2017 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 :

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1 2017 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 : , 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 是一項與 Medicare 和紐約州衛生署 (Medicaid) 均簽有合約, 以便經由全面整合雙重利惠 (FIDA) 示範計劃向參保者提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單及藥房網絡在每年 1 月 1 日可能會有所調整, 在全年內也可能會不時變更 You can get this information for free in other languages. Call and 711 for TTY/TDD users during hours of 8:00 a.m. and 8:00 p.m., 7 days a week. The call is free. Puede obtener esta información de manera gratuita en otros idiomas.llame al y TTY/TDD 711 de lunes a domingos de 8:00 a.m. a 8:00 p.m. La llamada es gratuita. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang.rele nan ak nan TTY/TDD (poumoun ki gen pwoblèm tande oswa moun ki bèbè) 711 de lendi a dimanch 8:00 a.m. - 8:00 p.m. Apèl la gratis. 이정보는다른언어로도제공됩니다 ( 무료 ). 월요일 - 일요일 8:00 a.m. 8:00 p.m. 중 나 TTY/TDD 711 로전화주십시오. 통화료는무료입니다.m 您可免費取得以其他語言撰寫的資訊 請於週一至週日上午 8 時至下午 8 時致電 ,TTY/TDD 使用者 :711 此為免付費電話 Данная информация доступна бесплатно на других языках.звоните по номеру или 711 (линия TTY/TDD) с понедельника по воскресенье с 8:00 до 20:00. Звонок бесплатный. È possibile ricevere queste informazioni in altre lingue gratuitamente.contatta il e TTY/TDD 711 dal lunedì alla domenica dalle ore 8:00 alle ore 20:00.Il servizio è gratuito. 請閱讀 : 本文件包含有關本計劃承保藥物的資訊 2017 年綜合處方藥一覽表 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 : , 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 i da.org HPMS Approved Formulary File Submission ID , Version Number 16 H8029_EPC15678_Accepted

2 I H8029_EPC15678_Accepted Elderplan FIDA Total Care (Medicare-Medicaid Plan) 2017 年承保藥物清單 ( 處方藥一覽表 ) 這是一份藥物清單, 參保者可從 Elderplan FIDA Total Care 獲取 Elderplan FIDA Total Care 是一項與 Medicare 和紐約州衛生署 (Medicaid) 均簽有合約, 以便 經由全面整合雙重利惠 (Fully Integrated Duals Advantage, 簡稱 FIDA) 示範計劃向參保者 提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單和 / 或藥房及醫療服務提供者網絡在全年內可能會有所變更 在做出會影響您的 變更之前, 我們將為您寄送通知 每年 1 月 1 日福利可能會發生變化 如需 Elderplan FIDA Total Care 的最新承保藥物清單, 您可以瀏覽網站 或致電 Elderplan FIDA Total Care 參保者服務部, 電話 : 可能會有適用的約束及限制 如需更多資訊, 請致電 Elderplan FIDA Total Care 參保者服務部 或細閱 Elderplan FIDA Total Care 參保者手冊 這意味著, 若要讓 Elderplan FIDA Total Care 償付您的服務, 您需要遵循某些規則 任何承保藥物均無需支付定額手續費 You can get this information for free in other languages. Call and TTY/TDD 711, 7 days a week, 8:00 A.M. to 8:00 P.M. The call is free. Puede obtener esta información en otros idiomas, en forma gratuita. Llame al , o al 711 para los usuarios de TTY/TDD, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. La llamada es gratuita. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan ak moun ki itilize sistèm TTY/TDD rele nan 711, 7 jou sou 7, apatide 8:00 AM jiska 8:00 PM. Apèl la gratis. 이정보를다른언어로비용없이얻으실수있습니다 번및 TTY/TDD 711 번으로주 7 일오전 8 시 - 오후 8 시중에연락해주십시오. 통화는무료입니다. 您可免費取得此資訊的其他語言版本 請致電 , 聽障 / 語障人士可致電 711, 服 務時間為上午 8 時至晚上 8 時, 每週 7 天 此為免付費電話 Вы можете получить эту информацию бесплатно на других языках. Звоните по телефону (TTY/TDD: 711) в любой день недели с 8:00 до 20:00. Звонок бесплатный.? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

3 II È possibile ricevere queste informazioni in altre lingue gratuitamente. Contatti il numero (non udenti: 711) 7 giorni su 7, dalle 8 alle 20. La chiamata è gratuita. 您可以免費取得此資訊的其他格式版本, 例如大號字體印刷版或音訊 請致電 , 聽障 / 語障人士可致電 711, 服務時間為上午 8 時至晚上 8 時, 每週 7 天 此為免付費 電話 紐約州設立了一個名為 Independent Consumer Advocacy Network (ICAN) 的參保者監察官計 劃, 就 Elderplan FIDA Total Care 提供的任何服務向參保者提供免費及保密的協助 您可撥打 免費電話 或瀏覽 icannys.org 聯絡 ICAN ( 聽障和語障人士可致電 711, 然 後按照提示撥打 )? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

4 III 常見問題 (FAQ) 在此處查找您對本承保藥物清單的問題解答 您可以閱讀全部的常見問題以瞭解更多資訊, 或是 查找特定的問題和解答 1. 承保藥物清單上有哪些處方藥?( 我們將承保藥物清單簡稱為 藥物清單 ) 從第 1 頁開始的承保藥物清單上的藥物是 Elderplan FIDA Total Care 承保的藥物 這些藥物可在 我們網絡內的藥房購買 如果我們與一家藥房簽訂合作協議並向您提供服務, 這家藥房即屬於我們 的網絡內藥房 我們將這些藥房稱為 網絡內藥房 Elderplan FIDA Total Care 在以下情況中承保藥物清單上的所有藥物 : 您的醫生或其他處方醫師表示您需要這些藥物以恢復健康或保持健康, 藥物對您的病情具有醫療必要性, 及 您會在 Elderplan FIDA Total Care 網絡內藥房配取處方藥 Elderplan FIDA Total Care 可能要求採取額外行動才能獲得某些藥物 ( 請參見下文第 5 題 ) 在某些情況下, 您必須採取一些行動才能獲得藥物, 例如首先嘗試其他藥物 您也可以在我們的網站 或致電參保者服務部 查 詢最新的承保藥物清單 2. 藥物清單會變更嗎? 是的 Elderplan FIDA Total Care 可能會在一年之中增加或刪減藥物清單上的藥物 一般而言, 藥物清單只會在以下情況下變更 : 出現一種新藥物, 其藥效與目前藥物清單上的藥物相同, 或 我們得知一種藥物不安全 我們也可能更改有關藥物的規則 例如, 我們可能 : 決定要求或不要求某種藥物獲得事先批准 ( 事先批准是您在獲得藥物之前需要從 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 處獲得的許可 ) 增加或改變您可以獲得的藥量 ( 稱為 數量限制 )? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

5 IV 增加或改變藥物的階段療法限制 ( 階段療法指您必須先嘗試一種藥物, 我們才會承保另一種藥物 ) ( 有關這些藥物規則的更多資訊, 請參閱第 V 頁 ) 如果您使用的藥物從藥物清單上刪除, 我們會告訴您 當我們改變承保藥物的規則時, 我們也會告訴您 下文中的問題 3 4 和 7 會提供藥物清單變更時的更多相關資訊 您可以隨時在網站 查詢 Elderplan FIDA Total Care 的最新藥物清單 您也可以致電參保者服務部 , 查詢最新的藥物清單 3. 如果市面上出現一種比較便宜的藥物, 而且藥效與目前藥物清單上的藥物相同時會如何處理? 如果出現一種比較便宜的藥物, 且藥效與目前藥物清單上的藥物相同 : 您的藥劑師可能在您下次配取處方藥時向您提供這種比較便宜的藥物 如果您和您的提供 者認為這種較便宜的藥物不適合您, 您的提供者可以告知藥劑師, 繼續為您提供您目前使 用的藥物 Elderplan FIDA Total Care 可能會決定將價格較高的藥物從藥物清單中刪除 如果您使用 的藥物因為市面上出現價格較低且藥效相同的藥物而被我們撤出藥物清單, 我們會在撤 出藥物清單之前至少 60 天或是當您要求重新配藥時告訴您 然後, 您可以在藥物清單變 更之前獲得 60 天份的供藥 如果您目前正在使用的藥物即將被刪除,Elderplan FIDA Total Care 會在我們更改藥物清 單前至少 60 天為您來信說明 如果您決定使用將從藥物清單上刪除的價格較高的藥物, 您 的護理經理還會將您藥物治療方案的變化告知您的跨科團隊 (IDT) 4. 當我們發現一種藥物不安全時會怎麼辦? 如果食品藥物管理局 (FDA) 表示您正在使用的一種藥物不安全, 我們會立刻從藥物清單刪除 我們還會寄信並致電告知您, 不安全的藥物已從藥物清單中刪除 如果您收到我們參保者服務部寄出的此類信函, 請立刻透過致電參保者服務部 聯絡您的護理經理 您的護理經理將與您和您的處方醫生合作, 在藥物清單上尋找安全的替代藥物 您的護理經理還會告知您的跨科團隊 (IDT) 此事宜, 確保及時更新您的護理計劃? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

6 V 5. 藥物承保有任何限制嗎? 還是需要採取任何行動才能獲得某些藥物? 是的, 某些藥物有承保規則或是對您可以獲得的藥量有限制 在某些情況下, 您或您的醫生或其他處方醫師必須採取一些行動才能獲得藥物 例如 : 事先批准 ( 或事先授權 ): 就某些藥物而言, 您或您的醫生或其他處方醫師在您配取處方藥前必須取得 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 的批准 若您未獲得批准, Elderplan FIDA Total Care 可能不會承保該藥物 數量限制 : 有時,Elderplan FIDA Total Care 會限制您可以獲得的藥量 階段療法 : 有時,Elderplan FIDA Total Care 要求您接受階段療法 這是指您必須按某種順序使用藥物來治療您的疾病 您可能必須先嘗試一種藥物, 我們才會承保另一種藥物 如果您的醫生認為第一種藥物對您無效, 我們才會承保第二種藥物 您可以透過第 1 頁開始的表格查詢您的藥物是否有額外的要求或限制 您也可以瀏覽我們的網站 瞭解更多資訊 我們已在線上刊載文件, 解釋我們事先授權和階段療法的限制 您也可以要求我們寄一份給您 您可以對這些限制提出 例外處理 要求 請參閱問題 11, 瞭解有關例外處理的更多資訊 如果您住在護理機構或其他長期護理機構, 而且需要一種不在藥物清單上的藥物, 或是您無法輕易取得需要的藥物, 我們可以為您提供幫助 無論您是否為 Elderplan FIDA Total Care 的新參保者, 我們都會為您需要的藥物承保 31 天份的緊急供藥 ( 除非處方開立更少天數 ), 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使用藥物清單上的另一種類似藥物, 或是否要求例外處理 請參閱第 11 題有關例外處理的詳細資訊 6. 您如何知道您想要的藥物是否有限制或需要採取什麼行動來獲得藥物? 第 1 頁的承保藥物清單有 必要行動 限制或使用上限 一欄 7. 如果我們更改承保某些藥物的規則會如何處理? 例如, 如果我們新增某種藥物的事先授權 ( 批准 ) 數量限制及 / 或階段療法限制 我們會告訴您, 我們是否對某種藥物新增了事先批准 數量限制及 / 或階段療法限制 我們會在增 加限制之前至少 60 天或是在您下次要求重新配取時告訴您 然後, 您可以在藥物清單變更之前獲? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

7 VI 得 60 天的藥量 這樣可以讓您有時間和醫生或其他處方醫師討論接下來該怎麼做 8. 如何查詢某種藥物是否列於藥物清單上? 有兩種方式可以查詢藥物 : 您可以按字母順序搜尋 ( 如果您知道如何拼寫藥物名稱 ), 或 您可以按照疾病搜尋 要按照字母順序搜尋, 請翻到第 73 頁的字母清單部分 然後在清單中查找藥物的名稱 要按疾病搜尋, 請翻到第 XII 頁的 按疾病排列的藥物清單 一節 本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物 9. 如果您想要使用的藥物不在藥物清單上怎麼辦? 如果您在藥物清單上沒有查到您的藥物, 請致電參保者服務部諮詢, 電話 : 如果您得知 Elderplan FIDA Total Care 不會承保該藥物, 您可以採取以下一種行動 : 向參保者服務部索取一份與您想要使用的藥物類似的清單 然後將該清單出示給您的醫生或其他處方醫師 他們可以開立藥物清單上與您想要使用的藥物類似的藥物 或 您可要求計劃或您的跨科團隊 (IDT) 破例承保您的藥物 請參閱第 11 題有關例外處理的詳細資訊 10. 如果您是 Elderplan FIDA Total Care 的新參保者, 而且在藥物清單上找不到您的藥物或是您在領取藥物時遇到困難該怎麼辦? 我們可以幫忙 我們會在您成為 Elderplan FIDA Total Care 參保者後的前 90 天按需要承保 90 天 的臨時性供藥, 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使 用藥物清單上的另一種類似藥物, 或是否要求例外處理 如果您符合以下條件, 我們會承保 90 天的臨時性供藥 : 您正在使用未列於我們藥物清單上的藥物, 或 根據保健計劃的規則, 您無法取得處方醫師所開立的藥量, 或 藥物需要 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 的事先批准, 或? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

8 VII 您正在使用的藥物屬於階段療法限制中的藥物 如果您住在護理機構或其他長期護理機構, 您可以重新配取 91 天的處方藥, 最多可長達 98 天 在您參保本計劃的前 90 天內, 您可多次重新配取藥物 這樣, 您的處方醫師有時間將您的藥物改成藥物清單上的藥物或是申請例外處理 Elderplan FIDA Total Care 現有參保者的護理等級變更當參保者從一個治療機構轉到另一個治療機構時, 護理等級會發生變化 例如, 如果您從醫院或專業護理機構 (SNF) 或門診機構轉入長期護理 (LTC) 機構,Elderplan FIDA Total Care 將承保 31 天的過渡期臨時性供藥 ( 除非您的處方寫明更少的天數 ) 在您入住長期護理機構的前 90 天內, Elderplan FIDA Total Care 將承保這些藥物的多次重新配取 如果您離開長期護理機構或出院返家,Elderplan FIDA Total Care 將承保 30 天的臨時性供藥 ( 除非您的處方寫明更少的天數 ) 這適用於可能未列於 Elderplan FIDA Total Care 藥物清單上的藥物, 或受事先授權或數量限制等承保限制的藥物 您的護理經理將與您和您的處方醫師合作, 協助您申請例外處理, 以更好地適應護理等級變更 11. 我可以申請例外處理以獲得藥物承保嗎? 是的 您可以向 Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 申請例外處理, 以承保不在藥物清單中的藥物 您也可以要求 Elderplan FIDA Total Care 或您的 IDT 更改針對藥物的相關規則 例如,Elderplan FIDA Total Care 可能會限制某種藥物的承保藥量 如果您的藥物有上限規定, 您可要求我們或您的 IDT 更改這項限制, 承保更多藥量 其他例子 : 您可要求我們或您的 IDT 撤銷階段療法限制或是事先批准要求 12. 取得例外處理需要多長時間? 首先,Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 必須收到您的處方醫師支持您申請例外處理的聲明 我們收到聲明後, 會在 72 小時內對您的例外處理申請作出決定 如果您或您的處方醫師認為等候 72 小時作出決定會對您的健康造成危害, 您可以申請加急例外處理 這是更快速的決定 如果您的處方醫師支持您的申請, 我們會在收到處方醫師的支持聲明後 24 小時內作出決定? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

9 VIII 13. 如何提出例外處理申請? 要提出例外處理申請, 請致電您的護理經理 您的護理經理將與您和您的提供者合作, 幫助您申請 例外處理 14. 什麼是副廠藥? 副廠藥的成份與原廠藥相同 副廠藥一般比原廠藥便宜, 而且副廠藥的名稱通常較不為人所知 副廠藥均已獲食品藥物管理局 (FDA) 批准 Elderplan FIDA Total Care 承保原廠藥和副廠藥 15. 什麼是 OTC 藥物? OTC 是指 非處方藥 Elderplan FIDA Total Care 承保部分 OTC 藥物 ( 若您的提供者開具該等藥物的處方 ) 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些 OTC 藥物可獲得承保 16. Elderplan FIDA Total Care 是否承保非藥物類 OTC 產品? Elderplan FIDA Total Care 承保部分非藥物類 OTC 產品 ( 若您的提供者開具該等產品的處方 ) 非藥物類 OTC 產品的例子包括紗布墊與敷料以及注射胰島素所用的針頭和注射器 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些非藥物類 OTC 產品可獲得承保 17. 您需支付多少定額手續費? 您無需為藥物清單上的藥物支付定額手續費? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

10 IX 18. 什麼是藥物等級? 等級指藥物清單上的的藥物組別 藥物等級 承保藥物的類型 定額手續費 ( 分攤費用 ) 1 副廠藥 $0 2 原廠藥 $0 3 非 Medicare Rx( 處方 ) 和 OTC( 非處方 ) 藥物 $0 註 : 如上文定額手續費一欄所述, 參保者無需為藥物清單上第 1 至第 3 級的藥物支付分攤費用? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

11 X 承保藥物清單 第 1 頁開始的承保藥物清單為您提供有關 Elderplan FIDA Total Care 承保藥物的資訊 若您難以在清單中找到所需的藥物, 請轉到第 73 頁開始的索引 表格的第一欄列出了藥物名稱 原廠藥用大寫字母表示 ( 如 LATUDA), 副廠藥則用小寫斜體字母表示 ( 如 losartan) 必要行動 限制或使用上限 一欄的資訊會說明 Elderplan FIDA Total Care 在承保您的藥物時是否有任何規定 符號 說明 * Medicaid 承保的非 D 部分藥物或 OTC 用品 B/D 由 Medicare B 部分或 D 部分承保 某些藥物可能由 Medicare B 部分或 D 部分承保 ( 視情況而定 ) 可能需要提交資訊, 描述藥物的用途與規定, 以便作出裁決 PA 需要事先授權 某些藥物需要您或您的醫師獲得事先授權才能配取 這表示您將需 要在配取處方藥前取得 Elderplan FIDA Total Care 或 IDT 的核准 ST QL 需要階段療法例外處理 您需要先嘗試藥物清單上的某些藥物, 我們才能承保此藥物 數量限制 Elderplan FIDA Total Care 會限制某些藥物的承保數量 除非另有說明, 數量限制指 30 天的供藥量 例如,Elderplan FIDA Total Care 規定 Fentanyl 貼片 30 天的數量限制為 10 片 LA NM 取藥限制 此藥物可能僅在某些藥房提供 如需更多資訊, 請致電參保者服 務部, 電話 : 不能在郵購藥房購買 註 : 藥物旁邊有 * 代表藥物不是 D 部分藥物 這些藥物有不同的上訴規則 上訴是指透過正式方式要求我們審查並更改您認為有誤的承保範圍決定 例如,Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 可能裁決某種您想要的藥物是 Medicare 或 Medicaid 不承保或不再承保的藥物 如果您或您的醫生或其他處方醫師不同意該裁決, 您可提出上訴 如需瞭解如何提出上訴, 請致電參保者服務部, 電話 : 或 Independent Consumer Advocacy Network (ICAN),? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

12 XI 電話 : ( 聽障和語障人士可致電 711, 然後按照提示撥打 ) 您 也可以參閱參保者手冊, 瞭解如何對裁決提出上訴? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

13 XII 按疾病排列的藥物清單 本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

14 NY_CY17_2T_MMP effective 11/01/2017 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 probenecid 1 $0 ULORIC 2 $0 ST MISCELLANEOUS acetaminophen CAPS 3 $0 NM; * acetaminophen CHEW 3 $0 NM; * acetaminophen LIQD 3 $0 NM; * acetaminophen SOLN 3 $0 NM; * acetaminophen SUPP 120mg, 3 $0 NM; * 325mg, 650mg ACETAMINOPHEN SUPP 120mg, 3 $0 NM; * 325mg, 650mg acetaminophen SUSP 3 $0 NM; * acetaminophen TABS 3 $0 NM; * acetaminophen TBCR 3 $0 NM; * acetaminophen TBDP 3 $0 NM; * aspirin CHEW 3 $0 NM; * aspirin SUPP 300mg, 600mg 3 $0 NM; * aspirin TABS 3 $0 NM; * aspirin TBEC 3 $0 NM; * aspirin buffered (cal carb-mag 3 $0 NM; * carb-mag oxide) FEVERALL INFANTS 3 $0 NM; * NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg 1 $0 QL (240 caps / 30 celecoxib CAPS 100mg 1 $0 QL (120 caps / 30 celecoxib CAPS 200mg 1 $0 QL (60 caps / 30 celecoxib CAPS 400mg 1 $0 QL (30 caps / 30 diclofenac potassium 1 $0 QL (120 tabs / 30 diclofenac sodium TB24 1 $0 diclofenac sodium TBEC 1 $0 diflunisal 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 1

15 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 ibuprofen CAPS 3 $0 NM; * ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen SUSP 100mg/5ml 3 $0 NM; * ibuprofen TABS 200mg 3 $0 NM; * ibuprofen TABS 400mg, 600mg, 1 $0 800mg ketoprofen CAPS 1 $0 MELOXICAM SUSP 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS; TBEC 1 $0 naproxen sodium TABS 275mg, 1 $0 550mg piroxicam CAPS 1 $0 sulindac TABS 1 $0 OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 butorphanol tartrate SOLN 1 $0 1mg/ml, 2mg/ml BUTRANS 5mcg/hr 2 $0 QL (16 patches / 28 BUTRANS 10mcg/hr 2 $0 QL (8 patches / 28 BUTRANS 15mcg/hr, 20mcg/hr 2 $0 QL (4 patches / 28 BUTRANS 7.5MCG/HR 2 $0 QL (8 patches / 28 nalbuphine hcl SOLN 1 $0 tramadol hcl TABS 1 $0 QL (240 tabs / 30 tramadol-acetaminophen 1 $0 QL (240 tabs / 30 OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH 1 $0 B/D endocet 1 $0 QL (360 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 2

16 fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30, PA fentanyl patch 12 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 25 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 50 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 75 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 100 mcg/hr 1 $0 QL (10 patches / 30, PA FENTORA 2 $0 QL (120 tabs / 30, PA hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 hydroco/apap tab $0 QL (360 tabs / 30 hydroco/apap tab mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen mg/15ml 1 $0 QL (5400 ml / 30 hydrocodone-ibuprofen tab mg 1 $0 QL (150 tabs / 30 hydromorphone hcl LIQD 1 $0 hydromorphone hcl SOLN 1 $0 B/D 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 HYSINGLA ER 20mg, 30mg, 2 $0 QL (60 tabs / 30 40mg, 60mg HYSINGLA ER 80mg, 100mg, 2 $0 QL (30 tabs / mg lorcet hd tab mg 1 $0 QL (360 tabs / 30 lorcet plus tab $0 QL (360 tabs / 30 lorcet tab 5-325mg 1 $0 QL (360 tabs / 30 methadone hcl CONC 1 $0 QL (120 ml / 30 methadone hcl SOLN 5mg/5ml, 1 $0 QL (600 ml / 30 10mg/5ml methadone hcl 5mg 1 $0 QL (240 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 3

