Empire FIDA Plan 2015 年 承 保 藥 物 清 單 ( 處 方 集 ) 此 為 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 參 與 者 可 獲 取 的 藥

Transcription

1 給 付 藥 物 ( 處 方 藥 物 ) 清 單 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) 2015 年 參 與 者 服 務 部 (TTY 711) 當 地 時 間 週 一 至 週 五 上 午 8 點 至 下 午 8 點 ENYDMKT Formulary CH 處 方 藥 物 ID 版 本..14 發 佈 時 間 11/01/2015

2 Empire FIDA Plan 2015 年 承 保 藥 物 清 單 ( 處 方 集 ) 此 為 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 參 與 者 可 獲 取 的 藥 物 清 單 Empire BlueCross BlueShield HealthPlus FIDA Plan 為 一 個 與 Medicare 及 紐 約 州 衛 生 署 (Medicaid) 訂 立 的 託 管 保 健 計 劃, 以 透 過 Fully Integrated Duals Advantage (FIDA) Demonstration 向 參 與 者 提 供 該 兩 項 計 劃 的 福 利 Empire BlueCross BlueShield HealthPlus 是 HealthPlus, LLC 的 商 標 名 稱, 該 公 司 屬 Blue Cross and Blue Shield Association 的 獨 立 持 照 組 織 福 利 承 保 藥 物 清 單 及 藥 房 以 及 服 務 提 供 者 網 絡 可 能 於 年 內 及 各 年 1 月 1 日 不 時 變 更 您 可 以 透 過 登 錄 或 於 週 一 至 週 五 上 午 8 時 至 下 午 8 致 電 Empire FIDA Plan 參 與 者 服 務 部, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 查 看 Empire FIDA Plan 的 最 新 承 保 藥 物 清 單 可 能 存 在 限 制 或 局 限 如 需 更 多 資 訊, 請 致 電 Empire FIDA Plan 參 與 者 服 務 部 或 查 閱 Empire FIDA Plan 參 與 者 手 冊 無 需 為 任 何 承 保 藥 物 支 付 共 付 費 您 可 以 免 費 獲 取 此 資 訊 的 其 他 版 本, 如 盲 文 或 大 字 版 本 請 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 您 可 以 免 費 獲 得 此 資 訊 的 其 他 語 言 版 本 請 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 Usted puede obtener esta información gratuitamente en otros idiomas.llame al (TTY ) (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local.la llamada es gratuita. 您 可 以 免 費 獲 得 此 資 訊 的 其 他 語 言 版 本 請 致 電 (TTY 711) 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 此 為 免 付 費 電 話 Ou ka jwenn enfòmasyon sa gratis nan lòt lang.rele (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. nan lè lokal.apèl sa gratis. È possibile ottenere queste informazioni gratuitamente in altre lingue.chiamare (TTY 711) dal lunedì al venerdì, dalle 8:00 alle 20:00 ora locale.la chiamata è gratuita. 이 정보는 다른 언어로 무료로 얻을 수 있습니다.현지 시간으로 월요일부터 금요일까지, 오전 8시에서 오후 8시 사이에 (TTY 711)번으로문의하십시오.통화는 무료입니다.? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

3 Вы можете получить данную информацию бесплатно на любом языке.звоните по номеру (TTY 711) с понедельника по пятницу с 8:00 до 20:00 по местному времени.звонок бесплатный. 紐 約 州 已 建 立 一 個 名 為 Independent Consumer Advocacy Network (ICAN) 的 參 與 者 調 查 官 計 劃, 以 就 Empire FIDA Plan 所 提 供 的 任 何 服 務 向 參 與 者 提 供 免 費 私 密 的 幫 助 您 可 以 致 電 免 費 電 話 或 登 錄 icannys.org 瞭 解 ICAN? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

4 常 見 問 題 ( 常 見 問 題 ) 如 果 您 對 承 保 藥 物 清 單 存 在 疑 問, 請 在 此 處 尋 找 相 關 答 案 您 可 以 閱 覽 所 有 常 見 問 題 瞭 解 更 多 資 訊, 或 直 接 找 到 想 瞭 解 的 問 題 及 相 關 答 案 1. 承 保 藥 物 清 單 上 包 括 哪 些 處 方 藥 物?( 我 們 將 承 保 藥 物 清 單 簡 稱 為 藥 物 清 單 ) 承 保 藥 物 清 單 ( 從 9 頁 開 始 ) 上 的 藥 物 為 Empire FIDA Plan 承 保 的 藥 物 此 等 藥 物 可 從 我 們 的 網 絡 內 藥 房 獲 取 倘 我 們 與 一 間 藥 房 達 成 協 議 合 作 並 向 您 提 供 服 務, 則 該 藥 房 為 我 們 的 網 絡 內 藥 房 我 們 將 此 等 藥 房 稱 為 網 絡 藥 房 倘 出 現 以 下 情 況,Empire FIDA Plan 將 承 保 藥 物 清 單 上 的 所 有 藥 物 : 您 的 醫 生 或 其 他 網 絡 處 方 醫 生 說 明 您 需 要 該 等 藥 物, 以 達 到 康 復 或 保 持 健 康, 該 藥 物 為 您 的 身 體 狀 況 醫 療 所 需, 及 您 於 Empire FIDA Plan 的 網 絡 藥 房 配 藥 Empire FIDA Plan 可 能 存 在 評 估 若 干 藥 物 的 其 他 步 驟 ( 見 下 文 問 題 5) 在 某 些 情 況 下, 在 獲 得 指 定 藥 物 之 前, 您 可 能 需 要 做 些 事, 如 先 嘗 試 其 他 藥 物 您 可 以 訪 問 我 們 的 網 站 或 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711), 以 查 閱 最 新 的 承 保 藥 物 清 單 2. 藥 物 清 單 是 否 會 變 更? 是 Empire FIDA Plan 可 能 於 年 內 在 藥 物 清 單 上 添 加 或 刪 除 藥 物 通 常 情 況 下, 藥 物 清 單 僅 在 發 生 以 下 情 況 時 才 會 變 更 : 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 新 藥 物 出 現, 或 我 們 得 知 某 種 藥 物 不 安 全 我 們 亦 可 能 變 更 有 關 藥 物 的 規 則 例 如, 我 們 可 能 : 決 定 就 某 種 藥 物 要 求 或 不 要 求 事 先 批 准 ( 事 先 批 准 指 您 在 獲 得 某 種 藥 物 前 由 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 作 出 的 批 准 ) 增 加 或 變 更 您 可 獲 取 藥 物 的 劑 量 ( 稱 為 劑 量 限 制 ) 就 某 項 藥 物 添 加 或 變 更 漸 進 式 治 療 限 制 ( 漸 進 式 治 療 指 在 我 們 承 保 另 一 種 藥 物 前, 您 必 須 嘗 試 一 種 藥 物 ) ( 有 關 此 等 藥 物 規 則 的 更 多 資 訊, 請 參 閱 第 9 頁 )? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

5 當 您 使 用 的 某 種 藥 物 從 藥 物 清 單 上 刪 除 時, 我 們 會 通 知 您 當 我 們 變 更 承 保 某 種 藥 物 的 規 則 時, 我 們 亦 會 通 知 您 下 文 問 題 3 4 及 7 提 供 有 關 藥 物 清 單 變 更 時 的 更 多 資 訊 您 可 以 隨 時 登 錄 在 綫 查 看 Empire FIDA Plan 的 最 新 藥 物 清 單 您 亦 可 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711), 以 查 核 當 前 藥 物 清 單 3. 當 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 較 便 宜 藥 物 出 現 時 會 如 何? 當 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 較 便 宜 藥 物 出 現 時 : 當 您 下 次 配 藥 時, 您 的 藥 劑 師 可 能 會 給 您 開 這 種 較 便 宜 的 藥 物 倘 您 及 您 的 服 務 提 供 者 認 為 這 種 較 便 宜 的 藥 物 不 適 合 您 使 用, 您 的 服 務 提 供 者 可 告 知 藥 劑 師 繼 續 提 供 您 目 前 使 用 的 藥 物 Empire FIDA Plan 可 能 決 定 將 較 貴 的 藥 物 從 藥 物 清 單 上 刪 除 倘 您 正 在 服 用 某 種 因 同 等 功 效 的 較 便 宜 藥 物 出 現 而 將 從 藥 物 清 單 上 刪 除 的 藥 物, 在 將 該 藥 物 自 藥 物 清 單 上 刪 除 之 前, 我 們 將 提 前 至 少 60 日 通 知 您, 或 在 您 再 次 配 藥 時 通 知 您 如 此, 您 可 在 藥 物 清 單 變 更 前 獲 得 60 天 的 藥 物 供 應 倘 您 收 到 此 類 通 知, 您 應 與 您 的 服 務 提 供 者 商 討 開 始 使 用 清 單 上 的 藥 物, 或 請 求 特 例 4. 當 我 們 發 現 某 種 藥 物 不 安 全 時 會 如 何? 倘 食 物 和 藥 品 管 理 局 (FDA) 認 為 您 正 在 使 用 的 某 種 藥 物 不 安 全, 我 們 會 立 即 將 其 從 藥 物 清 單 上 刪 除 我 們 會 向 您 寄 送 函 件 或 電 話 告 知 您 這 種 不 安 全 的 藥 物 已 從 藥 物 清 單 上 刪 除 如 果 您 收 到 關 於 不 安 全 藥 物 的 通 知, 請 立 即 聯 絡 您 的 醫 生 您 的 醫 生 會 幫 助 您 找 到 另 一 種 適 合 您 的 藥 物 5. 藥 物 承 保 是 否 存 在 任 何 局 限 或 限 制? 或 者 是 否 需 採 取 任 何 規 定 的 行 動, 以 獲 得 特 定 藥 物? 是 的, 某 些 藥 物 有 承 保 規 則 或 對 您 可 獲 取 的 劑 量 有 所 限 制 在 某 些 情 況 下, 在 獲 得 藥 物 之 前, 您 可 能 需 要 做 些 事 例 如 : 事 先 批 准 ( 或 事 先 核 准 ): 就 某 些 藥 物 而 言, 在 您 配 藥 之 前, 您 或 您 的 醫 生 或 其 他 處 方 醫 生 必 須 獲 得 來 自 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 的 批 准 倘 您 未 獲 批 准, Empire FIDA Plan 可 能 不 會 承 保 該 藥 物 劑 量 限 制 : 有 時,Empire FIDA Plan 會 限 制 您 可 獲 取 的 藥 物 劑 量 漸 進 式 治 療 : 有 時,Empire FIDA Plan 會 要 求 您 進 行 漸 進 式 治 療 這 意 味 著 您 須 根 據 您 的 身 體 狀 況 按 特 定 順 序 使 用 藥 物 在 我 們 承 保 另 一 種 藥 物 之 前, 您 可 能 須 先 使 用 某 種 藥 物 倘 您 的 醫 生 認 為 第 一 種 藥 物 並 不 適 合 您 使 用, 則 我 們 會 承 保 第 二 種 藥 物 您 可 以 透 過 查 看 從 第 9 頁 開 始 的 表 格 瞭 解 您 的 藥 物 是 否 存 在 任 何 其 他 要 求 您 亦 可 以 透 過 訪 問 我 們 的 網 站 獲 取 更 多 資 訊 我 們 已 公 佈 說 明 事 先 核 准 限 制 及 漸 進 式 治 療 限 制 相 關 事 項 的 在 綫 文 件 您 亦 可 以 要 求 我 們 給 您 寄 送 一 份 副 本 您 可 以 就 此 等 限 制 請 求 特 例 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 9? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

