) VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG ZEPATIER ORAL TABLET MG Interferons PA; QL (84 per 28 days) PA; QL (30 per 30 days) 80

97 INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir 1,000 mg/20 ml vial latexfree,sdv 50 mg/ml acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous recon soln 500 mg acyclovir sodium intravenous solution 50 mg/ml adefovir oral tablet 10 mg (Hepsera) PA NSO PA NSO PA NSO; QL (4 per 28 days) 81

98 entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg ganciclovir sodium intravenous recon soln 500 mg (Cytovene) ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg, 400 mg, 600 mg ribavirin inhalation recon soln 6 gram (Virazole) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VEMLIDY ORAL TABLET 25 MG VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml (Lovenox) (Lovenox) (Arixtra) QL (30 per 30 days) QL (24 per 30 days) 82

99 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin 25,000 unit/250 ml (100 unit/ml)-0.45% nacl bag l/f,inner,single-use 25,000 unit/250 ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG (Arixtra) (Arixtra) (Arixtra) (Jantoven) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) PA; QL (24 per 28 days) ST; QL (60 per 30 days) 83

100 XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 84

101 NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg (Agrylin) anagrelide oral capsule 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 (Cyklokapron) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) ST mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg 85

102 EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % QL (30 per 30 days) 86

103 AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 87

104 CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 88

105 CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dex4 glucose 4 gm tablet chew watermelon flavor 4 gram * dex4 glucose 40% gel 40 % * dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe 89

106 dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * glucose 4 gram tablet chew na/f, (TRUEplus caffeine free 4 gram * Glucose) glucose 40% gel tropical fruit 40 % * glutose 15 gel 3 pak, outer, u-d 40 % * HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 90

107 PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr clonidine transdermal patch weekly 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-TTS-1) (Catapres-TTS-2) (Catapres-TTS-3) (Cardura) guanfacine oral tablet 1 mg, 2 mg QL (4 per 28 days) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) 91

108 midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg ENTRESTO ORAL TABLET MG, MG, MG irbesartan oral tablet 150 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg olmesartan oral tablet 20 mg, 40 mg, 5 mg olmesartan-amlodipin-hcthiazid oral tablet mg, mg, mg, mg, mg olmesartan-hydrochlorothiazide oral tablet mg, mg, mg (Vazculep) (Minipress) (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Benicar) (Tribenzor) (Benicar HCT) PA; QL (180 per 30 days) QL (60 per 30 days) 92

109 telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) telmisartan-hydrochlorothiazid oral tablet mg, mg, 80- (Micardis HCT) 25 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg (Diovan) valsartan-hydrochlorothiazide oral tablet mg, mg, 320- (Diovan HCT) 12.5 mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 5 mg benazepril oral tablet 20 mg, 40 mg (Lotensin) benazepril-hydrochlorothiazide oral tablet mg, mg, 20- (Lotensin HCT) 25 mg benazepril-hydrochlorothiazide oral tablet mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg (Vasotec) enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet mg (Vaseretic) enalapril-hydrochlorothiazide oral tablet mg fosinopril oral tablet 10 mg, 20 mg, 40 mg 93

110 fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg, 5 mg (Prinivil) lisinopril oral tablet 2.5 mg, 20 mg, 30 mg, 40 mg (Zestril) lisinopril-hydrochlorothiazide oral tablet mg, mg, 20- (Zestoretic) 25 mg moexipril oral tablet 15 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg QBRELIS ORAL SOLUTION 1 MG/ML quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Accupril) quinapril-hydrochlorothiazide oral tablet mg, mg, 20- (Accuretic) 25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg (Altace) trandolapril oral tablet 1 mg, 2 mg (Mavik) trandolapril oral tablet 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg (Pacerone) disopyramide phosphate oral capsule 100 mg, 150 mg (Norpace) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg (Tikosyn) flecainide oral tablet 100 mg, 150 mg, 50 mg ST 94

111 lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 (Rythmol SR) mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet mg (Tenoretic 100) atenolol-chlorthalidone oral tablet mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg 95

112 bisoprolol fumarate oral tablet 10 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG BYVALSON ORAL TABLET 5-80 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml labetalol oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 (Toprol XL) mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet mg (Lopressor HCT) metoprolol tartrate intravenous solution 5 mg/5 ml (Lopressor) metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 50 mg (Lopressor) metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg pindolol oral tablet 10 mg, 5 mg 96

113 propranolol intravenous solution 1 mg/ml propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 (Inderal LA) mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg sotalol oral tablet 160 mg (Betapace AF) sotalol oral tablet 240 mg (Betapace) sotalol oral tablet 80 mg (Sotalol AF) timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg (Cardizem CD) diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg (Taztia XT) 97

114 diltiazem hcl oral capsule, extended release 360 mg (Tiazac) diltiazem hcl oral capsule, extended release 420 mg (Tiazac) diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg (Cartia XT) diltiazem hcl oral capsule,extended release 24hr 300 mg (Cardizem CD) diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg (Cardizem) diltiazem hcl oral tablet 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 (Matzim LA) mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg (Verelan PM) verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg (Verelan) verapamil oral tablet 120 mg, 80 mg (Calan) verapamil oral tablet 40 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg (Calan SR) 98

115 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG digitek oral tablet 125 mcg digitek oral tablet 250 mcg digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml (Lanoxin) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) 99

116 DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Digitek) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) 100

117 dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) epinephrine hcl (pf) injection solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml epinephrine injection auto-injector 0.15 mg/0.3 ml epinephrine injection auto-injector 0.3 % epinephrine injection auto-injector 0.3 mg/0.3 ml epinephrine injection syringe 0.1 mg/ml FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN ORAL TABLET MCG LANOXIN ORAL TABLET 62.5 MCG (Adrenaclick) (EpiPen Jr 2-Pak) (Adrenaclick) GENERIC FOR ADRENACLICK GENERIC FOR EPIPEN PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (60 per 30 days); AGE (Max 64 Years) 101

118 milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule mg amlodipine-olmesartan oral tablet mg, mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg, mg (Levophed (bitartrate)) (Norvasc) (Lotrel) (Azor) (Exforge) amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) mg CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 102

119 nicardipine oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 60 mg (Afeditab CR) nifedipine oral tablet extended release 90 mg (Adalat CC) Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous recon soln 500 mg (Diuril IV) chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM ORAL CAPSULE 100 MG, 50 MG furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) 103

120 hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg torsemide oral tablet 10 mg, 20 mg (Demadex) torsemide oral tablet 100 mg, 5 mg triamterene-hydrochlorothiazid oral capsule mg (Dyazide) triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet mg (Maxzide-25mg) triamterene-hydrochlorothiazid oral tablet mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg, (Caduet) 5-80 mg amlodipine-atorvastatin oral tablet mg, mg, mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) cholestyramine light oral powder 4 gram 104

121 cholestyramine light oral powder in packet 4 gram cholestyramine packet outer 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * ezetimibe oral tablet 10 mg (Zetia) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG JUXTAPID ORAL CAPSULE 5 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG PA; QL (30 per 30 days) PA; QL (90 per 30 days) PA; QL (45 per 30 days) PA; QL (4 per 28 days) QL (30 per 30 days) 105

122 lovastatin oral tablet 10 mg, 20 mg, 40 mg niacin 50 mg tablet 50 mg * niacin 500 mg capsule sa 500 mg * niacin 500 mg tablet 500 mg * (Niacor) niacin oral tablet extended release (Niaspan 24 hr 1,000 mg, 500 mg, 750 mg Extended-Release) niacin tr 500 mg caplet caplet 500 mg * (Endur-Acin) niacinamide 500 mg tablet 500 mg * (Niacin (niacinamide)) niacor oral tablet 500 mg omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg pravastatin oral tablet 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram prevalite packet outer 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML QL (120 per 30 days) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) 106

123 rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Crestor) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Zocor) simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 QL (240 per 30 days) GRAM VASCEPA ORAL CAPSULE 1 QL (120 per 30 days) GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) TEKAMLO ORAL TABLET 150- ST 10 MG, MG, MG, MG TEKTURNA HCT ORAL TABLET ST MG, MG, MG, MG TEKTURNA ORAL TABLET 150 ST MG, 300 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) isosorbide dinitrate oral tablet extended release 40 mg (ISOCHRON) isosorbide mononitrate oral tablet 10 mg, 20 mg 107

124 isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 mg/hr minoxidil oral tablet 10 mg, 2.5 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat) nitroglycerin transdermal patch 24 hour 0.1 mg/hr (Nitro-Dur) nitroglycerin transdermal patch 24 hour 0.2 mg/hr, 0.6 mg/hr (Minitran) nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Minitran) PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 14 MG, 7 MG QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (28 per 28 days) 108

125 AUSTEDO ORAL TABLET 12 MG, 9 MG AUSTEDO ORAL TABLET 6 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended release 12 hr 0.1 mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Cafcit) (Kapvay) (Focalin) (Dexedrine Spansule) (Dexedrine) (Adderall XR) (Adderall XR) PA; QL (120 per 30 days) PA; QL (60 per 30 days) PA PA PA PA PA QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (60 per 30 days) 109

126 dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG flumazenil intravenous solution 0.1 mg/ml GILENYA ORAL CAPSULE 0.5 MG guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg INGREZZA ORAL CAPSULE 40 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate oral capsule, er biphasic mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg, 40 mg methylphenidate oral capsule,er biphasic mg (Adderall) (Intuniv ER) (Lithobid) (Metadate CD) (Metadate CD) (Ritalin LA) QL (60 per 30 days) PA PA; QL (28 per 28 days) PA; QL (60 per 30 days) PA QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 110

127 methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml (Methylin) methylphenidate oral tablet 10 mg, 20 mg, 5 mg (Ritalin) methylphenidate oral tablet extended release 10 mg methylphenidate oral tablet extended release 20 mg (Metadate ER) methylphenidate oral tablet extended release 24hr 18 mg, 27 (Concerta) mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) NUEDEXTA ORAL CAPSULE MG OCREVUS INTRAVENOUS SOLUTION 30 MG/ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg (Rilutek) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (20 per 180 days) PA PA PA PA PA 111

128 SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Contraceptives Contraceptives altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) apri oral tablet mg QL (60 per 30 days) QL (60 per 30 days) PA; QL (14 per 30 days) PA; QL (60 per 30 days) PA; QL (112 per 28 days) PA; QL (1 per 28 days) QL (91 per 84 days) QL (91 per 84 days) 112

129 aranelle (28) oral tablet 0.5/1/ mg-mcg ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mgmcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg cryselle (28) oral tablet mgmcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg QL (91 per 84 days) QL (91 per 84 days) 113

130 cyred oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg (84)/10 mcg (7) deblitane oral tablet 0.35 mg delyla (28) oral tablet mgmcg desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 (Kariva (28)) desogestrel-ethinyl estradiol oral tablet mg (Emoquette) drospirenone-ethinyl estradiol oral tablet mg (Nikki (28)) drospirenone-ethinyl estradiol oral tablet mg (Ocella) econtra ez 1.5 mg tablet inner 1.5 QL (6 per 365 days) mg * elinest oral tablet mg-mcg ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg (Zovia 1/50E (28)) fallback solo 1.5 mg tablet outer 1.5 QL (6 per 365 days) mg * falmina (28) oral tablet mgmcg 114

131 femynor oral tablet mg-mcg gianvi (28) oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 (21) oral tablet mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) heather oral tablet 0.35 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg jencycla oral tablet 0.35 mg jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg jolivette oral tablet 0.35 mg juleber oral tablet mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mgmcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg QL (91 per 84 days) QL (91 per 84 days) 115

132 kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7) (LoSeasonique) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg- (Daysee) 30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg larin 1/20 (21) oral tablet 1-20 mgmcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) larissia oral tablet mg-mcg leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonor-eth estrad outer (Levora 0.15/ mg (28)) levonorgestrel 1.5 mg tablet (otc) 1.5 mg * (Plan B One-Step) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Lutera (28)) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg- (Quasense) 30 mcg QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) QL (91 per 84 days) 116

133 levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet (6)/75-40 (5)/125-30(10) (Enpresse) levora-28 oral tablet mg lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mgmcg lyza oral tablet 0.35 mg marlissa oral tablet mg microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) mono-linyah oral tablet mgmcg mononessa (28) oral tablet mg-mcg my way 1.5 mg tablet (otc) 1.5 mg * QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet mg-mcg necon 1/35 (28) oral tablet 1-35 mgmcg necon 1/50 (28) oral tablet 1-50 mgmcg 117