17 methadone hcl 10mg 1 $0 QL (240 tabs / 30 morphine ext-rel tab 15mg, 1 $0 QL (90 tabs / 30 30mg, 60mg, 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 MORPHINE SUL INJ 1MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 10MG/ML 1 $0 B/D MORPHINE SUL INJ 15MG/ML 1 $0 B/D MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml, 150mg/30ml 1 $0 B/D morphine sulfate SOLN.5mg/ml, 1 $0 B/D 1mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE TABS 1 $0 QL (180 tabs / 30 MORPHINE SULFATE ORAL SOL 1 $0 oxycodone hcl CAPS 1 $0 QL (180 caps / 30 oxycodone hcl CONC 1 $0 OXYCODONE HCL SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 oxycodone w/ acetaminophen $0 QL (360 tabs / mg oxycodone w/ acetaminophen 5-325mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen $0 QL (360 tabs / mg oxycodone w/ acetaminophen mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen soln 1 $0 QL (1800 ml / 30 OXYCONTIN 2 $0 QL (120 tabs / 30 ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 $0 B/D lidocaine inj 0.5% 1 $0 B/D lidocaine inj 1% 1 $0 B/D lidocaine inj 1.5% 1 $0 B/D lidocaine inj 2% 1 $0 B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS * - Non-Part D s, or OTC items that are covered by Medicaid 4

18 amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 sulfadiazine TABS 2 $0 tobramycin NEBU 2 $0 NM, PA tobramycin inj 1.2 gm/30ml 1 $0 tobramycin inj 1.2gm 2 $0 tobramycin inj 10mg/ml 1 $0 tobramycin inj 40mg/ml 1 $0 tobramycin inj 80mg/2ml 1 $0 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM IN ISO-OSMOTIC DE 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate SOLN 1 $0 clindamycin phosphate in d5w 1 $0 CLINDAMYCIN PHOSPHATE IN 2 $0 NACL clindamycin phosphate inj 1 $0 clindamycin sol 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 CUBICIN 2 $0 dapsone TABS 1 $0 daptomycin 2 $0 emverm 2 $0 imipenem-cilastatin 1 $0 INVANZ 2 $0 ivermectin TABS 1 $0 linezolid SOLN 2 $0 LINEZOLID SUSR; TABS 2 $0 LINEZOLID IN SODIUM CHLORIDE 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 5

19 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 50mg, 100mg 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM $0 SIVEXTRO 2 $0 sulfamethoxazole-trimethop ds 1 $0 sulfamethoxazole-trimethoprim 1 $0 sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 TIGECYCLINE 2 $0 trimethoprim TABS 1 $0 TYGACIL 2 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1 $0 VANCOMYCIN IN NACL 2 $0 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 CASPOFUNGIN ACETATE 2 $0 fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 fluconazole inj nacl $0 fluconazole inj nacl $0 fluconazole inj nacl $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA MYCAMINE 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 6

20 NOXAFIL SUSP; TBEC 2 $0 nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate 1 $0 APTIVUS 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 EDURANT 2 $0 EMTRIVA 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS 2 $0 ISENTRESS HD 2 $0 lamivudine 1 $0 LEXIVA 2 $0 NEVIRAPINE SUSP 1 $0 nevirapine TABS; TB24 1 $0 NORVIR 2 $0 PREZISTA 2 $0 RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 REYATAZ 2 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA 2 $0 TIVICAY 2 $0 TYBOST 2 $0 VIDEX PEDIATRIC 2 $0 VIRACEPT 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 7

21 VIRAMUNE SUSP 2 $0 VIREAD 2 $0 ZERIT SOLR 2 $0 ZIAGEN SOLN 2 $0 zidovudine 1 $0 ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION ABACAVIR SULFATE-LAMIVUDINE 2 $0 abacavir sulfate-lamivudinezidovudine 2 $0 ATRIPLA 2 $0 COMPLERA 2 $0 DESCOVY 2 $0 EVOTAZ 2 $0 GENVOYA 2 $0 KALETRA SOL 2 $0 KALETRA TAB MG 2 $0 KALETRA TAB MG 2 $0 lamivudine-zidovudine 1 $0 lopinavir-ritonavir 2 $0 ODEFSEY 2 $0 PREZCOBIX 2 $0 STRIBILD 2 $0 TRIUMEQ 2 $0 TRUVADA TAB $0 QL (60 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE 2 $0 cycloserine CAPS 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 paser d/r 2 $0 PRIFTIN 2 $0 pyrazinamide TABS 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 SIRTURO 2 $0 LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 8

22 TRECATOR 2 $0 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS 1 $0 acyclovir SUSP 1 $0 acyclovir TABS 1 $0 acyclovir sodium 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE SOLN 2 $0 DAKLINZA 2 $0 NM, PA entecavir 2 $0 EPCLUSA 2 $0 NM, PA EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 ganciclovir inj 500mg 1 $0 B/D HARVONI 2 $0 NM, PA lamivudine (hbv) 1 $0 MAVYRET 2 $0 NM, PA moderiba tab 200mg 1 $0 NM oseltamivir phosphate 1 $0 PEGASYS 2 $0 NM, PA PEGASYS PROCLICK 2 $0 NM, PA REBETOL SOLN 2 $0 NM RELENZA DISKHALER 2 $0 ribasphere CAPS 1 $0 NM ribasphere TABS 200mg 1 $0 NM ribasphere TABS 400mg, 600mg 2 $0 NM ribavirin 200mg 1 $0 NM rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA TAMIFLU SUSR 2 $0 TYZEKA 2 $0 valacyclovir hcl TABS 1 $0 VALCYTE SOLR 2 $0 valganciclovir hcl 2 $0 VEMLIDY 2 $0 VOSEVI 2 $0 NM, PA ZEPATIER 2 $0 NM, PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor 1 $0 cefaclor monohydrate er 2 $0 cefadroxil 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 9

23 CEFAZOLIN IN DEXTROSE 2 $0 2GM/100ML-4% cefazolin inj 1 $0 cefazolin sodium SOLR 1gm, 1 $0 20gm cefazolin sodium 1 gm/50ml 2 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefixime 1 $0 cefotaxime sodium 1gm, 2gm, 1 $0 500mg cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime SOLR 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1gm, 1 $0 2gm, 10gm, 250mg, 500mg cefuroxime axetil 1 $0 cefuroxime sodium 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 suprax CHEW 2 $0 SUPRAX SUSR 500mg/5ml 2 $0 tazicef SOLR 1 $0 tazicef vial 1 $0 TEFLARO 2 $0 ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS AZITHROMYCIN PACK 1 $0 azithromycin SOLR; SUSR; TABS 1 $0 clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s. 1 $0 ery-tab 1 $0 erythrocin lactobionate 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 erythromycin ethylsuccinate TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 10

24 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR 1 $0 ciprofloxacin er 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 ciprofloxacin inj 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 moxifloxacin hcl TABS 1 $0 PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 ampicillin susp 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1 $0 oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g procaine 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 penicilln gk inj 20mu 1 $0 pfizerpen-g 1 $0 piperacillin sodium-tazobactam 1 $0 sodium piperacillin/tazobactam 1 $0 TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 1 $0 doxycycline (monohydrate) CAPS 1 $0 50mg, 100mg doxycycline (monohydrate) TABS 1 $0 doxycycline hyclate CAPS 1 $0 doxycycline hyclate SOLR 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 11

25 doxycycline hyclate TABS 20mg, 1 $0 100mg minocycline hcl CAPS 1 $0 morgidox cap 1x50mg 1 $0 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 2 $0 B/D, NM BICNU 2 $0 B/D busulfan 2 $0 B/D BUSULFEX 2 $0 B/D CYCLOPHOSPHAMIDE CAPS 2 $0 B/D cyclophosphamide SOLR 2 $0 B/D dacarbazine 1 $0 B/D EMCYT 2 $0 GLEOSTINE 2 $0 HEXALEN 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D LEUKERAN 2 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D TREANDA 2 $0 B/D, NM ANTHRACYCLINES adriamycin 1 $0 B/D daunorubicin hcl 1 $0 B/D doxorubicin hcl 1 $0 B/D doxorubicin hcl liposomal inj 2 $0 B/D 2mg/ml doxorubicin inj 50mg 1 $0 B/D epirubicin hcl 1 $0 B/D idarubicin hcl 2 $0 B/D ANTIBIOTICS bleomycin sulfate 1 $0 B/D mitomycin SOLR 2 $0 B/D ANTIMETABOLITES adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 12

26 cladribine 2 $0 B/D cytarabine 20mg/ml 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D GEMCITABINE HCL SOLN 2 $0 B/D gemcitabine hcl SOLR 2 $0 B/D mercaptopurine TABS 1 $0 METHOTREXATE SODIUM 50mg/2ml 1 $0 B/D methotrexate sodium 50mg/2ml, 1 $0 B/D 100mg/4ml, 200mg/8ml, 250mg/10ml methotrexate sodium inj 1 $0 B/D NIPENT 2 $0 B/D PURIXAN 2 $0 NM TABLOID 2 $0 ANTIMITOTIC, TAXOIDS ABRAXANE 2 $0 B/D DOCEFREZ 2 $0 B/D DOCETAXEL 20mg/ml, 80mg/4ml, 2 $0 B/D 160mg/8ml docetaxel 80mg/4ml, 2 $0 B/D 200mg/10ml DOCETAXEL 20MG/2ML 2 $0 B/D DOCETAXEL 160MG/16ML 2 $0 B/D DOCETAXEL SOLN 80MG/8ML 2 $0 B/D paclitaxel 1 $0 B/D TAXOTERE 80mg/4ml 2 $0 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 $0 B/D vincasar 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN 2 $0 NM, LA, PA BELEODAQ 2 $0 NM, PA ERIVEDGE 2 $0 NM, LA, PA FARYDAK 2 $0 NM, LA, PA HERCEPTIN 2 $0 NM, PA IBRANCE 2 $0 NM, LA, PA IDHIFA 2 $0 NM, LA, PA ISTODAX (OVERFILL) 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 13

27 KADCYLA 2 $0 B/D, NM KEYTRUDA 2 $0 NM, PA KISQALI 2 $0 NM, PA KISQALI FEMARA 200 DOSE 2 $0 NM, PA KISQALI FEMARA 400 DOSE 2 $0 NM, PA KISQALI FEMARA 600 DOSE 2 $0 NM, PA LYNPARZA CAPS 2 $0 NM, LA, PA NINLARO 2 $0 NM, PA PROLEUKIN 2 $0 B/D, NM RITUXAN 2 $0 NM, LA, PA RITUXAN HYCELA 2 $0 NM, LA, PA RUBRACA 2 $0 NM, LA, PA TECENTRIQ 2 $0 NM, LA, PA VELCADE 2 $0 NM, PA VENCLEXTA 2 $0 NM, LA, PA VENCLEXTA STARTING PACK 2 $0 NM, LA, PA YERVOY 2 $0 NM, PA ZEJULA 2 $0 NM, LA, PA ZOLINZA 2 $0 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 hydroxyprogesterone caproate 2 $0 B/D (antineoplastic) letrozole TABS 1 $0 leuprolide acetate KIT 1 $0 NM, PA LUPRON DEPOT (1-MONTH) 2 $0 NM, PA 3.75mg LUPRON DEPOT INJ 11.25MG (3-2 $0 NM, PA MONTH) LYSODREN 2 $0 megestrol ac sus 40mg/ml 2 $0 PA; PA if 65 years and older megestrol ac tab 20mg 2 $0 PA; PA if 65 years and older megestrol ac tab 40mg 2 $0 PA; PA if 65 years and older * - Non-Part D s, or OTC items that are covered by Medicaid 14

28 MEGESTROL SUS 625MG/5ML 2 $0 PA nilutamide 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, LA, PA KINASE INHIBITORS AFINITOR 2 $0 NM, PA AFINITOR DISPERZ 2 $0 NM, PA ALECENSA 2 $0 NM, LA, PA ALUNBRIG 2 $0 NM, LA, PA BOSULIF 2 $0 NM, PA CABOMETYX 2 $0 NM, LA, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, LA, PA COTELLIC 2 $0 NM, LA, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA ICLUSIG 2 $0 NM, LA, PA imatinib mesylate 100mg 2 $0 QL (90 tabs / 30, NM, PA imatinib mesylate 400mg 2 $0 QL (60 tabs / 30, NM, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA 2 $0 NM, LA, PA IRESSA 2 $0 NM, LA, PA JAKAFI 2 $0 NM, LA, PA LENVIMA 8 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 10 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 14 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 18 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 20 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 24 MG DAILY DOSE 2 $0 NM, LA, PA MEKINIST 2 $0 NM, LA, PA NERLYNX 2 $0 NM, LA, PA NEXAVAR 2 $0 NM, LA, PA RYDAPT 2 $0 NM, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 15

29 SUTENT 2 $0 NM, PA TAFINLAR 2 $0 NM, LA, PA TAGRISSO 2 $0 NM, LA, PA TARCEVA 2 $0 NM, LA, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, LA, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYDELIG 2 $0 NM, LA, PA ZYKADIA 2 $0 NM, LA, PA MISCELLANEOUS bexarotene 2 $0 NM, PA DROXIA 2 $0 hydroxyurea CAPS 1 $0 LONSURF 2 $0 NM, PA MATULANE 2 $0 LA mitoxantrone hcl 1 $0 B/D, NM ODOMZO 2 $0 NM, LA, PA SYLATRON KIT 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 TRISENOX 2 $0 B/D PLATINUM-BASED AGENTS carboplatin 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin 1 $0 B/D PROTECTIVE AGENTS AMIFOSTINE 2 $0 B/D dexrazoxane 2 $0 B/D ELITEK 2 $0 B/D FUSILEV 2 $0 B/D, NM leucovorin calcium SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 leucovorin calcium for inj 500 mg 1 $0 B/D levoleucovorin calcium SOLN 2 $0 B/D, NM levoleucovorin calcium SOLR 2 $0 B/D, NM 50mg LEVOLEUCOVORIN CALCIUM SOLR 175mg 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 16

30 mesna 1 $0 B/D MESNEX TABS 2 $0 TOPOISOMERASE INHIBITORS etoposide SOLN 1 $0 B/D irinotecan inj 40mg/2ml 1 $0 B/D irinotecan inj 100/5ml 1 $0 B/D irinotecan inj 500mg/25ml 1 $0 B/D toposar 1 $0 B/D TOPOTECAN HCL SOLN 2 $0 B/D topotecan hcl SOLR 2 $0 B/D CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl cap 10-1 $0 20 mg amlodipine-benazepril hcl cap mg 1 $0 amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap 10-1 $0 40mg benazepril & hydrochlorothiazide 1 $0 captopril & hydrochlorothiazide 1 $0 enalapril maleate & 1 $0 hydrochlorothiazide fosinopril sodium & 1 $0 hydrochlorothiazide lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 1 $0 captopril TABS 1 $0 enalapril maleate TABS 1 $0 fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 17

31 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone 1 $0 spironolactone TABS 1 $0 ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate 1mg, 2mg, 1 $0 QL (30 tabs / 30 4mg doxazosin mesylate 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan 1 $0 medoxomil amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg candesartan cilexetilhydrochlorothiazide 1 $0 ENTRESTO 2 $0 irbesartan-hydrochlorothiazide 1 $0 losartan-hydrochlorothiazide 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 18

32 olmesartan medoxomil-amlodipine-hydrochlorothiazide $0 olmesartan medoxomilhydrochlorothiazide 1 $0 telmisartan-hydrochlorothiazide 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil 1 $0 irbesartan 1 $0 losartan potassium 1 $0 olmesartan medoxomil TABS 1 $0 telmisartan 1 $0 valsartan 1 $0 ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA; PA if 65 years and older DOFETILIDE 1 $0 NM flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 NORPACE CR 2 $0 PA; PA if 65 years and older pacerone 1 $0 propafenone hcl 1 $0 propafenone hcl 12hr 1 $0 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS 1 $0 lovastatin 1 $0 pravastatin sodium 1 $0 rosuvastatin calcium 1 $0 QL (30 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 19

33 simvastatin TABS 5mg, 10mg, 1 $0 20mg, 40mg simvastatin TABS 80mg 1 $0 QL (30 tabs / 30 ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine 1 $0 cholestyramine light 1 $0 colestipol hcl 1 $0 ezetimibe 1 $0 fenofibrate TABS 48mg, 54mg, 1 $0 145mg, 160mg fenofibrate micronized 67mg, 1 $0 134mg, 200mg gemfibrozil TABS 1 $0 JUXTAPID 2 $0 NM, LA, PA KYNAMRO 2 $0 NM, PA niacin er (antihyperlipidemic) 1 $0 QL (90 tabs / mg niacin er (antihyperlipidemic) 1 $0 750mg, 1000mg niacor 1 $0 omega-3-acid ethyl esters 1 $0 PRALUENT 2 $0 NM, PA prevalite 1 $0 triklo 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab mg 1 $0 metoprolol & hctz tab mg 1 $0 propranolol & hydrochlorothiazide 1 $0 BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2 $0 carvedilol 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 20

34 labetalol hcl TABS 1 $0 metoprolol succinate 1 $0 metoprolol tartrate SOCT 1 $0 metoprolol tartrate SOLN 1 $0 metoprolol tartrate TABS 25mg, 1 $0 50mg, 100mg nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 propranolol oral sol 1 $0 timolol maleate TABS 1 $0 CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab cr 1 $0 amlodipine besylate TABS 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-xr cap 1 $0 diltiazem cap 120mg cd 1 $0 diltiazem cap 180mg cd 1 $0 diltiazem cap 240mg cd 1 $0 diltiazem cap 300mg cd 1 $0 DILTIAZEM CAP 360MG CD 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl SOLN; TABS 1 $0 diltiazem hcl cap sr 24hr 1 $0 diltiazem hcl coated beads cap sr 1 $0 24hr diltiazem hcl extended release 1 $0 beads cap sr felodipine 1 $0 isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical xl 1 $0 nifedipine TB24 1 $0 nifedipine er 1 $0 nimodipine CAPS 2 $0 NYMALIZE 2 $0 taztia 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 21

35 verapamil cap er 100mg, 120mg, 1 $0 180mg, 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg 1 $0 verapamil hcl SOLN; TABS; TBCR 1 $0 verapamil tab er 1 $0 DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek.25mg 1 $0 PA; PA if 65 years and older digitek.125mg 1 $0 QL (30 tabs / 30 digox 125mcg 1 $0 QL (30 tabs / 30 digox 250mcg 1 $0 PA; PA if 65 years and older digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 digoxin TABS 250mcg 1 $0 PA; PA if 65 years and older digoxin inj 1 $0 DIGOXIN SOL 50MCG/ML 1 $0 PA; PA if 65 years and older DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl TABS 1 $0 bumetanide 1 $0 chlorothiazide tabs 1 $0 chlorthalidone 1 $0 furosemide SOLN; TABS 1 $0 furosemide inj 10mg/ml 1 $0 FUROSEMIDE INJ 10mg/ml 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & 1 $0 hydrochlorothiazide torsemide tabs 1 $0 triamterene & hydrochlorothiazide 1 $0 TABS triamterene & hydrochlorothiazide 1 $0 cap mg MISCELLANEOUS clonidine hcl PTWK; TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 22

36 DEMSER 2 $0 hydralazine hcl SOLN; TABS 1 $0 midodrine hcl 1 $0 minoxidil TABS 1 $0 NORTHERA 2 $0 NM, LA, PA RANEXA 2 $0 NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide dinitrate er 1 $0 isosorbide mononitrate er 1 $0 minitran 1 $0 nitro-bid 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin SUBL 1 $0 nitroglycerin td patch 1 $0 PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA 2 $0 NM, PA ADEMPAS 2 $0 QL (90 tabs / 30, NM, LA, PA LETAIRIS 2 $0 QL (30 tabs / 30, NM, LA, PA OPSUMIT 2 $0 NM, LA, PA REMODULIN 2 $0 NM, LA, PA REVATIO SUSR 2 $0 QL (224 ml / 30, NM, PA sildenafil citrate (pulmonary hypertension) TABS 1 $0 QL (90 tabs / 30, NM, PA TRACLEER 62.5mg 2 $0 QL (120 tabs / 30, NM, LA, PA TRACLEER 125mg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TABS 200mcg 2 $0 QL (480 tabs / 30, NM, LA, PA UPTRAVI TABS 400mcg 2 $0 QL (240 tabs / 30, NM, LA, PA UPTRAVI TABS 600mcg 2 $0 QL (150 tabs / 30, NM, LA, PA UPTRAVI TABS 800mcg 2 $0 QL (120 tabs / 30, NM, LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 23

37 UPTRAVI TABS 1000mcg 2 $0 QL (90 tabs / 30, NM, LA, PA UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TBPK 2 $0 NM, LA, PA VENTAVIS 2 $0 NM, PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 alprazolam tab 1mg 1 $0 QL (120 tabs / 30 alprazolam tab 2mg 1 $0 QL (150 tabs / 30 buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 1 $0 QL (45 tabs / 30 50mg fluvoxamine maleate TABS 1 $0 100mg lorazepam CONC 1 $0 QL (150 ml / 30 lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg 2 $0 QL (180 tabs / 30 APTIOM 400mg 2 $0 QL (90 tabs / 30 APTIOM 600mg, 800mg 2 $0 QL (60 tabs / 30 BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA BRIVIACT 2 $0 PA carbamazepine CHEW; CP12; 1 $0 SUSP; TABS; TB12 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (120 tabs / 30 clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 24

38 clonazepam TABS.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP 1mg 1 $0 QL (120 tabs / 30 clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 clonazepam TBDP.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP.25mg 1 $0 QL (480 tabs / 30 clonazepam TBDP.125mg 1 $0 QL (960 tabs / 30 clorazepate dipotassium 3.75mg, 7.5mg 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30, PA; PA if 65 years and older DIASTAT ACUDIAL 2 $0 DIASTAT PEDIATRIC 2 $0 diazepam CONC 1 $0 QL (240 ml / 30, PA; PA if 65 years and older diazepam SOLN 1mg/ml 1 $0 QL (1200 ml / 30, PA; PA if 65 years and older diazepam SOLN 5mg/ml 1 $0 diazepam TABS 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older DIAZEPAM GEL 1 $0 dilantin 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium CSDR; TB24; 1 $0 TBEC epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 1 $0 FYCOMPA SUSP 2 $0 QL (720 ml / 30, PA FYCOMPA TABS 2mg 2 $0 QL (180 tabs / 30, PA * - Non-Part D s, or OTC items that are covered by Medicaid 25

39 FYCOMPA TABS 4mg 2 $0 QL (90 tabs / 30, PA FYCOMPA TABS 6mg 2 $0 QL (60 tabs / 30, PA FYCOMPA TABS 8mg, 10mg, 12mg 2 $0 QL (30 tabs / 30, PA gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 gabapentin SOLN 1 $0 QL (2160 ml / 30 gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 LEVETIRACETAM IN SODIUM 2 $0 CHLORIDE LEVETIRACETAM IV 1 $0 levetiracetam oral soln 100 mg/ml 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg 2 $0 QL (120 caps / 30 LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 LYRICA SOLN 2 $0 QL (946 ml / 30 ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml 2 $0 PA; PA if 65 years and older phenobarbital sodium SOLN 130mg/ml 2 $0 PA; PA if 65 years and older phenytek 2 $0 phenytoin CHEW; SUSP 1 $0 phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 26