6 如 果 您 目 前 居 於 一 家 療 養 院 或 其 他 長 期 護 理 機 構, 並 需 要 某 種 藥 物 清 單 上 沒 有 的 藥 物, 或 您 無 法 輕 易 獲 取 該 種 藥 物, 我 們 可 以 幫 助 您 無 論 您 是 否 為 Empire FIDA Plan 的 新 參 與 者, 我 們 就 該 種 藥 物 承 保 31 日 的 緊 急 供 應 ( 除 非 您 的 處 方 未 達 31 日 ) 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 他 / 她 可 以 幫 助 您 決 定 是 否 使 用 藥 物 清 單 上 存 在 的 某 種 類 似 藥 物 替 代, 或 是 否 請 求 特 例 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 您 將 如 何 知 曉 您 想 要 的 某 種 藥 物 是 否 存 在 限 制 或 在 獲 取 該 藥 物 前 是 否 需 要 採 取 規 定 行 動? 位 於 第 9 頁 的 承 保 藥 物 清 單 上 印 有 標 籤 名 為 的 一 欄 7. 如 果 我 們 承 保 某 些 藥 物 的 規 則 發 生 變 更 會 如 何? 例 如, 倘 我 們 就 某 種 藥 物 添 加 事 先 核 准 ( 批 准 ) 劑 量 限 制 及 / 或 漸 進 式 治 療 限 制 倘 我 們 就 某 種 藥 物 添 加 事 先 核 准 ( 批 准 ) 劑 量 限 制 及 / 或 漸 進 式 治 療 限 制, 我 們 會 告 知 您 我 們 會 在 添 加 該 項 限 制 前 至 少 60 日 或 在 您 下 次 配 藥 時 告 知 您 如 此, 您 可 在 藥 物 清 單 變 更 前 獲 得 60 日 的 藥 物 供 應 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 對 策 8. 如 何 在 藥 物 清 單 上 找 到 某 種 藥 物? 有 兩 種 方 式 可 供 您 選 擇 : 您 可 以 按 字 母 搜 索 ( 如 果 您 知 道 如 何 拼 寫 該 藥 物 的 名 稱 ), 或 您 可 按 身 體 狀 況 搜 索 要 按 字 母 搜 索, 您 可 找 到 位 於 頁 碼 頁 面 的 字 母 清 單 一 節 然 後 在 清 單 上 尋 找 您 的 藥 物 的 名 稱 要 按 身 體 狀 況 搜 索, 您 可 找 到 位 於 頁 碼 頁 面 的 標 題 為 按 身 體 狀 況 分 類 的 藥 物 清 單 一 節 然 後 找 到 與 您 的 身 體 狀 況 相 符 的 一 節 例 如, 如 果 您 有 心 臟 問 題, 則 應 在 該 類 中 尋 找 在 該 處, 您 將 可 以 找 到 治 療 心 臟 病 的 藥 物 9. 倘 您 想 要 的 某 種 藥 物 不 在 藥 物 清 單 上 時 怎 麼 辦? 倘 您 發 現 您 的 藥 物 不 在 藥 物 清 單 上, 請 於 週 一 至 週 五 上 午 9 點 至 晚 上 9 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 如 果 您 得 知 Empire FIDA Plan 未 承 保 該 種 藥 物, 您 可 採 取 以 下 行 動 : 請 求 參 與 者 服 務 部 提 供 與 您 想 要 的 藥 物 類 似 的 藥 物 清 單 然 後 將 該 清 單 出 示 予 您 的 醫 生 或 其 他 處 方 醫 生 他 / 她 可 開 具 藥 物 清 單 上 一 種 與 您 想 要 的 藥 物 類 似 的 藥 物 或 您 可 向 此 計 劃 或 您 的 Interdisciplinary Team (IDT) 請 求 特 例, 以 承 保 您 的 藥 物 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 如 果 您 為 Empire FIDA Plan 的 新 參 與 者, 且 未 能 在 藥 物 清 單 上 找 到 您 的 藥 物 或 無 法 獲 得 藥 物 時 怎 麼 辦?? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

7 我 們 可 以 幫 助 您 如 有 需 要, 在 您 成 為 Empire FIDA Plan 參 與 者 的 首 90 日 內, 我 們 須 承 保 長 達 90 日 的 藥 物 臨 時 供 應 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 他 / 她 可 以 幫 助 您 決 定 是 否 使 用 藥 物 清 單 上 存 在 的 某 種 類 似 藥 物 替 代, 或 是 否 請 求 特 例 倘 以 下 情 況 發 生, 我 們 將 承 保 長 達 90 日 的 臨 時 供 應 : 您 在 使 用 藥 物 清 單 上 並 不 存 在 的 藥 物, 或 保 健 計 劃 規 則 使 您 未 獲 得 您 的 處 方 醫 生 規 定 的 劑 量, 或 該 種 藥 物 需 獲 得 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 的 事 先 批 准, 或 您 在 使 用 一 種 用 於 漸 進 式 治 療 的 藥 物 如 果 您 居 於 一 家 療 養 院 或 其 他 長 期 護 理 機 構, 您 可 在 長 達 98 日 內 按 您 的 處 方 重 新 配 藥 在 此 98 日 內, 您 可 多 次 配 藥 這 使 您 的 處 方 醫 生 有 時 間 將 您 的 藥 物 改 成 藥 物 清 單 上 已 有 的 藥 物, 或 請 求 特 例 如 果 您 的 護 理 級 別 變 更, 要 求 您 從 一 家 機 構 或 治 療 中 心 轉 移 至 另 一 家, 您 可 有 資 格 按 您 的 現 有 處 方 進 行 一 次 臨 時 配 藥 例 如, 如 果 您 從 醫 院 出 院, 且 根 據 醫 院 的 處 方, 您 需 再 使 用 某 些 藥 物, 您 還 可 以 進 行 一 次 配 藥 不 論 是 否 在 加 入 計 劃 的 首 90 日 內, 您 可 以 獲 得 一 次 臨 時 配 藥 特 例 欲 瞭 解 詳 情, 請 讓 您 的 處 方 醫 生 致 電 我 們 11. 您 是 否 可 以 請 求 特 例 承 保 藥 物? 是 的 您 可 以 請 求 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 破 例 承 保 藥 物 清 單 上 沒 有 的 藥 物 您 亦 可 以 請 求 Empire FIDA Plan 或 您 的 IDT 變 更 您 所 用 藥 物 的 相 關 規 則 例 如,Empire FIDA Plan 可 能 會 限 制 我 們 承 保 的 藥 物 劑 量 如 果 您 的 藥 物 存 在 劑 量 限 制, 您 可 以 要 求 我 們 或 您 的 IDT 變 更 該 限 制, 並 承 保 更 多 劑 量 其 他 示 例 : 您 可 以 要 求 我 們 或 您 的 IDT 取 消 漸 進 式 治 療 限 制 或 事 先 批 准 規 定 12. 獲 取 特 例 需 要 多 長 時 間? 首 先,Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 須 收 到 一 份 來 自 您 的 處 方 醫 生 表 明 支 持 您 的 特 例 請 求 的 聲 明 收 到 聲 明 之 後, 我 們 將 在 72 小 時 內 決 定 是 否 批 准 您 的 特 例 請 求 如 果 您 的 處 方 醫 生 認 為 72 小 時 的 等 待 時 間 會 讓 您 的 健 康 受 損, 您 可 請 求 緊 急 特 例 我 們 會 快 速 作 出 決 定 如 果 您 的 處 方 醫 生 支 持 您 的 請 求, 您 將 在 收 到 其 支 持 聲 明 後 24 小 時 內 得 到 我 們 的 答 復 13. 如 何 請 求 特 例? 要 請 求 特 例, 請 致 電 您 的 醫 療 經 理 人 您 的 醫 療 經 理 人 將 與 您 和 您 的 服 務 提 供 者 協 作, 幫 助 您 請 求 特 例? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

8 14. 什 麼 是 仿 製 藥 物? 仿 製 藥 物 為 由 與 品 牌 藥 物 相 同 的 成 份 製 成 的 藥 物 這 些 藥 物 通 常 較 品 牌 藥 物 便 宜, 且 知 名 度 不 高 仿 製 藥 物 已 獲 食 物 和 藥 品 管 理 局 (FDA) 批 准 Empire FIDA Plan 既 承 保 品 牌 藥 物, 亦 承 保 仿 製 藥 物 15. 什 麼 是 非 處 方 藥 物? OTC 指 非 處 方 當 您 的 服 務 提 供 者 將 若 干 非 處 方 藥 物 作 為 處 方 書 面 寫 明 時,Empire FIDA Plan 會 承 保 該 等 非 處 方 藥 物 您 可 以 閱 覽 Empire FIDA Plan 藥 物 清 單, 瞭 解 獲 承 保 的 非 處 方 藥 物 16. Empire FIDA Plan 是 否 承 保 非 處 方 非 藥 物 產 品? 當 您 的 服 務 提 供 者 將 若 干 非 處 方 非 藥 物 產 品 作 為 處 方 書 面 寫 明 時,Empire FIDA Plan 會 承 保 該 等 非 處 方 非 藥 物 產 品 Empire FIDA Plan 承 保 維 他 命 及 礦 物 質 等 非 藥 物 項 目 您 可 以 閱 覽 Empire FIDA Plan 藥 物 清 單, 瞭 解 獲 承 保 的 非 處 方 非 藥 物 產 品 有 哪 些 17. 什 麼 是 共 付 費? 您 無 需 為 藥 物 清 單 上 已 有 的 藥 物 支 付 共 付 費 18. 什 麼 是 藥 物 分 級? 分 級 即 為 具 有 不 同 規 則 及 規 章 的 各 種 不 同 類 型 藥 物 的 組 別 所 有 Empire FIDA Plan 分 級 都 無 需 共 付 費 第 1 級 藥 物 為 首 選 D 部 分 仿 製 及 品 牌 藥 物 第 2 級 藥 物 為 無 需 事 先 核 准 的 D 部 分 非 首 選 品 牌 及 仿 製 藥 物 第 3 級 包 括 非 D 部 分 藥 物 ( 品 牌 藥 物 與 仿 製 藥 物 ) 某 些 藥 物 可 能 需 要 事 先 核 准 第 4 級 包 括 處 方 內 的 非 處 方 藥 物 承 保 藥 物 清 單 從 下 頁 開 始 的 承 保 藥 物 清 單 提 供 Empire FIDA Plan 承 保 藥 物 的 相 關 資 訊 如 果 您 未 能 在 清 單 內 找 到 您 需 要 的 藥 物, 請 閱 覽 始 於 索 引 頁 碼 頁 面 的 索 引? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

9 圖 表 的 第 一 欄 列 明 藥 物 的 名 稱 品 牌 藥 物 為 大 寫 ( 如 ABELCET), 仿 製 藥 物 為 小 寫 斜 體 ( 如 fluconazole) 一 欄 內 的 資 訊 將 告 訴 您 Empire FIDA Plan 對 承 保 您 的 藥 物 是 否 存 在 任 何 規 則 下 文 為 一 欄 內 所 用 代 碼 的 含 義 ; B/D: 此 種 處 方 藥 物 可 能 根 據 Medicare B 部 分 ( 例 如, 意 味 著 您 應 從 服 務 提 供 者 處 獲 取 該 種 藥 物 ) 或 D 部 分 ( 意 味 著 您 應 從 您 的 藥 房 獲 取 該 種 藥 物 ) 承 保 視 乎 情 況 而 定 您 可 能 需 要 提 交 說 明 該 種 藥 物 的 使 用 事 項 的 資 料, 以 決 定 按 何 種 方 式 承 保 無 論 按 何 種 方 式, 您 無 需 為 此 種 藥 物 支 付 任 何 費 用 HI: 家 庭 注 射 此 種 處 方 藥 物 可 能 根 據 我 們 的 醫 療 福 利 承 保 如 需 更 多 資 訊, 請 致 電 會 員 服 務 部 LA: 供 應 有 限 此 種 處 方 藥 物 可 能 僅 可 從 若 干 藥 房 獲 取 如 需 更 多 資 訊, 請 致 電 會 員 服 務 部 MO: 郵 購 藥 物 此 種 處 方 藥 物 可 透 過 我 們 的 郵 購 服 務 及 零 售 網 絡 藥 房 獲 取 考 慮 就 您 的 長 期 ( 保 養 ) 藥 物 ( 如 高 血 壓 藥 物 ) 使 用 郵 寄 訂 購 零 售 網 絡 藥 房 可 能 更 適 合 於 短 期 處 方 藥 物 ( 如 抗 生 素 ) PAR: 需 要 事 先 核 准 就 若 干 藥 物 而 言, 此 計 劃 可 能 要 求 您 或 您 的 醫 師 獲 得 事 先 核 准 這 意 味 著 您 在 配 藥 前 需 獲 得 批 准 如 果 您 未 獲 得 批 准, 我 們 可 能 不 會 承 保 該 種 藥 物 QLL: 劑 量 限 制 就 若 干 藥 物 而 言, 此 計 劃 會 限 制 我 們 承 保 的 藥 物 劑 量 ST: 漸 進 式 治 療 在 某 些 情 況 下, 在 我 們 承 保 另 一 種 藥 物 之 前, 此 計 劃 可 能 要 求 您 先 嘗 試 若 干 藥 物 來 治 療 您 的 病 症 例 如, 倘 藥 物 A 及 藥 物 B 均 適 合 治 療 您 的 病 症, 我 們 可 能 不 會 承 保 藥 物 B, 除 非 您 已 先 嘗 試 使 用 藥 物 A 如 果 藥 物 A 對 您 而 言 沒 有 療 效, 則 我 們 會 承 保 藥 物 B 附 註 : 藥 物 後 的 星 標 (*) 指 該 種 藥 物 為 非 D 部 分 藥 物 此 等 藥 物 對 申 訴 亦 有 不 同 規 則 申 訴 即 為 請 求 我 們 審 閱 一 項 承 保 決 定 及 變 更 決 定 ( 倘 您 認 為 我 們 有 誤 ) 的 一 種 正 式 方 式 例 如,Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 可 能 決 定 您 想 要 的 某 種 藥 物 不 獲 或 不 再 獲 Medicare 或 Medicaid 承 保 倘 您 或 您 的 醫 生 或 您 的 處 方 醫 生 不 同 意 該 項 決 定, 您 可 以 申 訴 如 欲 瞭 解 如 何 申 訴 的 相 關 說 明, 請 致 電 參 與 者 服 務 部, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 或 FIDA 參 與 者 申 訴 部 您 亦 可 以 閱 覽 參 與 者 手 冊, 瞭 解 申 訴 方 法? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