134 necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg next choice one dose 1.5 mg tb (otc) 1.5 mg * nikki (28) oral tablet mg nora-be oral tablet 0.35 mg norethindrone (contraceptive) oral tablet 0.35 mg (Norlyroc) norethindrone ac-eth estradiol oral (Microgestin 1/20 tablet 1-20 mg-mcg (21)) norethindrone-e.estradiol-iron oral (Microgestin 24 tablet 1 mg-20 mcg (24)/75 mg (4) FE) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg (Tri-Lo-Marzia) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (Tri-Sprintec (28)) (28) norgestimate-ethinyl estradiol oral tablet mg-mcg (Sprintec (28)) norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg NUVARING VAGINAL RING MG/24 HR ocella oral tablet mg ogestrel (28) oral tablet mgmcg QL (6 per 365 days) ST; QL (1 per 28 days) 118

135 opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) mg * option mg tablet 1.5 mg * QL (6 per 365 days) orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg react 1.5 mg tablet 1.5 mg * QL (6 per 365 days) reclipsen (28) oral tablet mg setlakin oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg sharobel oral tablet 0.35 mg sprintec (28) oral tablet mgmcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 119

136 tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx21 /0.01 mg x 5 vyfemla (28) oral tablet mgmcg wera (28) oral tablet mg-mcg xulane transdermal patch weekly mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mgmcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg Cough And Cold Products Cough And Cold Products QL (3 per 28 days) 120

137 15dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-150gfn-15dm liquid mg/5 ml * 3brm-15dm-30pse liquid mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin peak cld dm max mg/5 ml * adult robitussin peak cold dm nondrowsy mg/5 ml * adult wal-tussin dm max liq a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup a/f,s/f,chry-menthol mg/5 ml * adult wal-tussin liquid 100 mg/5 ml * alka-seltzer plus mucus-conges mg * ambi 10peh-4cpm-20dm tablet mg * ambi 20dm-4cpm tablet 4-20 mg * ambi 40pse-400gfn-20dm tablet mg * ambi 60pse-4cpm-20dm tablet mg * benzonatate 100 mg capsule 100 mg * (Tessalon Perles) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 121

138 benzonatate 200 mg capsule 200 mg * 3 $0 bio-dtuss dmx liquid mg/5 ml * bionel pediatric liquid mg/5 ml * biospec dmx liquid mg/5 ml * bp 8 cough oral suspension a/f, grape (otc) mg/5 ml * bromfed dm cough syrup mg/5 ml * 3 $0 bromphenir-pseudoephed-dm syr (rx) mg/5 ml * (Bromfed DM) 3 $0 brotapp dm liquid mg/5 ml * centergy dm pediatric drops mg/ml * 3 $0 cheratussin ac syrup (otc) mg/5 ml * cheratussin dac syrup mg/5 ml * child plus cough-runny nose cherry flavor mg/5 ml * child robitussin er 30 mg/5 ml 30 mg/5 ml * child sudafed pe cough-cold lq mg/5 ml * child triaminic cgh-congst syr mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f mg/5 ml * children's silfedrine liq 15 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * 122

139 chl mucinex chest congest liq a/f 100 mg/5 ml * codituss dm syrup mg/5 ml * cold multi-symptom day-night pseudoephedrine-free mg * cold multi-symptom night liq a/f, honey lemon mg/15 ml * cold relief multi-symp caplet cplt,12 day,12 night mg * cold-flu relief d/n softgel mg(d)/ mg * cold-flu relief liquid ,000 mg/30 ml * congestac tablet mg * congest-eze mg caplet mg * coricidin hbp cold-multi sympt mg/15 ml * coricidin hbp softgel mg * cough & cold tablet 4-30 mg * cough relief liquid 15 mg/5 ml * cough syrup 200 mg/10 ml 100 mg/5 ml * cvs chest cong relief pe tab mg * cvs chest congest + cough liq mg/5 ml * cvs chest congest relief dm tb mg * cvs child cold-cough day liq mg/5 ml * 123

140 cvs child cough & runny nose mg/5 ml * cvs child cough dm er 30 mg/5 30 mg/5 ml * cvs child's chest congest liq 100 mg/5 ml * cvs cough & sore throat susp mg/5 ml * cvs nighttime cough liquid cherry flavor mg/15 ml * cvs tussin cf liquid a/f, non drowsy mg/5 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq mg/5 ml * daytime cold & cough liquid 1, mg/30 ml * daytime cough liquid a/f, gluten-free 5 mg/5 ml * daytime-nighttime cold-flu liq multisymptom mg/15 ml * daytime-nighttime cough liquid 15mg/15ml(d)/ mg/30ml * delsym cough+chest cngst dm lq mg/5 ml * despec-dm tablet mg * dextromethorphan er 30 mg/5 ml 30 (12-Hour Cough mg/5 ml * Relief) diabetic tussin dm liquid mg/5 ml * diabetic tussin dm max-str liq mg/5 ml * diabetic tussin ex liquid a/f,d/f,na/f,s/f 100 mg/5 ml * 124

141 DIMETAPP LONG-ACTING COUGH LIQ MG/5 ML * ed bron gp liquid mg/5 ml * entre-cough liquid mg/5 ml * expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold mg/5 ml * extra action cough syrup mg/5 ml * flu hbp tablet mg * geri-tussin dm syrup mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * (Coughtab) guaifenesin er 1,200 mg tablet 1,200 (Mucinex) mg * guaifenesin er 600 mg tablet 600 mg * (Mucinex) head congestion day-night pack mg * hydrocodone-chlorphen er susp 10- (Tussionex 8 mg/5 ml * Pennkinetic ER) 3 $0 hydrocodone-homatropine mg tablet mg * (Tussigon) 3 $0 hydrocodone-homatropine syrup 5- (Hydrocodone 1.5 mg/5 ml * Compound) 3 $0 hydromet syrup mg/5 ml * 3 $0 kidkare cough & cold liquid mg/5 ml * liquibid d-r tablet mg * lohist-dm syrup mg/5 ml * 125

142 lortuss ex liquid mg/5 ml * mar-cof bp liquid mg/5 ml * mar-cof cg liquid mg/5 ml * MUCINEX FAST-MAX COLD- FLU-THRT MG * mucinex fast-max dm max liquid maximum strength mg/5 ml * mucus dm mg tablet mg * mucus dm max 1, mg tab 60-1,200 mg * mucus relief 400 mg tablet d/f 400 mg * nasal-sinus decongest tab 30 mg * NEO DM SYRUP MG/5 ML * neo-tuss liquid mg/5 ml * night time cold med liquid mg/15 ml * night time cough & sore throat ,000 mg/30 ml * nohist-dm liquid mg/5 ml * pecgen dmx mg/5 ml liq mg/5 ml * pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * promethazine vc-codeine syrup mg/5 ml * 3 $0 promethazine-codeine syrup mg/5 ml * 3 $0 126

143 promethazine-dm syrup mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * (Nasal Decongestant (pseudoeph)) 3 $0 pseudoephedrine 30 mg tablet 30 mg * (Sudafed) pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * (Sudogest) pv flu relief therapy liquid daytime mg/15 ml * pv night-time softgel multisympt.,softgel mg * pv tussin pe liquid mg/5 ml * ra anti-tussive dm syrup mg/5 ml * ra day cold-flu relief softgel a/f, multi-symptom mg * ra daytime cold-flu liquid a/f,antihist free mg/15 ml * ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * refenesen 400 mg tablet 400 mg * refenesen pe caplet mg * relcof c liquid mg/5 ml * REZIRA SOLUTION 60-5 MG/5 ML * 3 $0 127

144 robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup mg/5 ml * robitussin cough-chest dm liq mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid mg/5 ml * rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * sm adult nasal decongestant lq 15 mg/5 ml * sm cold & cough liquid children's, day time mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * 128

145 sm nite time cold-flu liquid ,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * sm pedia relief liquid mg/5 ml * sm severe cold m-s caplet mg * sm tussin cf syrup mg/5 ml * sudafed 30 mg tablet nondrowsy,max-str 30 mg * sudogest 30 mg tablet boxed 30 mg * sudogest 60 mg tablet 60 mg * suphedrin liquid 15 mg/5 ml * suphedrine pe combo pack cplt mg * triaminic daytime cold-cough children's, cherry mg/5 ml * tusnel diabetic liquid (otc) mg/5 ml * TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * tussin cold-congestion gelcap liquid gelcap mg * tussin dm syrup mg/5 ml * vicks dayquil cough liquid a/f,8 hr rlf 5 mg/5 ml * vicks nature fusion cough liq 5 mg/5 ml * 129

146 vicks nyquil liquicaps cold & flu mg * virtussin ac liquid mg/5 ml * virtussin dac liquid mg/5 ml * v-r infant non-asa cold drp mg/1.6 ml * v-r non-aspirin flu gelcap gelatin caplet mg * v-r pedia relief inf drops decongestant mg/0.8 ml * vr triacting cold-cough liq mg/5 ml * v-r tussin cf syrup mg/5 ml * wal-flu severe cold-cough pckt mg * wal-phed 30 mg tablet non-drowsy 30 mg * wal-phed pe day-night combo pk caplet mg * wal-tussin cough 15 mg softgel 15 mg * wal-tussin max str cough syrup maximum strength 15 mg/5 ml * zephrex-d 30 mg tablet 30 mg * zyncof mg/5 ml liquid mg/5 ml * Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous (Paroex Oral membrane mouthwash 0.12 % Rinse) oralone dental paste 0.1 % 130

147 periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide dental paste 0.1 % (Salagen (pilocarpine)) (Oralone) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% gel 10 % * acne medication 10% lotion 10 % * acne medication 5% gel 5 % * ACNE MEDICATION 5% LOTION 5 % * acyclovir topical ointment 5 % (Zovirax) QL (5 per 4 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * ammonium lactate 12% cream fragrance free (otc) 12 % * (Geri-Hydrolac) ammonium lactate 12% lotion fragrance free (otc) 12 % * (AmLactin) ammonium lactate topical cream 12 % (Geri-Hydrolac) ammonium lactate topical lotion 12 % (AmLactin) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (otc) 10 % * (Acne Medication) benzoyl peroxide 5% gel aqueous (otc) 5 % * (BP) 131

148 BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram (Vectical) CASTELLANI PAINT 1.5% COLORLESS 1.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 PA MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 PA MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN PA SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS PA SYRINGE 150 MG/ML cutter backwoods 25% spray 25 % * QL (340 per 180 days) cutter skinsations 7% spray 7 % * QL (354 per 180 days) cvs skin treatment body lotion 12 % * diclofenac sodium topical gel 3 % (Solaraze) DUPIXENT SUBCUTANEOUS PA SYRINGE 300 MG/2 ML fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % geri-hydrolac 12% lotion 12 % * geri-hydrolac 5% lotion 5 % * 132

149 imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) INSECT REPELLENT 20% QL (236 per 180 days) SPRAY 20 % * LACTINOL HX CREAM * lobana bath oil * methoxsalen oral capsule,liqdfilled,rapid rel 10 mg (Oxsoralen Ultra) NATRAPEL 20% SPRAY 20 % * QL (354 per 180 days) off active 15% spray 15 % * QL (340 per 180 days) off deep woods 25% spray 25 % * QL (340 per 180 days) off deep woods dry 25% spray 25 % QL (226 per 180 days) * off familycare 15% rplnt i spr 15 % QL (142 per 180 days) * PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 % * PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox topical solution 0.5 % (Condylox) potassium hydroxide topical solution 5 % pv acne pimple 10% gel 10 % * repel sportsmen 25% spray 25 % * QL (368 per 180 days) repel sportsmen max 40% spray 40 QL (368 per 180 days) % * SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SILIQ SUBCUTANEOUS PA SYRINGE 210 MG/1.5 ML TALTZ 80 MG/ML PA AUTOINJECTOR P/F,L/F,SDV,OUTER 80 MG/ML 133

150 TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg zinc oxide 20% ointment 20 % * Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitraycin Plus) bacitraycin plus 500 unit/gm 500 unit/gram * clindamycin phosphate topical gel 1 % (Clindagel) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Clindacin P) cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % (Ery Pads) gentamicin topical cream 0.1 % PA PA 134