40 POTIGA 50mg 2 $0 POTIGA 200mg 2 $0 QL (180 tabs / 30 POTIGA 300mg, 400mg 2 $0 QL (90 tabs / 30 primidone TABS 1 $0 roweepra 1 $0 SABRIL PACK 2 $0 QL (180 packets / 30, NM, LA, PA SABRIL TABS 2 $0 QL (180 tabs / 30, NM, LA, PA SPRITAM 2 $0 TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN 1 $0 valproic acid 1 $0 vigabatrin powd pack 2 $0 QL (180 packets / 30, NM, LA, PA VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 VIMPAT TABS 100mg, 150mg, 2 $0 QL (60 tabs / mg zonisamide CAPS 1 $0 ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 1 $0 QL (60 tabs / 30 5mg donepezil hydrochloride TABS 1 $0 10mg, 23mg donepezil hydrochloride TBDP 1 $0 QL (60 tabs / 30 5mg donepezil hydrochloride TBDP 10mg 1 $0 galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 1 $0 QL (180 tabs / 30 4mg galantamine hydrobromide TABS 1 $0 QL (90 tabs / 30 8mg galantamine hydrobromide TABS 1 12mg $0 * - Non-Part D s, or OTC items that are covered by Medicaid 27

41 galantamine hydrobromide er 1 $0 QL (30 caps / 30 8mg, 16mg galantamine hydrobromide er 1 $0 24mg memantine hcl SOLN 1 $0 PA; PA if < 30 yrs memantine hcl TABS 5mg 1 $0 PA; PA if < 30 yrs MEMANTINE HCL TABS 10mg 1 $0 PA; PA if < 30 yrs NAMENDA XR 2 $0 PA; PA if < 30 yrs NAMENDA XR TITRATION PACK 2 $0 PA; PA if < 30 yrs NAMZARIC 2 $0 rivastigmine tartrate 1 $0 rivastigmine td patch 24hr 4.6 mg/24hr 1 $0 QL (30 patches / 30 rivastigmine td patch 24hr 9.5 mg/24hr 1 $0 QL (30 patches / 30 rivastigmine td patch 24hr 13.3 mg/24hr 1 $0 QL (30 patches / 30 ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS 2 $0 PA; PA if 65 years and older amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 amoxapine tab 150mg 1 $0 bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 1 $0 QL (45 tabs / 30 10mg, 20mg citalopram hydrobromide TABS 1 $0 QL (30 tabs / 30 40mg clomipramine hcl CAPS 2 $0 PA; PA if 65 years and older desipramine hcl TABS 1 $0 desvenlafaxine succinate 1 $0 QL (30 tabs / 30 doxepin hcl CAPS; CONC 2 $0 PA; PA if 65 years and older duloxetine hcl CPEP 20mg 1 $0 QL (180 caps / 30 duloxetine hcl CPEP 30mg 1 $0 QL (120 caps / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 28

42 duloxetine hcl CPEP 60mg 1 $0 QL (60 caps / 30 EMSAM 2 $0 QL (30 patches / 30, PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 escitalopram oxalate TABS 5mg, 10mg 1 $0 QL (45 tabs / 30 escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 FETZIMA 20mg 2 $0 QL (180 caps / 30 FETZIMA 40mg 2 $0 QL (90 caps / 30 FETZIMA 80mg, 120mg 2 $0 QL (30 caps / 30 FETZIMA TITRATION PACK 2 $0 fluoxetine cap 10mg 1 $0 QL (30 caps / 30 fluoxetine cap 20mg 1 $0 QL (120 caps / 30 fluoxetine cap 40mg 1 $0 fluoxetine hcl SOLN 1 $0 fluoxetine hcl TABS 10mg 1 $0 QL (45 tabs / 30 fluoxetine hcl TABS 20mg 1 $0 imipramine hcl TABS 2 $0 PA; PA if 65 years and older maprotiline hcl 1 $0 MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 mirtazapine TABS 7.5mg, 15mg 1 $0 QL (45 tabs / 30 mirtazapine TABS 30mg, 45mg 1 $0 mirtazapine TBDP 15mg 1 $0 QL (30 tabs / 30 mirtazapine TBDP 30mg, 45mg 1 $0 nefazodone hcl 1 $0 nortriptyline hcl CAPS; SOLN 1 $0 paroxetine hcl tabs 10mg, 20mg, 1 $0 QL (45 tabs / 30 40mg paroxetine hcl tabs 30mg 1 $0 QL (60 tabs / 30 PAXIL SUSP 2 $0 QL (900 ml / 30 phenelzine sulfate TABS 1 $0 PRISTIQ 2 $0 QL (30 tabs / 30 protriptyline hcl 1 $0 sertraline hcl CONC 1 $0 sertraline hcl TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 sertraline hcl TABS 100mg 1 $0 tranylcypromine sulfate 1 $0 trazodone hcl TABS 50mg, 100mg, 150mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 29

43 trimipramine maleate CAPS 25mg 2 $0 QL (240 caps / 30, PA; PA if 65 years and older trimipramine maleate CAPS 50mg 2 $0 QL (120 caps / 30, PA; PA if 65 years and older trimipramine maleate CAPS 100mg 2 $0 QL (60 caps / 30, PA; PA if 65 years and older TRINTELLIX 5mg 2 $0 QL (120 tabs / 30 TRINTELLIX 10mg 2 $0 QL (60 tabs / 30 TRINTELLIX 20mg 2 $0 QL (30 tabs / 30 venlafaxine hcl CP mg, 1 $0 QL (30 caps / 30 75mg venlafaxine hcl CP24 150mg 1 $0 QL (60 caps / 30 venlafaxine hcl TABS 1 $0 VIIBRYD STARTER PACK 2 $0 VIIBRYD TAB 2 $0 QL (30 tabs / 30 ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS 1 $0 QL (120 caps / 30 amantadine hcl SYRP; TABS 1 $0 APOKYN 2 $0 NM, LA, PA BENZTROPINE MESYLATE SOLN 1 $0 benztropine mesylate TABS 2 $0 PA; PA if 65 years and older bromocriptine mesylate CAPS; 1 $0 TABS carbidopa-levodopa 1 $0 CARBIDOPA/LEVODOPA/ENTACAPO1 $0 NE ENTACAPONE 1 $0 NEUPRO 2 $0 pramipexole tab 0.5mg 1 $0 pramipexole tab 0.25mg 1 $0 pramipexole tab 0.75mg 1 $0 pramipexole tab 0.125mg 1 $0 pramipexole tab 1.5mg 1 $0 pramipexole tab 1mg 1 $0 rasagiline mesylate TABS 1 $0 ropinirole tab 0.5mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 30

44 ropinirole tab 0.25mg 1 $0 ropinirole tab 1mg 1 $0 ropinirole tab 2mg 1 $0 ropinirole tab 3mg 1 $0 ropinirole tab 4mg 1 $0 ropinirole tab 5mg 1 $0 selegiline hcl CAPS; TABS 1 $0 trihexyphenidyl hcl 2 $0 PA; PA if 65 years and older ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA PRSY 2 $0 QL (1 syringe / 28 ABILIFY MAINTENA SRER 2 $0 QL (1 vial / 28 aripiprazole odt 2 $0 QL (60 tabs / 30 aripiprazole oral solution 1 mg/ml 2 $0 QL (900 ml / 30 aripiprazole tab 2mg, 5mg, 10mg, 1 $0 QL (30 tabs / 30 15mg aripiprazole tab 20mg, 30mg 2 $0 QL (30 tabs / 30 ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml 2 $0 QL (1 syringe / 28 ARISTADA 1064mg/3.9ml 2 $0 QL (1 syringe / 56 chlorpromazine hcl TABS 1 $0 chlorpromazine inj 2 $0 CLOZAPINE ODT 12.5mg, 25mg 1 $0 PA CLOZAPINE ODT 100mg 1 $0 QL (270 tabs / 30, PA CLOZAPINE ODT 150mg 1 $0 QL (180 tabs / 30, PA CLOZAPINE ODT 200mg 2 $0 QL (135 tabs / 30, PA clozapine tab 25mg 1 $0 clozapine tab 50mg 1 $0 clozapine tab 100mg 1 $0 QL (270 tabs / 30 clozapine tab 200mg 1 $0 QL (135 tabs / 30 FANAPT 2 $0 QL (60 tabs / 30 FANAPT TITRATION PACK 2 $0 fluphenazine decanoate SOLN 1 $0 fluphenazine hcl 1 $0 GEODON SOLR 2 $0 QL (6 ml / 3 haloperidol TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 31

45 haloperidol decanoate SOLN 1 $0 haloperidol lactate inj 5 mg/ml 1 $0 haloperidol lactate oral conc 2 mg/ml 1 $0 INVEGA SUST INJ 39 MG/0.25 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 78 MG/0.5 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 117 MG/0.75 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 234 MG/1.5 ML 2 $0 QL (1 injection / 28 INVEGA TRINZA 2 $0 QL (1 syringe / 90 LATUDA 20mg 2 $0 QL (240 tabs / 30 LATUDA 40mg, 120mg 2 $0 QL (30 tabs / 30 LATUDA 60mg, 80mg 2 $0 QL (60 tabs / 30 loxapine succinate 1 $0 molindone hcl 10mg 1 $0 molindone hcl 25mg 1 $0 NUPLAZID 2 $0 QL (60 tabs / 30, NM, LA, PA olanzapine SOLR 1 $0 QL (3 vials / 1 day) olanzapine TABS 2.5mg 1 $0 QL (240 tabs / 30 olanzapine TABS 5mg 1 $0 QL (120 tabs / 30 olanzapine TABS 7.5mg 1 $0 QL (30 tabs / 30 olanzapine TABS 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg olanzapine TBDP 5mg 1 $0 QL (30 tabs / 30 olanzapine TBDP 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg paliperidone 1.5mg, 3mg, 9mg 2 $0 QL (30 tabs / 30 paliperidone 6mg 2 $0 QL (60 tabs / 30 perphenazine TABS 1 $0 pimozide 1 $0 quetiapine fumarate TABS 1 $0 QL (90 tabs / 30 quetiapine fumarate TB24 50mg 1 $0 QL (120 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 32

46 quetiapine fumarate TB24 1 $0 QL (30 tabs / mg, 200mg quetiapine fumarate TB24 1 $0 QL (60 tabs / mg, 400mg REXULTI 1mg 2 $0 QL (90 tabs / 30 REXULTI 2mg 2 $0 QL (60 tabs / 30 REXULTI 3mg, 4mg 2 $0 QL (30 tabs / 30 REXULTI.5mg 2 $0 QL (180 tabs / 30 REXULTI.25mg 2 $0 QL (360 tabs / 30 RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 risperidone SOLN 1 $0 QL (240 ml / 30 risperidone TABS 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TABS 4mg 1 $0 QL (120 tabs / 30 risperidone TABS.25mg,.5mg 1 $0 QL (90 tabs / 30 risperidone TBDP 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TBDP 4mg 1 $0 QL (120 tabs / 30 risperidone TBDP.25mg,.5mg 1 $0 QL (90 tabs / 30 SAPHRIS 2.5mg 2 $0 QL (240 tabs / 30 SAPHRIS 5mg 2 $0 QL (120 tabs / 30 SAPHRIS 10mg 2 $0 QL (60 tabs / 30 thioridazine hcl TABS 2 $0 PA; PA if 65 years and older thiothixene 1 $0 trifluoperazine hcl 1 $0 VERSACLOZ 2 $0 QL (600 ml / 30, PA VRAYLAR 1.5mg 2 $0 QL (120 caps / 30 VRAYLAR 3mg 2 $0 QL (60 caps / 30 VRAYLAR 4.5mg, 6mg 2 $0 QL (30 caps / 30 VRAYLAR THERAPY PACK 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 33

47 ziprasidone hcl 20mg, 40mg 1 $0 QL (60 caps / 30 ziprasidone hcl 60mg, 80mg 1 $0 QL (90 caps / 30 ZYPREXA RELPREVV 300mg 2 $0 QL (2 vials / 28, PA ZYPREXA RELPREVV 405mg 2 $0 QL (1 vial / 28, PA ZYPREXA RELPREVV INJ 210MG 2 $0 QL (2 vials / 28, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 cap sr 24hr 5 mg amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 cap sr 24hr 10 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 15 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 20 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 25 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 30 mg amphetamine-dextroamphetamine 1 $0 QL (360 tabs / 30 tab 5 mg amphetamine-dextroamphetamine 1 $0 QL (240 tabs / 30 tab 7.5 mg amphetamine-dextroamphetamine 1 $0 QL (180 tabs / 30 tab 10 mg amphetamine-dextroamphetamine 1 $0 QL (144 tabs / 30 tab 12.5 mg amphetamine-dextroamphetamine 1 $0 QL (120 tabs / 30 tab 15 mg amphetamine-dextroamphetamine 1 $0 QL (90 tabs / 30 tab 20 mg amphetamine-dextroamphetamine 1 $0 QL (60 tabs / 30 tab 30 mg atomoxetine hcl 10mg, 18mg, 25mg 1 $0 QL (120 caps / 30 atomoxetine hcl 40mg 1 $0 QL (60 caps / 30 atomoxetine hcl 60mg, 80mg, 1 $0 QL (30 caps / mg guanfacine er (adhd) 2 $0 PA; PA if 65 years and older metadate er tab 20mg 1 $0 QL (90 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 34

48 methylphenidate hcl TABS 5mg, 10mg 1 $0 QL (180 tabs / 30 methylphenidate hcl TABS 20mg 1 $0 QL (90 tabs / 30 methylphenidate hcl TBCR 1 $0 QL (90 tabs / 30 methylphenidate hcl oral soln 5mg/5ml 1 $0 QL (1800 ml / 30 methylphenidate hcl oral soln 10mg/5ml 1 $0 QL (900 ml / 30 STRATTERA 10mg, 18mg, 25mg 2 $0 QL (120 caps / 30 STRATTERA 40mg 2 $0 QL (60 caps / 30 STRATTERA 60mg, 80mg, 100mg 2 $0 QL (30 caps / 30 HYPNOTICS - DRUGS TO TREAT INSOMNIA eszopiclone 2 $0 QL (30 tabs / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year HETLIOZ 2 $0 NM, LA, PA SILENOR 3mg 2 $0 QL (60 tabs / 30 SILENOR 6mg 2 $0 QL (30 tabs / 30 temazepam 7.5mg 1 $0 QL (30 caps / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year temazepam 15mg 1 $0 QL (60 caps / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year zolpidem tartrate TABS 2 $0 QL (30 tabs / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES dihydroergotamine mesylate 1 $0 1mg/ml eletriptan hydrobromide 1 $0 QL (12 tabs / 30 ergotamine w/ caffeine 1 $0 migergot 2 $0 naratriptan hcl 1 $0 QL (12 tabs / 30 RELPAX 2 $0 QL (12 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 35

49 rizatriptan benzoate 1 $0 QL (18 tabs / 30 SUMATRIPTAN SOLN 5mg/act 1 $0 QL (24 inhalers / 30 SUMATRIPTAN SOLN 20mg/act 1 $0 QL (12 inhalers / 30 SUMATRIPTAN INJ 4MG/0.5ML 1 $0 QL (18 injections / 30 sumatriptan inj 6mg/0.5ml 1 $0 QL (12 injections / 30 sumatriptan succinate TABS 1 $0 QL (12 tabs / 30 zolmitriptan TABS 1 $0 QL (12 tabs / 30 zolmitriptan odt 1 $0 QL (12 tabs / 30 MISCELLANEOUS AUSTEDO 6mg 2 $0 QL (60 tabs / 30, NM, LA, PA AUSTEDO 9mg, 12mg 2 $0 QL (120 tabs / 30, NM, LA, PA lithium carbonate CAPS; TABS 1 $0 lithium carbonate er 1 $0 LITHIUM SOLN 8MEQ/5ML 2 $0 NUEDEXTA 2 $0 PA pyridostigmine tab 60mg 1 $0 riluzole 1 $0 TETRABENAZINE 12.5mg 2 $0 QL (240 tabs / 30, NM, PA TETRABENAZINE 25mg 2 $0 QL (120 tabs / 30, NM, PA MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA 2 $0 NM, LA, PA BETASERON 2 $0 QL (14 syringes / 28, NM, PA COPAXONE INJ 40MG/ML 2 $0 QL (12 syringes / 28, NM, PA GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28, NM, PA glatopa 2 $0 QL (30 syringes / 30, NM, PA TYSABRI 2 $0 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 36

50 carisoprodol TABS 350mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older cyclobenzaprine hcl TABS 5mg, 10mg 2 $0 PA; PA if 65 years and older dantrolene sodium CAPS 1 $0 methocarbamol TABS 2 $0 PA; PA if 65 years and older tizanidine hcl TABS 1 $0 NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil 50mg 1 $0 QL (150 tabs / 30, PA armodafinil 150mg 1 $0 QL (60 tabs / 30, PA ARMODAFINIL 200mg 1 $0 QL (30 tabs / 30, PA armodafinil 250mg 1 $0 QL (30 tabs / 30, PA XYREM 2 $0 QL (540 ml / 30, LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1 $0 buprenorphine hcl SUBL 1 $0 PA buprenorphine hcl-naloxone hcl sl 1 $0 QL (120 tabs / 30, PA buproban tab 150mg 1 $0 bupropion hcl (smoking deterrent) 1 $0 CHANTIX 2 $0 PA CHANTIX CONTINUING MONTH 2 $0 PA CHANTIX STARTER PACK 2 $0 PA diphenhydramine hcl (sleep) 3 $0 NM; * disulfiram TABS 1 $0 naloxone inj 0.4mg/ml 1 $0 naloxone inj 1mg/ml 1 $0 naltrexone hcl TABS 1 $0 nicotine 7mg/24hr, 14mg/24hr, 21mg/24hr 3 $0 NM; * NICOTINE 7mg/24hr, 14mg/24hr, 3 $0 NM; * 21mg/24hr nicotine polacrilex GUM; LOZG 3 $0 NM; * NICOTROL INHALER 2 $0 NICOTROL NS 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 37

51 SUBOXONE MIS 2-0.5MG 2 $0 QL (120 SL films / 30, PA SUBOXONE MIS 4-1MG 2 $0 QL (120 SL films / 30, PA SUBOXONE MIS 8-2MG 2 $0 QL (120 SL films / 30, PA SUBOXONE MIS 12-3MG 2 $0 QL (60 SL films / 30, PA ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 2 $0 PA ANDRODERM 2 $0 QL (30 patches / 30, PA AXIRON 2 $0 QL (440 ml / 30, PA oxandrolone TABS 1 $0 PA testosterone SOLN 1 $0 QL (440 ml / 30, PA testosterone cypionate SOLN 1 $0 PA testosterone enanthate SOLN 1 $0 PA ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS 2 $0 BYDUREON INJ 2 $0 QL (4 vials / 28 BYDUREON PEN 2 $0 QL (4 pens / 28 BYETTA 2 $0 QL (1 pen / 30 GAUZE PADS 2" X 2" 2 $0 HUMULIN R INJ U $0 B/D HUMULIN R U-500 KWIKPEN 2 $0 INSULIN PEN NEEDLE 2 $0 INSULIN SAFETY NEEDLES 2 $0 INSULIN SYRINGE 2 $0 LANTUS 2 $0 LANTUS SOLOSTAR 2 $0 LEVEMIR 2 $0 LEVEMIR FLEXTOUCH 2 $0 NOVOLIN 70/30 2 $0 (brand RELION not covered) NOVOLIN N 2 $0 (brand RELION not covered) NOVOLIN R 2 $0 (brand RELION not covered) NOVOLOG 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 38

52 NOVOLOG FLEXPEN 2 $0 NOVOLOG MIX 70/30 2 $0 NOVOLOG MIX 70/30 PREFILL 2 $0 NOVOLOG PENFILL 2 $0 SYMLINPEN 60 2 $0 QL (8 pens / 30, PA SYMLINPEN $0 QL (4 pens / 30, PA TOUJEO SOLOSTAR 2 $0 TRESIBA FLEXTOUCH 2 $0 TRULICITY 2 $0 QL (4 pens / 28 VICTOZA 2 $0 QL (3 pens / 30 ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose 1 $0 FARXIGA 5mg 2 $0 QL (60 tabs / 30 FARXIGA 10mg 2 $0 QL (30 tabs / 30 glimepiride 1mg 1 $0 QL (240 tabs / 30 glimepiride 2mg 1 $0 QL (120 tabs / 30 glimepiride 4mg 1 $0 QL (60 tabs / 30 glip/metform tab m 1 $0 QL (240 tabs / 30 glip/metform tab m 1 $0 QL (120 tabs / 30 glip/metform tab 5-500mg 1 $0 QL (120 tabs / 30 glipizide TABS 5mg 1 $0 QL (240 tabs / 30 glipizide TABS 10mg 1 $0 QL (120 tabs / 30 glipizide TB24 2.5mg 1 $0 QL (240 tabs / 30 glipizide TB24 5mg 1 $0 QL (120 tabs / 30 glipizide TB24 10mg 1 $0 QL (60 tabs / 30 GLIPIZIDE XL TB24 2.5MG 1 $0 QL (240 tabs / 30 GLIPIZIDE XL TB24 5MG 1 $0 QL (120 tabs / 30 glyburide TABS 1.25mg 2 $0 QL (480 tabs / 30, PA; PA if 65 years and older * - Non-Part D s, or OTC items that are covered by Medicaid 39

53 glyburide TABS 2.5mg 2 $0 QL (240 tabs / 30, PA; PA if 65 years and older glyburide TABS 5mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older glyburide micronized 1.5mg 2 $0 QL (240 tabs / 30, PA; PA if 65 years and older glyburide micronized 3mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older glyburide micronized 6mg 2 $0 QL (60 tabs / 30, PA; PA if 65 years and older INVOKAMET TAB MG 2 $0 QL (120 tabs / 30 INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB MG 2 $0 QL (120 tabs / 30 INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 INVOKANA 100mg 2 $0 QL (90 tabs / 30 INVOKANA 300mg 2 $0 QL (30 tabs / 30 JANUMET 2 $0 QL (60 tabs / 30 JANUMET XR TAB MG 2 $0 QL (60 tabs / 30 JANUMET XR TAB $0 QL (60 tabs / 30 JANUMET XR TAB $0 QL (30 tabs / 30 JANUVIA 2 $0 QL (30 tabs / 30 JENTADUETO 2 $0 QL (60 tabs / 30 JENTADUETO TAB XR MG 2 $0 QL (60 tabs / 30 JENTADUETO TAB XR MG 2 $0 QL (30 tabs / 30 metformin hcl TABS 500mg 1 $0 QL (150 tabs / 30 metformin hcl TABS 850mg 1 $0 QL (90 tabs / 30 metformin hcl TABS 1000mg 1 $0 QL (75 tabs / 30 metformin hcl TB24 500mg 1 $0 QL (120 tabs / 30 ; (generic of GLUCOPHAGE XR) * - Non-Part D s, or OTC items that are covered by Medicaid 40

54 metformin hcl TB24 750mg 1 $0 QL (60 tabs / 30 ; (generic of GLUCOPHAGE XR) nateglinide 1 $0 QL (90 tabs / 30 pioglitazone hcl 1 $0 QL (30 tabs / 30 repaglinide 2mg 1 $0 QL (240 tabs / 30 repaglinide.5mg, 1mg 1 $0 QL (120 tabs / 30 TRADJENTA 2 $0 QL (30 tabs / 30 XIGDUO XR TAB 5-500MG 2 $0 QL (60 tabs / 30 XIGDUO XR TAB MG 2 $0 QL (60 tabs / 30 XIGDUO XR TAB MG 2 $0 QL (30 tabs / 30 XIGDUO XR TAB MG 2 $0 QL (30 tabs / 30 BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium TABS 5mg, 10mg, 40mg 1 $0 alendronate sodium TABS 35mg, 1 $0 QL (4 tabs / 28 70mg pamidronate disodium 1 $0 B/D zoledronic acid SOLN 5mg/100ml 1 $0 B/D, NM zoledronic acid SOLR 1 $0 B/D, NM zoledronic inj 4mg/5ml 1 $0 B/D, NM CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg, 90mg 2 $0 QL (120 tabs / 30, NM SENSIPAR 60mg 2 $0 QL (60 tabs / 30, NM CHELATING AGENTS CHEMET 2 $0 DEPEN TITRATABS 2 $0 EXJADE 2 $0 NM, LA, PA FERRIPROX 2 $0 NM, LA, PA kionex 1 $0 sodium polystyrene sulfonate 1 $0 sps susp 15gm/60ml 1 $0 SYPRINE 2 $0 CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab 1 $0 alyacen 1/35 1 $0 apri 28 day 1 $0 aranelle 28 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 41