10 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 $0 B/D PAR; MO AMBISOME 2 $0 B/D PAR; MO amphotericin b 2 $0 B/D PAR; MO CANCIDAS 2 $0 B/D PAR; MO clotrimazole mucous membrane 2 $0 MO ERAXIS(WATER DILUENT) 2 $0 PAR; MO fluconazole 2 $0 MO fluconazole in dextrose(iso-o) 2 $0 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 2 $0 MO 2 $0 flucytosine 2 $0 MO griseofulvin microsize oral suspension 2 $0 MO griseofulvin ultramicrosize 2 $0 MO itraconazole 2 $0 PAR; MO ketoconazole oral 2 $0 MO NOXAFIL ORAL SUSPENSION 2 $0 PAR; MO; QLL (630 per 30 days) nystatin oral suspension 2 $0 MO nystatin oral tablet 2 $0 MO terbinafine hcl oral 2 $0 MO; QLL (30 per 30 days) voriconazole intravenous 2 $0 MO voriconazole oral suspension for reconstitution 2 $0 PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg 2 $0 PAR; MO; QLL (120 per 30 days) ANTIVIRALS abacavir 2 $0 MO abacavir-lamivudine-zidovudine 2 $0 MO acyclovir oral capsule 2 $0 MO ENYDMEM

11 acyclovir oral suspension 200 mg/5 ml 2 $0 MO acyclovir oral tablet 2 $0 MO acyclovir sodium intravenous recon soln 500 mg 2 $0 B/D PAR acyclovir sodium intravenous solution 2 $0 B/D PAR; MO adefovir 2 $0 MO amantadine hcl oral capsule 2 $0 MO amantadine hcl oral tablet 2 $0 MO APTIVUS ORAL CAPSULE 2 $0 MO APTIVUS ORAL SOLUTION 2 $0 ATRIPLA 2 $0 MO BARACLUDE 2 $0 PAR; MO cidofovir 2 $0 B/D PAR; MO COMPLERA 2 $0 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 $0 MO DAKLINZA 2 $0 PAR; MO; QLL (30 per 30 days) didanosine 2 $0 MO EDURANT 2 $0 MO EMTRIVA 2 $0 MO entecavir 2 $0 PAR; MO EPIVIR HBV ORAL SOLUTION 2 $0 MO EPIVIR ORAL SOLUTION 2 $0 MO EPZICOM 2 $0 MO EVOTAZ 2 $0 MO famciclovir oral tablet 125 mg, 250 mg 2 $0 MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg 2 $0 MO; QLL (21 per 7 days) foscarnet 2 $0 B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN 2 $0 MO; QLL (60 per 30 days) ganciclovir sodium 2 $0 MO HARVONI 2 $0 PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 2 $0 MO ENYDMEM

12 INTELENCE ORAL TABLET 25 MG 2 $0 INVIRASE 2 $0 MO ISENTRESS 2 $0 MO KALETRA 2 $0 MO lamivudine 2 $0 MO lamivudine-zidovudine 2 $0 MO LEXIVA 2 $0 MO nevirapine 2 $0 MO NORVIR 2 $0 MO OLYSIO 2 $0 PAR; MO PREZCOBIX 2 $0 MO PREZISTA ORAL SUSPENSION 2 $0 MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 $0 MO RELENZA DISKHALER 2 $0 MO; QLL (60 per 180 days) RESCRIPTOR 2 $0 MO RETROVIR INTRAVENOUS 2 $0 MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 2 $0 MO REYATAZ ORAL POWDER IN PACKET 2 $0 MO ribasphere oral capsule 2 $0 PAR; MO ribasphere oral tablet 200 mg 2 $0 PAR; MO ribavirin oral capsule 2 $0 PAR; MO ribavirin oral tablet 200 mg 2 $0 PAR; MO rimantadine 2 $0 MO SELZENTRY 2 $0 MO SOVALDI 2 $0 PAR; MO stavudine 2 $0 MO STRIBILD 2 $0 MO SUSTIVA 2 $0 MO SYNAGIS 2 $0 PAR; MO; LA ENYDMEM

13 TAMIFLU ORAL CAPSULE 30 MG 2 $0 MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG 2 $0 MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG 2 $0 MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY 2 $0 MO TRIUMEQ 2 $0 MO TRIZIVIR 2 $0 MO TRUVADA 2 $0 MO TYBOST 2 $0 MO 2 $0 MO; QLL (360 per 180 days) TYZEKA 2 $0 PAR; MO valacyclovir 2 $0 MO; QLL (30 per 1 day) VALCYTE ORAL TABLET 2 $0 MO valganciclovir 2 $0 MO VIDEX 2 GRAM PEDIATRIC 2 $0 MO VIDEX 4 GRAM PEDIATRIC 2 $0 MO VIEKIRA PAK 2 $0 PAR; MO VIRACEPT ORAL TABLET 2 $0 MO VIRAMUNE XR 2 $0 MO VIRAZOLE 2 $0 PAR; MO VIREAD ORAL POWDER 2 $0 MO; QLL (240 per 30 days) VIREAD ORAL TABLET 2 $0 MO VITEKTA 2 $0 MO ZIAGEN ORAL SOLUTION 2 $0 MO zidovudine 2 $0 MO CEPHALOSPORINS cefaclor oral capsule 2 $0 MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 2 $0 MO cefaclor oral tablet extended release 12 hr 2 $0 MO cefadroxil oral capsule 2 $0 MO ENYDMEM

14 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2 $0 MO cefadroxil oral tablet 2 $0 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2 $0 MO cefazolin injection recon soln 1 gram, 500 mg 2 $0 MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g 2 $0 cefazolin intravenous 2 $0 cefdinir 2 $0 MO cefepime 2 $0 MO cefoxitin in dextrose, iso-osm 2 $0 cefoxitin intravenous recon soln 1 gram 2 $0 MO cefoxitin intravenous recon soln 10 gram, 2 gram 2 $0 cefpodoxime 2 $0 MO cefprozil 2 $0 MO ceftazidime injection recon soln 1 gram, 2 gram 2 $0 MO ceftazidime injection recon soln 6 gram 2 $0 ceftriaxone in dextrose,iso-os 2 $0 MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg 2 $0 MO ceftriaxone injection recon soln 10 gram 2 $0 ceftriaxone intravenous recon soln 2 $0 MO cefuroxime axetil oral tablet 2 $0 MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg 2 $0 MO cefuroxime sodium intravenous 2 $0 cephalexin oral capsule 250 mg, 500 mg 1 $0 MO cephalexin oral suspension for reconstitution 1 $0 MO cephalexin oral tablet 1 $0 MO TEFLARO 2 $0 MO ERYTHROMYCINS / OTHER MACROLIDES ENYDMEM

15 azithromycin intravenous 2 $0 MO azithromycin oral suspension for reconstitution 2 $0 MO azithromycin oral tablet 250 mg (6 pack) 2 $0 azithromycin oral tablet 250 mg, 500 mg, 600 mg 2 $0 MO clarithromycin oral suspension for reconstitution 2 $0 MO clarithromycin oral tablet 2 $0 MO clarithromycin oral tablet extended release 24 hr 2 $0 MO; QLL (28 per 1 day) ery-tab 2 $0 MO erythrocin (as stearate) oral tablet 250 mg 2 $0 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 erythromycin ethylsuccinate oral tablet 2 $0 MO erythromycin oral tablet 2 $0 MO MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 $0 MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION 2 $0 MO; QLL (180 per 3 days) ALINIA ORAL TABLET 2 $0 MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 2 $0 MO atovaquone 2 $0 PAR; MO atovaquone-proguanil 2 $0 MO AZACTAM IN DEXTROSE (ISO-OSM) 2 $0 aztreonam 2 $0 MO baciim 2 $0 BILTRICIDE 2 $0 MO CAPASTAT 2 $0 CAYSTON 2 $0 PAR; MO; LA chloramphenicol sod succinate 2 $0 chloroquine phosphate oral 2 $0 MO clindamycin hcl 2 $0 MO ENYDMEM

16 clindamycin phosphate injection 2 $0 MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml 2 $0 2 $0 MO colistin (colistimethate na) 2 $0 MO DAPSONE 2 $0 MO DARAPRIM 2 $0 MO ethambutol 2 $0 MO gentamicin injection 2 $0 MO gentamicin sulfate (ped) (pf) 2 $0 MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml 2 $0 MO 2 $0 2 $0 hydroxychloroquine oral 1 $0 MO imipenem-cilastatin 2 $0 MO INVANZ INJECTION 2 $0 MO isoniazid oral 1 $0 MO ivermectin oral 2 $0 MO linezolid intravenous 2 $0 linezolid oral 2 $0 PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride 2 $0 mefloquine 2 $0 MO MEPRON 2 $0 PAR; MO meropenem 2 $0 MO metro i.v. 2 $0 MO metronidazole in nacl (iso-os) 2 $0 MO metronidazole oral 2 $0 MO MYCOBUTIN 2 $0 MO ENYDMEM

17 NEBUPENT 2 $0 B/D PAR; MO neomycin 2 $0 MO paromomycin 2 $0 MO PASER 2 $0 MO PENTAM 2 $0 MO pin-x oral suspension 4 $0 [*] PIN-X ORAL TABLET,CHEWABLE 4 $0 MO; [*] PRIFTIN 2 $0 MO PRIMAQUINE 2 $0 MO pyrazinamide 2 $0 MO reese's pinworm medicine 4 $0 [*] rifabutin 2 $0 MO rifampin intravenous 2 $0 MO rifampin oral 2 $0 MO RIFATER 2 $0 MO STREPTOMYCIN INTRAMUSCULAR 2 $0 MO STROMECTOL 2 $0 MO SYNERCID 2 $0 tobramycin in % nacl 2 $0 B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln 2 $0 tobramycin sulfate injection solution 2 $0 MO TRECATOR 2 $0 MO TYGACIL 2 $0 MO XIFAXAN ORAL TABLET 550 MG 2 $0 MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 MO 2 $0 PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET 2 $0 PAR; MO; QLL (28 per 1 day) ENYDMEM