151 gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin GU solution 40 mg-200,000 unit/ml Irrigant) neosporin ointment 3.5mg-400 unit- 5,000 unit/gram * rosadan topical cream 0.75 % selenium sulfide topical lotion 2.5 % silver nitrate topical ointment 10 % silver nitrate topical solution 10 %, 25 %, 50 % silver sulfadiazine topical cream 1 % (Thermazene) ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % (Klaron) triple antibiotic ointment 3.5mg-400 unit- 5,000 unit/gram * Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % ala-scalp topical lotion 2 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % anti-itch 1% lotion 1 % * aquanil hc 1% lotion 1 % * beta hc 1% lotion 1 % * 135

152 betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.12 % (Luxiq) betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % (Diprolene AF) betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % (Diprolene) clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Cormax) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % clocortolone pivalate topical cream 0.1 % (Cloderm) cormax scalp solution 0.05 % 136

153 cortaid 1% cream 12 hr, anti-itch 1 % * cortizone-10 1% creme 1 % * cortizone-10 1% creme maximum strength 1 % * cortizone-10 1% ointment 1 % * dermarest eczema 1% lotion 1 % * desonide topical cream 0.05 % (Tridesilon) desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % EUCRISA TOPICAL OINTMENT 2 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical cream 0.05 % (Ultravate) halobetasol propionate topical ointment 0.05 % (Ultravate) hydro skin 1% lotion 1 % * hydrocortisone 0.5% cream (otc) 0.5 % * hydrocortisone 0.5% ointment 0.5 % * 137

154 hydrocortisone 1% cream maximum (Hydrocream) strength (otc) 1 % * hydrocortisone 1% cream maximum strength 1 % * hydrocortisone 1% lotion (otc) 1 % (Cortisone * (hydrocortisone)) hydrocortisone 1% ointment carton (Anti-Itch (HC)) (otc) 1 % * hydrocortisone buty 0.1% cream 0.1 (Locoid) % hydrocortisone butyrate topical (Locoid) ointment 0.1 % hydrocortisone butyrate topical (Locoid) solution 0.1 % hydrocortisone topical cream 1 % (Hydrocream) hydrocortisone topical cream 2.5 % (Ala-Cort) hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % neosporin 1% anti-itch cream 1 % * prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 (Dermatop) % preparation h hc 1% cream 1 % * hydrocortisone butyr-emollient (Locoid topical cream 0.1 % Lipocream) 138

155 procto-med hc topical cream with perineal applicator 2.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % recort plus 1% cream 1 % * tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical cream %, 0.5 % triamcinolone acetonide topical cream 0.1 % (Triderm) triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex topical ointment 0.05 % tridesilon topical cream 0.05 % u-cort topical cream 1-10 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tazarotene topical cream 0.1 % (Tazorac) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel (Retin-A Micro PA with pump 0.04 %, 0.1 % Pump) tretinoin topical cream %, PA (Retin-A) 0.05 %, 0.1 % 139

156 tretinoin topical gel 0.01 %, PA (Retin-A) % tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * cvs permethrin 1% lotion 1 % * (Nix Creme Rinse) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * sm lice treatment 1% crm rinse 1 % * v-r lice cream rinse 1 % * Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 6MMX31G 0.3 ML 31 GAUGE X 15/64" BD INSULIN SYR 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64" BD INSULIN SYR 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" BLADDER CONTROL PAD X- LONG 9'S,X-LONG * 140

157 GAUZE PAD TOPICAL BANDAGE 2 X 2 " GAUZE PADS, STERILE 2"X2" 2 X 2 " INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29 GAUGE INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 1 ML 29 GAUGE X 1/2" INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" (Ultilet Insulin Syringe) (TRUEplus Insulin) (Lite Touch Insulin Syringe) (incontrol Pen Needle) VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT 141

158 ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG PA PA; LA PA QL (90 per 30 days) 142

159 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % altacaine ophthalmic drops 0.5 % altamist 0.65% nose spray 0.65 % * apraclonidine ophthalmic drops 0.5 (Iopidine) % artificial tears * artificial tears 1.4 % drops 1.4 % * artificial tears drops p/f, sterile % * artificial tears eye drops strl % * ARTIFICIAL TEARS EYE OINTMENT % * atropine ophthalmic drops 1 % ayr saline 0.65% nose drops 0.65 % * ayr saline 0.65% nose spray 0.65 % * azelastine nasal aerosol,spray 137 mcg (0.1 %) QL (30 per 25 days) 143

160 azelastine ophthalmic drops 0.05 % bion tears eye drops % * carteolol ophthalmic drops 1 % cromolyn ophthalmic drops 4 % cvs artificial tears drops sterile % * cvs lubricant 0.6% eye drops 0.6 % * cvs lubricant dry eye rlf 1% 1 % * cvs lubricant eye ointment p/f % * cvs lubricant gel eye drops % * cvs lubricating eye drops dry eye soln % * cvs nasal spray 0.05% 0.05 % * cvs saline 0.65% nose spray 0.65 % * cyclopentolate ophthalmic drops 0.5 %, 1 %, 2 % (Cyclogyl) CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * dristan long lasting mist 0.05 % * epinastine ophthalmic drops 0.05 % (Elestat) eq gentle 0.3% eye drops 0.3 % * eq revive plus 0.5% eye drops 0.5 % * flucaine ophthalmic drops % GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * 144

161 GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * GENTEAL TEARS 0.1%-0.2%- 0.3% % * genteal tears 0.1%-0.3% drop % * homatropaire ophthalmic drops 5 % homatropine hbr ophthalmic drops 5 % (Homatropaire) ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % isopto tears 0.5% eye drops 0.5 % * LACRISERT OPHTHALMIC INSERT 5 MG little remedies stuffy nose kt w/ nasal aspirator 0.65 % * lubricant % eye drops % * lubricant % eye drops % * lubricating plus 0.5% eye drps p/f, 30x0.4ml 0.5 % * lubrifresh pm eye ointment % * mucinex sinus-max nasal spray full force 0.05 % * muro-128 2% eye drops 2 % * muro-128 5% eye drops 5 % * muro-128 5% eye ointment 5 % * naphazoline ophthalmic drops 0.1 % natural balance tears drops 0.4 % * natural balance tears eye drop % * QL (30 per 28 days) QL (15 per 10 days) 145

162 nature's tears drops 0.4 % * neo-synephrine 12 hour spray 0.05 % * ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0.1 % (Patanol) OTOVEL OTIC SOLUTION % (0.25 ML) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops 10 %, 2.5 % proparacaine ophthalmic drops 0.5 % pure & gentle eye drops lubricant 0.3 % * pv artificial tears 0.4 % * pv lubricant 1.4 % eye drops 1.4 % * pv pure-gentle eye drops sterile 0.3 % * REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * retaine cmc 0.5% eye drops 0.5 % * retaine hpmc 0.3% eye drops 0.3 % * retaine pm eye ointment % * sea soft 0.65% nasal mist 0.65 % * sm lubricant eye drops strl % * sochlor 5% eye drops 5 % * sodium chloride 5% eye drop 5 % * (Altachlore) ST 146

163 sodium chloride 5% eye oint 5 % * (Altachlore) soothe night time lub eye oint % * SYSTANE 0.3% EYE GEL 0.3 % * SYSTANE GEL EYE DROPS % * tears again 1.4 % drops 1.4 % * tears again eye ointment % * tears naturale free drops u- d,36x.9ml,p/f % * ultra fresh pm ointment * vicks qlearquil 0.05% mist 0.05 % * vicks sinex 12 hour spray 0.05 % * Eye, Ear, Nose, Throat Anti- Infectives Agents acetic acid otic solution 2 % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram (Polycin) bleph-10 ophthalmic drops 10 % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) 147

164 gentamicin ophthalmic drops 0.3 % gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Gentak) levofloxacin ophthalmic drops 0.5 % MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic ointment ,000 (Neo-Polycin HC) mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 (Neo-Polycin) mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension (Maxitrol) 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin (neopolym-gramicid)) ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension , mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-1% 148

165 neo-polycin ophthalmic ointment ,000 mg-unit-unit/g ofloxacin ophthalmic drops 0.3 % (Ocuflox) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 (Polytrim) mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic drops 10 % (Bleph-10) sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension (TobraDex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti- Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % ST 149

166 bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0.1 % (FML Liquifilm) flurbiprofen sodium ophthalmic drops 0.03 % (Ocufen) fluticasone nasal spray,suspension (Flonase Allergy 50 mcg/actuation Relief) ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 % (Acular LS) ketorolac ophthalmic drops 0.5 % (Acular) LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % (Pred Forte) prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS MULTIDOSE OPHTHALMIC DROPS 0.05 % QL (50 per 25 days) QL (5.5 per 30 days) 150

167 RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * cvs gas relief 125 mg chew tab extra strength 125 mg * cvs gas relief 125 mg softgel softgel 125 mg * cvs gas relief 80 mg tab chew 80 mg * gas relief 125 mg chew tablet max str,lactose-free 125 mg * gas relief 20 mg/0.3 ml drops dyefree 40 mg/0.6 ml * gas relief 80 tablet chew 80 mg * gas-x ultra strength softgel 180 mg * mi-acid gas 80 mg tab chew 80 mg * mytab gas 80 mg tablet chew 80 mg * mytab gas max str 125 mg tab 125 mg * simethicone 180 mg softgel 180 mg (Gas-X Ultra- * Strength) v-r anti-gas 166 mg softgel 166 mg * Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * amoxicil-clarithromy-lansopraz oral combo pack mg (Prevpac) QL (60 per 30 days) 151

168 CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg (Heartburn Relief (cimetidine)) cimetidine oral tablet 300 mg, 400 mg, 800 mg cvs acid reducer 150 mg tablet maximum strength 150 mg * cvs cimetidine 200 mg tablet (otc) (Heartburn Relief 200 mg * (cimetidine)) esomeprazole sodium intravenous recon soln 20 mg esomeprazole sodium intravenous recon soln 40 mg (Nexium IV) famotidine (pf) intravenous solution 20 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml famotidine 20 mg/2 ml vial latexfree, p/f, sdv 20 mg/2 ml famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml famotidine oral tablet 20 mg (Heartburn Prevention) famotidine oral tablet 40 mg (Pepcid) gnp acid reducer 10 mg tablet 10 mg * lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24Hr) lansoprazole oral capsule,delayed release(dr/ec) 15 mg (Prevacid 24Hr) lansoprazole oral capsule,delayed release(dr/ec) 30 mg (Prevacid) 152

169 misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * omeprazole mag dr 20.6 mg cap two 14-days course 20 mg * omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole intravenous recon soln (Protonix) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max (Heartburn strength (otc) 20 mg * Prevention) pv acid relief 200 mg tablet 200 mg * ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Wal-Zan 75) ranitidine hcl injection solution 25 mg/ml, 50 mg/2 ml (25 mg/ml) (Zantac) ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg (Heartburn Relief (ranitidine)) ranitidine hcl oral tablet 300 mg (Zantac) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * zantac 75 mg tablet 75 mg * Gastrointestinal Agents, Other acid gone antacid liquid mg/15 ml * almacone liquid mg/5 ml * 153

170 almacone-2 liquid mg/5 ml * aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol 525 mg/30 ml susp 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * calcium antacid 750 mg tb chew gluten-free 300 mg (750 mg) * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * comfort gel suspension regular str, cherry mg/5 ml * (Calcium 500) QL (60 per 30 days) 154

171 constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) cvs antacid ultra tab chew ultra strength 400 mg calcium (1,000 mg) * cvs antacid-antigas tab chew 1, mg * cvs anti-diarrheal 2 mg sftgel softgel 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * cvs flavor chew antacid 750 mg 300 mg (750 mg) * cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Imodium A-D) diamode 2 mg tablet outer, f/c 2 mg * dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg (Lomotil) enulose oral solution 10 gram/15 ml foaming antacid liquid mg/15 ml * GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG PA PA 155

172 gelusil antacid & antigas liq mg/5 ml * gelusil tablet chewable cool mint mg * generlac oral solution 10 gram/15 ml geri-lanta liquid mg/5 ml * glycopyrrolate injection solution 0.2 mg/ml (Robinul) glycopyrrolate oral tablet 1 mg (Robinul) glycopyrrolate oral tablet 2 mg (Robinul Forte) imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * imodium a-d 2 mg softgel 2 mg * kaopectate 262 mg/15 ml susp 262 mg/15 ml * kionex 15 gm/60 ml suspension gram/60 ml kionex oral powder lactulose oral solution 10 gram/15 ml (Enulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG loperamide 1 mg/5 ml liquid 1 mg/5 (Anti-Diarrheal ml * (loperamide)) loperamide 1 mg/7.5 ml susp mint 1 mg/7.5 ml * (Imodium A-D) loperamide oral capsule 2 mg (Imodium A-D) maalox advanced suspension regular strength mg/5 ml * magnesium 250 mg tablet p/f 250 mg * QL (30 per 30 days) 156