55 aubra 28 day 1 $0 aviane 28 1 $0 balziva 28 day 1 $0 bekyree 28 day 1 $0 blisovi 21 fe 1.5/30 28 day pack 1 $0 blisovi 21 fe 1/20 28 day pack 1 $0 briellyn 28 day 1 $0 camila 28 day 1 $0 caziant pak 1 $0 cryselle 28 1 $0 cyclafem 1/35 28 day 1 $0 cyclafem 7/7/7 28 day 1 $0 cyred tab 1 $0 deblitane 28 day 1 $0 delyla 28 day 1 $0 desogestrel & ethinyl estradiol 1 $0 desogestrel-ethinyl estradiol 1 $0 (biphasic) drospirenone-ethinyl estradiol 1 $0 ELLA 2 $0 emoquette 1 $0 enpresse 28 day 1 $0 errin 28 day 1 $0 estarylla tab $0 ethynodiol tab $0 falmina 28 day 1 $0 femynor 28 day 1 $0 GIANVI 1 $0 gildagia 1 $0 gildess tab 1.5/30 1 $0 heather 1 $0 introvale 91 day 1 $0 isibloom 28 day 1 $0 JOLESSA TAB MG 1 $0 JOLIVETTE 1 $0 juleber 28 day 1 $0 junel 1.5/30 21 day 1 $0 junel 1/20 21 day 1 $0 junel fe 1.5/30 28 day 1 $0 junel fe 1/20 28 day 1 $0 kariva 28 day 1 $0 kelnor 1/35 28 day 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 42

56 kimidess 28 day 1 $0 larin 1.5/30 1 $0 larin 1/20 1 $0 larin fe 1.5/30 1 $0 larin fe 1/20 1 $0 larissia tab 1 $0 LEENA 1 $0 lessina 28 day 1 $0 levonest 28 day 1 $0 levonor/ethi tab 1 $0 levonorgestrel & eth estradiol 1 $0 levonorgestrel (emergency oc) 1 $0 1.5mg levonorgestrel (emergency oc) 3 $0 NM; * 1.5mg LEVONORGESTREL (EMERGENCY 3 $0 NM; * OC) 1.5mg levonorgestrel-ethinyl estradiol 1 $0 (91-day) levora 0.15/30 28 day 1 $0 loryna 28 day 1 $0 low-ogestrel 1 $0 lutera 28 day 1 $0 lyza 1 $0 marlissa 28 day 1 $0 medroxyprogesterone acetate 1 $0 (contraceptive) SUSP MEDROXYPROGESTERONE 1 $0 ACETATE (CONTRACEPTIVE) SUSY MICROGESTIN 1.5/30 1 $0 MICROGESTIN 1/20 1 $0 MICROGESTIN FE 1.5/30 1 $0 MICROGESTIN FE 1/20 1 $0 mono-linyah tab $0 MONONESSA 1 $0 myzilra 1 $0 necon 0.5/35 28 day 1 $0 NECON 7/7/7 1 $0 necon 10/ $0 necon tab 1/35 1 $0 NECON TAB 1/ $0 nikki 28 day 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 43

57 NORA-BE TAB 1 $0 norethindrone (contraceptive) 1 $0 norethindrone acet & eth estra 1 $0 norgest/ethi tab 0.25/35 1 $0 norgestimate-ethinyl estradiol 1 $0 (triphasic) norlyroc 28 day 1 $0 nortrel 0.5/35 28 day 1 $0 nortrel 1/35 21 day 1 $0 nortrel 1/35 28 day 1 $0 nortrel 7/7/7 28 day 1 $0 NUVARING 2 $0 OCELLA TAB MG 1 $0 orsythia 28 day 1 $0 philith 1 $0 pimtrea pack 1 $0 pirmella 1/35 28 day 1 $0 portia 28 day 1 $0 previfem 28 day 1 $0 quasense 91 day 1 $0 reclipsen 28 day 1 $0 setlakin tab 1 $0 sharobel 28 day 1 $0 sprintec 28 day 1 $0 sronyx 1 $0 syeda 1 $0 tarina fe 1/20 28 day 1 $0 TILIA FE 1 $0 tri-legest 28 day 1 $0 tri-linyah 1 $0 tri-lo marzia 1 $0 tri-lo-estarylla 1 $0 tri-lo-sprintec 28 day 1 $0 tri-previfem 28 day 1 $0 tri-sprintec 28 day 1 $0 TRINESSA 1 $0 TRINESSA LO TAB 1 $0 trivora 28 day 1 $0 velivet 28 day 1 $0 vestura 1 $0 vienva 28 day 1 $0 viorele 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 44

58 vyfemla 28 day 1 $0 xulane 1 $0 zarah 1 $0 zenchent 28 day 1 $0 zovia 1/35e 28 day 1 $0 zovia 1/50e 28 day 1 $0 ENDOMETRIOSIS danazol CAPS 1 $0 SYNAREL 2 $0 ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN 2 $0 NM, LA, PA ALDURAZYME 2 $0 NM, LA, PA BUPHENYL TABS 2 $0 NM, LA, PA CARBAGLU 2 $0 NM, LA, PA CERDELGA 2 $0 NM, PA CEREZYME 2 $0 NM, LA, PA CYSTADANE 2 $0 NM, LA CYSTAGON 2 $0 NM, LA, PA FABRAZYME 2 $0 NM, LA, PA KUVAN 2 $0 NM, LA, PA levocarnitine (metabolic modifiers) 1 $0 B/D LUMIZYME 2 $0 NM, LA, PA NAGLAZYME 2 $0 NM, LA, PA ORFADIN 2 $0 NM, LA, PA RAVICTI 2 $0 NM, PA sodium phenylbutyrate 2 $0 NM, PA ZAVESCA 2 $0 NM, LA, PA ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml 2 $0 estrace CREA 2 $0 estradiol PTWK 2 $0 PA; PA if 65 years and older estradiol TABS 2 $0 PA; PA if 65 years and older estradiol vaginal tab 10 mcg 1 $0 estradiol valerate OIL 1 $0 fyavolv tab 1-5mg 2 $0 PA; PA if 65 years and older jinteli 2 $0 PA; PA if 65 years and older norethindrone acetate-ethinyl estradiol 1mg-5mcg 2 $0 PA; PA if 65 years and older * - Non-Part D s, or OTC items that are covered by Medicaid 45

59 yuvafem vaginal tablet 10 mcg 1 $0 GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS 1 $0 dexamethasone CONC; ELIX; SOLN; TABS 1 $0 dexamethasone sodium phosphate 1 $0 fludrocortisone acetate TABS 1 $0 hydrocortisone TABS 1 $0 methylpr ace inj 40mg/ml 1 $0 B/D methylpr ace inj 80mg/ml 1 $0 B/D methylpr ss inj 1gm 1 $0 B/D methylpr ss inj 40mg 1 $0 B/D methylpr ss inj 125 mg 1 $0 B/D methylpred pak 4mg 1 $0 methylpred tab 4mg 1 $0 B/D methylpred tab 8mg 1 $0 B/D methylpred tab 16mg 1 $0 B/D methylpred tab 32mg 1 $0 B/D pred sod pho sol 5mg/5ml 1 $0 B/D prednisolone sol 15mg/5ml 1 $0 B/D prednisolone sol 25mg/5ml 1 $0 B/D prednisolone syp 15mg/5ml 1 $0 B/D prednisone con 5mg/ml 2 $0 B/D prednisone pak 5mg 1 $0 prednisone pak 10mg 1 $0 prednisone sol 5mg/5ml 1 $0 B/D prednisone tab 1mg 1 $0 B/D prednisone tab 2.5mg 1 $0 B/D prednisone tab 5mg 1 $0 B/D prednisone tab 10mg 1 $0 B/D prednisone tab 20mg 1 $0 B/D prednisone tab 50mg 1 $0 B/D SOLU-CORTEF 250mg 2 $0 GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN HYPOKIT 2 $0 GLUCAGON EMERGENCY KIT 2 $0 HM GLUCOSE 3 $0 NM; * PROGLYCEM SUS 50MG/ML 2 $0 SM GLUCOSE 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 46

60 HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES NORDITROPIN FLEXPRO 2 $0 NM, PA MISCELLANEOUS cabergoline 1 $0 calcitonin (salmon) 1 $0 B/D FORTICAL 2 $0 B/D INCRELEX 2 $0 NM, LA, PA KORLYM 2 $0 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG (3-2 $0 NM, PA MONTH) LUPRON DEP-PED INJ 15MG 2 $0 NM, PA LUPRON DEP-PED INJ 30MG (3-2 $0 NM, PA MONTH) methergine 0.2 mg tab 1 $0 methylergonovine maleate TABS 1 $0 MIACALCIN 200 UNIT/ML 2 $0 B/D octreotide acetate 50mcg/ml, 1 $0 NM, PA 100mcg/ml, 200mcg/ml octreotide acetate 500mcg/ml, 2 $0 NM, PA 1000mcg/ml PROLIA 2 $0 QL (1 syringe / 180, NM raloxifene hcl 1 $0 SANDOSTATIN LAR DEPOT 2 $0 NM, PA SIGNIFOR 2 $0 NM, LA, PA SOMATULINE DEPOT 2 $0 NM, PA SOMAVERT 2 $0 NM, LA, PA XGEVA 2 $0 NM, PA PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID LEVELS FORTEO 2 $0 QL (1 pen / 28, NM, PA NATPARA 2 $0 NM, PA PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA 2 $0 calcium acetate (phosphate binder) 1 $0 RENVELA PAK 0.8GM 2 $0 RENVELA PAK 2.4GM 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 47

61 RENVELA TAB 800MG 2 $0 PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab 1 $0 norethindrone acetate TABS 1 $0 THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levothyroxine sodium TABS 1 $0 25mcg, 50mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg LEVOTHYROXINE SODIUM TABS 1 $0 75mcg, 300mcg LEVOXYL 1 $0 liothyronine sodium TABS 1 $0 methimazole TABS 1 $0 propylthiouracil TABS 1 $0 SYNTHROID 2 $0 UNITHROID 1 $0 VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray 1 $0 desmopressin acetate spray 1 $0 refrigerated desmopressin acetate tabs 1 $0 desmopressin inj 4mcg/ml 1 $0 DESMOPRESSIN SOL 0.01% 1 $0 STIMATE 2 $0 NM GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTACIDS alum & mag hydrox-simethicone 3 $0 NM; * ALUMINUM HYDROXIDE 3 $0 NM; * aluminum hydroxide-mag carb 3 $0 NM; * calcium carbonate (antacid) 3 $0 NM; * CHEW; TABS GAVISCON CHEW 3 $0 NM; * GAVISCON EXTRA STRENGTH R 3 $0 NM; * magnesium oxide TABS 420mg 3 $0 NM; * mi-acid 3 $0 NM; * sodium bicarbonate (antacid) 3 $0 NM; * ANTI-DIARRHEAL bismuth subsalicylate CHEW; 3 $0 NM; * SUSP loperamide hcl LIQD; TABS 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 48

62 ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant 1 $0 B/D compro 1 $0 dimenhydrinate TABS 3 $0 NM; * dronabinol 1 $0 B/D, QL (60 caps / 30 EMEND SUSR 2 $0 B/D EMEND CAP 40MG 2 $0 B/D EMEND CAP 80MG 2 $0 B/D EMEND CAP 125MG 2 $0 B/D EMEND PAK 80 & $0 B/D granisetron hcl SOLN 1 $0 granisetron hcl TABS 1 $0 B/D meclizine hcl CHEW 3 $0 NM; * meclizine hcl TABS 12.5mg 3 $0 NM; * meclizine hcl TABS 12.5mg, 25mg 1 $0 metoclopramide hcl SOLN; TABS 1 $0 metoclopramide inj 1 $0 ondansetron hcl TABS 1 $0 B/D ondansetron hcl inj 1 $0 ondansetron hcl oral soln 1 $0 B/D ondansetron odt 1 $0 B/D phenadoz 2 $0 PA; PA if 65 years and older phenergan SUPP 2 $0 PA; PA if 65 years and older prochlorperazine inj 1 $0 prochlorperazine maleate TABS 1 $0 prochlorperazine supp 1 $0 promethazine hcl SOLN; SUPP; SYRP; TABS 2 $0 PA; PA if 65 years and older promethegan 2 $0 PA; PA if 65 years and older scopolamine 2 $0 QL (10 patches / 30, PA; PA if 65 years and older TRANSDERM-SCOP 2 $0 QL (10 patches / 30, PA; PA if 65 years and older ANTISPASMODICS - DRUGS FOR STOMACH SPASMS dicyclomine hcl CAPS 1 $0 dicyclomine hcl SOLN 10mg/5ml 1 $0 dicyclomine hcl TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 49

63 glycopyrrolate TABS 1 $0 glycopyrrolate soln 4mg/20ml 1 $0 H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID cimetidine TABS 200mg 3 $0 NM; * famotidine SOLN 1 $0 famotidine SUSR 1 $0 famotidine TABS 10mg, 20mg 3 $0 NM; * famotidine TABS 20mg, 40mg 1 $0 famotidine inj 1 $0 ranitidine hcl TABS 75mg, 150mg 3 $0 NM; * ranitidine hcl TABS 150mg, 1 $0 300mg ranitidine hcl inj 1 $0 ranitidine syrup 1 $0 INFLAMMATORY BOWEL DISEASE APRISO 2 $0 balsalazide disodium 1 $0 budesonide ec 2 $0 CANASA 2 $0 colocort enema 100mg 1 $0 DELZICOL 2 $0 DIPENTUM 2 $0 HYDROCORTISONE (ENEMA) 1 $0 MESALAMINE TBEC 800mg 1 $0 mesalamine enema 1 $0 mesalamine w/ cleanser 1 $0 sulfasalazine TABS 1 $0 sulfasalazine ec 1 $0 LAXATIVES bisacodyl SUPP; TBEC 3 $0 NM; * calcium polycarbophil 3 $0 NM; * constulose 1 $0 docusate calcium 3 $0 NM; * docusate sodium CAPS; LIQD; 3 $0 NM; * SYRP; TABS docusol mini 3 $0 NM; * enemeez mini 3 $0 NM; * enemeez plus 3 $0 NM; * enulose 1 $0 FLEET BISACODYL 3 $0 NM; * gavilyte-c 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 50

64 gavilyte-g 1 $0 gavilyte-h 1 $0 gavilyte-n 1 $0 generlac 1 $0 glycerin (laxative) 3 $0 NM; * GOLYTELY 2 $0 KONSYL PACK 100% 3 $0 NM; * KONSYL POWD 60.3%, 71.67% 3 $0 NM; * KONSYL-D 3 $0 NM; * lactulose 1 $0 lactulose (encephalopathy) 1 $0 magnesium citrate SOLN 3 $0 NM; * magnesium hydroxide SUSP 3 $0 NM; * methylcellulose (laxative) 3 $0 NM; * MINERAL OIL OIL 3 $0 NM; * MOVIPREP 2 $0 NULYTELY/FLAVOR PACKS 2 $0 PEG 3350-KCL-SOD BICARB-SOD 1 $0 CHLORIDE-SOD SULFATE peg 3350-potassium chloride-sod 1 $0 bicarbonate-sod chloride PEG 3350/ELECTROLYTES 1 $0 polyethylene glycol 3350 PACK 1 $0 polyethylene glycol 3350 PACK 3 $0 NM; * polyethylene glycol 3350 POWD 1 $0 polyethylene glycol 3350 POWD 3 $0 NM; * psyllium 3 $0 NM; * sennosides 3 $0 NM; * sennosides-docusate sodium 3 $0 NM; * sodium phosphates 3 $0 NM; * SUPREP BOWEL PREP KIT 2 $0 trilyte 1 $0 MISCELLANEOUS alosetron hcl 2 $0 PA AMITIZA CAP 8MCG 2 $0 QL (60 caps / 30 AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 cromolyn sodium (mastocytosis) 2 $0 diphenoxylate w/ atropine 1 $0 GATTEX 2 $0 NM, LA, PA LINZESS 72mcg, 290mcg 2 $0 QL (30 caps / 30 LINZESS 145mcg 2 $0 QL (60 caps / 30 loperamide hcl CAPS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 51

65 misoprostol TABS 1 $0 MOVANTIK 12.5mg 2 $0 QL (60 tabs / 30 MOVANTIK 25mg 2 $0 QL (30 tabs / 30 RELISTOR SOLN 2 $0 PA SUCRAID 2 $0 LA sucralfate TABS 1 $0 ursodiol CAPS; TABS 1 $0 XIFAXAN 550mg 2 $0 PA PANCREATIC ENZYMES CREON 2 $0 ZENPEP 2 $0 PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT 2 $0 QL (30 caps / 30 esomeprazole magnesium 1 $0 QL (30 caps / 30 esomeprazole sodium inj 1 $0 GNP OMEPRAZOLE 3 $0 NM; * HM OMEPRAZOLE 3 $0 NM; * lansoprazole CPDR 15mg 3 $0 NM; * lansoprazole CPDR 15mg, 30mg 1 $0 QL (30 caps / 30 NEXIUM GRA 2.5MG DR 2 $0 NEXIUM GRA 5MG DR 2 $0 NEXIUM GRA 10MG DR 2 $0 QL (30 packets / 30 NEXIUM GRA 20MG DR 2 $0 QL (30 packets / 30 NEXIUM GRA 40MG DR 2 $0 QL (30 packets / 30 OMEPRAZOLE TBEC 3 $0 NM; * omeprazole cap 10mg 1 $0 QL (30 caps / 30 omeprazole cap 20mg 1 $0 QL (60 caps / 30 omeprazole cap 40mg 1 $0 QL (30 caps / 30 pantoprazole sodium tbec 1 $0 QL (30 tabs / 30 PRILOSEC OTC 3 $0 NM; * rabeprazole sodium 1 $0 QL (30 tabs / 30 SM OMEPRAZOLE 3 $0 NM; * GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl 1 $0 QL (30 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 52

66 dutasteride 1 $0 QL (30 caps / 30 dutasteride-tamsulosin hcl 1 $0 QL (30 caps / 30 finasteride TABS 5mg 1 $0 tamsulosin hcl 1 $0 MISCELLANEOUS bethanechol chloride TABS 1 $0 ELMIRON 2 $0 potassium citrate (alkalinizer) 1 $0 15meq POTASSIUM CITRATE (ALKALINIZER) 540mg, 1080mg 1 $0 URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ 25mg 2 $0 QL (60 tabs / 30 MYRBETRIQ 50mg 2 $0 QL (30 tabs / 30 oxybutynin chloride SYRP 1 $0 oxybutynin chloride TABS 1 $0 oxybutynin chloride TB24 5mg 1 $0 QL (30 tabs / 30 oxybutynin chloride TB24 10mg, 1 $0 QL (60 tabs / 30 15mg tolterodine tartrate cap er 1 $0 QL (30 caps / 30 tolterodine tartrate tabs 1 $0 TOVIAZ 2 $0 QL (30 tabs / 30 trospium chloride TABS 1 $0 QL (60 tabs / 30 VESICARE 2 $0 QL (30 tabs / 30 VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal 1 $0 clotrimazole vaginal 3 $0 NM; * metronidazole vaginal 1 $0 miconazole nitrate vaginal CREA 3 $0 NM; * miconazole nitrate vaginal SUPP 3 $0 NM; * 100mg terconazole vaginal 1 $0 VANDAZOLE 1 $0 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN 2 $0 ELIQUIS 2 $0 PA enoxaparin sodium 30mg/0.3ml, 1 $0 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml * - Non-Part D s, or OTC items that are covered by Medicaid 53

67 ENOXAPARIN SODIUM 1 $0 300mg/3ml fondaparinux sodium 2.5mg/0.5ml 1 $0 fondaparinux sodium 5mg/0.4ml, 2 $0 7.5mg/0.6ml, 10mg/0.8ml heparin sod (porcine) in d5w 2 $0 HEPARIN SOD (PORCINE) IN D5W 2 $0 heparin sod inj 1000/ml 1 $0 B/D heparin sod inj 5000/ml 1 $0 B/D heparin sod inj 10000/ml 1 $0 B/D heparin sod inj 20000/ml 1 $0 B/D HEPARIN SODIUM/D5W 2 $0 HEPARIN SODIUM/NACL 0.45% 2 $0 jantoven 1 $0 PRADAXA 2 $0 warfarin sodium 1 $0 XARELTO 2 $0 XARELTO STARTER PACK 2 $0 HEMATOPOIETIC GROWTH FACTORS GRANIX 2 $0 NM, PA LEUKINE 2 $0 NM, PA MOZOBIL 2 $0 NM, PA NEUPOGEN 2 $0 NM, PA PROCRIT 2 $0 NM, PA IRON ferrous gluconate TABS 27mg, 3 $0 NM; * 324mg FERROUS GLUCONATE TABS 3 $0 NM; * 324mg ferrous sulfate ELIX 3 $0 NM; * FERROUS SULFATE LIQD 3 $0 NM; * ferrous sulfate SOLN 3 $0 NM; * FERROUS SULFATE SYRP 3 $0 NM; * ferrous sulfate TABS 325mg 3 $0 NM; * FERROUS SULFATE TBEC 324mg 3 $0 NM; * ferrous sulfate TBEC 325mg 3 $0 NM; * INFED 3 $0 NM; * polysaccharide iron complex 3 $0 NM; * sodium ferric gluconate complex in 3 $0 NM; * sucrose VENOFER 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 54

68 MISCELLANEOUS anagrelide hcl 1 $0 cilostazol 1 $0 CINRYZE 2 $0 NM, LA, PA FIRAZYR 2 $0 NM, PA HAEGARDA 2 $0 NM, LA, PA pentoxifylline TBCR 1 $0 PROMACTA 12.5mg 2 $0 QL (360 tabs / 30, NM, LA, PA PROMACTA 25mg 2 $0 QL (180 tabs / 30, NM, LA, PA PROMACTA 50mg 2 $0 QL (90 tabs / 30, NM, LA, PA PROMACTA 75mg 2 $0 QL (60 tabs / 30, NM, LA, PA tranexamic acid SOLN; TABS 1 $0 PLATELET AGGREGATION INHIBITORS ASPIRIN-DIPYRIDAMOLE 1 $0 BRILINTA 2 $0 clopidogrel bisulfate TABS 75mg 1 $0 EFFIENT 2 $0 prasugrel hcl 1 $0 ZONTIVITY 2 $0 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS HUMIRA INJ 10MG/0.2ML 2 $0 QL (2 syringes / 28, NM, PA HUMIRA KIT 20MG/0.4ML 2 $0 QL (2 syringes / 28, NM, PA HUMIRA KIT 40MG/0.8ML 2 $0 QL (6 syringes / 28, NM, PA HUMIRA PEDIATRIC CROHNS 2 $0 NM, PA DISEASE HUMIRA PEN 2 $0 QL (6 pens / 28, NM, PA HUMIRA PEN-CROHNS DISEASE 2 $0 NM, PA HUMIRA PEN-PSORIASIS STAR 2 $0 NM, PA hydroxychloroquine sulfate 1 $0 leflunomide TABS 1 $0 methotrexate sodium tabs 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 55