18 PENICILLINS amoxicillin oral capsule 1 $0 MO amoxicillin oral suspension for reconstitution 1 $0 MO amoxicillin oral tablet 1 $0 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 $0 MO amoxicillin-pot clavulanate 2 $0 MO ampicillin 2 $0 MO ampicillin sodium injection 2 $0 MO ampicillin sodium intravenous 2 $0 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 2 $0 MO ampicillin-sulbactam injection recon soln 15 gram 2 $0 ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram 2 $0 2 $0 MO BICILLIN C-R 2 $0 MO BICILLIN L-A 2 $0 MO dicloxacillin 2 $0 MO nafcillin injection 2 $0 MO nafcillin intravenous recon soln 2 gram 2 $0 MO oxacillin injection 2 $0 MO oxacillin intravenous 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g potassium 2 $0 MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml 2 $0 MO 2 $0 penicillin g sodium 2 $0 MO penicillin v potassium 2 $0 MO piperacillin-tazobactam 2 $0 MO ENYDMEM

19 QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg 1 $0 MO; QLL (14 per 1 day) 1 $0 MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet 1 $0 MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 $0 MO 1 $0 levofloxacin intravenous 2 $0 MO levofloxacin oral tablet 2 $0 MO; QLL (14 per 1 day) moxifloxacin 2 $0 MO; QLL (21 per 1 day) ofloxacin oral tablet 400 mg 2 $0 SULFA'S / RELATED AGENTS sulfadiazine oral 2 $0 MO sulfamethoxazole-trimethoprim 1 $0 MO TETRACYCLINES demeclocycline oral 2 $0 MO DOXY $0 MO doxycycline hyclate intravenous 2 $0 doxycycline hyclate oral capsule 2 $0 MO doxycycline hyclate oral tablet 100 mg, 20 mg 2 $0 MO doxycycline hyclate oral tablet 50 mg 2 $0 doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg 2 $0 MO 2 $0 MO doxycycline monohydrate oral capsule 75 mg 2 $0 MO; QLL (60 per 1 day) doxycycline monohydrate oral tablet 2 $0 MO minocycline oral capsule 2 $0 MO minocycline oral tablet 2 $0 MO ENYDMEM

20 tetracycline 2 $0 MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG 2 $0 PAR; MO methenamine hippurate 2 $0 MO nitrofurantoin macrocrystal oral capsule 50 mg 2 $0 PAR; MO trimethoprim 2 $0 MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML 2 $0 B/D PAR; MO 2 $0 B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM 2 $0 B/D PAR vancomycin intravenous 2 $0 B/D PAR; MO vancomycin oral capsule 125 mg 2 $0 PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg 2 $0 PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 2 $0 PAR; MO dexrazoxane hcl intravenous recon soln 250 mg 2 $0 B/D PAR dexrazoxane hcl intravenous recon soln 500 mg 2 $0 B/D PAR; MO ELITEK 2 $0 PAR; MO FUSILEV 2 $0 B/D PAR; MO KEPIVANCE 2 $0 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg 2 $0 B/D PAR; MO leucovorin calcium injection recon soln 500 mg 2 $0 B/D PAR leucovorin calcium oral 2 $0 MO mesna 2 $0 B/D PAR; MO MESNEX ORAL 2 $0 MO XGEVA 2 $0 PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ENYDMEM

21 ABRAXANE 2 $0 B/D PAR; MO AFINITOR 2 $0 PAR; MO AFINITOR DISPERZ 2 $0 PAR; MO ALIMTA 2 $0 PAR; MO anastrozole 2 $0 MO ARRANON 2 $0 B/D PAR ARZERRA 2 $0 B/D PAR; MO ASTAGRAF XL 2 $0 B/D PAR; MO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) 2 $0 PAR; MO 2 $0 PAR azacitidine 2 $0 PAR; MO azathioprine 2 $0 B/D PAR; MO BELEODAQ 2 $0 PAR; MO bexarotene 2 $0 PAR; MO bicalutamide 2 $0 MO BICNU 2 $0 B/D PAR; MO bleomycin 2 $0 B/D PAR; MO BLINCYTO 2 $0 PAR; MO BOSULIF 2 $0 PAR; MO BUSULFEX 2 $0 B/D PAR CAPRELSA 2 $0 PAR; MO; LA carboplatin intravenous solution 2 $0 B/D PAR; MO CELLCEPT INTRAVENOUS 2 $0 B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PAR; MO cisplatin 2 $0 B/D PAR; MO cladribine 2 $0 B/D PAR; MO CLOLAR 2 $0 B/D PAR; MO COMETRIQ 2 $0 PAR; MO ENYDMEM

22 COSMEGEN 2 $0 B/D PAR; MO cyclophosphamide oral capsule 2 $0 B/D PAR; MO cyclosporine intravenous 2 $0 B/D PAR cyclosporine modified 2 $0 B/D PAR; MO cyclosporine oral capsule 2 $0 B/D PAR; MO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) 2 $0 PAR; MO 2 $0 PAR cytarabine 2 $0 B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) 2 $0 B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml 2 $0 B/D PAR dacarbazine 2 $0 B/D PAR; MO daunorubicin intravenous solution 2 $0 B/D PAR DAUNOXOME 2 $0 B/D PAR; MO decitabine 2 $0 B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO DOXIL 2 $0 B/D PAR; MO doxorubicin intravenous recon soln 2 $0 B/D PAR doxorubicin intravenous solution 2 $0 B/D PAR; MO DROXIA 2 $0 MO EMCYT 2 $0 MO epirubicin intravenous solution 200 mg/100 ml 2 $0 B/D PAR epirubicin intravenous solution 50 mg/25 ml 2 $0 B/D PAR; MO ERBITUX 2 $0 PAR; MO ERIVEDGE 2 $0 PAR; MO ENYDMEM

23 ERWINAZE 2 $0 B/D PAR; MO ETOPOPHOS 2 $0 B/D PAR; MO etoposide intravenous 2 $0 B/D PAR; MO exemestane 2 $0 MO FARESTON 2 $0 MO FARYDAK ORAL CAPSULE 10 MG 2 $0 PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG 2 $0 PAR; MO; QLL (30 per 30 days) FASLODEX 2 $0 PAR; MO FIRMAGON KIT W DILUENT SYRINGE 2 $0 B/D PAR; MO fludarabine intravenous recon soln 2 $0 B/D PAR; MO fludarabine intravenous solution 2 $0 B/D PAR fluorouracil intravenous 2 $0 B/D PAR; MO flutamide 2 $0 MO FOLOTYN 2 $0 B/D PAR; MO GAZYVA 2 $0 PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg 2 $0 B/D PAR; MO gemcitabine intravenous recon soln 2 gram 2 $0 B/D PAR gemcitabine intravenous solution 2 $0 B/D PAR gengraf 2 $0 B/D PAR; MO GILOTRIF 2 $0 PAR; MO GLEEVEC 2 $0 PAR; MO GLEOSTINE 2 $0 MO HALAVEN 2 $0 PAR; MO HERCEPTIN 2 $0 PAR; MO HEXALEN 2 $0 MO hydroxyurea 2 $0 MO IBRANCE 2 $0 PAR; MO; QLL (30 per 30 days) ICLUSIG 2 $0 PAR; MO idarubicin 2 $0 B/D PAR IFEX 2 $0 B/D PAR; MO ENYDMEM

24 ifosfamide intravenous recon soln 1 gram 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 3 gram 2 $0 B/D PAR ifosfamide intravenous solution 2 $0 B/D PAR IMBRUVICA 2 $0 PAR; MO INLYTA 2 $0 PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml 2 $0 B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml 2 $0 B/D PAR ISTODAX 2 $0 PAR; MO IXEMPRA 2 $0 B/D PAR; MO JAKAFI 2 $0 PAR; MO JEVTANA 2 $0 B/D PAR; MO KADCYLA 2 $0 PAR; MO KEYTRUDA 2 $0 PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole 2 $0 MO LEUKERAN 2 $0 MO 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (90 per 30 days) leuprolide 2 $0 PAR; MO LOMUSTINE 2 $0 MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) 2 $0 PAR; MO 2 $0 PAR; MO LYNPARZA 2 $0 PAR; MO; QLL (480 per 30 days) LYSODREN 2 $0 MO MATULANE 2 $0 MO megestrol oral suspension 400 mg/10 ml (10 ml) 2 $0 PAR ENYDMEM

25 megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 $0 PAR; MO megestrol oral tablet 2 $0 PAR; MO MEKINIST 2 $0 PAR; MO melphalan hcl 2 $0 B/D PAR mercaptopurine 2 $0 MO methotrexate sodium 2 $0 MO methotrexate sodium (pf) injection recon soln 2 $0 methotrexate sodium (pf) injection solution 2 $0 MO mitomycin 2 $0 B/D PAR; MO mitoxantrone 2 $0 MO MUSTARGEN 2 $0 B/D PAR; MO mycophenolate mofetil 2 $0 B/D PAR; MO mycophenolate sodium 2 $0 B/D PAR; MO NEXAVAR 2 $0 PAR; MO; LA; QLL (120 per 30 days) NILANDRON 2 $0 MO NIPENT 2 $0 B/D PAR; MO NULOJIX 2 $0 B/D PAR; MO octreotide acetate 2 $0 PAR; MO ONCASPAR 2 $0 B/D PAR; MO OPDIVO 2 $0 PAR; MO oxaliplatin intravenous recon soln 100 mg 2 $0 B/D PAR; MO oxaliplatin intravenous recon soln 50 mg 2 $0 B/D PAR oxaliplatin intravenous solution 2 $0 B/D PAR; MO paclitaxel 2 $0 B/D PAR; MO PERJETA 2 $0 PAR; MO POMALYST 2 $0 PAR; MO PROGRAF INTRAVENOUS 2 $0 B/D PAR; MO PURIXAN 2 $0 PAR; MO RAPAMUNE 2 $0 B/D PAR; MO ENYDMEM

26 REVLIMID ORAL CAPSULE 10 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG 2 $0 PAR; MO; LA; QLL (150 per 30 days) RITUXAN 2 $0 PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PAR 2 $0 B/D PAR; MO sirolimus 2 $0 B/D PAR; MO SOLTAMOX 2 $0 MO SOMATULINE DEPOT 2 $0 MO SPRYCEL 2 $0 PAR; MO STIVARGA 2 $0 PAR; MO; QLL (120 per 30 days) SUTENT 2 $0 PAR; MO SYNRIBO 2 $0 PAR; MO TABLOID 2 $0 MO tacrolimus oral 2 $0 B/D PAR; MO TAFINLAR 2 $0 PAR; MO tamoxifen 2 $0 MO TARCEVA 2 $0 PAR; MO TARGRETIN 2 $0 PAR; MO TASIGNA 2 $0 PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG 2 $0 PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 2 $0 PAR; MO; QLL (60 per 30 days) thiotepa 2 $0 B/D PAR; MO toposar 2 $0 B/D PAR; MO topotecan 2 $0 B/D PAR; MO TORISEL 2 $0 B/D PAR; MO TREANDA 2 $0 B/D PAR; MO ENYDMEM

27 TRELSTAR 2 $0 MO TRELSTAR DEPOT 2 $0 TRELSTAR LA 2 $0 tretinoin (chemotherapy) 2 $0 MO TREXALL 2 $0 MO TRISENOX 2 $0 B/D PAR; MO TYKERB 2 $0 PAR; MO; LA UNITUXIN 2 $0 MO VECTIBIX 2 $0 PAR; MO VELCADE 2 $0 PAR; MO vinblastine intravenous solution 2 $0 B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml 2 $0 B/D PAR vincasar pfs intravenous solution 2 mg/2 ml 2 $0 B/D PAR; MO vincristine 2 $0 B/D PAR; MO vinorelbine 2 $0 B/D PAR; MO VOTRIENT 2 $0 PAR; MO XALKORI 2 $0 PAR; MO XTANDI 2 $0 PAR; MO YERVOY 2 $0 PAR; MO ZALTRAP 2 $0 PAR; MO ZANOSAR 2 $0 B/D PAR; MO ZELBORAF 2 $0 PAR; MO ZOLINZA 2 $0 PAR; MO ZORTRESS 2 $0 B/D PAR; MO ZYDELIG 2 $0 PAR; MO; QLL (60 per 30 days) ZYKADIA 2 $0 PAR; MO ZYTIGA 2 $0 PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM 2 $0 ST; MO ENYDMEM