173 magnesium 400 mg tablet glutenfree 400 mg * (MgO) magnesium oxide 500 mg capsule 500 mg * magnesium oxide 500 mg tablet p/f,s/f,lactose-free 500 mg * (Phillips) magnesium-oxide 400 mg tablet 241.3mg elemental 400 mg * (MgO) masanti liquid mg/5 ml * medi-first pep-t-med tab chew 262 mg * methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg (Reglan) mgo 400 mg tablet 400 mg * mi acid suspension mg/5 ml, mg/5 ml * mi-acid ds tablet mg * mintox maximum strength susp max str, lemon creme mg/5 ml * mintox plus tablet chewable mg * mintox suspension mint creme mg/5 ml * MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM QL (30 per 30 days) 157

174 OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * pink bismuth tablet chew 262 mg * ra magnesium 500 mg capsule 500 mg * RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension mg/5 ml * riginic suspension mg/5 ml * ri-mox suspension mg/5 ml * sm antacid anti-gas liquid mg/5 ml * sm foaming antacid tablet chew mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 10 gr 650 mg * sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 158

175 soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps (with sorbitol) oral suspension gram/60 ml ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg (URSO 250) ursodiol oral tablet 500 mg (URSO Forte) VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 MG XERMELO ORAL TABLET 250 MG Laxatives alophen pills 5 mg * bisac-evac 10 mg suppository 10 mg * bisacodyl 10 mg suppository 10 mg * (Biscolax) bisacodyl ec 5 mg tablet 5 mg * (Fleet Laxative) biscolax 10 mg suppository 10 mg * clearlax powder 14 once-daily doses 17 gram/dose * cvs enema disposable 19-7 gram/118 ml * cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * cvs kids 100 mg mini enema 100 mg/5 ml * cvs purelax powder 17 gram/dose * cvs purelax powder packet s/f, 10 daily doses 17 gram * doc-q-lace 100 mg softgel 100 mg * QL (30 per 30 days) ST; QL (60 per 30 days) PA; QL (90 per 30 days) 159

176 docu liquid 50 mg/5 ml 50 mg/5 ml * docusate sodium 100 mg tablet crushable 100 mg * (Move It Along) docusate sodium-senna tablet mg * docusol mini-enema outer 283 mg * dok 100 mg softgel softgel 100 mg * dok 100 mg tablet 100 mg * dulcolax ss 100 mg softgel 100 mg * enema disposable 19-7 gram/118 ml * enema ready to use latex-free 19-7 gram/118 ml * enemeez mini enema 5cc tubes, outer 283 mg/5 ml * enemeez plus mini enema outer mg/5 ml * eq fiber therapy powder * eql fiber therapy powder 3.4 gram/7 gram * equalactin 500 mg tab chew 500 mg * evac-u-gen 8.6 mg tablet 8.6 mg * fiber tablet unboxed 625 mg * fiber therapy powder 2 gram/19 gram * fiber-lax captabs 500mg polycarbophil 625 mg * FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram 160

177 gavilyte-n oral recon soln 420 gram glycolax powder 31 doses (otc) 17 gram/dose * healthylax powder packet 14x17gm, outer 17 gram * hydrocil instant packet * KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f 625 mg * konsyl psyllium fiber packet orange, gluten free 3.4 gram * kro gentlelax 17 gram powder 17 gram/dose * magic bullet 10 mg suppos 10 mg * milk of magnesia suspension 400 mg/5 ml * mineral oil laxative * MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * oral saline laxative liquid s/f, ginger lemon gram/15 ml * peg 3350-electrolytes oral recon soln gram (GaviLyte-G) peg 3350-electrolytes oral recon (Colyte with Flavor soln gram Packs) peg-electrolyte soln oral recon soln 420 gram (GaviLyte-N) peri-colace tablet mg * phillips' lax liqui-gels 100 mg * phosphate oral saline laxative s/f, ginger lemon gram/15 ml * polyethylene glycol 3350 oral powder 17 gram/dose (GlycoLax) 161

178 polyethylene glycol 3350 oral powder in packet 17 gram (Gavilax) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (GlycoLax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Gavilax) polyethylene glycol 3350 powd outer (otc) 17 gram * (Gavilax) promolaxin 100 mg tablet 100 mg * pv fiber therapy powder * pv senna 8.6 mg softgel 8.6 mg * qc mineral oil heavy * (Mineral Oil Heavy) qc natura-lax 17 gm powder 17 gram/dose * ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * reguloid powder * senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * senexon tablet 8.6 mg * senna 8.6 mg tablet 8.6 mg * senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * senna-lax 8.6 mg tablet 8.6 mg * senokot-s tablet mg * silace 50 mg/5 ml liquid 50 mg/5 ml * silace 60 mg/15 ml syrup 60 mg/15 ml * sm fiber laxative 500 mg cplt 500 mg * 162

179 sm fiber smooth powder * smoothlax powder packet s/f, 10 daily doses 17 gram * stool softener 240 mg softgel softgel 240 mg * SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg (Eliphos) eliphos oral tablet 667 mg magnebind 400 oral tablet mg PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG VELPHORO ORAL TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG (Urecholine) 163

180 oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 (Ditropan XL) mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg (Uroxatral) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule,extended release 24hr 0.4 mg (Flomax) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG deferoxamine injection recon soln 2 gram, 500 mg (Desferal) QL (30 per 30 days) 164

181 DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 10 mg danazol oral capsule 100 mg, 200 mg, 50 mg oxandrolone oral tablet 10 mg, 2.5 (Oxandrin) mg testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (Depo- Testosterone) PA PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) PA 165

182 testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr estradiol transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml (Vogelxo) (Vogelxo) (AndroGel) (Vogelxo) (Estrace) (Vivelle-Dot) (Minivelle) (Climara) (Delestrogen) PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) 166

183 estradiol-norethindrone acet oral tablet mg estradiol-norethindrone acet oral tablet mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG (Mimvey Lo) (Mimvey) mimvey lo oral tablet mg mimvey oral tablet mg PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, PA-HRM; AGE (Max 64 Years) 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET PA-HRM; AGE (Max MG (14)/ 0.625MG-5MG(14) 64 Years) PREMPRO ORAL TABLET MG, MG, MG, MG PA-HRM; AGE (Max 64 Years) raloxifene oral tablet 60 mg (Evista) yuvafem vaginal tablet 10 mcg QL (18 per 28 days) Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 mg betamethasone acet,sod phos (Celestone injection suspension 6 mg/ml Soluspan) cortisone oral tablet 25 mg 167

184 dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml EMFLAZA ORAL SUSPENSION MG/ML EMFLAZA ORAL TABLET 18 MG EMFLAZA ORAL TABLET 30 MG, 6 MG EMFLAZA ORAL TABLET 36 MG fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 (Depo-Medrol) mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg (Medrol) methylprednisolone oral tablets,dose pack 4 mg (Medrol (Pak)) methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 (Pediapred) ml) PA PA; QL (30 per 30 days) PA; QL (60 per 30 days) PA 168

185 prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 2.5 mg, 5 mg, 50 mg prednisone oral tablet 10 mg prednisone oral tablet 20 mg (Deltasone) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML Pituitary desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0.1 QL (15 per 30 days) (DDAVP) mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) QL (15 per 30 days) desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) GENOTROPIN MINIQUICK PA SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS PA CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION PA CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION PA RECON SOLN 5 (15 UNIT) MG 169

186 INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml (Sandostatin) (Sandostatin) QL (1 per 84 days) PA PA PA 170

187 OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml PA PA PA PA PA QL (1 per 28 days) QL (1 per 360 days) PA PA QL (10 per 28 days) PA NSO 171

188 medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 112 mcg, 300 mcg, 50 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Depo-Provera) (Depo-Provera) (Provera) (Megace) (Megace ES) (Aygestin) (Prometrium) (Levoxyl) (Unithroid) (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg Immunological Agents Immunological Agents QL (1 per 84 days) QL (1 per 84 days) 172

189 ACTEMRA INTRAVENOUS PA SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS PA SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon soln 100 mg CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) 250 mg/5 ml cyclosporine modified oral capsule (Neoral) 100 mg, 25 mg cyclosporine modified oral capsule (Gengraf) 50 mg cyclosporine modified oral solution (Neoral) 100 mg/ml cyclosporine oral capsule 100 mg, (Sandimmune) 25 mg 173

190 ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE, % RANGE (10 ML), % RANGE (2 ML) GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 10 % gengraf oral capsule 100 mg, 25 mg, 50 mg gengraf oral solution 100 mg/ml HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) PA 174

191 HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML PA PA PA PA PA PA 175

192 IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil hcl intravenous recon soln 500 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML (Arava) (CellCept Intravenous) (CellCept) (CellCept) (CellCept) (Myfortic) OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PA; QL (18.76 per 28 days) PA PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 176

193 OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg STELARA INTRAVENOUS SOLUTION 130 MG/26 ML (Rapamune) PA PA PA PA 177

194 STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML (Prograf) XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML PA PA; LA; QL (15 per 28 days) PA; QL (60 per 30 days) PA; QL (30 per 30 days) 178

195 BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 179

196 GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML QL (1.5 per 365 days) 180

197 MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML QL (2 per 365 days) QL (2 per 365 days) 181

198 RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML 182

199 TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) QL (2 per 365 days) QL (1 per 365 days) 183

200 APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) colocort rectal enema 100 mg/60 ml DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG hydrocortisone rectal enema 100 mg/60 ml (Colocort) LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 800 mg (Asacol HD) UCERIS RECTAL FOAM 2 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % LACTATED RINGERS IRRIGATION SOLUTION ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Sterile Saline) sorbitol irrigation solution 3 %, 3.3 % sorbitol-mannitol urethral solution g/100 ml ST 184

201 water for irrigation, sterile irrigation solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 (Curity Sterile Water) QL (300 per 28 days) ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg QL (4 per 28 days) alendronate oral tablet 70 mg (Fosamax) QL (4 per 28 days) calcitonin (salmon) nasal QL (3.7 per 28 days) spray,non-aerosol 200 unit/actuation (Miacalcin) calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Hectorol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML PA; QL (2.4 per 28 days) FORTICAL NASAL SPRAY,NON- QL (3.7 per 28 days) AEROSOL 200 UNIT/ACTUATION ibandronate intravenous solution 3 QL (3 per 84 days) mg/3 ml ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) 185

202 MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol hemodialysis port injection solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol intravenous solution 2 mcg/ml (Zemplar) paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML RAYALDEE ORAL QL (60 per 30 days) CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 30 days) TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 PA; QL (1.56 per 30 days) MCG/1.56 ML) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml (Zometa) zoledronic acid-mannitol-water QL (100 per 300 days) (Reclast) intravenous piggyback 5 mg/100 ml 186

203 zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 mg BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG (Ethyol) CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) fomepizole intravenous solution 1 gram/ml GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG PA PA PA; LA 187

204 GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg (Vistaril) INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEVEYIS ORAL TABLET 50 MG leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution 100 mg/ml (Carnitor) levocarnitine oral tablet 330 mg (Carnitor) LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MINERAL OIL HEAVY * (Muri-Lube) ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML PA PA; QL (120 per 30 days) PA 188

205 PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet (Mestinon extended release 180 mg Timespan) ra feminine care douche * REMICADE INTRAVENOUS RECON SOLN 100 MG sb disp douche extra clns v&w * SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) summer's eve dche-xtra clns 12's,extra-cleansing * summer's eve douche-ultra clns 12's,2pk,ultra clns * SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG PA QL (60 per 30 days) PA NSO; QL (60 per 30 days) THIOLA ORAL TABLET 100 MG TYBOST ORAL TABLET 150 MG QL (30 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg (Diamox Sequels) 189

206 acetazolamide sodium injection recon soln 500 mg ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % bimatoprost ophthalmic drops 0.03 % brimonidine ophthalmic drops 0.15 % (Alphagan P) brimonidine ophthalmic drops 0.2 % COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) QL (2.5 per 25 days) 190