69 REMICADE 2 $0 NM, PA XATMEP 2 $0 B/D XELJANZ 2 $0 QL (60 tabs / 30, NM, PA XELJANZ XR 2 $0 QL (30 tabs / 30, NM, PA IMMUNOGLOBULINS BIVIGAM 2 $0 NM, PA CARIMUNE NANOFILTERED 2 $0 NM, PA FLEBOGAMMA DIF 2 $0 NM, PA GAMASTAN S/D 2 $0 B/D, NM GAMMAGARD LIQUID 2 $0 NM, PA GAMMAGARD S/D 2 $0 NM, PA GAMMAKED 2 $0 NM, PA GAMMAPLEX 5gm/100ml, 2 $0 NM, PA 5gm/50ml, 10gm/200ml, 20gm/200ml GAMMAPLEX 10GM/100ML 2 $0 NM, PA GAMUNEX-C 2 $0 NM, PA OCTAGAM 1gm/20ml, 2gm/20ml, 2 $0 NM, PA 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN 2 $0 NM, PA IMMUNOMODULATORS ACTIMMUNE 2 $0 NM, LA, PA ARCALYST 2 $0 NM, PA INTRON-A INJ 10MU 2 $0 B/D, NM INTRON-A INJ 18MU 2 $0 B/D, NM INTRON-A INJ 25MU 2 $0 B/D, NM INTRON-A INJ 50MU 2 $0 B/D, NM POMALYST CAP 1MG 2 $0 NM, LA, PA POMALYST CAP 2MG 2 $0 NM, LA, PA POMALYST CAP 3MG 2 $0 NM, LA, PA POMALYST CAP 4MG 2 $0 NM, LA, PA REVLIMID 2 $0 NM, LA, PA THALOMID 2 $0 NM, PA IMMUNOSUPPRESSANTS azathioprine SOLR; TABS 1 $0 B/D BENLYSTA SOLR 2 $0 NM, PA cyclosporine CAPS; SOLN 1 $0 B/D cyclosporine modified (for microemulsion) 1 $0 B/D * - Non-Part D s, or OTC items that are covered by Medicaid 56

70 gengraf 1 $0 B/D mycophenolate mofetil CAPS; 1 $0 B/D TABS mycophenolate mofetil SUSR 2 $0 B/D mycophenolate sodium 1 $0 B/D NEORAL 2 $0 B/D NULOJIX 2 $0 B/D PROGRAF CAPS 2 $0 B/D RAPAMUNE SOLN 2 $0 B/D SANDIMMUNE SOLN 100mg/ml 2 $0 B/D sirolimus TABS 2mg 2 $0 B/D sirolimus TABS.5mg, 1mg 1 $0 B/D tacrolimus CAPS 1 $0 B/D ZORTRESS TAB 0.5MG 2 $0 B/D ZORTRESS TAB 0.25MG 2 $0 B/D ZORTRESS TAB 0.75MG 2 $0 B/D VACCINES ACTHIB 2 $0 ADACEL 2 $0 BCG VACCINE 2 $0 BEXSERO 2 $0 BOOSTRIX 2 $0 DAPTACEL 2 $0 DIPHTHERIA/TETANUS TOXOID 2 $0 B/D ENGERIX-B SUSP 2 $0 B/D GARDASIL 2 $0 GARDASIL 9 2 $0 HAVRIX 2 $0 HIBERIX 2 $0 IMOVAX RABIES (H.D.C.V.) 2 $0 INFANRIX 2 $0 IPOL INACTIVATED IPV 2 $0 IXIARO 2 $0 KINRIX 2 $0 M-M-R II 2 $0 MENACTRA 2 $0 MENOMUNE-A/C/Y/W $0 MENVEO 2 $0 PEDIARIX 2 $0 PEDVAX HIB 2 $0 PENTACEL 2 $0 PROQUAD 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 57

71 QUADRACEL 2 $0 RABAVERT 2 $0 RECOMBIVAX HB 2 $0 B/D ROTARIX 2 $0 ROTATEQ 2 $0 SYNAGIS 2 $0 NM TENIVAC 2 $0 B/D TETANUS/DIPHTHERIA TOXOID 2 $0 B/D TRUMENBA 2 $0 TWINRIX INJ 2 $0 TYPHIM VI 2 $0 VAQTA 2 $0 VARIVAX 2 $0 YF-VAX 2 $0 ZOSTAVAX 2 $0 QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES KLOR-CON 8 1 $0 KLOR-CON 10 1 $0 klor-con m10 1 $0 klor-con m15 1 $0 klor-con m20 1 $0 klor-con spr cap 8meq 1 $0 klor-con spr cap 10meq 1 $0 MAGNESIUM SULFATE SOLN 2 $0 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 2gm/50ml, 50% 1 $0 MAGNESIUM SULFATE SOLN 50% 1 $0 magnesium sulfate in d5w 1 $0 MAGNESIUM SULFATE IN D5W 2 $0 oral electrolytes 3 $0 NM; * potassium chloride CPCR 1 $0 POTASSIUM CHLORIDE PACK 1 $0 POTASSIUM CHLORIDE SOLN 1 $0 10%, 20% potassium chloride TBCR 1 $0 potassium chloride microencapsulated crystals er 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 58

72 SODIUM CHLORIDE SOLN 1 $0 2.5meq/ml sodium fluoride chew; tab; $0 (0.5 f) mg/ml soln TPN ELECTROLYTES 2 $0 B/D IV NUTRITION AMINOSYN 2 $0 B/D AMINOSYN 7%/ELECTROLYTES 2 $0 B/D AMINOSYN 8.5%/ELECTROLYTE 2 $0 B/D AMINOSYN II 8.5% 2 $0 B/D AMINOSYN II 8.5%/ELECTROL 2 $0 B/D AMINOSYN II 10% 2 $0 B/D AMINOSYN M 2 $0 B/D AMINOSYN-HBC 2 $0 B/D AMINOSYN-PF 7% 2 $0 B/D AMINOSYN-PF INJ 10% 2 $0 B/D AMINOSYN-RF 2 $0 B/D CLINIMIX 2.75%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 25% 2 $0 B/D CLINIMIX 5%/DEXTROSE 15% 2 $0 B/D CLINIMIX 5%/DEXTROSE 20% 2 $0 B/D CLINIMIX 5%/DEXTROSE 25% 2 $0 B/D CLINIMIX INJ 4.25/D10 2 $0 B/D CLINIMIX INJ 4.25/D20 2 $0 B/D FREAMINE HBC 6.9% 2 $0 B/D FREAMINE III 2 $0 B/D HEPATAMINE 2 $0 B/D INTRALIPID INJ 20% 2 $0 B/D INTRALIPID INJ 30% 2 $0 B/D NEPHRAMINE 2 $0 B/D nutrilipid inj 20% 2 $0 B/D premasol sol 6% 1 $0 B/D premasol sol 10% 2 $0 B/D PROCALAMINE 2 $0 B/D PROSOL 2 $0 B/D TRAVASOL 2 $0 B/D TROPHAMINE INJ 10% 2 $0 B/D IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45% 1 $0 DEXTROSE 5% 1 $0 DEXTROSE 5% /ELECTROLYTE 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 59

73 DEXTROSE 5%/LACTATED RING 1 $0 DEXTROSE 5%/NACL 0.2% 1 $0 DEXTROSE 5%/NACL 0.3% 1 $0 DEXTROSE 5%/NACL 0.9% 1 $0 DEXTROSE 5%/NACL 0.33% 1 $0 DEXTROSE 5%/NACL 0.45% 1 $0 DEXTROSE 5%/NACL 0.225% 1 $0 DEXTROSE 5%/POTASSIUM CHL 1 $0 DEXTROSE 10% FLEX CONTAIN 1 $0 DEXTROSE 10%/NACL 0.2% 2 $0 DEXTROSE 10%/NACL 0.45% 1 $0 DEXTROSE 50% 1 $0 DEXTROSE INJ 70% 1 $0 IONOSOL-B/DEXTROSE 5% 2 $0 IONOSOL-MB/DEXTROSE 5% 2 $0 ISOLYTE P 2 $0 ISOLYTE S 2 $0 KCL0.15%/D5W/NACL0.2% 1 $0 KCL0.15%/D5W/NACL0.225% 2 $0 KCL 0.3%/D5W/NACL 0.9% 1 $0 KCL 0.3%/D5W/NACL 0.45% 1 $0 KCL 0.15%/D5W/NACL 0.9% 1 $0 KCL 0.075%/D5W/NACL 0.45% 1 $0 KCL IN NACL INJ $0 KCL/D5W INJ 0.3% 1 $0 KCL/D5W/NACL INJ 0.22%/0.45% 1 $0 KCL/D5W/NACL INJ.15/.33% 1 $0 KCL/D5W/NACL INJ.15/.45% 1 $0 KCL/NACL INJ $0 KCL/NACL INJ 0.15%-0.9% 1 $0 LACTATED RINGER'S INJ 1 $0 NORMOSOL-M IN D5W 2 $0 NORMOSOL-R 2 $0 NORMOSOL-R IN D5W 2 $0 PLASMA-LYTE A 2 $0 PLASMA-LYTE $0 pot chloride inj 2meq/ml 1 $0 POTASSIUM CHLORIDE 1 $0 SOLN.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 60

74 RINGER'S 1 $0 SODIUM CHLORIDE SOLN 3%, 1 $0 5% SODIUM CHLORIDE 0.45% VIA 1 $0 SODIUM CHLORIDE INJ 0.9% 1 $0 MINERALS calcium carbonate TABS 3 $0 NM; * calcium carbonate (antacid) SUSP 3 $0 NM; * calcium carbonate-cholecalciferol 3 $0 NM; * calcium carbonate-vitamin d 3 $0 NM; * calcium citrate TABS 950mg 3 $0 NM; * calcium citrate-vitamin d 3 $0 NM; * CALCIUM GLUCONATE TABS 3 $0 NM; * 500mg mag64 3 $0 NM; * MAGNEBIND $0 NM; * magnesium TABS 250mg 3 $0 NM; * magnesium oxide (mg supplement) 3 $0 NM; * oyster shell 3 $0 NM; * MISCELLANEOUS ORA-BLEND 3 $0 NM; * ORA-BLEND SF 3 $0 NM; * ORA-PLUS 3 $0 NM; * ORA-SWEET 3 $0 NM; * ORA-SWEET SF 3 $0 NM; * SUSPENDOL-S 3 $0 NM; * SYRSPEND SF LIQD 3 $0 NM; * VITAMINS AQUADEKS CAPS 3 $0 NM; * ascorbic acid CHEW 3 $0 NM; * ascorbic acid TABS 250mg, 3 $0 NM; * 500mg b complex w/ c 3 $0 NM; * b-complex vitamins 3 $0 NM; * b-complex w/ c & e + zn 3 $0 NM; * b-complex w/ c & folic acid 3 $0 NM; * b-complex w/ minerals 3 $0 NM; * biotin CAPS 5mg, 5000mcg 3 $0 NM; * biotin TABS 300mcg 3 $0 NM; * calcitriol CAPS 1 $0 B/D calcitriol inj 1 $0 B/D calcitriol oral soln 1 mcg/ml 1 $0 B/D * - Non-Part D s, or OTC items that are covered by Medicaid 61

75 CERTAVITE SENIOR/ANTIOXID 3 $0 NM; * cholecalciferol LIQD; TABS 3 $0 NM; * cyanocobalamin SOLN; TABS 3 $0 NM; * ELDERTONIC 3 $0 NM; * ergocalciferol CAPS; SOLN 3 $0 NM; * folic acid SOLN 3 $0 NM; * folic acid TABS 1mg, 400mcg 3 $0 NM; * hydroxocobalamin SOLN 3 $0 NM; * MEPHYTON 3 $0 NM; * multiple vitamin 3 $0 NM; * multiple vitamins w/ iron 3 $0 NM; * multiple vitamins w/ minerals 3 $0 NM; * NASCOBAL 3 $0 NM; * niacin CPCR 500mg 3 $0 NM; * niacin TABS 50mg, 500mg 3 $0 NM; * niacin TBCR 3 $0 NM; * niacinamide TABS 500mg 3 $0 NM; * ONCOVITE 3 $0 NM; * paricalcitol CAPS 1 $0 B/D pediatric multiple vitamin w/ c 3 $0 NM; * pediatric multiple vitamin w/ c & fa 3 $0 NM; * pediatric multiple vitamin w/ minerals & c 3 $0 NM; * pediatric multiple vitamins w/ iron 3 $0 NM; * pediatric vitamins adc 3 $0 NM; * phytonadione SOLN 3 $0 NM; * PRENATAL 3 $0 NM; * prenatal vitamin/folic acid > $0 mg (generic) pyridoxine hcl SOLN 3 $0 NM; * pyridoxine hcl TABS 50mg, 3 $0 NM; * 100mg THERA 3 $0 NM; * THERA M PLUS 3 $0 NM; * THERA-M 3 $0 NM; * THERA/BETA-CAROTENE 3 $0 NM; * thiamine hcl SOLN; TABS 3 $0 NM; * TRI-VI-SOL 3 $0 NM; * vitamin a CAPS 8000unit, 3 $0 NM; * 10000unit vitamins w/ lipotropics 3 $0 NM; * OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS * - Non-Part D s, or OTC items that are covered by Medicaid 62

76 ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-poly-neomycin-hc 1 $0 blephamide OINT 2 $0 neomycin-polymy-dexameth 1 $0 neomycin-polymyxin-hc (ophth) 1 $0 sulfacetamide sod-prednisolone 1 $0 TOBRADEX OINT 2 $0 TOBRADEX ST 2 $0 tobramycin-dexamethasone 1 $0 ZYLET 2 $0 ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS bacitracin (ophthalmic) 1 $0 bacitracin-polymyxin b (ophth) 1 $0 BESIVANCE 2 $0 CILOXAN OINT 2 $0 ciprofloxacin hcl (ophth) 1 $0 erythromycin (ophth) 1 $0 gatifloxacin (ophth) 1 $0 gentak 1 $0 gentamicin sulfate (ophth) 1 $0 MOXEZA 2 $0 moxifloxacin hcl (ophth) 1 $0 NATACYN 2 $0 neomycin-bacitracin zn-polymyxin 1 $0 neomycin-polymyxin-gramicidin 1 $0 ofloxacin (ophth) 1 $0 polymyxin b-trimethoprim 1 $0 sulfacet sod oin 10% op 1 $0 sulfacetamide sodium (ophth) 1 $0 tobramycin (ophth) 1 $0 TOBREX OINT 2 $0 trifluridine SOLN 1 $0 VIGAMOX 2 $0 ZIRGAN 2 $0 ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX 2 $0 bromfenac sodium (ophth) 1 $0 BROMSITE 2 $0 dexamethasone sodium phosphate 1 $0 (ophth) diclofenac sodium (ophth) 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 63

77 DUREZOL 2 $0 FLUOROMETHOLONE 1 $0 flurbiprofen sodium 1 $0 ILEVRO 2 $0 ketorolac tromethamine (ophth) 1 $0 LOTEMAX 2 $0 MAXIDEX 2 $0 PREDNISOLONE ACETATE (OPHTH) 1 $0 prednisolone sodium phosphate (ophth) 2 $0 ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine drop 0.05% 1 $0 BEPREVE 2 $0 cromolyn sodium (ophth) 1 $0 LASTACAFT 2 $0 olopatadine hcl.2% 1 $0 PATADAY 2 $0 PAZEO 2 $0 ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% 2 $0 AZOPT 2 $0 betaxolol hcl (ophth) 1 $0 BETOPTIC-S 2 $0 brimonidine sol 0.2% 1 $0 BRIMONIDINE SOL 0.15% 1 $0 carteolol hcl (ophth) 1 $0 COMBIGAN 2 $0 dorzolamide hcl 1 $0 dorzolamide hcl-timolol maleate 1 $0 ISTALOL 2 $0 latanoprost SOLN 1 $0 levobunolol hcl 1 $0 LUMIGAN 2 $0 metipranolol 1 $0 PHOSPHOLINE IODIDE 2 $0 PILOCARPINE HCL SOLN 1 $0 SIMBRINZA 2 $0 timolol maleate (ophth) soln 1 $0 TIMOLOL MALEATE GEL 1 $0 TRAVATAN Z 2 $0 MISCELLANEOUS artificial tear ointment 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 64

78 artificial tear solution 3 $0 NM; * carboxymethylcellulose sodium 3 $0 NM; * (ophth) carboxymethylcellulose-glycerin 3 $0 NM; * carboxymethylcellulosehypromellose 3 $0 NM; * CYSTARAN 2 $0 NM, LA, PA GENTEAL SEVERE 3 $0 NM; * MURO 128 OINT 3 $0 NM; * MURO 128 SOLN 2% 3 $0 NM; * naphazoline hcl SOLN 1 $0 polyethylene glycol-propylene 3 $0 NM; * glycol (ophth) polyvinyl alcohol SOLN 3 $0 NM; * PROLENSA 2 $0 proparacaine hcl SOLN 1 $0 REFRESH CELLUVISC 3 $0 NM; * RESTASIS 2 $0 QL (64 vials / 30 RESTASIS MULTIDOSE 2 $0 QL (1 bottle / 30 sodium chloride hypertonic 3 $0 NM; * SYSTANE OVERNIGHT THERAPY 3 $0 NM; * white petrolatum-mineral oil 3 $0 NM; * RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPTA 2 $0 QL (60 blisters / 30 BEVESPI AEROSPHERE 2 $0 QL (1 inhaler / 30 COMBIVENT RESPIMAT 2 $0 QL (2 inhalers / 30 ipratropium-albuterol nebu 1 $0 B/D ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA 2 $0 QL (2 inhalers / 30 INCRUSE ELLIPTA 2 $0 QL (1 inhaler / 30 ipratropium bromide SOLN 1 $0 B/D ipratropium bromide (nasal) 1 $0 ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine spr 0.1% 1 $0 azelastine spr 0.15% 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 65

79 cetirizine hcl CHEW 10mg 3 $0 NM; * cetirizine hcl SOLN 3 $0 NM; * cetirizine hcl SYRP 3 $0 NM; * cetirizine hcl TABS 3 $0 NM; * cetirizine syrup 1 $0 chlorpheniramine maleate SYRP; 3 $0 NM; * TABS cyproheptadine hcl SYRP; TABS 2 $0 PA; PA if 65 years and older diphenhydramine hcl CAPS 3 $0 NM; * diphenhydramine hcl LIQD 3 $0 NM; * diphenhydramine hcl SYRP 3 $0 NM; * diphenhydramine hcl TABS 25mg 3 $0 NM; * diphenhydramine inj 1 $0 fexofenadine hcl SUSP; TABS 3 $0 NM; * hydroxyzine hcl SOLN; SYRP; TABS 2 $0 PA; PA if 65 years and older hydroxyzine pamoate CAPS 2 $0 PA; PA if 65 years and older levocetirizine dihydrochloride 1 $0 loratadine SOLN; SYRP; TABS 3 $0 NM; * silphen cough 3 $0 NM; * BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate NEBU 1 $0 B/D albuterol sulfate SYRP; TABS; 1 $0 TB12 levalbuterol conc 1.25mg/0.5ml 1 $0 B/D levalbuterol hcl NEBU 1 $0 B/D 1.25mg/0.5ml LEVALBUTEROL TARTRATE HFA 1 $0 QL (2 inhalers / 30 SEREVENT DISKUS 2 $0 QL (60 inhalations / 30 terbutaline sulfate SOLN 2 $0 terbutaline sulfate TABS 1 $0 VENTOLIN HFA 2 $0 QL (2 inhalers / 30 COUGH AND COLD benzonatate 3 $0 NM; * brompheniramine & phenyleph 3 $0 NM; * brompheniramine & pseudoeph 3 $0 NM; * brotapp dm 3 $0 NM; * cetirizine-pseudoephedrine 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 66

80 chlorpheniramine & phenylephrine 3 $0 NM; * chlorpheniramine & pseudoeph 3 $0 NM; * chlorpheniramine-dm 3 $0 NM; * cromolyn sodium (nasal) 3 $0 NM; * dextromethorphan-guaifenesin 3 $0 NM; * guaifenesin LIQD; SOLN; SYRP; 3 $0 NM; * TABS; TB12 loratadine & pseudoephedrine 3 $0 NM; * NASAL DECONGESTANT LIQD 3 $0 NM; * nasal decongestant SYRP 3 $0 NM; * oxymetazoline hcl SOLN 3 $0 NM; * phenylephrine hcl (oral) 3 $0 NM; * phenylephrine w/ dm-gg 3 $0 NM; * phenylephrine-brompheniraminedm 3 $0 NM; * phenylephrine-chlorpheniraminedm 3 $0 NM; * w/ apap phenylephrine-guaifenesin 3 $0 NM; * PHENYLHISTINE DH 3 $0 NM; * pseudoephedrine hcl LIQD 3 $0 NM; * pseudoephedrine hcl TABS 30mg 3 $0 NM; * pseudoephedrine-chlorphen-dm 3 $0 NM; * triprolidine & pseudoephedrine 3 $0 NM; * LEUKOTRIENE MODULATORS montelukast sodium CHEW; 1 $0 PACK; TABS zafirlukast 1 $0 MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu 1 $0 B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% 1 $0 B/D ARALAST NP 2 $0 NM, LA, PA DALIRESP 2 $0 EPIPEN 2-PAK 2 $0 EPIPEN-JR 2-PAK 2 $0 ESBRIET 2 $0 NM, PA KALYDECO 2 $0 NM, PA OFEV 2 $0 NM, PA ORKAMBI 2 $0 NM, PA PROLASTIN-C 2 $0 NM, LA, PA PULMOZYME 2 $0 NM, PA saline.65% 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 67

81 XOLAIR 2 $0 NM, LA, PA ZEMAIRA 2 $0 NM, LA, PA NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide (nasal) 1 $0 QL (2 bottles / 30 fluticasone propionate (nasal) 1 $0 QL (1 bottle / 30 STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA 2 $0 QL (30 inhalations / 30 budesonide 1 $0 B/D (inhalation).25mg/2ml,.5mg/2m l FLOVENT DISKUS 50mcg/blist, 100mcg/blist 2 $0 QL (120 inhalations / 30 FLOVENT DISKUS 250mcg/blist 2 $0 QL (240 inhalations / 30 FLOVENT HFA 2 $0 QL (2 inhalers / 30 PULMICORT FLEXHALER 2 $0 QL (2 inhalers / 30 STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS 2 $0 QL (60 inhalations / 30 ADVAIR HFA 2 $0 QL (1 inhaler / 30 BREO ELLIPTA 2 $0 QL (60 blisters / 30 SYMBICORT 2 $0 QL (1 inhaler / 30 XANTHINES - DRUGS TO TREAT COPD aminophylline inj 1 $0 elixophyllin 2 $0 theo-24 2 $0 theophylline 1 $0 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE adapalene CREA 1 $0 adapalene GEL.1% 1 $0 amnesteem 1 $0 PA AVITA 1 $0 PA benzoyl peroxide GEL 5%, 10% 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 68