28 BANZEL ORAL SUSPENSION 2 $0 PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG 2 $0 PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG 2 $0 PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr 2 $0 MO carbamazepine oral suspension 100 mg/5 ml 2 $0 MO carbamazepine oral tablet 2 $0 MO carbamazepine oral tablet extended release 12 hr 2 $0 MO carbamazepine oral tablet,chewable 2 $0 MO CELONTIN ORAL CAPSULE 300 MG 2 $0 MO clonazepam oral tablet 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating mg 2 $0 PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg 2 $0 PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) diazepam rectal 2 $0 MO; QLL (2 per 1 day) DILANTIN CAPSULES 2 $0 MO DILANTIN EXTENDED CAPSULES 2 $0 MO DILANTIN INFATABS 2 $0 MO divalproex 2 $0 MO epitol 2 $0 MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (180 per 30 days) felbamate 2 $0 MO ENYDMEM

29 fosphenytoin 2 $0 B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG 2 $0 MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG 2 $0 MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG 2 $0 MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG 2 $0 MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG 2 $0 MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg 2 $0 MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg 2 $0 MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg 2 $0 MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 2 $0 MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 2 $0 QLL (2160 per 30 days) gabapentin oral tablet 600 mg 2 $0 MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg 2 $0 MO; QLL (135 per 30 days) GABITRIL 2 $0 MO lamotrigine oral tablet 2 $0 MO lamotrigine oral tablet, chewable dispersible 2 $0 MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO levetiracetam intravenous 2 $0 B/D PAR; MO levetiracetam oral solution 100 mg/ml 2 $0 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 2 $0 levetiracetam oral tablet 2 $0 MO levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 100 MG 2 $0 PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG 2 $0 PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG 2 $0 PAR; MO; QLL (90 per 30 days) ENYDMEM

30 LYRICA ORAL CAPSULE 225 MG, 300 MG 2 $0 PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG 2 $0 PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG 2 $0 PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG 2 $0 PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION 2 $0 PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION 2 $0 PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG 2 $0 PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG 2 $0 PAR; MO; QLL (60 per 30 days) oxcarbazepine 2 $0 MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) phenobarbital oral elixir 2 $0 PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg 2 $0 PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg 2 $0 PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg 2 $0 PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg 2 $0 PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg 2 $0 PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg 2 $0 PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg 2 $0 PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg 2 $0 PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml 2 $0 phenytoin oral suspension 125 mg/5 ml 2 $0 MO phenytoin oral tablet,chewable 2 $0 MO phenytoin sodium extended 2 $0 MO phenytoin sodium intravenous solution 2 $0 B/D PAR; MO phenytoin sodium intravenous syringe 2 $0 B/D PAR ENYDMEM

31 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG 2 $0 MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG 2 $0 MO; QLL (270 per 30 days) primidone 2 $0 MO SABRIL 2 $0 PAR; MO; LA; QLL (180 per 30 days) tiagabine 2 $0 MO topiramate oral capsule, sprinkle 2 $0 PAR; MO topiramate oral tablet 2 $0 PAR; MO valproate sodium 2 $0 B/D PAR; MO valproic acid 2 $0 MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) 2 $0 MO 2 $0 VIMPAT INTRAVENOUS 2 $0 B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION 2 $0 MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG 2 $0 MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG 2 $0 MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG 2 $0 MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG 2 $0 MO; QLL (240 per 30 days) zonisamide 2 $0 MO ANTIPARKINSONISM AGENTS APOKYN 2 $0 PAR; MO; LA AZILECT 2 $0 MO benztropine oral 2 $0 PAR; MO bromocriptine 2 $0 MO carbidopa-levodopa 2 $0 MO entacapone 2 $0 MO NEUPRO 2 $0 PAR; MO; QLL (30 per 30 days) pramipexole oral tablet 2 $0 MO ropinirole oral tablet 2 $0 MO ENYDMEM

32 selegiline hcl 2 $0 MO TASMAR ORAL TABLET 100 MG 2 $0 MO tolcapone 2 $0 MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR 2 $0 MO MIGRANAL 2 $0 MO; QLL (8 per 28 days) rizatriptan 2 $0 MO; QLL (12 per 30 days) sumatriptan succinate oral 2 $0 MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (auto-injector) 2 $0 MO; QLL (4 per 30 days) 2 $0 QLL (4 per 30 days) sumatriptan succinate subcutaneous solution 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 2 $0 QLL (4 per 30 days) zolmitriptan 2 $0 MO; QLL (9 per 30 days) ZOMIG NASAL 2 $0 MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 2 $0 PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg 2 $0 MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating 2 $0 MO; QLL (30 per 30 days) EXELON TRANSDERMAL 2 $0 MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr 2 $0 MO; QLL (30 per 30 days) galantamine oral solution 2 $0 MO; QLL (180 per 30 days) galantamine oral tablet 2 $0 MO; QLL (60 per 30 days) GILENYA 2 $0 PAR; MO; QLL (30 per 30 days) ENYDMEM

33 GLATOPA 2 $0 PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION 2 $0 PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG 2 $0 MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG 2 $0 MO; QLL (90 per 30 days) NAMENDA TITRATION PAK 2 $0 MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC 2 $0 MO 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) NUEDEXTA 2 $0 MO; QLL (60 per 30 days) rivastigmine tartrate oral capsule 2 $0 MO; QLL (60 per 30 days) rivastigmine transdermal patch 2 $0 MO; QLL (30 per 30 days) TECFIDERA 2 $0 PAR; MO tetrabenazine oral tablet 12.5 mg 2 $0 PAR; MO; QLL (240 per 30 days) tetrabenazine oral tablet 25 mg 2 $0 PAR; MO; QLL (120 per 30 days) TYSABRI 2 $0 MO; LA XENAZINE ORAL TABLET 12.5 MG 2 $0 PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG 2 $0 PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 2 $0 MO cyclobenzaprine oral tablet 2 $0 PAR; MO dantrolene 2 $0 MO MESTINON ORAL SYRUP 2 $0 MO MESTINON TIMESPAN 2 $0 MO pyridostigmine bromide 2 $0 MO tizanidine oral tablet 2 $0 MO NARCOTIC ANALGESICS ABSTRAL 2 $0 PAR; MO; QLL (120 per 30 days) ENYDMEM

34 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml 2 $0 QLL (4500 per 30 days) 2 $0 MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (180 per 30 days) ACTIQ 2 $0 PAR; MO; QLL (120 per 30 days) buprenorphine hcl injection solution 2 $0 MO buprenorphine hcl injection syringe 2 $0 buprenorphine hcl sublingual tablet 2 mg 2 $0 PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg 2 $0 PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine 2 $0 PAR; MO duramorph (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR; MO duramorph (pf) injection solution 1 mg/ml 2 $0 B/D PAR endocet oral tablet mg, mg, mg 2 $0 MO; QLL (360 per 30 days) fentanyl citrate 2 $0 PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr 2 $0 ST; MO; QLL (15 per 30 days) FENTORA 2 $0 PAR; MO; QLL (120 per 30 days) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg 2 $0 QLL (2700 per 30 days) 2 $0 MO; QLL (2700 per 30 days) 2 $0 MO; QLL (390 per 30 days) 2 $0 MO; QLL (360 per 30 days) hydrocodone-ibuprofen 2 $0 MO; QLL (480 per 30 days) hydromorphone oral tablet 2 mg, 4 mg 2 $0 MO; QLL (360 per 30 days) hydromorphone oral tablet 8 mg 2 $0 MO; QLL (180 per 30 days) ENYDMEM

35 LAZANDA 2 $0 PAR; MO; QLL (30 per 30 days) levorphanol tartrate 2 $0 MO; QLL (180 per 30 days) methadone injection 2 $0 methadone intensol 2 $0 MO; QLL (180 per 30 days) methadone oral concentrate 2 $0 MO; QLL (180 per 30 days) methadone oral solution 10 mg/5 ml 2 $0 MO; QLL (900 per 30 days) methadone oral solution 5 mg/5 ml 2 $0 MO; QLL (1800 per 30 days) methadone oral tablet 10 mg 2 $0 MO; QLL (180 per 30 days) methadone oral tablet 5 mg 2 $0 MO; QLL (360 per 30 days) methadose oral concentrate 2 $0 MO; QLL (180 per 30 days) morphine (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR morphine (pf) injection solution 1 mg/ml 2 $0 B/D PAR; MO morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml 2 $0 MO 2 $0 morphine concentrate oral solution 2 $0 MO; QLL (270 per 30 days) morphine intravenous cartridge 2 $0 MORPHINE INTRAVENOUS CARTRIDGE 2 $0 morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml 2 $0 morphine intravenous solution 50 mg/ml 2 $0 MO morphine intravenous syringe 2 mg/ml, 4 mg/ml 2 $0 morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (60 per 30 days) morphine oral solution 20 mg/5 ml 2 $0 MO; QLL (1350 per 30 days) morphine oral tablet 15 mg 2 $0 MO; QLL (360 per 30 days) morphine oral tablet 30 mg 2 $0 MO; QLL (180 per 30 days) ENYDMEM

36 morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg 2 $0 MO; QLL (90 per 30 days) morphine oral tablet extended release 200 mg 2 $0 MO; QLL (60 per 30 days) oxycodone oral capsule 2 $0 MO; QLL (360 per 30 days) oxycodone oral concentrate 2 $0 MO; QLL (360 per 30 days) oxycodone oral tablet 10 mg, 5 mg 2 $0 MO; QLL (360 per 30 days) oxycodone oral tablet 15 mg 2 $0 MO; QLL (540 per 30 days) oxycodone oral tablet 20 mg, 30 mg 2 $0 MO; QLL (180 per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg 2 $0 MO; QLL (360 per 30 days) oxycodone-aspirin 2 $0 MO; QLL (360 per 30 days) SUBSYS 2 $0 PAR; MO; LA; QLL (120 per 30 days) NON-NARCOTIC ANALGESICS acephen rectal suppository 120 mg, 650 mg 4 $0 MO; [*] acephen rectal suppository 325 mg 4 $0 [*] acetadryl 4 $0 [*] aceta-gesic 4 $0 [*] ACETAMINOPHEN EXTRA STRENGTH 4 $0 [*] acetaminophen oral drops,suspension 4 $0 [*] acetaminophen oral elixir 4 $0 [*] acetaminophen oral liquid 500 mg/5 ml 4 $0 [*] acetaminophen oral solution 160 mg/5 ml (5 ml) 4 $0 MO; [*] acetaminophen oral solution 325 mg/10.15 ml, 650 mg/20.3 ml 4 $0 [*] acetaminophen oral suspension 160 mg/5 ml 4 $0 [*] acetaminophen oral tablet 4 $0 MO; [*] acetaminophen oral tablet extended release 4 $0 [*] acetaminophen oral tablet,disintegrating 4 $0 [*] acetaminophen pain relief 4 $0 [*] acetaminophen pm 4 $0 [*] acetaminophen pm extra str 4 $0 [*] ENYDMEM

37 acetaminophen rectal suppository 120 mg, 650 mg 4 $0 [*] ADDED STRENGTH PAIN RELIEVER 4 $0 [*] adult low dose aspirin 4 $0 MO; [*] arthritis pain relief (acetam) 4 $0 [*] aspir-81 4 $0 [*] aspirin childrens 4 $0 [*] aspirin low dose 4 $0 MO; [*] aspirin low-strength 4 $0 [*] aspirin oral tablet 325 mg 4 $0 MO; [*] aspirin oral tablet,chewable 4 $0 MO; [*] aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg 4 $0 MO; [*] aspirin, buffered 4 $0 [*] aspir-low 4 $0 MO; [*] aspir-trin 4 $0 MO; [*] athenol 4 $0 [*] bayer plus extra strength 4 $0 MO; [*] betatemp 4 $0 [*] buprenorphine-naloxone sublingual tablet mg 2 $0 PAR; MO; QLL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg 2 $0 PAR; MO; QLL (90 per 30 days) butorphanol tartrate injection 2 $0 MO butorphanol tartrate nasal 2 $0 MO; QLL (5 per 28 days) child aspirin 4 $0 [*] child ibuprofen 4 $0 [*] children's acetaminophen oral suspension 160 mg/5 ml, 160 mg/5 ml (5 ml) CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 325 MG/10.15 ML 4 $0 [*] 4 $0 [*] children's aspirin 4 $0 MO; [*] children's ibuprofen 4 $0 MO; [*] children's mapap 4 $0 [*] ENYDMEM