207 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium +d & min chew tab 600 mg (1,500 mg)-400 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg calcium (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated mg-unit * (Timoptic-XE) (Calcium D) (Calcium 600 with Vitamin D3) (Calcium 600 with Vitamin D3) (Calcium Citrate + D) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (30 per 30 days) 191

208 calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate 648 mg tab 61 mg (648 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * CALTRATE D SOFT CHEW TAB CHOCOLATE TRUFFLE 600 MG (1,500 MG)-800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * cvs calcium citrate-vit d tab (Citrus Calcium) mg-unit * cvs magnesium 250 mg tablet 250 mg * cvs pediatric electrolyte soln * cvs pediatric electrolyte soln a/f, p/f * d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution 192

209 dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql cal 600-vit d3-min chew tb 600 mg (1,500 mg)-400 unit * eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION kcl 10 meq in d5w-0.3% nacl singleuse 20 meq/l 193

210 KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq liquid calcium 600-vit d3 sfgl 600 mg(1,500mg) -400 unit * liquid calcium 600-vit d3 sfgl softgel,p/f,gluten-f 600 mg(1,500mg) -500 unit * liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 unit * mag delay dr 70 mg tablet 70 mg * mag64 dr 64 mg tablet 64 mg * mag-g 500 mg tablet 27 mg (500 mg) * magnesium 250 mg tablet 250 mg * magnesium 300 mg capsule 300 mg * magnesium gluc 500 mg tablet 27 mg (500 mg) * (Mag-G) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) 194

211 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION L/F, SINGLE-USE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 71.5 mg tablet 71.5 mg * oralyte freezer pops * oralyte solution * oysco-500 tablet 500 mg calcium (1,250 mg) * oyster shell calcium 500 mg tb 500mg elemental ca 500 mg calcium (1,250 mg) * oyster shell calcium-vit d tab 500 mg(1,250mg) -200 unit * pediatric electrolyte solution * PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION 195

212 PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet extended release 20 meq potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con Sprinkle) (Klor-Con) (K-Tab) (K-Tab) (Klor-Con M10) 196

213 potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg) potassium citrate oral tablet extended release 15 meq potassium citrate oral tablet extended release 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg potassium cl 10 meq/50 ml sol single use 10 meq/50 ml potassium cl 20 meq/50 ml sol single use 20 meq/50 ml potassium cl er 20 meq tablet microencapsulated 20 meq ra cal 600-vit d3-min chew tab 600 mg calcium- 400 unit-40 mg * ra oyster shell-vitamin d tab s/f, p/f (Urocit-K 10) (Urocit-K 15) (Urocit-K 5) (Cytra K Crystals) (Klor-Con M20) 250 (625)-125 mg-unit * ra pediatric electrolyte soln a/f * ra pediatric freezer pops * ringer's intravenous parenteral solution 197

214 sm calcium citrate-vit d cplt caplet, gluten-free mg-unit * (Citrus Calcium) sm magnesium 250 mg tablet 250 mg * sm pediatric electrolyte soln * sodium acetate intravenous solution 2 meq/ml sodium bicarbonate intravenous syringe 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids 198

215 ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION (Pulmicort) QL (60 per 30 days) QL (12 per 28 days) QL (30 per 30 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) 199

216 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION QL (21.2 per 28 days) QL (17.4 per 25 days) QL (12 per 25 days) QL (11 per 25 days) QL (60 per 30 days) 200

217 ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION QL (25.8 per 28 days) QL (8 per 30 days) QL (60 per 30 days) QL (4 per 28 days) 201

218 STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 (Theochron) mg theophylline oral tablet extended release 12 hr 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Acetadote) acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * (Nasalcrom) QL (4 per 28 days) PA 202

219 DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG ESBRIET ORAL TABLET 267 MG ESBRIET ORAL TABLET 801 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet 250 mg, 350 mg (Soma) chlorzoxazone oral tablet 500 mg (Parafon Forte DSC) cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (270 per 30 days) PA; QL (90 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA; QL (60 per 30 days) PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 203

220 dantrolene oral capsule 25 mg, 50 mg (Dantrium) metaxall oral tablet 800 mg metaxalone oral tablet 400 mg metaxalone oral tablet 800 mg (Metaxall) methocarbamol oral tablet 500 mg (Robaxin) methocarbamol oral tablet 750 mg (Robaxin-750) revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Nuvigil) (Lunesta) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) 204

221 HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG SILENOR ORAL TABLET 3 MG, 6 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) zolpidem oral tablet 10 mg, 5 mg (Ambien) PA; QL (30 per 30 days) QL (30 per 30 days) LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) 205

222 zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) 206

223 TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z advanced formula tab w/ lutein & lycopene mg-mcg-mcg-mcg * a thru z select 50+ formula tb advanced formula mgmcg-mcg * a thru z select men 50+ tablet mcg * a thru z select multivit tab mcg * a thru z select multivit tab iron-free, 50+ form mg-mcg-mcg * a thru z select tablet new formulation * a thru z select women's tablet * PA PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (400 per 365 days) 207

224 abc plus tablet mgmcg-mcg * adult multi gummies 200 mcg * adult multivitamin gummies assorted flavors 200 mcg * adult one daily gummies 200 mcg * adults 50+ multivitamin tablet mg-mcg-mcg * animal chews tablet * antioxidant softgel softgel * apatate forte liquid * b complete tablet * b complex capsule * (Super B-50 Complex) b complex formula #1 tablet * b complex tablet * b mcg tablet 500 mcg * b-12 dots 500 mcg tablet 500 mcg * baby vitamin d3 400 unit/drop 400 unit/0.2 ml * baby vitamin d3 400 unit/drop 400 unit/drop * balance b-100 tablet * balance b-50 tablet * balance b-50 tablet inner,p/f,gluten/f * balanced b-100 tablet * balanced b-100 tablet 100 mg * balanced b-50 tablet * balanced b-complex caplet p/f,nolactose 400 mcg * b-complex plus vitamin c cplt caplet * (Superplex-T) b-complex with b12 tablet * 208

225 b-complex with c tablet * (Superplex-T) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * bee-zee tablet * biosupp liquid * biotin 300 mcg tablet 300 mcg * biovol syrup * c complex 500 mg tablet sa 500 mg * calcidol drops 8,000 unit/ml * calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * calcium 250-vit d3 125 tablet 250- (Oyster Shell 125 mg-unit * Calcium-Vit D3) calcium vit d 400 caplet s/f, p/f, caplet 600 mg(1,500mg) -400 unit * calcium vit d tablet mg-unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 (Calcium mg(1,500mg) -400 unit * D(3)) centamin liquid 9 mg iron/15 ml * central-vite seniors tablet * centram-care multivit-min liq 9 mg iron/15 ml * centravites 50 plus tablet * centravites 50 plus tablet outer mg-mcg-mcg * centrum adults tablet mgmcg * centrum complete multivit tab mg-mcg * 209

226 centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults mg-mcg-mcg * centrum women tablet mgmcg * century ultimate men's tablet mcg * century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * cerovite jr tablet chew * cerovite liquid 9 mg iron/15 ml * cerovite senior tablet * certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet mg-mcg * chewable-vite tablet * chew-vites-iron tablet chew * child chew + iron tab chew * child chew vitamin tablet * child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Fer-In-Sol) child multivitamin plus iron 18 mg iron * childrens chew vitamin tab * children's chewable vitamin * childrens multivit tab chew * childrens vit-iron tab chew * compete tablet * 210

227 complete multi 50+ tablet mcg * complete multi tablet mg-mcg-mcg-mcg * X complete multivitamin tab * complete senior tablet * cvs bal b-100 tablet * cvs bal b-50 tablet * cvs balanced b-150 tablet * cvs b-complex-vit c caplet caplet * (Superplex-T) cvs calcium vit d tablet oyster shell 500 mg(1,250mg) -125 unit * cvs calcium 600-vit d3 800 tab 600 (Caltrate with mg(1,500mg) -800 unit * Vitamin D3) cvs calcium 600-vit d3 800 tab p/f, (Caltrate with s/f,gluten-free 600 mg(1,500mg) - Vitamin D3) 800 unit * cvs child vit-mineral tab * cvs children's chewable vit * cvs childs vit with c tab chew * cvs child's vitamin-iron tb * cvs daily gummies p/f, gluten-free 200 mcg * cvs daily multiple tablet * cvs daily multiple tablet for women * cvs gummy swirls chewable * cvs hair, skin and nails cplt * cvs iron 27 mg tablet 240 mg (27 mg iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * cvs men's multi-vit tablet * cvs prenatal vitamin tablet * 211

228 cvs spectravite adult 50+ tabs mg-mcg-mcg * cvs spectravite adult gummy 200 mcg * cvs spectravite advanced tab mg-mcg * cvs spectravite senior * cvs spectravite senior tab * cvs spectravite ultra men's tb mcg * cvs spectravite ultra women tb mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vitamin b-100 complx tb * cvs vitamin c 1,000 mg tb chw 1,000 mg * cvs vitamin d3 1,000 unit sfgl softgel (Vitamin D3) 1,000 unit * cvs vitamin d3 400 unit/drop 400 unit/drop * (Baby Ddrops) cvs women's daily gummies p/f,gummies 200 mcg * cyanocobalamin 1,000 mcg/ml 25's 1,000 mcg/ml * (Vitamin B-12) 3 $0 d3 dots 2,000 unit tablet p/f 2,000 unit * daily multi vitamin-iron tab * daily multiple tablet mg-mcg * daily multiple vitamin tab sugar coated * daily multivitamin-iron tablet mg-mcg * daily value multivitamin tab s/f * 212

229 daily vitamin + iron tablet * daily vitamin formula tablet * daily vitamin formula tablet * daily vitamin formula-iron tab mg-mcg * daily vite tablet s/f, p/f * daily vite tablet s/f,p/f * daily vite with iron tablet * daily-vite tablet * daily-vites with iron tablet * delta d3 400 unit tablet s/f,l/f,y/f,gluten/f 400 unit * dino-life extra c tab chew * dino-life iron-zinc tb chew * dino-life tablet chewable * d-vi-sol 400 units/ml drop 400 unit/ml * eldertonic elixir mg * ellis tonic * eq child complete chew tablet 18 mg iron * eq complete multivitamin tab mg-mcg-mcg * eq complete multivitamin tab glutenfree mg-mcg * eq one daily men's tablet gluten free mcg * eql central-vite select tablet * eql century mature tablet mcg * eql century multi-vitamin tab mg * eql chewable multi vitamin tab * 213

230 eql child's multivit tab chew with vitamin c * eql childs multivit-mineral tb * eql eye health plus lutein tab 1,000 unit-200 mg-60 unit-2 mg * eql one daily 50 plus tablet * eql one daily essential tablet * eql one daily maximum tablet mg * eql one daily men's tablet * eql prenatal vitamin tablet 28 mg iron- 800 mcg * eql super b complex tablet 400 mcg * ergocalciferol 8,000 units/ml 8,000 unit/ml * (Calcidol) essentia tablet mg-mcg * essential balance tablet * essential daily tablet w/iron & calcium mg * feosol 65 mg tablet 325 mg (65 mg iron) * ferocon capsule mg * 3 $0 ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule mg * ferric x-150 capsule 150 mg iron * ferrocite tablet 324 mg (106 mg iron) * ferrous fumarate 324 mg tab 324 mg (Ferrocite) (106 mg iron) * 214

231 ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Ferate) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * ferrous sulf 220 mg/5 ml elix 220 mg (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) * ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (FerrouSul) flintstones complete tablet * flintstones extra c tab chew * flintstones tablet chewable * flintstones with iron tab chew 18 mg iron * folic acid 1 mg tablet (rx) 1 mg * 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * fosfree tablet mg * geravim liquid * geriaton liquid * gnp calcium 500-vit d3 600 tab 500mg (1,250mg) -600 unit * (Os-Cal D3) gnp century mature tablet glutenfree mg-mcg-mcg * gnp century tablet adults mg-mcg-mcg * 215