82 benzoyl peroxide-erythromycin 1 $0 claravis 1 $0 PA clindacin-p pad 1% 1 $0 clindamycin phosphate (topical) 1 $0 GEL; LOTN; SOLN; SWAB ery pad 2% 1 $0 erythromycin (acne aid) 1 $0 myorisan 1 $0 PA sulfacetamide sodium (acne) 1 $0 tretinoin CREA 1 $0 PA TRETINOIN GEL.01% 1 $0 PA tretinoin GEL.025% 1 $0 PA zenatane 1 $0 PA DERMATOLOGY, ANTIBIOTICS bacitracin (topical) 3 $0 NM; * bacitracin zinc OINT 3 $0 NM; * gentamicin sulfate (topical) 1 $0 mupirocin OINT 1 $0 SILVER SULFADIAZINE CREA 1 $0 SSD 1 $0 SULFAMYLON 2 $0 DERMATOLOGY, ANTIFUNGALS ALEVAZOL 3 $0 NM; * castellani paint 3 $0 NM; * ciclopirox CREA; GEL; SUSP 1 $0 ciclopirox shampoo 1% 1 $0 clotrimazole (topical) CREA 1% 1 $0 clotrimazole (topical) CREA 1% 3 $0 NM; * clotrimazole (topical) SOLN 1 $0 ketoconazole cream 1 $0 miconazole nitrate (topical) 3 $0 NM; * nyamyc 1 $0 nyata 1 $0 nystatin (topical) 1 $0 nystop 1 $0 terbinafine hcl (topical) 3 $0 NM; * tolnaftate AERP; CREA; POWD 3 $0 NM; * DERMATOLOGY, ANTIPRURITIC DOXEPIN HCL (ANTIPRURITIC) 1 $0 procto-med 1 $0 procto-pak 1 $0 proctosol hc cre 2.5% 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 69

83 proctozone hc 1 $0 DERMATOLOGY, ANTIPSORIATICS acitretin 2 $0 PA calcipotriene CREA 1 $0 calcipotriene SOLN 1 $0 8-MOP 2 $0 tazarotene CREA 1 $0 PA TAZORAC CREA 2 $0 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 $0 selenium sulfide LOTN 1 $0 DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 $0 alclometasone dipropionate 1 $0 betamethasone dipropionate 1 $0 (topical) betamethasone dipropionate augmented CREA; GEL; LOTN 1 $0 BETAMETHASONE DIPROPIONATE 1 $0 AUGMENTED OINT betamethasone valerate CREA 1 $0 betamethasone valerate LOTN 1 $0 betamethasone valerate OINT 1 $0 desoximetasone CREA 1 $0 desoximetasone GEL 1 $0 DESOXIMETASONE OINT.05% 1 $0 desoximetasone OINT.25% 1 $0 fluocinolone acetonide CREA; OIL; 1 $0 OINT; SOLN fluocinonide CREA.05% 1 $0 fluocinonide GEL 1 $0 fluocinonide SOLN 1 $0 fluocinonide emulsified base 1 $0 fluticasone propionate CREA 1 $0 fluticasone propionate OINT 1 $0 halobetasol propionate 1 $0 hydrocortisone (topical) CREA 1% 3 $0 NM; * hydrocortisone (topical) CREA 1%, 2.5% 1 $0 hydrocortisone (topical) LOTN 1% 3 $0 NM; * hydrocortisone (topical) LOTN 2.5% 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 70

84 hydrocortisone (topical) OINT 1% 3 $0 NM; * hydrocortisone (topical) OINT 1 $0 1%, 2.5% hydrocortisone butyrate 1 $0 hydrocortisone valerate 1 $0 hydrocortisone-aloe vera 3 $0 NM; * mometasone furoate CREA 1 $0 mometasone furoate OINT 1 $0 mometasone furoate SOLN 1 $0 texacort soln 2.5% 2 $0 triamcinolone acetonide (topical) 1 $0 CREA; LOTN; OINT triderm 1 $0 DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH 1 $0 QL (3 patches / 1 day), PA lidocaine hcl GEL 1 $0 PA lidocaine hcl SOLN 4% 1 $0 PA lidocaine oint 5% 1 $0 PA lidocaine-prilocaine 1 $0 PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA 3 $0 NM; * ammonium lactate CREA; LOTN 1 $0 diclofenac sodium (topical) 1% gel 1 $0 PA fluorouracil (topical) CREA 5% 1 $0 fluorouracil (topical) SOLN 1 $0 imiquimod CREA 1 $0 metronidazole (topical) CREA; 1 $0 LOTN metronidazole gel 0.75% 1 $0 PANRETIN 2 $0 PICATO 2 $0 podofilox SOLN 1 $0 POLYBASE 3 $0 NM; * rosadan cre 0.75% 1 $0 tacrolimus (topical) 1 $0 TARGRETIN GEL 2 $0 NM, PA VALCHLOR 2 $0 NM, LA, PA zinc oxide (topical) 3 $0 NM; * DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 2 $0 malathion 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 71

85 permethrin CREA 1 $0 permethrin LIQD; LOTN 3 $0 NM; * pyrethrins-piperonyl butoxide 3 $0 NM; * DERMATOLOGY, WOUND CARE AGENTS ACETIC ACID.25% 1 $0 REGRANEX 2 $0 PA SANTYL 2 $0 SODIUM CHLORIDE 0.9% 1 $0 STERILE WATER IRRIGATION 1 $0 MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 1 $0 chlorhexidine gluconate (mouththroat) 1 $0 clotrimazole TROC 1 $0 lidocaine hcl (mouth-throat) 1 $0 nystatin (mouth-throat) 1 $0 paroex sol 0.12% 1 $0 periogard 1 $0 PILOCARPINE HCL (ORAL) 5mg 1 $0 pilocarpine hcl (oral) 7.5mg 1 $0 triamcinolone acetonide (mouth) 1 $0 OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR ACETIC ACID (OTIC) 1 $0 acetic acid-aluminum acetate 1 $0 CIPRODEX 2 $0 fluocinolone acetonide (otic) 1 $0 neomycin-polymyxin-hc (otic) 1 $0 ofloxacin (otic) 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 72

86 Index 8 8-MOP...70 A abacavir sulfate...7 ABACAVIR SULFATE-LAMIVUDINE...8 abacavir sulfate-lamivudine-zidovudine.8 ABELCET...6 ABILIFY MAINTENA...31 ABRAXANE...13 ABREVA...71 acamprosate calcium...37 acarbose...39 acebutolol hcl...20 acetaminophen...1 ACETAMINOPHEN...1 acetaminophen w/ codeine...2 acetazolamide...22 ACETIC ACID...72 acetic acid-aluminum acetate...72 ACETIC ACID (OTIC)...72 acetylcysteine...67 acitretin...70 ACTHIB...57 ACTIMMUNE...56 acyclovir...9 acyclovir sodium...9 ADACEL...57 ADAGEN...45 adapalene...68 ADCIRCA...23 adefovir dipivoxil...9 ADEMPAS...23 adriamycin...12 adrucil...12 ADVAIR DISKUS...68 ADVAIR HFA...68 afeditab cr...21 AFINITOR...15 AFINITOR DISPERZ...15 ala-cort...70 ALBENZA...5 albuterol sulfate...66 alclometasone dipropionate...70 ALCOHOL SWABS...38 ALDURAZYME...45 ALECENSA...15 alendronate sodium...41 ALEVAZOL...69 alfuzosin hcl...52 ALIMTA...12 ALINIA...5 allopurinol tab...1 alosetron hcl...51 ALPHAGAN P SOL 0.1%...64 alprazolam tab 0.25mg...24 alprazolam tab 0.5mg...24 alprazolam tab 1mg...24 alprazolam tab 2mg...24 ALREX...63 altavera tab...41 alum & mag hydrox-simethicone...48 ALUMINUM HYDROXIDE...48 aluminum hydroxide-mag carb...48 ALUNBRIG...15 alyacen 1/ amantadine hcl...30 AMBISOME...6 AMIFOSTINE...16 amikacin sulfate...5 amiloride & hydrochlorothiazide...22 amiloride hcl...22 aminophylline inj...68 AMINOSYN...59 AMINOSYN-HBC...59 AMINOSYN-PF 7%...59 AMINOSYN-PF INJ 10%...59 AMINOSYN-RF...59 AMINOSYN 7%/ELECTROLYTES...59 AMINOSYN 8.5%/ELECTROLYTE...59 AMINOSYN II 10%...59 AMINOSYN II 8.5%...59 AMINOSYN II 8.5%/ELECTROL...59 AMINOSYN M...59 amiodarone hcl...19 AMITIZA CAP 24MCG...51 AMITIZA CAP 8MCG...51 amitriptyline hcl...28 amlodipine--benazepril hcl cap mg...17 amlodipine-benazepril hcl cap 10-40mg...17 amlodipine-benazepril hcl cap mg...17 amlodipine-benazepril hcl cap 5-10 mg 17 73

87 amlodipine-benazepril hcl cap 5-20 mg 17 amlodipine-benazepril hcl cap 5-40 mg 17 amlodipine-valsartan-hydrochlorothiazide mg...18 amlodipine-valsartan-hydrochlorothiazide mg...18 amlodipine-valsartan-hydrochlorothiazide mg...18 amlodipine-valsartan-hydrochlorothiazide mg...18 amlodipine-valsartan-hydrochlorothiazide mg...18 amlodipine besylate...21 amlodipine besylate-olmesartan medoxomil...18 amlodipine besylate-valsartan tab mg...18 amlodipine besylate-valsartan tab mg...18 amlodipine besylate-valsartan tab mg...18 amlodipine besylate-valsartan tab mg...18 ammonium lactate...71 amnesteem...68 amoxapine tab 100mg...28 amoxapine tab 150mg...28 amoxapine tab 25mg...28 amoxapine tab 50mg...28 amoxicillin...11 amoxicillin & pot clavulanate...11 amphetamine-dextroamphetamine cap sr 24hr 10 mg...34 amphetamine-dextroamphetamine cap sr 24hr 15 mg...34 amphetamine-dextroamphetamine cap sr 24hr 20 mg...34 amphetamine-dextroamphetamine cap sr 24hr 25 mg...34 amphetamine-dextroamphetamine cap sr 24hr 30 mg...34 amphetamine-dextroamphetamine cap sr 24hr 5 mg...34 amphetamine-dextroamphetamine tab 10 mg...34 amphetamine-dextroamphetamine tab 12.5 mg...34 amphetamine-dextroamphetamine tab 15 mg...34 amphetamine-dextroamphetamine tab 20 mg...34 amphetamine-dextroamphetamine tab 30 mg...34 amphetamine-dextroamphetamine tab 5 mg...34 amphetamine-dextroamphetamine tab 7.5 mg...34 amphotericin b...6 ampicillin & sulbactam sodium...11 ampicillin cap 250 mg...11 ampicillin cap 500 mg...11 ampicillin inj...11 ampicillin sodium...11 ampicillin susp...11 AMPYRA...36 ANADROL anagrelide hcl...55 anastrozole...14 ANDRODERM...38 ANORO ELLIPTA...65 APOKYN...30 aprepitant...49 apri 28 day...41 APRISO...50 APTIOM...24 APTIVUS...7 AQUADEKS...61 ARALAST NP...67 aranelle ARCALYST...56 aripiprazole odt...31 aripiprazole oral solution 1 mg/ml...31 aripiprazole tab...31 ARISTADA...31 armodafinil...37 ARMODAFINIL...37 ARNUITY ELLIPTA...68 artificial tear ointment...64 artificial tear solution...65 ascorbic acid...61 aspirin...1 ASPIRIN-DIPYRIDAMOLE...55 aspirin buffered (cal carb-mag carb-mag oxide)...1 atenolol...20 atenolol & chlorthalidone

88 atomoxetine hcl...34 atorvastatin calcium...19 atovaquone...5 atovaquone-proguanil hcl...7 ATRIPLA...8 ATROVENT HFA...65 aubra 28 day...42 AURYXIA...47 AUSTEDO...36 AVASTIN...13 aviane AVITA...68 AXIRON...38 azacitidine...12 AZACTAM/DEX INJ 2GM...5 AZACTAM IN ISO-OSMOTIC DE...5 azathioprine...56 azelastine drop 0.05%...64 azelastine spr 0.1%...65 azelastine spr 0.15%...65 azithromycin...10 AZITHROMYCIN...10 AZOPT...64 aztreonam...5 B b-complex vitamins...61 b-complex w/ c & e + zn...61 b-complex w/ c & folic acid...61 b-complex w/ minerals...61 bacitracin-poly-neomycin-hc...63 bacitracin-polymyxin b (ophth)...63 bacitracin (ophthalmic)...63 bacitracin (topical)...69 bacitracin zinc...69 baclofen...36 balsalazide disodium...50 balziva 28 day...42 BANZEL SUS 40MG/ML...24 BANZEL TAB 200MG...24 BANZEL TAB 400MG...24 BARACLUDE...9 BCG VACCINE...57 b complex w/ c...61 bekyree 28 day...42 BELEODAQ...13 benazepril & hydrochlorothiazide...17 benazepril hcl...17 BENDEKA...12 BENLYSTA...56 benzonatate...66 benzoyl peroxide...68 benzoyl peroxide-erythromycin...69 benztropine mesylate...30 BENZTROPINE MESYLATE...30 BEPREVE...64 BESIVANCE...63 betamethasone dipropionate (topical)..70 betamethasone dipropionate augmented...70 BETAMETHASONE DIPROPIONATE AUGMENTED...70 betamethasone valerate...70 BETASERON...36 betaxolol hcl (ophth)...64 bethanechol chloride...53 BETOPTIC-S...64 BEVESPI AEROSPHERE...65 bexarotene...16 BEXSERO...57 bicalutamide...14 BICILLIN L-A...11 BICNU...12 BILTRICIDE...5 biotin...61 bisacodyl...50 bismuth subsalicylate...48 bisoprolol & hydrochlorothiazide...20 bisoprolol fumarate...20 BIVIGAM...56 bleomycin sulfate...12 blephamide...63 blisovi 21 fe 1/20 28 day pack...42 blisovi 21 fe 1.5/30 28 day pack...42 BOOSTRIX...57 BOSULIF...15 BREO ELLIPTA...68 briellyn 28 day...42 BRILINTA...55 BRIMONIDINE SOL 0.15%...64 brimonidine sol 0.2%...64 BRIVIACT...24 bromfenac sodium (ophth)...63 bromocriptine mesylate...30 brompheniramine & phenyleph...66 brompheniramine & pseudoeph...66 BROMSITE

89 brotapp dm...66 budesonide (inhalation)...68 budesonide ec...50 bumetanide...22 BUPHENYL...45 buprenorphine hcl...37 buprenorphine hcl-naloxone hcl sl...37 buproban tab 150mg...37 bupropion hcl...28 bupropion hcl (smoking deterrent)...37 buspirone hcl...24 busulfan...12 BUSULFEX...12 butorphanol tartrate...2 BUTRANS...2 BUTRANS 7.5MCG/HR...2 BYDUREON INJ...38 BYDUREON PEN...38 BYETTA...38 BYSTOLIC...20 C cabergoline...47 CABOMETYX...15 calcipotriene...70 calcitonin (salmon)...47 calcitriol...61 calcitriol inj...61 calcitriol oral soln 1 mcg/ml...61 calcium acetate (phosphate binder)...47 calcium carbonate...61 calcium carbonate-cholecalciferol...61 calcium carbonate-vitamin d...61 calcium carbonate (antacid)...48, 61 calcium citrate...61 calcium citrate-vitamin d...61 CALCIUM GLUCONATE...61 calcium polycarbophil...50 camila 28 day...42 CANASA...50 CANCIDAS...6 candesartan cilexetil...19 candesartan cilexetil-hydrochlorothiazide...18 CAPASTAT SULFATE...8 CAPRELSA...15 captopril...17 captopril & hydrochlorothiazide...17 CARBAGLU...45 carbamazepine...24 carbidopa-levodopa...30 CARBIDOPA/LEVODOPA/ENTACAPONE.30 carboplatin...16 carboxymethylcellulose-glycerin...65 carboxymethylcellulose-hypromellose..65 carboxymethylcellulose sodium (ophth)...65 CARIMUNE NANOFILTERED...56 carisoprodol...37 carteolol hcl (ophth)...64 cartia xt cap 120/24hr...21 cartia xt cap 180/24hr...21 cartia xt cap 240/24hr...21 cartia xt cap 300/24hr...21 carvedilol...20 CASPOFUNGIN ACETATE...6 castellani paint...69 CAYSTON...5 caziant pak...42 cefaclor...9 cefaclor monohydrate er...9 cefadroxil...9 CEFAZOLIN IN DEXTROSE 2GM/100ML- 4%...10 cefazolin inj...10 cefazolin sodium...10 cefazolin sodium 1 gm/50ml...10 cefdinir...10 cefepime hcl...10 cefixime...10 cefotaxime sodium...10 cefoxitin sodium...10 cefpodoxime proxetil...10 cefprozil...10 ceftazidime...10 CEFTAZIDIME/DEXTROSE...10 ceftriaxone sodium...10 cefuroxime axetil...10 cefuroxime sodium...10 celecoxib...1 CELONTIN...24 cephalexin...10 CERDELGA...45 CEREZYME...45 CERTAVITE SENIOR/ANTIOXID...62 cetirizine-pseudoephedrine...66 cetirizine hcl

90 cetirizine syrup...66 cevimeline hcl...72 CHANTIX...37 CHANTIX CONTINUING MONTH...37 CHANTIX STARTER PACK...37 CHEMET...41 chlorhexidine gluconate (mouth-throat)...72 chloroquine phosphate...7 chlorothiazide tabs...22 chlorpheniramine-dm...67 chlorpheniramine & phenylephrine...67 chlorpheniramine & pseudoeph...67 chlorpheniramine maleate...66 chlorpromazine hcl...31 chlorpromazine inj...31 chlorthalidone...22 cholecalciferol...62 cholestyramine...20 cholestyramine light...20 ciclopirox...69 ciclopirox shampoo 1%...69 cilostazol...55 CILOXAN...63 cimetidine...50 CINRYZE...55 CIPRODEX...72 ciprofloxacin...11 ciprofloxacin er...11 ciprofloxacin hcl (ophth)...63 ciprofloxacin hcl tab...11 ciprofloxacin in d5w...11 ciprofloxacin inj...11 cisplatin...16 citalopram hydrobromide...28 cladribine...13 claravis...69 clarithromycin...10 clarithromycin er...10 clarithromycin for susp...10 clindacin-p pad 1%...69 clindamycin cap 300mg...5 clindamycin cap 75mg...5 clindamycin hcl cap 150 mg...5 clindamycin phosphate...5 clindamycin phosphate (topical)...69 clindamycin phosphate in d5w...5 clindamycin phosphate inj...5 CLINDAMYCIN PHOSPHATE IN NACL...5 clindamycin phosphate vaginal...53 clindamycin sol 75mg/5ml...5 CLINIMIX 2.75%/DEXTROSE 5%...59 CLINIMIX 4.25%/DEXTROSE 25%...59 CLINIMIX 4.25%/DEXTROSE 5%...59 CLINIMIX 5%/DEXTROSE 15%...59 CLINIMIX 5%/DEXTROSE 20%...59 CLINIMIX 5%/DEXTROSE 25%...59 CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D clomipramine hcl...28 clonazepam...24, 25 clonidine hcl...22 clopidogrel bisulfate...55 clorazepate dipotassium...25 clotrimazole...72 clotrimazole (topical)...69 clotrimazole vaginal...53 CLOZAPINE ODT...31 clozapine tab 100mg...31 clozapine tab 200mg...31 clozapine tab 25mg...31 clozapine tab 50mg...31 COARTEM...7 colchicine w/ probenecid...1 COLCRYS...1 colestipol hcl...20 colistimethate sodium...5 colocort enema 100mg...50 COMBIGAN...64 COMBIVENT RESPIMAT...65 COMETRIQ...15 COMPLERA...8 compro...49 constulose...50 COPAXONE INJ 40MG/ML...36 cortisone acetate...46 COTELLIC...15 COUMADIN...53 CREON...52 CRIXIVAN...7 cromolyn sodium (mastocytosis)...51 cromolyn sodium (nasal)...67 cromolyn sodium (ophth)...64 cromolyn sodium nebu...67 cryselle CUBICIN

91 cyanocobalamin...62 cyclafem 1/35 28 day...42 cyclafem 7/7/7 28 day...42 cyclobenzaprine hcl...37 cyclophosphamide...12 CYCLOPHOSPHAMIDE...12 cycloserine...8 cyclosporine...56 cyclosporine modified (for microemulsion)...56 cyproheptadine hcl...66 cyred tab...42 CYSTADANE...45 CYSTAGON...45 CYSTARAN...65 cytarabine...13 D dacarbazine...12 DAKLINZA...9 DALIRESP...67 danazol...45 dantrolene sodium...37 dapsone...5 DAPTACEL...57 daptomycin...5 daunorubicin hcl...12 deblitane 28 day...42 DELESTROGEN...45 delyla 28 day...42 DELZICOL...50 DEMSER...23 DEPEN TITRATABS...41 DEPO-PROVERA INJ 400/ML...14 DESCOVY...8 desipramine hcl...28 desmopressin acetate spray...48 desmopressin acetate spray refrigerated...48 desmopressin acetate tabs...48 desmopressin inj 4mcg/ml...48 DESMOPRESSIN SOL 0.01%...48 desogestrel-ethinyl estradiol (biphasic) 42 desogestrel & ethinyl estradiol...42 desoximetasone...70 DESOXIMETASONE...70 desvenlafaxine succinate...28 dexamethasone...46 dexamethasone sodium phosphate...46 dexamethasone sodium phosphate (ophth)...63 DEXILANT...52 dexrazoxane...16 dextromethorphan-guaifenesin...67 DEXTROSE 10%/NACL 0.2%...60 DEXTROSE 10%/NACL 0.45%...60 DEXTROSE 10% FLEX CONTAIN...60 DEXTROSE 2.5%/NACL 0.45%...59 DEXTROSE 5%...59 DEXTROSE 5% /ELECTROLYTE...59 DEXTROSE 5%/LACTATED RING...60 DEXTROSE 5%/NACL 0.2%...60 DEXTROSE 5%/NACL 0.225%...60 DEXTROSE 5%/NACL 0.3%...60 DEXTROSE 5%/NACL 0.33%...60 DEXTROSE 5%/NACL 0.45%...60 DEXTROSE 5%/NACL 0.9%...60 DEXTROSE 5%/POTASSIUM CHL...60 DEXTROSE 50%...60 DEXTROSE INJ 70%...60 DIASTAT ACUDIAL...25 DIASTAT PEDIATRIC...25 diazepam...25 DIAZEPAM GEL...25 diclofenac potassium...1 diclofenac sodium...1 diclofenac sodium (ophth)...63 diclofenac sodium (topical) 1% gel...71 dicloxacillin sodium...11 dicyclomine hcl...49 didanosine...7 DIFICID...10 diflunisal...1 digitek...22 digox...22 digoxin...22 digoxin inj...22 DIGOXIN SOL 50MCG/ML...22 dihydroergotamine mesylate...35 dilantin...25 DILANTIN-125 SUS 125/5ML...25 dilt-xr cap...21 diltiazem cap 120mg cd...21 diltiazem cap 180mg cd...21 diltiazem cap 240mg cd...21 diltiazem cap 300mg cd...21 DILTIAZEM CAP 360MG CD