38 children's medi-profen 4 $0 [*] children's medi-tabs 4 $0 [*] children's non-aspirin oral elixir 4 $0 [*] children's non-aspirin oral suspension 4 $0 [*] children's non-aspirin oral tablet,chewable 4 $0 [*] children's non-aspirin pain 4 $0 [*] children's pain & fever relief oral elixir 4 $0 MO; [*] children's pain & fever relief oral suspension 4 $0 MO; [*] children's pain & fever relief oral tablet,chewable 4 $0 MO; [*] children's profen ib 4 $0 [*] children's q-pap 4 $0 MO; [*] children's silapap 4 $0 [*] diclofenac potassium 2 $0 MO diclofenac sodium oral 2 $0 MO diflunisal 2 $0 MO diphenhydramine-acetaminophen 4 $0 [*] ENTERIC COATED ASPIRIN 4 $0 [*] etodolac oral capsule 200 mg 2 $0 MO etodolac oral tablet 2 $0 MO etodolac oral tablet extended release 24 hr 2 $0 MO fenoprofen oral tablet 2 $0 MO fever reducer 4 $0 [*] fever reducer & pain reliever oral suspension 4 $0 [*] feverall rectal suppository 120 mg, 325 mg, 650 mg 4 $0 [*] flanax (naproxen) 4 $0 [*] flurbiprofen 2 $0 MO ibu-drops 4 $0 [*] IBUPROFEN IB 4 $0 [*] ibuprofen jr strength 4 $0 [*] ibuprofen oral capsule 4 $0 [*] ENYDMEM

39 ibuprofen oral drops,suspension 4 $0 [*] ibuprofen oral suspension 2 $0 MO ibuprofen oral tablet 100 mg 4 $0 [*] ibuprofen oral tablet 200 mg 4 $0 MO; [*] ibuprofen oral tablet 400 mg, 600 mg, 800 mg 2 $0 MO ibuprofen pm oral tablet 4 $0 [*] ibuprofen-diphenhydramine cit 4 $0 [*] ibuprofen-diphenhydramine hcl 4 $0 [*] infant fever reducer-pain relf 4 $0 [*] infants ibu-drops 4 $0 [*] infant's ibuprofen 4 $0 [*] infant's medi-profen 4 $0 [*] infant's non-aspirin 4 $0 [*] infants profenib 4 $0 [*] i-prin 4 $0 [*] jr. acetaminophen 4 $0 [*] junior mapap 4 $0 MO; [*] lite coat aspirin 4 $0 [*] little remedies fever & pain 4 $0 [*] LO-DOSE ASPIRIN 4 $0 [*] mapap (acetaminophen) oral capsule 4 $0 MO; [*] mapap (acetaminophen) oral drops,suspension 4 $0 [*] mapap (acetaminophen) oral elixir 4 $0 MO; [*] mapap (acetaminophen) oral liquid 4 $0 MO; [*] mapap (acetaminophen) oral suspension 4 $0 [*] mapap (acetaminophen) oral tablet 4 $0 MO; [*] mapap (acetaminophen) oral tablet,chewable 4 $0 MO; [*] mapap arthritis pain 4 $0 MO; [*] mapap extra strength 4 $0 MO; [*] mapap pm 4 $0 MO; [*] ENYDMEM

40 meclofenamate oral 2 $0 MO meloxicam oral suspension 2 $0 MO; QLL (300 per 30 days) meloxicam oral tablet 1 $0 MO; QLL (30 per 30 days) MENSTRUAL COMPLETE 4 $0 [*] menstrual relief 4 $0 [*] nabumetone 2 $0 MO nalbuphine injection 2 $0 MO naloxone injection solution 2 $0 MO naloxone injection syringe 0.4 mg/ml 2 $0 naloxone injection syringe 1 mg/ml 2 $0 MO naltrexone oral 2 $0 MO naproxen 2 $0 MO naproxen sodium oral capsule 4 $0 [*] naproxen sodium oral tablet 220 mg 4 $0 MO; [*] naproxen sodium oral tablet 275 mg, 550 mg 2 $0 MO NORTEMP 4 $0 [*] oxaprozin 2 $0 MO pain-off 4 $0 [*] pamprin max 4 $0 [*] pediacare fever reducer 4 $0 [*] percogesic 4 $0 [*] percogesic extra strength 4 $0 MO; [*] pharbetol 4 $0 [*] piroxicam 2 $0 MO provil 4 $0 [*] q-pap extra strength 4 $0 MO; [*] q-pap oral drops 4 $0 MO; [*] q-pap oral liquid 4 $0 MO; [*] q-pap oral tablet 325 mg 4 $0 [*] q-pap oral tablet 500 mg 4 $0 MO; [*] ENYDMEM

41 silapap 4 $0 [*] SUBOXONE SUBLINGUAL FILM 12-3 MG 2 $0 PAR; MO; QLL (60 per 30 days) SUBOXONE SUBLINGUAL FILM MG 2 $0 PAR; MO; QLL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG 2 $0 PAR; MO; QLL (180 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG 2 $0 PAR; MO; QLL (90 per 30 days) sulindac oral 2 $0 MO tolmetin 2 $0 MO tramadol oral tablet 2 $0 MO; QLL (240 per 30 days) tramadol-acetaminophen 2 $0 MO; QLL (240 per 30 days) tri-buffered aspirin 4 $0 MO; [*] VOLTAREN GEL TOPICAL GEL 1 % 2 $0 MO; QLL (1000 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 2 $0 MO; QLL (1 per 28 days) 2 $0 QLL (1 per 28 days) ABILIFY ORAL TABLET 10 MG 2 $0 MO; QLL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG 2 $0 MO; QLL (60 per 30 days) ABILIFY ORAL TABLET 2 MG 2 $0 MO; QLL (450 per 30 days) ABILIFY ORAL TABLET 30 MG 2 $0 MO; QLL (30 per 30 days) ABILIFY ORAL TABLET 5 MG 2 $0 MO; QLL (180 per 30 days) ADASUVE 2 $0 alprazolam oral tablet 2 $0 MO; QLL (90 per 30 days) amitriptyline 2 $0 PAR; MO amoxapine 2 $0 MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg 2 $0 PAR; MO; QLL (90 per 30 days) amphetamine salt combo oral tablet 30 mg 2 $0 PAR; MO; QLL (60 per 30 days) aripiprazole oral solution 2 $0 MO; QLL (900 per 30 days) aripiprazole oral tablet 10 mg 2 $0 MO; QLL (90 per 30 days) aripiprazole oral tablet 15 mg, 20 mg 2 $0 MO; QLL (60 per 30 days) ENYDMEM

42 aripiprazole oral tablet 2 mg 2 $0 MO; QLL (450 per 30 days) aripiprazole oral tablet 30 mg 2 $0 MO; QLL (30 per 30 days) aripiprazole oral tablet 5 mg 2 $0 MO; QLL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG 2 $0 ST; MO; QLL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG 2 $0 ST; MO; QLL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG 2 $0 ST; MO; QLL (120 per 30 days) bupropion hcl oral tablet 100 mg 2 $0 MO; QLL (135 per 30 days) bupropion hcl oral tablet 75 mg 2 $0 MO; QLL (180 per 30 days) bupropion hcl oral tablet extended release 100 mg 2 $0 MO; QLL (120 per 30 days) bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (90 per 30 days) 2 $0 MO; QLL (45 per 30 days) buspirone 2 $0 MO chlorpromazine 2 $0 PAR; MO citalopram oral solution 1 $0 MO; QLL (600 per 30 days) citalopram oral tablet 10 mg 1 $0 MO; QLL (120 per 30 days) citalopram oral tablet 20 mg 1 $0 MO; QLL (60 per 30 days) citalopram oral tablet 40 mg 1 $0 MO; QLL (30 per 30 days) clomipramine 2 $0 PAR; MO clorazepate dipotassium 2 $0 MO; QLL (120 per 30 days) clozapine oral tablet 100 mg 2 $0 MO; QLL (270 per 30 days) clozapine oral tablet 200 mg 2 $0 MO; QLL (135 per 30 days) clozapine oral tablet 25 mg 2 $0 MO; QLL (1080 per 30 days) clozapine oral tablet 50 mg 2 $0 MO; QLL (540 per 30 days) clozapine oral tablet,disintegrating 100 mg 2 $0 QLL (270 per 30 days) clozapine oral tablet,disintegrating 12.5 mg 2 $0 QLL (2160 per 30 days) clozapine oral tablet,disintegrating 150 mg 2 $0 QLL (180 per 30 days) clozapine oral tablet,disintegrating 200 mg 2 $0 QLL (135 per 30 days) ENYDMEM

43 clozapine oral tablet,disintegrating 25 mg 2 $0 QLL (1080 per 30 days) desipramine oral 2 $0 MO DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 QLL (120 per 30 days) 2 $0 QLL (240 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (120 per 30 days) dextroamphetamine oral tablet 10 mg 2 $0 PAR; MO; QLL (180 per 30 days) dextroamphetamine oral tablet 5 mg 2 $0 PAR; MO; QLL (90 per 30 days) diazepam injection solution 2 $0 diazepam injection syringe 2 $0 MO diazepam intensol 2 $0 PAR; MO; QLL (240 per 30 days) diazepam oral concentrate 2 $0 PAR; QLL (240 per 30 days) diazepam oral solution 5 mg/5 ml 2 $0 MO; QLL (1200 per 30 days) diazepam oral tablet 10 mg 2 $0 PAR; MO; QLL (120 per 30 days) diazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (600 per 30 days) diazepam oral tablet 5 mg 2 $0 PAR; MO; QLL (240 per 30 days) doxepin oral 2 $0 PAR; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) ENYDMEM

44 duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg 2 $0 MO; QLL (90 per 30 days) 2 $0 MO; QLL (60 per 30 days) EMSAM 2 $0 PAR; MO; QLL (30 per 30 days) ergoloid 2 $0 PAR; MO escitalopram oxalate oral solution 1 $0 MO; QLL (600 per 30 days) escitalopram oxalate oral tablet 10 mg 1 $0 MO; QLL (60 per 30 days) escitalopram oxalate oral tablet 20 mg 1 $0 MO; QLL (30 per 30 days) escitalopram oxalate oral tablet 5 mg 1 $0 MO; QLL (120 per 30 days) FANAPT ORAL TABLET 1 MG 2 $0 MO; QLL (720 per 30 days) FANAPT ORAL TABLET 10 MG 2 $0 MO; QLL (72 per 30 days) FANAPT ORAL TABLET 12 MG 2 $0 MO; QLL (60 per 30 days) FANAPT ORAL TABLET 2 MG 2 $0 MO; QLL (360 per 30 days) FANAPT ORAL TABLET 4 MG 2 $0 MO; QLL (180 per 30 days) FANAPT ORAL TABLET 6 MG 2 $0 MO; QLL (120 per 30 days) FANAPT ORAL TABLET 8 MG 2 $0 MO; QLL (90 per 30 days) FANAPT ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (8 per 30 days) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 150 MG FAZACLO ORAL TABLET,DISINTEGRATING 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG 2 $0 QLL (270 per 30 days) 2 $0 QLL (2160 per 30 days) 2 $0 QLL (180 per 30 days) 2 $0 QLL (135 per 30 days) 2 $0 QLL (1080 per 30 days) 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (180 per 30 days) ENYDMEM