232 gnp century tablet gluten-free mg-mcg * gnp one daily essential tablet * gs prenatal vitamins tablet mg-mcg * gummi bear multivit tab chew multivit & minerals * hair vitamins * hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * hi-b complex tablet * hm animal shapes complete chew child's, w/ choline 18 mg iron * hm complete 50+ tablet mg-mcg-mcg * hm complete women tablet mg-mcg * hm one daily with iron tablet glutenfree mg-mcg * hm super vitamin b complex glutenfree 400 mcg * honey bears chew tab * honey bears-iron-zinc tab chew * icaps plus tablet lactose free * iferex 150 capsule 150 mg iron * iron 27 mg tablet 236 mg (27 mg iron) * iron 28 mg tablet 256 mg (28 mg iron) * kenwood therapeutic liquid * kids multivitamin complete tab 18 mg iron * kobee tablet 0.4 mg * kpn tablet * life-pack women's p/f,s/f 0.8 mg * 216

233 little animals child tb chw * little animals-iron tab chew * lysiplex plus liquid * MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * mega multivitamin-mineral tab * mega multivit-chelated min tab * men's multivitamin gummies 200 mcg * MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * multi complete-iron tablet mg-mcg * multi for her tablet 18 mg iron-600 mcg-80 mcg * multi-day plus iron tablet mg-mcg * multi-delyn liquid s/f,a/f * multi-delyn with iron liquid 10 mg iron/5 ml * multilex tablet * multilex-t-m-minerals tab * multiple vitamin with iron tab * (One Daily Plus Iron) multiple vitamin w-minerals tb * multiple vitamins tablet one daily * multivitamin child tab chew * (Flintstones/Extra C) multi-vitamin daily tablet * multivitamin-mineral liquid 9 mg iron/15 ml * multivitamins tablet * (Vitamins for Hair) 217

234 multivit-fluor 0.25 mg/ml drop 0.25 mg/ml multivit-iron child tab chew children's * multivit-mineral hp cap * multivit-minerals tablet s/f,p/f * (Bee-Zee) my favorite multiple liquid * myvitalife soft-gel capsule * NASCOBAL 500 MCG NASAL SPRAY OUTER 500 MCG/SPRAY 3 $0 * nephplex rx tablet mg-mg-mcg-mg * 3 $0 nephron fa tablet mg * 3 $0 nephro-vite rx tablet mgmg-mcg * 3 $0 niacinamide er 500 mg tablet 500 mg * nu-iron 150 capsule 150 mg iron * ocutabs tablet s/f, w/lutein * onccor tablet mcg * once daily tablet * once daily with iron tablet * oncovite tablet * one daily complete tablet * one daily complete tablet mg * one daily essential tablet * one daily for women tablet mg * one daily gummy vites gummie 200 mcg * one daily maximum tablet mg * 218

235 one daily multivitamin tab * one daily multivitamin tablet * one daily multivitamin tablet 400 mcg * one daily multivitamin-iron tb mg-mcg * one daily plus iron tablet mg-mcg * one daily tablet * one daily tablet * one daily tablet men's formula * one daily with minerals tablet * one-a-day essential tablet * one-a-day max formula tab * one-a-day men's tablet mcg * one-a-day teen advantage tab mg-mcg * one-a-day teen advantage tab 9 mg iron-400 mcg * oysco 500-vit d3 200 tablet 500 mg(1,250mg) -200 unit * oysco d tablet mg-unit * oyster shell 500-vit d3 200 tb 500 mg(1,250mg) -200 unit * oyster shell calcium tablet 500 mg(1,250mg) -400 unit * oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(1,250mg) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(1,250mg) -400 unit * perry prenatal capsule mg * pharmacist multi-vite tab * 219

236 phytonadione 1 mg/0.5 ml syr latexfree, p/f,sdv 1 mg/0.5 ml * 3 $0 pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- 1 mg poly-iron 150 mg capsule 150 mg iron * poly-vita drops 1, unitmg-unit/ml * poly-vita with iron drops 1,500 unit- 400 unit-10 mg/ml * poly-vitamin drops 1, unit-mg-unit/ml * poly-vitamin tab chew * polyvitamin w-iron drops 1,500 unit-400 unit-10 mg/ml * polyvitamin with iron tab chew * prenatal formula tablet 28 mg iron- 800 mcg * prenatal multivitamin tablet 28 mg iron- 800 mcg * prenatal tablet (otc) 27 mg iron- 0.8 mg * prenatal tablet (otc) 27 mg iron- 0.8 mg * prenatal tablet 27 mg iron- 800 mcg * prenatal tablet 28 mg iron- 800 mcg * prenatal tablet 28 mg iron- 800 mcg (Prenatal) * prenatal tablet 28 mg iron- 800 mcg (Prenatal Vitamin * with Minerals) prenatal tablet outer (otc) 27 mg iron- 0.8 mg * (All Rx Prenatal Vitamins Covered) 220

237 prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg prenatal vitamin tablet 27 mg iron- 800 mcg * prenatal vitamins tablet phosphorus free 28 mg iron- 800 mcg * prosight tablet 5, unit-mgunit * pub multivitamin 50 plus tab * pv b-100 complex * pv b-50 complex * pv kid's gummy bear tab chew chewable * pv kid's vit + extra c chew tb * pv kid's vit + iron tab chew * pv kid's vit complete tab chew * pv kid's vitamins chew tab * pv kids vitamins chew tab 300 mcg * pv kids vitamins complete mg-mcg * pv kids vitamins+iron tab chew 15 mg iron * pv multivital platinum tablet * pv multivital platinum tablet w/lutein & lycopene mcg * pv multivital tablet mg * pv multivital tablet mg-mcg-mcg-mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pv stress 500 tablet * pyridoxine 100 mg/ml vial 25's 100 mg/ml * 3 $0 (All Rx Prenatal Vitamins Covered) 221

238 pyridoxine 250 mg tablet 250 mg * (Vitamin B-6) qc child complete vit chew tab 18 mg iron * qc children's chewable tablet * qc maximum daily multivit tab mg * qc multi-vite 50 & over tablet w/lycopene * qc multi-vite tablet mg-mcg * qc women's daily multivit tab mg * ra balanced b-100 tablet 0.4 mg * ra balanced b-50 tablet natural,p/f * ra b-complex tablet p/f * ra b-complex tablet p/f * (Stress B-Biotin) ra central vite select tab p/f * ra central-vite select tab p/f * ra central-vite senior tablet mg-mcg-mcg * ra central-vite tablet mg-mcg-mcg * ra central-vite tablet mgmcg * ra hi-cal plus vitamin d tab 500 mg(1,250mg) -200 unit * ra one daily energy tablet * ra one daily maximum tablet mg * ra one daily multi-vitamin tab p/f * ra one daily plus iron tablet * ra prenatal tablet 28 mg iron- 800 mcg * 222

239 ra therapeutic m multivit tab mg * ra vit b-12 1,000 mcg/ml liq 1,000 mcg/ml * ra vitamin b-12 1,000 mcg tab timed-release 1,000 mcg * (Vitamin B-12) ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 mg * ra vitamin c 500 mg tab chew p/f 500 mg * ra vitamin d3 1,000 unit tab s/f,gluten/f,yeast/f 1,000 unit * rena-vite rx tablet mg-mgmcg * 3 $0 right step prenatal vit tab 27 mg iron- 0.8 mg * scooby-doo one a day tablet * senior tabs mg-mcgmcg * sentry multivit & mineral cplt mg-mcg-mcg-mcg * sentry senior multivitamin tab sodium/f,yeast/f mcg * sentry senior tablet mgmcg-mcg * sentry tablet mg-mcg * sm animal shapes complete chew gluten-free 18 mg iron * sm animal shapes tab chew * (Flintstones/Extra C) sm animal shapes tab chew toddlers * sm animal shapes w-iron tab children's * 223

240 sm b complex with vit c tablet gluten-free * (Superplex-T) sm complete advanced tablet mg-mcg-mcg-mcg * sm complete multi-vit-mineral advanced formula mg-mcg * sm complete senior formula tab * sm complete senior formula tab mg-mcg-mcg * sm complete tablet mg * sm multivitamin w-iron tab * (One Daily Plus Iron) sm multivitamins tablet * (Vitamins for Hair) sm natural balanced b-100 tab 100 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet mg * sm ultimate men's complete tab mcg * sm vitamin b complex tablet glutenfree 0.4 mg * (Balanced B-100) sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet 1 mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * stress formula with iron tab * 224

241 stress formula with iron tab 500 mg- 400 mcg- 18 mg iron * stress formula with iron tab 500 mg- 400 mcg- 27 mg iron * stress formula with zinc tab * stress-c tablet * stress-c with iron tablet 500 mg-400 mcg- 18 mg iron * sunvite tablet 18 mg iron-400 mcg- 25 mcg * super b complex-c caplet caplet * super b maxi complex caplet 0.4 mg * super b with vit c capsule * super b-50 complex capsule * super b-50 complex plus tab * super b-complex folic-vit c tb p/f 400 mcg * super multiple vit-mineral tab * super multivitamin tablet * super quints b-50 tablet 0.4 mg * super quints b-50 tablets * super thera vite m tablet * superior 35 vit-mineral tab sa * superplex-t tablet * support liquid * support-500 softgel * sv hair, skin and nails caplet 1 mg iron-66.7 mcg-1,000 mcg * tab-a-vite tablet * tab-a-vite with iron tablet * tab-a-vite-minerals tablet * thera m plus tablet 9 mg iron-400 mcg * 225

242 thera tablet 400 mcg * thera-d 2000 tablet 2,000 unit * theradex m tablet mg * thera-m caplet * thera-m caplet caplet mg * thera-m tablet w/beta carotene 9 mg iron-400 mcg * therapeutic-m caplet caplet 9 mg iron-400 mcg * therapeutic-m tablet mgmcg * thera-tabs tablet * theratrum complete 50 plus p/f,caplet * theratrum complete tablet w/lutein, p/f * therems tablet * total b with vit c caplet * totalday multiple tablet sa * tri-vi-sol drops 750 unit-35 mg -400 unit/ml * tri-vita drops 1, unit-mgunit/ml * tri-vitamin drops 1, unit- mg-unit/ml * ultra b-100 complex tablet * unicomplex-m tablet * v-c forte capsule 1 mg * 3 $0 vic-forte capsule 1 mg * 3 $0 vision plus lutein vitamin tab * vision vitamins * vit d mg (50,000 unit) capsule 50,000 unit * 3 $0 226

243 vitalets tablet chewable child, orange,s/f * vitamin a 10,000 units capsule soluble 10,000 unit * vitamin and minerals tablet * vitamin b complex capsule * vitamin b complex tablet 500 mg- 400 mcg- 18 mg iron * vitamin b complex-vit c cap * (Support-500) vitamin b complex-vit c tablet * (Superplex-T) vitamin b mg tablet 100 mg * vitamin b-1 50 mg tablet 50 mg * vitamin b-12 1,000 mcg tablet 1,000 mcg * vitamin b mcg tablet 100 mcg * vitamin b mcg tablet 250 mcg * vitamin b mcg tablet 500 mcg * vitamin b12-folic acid tablet mcg * vitamin b-50 complex tablet s/f,p/f,dairy-free 0.4 mg * (Balanced B-100) vitamin b mg tablet p/f 250 mg * vitamin b-6 50 mg tablet 50 mg * vitamin b-complex & c caplet p/f,lactose free mcg-mg * vitamin c 1,000 mg tablet 1,000 mg * vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * vitamin c 250 mg tablet 250 mg * 227

244 vitamin c 250 mg tablet chew 250 mg * vitamin c 500 mg tablet chew 500 mg * vitamin c 500 mg/5 ml liquid 500 mg/5 ml * vitamin d 1,000 unit tablet 1,000 unit * vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * vitamin d3 10,000 unit softgel softgel 10,000 unit * (Maximum D3) vitamin d3 10,000 unit softgel softgel,p/f,s/f 10,000 unit * (Maximum D3) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (D3 DOTS) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Kids Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * vitamin d3 400 unit/5 ml liq 400 unit/5 ml * vitamin d3 400 unit/ml drop a/f, s/f, fruit 400 unit/ml * (Just D) vitamin d3 5,000 unit capsule s/f, p/f (Dialyvite Vitamin 5,000 unit * D) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * vitamin k 100 mcg tablet p/f,na/f,wheat-free 100 mcg * vitamin k-1 1 mg/0.5 ml ampul sdv,latex-free 1 mg/0.5 ml * 3 $0 vitamin k-1 10 mg/ml ampul sdv,latex-free 10 mg/ml * 3 $0 vitamins for hair tablet * 228