92 diltiazem cap er/12hr...21 diltiazem hcl...21 diltiazem hcl cap sr 24hr...21 diltiazem hcl coated beads cap sr 24hr 21 diltiazem hcl extended release beads cap sr...21 dimenhydrinate...49 DIPENTUM...50 diphenhydramine hcl...66 diphenhydramine hcl (sleep)...37 diphenhydramine inj...66 diphenoxylate w/ atropine...51 DIPHTHERIA/TETANUS TOXOID...57 disopyramide phosphate...19 disulfiram...37 divalproex sodium...25 DOCEFREZ...13 docetaxel...13 DOCETAXEL...13 DOCETAXEL 160MG/16ML...13 DOCETAXEL 20MG/2ML...13 DOCETAXEL SOLN 80MG/8ML...13 docusate calcium...50 docusate sodium...50 docusol mini...50 DOFETILIDE...19 donepezil hydrochloride...27 dorzolamide hcl...64 dorzolamide hcl-timolol maleate...64 doxazosin mesylate...18 doxepin hcl...28 DOXEPIN HCL (ANTIPRURITIC)...69 doxorubicin hcl...12 doxorubicin hcl liposomal inj 2mg/ml...12 doxorubicin inj 50mg...12 doxy...11 doxycycline (monohydrate)...11 doxycycline hyclate...11, 12 dronabinol...49 drospirenone-ethinyl estradiol...42 DROXIA...16 duloxetine hcl...28, 29 DURAMORPH...2 DUREZOL...64 dutasteride...53 dutasteride-tamsulosin hcl...53 E e.e.s EDURANT...7 EFFIENT...55 ELDERTONIC...62 eletriptan hydrobromide...35 ELIQUIS...53 ELITEK...16 elixophyllin...68 ELLA...42 ELMIRON...53 EMCYT...12 EMEND...49 EMEND CAP 125MG...49 EMEND CAP 40MG...49 EMEND CAP 80MG...49 EMEND PAK 80 & emoquette...42 EMSAM...29 EMTRIVA...7 emverm...5 enalapril maleate...17 enalapril maleate & hydrochlorothiazide...17 endocet...2 enemeez mini...50 enemeez plus...50 ENGERIX-B...57 enoxaparin sodium...53 ENOXAPARIN SODIUM...54 enpresse 28 day...42 ENTACAPONE...30 entecavir...9 ENTRESTO...18 enulose...50 EPCLUSA...9 EPIPEN-JR 2-PAK...67 EPIPEN 2-PAK...67 epirubicin hcl...12 epitol...25 EPIVIR HBV...9 eplerenone...18 ergocalciferol...62 ergotamine w/ caffeine...35 ERIVEDGE...13 errin 28 day...42 ery-tab...10 ery pad 2%...69 erythrocin lactobionate...10 erythrocin stearate

93 erythromycin (acne aid)...69 erythromycin (ophth)...63 erythromycin base...10 erythromycin cap 250mg ec...10 erythromycin ethylsuccinate...10 ESBRIET...67 escitalopram oxalate...29 esomeprazole magnesium...52 esomeprazole sodium inj...52 estarylla tab estrace...45 estradiol...45 estradiol vaginal tab 10 mcg...45 estradiol valerate...45 eszopiclone...35 ethambutol hcl...8 ethosuximide...25 ethynodiol tab etodolac...2 etodolac er...2 etoposide...17 EURAX...71 EVOTAZ...8 exemestane...14 EXJADE...41 ezetimibe...20 F FABRAZYME...45 falmina 28 day...42 famciclovir...9 famotidine...50 famotidine inj...50 FANAPT...31 FANAPT TITRATION PACK...31 FARESTON...14 FARXIGA...39 FARYDAK...13 FASLODEX...14 felbamate...25 felodipine...21 femynor 28 day...42 fenofibrate...20 fenofibrate micronized...20 fentanyl citrate...3 fentanyl patch 100 mcg/hr...3 fentanyl patch 12 mcg/hr...3 fentanyl patch 25 mcg/hr...3 fentanyl patch 50 mcg/hr...3 fentanyl patch 75 mcg/hr...3 FENTORA...3 FERRIPROX...41 ferrous gluconate...54 FERROUS GLUCONATE...54 ferrous sulfate...54 FERROUS SULFATE...54 FETZIMA...29 FETZIMA TITRATION PACK...29 FEVERALL INFANTS...1 fexofenadine hcl...66 finasteride...53 FIRAZYR...55 FLEBOGAMMA DIF...56 flecainide acetate...19 FLEET BISACODYL...50 FLOVENT DISKUS...68 FLOVENT HFA...68 fluconazole...6 fluconazole in dextrose...6 fluconazole inj nacl fluconazole inj nacl fluconazole inj nacl flucytosine...6 fludarabine phosphate...13 fludrocortisone acetate...46 flunisolide (nasal)...68 fluocinolone acetonide...70 fluocinolone acetonide (otic)...72 fluocinonide...70 fluocinonide emulsified base...70 FLUOROMETHOLONE...64 fluorouracil...13 fluorouracil (topical)...71 fluoxetine cap 10mg...29 fluoxetine cap 20mg...29 fluoxetine cap 40mg...29 fluoxetine hcl...29 fluphenazine decanoate...31 fluphenazine hcl...31 flurbiprofen...2 flurbiprofen sodium...64 flutamide...14 fluticasone propionate...70 fluticasone propionate (nasal)...68 fluvoxamine maleate...24 folic acid...62 fondaparinux sodium

94 FORTEO...47 FORTICAL...47 fosinopril sodium...17 fosinopril sodium & hydrochlorothiazide...17 FREAMINE HBC 6.9%...59 FREAMINE III...59 furosemide...22 furosemide inj...22 FUROSEMIDE INJ...22 FUSILEV...16 FUZEON...7 fyavolv tab 1-5mg...45 FYCOMPA...25, 26 G gabapentin...26 GABITRIL...26 galantamine hydrobromide...27 galantamine hydrobromide er...28 GAMASTAN S/D...56 GAMMAGARD LIQUID...56 GAMMAGARD S/D...56 GAMMAKED...56 GAMMAPLEX...56 GAMMAPLEX 10GM/100ML...56 GAMUNEX-C...56 ganciclovir inj 500mg...9 GARDASIL...57 GARDASIL gatifloxacin (ophth)...63 GATTEX...51 GAUZE PADS gavilyte-c...50 gavilyte-g...51 gavilyte-h...51 gavilyte-n...51 GAVISCON...48 GAVISCON EXTRA STRENGTH R...48 gemcitabine hcl...13 GEMCITABINE HCL...13 gemfibrozil...20 generlac...51 gengraf...57 gentak...63 gentamicin in saline...5 gentamicin sulfate...5 gentamicin sulfate (ophth)...63 gentamicin sulfate (topical)...69 GENTEAL SEVERE...65 GENVOYA...8 GEODON...31 GIANVI...42 gildagia...42 gildess tab 1.5/ GILENYA CAP 0.5MG...36 GILOTRIF TAB 20MG...15 GILOTRIF TAB 30MG...15 GILOTRIF TAB 40MG...15 glatopa...36 GLEOSTINE...12 glimepiride...39 glip/metform tab m...39 glip/metform tab m...39 glip/metform tab 5-500mg...39 glipizide...39 GLIPIZIDE XL TB24 2.5MG...39 GLIPIZIDE XL TB24 5MG...39 GLUCAGEN HYPOKIT...46 GLUCAGON EMERGENCY KIT...46 glyburide...39, 40 glyburide micronized...40 glycerin (laxative)...51 glycopyrrolate...50 glycopyrrolate soln 4mg/20ml...50 GNP OMEPRAZOLE...52 GOLYTELY...51 granisetron hcl...49 GRANIX...54 griseofulvin microsize...6 griseofulvin ultramicrosize...6 guaifenesin...67 guanfacine er (adhd)...34 H HAEGARDA...55 halobetasol propionate...70 haloperidol...31 haloperidol decanoate...32 haloperidol lactate inj 5 mg/ml...32 haloperidol lactate oral conc 2 mg/ml..32 HARVONI...9 HAVRIX...57 heather...42 heparin sod (porcine) in d5w...54 HEPARIN SOD (PORCINE) IN D5W...54 heparin sod inj 1000/ml...54 heparin sod inj 10000/ml

95 heparin sod inj 20000/ml...54 heparin sod inj 5000/ml...54 HEPARIN SODIUM/D5W...54 HEPARIN SODIUM/NACL 0.45%...54 HEPATAMINE...59 HERCEPTIN...13 HETLIOZ...35 HEXALEN...12 HIBERIX...57 HM GLUCOSE...46 HM OMEPRAZOLE...52 HUMIRA INJ 10MG/0.2ML...55 HUMIRA KIT 20MG/0.4ML...55 HUMIRA KIT 40MG/0.8ML...55 HUMIRA PEDIATRIC CROHNS DISEASE 55 HUMIRA PEN...55 HUMIRA PEN-CROHNS DISEASE...55 HUMIRA PEN-PSORIASIS STAR...55 HUMULIN R INJ U HUMULIN R U-500 KWIKPEN...38 hydralazine hcl...23 hydrochlorothiazide...22 hydroco/apap tab mg...3 hydroco/apap tab 5-325mg...3 hydroco/apap tab hydrocodone-acetaminophen mg/15ml...3 hydrocodone-ibuprofen tab mg.3 hydrocortisone...46 hydrocortisone-aloe vera...71 HYDROCORTISONE (ENEMA)...50 hydrocortisone (topical)...70, 71 hydrocortisone butyrate...71 hydrocortisone valerate...71 hydromorphone hcl...3 hydroxocobalamin...62 hydroxychloroquine sulfate...55 hydroxyprogesterone caproate (antineoplastic)...14 hydroxyurea...16 hydroxyzine hcl...66 hydroxyzine pamoate...66 HYSINGLA ER...3 I IBRANCE...13 ibuprofen...2 ICLUSIG...15 idarubicin hcl...12 IDHIFA...13 IFEX INJ 3GM...12 ifosfamide inj 1gm...12 ifosfamide inj 1gm/20ml...12 IFOSFAMIDE INJ 3GM...12 ifosfamide inj 3gm/60ml...12 ILEVRO...64 imatinib mesylate...15 IMBRUVICA CAP 140MG...15 imipenem-cilastatin...5 imipramine hcl...29 imiquimod...71 IMOVAX RABIES (H.D.C.V.)...57 INCRELEX...47 INCRUSE ELLIPTA...65 indapamide...22 INFANRIX...57 INFED...54 INLYTA...15 INSULIN PEN NEEDLE...38 INSULIN SAFETY NEEDLES...38 INSULIN SYRINGE...38 INTELENCE...7 INTRALIPID INJ 20%...59 INTRALIPID INJ 30%...59 INTRON-A INJ 10MU...56 INTRON-A INJ 18MU...56 INTRON-A INJ 25MU...56 INTRON-A INJ 50MU...56 introvale 91 day...42 INVANZ...5 INVEGA SUST INJ 117 MG/0.75 ML...32 INVEGA SUST INJ 156MG/ML...32 INVEGA SUST INJ 234 MG/1.5 ML...32 INVEGA SUST INJ 39 MG/0.25 ML...32 INVEGA SUST INJ 78 MG/0.5 ML...32 INVEGA TRINZA...32 INVIRASE...7 INVOKAMET TAB MG...40 INVOKAMET TAB MG...40 INVOKAMET TAB MG...40 INVOKAMET TAB MG...40 INVOKAMET XR TAB MG...40 INVOKAMET XR TAB MG...40 INVOKAMET XR TAB MG...40 INVOKAMET XR TAB MG...40 INVOKANA...40 IONOSOL-B/DEXTROSE 5%

96 IONOSOL-MB/DEXTROSE 5%...60 IPOL INACTIVATED IPV...57 ipratropium-albuterol nebu...65 ipratropium bromide...65 ipratropium bromide (nasal)...65 irbesartan...19 irbesartan-hydrochlorothiazide...18 IRESSA...15 irinotecan inj 100/5ml...17 irinotecan inj 40mg/2ml...17 irinotecan inj 500mg/25ml...17 ISENTRESS...7 ISENTRESS HD...7 isibloom 28 day...42 ISOLYTE P...60 ISOLYTE S...60 isoniazid...8 isoniazid inj 100 mg/ml...8 isoniazid syp 50mg/5ml...8 isosorbide dinitrate...23 isosorbide dinitrate er...23 isosorbide mononitrate er...23 isosorb mononitrate tab...23 isradipine...21 ISTALOL...64 ISTODAX (OVERFILL)...13 itraconazole...6 ivermectin...5 IXIARO...57 J JAKAFI...15 jantoven...54 JANUMET...40 JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG...40 JANUVIA...40 JENTADUETO...40 JENTADUETO TAB XR MG...40 JENTADUETO TAB XR MG...40 jinteli...45 JOLESSA TAB MG...42 JOLIVETTE...42 juleber 28 day...42 junel 1/20 21 day...42 junel 1.5/30 21 day...42 junel fe 1/20 28 day...42 junel fe 1.5/30 28 day...42 JUXTAPID...20 K KADCYLA...14 KALETRA SOL...8 KALETRA TAB MG...8 KALETRA TAB MG...8 KALYDECO...67 kariva 28 day...42 KCL/D5W/NACL INJ.15/.33%...60 KCL/D5W/NACL INJ.15/.45%...60 KCL/D5W/NACL INJ 0.22%/0.45%...60 KCL/D5W INJ 0.3%...60 KCL/NACL INJ 0.15%-0.9%...60 KCL/NACL INJ KCL 0.075%/D5W/NACL 0.45%...60 KCL0.15%/D5W/NACL0.2%...60 KCL0.15%/D5W/NACL0.225%...60 KCL 0.15%/D5W/NACL 0.9%...60 KCL 0.3%/D5W/NACL 0.45%...60 KCL 0.3%/D5W/NACL 0.9%...60 KCL IN NACL INJ kelnor 1/35 28 day...42 ketoconazole...6 ketoconazole cream...69 ketoconazole shampoo...70 ketoprofen...2 ketorolac tromethamine (ophth)...64 KEYTRUDA...14 kimidess 28 day...43 KINRIX...57 kionex...41 KISQALI...14 KISQALI FEMARA 200 DOSE...14 KISQALI FEMARA 400 DOSE...14 KISQALI FEMARA 600 DOSE...14 KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con spr cap 10meq...58 klor-con spr cap 8meq...58 KONSYL...51 KONSYL-D...51 KORLYM...47 KUVAN...45 KYNAMRO

97 L labetalol hcl...21 LACTATED RINGER'S INJ...60 lactulose...51 lactulose (encephalopathy)...51 lamivudine...7 lamivudine-zidovudine...8 lamivudine (hbv)...9 lamotrigine...26 lansoprazole...52 LANTUS...38 LANTUS SOLOSTAR...38 larin 1/ larin 1.5/ larin fe 1/ larin fe 1.5/ larissia tab...43 LASTACAFT...64 latanoprost...64 LATUDA...32 LEENA...43 leflunomide...55 LENVIMA 10 MG DAILY DOSE...15 LENVIMA 14 MG DAILY DOSE...15 LENVIMA 18 MG DAILY DOSE...15 LENVIMA 20 MG DAILY DOSE...15 LENVIMA 24 MG DAILY DOSE...15 LENVIMA 8 MG DAILY DOSE...15 lessina 28 day...43 LETAIRIS...23 letrozole...14 leucovorin calcium...16 leucovorin calcium for inj 500 mg...16 LEUKERAN...12 LEUKINE...54 leuprolide acetate...14 levalbuterol conc 1.25mg/0.5ml...66 levalbuterol hcl...66 LEVALBUTEROL TARTRATE HFA...66 LEVEMIR...38 LEVEMIR FLEXTOUCH...38 levetiracetam...26 LEVETIRACETAM IN SODIUM CHLORIDE...26 LEVETIRACETAM IV...26 levetiracetam oral soln 100 mg/ml...26 levobunolol hcl...64 levocarnitine (metabolic modifiers)...45 levocetirizine dihydrochloride...66 levofloxacin...11 levofloxacin in d5w...11 levofloxacin inj 25mg/ml...11 levofloxacin oral soln 25 mg/ml...11 levoleucovorin calcium...16 LEVOLEUCOVORIN CALCIUM...16 levonest 28 day...43 levonor/ethi tab...43 levonorgestrel-ethinyl estradiol (91-day)...43 levonorgestrel (emergency oc)...43 LEVONORGESTREL (EMERGENCY OC)..43 levonorgestrel & eth estradiol...43 levora 0.15/30 28 day...43 levothyroxine sodium...48 LEVOTHYROXINE SODIUM...48 LEVOXYL...48 LEXIVA...7 lidocaine...71 lidocaine-prilocaine...71 lidocaine hcl...71 lidocaine hcl (local anesth.)...4 lidocaine hcl (mouth-throat)...72 lidocaine inj 0.5%...4 lidocaine inj 1.5%...4 lidocaine inj 1%...4 lidocaine inj 2%...4 lidocaine oint 5%...71 linezolid...5 LINEZOLID...5 LINEZOLID IN SODIUM CHLORIDE...5 LINZESS...51 liothyronine sodium...48 lisinopril...17 lisinopril & hydrochlorothiazide...17 lithium carbonate...36 lithium carbonate er...36 LITHIUM SOLN 8MEQ/5ML...36 LONSURF...16 loperamide hcl...48, 51 lopinavir-ritonavir...8 loratadine...66 loratadine & pseudoephedrine...67 lorazepam...24 lorcet hd tab mg...3 lorcet plus tab lorcet tab 5-325mg

98 loryna 28 day...43 losartan-hydrochlorothiazide...18 losartan potassium...19 LOTEMAX...64 lovastatin...19 low-ogestrel...43 loxapine succinate...32 LUMIGAN...64 LUMIZYME...45 LUPRON DEP-PED INJ 11.25MG...47 LUPRON DEP-PED INJ 11.25MG (3- MONTH)...47 LUPRON DEP-PED INJ 15MG...47 LUPRON DEP-PED INJ 30MG (3-MONTH)...47 LUPRON DEP-PED INJ 7.5MG...47 LUPRON DEPOT (1-MONTH)...14 LUPRON DEPOT INJ 11.25MG (3-MONTH)...14 lutera 28 day...43 LYNPARZA...14 LYRICA...26 LYSODREN...14 lyza...43 M M-M-R II...57 mag MAGNEBIND magnesium...61 magnesium citrate...51 magnesium hydroxide...51 magnesium oxide...48 magnesium oxide (mg supplement)...61 magnesium sulfate...58 MAGNESIUM SULFATE...58 magnesium sulfate in d5w...58 MAGNESIUM SULFATE IN D5W...58 malathion...71 maprotiline hcl...29 marlissa 28 day...43 MARPLAN TAB 10MG...29 MATULANE...16 MAVYRET...9 MAXIDEX...64 meclizine hcl...49 medroxyprogesterone acetate (contraceptive)...43 MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE)...43 medroxyprogesterone acetate tab...48 mefloquine hcl...7 megestrol ac sus 40mg/ml...14 megestrol ac tab 20mg...14 megestrol ac tab 40mg...14 MEGESTROL SUS 625MG/5ML...15 MEKINIST...15 meloxicam...2 MELOXICAM...2 melphalan hcl...12 memantine hcl...28 MEMANTINE HCL...28 MENACTRA...57 MENOMUNE-A/C/Y/W MENVEO...57 MEPHYTON...62 mercaptopurine...13 meropenem...6 MESALAMINE...50 mesalamine enema...50 mesalamine w/ cleanser...50 mesna...17 MESNEX...17 metadate er tab 20mg...34 metformin hcl...40, 41 methadone hcl...3 methadone hcl 10mg...4 methadone hcl 5mg...3 methazolamide...22 methenamine hippurate...6 methergine 0.2 mg tab...47 methimazole...48 methocarbamol...37 methotrexate sodium...13 METHOTREXATE SODIUM...13 methotrexate sodium inj...13 methotrexate sodium tabs...55 methyclothiazide...22 methylcellulose (laxative)...51 methylergonovine maleate...47 methylphenidate hcl...35 methylphenidate hcl oral soln...35 methylpr ace inj 40mg/ml...46 methylpr ace inj 80mg/ml...46 methylpred pak 4mg...46 methylpred tab 16mg...46 methylpred tab 32mg

99 methylpred tab 4mg...46 methylpred tab 8mg...46 methylpr ss inj 125 mg...46 methylpr ss inj 1gm...46 methylpr ss inj 40mg...46 metipranolol...64 metoclopramide hcl...49 metoclopramide inj...49 metolazone...22 metoprolol & hctz tab mg...20 metoprolol & hctz tab mg...20 metoprolol & hctz tab 50-25mg...20 metoprolol succinate...21 metoprolol tartrate...21 metronidazole...6 metronidazole (topical)...71 metronidazole gel 0.75%...71 metronidazole in nacl...6 metronidazole vaginal...53 mexiletine hcl...19 mi-acid...48 MIACALCIN 200 UNIT/ML...47 miconazole nitrate (topical)...69 miconazole nitrate vaginal...53 MICROGESTIN 1/ MICROGESTIN 1.5/ MICROGESTIN FE 1/ MICROGESTIN FE 1.5/ midodrine hcl...23 migergot...35 MINERAL OIL...51 minitran...23 minocycline hcl...12 minoxidil...23 mirtazapine...29 misoprostol...52 mitomycin...12 mitoxantrone hcl...16 moderiba tab 200mg...9 moexipril-hydrochlorothiazide...17 moexipril hcl...17 molindone hcl 10mg...32 molindone hcl 25mg...32 mometasone furoate...71 mono-linyah tab MONONESSA...43 montelukast sodium...67 morgidox cap 1x50mg...12 morphine ext-rel tab...4 morphine sulfate...4 MORPHINE SULFATE...4 MORPHINE SULFATE ORAL SOL...4 MORPHINE SUL INJ 10MG/ML...4 MORPHINE SUL INJ 15MG/ML...4 MORPHINE SUL INJ 1MG/ML...4 MORPHINE SUL INJ 4MG/ML...4 MOVANTIK...52 MOVIPREP...51 MOXEZA...63 moxifloxacin hcl...11 moxifloxacin hcl (ophth)...63 MOZOBIL...54 MULTAQ...19 multiple vitamin...62 multiple vitamins w/ iron...62 multiple vitamins w/ minerals...62 mupirocin...69 MURO MUSTARGEN...12 MYCAMINE...6 mycophenolate mofetil...57 mycophenolate sodium...57 myorisan...69 MYRBETRIQ...53 myzilra...43 N nabumetone...2 nadolol...21 nafcillin sodium...11 NAGLAZYME...45 nalbuphine hcl...2 naloxone inj 0.4mg/ml...37 naloxone inj 1mg/ml...37 naltrexone hcl...37 NAMENDA XR...28 NAMENDA XR TITRATION PACK...28 NAMZARIC...28 naphazoline hcl...65 naproxen...2 naproxen sodium...2 naratriptan hcl...35 nasal decongestant...67 NASAL DECONGESTANT...67 NASCOBAL...62 NATACYN...63 nateglinide