45 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG 2 $0 PAR; MO; QLL (90 per 30 days) fluoxetine oral capsule 10 mg 1 $0 MO; QLL (240 per 30 days) fluoxetine oral capsule 20 mg 1 $0 MO; QLL (120 per 30 days) fluoxetine oral capsule 40 mg 1 $0 MO; QLL (60 per 30 days) fluoxetine oral solution 1 $0 MO; QLL (600 per 30 days) fluoxetine oral tablet 10 mg 1 $0 MO; QLL (240 per 30 days) fluoxetine oral tablet 20 mg 1 $0 MO; QLL (120 per 30 days) fluphenazine decanoate 2 $0 MO fluphenazine hcl 2 $0 MO fluvoxamine oral tablet 100 mg 2 $0 MO; QLL (90 per 30 days) fluvoxamine oral tablet 25 mg 2 $0 MO; QLL (360 per 30 days) fluvoxamine oral tablet 50 mg 2 $0 MO; QLL (180 per 30 days) GEODON INTRAMUSCULAR 2 $0 MO guanfacine oral tablet extended release 24 hr 2 $0 PAR; MO; QLL (30 per 30 days) guanidine 2 $0 MO haloperidol 2 $0 MO haloperidol decanoate 2 $0 MO haloperidol lactate 2 $0 MO imipramine hcl 2 $0 PAR; MO INTUNIV ER 2 $0 PAR; MO; QLL (30 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (40 per 30 days) INVEGA SUSTENNA 2 $0 MO; QLL (2 per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML 2 $0 MO; QLL (0.875 per 90 days) ENYDMEM

46 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG 2 $0 MO; QLL (1.315 per 90 days) 2 $0 MO; QLL (1.75 per 90 days) 2 $0 MO; QLL (2.625 per 90 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) LATUDA ORAL TABLET 120 MG 2 $0 MO; QLL (30 per 30 days) LATUDA ORAL TABLET 20 MG 2 $0 MO; QLL (240 per 30 days) LATUDA ORAL TABLET 40 MG 2 $0 MO; QLL (120 per 30 days) LATUDA ORAL TABLET 60 MG 2 $0 MO; QLL (75 per 30 days) LATUDA ORAL TABLET 80 MG 2 $0 MO; QLL (60 per 30 days) lithium carbonate 2 $0 MO lithium citrate oral solution 8 meq/5 ml 2 $0 MO lorazepam oral tablet 2 $0 MO; QLL (90 per 30 days) loxapine succinate 2 $0 MO maprotiline oral tablet 25 mg 2 $0 MO; QLL (270 per 30 days) maprotiline oral tablet 50 mg 2 $0 MO; QLL (135 per 30 days) maprotiline oral tablet 75 mg 2 $0 MO MARPLAN 2 $0 MO methylphenidate oral tablet 2 $0 PAR; MO; QLL (90 per 30 days) mirtazapine oral tablet 15 mg 2 $0 MO; QLL (90 per 30 days) mirtazapine oral tablet 30 mg 2 $0 MO; QLL (45 per 30 days) mirtazapine oral tablet 45 mg 2 $0 MO; QLL (30 per 30 days) mirtazapine oral tablet 7.5 mg 2 $0 MO; QLL (180 per 30 days) mirtazapine oral tablet,disintegrating 15 mg 2 $0 MO; QLL (90 per 30 days) mirtazapine oral tablet,disintegrating 30 mg 2 $0 MO; QLL (45 per 30 days) mirtazapine oral tablet,disintegrating 45 mg 2 $0 MO; QLL (30 per 30 days) modafinil oral tablet 100 mg 2 $0 PAR; MO; QLL (30 per 30 days) ENYDMEM

47 modafinil oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) nefazodone oral tablet 100 mg 2 $0 MO; QLL (180 per 30 days) nefazodone oral tablet 150 mg 2 $0 MO; QLL (120 per 30 days) nefazodone oral tablet 200 mg 2 $0 MO; QLL (90 per 30 days) nefazodone oral tablet 250 mg 2 $0 MO; QLL (72 per 30 days) nefazodone oral tablet 50 mg 2 $0 MO; QLL (360 per 30 days) nortriptyline 2 $0 MO olanzapine intramuscular 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet 10 mg 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet 15 mg 2 $0 MO; QLL (40 per 30 days) olanzapine oral tablet 2.5 mg 2 $0 MO; QLL (240 per 30 days) olanzapine oral tablet 20 mg 2 $0 MO; QLL (30 per 30 days) olanzapine oral tablet 5 mg 2 $0 MO; QLL (120 per 30 days) olanzapine oral tablet 7.5 mg 2 $0 MO; QLL (80 per 30 days) olanzapine oral tablet,disintegrating 10 mg 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg 2 $0 MO; QLL (40 per 30 days) olanzapine oral tablet,disintegrating 20 mg 2 $0 MO; QLL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg 2 $0 MO; QLL (120 per 30 days) ORAP 2 $0 MO paroxetine hcl oral tablet 10 mg 1 $0 MO; QLL (180 per 30 days) paroxetine hcl oral tablet 20 mg 1 $0 MO; QLL (90 per 30 days) paroxetine hcl oral tablet 30 mg 1 $0 MO; QLL (60 per 30 days) paroxetine hcl oral tablet 40 mg 1 $0 MO; QLL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg 1 $0 MO; QLL (180 per 30 days) 1 $0 MO; QLL (90 per 30 days) 1 $0 MO; QLL (60 per 30 days) PAXIL ORAL SUSPENSION 2 $0 MO; QLL (900 per 30 days) perphenazine 2 $0 MO ENYDMEM

48 phenelzine 2 $0 MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline 2 $0 MO 2 $0 PAR; MO; QLL (120 per 30 days) 2 $0 PAR; MO; QLL (480 per 30 days) 2 $0 PAR; MO; QLL (240 per 30 days) quetiapine oral tablet 100 mg 1 $0 MO; QLL (240 per 30 days) quetiapine oral tablet 200 mg 1 $0 MO; QLL (120 per 30 days) quetiapine oral tablet 25 mg 1 $0 MO; QLL (960 per 30 days) quetiapine oral tablet 300 mg 1 $0 MO; QLL (80 per 30 days) quetiapine oral tablet 400 mg 1 $0 MO; QLL (60 per 30 days) quetiapine oral tablet 50 mg 1 $0 MO; QLL (480 per 30 days) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 2 $0 PAR; MO; QLL (60 per 30 days) REXULTI ORAL TABLET 3 MG, 4 MG 2 $0 PAR; MO; QLL (30 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML 2 $0 MO; QLL (2 per 28 days) 2 $0 MO risperidone oral solution 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet 0.25 mg 1 $0 MO; QLL (1920 per 30 days) risperidone oral tablet 0.5 mg 1 $0 MO; QLL (960 per 30 days) risperidone oral tablet 1 mg 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet 2 mg 1 $0 MO; QLL (240 per 30 days) risperidone oral tablet 3 mg 1 $0 MO; QLL (160 per 30 days) risperidone oral tablet 4 mg 1 $0 MO; QLL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg 1 $0 MO; QLL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg 1 $0 MO; QLL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg 1 $0 MO; QLL (240 per 30 days) ENYDMEM

49 risperidone oral tablet,disintegrating 3 mg 1 $0 MO; QLL (160 per 30 days) risperidone oral tablet,disintegrating 4 mg 1 $0 MO; QLL (120 per 30 days) ROZEREM 2 $0 MO; QLL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (160 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (80 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (480 per 30 days) sertraline oral concentrate 1 $0 MO; QLL (300 per 30 days) sertraline oral tablet 100 mg 1 $0 MO; QLL (60 per 30 days) sertraline oral tablet 25 mg 1 $0 MO; QLL (240 per 30 days) sertraline oral tablet 50 mg 1 $0 MO; QLL (120 per 30 days) sleep aid (doxylamine) 4 $0 [*] STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (30 per 30 days) SURMONTIL 2 $0 PAR; MO temazepam oral capsule 15 mg, 22.5 mg, 30 mg 2 $0 MO; QLL (30 per 30 days) thioridazine 2 $0 PAR; MO thiothixene 2 $0 MO tranylcypromine 2 $0 MO trazodone 2 $0 MO ENYDMEM

50 trifluoperazine 2 $0 MO ultra sleep (doxylamine succ) 4 $0 [*] venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (90 per 30 days) venlafaxine oral tablet 100 mg 2 $0 MO; QLL (113 per 30 days) venlafaxine oral tablet 25 mg 2 $0 MO; QLL (450 per 30 days) venlafaxine oral tablet 37.5 mg 2 $0 MO; QLL (300 per 30 days) venlafaxine oral tablet 50 mg 2 $0 MO; QLL (225 per 30 days) venlafaxine oral tablet 75 mg 2 $0 MO; QLL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (90 per 30 days) VERSACLOZ 2 $0 LA; QLL (600 per 30 days) VIIBRYD ORAL TABLET 10 MG 2 $0 ST; MO; QLL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG 2 $0 ST; MO; QLL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG 2 $0 ST; MO; QLL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) 2 $0 ST; QLL (30 per 30 days) 2 $0 ST; MO; QLL (30 per 30 days) XYREM 2 $0 PAR; MO; LA; QLL (540 per 30 days) zaleplon oral capsule 10 mg 2 $0 PAR; MO; QLL (60 per 30 days) zaleplon oral capsule 5 mg 2 $0 PAR; MO; QLL (30 per 30 days) zenzedi oral tablet 10 mg 2 $0 PAR; MO; QLL (180 per 30 days) ENYDMEM

51 zenzedi oral tablet 5 mg 2 $0 PAR; MO; QLL (90 per 30 days) ziprasidone hcl oral capsule 20 mg 2 $0 MO; QLL (240 per 30 days) ziprasidone hcl oral capsule 40 mg 2 $0 MO; QLL (120 per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg 2 $0 MO; QLL (60 per 30 days) zolpidem oral tablet 2 $0 PAR; MO; QLL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG 2 $0 LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS 2 $0 MO; LA amiodarone intravenous solution 2 $0 B/D PAR; MO amiodarone intravenous syringe 2 $0 B/D PAR amiodarone oral 2 $0 MO flecainide 2 $0 MO lidocaine (pf) intravenous solution 2 $0 MO lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) 2 $0 mexiletine 2 $0 MO MULTAQ 2 $0 MO; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg 2 $0 MO procainamide injection solution 100 mg/ml 2 $0 MO procainamide injection solution 500 mg/ml 2 $0 propafenone oral tablet 2 $0 MO quinidine sulfate tablets oral tablet 200 mg, 300 mg 2 $0 MO sorine oral tablet 120 mg, 160 mg, 80 mg 2 $0 MO sorine oral tablet 240 mg 2 $0 sotalol af 2 $0 MO sotalol oral 2 $0 MO ENYDMEM

52 TIKOSYN 2 $0 MO ANTIHYPERTENSIVE THERAPY acebutolol 1 $0 MO afeditab cr 2 $0 MO amiloride oral 2 $0 MO amiloride-hydrochlorothiazide 2 $0 MO amlodipine oral tablet 10 mg, 2.5 mg 1 $0 MO; QLL (30 per 30 days) amlodipine oral tablet 5 mg 1 $0 MO; QLL (45 per 30 days) amlodipine-benazepril 1 $0 MO amlodipine-valsartan 2 $0 MO; QLL (30 per 30 days) amlodipine-valsartan-hcthiazid 2 $0 MO; QLL (30 per 30 days) atenolol 1 $0 MO atenolol-chlorthalidone 1 $0 MO AZOR 2 $0 MO; QLL (30 per 30 days) benazepril 1 $0 MO benazepril-hydrochlorothiazide 1 $0 MO betaxolol oral 2 $0 MO bisoprolol fumarate 2 $0 MO bisoprolol-hydrochlorothiazide 2 $0 MO bumetanide 2 $0 MO BYSTOLIC 2 $0 MO candesartan oral tablet 16 mg, 4 mg, 8 mg 1 $0 MO; QLL (60 per 30 days) candesartan oral tablet 32 mg 1 $0 MO; QLL (30 per 30 days) candesartan-hydrochlorothiazid oral tablet mg candesartan-hydrochlorothiazid oral tablet mg, mg 1 $0 MO; QLL (60 per 30 days) 1 $0 MO; QLL (30 per 30 days) captopril 1 $0 MO captopril-hydrochlorothiazide 1 $0 MO cartia xt 2 $0 MO carvedilol 1 $0 MO ENYDMEM