245 vitatrum tablet mgmcg-mcg-mcg * vitrum 50+ senior tablet mcg * vitrum senior tablet f/f,p/f * vol-care rx tablet mg-mgmcg * 3 $0 vp-vite rx tablet mg-mgmcg * 3 $0 v-r calcium d 133 caplet mg-unit * v-r natural b-100 tablet * v-r vitamin c tr 500 mg caplet 500 mg * women's multivitamin gummies gluten-f, lactose-f 200 mcg * yelets tablet mg-mcg * zoo chews gummie tablet * 229

246 INDEX 3 3 day vaginal pse-150gfn-15dm day vaginal MOP A a thru z a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen... 3 acetaminophen... 3, 5 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 184 acetylcysteine acid gone antacid acid reducer (famotidine) , 152 acid reducer (ranitidine) acid relief (cimetidine) acitretin acne medication , 133 ACNE MEDICATION ACTEMRA ACTHIB (PF) ACTIMMUNE actinel pediatric acyclovir... 81, 131 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 178 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max adult multivitamin gummies 208 adult nasal decongestant adult one daily gummies adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults 50 plus ADVAIR DISKUS ADVAIR HFA ADVIL... 11, 12 afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-12 allergy-sinus ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy relief (cetirizine) allergy relief (clemastine) allergy relief(diphenhydramin) aller-tec d allopurinol ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 55 alophen alosetron ALPHAGAN P alprazolam ALREX altacaine altamist I-1

247 altavera (28) aluminum hydroxide gel ALUNBRIG alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate... 26, 27 amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE ANADROL anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes complete 216, 223 animal shapes plus iron ANORO ELLIPTA antacid anti-gas (ca carb-sim) antacid ultra strength antacid-antigas ii anti-diarrheal anti-diarrheal (loperamide). 154, 155 antifungal (tolnaftate)... 55, 58 antifungal cream anti-gas maximum strength anti-itch (hc) antioxidant antitussive dm apatate forte APOKYN apraclonidine aprepitant apri APRISO aprodine APTIOM APTIVUS aquanil hc aranelle (28) ARCALYST aripiprazole ARISTADA armodafinil ARNUITY ELLIPTA ARTIFICIAL TEARS (PETRO/MIN) artificial tears (pf) artificial tears (polyvin alc) artificial tears(dext70-hypro) 143 artificial tears(glycerin-peg). 144 artificial tears(hypromellose) 146 ascomp with codeine... 3 ascorbic acid (vitamin c) , 227 ashlyna aspirin aspirin, buffered aspirin-dipyridamole aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA I-2

248 atropine... 42, 143 ATROVENT HFA AUBAGIO aubra AUSTEDO AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine , 144 azithromycin... 24, 25 AZOPT aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 209, 214, 216, 225 b-100 complex b-12 dots b-50 complex baby vitamin d bacitracin... 19, 134, 147 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 222 balanced b balanced b , 222 balsalazide balziva (28) banophen banophen allergy BANZEL BAVENCIO baza antifungal BCG VACCINE, LIVE (PF) 178 b-complex b-complex with vitamin c , 209, 211, 224, 227 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bee-zee bekyree (28) BELBUCA... 4 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENLYSTA benzonatate , 122 benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 167 betamethasone dipropionate. 136 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 95, 190 bethanechol chloride BETHKIS bexarotene BEXSERO bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP , 179 BOSULIF bp 8 cough BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm bromfenac bromocriptine... 69, 70 brompheniramine-pseudoephdm , 122 brotapp dm budesonide , 199 I-3

249 bufferin bumetanide BUNAVAIL BUPHENYL buprenorphine hcl... 4, 16 buprenorphine-naloxone buproban bupropion hcl bupropion hcl (smoking deter)16 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC BYVALSON C c complex cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor , 197 caffeine citrate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol , 185 calcium d (d3) calcium calcium d(3) , 209 calcium 600 with vitamin d3 194 calcium acetate calcium antacid calcium carbonate , 191 calcium carbonate-vit d3-min , 193 calcium carbonate-vitamin d , 193, 209, 211, 215 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d , 192, 198 calcium gluconate calcium+d CALDOLOR cal-gest antacid CALTRATE D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 5 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 93 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 22 cefdinir cefditoren pivoxil cefepime CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 23 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 23 cefuroxime axetil cefuroxime sodium celecoxib CELONTIN centamin centergy dm central vite with lutein central-vite central-vite for seniors central-vite select , 222 central-vite senior centram-care centravites 50 plus centrum , 210 centrum complete centrum silver centrum women century , 216 century adults century mature , 215 century ultimate men's century ultimate women's cephalexin I-4

250 CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula cerovite jr cerovite senior certavite senior-antioxidant certavite-antioxid (iron gluc) 210 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX cheratussin ac cheratussin dac chest congestion relief + dm 123 chest congestion relief pe chewable multi vitamin chewable-vite chewable-vite with iron child chest congestion + cough child complete multivitamin 213 child cough and sore throat child mucinex chest congestion child multivitamin plus iron. 210 child plus cough and runnynose child triaminic cold-allergy child triaminic cough-congest child vitamin with minerals. 211 child wal-tap cold-allergy child wal-tussin cough relief 122 CHILDREN'S ADVIL children's allegra allergy children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 210 children's chewable w/minerals CHILDREN'S CLARITIN children's cold-cough daytime children's complete vitamin. 222 children's cough and runnynose children's cough dm er children's mapap... 5 children's mucinex cough children's multivit w/extra c. 214 children's non-aspirin... 5 children's pain reliever children's pain-fever relief... 5, 7 children's pepto children's robitussin er children's silfedrine children's soothe children's sudafed children's sudafed pe cough. 122 children's tactinal... 5 children's wal-fex children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine... 71, 72 chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 208, 212, 228 cholestyramine (with sugar). 105 cholestyramine light , 105 ciclopirox cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 28, 147 ciprofloxacin in 5 % dextrose 28 ciprofloxacin lactate citalopram citracal + d maximum citrus calcium clarithromycin CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 20 clindamycin palmitate hcl I-5

251 clindamycin pediatric clindamycin phosphate... 20, 64, 134 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 91, 109 clopidogrel clorazepate dipotassium clorpres clotrimazole... 55, 56 clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm COLCRYS cold and cough (diphenhydr-pe) cold and cough (pe-dm) cold multi-symptom day/night cold multi-symptom nighttime cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 201 COMETRIQ comfort gel comfort gel extra strength compete COMPLERA complete complete complete multi complete multi complete multivitamin. 211, 213 complete multivitamin-mineral , 224 complete senior , 224 complete women compoz compro COMVAX (PF) CONDYLOX congestac congest-eze constulose COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR cormax cortaid cortisone cortizone cortizone-10 with aloe COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 132 COTELLIC cough and cold cough and runny nose cough relief cough syrup cough syrup dm CREON critic-aid clear af CRIXIVAN cromolyn , 155, 202 cryselle (28) CUPRIMINE cutter backwoods cutter skinsations cyanocobalamin (vitamin b-12) , 212, 223, 227 cyclafem 1/35 (28) cyclafem 7/7/7 (28) I-6

252 cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride daily gummies daily multiple , 212 daily multi-vitamin daily multivitamin with iron 212 daily multi-vitamins/iron daily value daily vitamin formula daily vitamin formula-iron daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene , 204 dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough daytime cold-flu daytime cold-flu relief (pe) day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm delta d delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine... 47, 48 desmopressin desog-e.estradiol/e.estradiol. 114 desogestrel-ethinyl estradiol 114 desonide desoximetasone despec-dm (pseudoeph-dmguaif) desvenlafaxine succinate dex4 glucose dexamethasone dexamethasone sodium phosphate , 168 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine , 110 dextromethorphan polistirex 124 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringer's dextrose 5 % in water (d5w).. 89 dextrose 5 %-lactated ringers192 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm diabetic tussin ex diamode diazepam diazepam intensol diclofenac potassium diclofenac sodium... 12, 13, 132, 150 diclofenac-misoprostol I-7

253 dicloxacillin dicyclomine didanosine DIFICID diflunisal digitek digoxin... 99, 100 DIGOXIN dihydroergotamine DILANTIN diltiazem hcl... 97, 98 dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion DIMETAPP LONG-ACTING (CPM-DM) dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex... 42, 43 dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol doxorubicin doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) 160 DULERA duloxetine DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin d-vi-sol DYRENIUM E e.c. prin e.e.s e.e.s. granules econazole econtra ez ecotrin ed a-hist ed bron gp ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON EMCYT EMEND EMFLAZA emoquette EMPLICITI EMSAM EMTRIVA... 76, 77 enalapril maleate enalaprilat enalapril-hydrochlorothiazide 93 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin enema , 162 enema disposable , 160 enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir I-8

254 entre-cough ENTRESTO enulose ENVARSUS XR EPCLUSA epinastine epinephrine epinephrine hcl (pf) epitol EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) eq gentle equalactin ergocalciferol (vitamin d2). 214, 226 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 25, 147 erythromycin ethylsuccinate.. 25 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 214 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 167 estropipate eszopiclone ethambutol... 65, 66 ethosuximide ethynodiol diac-eth estradiol 114 etodolac ETOPOPHOS etoposide EUCRISA evac-u-gen (sennosides) EVOTAZ exemestane EXJADE EXONDYS expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche eye health plus lutein ezetimibe F FABRAZYME fallback solo falmina (28) famciclovir famotidine , 153 famotidine (pf) famotidine (pf)-nacl (iso-os) 152 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine feminine care douche FEMRING femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 105 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 5, 6 fentanyl citrate... 5 feosol ferocon ferretts ferrex ferrex 150 plus ferric x FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 216 ferrous sulfate , 215 FETZIMA feverall... 6 fexofenadine fiber (calcium polycarbophil) fiber (psyllium husk/sugar) fiber laxative (methylcellulo)162 fiber smooth fiber therapy (m-cell/sugar) fiber therapy (m-cellulose) fiber therapy sugar free fiber therapy(psyl seed-sugar) fiber-lax finasteride FIRAZYR flavor chews antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA , 200 floxuridine I-9

255 flu formula daytime-nighttime flu hbp flu relief therapy daytime flu severe cold-congestion flucaine fluconazole fluconazole in nacl (iso-osm). 56 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluocinonide-e fluorometholone fluorouracil... 34, 132 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 150 fluvoxamine foaming antacid , 158 folic acid fomepizole fondaparinux... 82, 83 foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure fungoid-d furosemide FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX GAMMAPLEX (WITH SORBITOL) ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) , 180 gas relief gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 19, 134, 135, 148 gentamicin in nacl (iso-osm).. 19 gentamicin sulfate (ped) (pf).. 19 gentamicin sulfate (pf) GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears GENTEAL TEARS (DXTRN- HPM-GLY) gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-lanta geri-tussin dm gianvi (28) gildagia gildess 1.5/30 (21) gildess 1/20 (21) gildess 24 fe gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate glydo GLYXAMBI granisetron (pf) granisetron hcl GRANIX I-10

256 griseofulvin microsize guaifenesin guanfacine... 91, 110 guanidine gummi bear multivitamin , 221 gummy swirls H hair vitamins hair,skin and nails , 225 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthylax heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex.. 83 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN hi-b complex HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen... 6 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen... 6 hydrocortisone , 138, 168, 184 hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet hydromorphone... 7 hydromorphone (pf)... 6, 7 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 7 I ibandronate IBRANCE ibuprofen... 12, 13, 14 ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide indomethacin... 13, 14 indomethacin sodium INFANRIX (DTAP) (PF) infant's advil infant's ibuprofen infants' non-aspirin cold infant's pain reliever... 7 INFLECTRA INGREZZA INLYTA INSECT REPELLENT (PICARIDIN) insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A I-11

257 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide , 201 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA iron high potency ISENTRESS ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate. 107, 108 isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette juleber junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe junior mapap... 7 JUXTAPID K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) kelnor 1/35 (28) ketoconazole ketoprofen ketorolac... 14, 150 KEVEYIS KEYTRUDA kidkare cough/cold kids mini enema kids multivitamin complete kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kids vitamins complete kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle kobee konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM kpn KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad. 116 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine... 43, 44 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) larissia LARTRUVO latanoprost LATUDA laxative peg I-12