100 NATPARA...47 NEBUPENT...6 necon 0.5/35 28 day...43 necon 10/ NECON 7/7/ necon tab 1/ NECON TAB 1/ nefazodone hcl...29 neomycin-bacitracin zn-polymyxin...63 neomycin-polymy-dexameth...63 neomycin-polymyxin-gramicidin...63 neomycin-polymyxin-hc (ophth)...63 neomycin-polymyxin-hc (otic)...72 neomycin sulfate...5 NEORAL...57 NEPHRAMINE...59 NERLYNX...15 NEUPOGEN...54 NEUPRO...30 nevirapine...7 NEVIRAPINE...7 NEXAVAR...15 NEXIUM GRA 10MG DR...52 NEXIUM GRA 2.5MG DR...52 NEXIUM GRA 20MG DR...52 NEXIUM GRA 40MG DR...52 NEXIUM GRA 5MG DR...52 niacin...62 niacinamide...62 niacin er (antihyperlipidemic)...20 niacor...20 nicardipine hcl...21 nicotine...37 NICOTINE...37 nicotine polacrilex...37 NICOTROL INHALER...37 NICOTROL NS...37 nifedical xl...21 nifedipine...21 nifedipine er...21 nikki 28 day...43 nilutamide...15 nimodipine...21 NINLARO...14 NIPENT...13 nitro-bid...23 NITRO-DUR DIS 0.3MG/HR...23 NITRO-DUR DIS 0.8MG/HR...23 nitrofurantoin macrocrystal...6 nitrofurantoin monohyd macro...6 nitroglycerin...23 nitroglycerin td patch...23 NORA-BE TAB...44 NORDITROPIN FLEXPRO...47 norethindrone (contraceptive)...44 norethindrone acet & eth estra...44 norethindrone acetate...48 norethindrone acetate-ethinyl estradiol 1mg-5mcg...45 norgest/ethi tab 0.25/ norgestimate-ethinyl estradiol (triphasic)...44 norlyroc 28 day...44 NORMOSOL-M IN D5W...60 NORMOSOL-R...60 NORMOSOL-R IN D5W...60 NORPACE CR...19 NORTHERA...23 nortrel 0.5/35 28 day...44 nortrel 1/35 21 day...44 nortrel 1/35 28 day...44 nortrel 7/7/7 28 day...44 nortriptyline hcl...29 NORVIR...7 NOVOLIN 70/ NOVOLIN N...38 NOVOLIN R...38 NOVOLOG...38 NOVOLOG FLEXPEN...39 NOVOLOG MIX 70/ NOVOLOG MIX 70/30 PREFILL...39 NOVOLOG PENFILL...39 NOXAFIL...7 NUEDEXTA...36 NULOJIX...57 NULYTELY/FLAVOR PACKS...51 NUPLAZID...32 nutrilipid inj 20%...59 NUVARING...44 nyamyc...69 nyata...69 NYMALIZE...21 nystatin...7 nystatin (mouth-throat)...72 nystatin (topical)...69 nystop

101 O OCELLA TAB MG...44 OCTAGAM...56 octreotide acetate...47 ODEFSEY...8 ODOMZO...16 OFEV...67 ofloxacin (ophth)...63 ofloxacin (otic)...72 olanzapine...32 olmesartan medoxomil...19 olmesartan medoxomil-amlodipinehydrochlorothiazide...19 olmesartan medoxomilhydrochlorothiazide...19 olopatadine hcl...64 omega-3-acid ethyl esters...20 OMEPRAZOLE...52 omeprazole cap 10mg...52 omeprazole cap 20mg...52 omeprazole cap 40mg...52 ONCOVITE...62 ondansetron hcl...49 ondansetron hcl inj...49 ondansetron hcl oral soln...49 ondansetron odt...49 ONFI...26 OPSUMIT...23 ORA-BLEND...61 ORA-BLEND SF...61 ORA-PLUS...61 ORA-SWEET...61 ORA-SWEET SF...61 oral electrolytes...58 ORFADIN...45 ORKAMBI...67 orsythia 28 day...44 oseltamivir phosphate...9 oxacillin sodium...11 oxaliplatin...16 oxandrolone...38 oxcarbazepine...26 oxybutynin chloride...53 oxycodone hcl...4 OXYCODONE HCL...4 oxycodone w/ acetaminophen mg...4 oxycodone w/ acetaminophen mg...4 oxycodone w/ acetaminophen 5-325mg 4 oxycodone w/ acetaminophen mg...4 oxycodone w/ acetaminophen soln...4 OXYCONTIN...4 oxymetazoline hcl...67 oyster shell...61 P pacerone...19 paclitaxel...13 paliperidone...32 pamidronate disodium...41 PANRETIN...71 pantoprazole sodium tbec...52 paricalcitol...62 paroex sol 0.12%...72 paromomycin sulfate...5 paroxetine hcl tabs...29 paser d/r...8 PATADAY...64 PAXIL...29 PAZEO...64 PEDIARIX...57 pediatric multiple vitamins w/ iron...62 pediatric multiple vitamin w/ c...62 pediatric multiple vitamin w/ c & fa...62 pediatric multiple vitamin w/ minerals & c...62 pediatric vitamins adc...62 PEDVAX HIB...57 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE...51 peg 3350-potassium chloride-sod bicarbonate-sod chloride...51 PEG 3350/ELECTROLYTES...51 PEGANONE...26 PEGASYS...9 PEGASYS PROCLICK...9 PENICILLIN G POT IN DEXTROSE...11 penicillin g procaine...11 penicillin g sodium...11 penicillin v potassium...11 penicilln gk inj 20mu...11 penicilln gk inj 5mu...11 PENTACEL...57 PENTAM pentoxifylline

102 perindopril erbumine...18 periogard...72 permethrin...72 perphenazine...32 pfizerpen-g...11 phenadoz...49 phenelzine sulfate...29 phenergan...49 phenobarbital...26 phenobarbital sodium...26 PHENOBARBITAL SODIUM...26 phenylephrine-brompheniramine-dm...67 phenylephrine-chlorpheniramine-dm w/ apap...67 phenylephrine-guaifenesin...67 phenylephrine hcl (oral)...67 phenylephrine w/ dm-gg...67 PHENYLHISTINE DH...67 phenytek...26 phenytoin...26 phenytoin sodium...26 phenytoin sodium extended...26 philith...44 PHOSPHOLINE IODIDE...64 phytonadione...62 PICATO...71 PILOCARPINE HCL...64 pilocarpine hcl (oral)...72 PILOCARPINE HCL (ORAL)...72 pimozide...32 pimtrea pack...44 pindolol...21 pioglitazone hcl...41 piperacillin/tazobactam...11 piperacillin sodium-tazobactam sodium 11 pirmella 1/35 28 day...44 piroxicam...2 PLASMA-LYTE PLASMA-LYTE A...60 podofilox...71 POLYBASE...71 polyethylene glycol-propylene glycol (ophth)...65 polyethylene glycol polymyxin b-trimethoprim...63 polysaccharide iron complex...54 polyvinyl alcohol...65 POMALYST CAP 1MG...56 POMALYST CAP 2MG...56 POMALYST CAP 3MG...56 POMALYST CAP 4MG...56 portia 28 day...44 potassium chloride...58 POTASSIUM CHLORIDE...58, 60 potassium chloride in nacl...60 potassium chloride microencapsulated crystals er...58 potassium citrate (alkalinizer)...53 POTASSIUM CITRATE (ALKALINIZER)..53 pot chloride inj 2meq/ml...60 POTIGA...27 PRADAXA...54 PRALUENT...20 pramipexole tab 0.125mg...30 pramipexole tab 0.25mg...30 pramipexole tab 0.5mg...30 pramipexole tab 0.75mg...30 pramipexole tab 1.5mg...30 pramipexole tab 1mg...30 prasugrel hcl...55 pravastatin sodium...19 prazosin hcl...18 PREDNISOLONE ACETATE (OPHTH)...64 prednisolone sodium phosphate (ophth)...64 prednisolone sol 15mg/5ml...46 prednisolone sol 25mg/5ml...46 prednisolone syp 15mg/5ml...46 prednisone con 5mg/ml...46 prednisone pak 10mg...46 prednisone pak 5mg...46 prednisone sol 5mg/5ml...46 prednisone tab 10mg...46 prednisone tab 1mg...46 prednisone tab 2.5mg...46 prednisone tab 20mg...46 prednisone tab 50mg...46 prednisone tab 5mg...46 pred sod pho sol 5mg/5ml...46 premasol sol 10%...59 premasol sol 6%...59 PRENATAL...62 prenatal vitamin/folic acid > 0.8 mg (generic)...62 prevalite...20 previfem 28 day

103 PREZCOBIX...8 PREZISTA...7 PRIFTIN...8 PRILOSEC OTC...52 PRIMAQUINE PHOSPHATE...7 primidone...27 PRISTIQ...29 PRIVIGEN...56 probenecid...1 PROCALAMINE...59 prochlorperazine inj...49 prochlorperazine maleate...49 prochlorperazine supp...49 PROCRIT...54 procto-med...69 procto-pak...69 proctosol hc cre 2.5%...69 proctozone hc...70 PROGLYCEM SUS 50MG/ML...46 PROGRAF...57 PROLASTIN-C...67 PROLENSA...65 PROLEUKIN...14 PROLIA...47 PROMACTA...55 promethazine hcl...49 promethegan...49 propafenone hcl...19 propafenone hcl 12hr...19 proparacaine hcl...65 propranolol & hydrochlorothiazide...20 propranolol cap er...21 propranolol hcl...21 propranolol oral sol...21 propylthiouracil...48 PROQUAD...57 PROSOL...59 protriptyline hcl...29 pseudoephedrine-chlorphen-dm...67 pseudoephedrine hcl...67 psyllium...51 PULMICORT FLEXHALER...68 PULMOZYME...67 PURIXAN...13 pyrazinamide...8 pyrethrins-piperonyl butoxide...72 pyridostigmine tab 60mg...36 pyridoxine hcl...62 Q QUADRACEL...58 quasense 91 day...44 quetiapine fumarate...32, 33 quinapril-hydrochlorothiazide...17 quinapril hcl...18 quinidine gluconate...19 quinidine sulfate...19 quinine sulfate...7 R RABAVERT...58 rabeprazole sodium...52 raloxifene hcl...47 ramipril...18 RANEXA...23 ranitidine hcl...50 ranitidine hcl inj...50 ranitidine syrup...50 RAPAMUNE...57 rasagiline mesylate...30 RAVICTI...45 REBETOL SOLN...9 reclipsen 28 day...44 RECOMBIVAX HB...58 REFRESH CELLUVISC...65 REGRANEX...72 RELENZA DISKHALER...9 RELISTOR...52 RELPAX...35 REMICADE...56 REMODULIN...23 RENVELA PAK 0.8GM...47 RENVELA PAK 2.4GM...47 RENVELA TAB 800MG...48 repaglinide...41 RESCRIPTOR...7 RESTASIS...65 RESTASIS MULTIDOSE...65 RETROVIR IV INFUSION...7 REVATIO...23 REVLIMID...56 REXULTI...33 REYATAZ...7 ribasphere...9 ribavirin 200mg...9 rifabutin...8 rifampin...8 RIFATER

104 riluzole...36 rimantadine hydrochloride...9 RINGER'S...61 RISPERDAL INJ 12.5MG...33 RISPERDAL INJ 25MG...33 RISPERDAL INJ 37.5MG...33 RISPERDAL INJ 50MG...33 risperidone...33 RITUXAN...14 RITUXAN HYCELA...14 rivastigmine tartrate...28 rivastigmine td patch 24hr 13.3 mg/24hr...28 rivastigmine td patch 24hr 4.6 mg/24hr...28 rivastigmine td patch 24hr 9.5 mg/24hr...28 rizatriptan benzoate...36 ropinirole tab 0.25mg...31 ropinirole tab 0.5mg...30 ropinirole tab 1mg...31 ropinirole tab 2mg...31 ropinirole tab 3mg...31 ropinirole tab 4mg...31 ropinirole tab 5mg...31 rosadan cre 0.75%...71 rosuvastatin calcium...19 ROTARIX...58 ROTATEQ...58 roweepra...27 RUBRACA...14 RYDAPT...15 S SABRIL...27 saline...67 SANDIMMUNE...57 SANDOSTATIN LAR DEPOT...47 SANTYL...72 SAPHRIS...33 scopolamine...49 selegiline hcl...31 selenium sulfide...70 SELZENTRY...7 sennosides...51 sennosides-docusate sodium...51 SENSIPAR...41 SEREVENT DISKUS...66 sertraline hcl...29 setlakin tab...44 sharobel 28 day...44 SIGNIFOR...47 sildenafil citrate (pulmonary hypertension)...23 SILENOR...35 silphen cough...66 SILVER SULFADIAZINE...69 SIMBRINZA...64 simvastatin...20 sirolimus...57 SIRTURO...8 SIVEXTRO...6 SM GLUCOSE...46 SM OMEPRAZOLE...52 sodium bicarbonate (antacid)...48 SODIUM CHLORIDE...59, 61 SODIUM CHLORIDE 0.45% VIA...61 SODIUM CHLORIDE 0.9%...72 sodium chloride hypertonic...65 SODIUM CHLORIDE INJ 0.9%...61 sodium ferric gluconate complex in sucrose...54 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln...59 sodium phenylbutyrate...45 sodium phosphates...51 sodium polystyrene sulfonate...41 SOLTAMOX...15 SOLU-CORTEF...46 SOMATULINE DEPOT...47 SOMAVERT...47 sorine...19 sotalol hcl...19 sotalol hcl (afib/afl)...19 SOVALDI...9 spironolactone...18 spironolactone & hydrochlorothiazide..22 sprintec 28 day...44 SPRITAM...27 SPRYCEL...15 sps susp 15gm/60ml...41 sronyx...44 SSD...69 stavudine...7 STERILE WATER IRRIGATION...72 STIMATE...48 STIVARGA

105 STRATTERA...35 streptomycin sulfate...5 STRIBILD...8 SUBOXONE MIS 12-3MG...38 SUBOXONE MIS 2-0.5MG...38 SUBOXONE MIS 4-1MG...38 SUBOXONE MIS 8-2MG...38 SUCRAID...52 sucralfate...52 sulfacetamide sod-prednisolone...63 sulfacetamide sodium (acne)...69 sulfacetamide sodium (ophth)...63 sulfacet sod oin 10% op...63 sulfadiazine...5 sulfamethoxazole-trimethop ds...6 sulfamethoxazole-trimethoprim...6 sulfamethoxazole-trimethoprim inj...6 SULFAMYLON...69 sulfasalazine...50 sulfasalazine ec...50 sulindac...2 SUMATRIPTAN...36 SUMATRIPTAN INJ 4MG/0.5ML...36 sumatriptan inj 6mg/0.5ml...36 sumatriptan succinate...36 suprax...10 SUPRAX...10 SUPREP BOWEL PREP KIT...51 SUSPENDOL-S...61 SUSTIVA...7 SUTENT...16 syeda...44 SYLATRON KIT 200MCG...16 SYLATRON KIT 300MCG...16 SYLATRON KIT 600MCG...16 SYMBICORT...68 SYMLINPEN SYMLINPEN SYNAGIS...58 SYNAREL...45 SYNERCID...6 SYNRIBO...16 SYNTHROID...48 SYPRINE...41 SYRSPEND SF...61 SYSTANE OVERNIGHT THERAPY...65 T TABLOID...13 tacrolimus...57 tacrolimus (topical)...71 TAFINLAR...16 TAGRISSO...16 TAMIFLU SUSR...9 tamoxifen citrate...15 tamsulosin hcl...53 TARCEVA...16 TARGRETIN...71 tarina fe 1/20 28 day...44 TASIGNA...16 TAXOTERE...13 tazarotene...70 tazicef...10 tazicef vial...10 TAZORAC...70 taztia...21 TECENTRIQ...14 TEFLARO...10 TEGRETOL...27 TEGRETOL-XR...27 telmisartan...19 telmisartan-hydrochlorothiazide...19 temazepam...35 TENIVAC...58 terazosin hcl...18 terbinafine hcl...7 terbinafine hcl (topical)...69 terbutaline sulfate...66 terconazole vaginal...53 testosterone...38 testosterone cypionate...38 testosterone enanthate...38 TETANUS/DIPHTHERIA TOXOID...58 TETRABENAZINE...36 texacort soln 2.5%...71 THALOMID...56 theo theophylline...68 THERA...62 THERA-M...62 THERA/BETA-CAROTENE...62 THERA M PLUS...62 thiamine hcl...62 thioridazine hcl...33 thiothixene...33 tiagabine hcl...27 TIGECYCLINE

106 TILIA FE...44 timolol maleate...21 timolol maleate (ophth) soln...64 TIMOLOL MALEATE GEL...64 TIVICAY...7 tizanidine hcl...37 TOBRADEX...63 TOBRADEX ST...63 tobramycin...5 tobramycin-dexamethasone...63 tobramycin (ophth)...63 tobramycin inj 1.2gm...5 tobramycin inj 1.2 gm/30ml...5 tobramycin inj 10mg/ml...5 tobramycin inj 40mg/ml...5 tobramycin inj 80mg/2ml...5 TOBREX...63 tolnaftate...69 tolterodine tartrate cap er...53 tolterodine tartrate tabs...53 topiramate...27 toposar...17 topotecan hcl...17 TOPOTECAN HCL...17 torsemide tabs...22 TOUJEO SOLOSTAR...39 TOVIAZ...53 TPN ELECTROLYTES...59 TRACLEER...23 TRADJENTA...41 tramadol-acetaminophen...2 tramadol hcl...2 trandolapril...18 tranexamic acid...55 TRANSDERM-SCOP...49 tranylcypromine sulfate...29 TRAVASOL...59 TRAVATAN Z...64 trazodone hcl...29 TREANDA...12 TRECATOR...9 TRELSTAR DEP INJ 3.75MG...15 TRELSTAR LA INJ 11.25MG...15 TRESIBA FLEXTOUCH...39 tretinoin...69 TRETINOIN...69 tretinoin (chemotherapy)...16 tri-legest 28 day...44 tri-linyah...44 tri-lo-estarylla...44 tri-lo-sprintec 28 day...44 tri-lo marzia...44 tri-previfem 28 day...44 tri-sprintec 28 day...44 TRI-VI-SOL...62 triamcinolone acetonide (mouth)...72 triamcinolone acetonide (topical)...71 triamterene & hydrochlorothiazide...22 triamterene & hydrochlorothiazide cap mg...22 triderm...71 trifluoperazine hcl...33 trifluridine...63 trihexyphenidyl hcl...31 triklo...20 trilyte...51 trimethoprim...6 trimipramine maleate...30 TRINESSA...44 TRINESSA LO TAB...44 TRINTELLIX...30 triprolidine & pseudoephedrine...67 TRISENOX...16 TRIUMEQ...8 trivora 28 day...44 TROPHAMINE INJ 10%...59 trospium chloride...53 TRULICITY...39 TRUMENBA...58 TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB TWINRIX INJ...58 TYBOST...7 TYGACIL...6 TYKERB...16 TYPHIM VI...58 TYSABRI...36 TYZEKA...9 U ULORIC...1 UNITHROID...48 UPTRAVI...23, 24 ursodiol

107 V valacyclovir hcl...9 VALCHLOR...71 VALCYTE...9 valganciclovir hcl...9 valproate sodium...27 valproic acid...27 valsartan...19 valsartan & hctz tab mg...19 valsartan & hctz tab mg...19 valsartan & hctz tab mg...19 valsartan & hctz tab mg...19 valsartan & hctz tab mg...19 vancomycin hcl...6 VANCOMYCIN IN NACL...6 VANDAZOLE...53 VAQTA...58 VARIVAX...58 VASCEPA...20 VELCADE...14 velivet 28 day...44 VEMLIDY...9 VENCLEXTA...14 VENCLEXTA STARTING PACK...14 venlafaxine hcl...30 VENOFER...54 VENTAVIS...24 VENTOLIN HFA...66 verapamil cap er...22 VERAPAMIL CAP ER...22 verapamil hcl...22 verapamil tab er...22 VERSACLOZ...33 VESICARE...53 vestura...44 VICTOZA...39 VIDEX PEDIATRIC...7 vienva 28 day...44 vigabatrin powd pack...27 VIGAMOX...63 VIIBRYD STARTER PACK...30 VIIBRYD TAB...30 VIMPAT...27 vinblastine sulfate...13 vincasar...13 vincristine sulfate...13 vinorelbine tartrate...13 viorele...44 VIRACEPT...7 VIRAMUNE...8 VIREAD...8 vitamin a...62 vitamins w/ lipotropics...62 voriconazole...7 VOSEVI...9 VOTRIENT...16 VRAYLAR...33 VRAYLAR THERAPY PACK...33 vyfemla 28 day...45 W warfarin sodium...54 WELCHOL...20 white petrolatum-mineral oil...65 X XALKORI...16 XARELTO...54 XARELTO STARTER PACK...54 XATMEP...56 XELJANZ...56 XELJANZ XR...56 XGEVA...47 XIFAXAN...52 XIGDUO XR TAB MG...41 XIGDUO XR TAB MG...41 XIGDUO XR TAB MG...41 XIGDUO XR TAB 5-500MG...41 XOLAIR...68 XTANDI...15 xulane...45 XYREM...37 Y YERVOY...14 YF-VAX...58 yuvafem vaginal tablet 10 mcg...46 Z zafirlukast...67 zarah...45 ZAVESCA...45 ZEJULA...14 ZELBORAF...16 ZEMAIRA...68 zenatane...69 zenchent 28 day...45 ZENPEP...52 ZEPATIER...9 ZERIT

108 ZIAGEN...8 zidovudine...8 zinc oxide (topical)...71 ziprasidone hcl...34 ZIRGAN...63 zoledronic acid...41 zoledronic inj 4mg/5ml...41 ZOLINZA...14 zolmitriptan...36 zolmitriptan odt...36 zolpidem tartrate...35 zonisamide...27 ZONTIVITY...55 ZORTRESS TAB 0.25MG...57 ZORTRESS TAB 0.5MG...57 ZORTRESS TAB 0.75MG...57 ZOSTAVAX...58 zovia 1/35e 28 day...45 zovia 1/50e 28 day...45 ZYDELIG...16 ZYKADIA...16 ZYLET...63 ZYPREXA RELPREVV...34 ZYPREXA RELPREVV INJ 210MG...34 ZYTIGA

109 Elderplan, Inc. 非歧視通知 - 歧視屬於違法 Elderplan/HomeFirst 遵守適用的聯邦民權法, 不會因種族 膚色 原國籍 年齡 殘障或性別而歧視他人 Elderplan, Inc. 不會因種族 膚色 原國籍 年齡 殘障或性別將人拒之門外或給予他們不同待遇 Elderplan/HomeFirst: 向殘障人士提供免費協助和服務, 幫助他們與我們進行有效溝通, 比如 : o 合格的手語翻譯員 o 其他格式 ( 大字印刷 音訊 可存取的電子格式 其他格式 ) 的書面資訊 向母語並非英語的人士提供免費語言服務, 比如 : o 合格的翻譯員 o 用其他語言書寫的資訊 如果您需要這些服務, 請聯絡民權協調員 如果您認為 Elderplan/HomeFirst 因種族 膚色 原國籍 年齡 殘障或性別而未能提供這些服務或在其他方面存在歧視行為, 您可向以下人員或機構提出申訴 : Civil Rights Coordinator th Avenue Brooklyn, NY, 電話 : , 聽障 / 語障專線 :711 傳真 : 您可親自或透過郵件 電話或傳真的方式提出申訴 如果您在提出申訴時需要幫助, 民權協調員可向您提供幫助 您還可透過民權辦公室投訴入口網站 以電子形式向美國衛生與公眾服務部民權辦公室提出民權投訴, 或者透過郵件或電話進行此投訴 : U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, D.C 電話 : , 聽障 / 語障專線 : 投訴表格可在以下網址獲取 :

110 多語言提示 ATTENTION: If you speak a non-english language or require assistance in ASL, language assistance services, free of charge, are available to you.call (TTY:711). ( 西班牙語 )ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). ( 中文 ) 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 (TTY:711). ( 俄語 )ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ( 法國克里奧爾語 )ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). ( 韓語 ) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ( 義大利語 )ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ( 意第緒語 ) אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט 711) (TTY: ( 孟加拉語 ) 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) ( 波蘭語 )UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ( 阿拉伯語 (ملحوظة: إذا كنت تتحدث لغة غير اإلنجليزية أو تحتاج إلى مساعدة في ASL فإن خدمات المساعدة اللغوية تتوافر لك مجانا. اتصل برقم (711 (TTY: ( 法語 )ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). ) 烏爾都語 )خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: 711) ( 菲律賓語 )PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711).

111 ( 希臘語 )ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 711). ( 阿爾巴尼亞語 )KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711).