258 LAZANDA... 7 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 29, 148 levofloxacin in d5w levoleucovorin LEVOLEUCOVORIN levonest (28) levonorgestrel levonorgestrel-ethinyl estrad 116 levonorg-eth estrad triphasic 117 levora levothyroxine LEXIVA LIALDA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 15, 95 lidocaine hcl lidocaine in 5 % dextrose (pf) 95 lidocaine viscous lidocaine-prilocaine life-pack women's linezolid LINZESS liothyronine liquibid d-r liquid calcium with vitamin d lisinopril lisinopril-hydrochlorothiazide 94 lithium carbonate lithium citrate little animals little animals-iron little remedies LIVALO lobana bath lohist-dm lomedia 24 fe LONSURF loperamide , 156 lopinavir-ritonavir loratadine... 60, 62 loratadine-d... 61, 62 lorazepam lorcet (hydrocodone)... 7 lorcet hd... 7 lorcet plus... 7 lortuss ex loryna (28) losartan losartan-hydrochlorothiazide. 92 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 145 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 146 lubricant eye (propyl glycol) 144 lubricant gel lubricating drops lubricating plus lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M maalox advanced MACUVITE EYE CARE mag mag-delay mag-g magnebind magnesium , 194, 198 magnesium (oxide/aa chelate) magnesium gluconate magnesium oxide. 156, 157, 158 magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water. 194, 195 malathion mapap (acetaminophen)... 7, 8 mapap arthritis pain... 8 mapap extra strength... 7 maprotiline mar-cof bp mar-cof cg I-13

259 margesic... 8 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin meclizine medi-meclizine medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral megestrol... 37, 172 MEKINIST meloxicam memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's multivitamin gummies 217 men's one daily , 214 MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem mesalamine mesna MESNEX MESTINON metaproterenol metaxall metaxalone metformin methadone... 8 methadose... 8 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide methylphenidate , 111 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 20, 64, 135 metronidazole in nacl (iso-os) 20 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 56, 57 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 8, 9 MORPHINE... 8, 9 morphine concentrate... 8 motion sickness motion sickness relief(mecliz)... 66, 68 MOVANTIK MOVIPREP MOXEZA I-14

260 moxifloxacin MOZOBIL MUCINEX FAST-MAX COLD-FLU-THRT mucinex fast-max dm max mucinex sinus-max mucus dm mucus dm max mucus relief , 127 MULTAQ multi complete with iron multi for her multi-day with iron multi-delyn multi-delyn with iron multilex multilex-t and m multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multivital multivital platinum multivitamin , 224 multivitamin 50 plus multi-vitamin hp/minerals multi-vitamin with fluoride multivitamin with iron. 217, 224 multivitamin with minerals. 217, 218 multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN nasal and sinus decongestant 126 nasal spray (oxymetazoline). 144 NASCOBAL NATACYN nateglinide NATPARA NATRAPEL natural b natural b-100 complex natural balance natural balance tears natural calcium natural fiber laxative therapy 161 natura-lax nature's tears (hypromellose) 146 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone NEO DM neomycin neomycin-bacitracin-poly-hc 148 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA NEUPOGEN... 84, 85 NEUPRO NEVANAC nevirapine NEXAVAR next choice one dose niacin niacinamide , 218 niacor nicardipine nicorelief NICORETTE nicotine nicotine (polacrilex) NICOTROL nifedical xl nifedipine night time night time cold medicine I-15

261 night time cold-flu night time cold-flu relief night time cough-sore throat 126 nighttime cough nikki (28) nilutamide NINLARO NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose 108 NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength.. 9, 10 non-aspirin flu non-aspirin jr strength... 5 nora-be NORDITROPIN FLEXPRO 170 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp... 9 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 9 NUCYNTA ER... 9 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING nyamyc nyata nystatin... 57, 58 nystatin-triamcinolone nystop nyt-time sleep O OCALIVA ocean nasal ocella OCREVUS OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV off active off deep woods off deep woods dry off familycare (with deet) ofloxacin... 29, 149 ogestrel (28) olanzapine olanzapine-fluoxetine olmesartan olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium OMNITROPE ONCASPAR onccor once daily oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily , 222 one daily 50 plus one daily complete one daily energy one daily essential 214, 216, 218 one daily for women one daily gummy vites one daily maximum , 222 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 219 one daily plus iron 216, 219, 222 one daily plus minerals I-16

262 one daily with iron , 219 one-a-day essential one-a-day maximum formula219 one-a-day men's multivitamin one-a-day teen advantage ONFI ONIVYDE opcicon one-step OPDIVO OPSUMIT option oral saline laxative oralone oralyte ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orsythia oseltamivir OTEZLA OTEZLA STARTER OTOVEL OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 27 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 9 oxycodone-acetaminophen 9, 10 oxycodone-aspirin OXYCONTIN oxymorphone oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium-vit d , 197 oyster shell calcium-vit d oystercal-d P pacerone pain relief... 5, 10 pain relief adult... 5 pain reliever jr strength paliperidone PANRETIN pantoprazole paricalcitol PARICALCITOL paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx pedia relief pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte , 195, 197, 198 pediatric freezer pops pediatric multivitamin.. 217, 223 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 141 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline perry prenatal persa-gel pfizerpen-g pharbetol pharmacist favorite multi-vit 219 phenadoz phenelzine phenobarbital phenylephrine hcl... 92, 146 phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended philith phillips phillips' liqui-gels PHOSLYRA phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k1).. 220, 228 PICATO pilocarpine hcl , 190 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam I-17

263 pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY pnv cmb#95-ferrous fumarate-fa podofilox polyethylene glycol , 162 poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium chlorid-d5-0.45%nacl potassium chloride , 197 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl , 197 potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid. 197 potassium hydroxide POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 168 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 220, 221, 224 prenatal formula , 221 prenatal multivitamins prenatal plus (calcium carb). 220 prenatal tablet prenatal vitamin , 214, 220, 221 prenatal vitamin plus low iron prenatal vit-iron fum-folic ac 220 prenatal vits96-iron fum-folic preparation h hydrocortisone 138 PREVAIL BLADDER CONTROL PAD prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 62, 68 promethazine vc-codeine promethazine-codeine promethazine-dm promethegan promolaxin propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight I-18

264 PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure and gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) 221, 222 Q QBRELIS q-dryl q-pap q-pap extra strength QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide 94 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE rasagiline RASUVO (PF) RAVICTI RAYALDEE react REBIF (WITH ALBUMIN) 111 REBIF REBIDOSE REBIF TITRATION PACK 111 reclipsen (28) RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 58 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX 106 REPATHA SURECLICK REPATHA SYRINGE repel sportsmen repel sportsmen max reprexain RESCRIPTOR RESTASIS RESTASIS MULTIDOSE retaine cmc retaine hpmc retaine pm RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA ribasphere ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ii right step prenatal vitamins riginic riluzole rimantadine ri-mox ringer's , 197 risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA ROZEREM RUBRACA RYDAPT rydex rynex dm S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline nose I-19

265 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs senna senna lax senna with docusate sodium. 160 senokot-s SENSIPAR sentry sentry (with lutein) sentry senior SEREVENT DISKUS SEROSTIM sertraline setlakin sharobel SIGNIFOR silace siladryl sa sildenafil SILENOR SILIQ siltussin sa silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 62 sleep aid (doxylamine) smoflipid smoothlax sochlor sodium acetate sodium bicarbonate , 198 sodium chloride , 147, 184, 198, 203 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe night time lubricant soothe regular strength sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spectravite adult spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra men's sr spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd st joseph aspirin st. joseph aspirin stavudine... 78, 79 STELARA , 178 STERILE GAUZE PAD STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin stress stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula 600 c stress formula plus iron stress formula with iron stress formula with iron(sulf)225 stress formula with zinc STRIBILD I-20

266 STRIVERDI RESPIMAT SUBOXONE sucralfate sudafed sudogest sudogest sinus and allergy sulfacetamide sodium sulfacetamide sodium (acne) 135 sulfacetamide-prednisolone. 149 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac sumatriptan sumatriptan succinate summer's eve disposable douche summers eve extra cleansing 189 sunvite super b complex-vitamin c.. 212, 224, 225 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNJARDY XR SYNRIBO SYPRINE SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 178 tactinal tactinal extra strength TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA tazarotene tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID the magic bullet theophylline theophylline in dextrose 5 % 202 thera thera m plus (ferrous fumarat) thera-d theradex m thera-m therapeutic liquid I-21

267 therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals , 226 thera-tabs theratrum complete 50 plus theratrum complete with lutein therems THIOLA thioridazine thiotepa thiothixene tiagabine TICE BCG tigecycline tilia fe timolol maleate... 97, 190, 191 TIVICAY tizanidine TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone. 149 TOLAK tolazamide tolbutamide tolmetin tolnaftate tolterodine topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin , 140 tretinoin (chemotherapy) tretinoin microspheres TREXALL tri femynor triacting m-sym cold/cough. 130 triamcinolone acetonide 131, 139 triaminic cold and cough (pe) triamterene-hydrochlorothiazid trianex tri-buffered aspirin tridesilon tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRINTELLIX triple antibiotic , 135 triple paste af tri-previfem (28) tri-sprintec (28) TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28) TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA tusnel diabetic TUSNEL NEW FORMULA 129 TUSSI PRES-B tussin cf , 130 tussin cf (pe-dm-guaif) tussin cold-congestion tussin cough (dm only) tussin dm tussin dm cough and chest tussin pe TWINRIX (PF) TYBOST TYKERB TYMLOS TYPHIM VI TYSABRI TYVASO TYZEKA U UCERIS u-cort ULORIC I-22

268 ultimate men's complete ultra b-100 complex ultra fresh pm unicomplex-m unisom (diphenhydramine) unisom (doxylamine) unisom sleepgels UNITUXIN UPTRAVI ursodiol V vagistat valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 46 valsartan valsartan-hydrochlorothiazide 93 VALSTAR vancomycin vancomycin in dextrose 5 %.. 21 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28) VELPHORO VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil VERSACLOZ VESICARE vestura (28) VGO VIBERZI vic-forte vicks dayquil cough vicks nature fusion cough vicks nyquil cold/flu liquicap vicks qlearquil nighttime rlf vicks qlearquil(oxymetazoline) vicks sinex 12-hour vicodin vicodin es vicodin hp VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine viorele (28) VIRACEPT VIRAZOLE VIREAD virtussin ac virtussin dac vision vision plus lutein vit b complex-folic acid 224, 227 vitalets vitamin a vitamin b complex , 222 vitamin b vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 227, 228, 229 vitamin d , 224, 228 vitamin k vitamin k vitamins and minerals vitamins b complex , 227 vitamins for hair vitatrum VITEKTA vitrum senior vol-care rx VOLTAREN voriconazole... 58, 59 VOTRIENT VPRIV vp-vite rx VRAYLAR vyfemla (28) W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-flu severe cold-cough wal-itin wal-itin d wal-itin d 12 hour wal-phed... 64, 130 wal-phed pe day-night wal-phed pe sinus and allergy 64 wal-profen wal-sleep z wal-som (diphenhydramine).. 64 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin dm wal-tussin max strength cough wal-zan wal-zyr (cetirizine) I-23

269 wal-zyr d warfarin water for irrigation, sterile WELCHOL wera (28) womens daily gummies women's daily multivitamin. 222 women's multivitamin gummies X XALKORI XARELTO... 83, 84 XELJANZ XELJANZ XR XERMELO XIFAXAN XOLAIR XTAMPZA ER XTANDI xulane xylon XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS yuvafem Z zafirlukast zaleplon zantac zarah ZARXIO ZAVESCA zebutal ZEJULA ZELBORAF ZEMPLAR zenatane zenchent (28) ZENPEP ZEPATIER zephrex-d ZERIT ZIAGEN zidovudine ZINBRYTA zinc oxide ZIOPTAN (PF) ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan zolpidem , 206 ZOMACTON ZOMETA zonisamide zoo chews ZORBTIVE ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) z-sleep... 62, 63 ZUBSOLV ZURAMPIC ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA I-24

270 若要投保 VNSNY CHOICE FIDA Complete 或進一步瞭解健康照護的其他選擇, 請致電投保仲介 (New York Medicaid Choice) 免付費電話 : FIDA TTY 聽障專線 : 星期一至星期五早上 8:30 至晚上 8:00 星期六上午 10:00 至下午 6:00 或造訪網站 : nymedicaidchoice.com 對 VNSNY CHOICE FIDA Complete Medicare-Medicaid 健康計劃有疑問? 請撥打 CHOICE 免付費電話 : TTY: 711 每週 7 天, 早上 8:00 至晚上 8: Broadway, New York, NY vnsnychoice.org 處方集 ID: , 版本 : 13