53 chlorothiazide 2 $0 MO chlorothiazide sodium 2 $0 MO chlorthalidone oral tablet 25 mg, 50 mg 2 $0 MO clonidine hcl oral tablet 1 $0 MO clonidine patches 2 $0 MO; QLL (4 per 28 days) COREG CR 2 $0 ST; MO DEMSER 2 $0 MO diltiazem hcl intravenous 2 $0 diltiazem hcl oral capsule, extended release 2 $0 MO diltiazem hcl oral capsule,ext release degradable 2 $0 MO diltiazem hcl oral capsule,extended release 12 hr 2 $0 MO diltiazem hcl oral capsule,extended release 24hr 2 $0 MO diltiazem hcl oral tablet 2 $0 MO diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg 2 $0 2 $0 MO dilt-xr 2 $0 MO doxazosin 2 $0 MO enalapril maleate 1 $0 MO enalapril-hydrochlorothiazide 1 $0 MO eplerenone 2 $0 MO eprosartan 1 $0 MO; QLL (30 per 30 days) felodipine 2 $0 MO fosinopril 1 $0 MO fosinopril-hydrochlorothiazide 1 $0 MO furosemide injection 2 $0 MO furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 $0 MO furosemide oral tablet 1 $0 MO hydralazine 2 $0 MO hydrochlorothiazide 1 $0 MO ENYDMEM

54 indapamide 1 $0 MO irbesartan 1 $0 MO; QLL (30 per 30 days) irbesartan-hydrochlorothiazide oral tablet mg irbesartan-hydrochlorothiazide oral tablet mg 1 $0 MO; QLL (60 per 30 days) 1 $0 MO; QLL (30 per 30 days) isradipine 2 $0 MO labetalol intravenous solution 2 $0 MO labetalol oral 2 $0 MO lisinopril 1 $0 MO lisinopril-hydrochlorothiazide 1 $0 MO losartan oral tablet 100 mg 1 $0 MO; QLL (30 per 30 days) losartan oral tablet 25 mg, 50 mg 1 $0 MO; QLL (60 per 30 days) losartan-hydrochlorothiazide 1 $0 MO; QLL (30 per 30 days) methyclothiazide 2 $0 MO metolazone 1 $0 MO metoprolol succinate 2 $0 MO metoprolol ta-hydrochlorothiaz 2 $0 MO metoprolol tartrate intravenous solution 2 $0 MO metoprolol tartrate intravenous syringe 2 $0 metoprolol tartrate oral 1 $0 MO minoxidil oral 2 $0 MO moexipril 1 $0 MO moexipril-hydrochlorothiazide 1 $0 MO nadolol 1 $0 MO nadolol-bendroflumethiazide 2 $0 MO nicardipine 2 $0 MO nifedical xl 2 $0 MO nifedipine oral tablet extended release 2 $0 MO nifedipine oral tablet extended release 24hr 2 $0 MO nimodipine 2 $0 MO ENYDMEM

55 perindopril erbumine 1 $0 MO pindolol 2 $0 MO prazosin oral 2 $0 MO propranolol intravenous 2 $0 propranolol oral 2 $0 MO propranolol-hydrochlorothiazid 2 $0 MO quinapril 1 $0 MO quinapril-hydrochlorothiazide 1 $0 MO ramipril 1 $0 MO spironolactone 1 $0 MO spironolacton-hydrochlorothiaz 1 $0 MO taztia xt 2 $0 MO TEKTURNA 2 $0 MO; QLL (30 per 30 days) TEKTURNA HCT 2 $0 MO; QLL (30 per 30 days) telmisartan oral tablet 20 mg, 40 mg 1 $0 MO; QLL (30 per 30 days) telmisartan oral tablet 80 mg 1 $0 MO; QLL (60 per 30 days) telmisartan-amlodipine 1 $0 MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet mg, mg telmisartan-hydrochlorothiazid oral tablet mg 1 $0 MO; QLL (30 per 30 days) 1 $0 MO; QLL (60 per 30 days) terazosin 1 $0 MO timolol maleate oral 2 $0 MO torsemide oral 1 $0 MO trandolapril 1 $0 MO triamterene-hydrochlorothiazid oral capsule mg 1 $0 MO triamterene-hydrochlorothiazid oral tablet 1 $0 MO TRIBENZOR 2 $0 MO; QLL (30 per 30 days) valsartan oral tablet 160 mg 2 $0 MO; QLL (60 per 30 days) valsartan oral tablet 320 mg 2 $0 MO; QLL (30 per 30 days) ENYDMEM

56 valsartan oral tablet 40 mg, 80 mg 2 $0 MO; QLL (90 per 30 days) valsartan-hydrochlorothiazide 1 $0 MO; QLL (30 per 30 days) verapamil intravenous solution 2 $0 MO verapamil intravenous syringe 2 $0 verapamil oral 2 $0 MO CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 125 MCG 1 $0 MO; QLL (30 per 30 days) digox oral tablet 125 mcg 1 $0 MO; QLL (30 per 30 days) digoxin oral solution 50 mcg/ml 2 $0 MO digoxin oral tablet 125 mcg 1 $0 MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 125 MCG 2 $0 MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 62.5 MCG 2 $0 MO COAGULATION THERAPY AGGRENOX 2 $0 MO; QLL (60 per 30 days) aspirin-dipyridamole 2 $0 MO; QLL (60 per 30 days) BRILINTA ORAL TABLET 90 MG 2 $0 MO; QLL (60 per 30 days) cilostazol 2 $0 MO clopidogrel oral tablet 300 mg 2 $0 MO; QLL (1 per 30 days) clopidogrel oral tablet 75 mg 2 $0 MO; QLL (30 per 30 days) COUMADIN ORAL 2 $0 MO EFFIENT 2 $0 MO; QLL (30 per 30 days) ELIQUIS ORAL TABLET 2.5 MG 2 $0 MO; QLL (60 per 30 days) ELIQUIS ORAL TABLET 5 MG 2 $0 MO; QLL (74 per 30 days) enoxaparin subcutaneous solution 2 $0 MO; QLL (84 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml 2 $0 MO; QLL (28 per 30 days) 2 $0 MO; QLL (22.4 per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml 2 $0 MO; QLL (8.4 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml 2 $0 MO; QLL (11.2 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml 2 $0 MO; QLL (16.8 per 30 days) ENYDMEM

57 fondaparinux subcutaneous syringe 10 mg/0.8 ml 2 $0 MO; QLL (24 per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 2 $0 MO; QLL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml 2 $0 MO; QLL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 2 $0 MO; QLL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 2 $0 MO FRAGMIN SUBCUTANEOUS SYRINGE 2 $0 MO heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR heparin (porcine) injection cartridge 2 $0 B/D PAR; MO heparin (porcine) injection solution 2 $0 B/D PAR; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml 2 $0 B/D PAR 2 $0 B/D PAR heparin, porcine (pf) injection 2 $0 B/D PAR; MO jantoven 1 $0 MO MEPHYTON 3 $0 MO; [*] pentoxifylline 2 $0 MO PRADAXA 2 $0 MO; QLL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) PROMACTA ORAL TABLET 50 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) tranexamic acid intravenous 2 $0 MO vitamin k injection 3 $0 MO; [*] VITAMIN K ORAL 4 $0 MO; [*] ENYDMEM

58 VITAMIN K1 3 $0 [*] vitamin k1 injection 3 $0 MO; [*] warfarin 1 $0 MO XARELTO ORAL TABLET 10 MG, 20 MG 2 $0 MO; QLL (30 per 30 days) XARELTO ORAL TABLET 15 MG 2 $0 MO; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (51 per 365 days) LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin 1 $0 MO; QLL (30 per 30 days) atorvastatin 1 $0 MO; QLL (30 per 30 days) cholestyramine (with sugar) 2 $0 MO cholestyramine light 2 $0 MO colestipol 2 $0 MO CRESTOR 2 $0 MO; QLL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg 2 $0 MO; QLL (30 per 30 days) fenofibrate nanocrystallized 2 $0 MO fenofibrate oral tablet 160 mg, 54 mg 2 $0 MO; QLL (30 per 30 days) gemfibrozil oral 2 $0 MO lovastatin oral tablet 10 mg, 20 mg 1 $0 MO; QLL (30 per 30 days) lovastatin oral tablet 40 mg 1 $0 MO; QLL (60 per 30 days) NIACIN (INOSITOL NIACINATE) ORAL TABLET 4 $0 [*] niacin oral tablet 500 mg 4 $0 MO; [*] niacin oral tablet extended release 24 hr 1,000 mg, 750 mg 2 $0 MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg 2 $0 MO; QLL (30 per 30 days) NIACOR 1 $0 MO omega-3 acid ethyl esters 2 $0 PAR; MO pravastatin 1 $0 MO; QLL (30 per 30 days) prevalite 2 $0 MO simvastatin 1 $0 MO; QLL (30 per 30 days) ENYDMEM

59 WELCHOL 2 $0 MO ZETIA 2 $0 MO; QLL (30 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 2 $0 MO VECAMYL 2 $0 NITRATES isosorbide dinitrate oral 2 $0 MO isosorbide mononitrate 2 $0 MO nitro-bid 2 $0 MO nitroglycerin intravenous 2 $0 B/D PAR nitroglycerin transdermal patch 24 hour 2 $0 MO NITROSTAT 1 $0 MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 2 $0 MO calcipotriene topical cream 2 $0 MO; QLL (120 per 30 days) calcipotriene topical ointment 2 $0 MO; QLL (120 per 30 days) calcipotriene topical solution 2 $0 MO; QLL (60 per 30 days) selenium sulfide topical suspension 2 $0 MO BURN THERAPY silver sulfadiazine 2 $0 MO ssd 2 $0 MO MISCELLANEOUS DERMATOLOGICALS A & D ZINC OXIDE CREAM 4 $0 MO; [*] A + D (LAN, PET) 4 $0 MO; [*] allergy cream (diphenhyd, zn) 4 $0 [*] ammonium lactate topical 2 $0 MO anti-itch (diphenhydramine) topical gel 4 $0 [*] anti-itch(diphenhyd) with zinc topical cream 4 $0 [*] ENYDMEM

60 ANTI-ITCH(DIPHENHYD) WITH ZINC TOPICAL CREAM 4 $0 [*] banophen anti-itch 4 $0 [*] calohist 4 $0 [*] carb-o-philic topical cream 20 % 4 $0 [*] diclofenac sodium topical gel 2 $0 PAR; MO; QLL (100 per 30 days) diphenhydramine hcl topical 4 $0 [*] ELIDEL 2 $0 PAR; MO; QLL (60 per 1 day) fluorouracil topical cream 5 % 2 $0 MO fluorouracil topical solution 2 $0 MO gormel 4 $0 MO; [*] imiquimod 2 $0 MO itch relief (diphenhydramine) topical gel 4 $0 [*] itch relief (pramoxine-zinc) 4 $0 [*] methoxsalen rapid 2 $0 PAR; MO OXSORALEN 2 $0 MO PANRETIN 2 $0 MO podofilox 2 $0 MO PROTOPIC 2 $0 PAR; MO; QLL (60 per 1 day) RUBBING ALCOHOL (ETHANOL) 4 $0 MO; [*] tacrolimus topical 2 $0 PAR; MO; QLL (60 per 1 day) U-CORT 2 $0 MO urea topical cream 20 % 4 $0 MO; [*] ureacin-20 4 $0 MO; [*] UVADEX 2 $0 VALCHLOR 2 $0 MO vitamin a & d diaper rash 4 $0 [*] vitamin a and d 4 $0 [*] vits a and d-white pet-lanolin topical ointment 4 $0 MO; [*] vits a and d-white pet-lanolin topical ointment in packet 4 $0 [*] ENYDMEM

61 ZINC OXIDE DIAPER CREAM 4 $0 [*] zinc oxide topical ointment, 40 % 4 $0 [*] zinc oxide topical ointment 20 % 4 $0 MO; [*] THERAPY FOR ACNE acne treatment (benzoyl perox) topical gel 4 $0 [*] adapalene topical gel 0.3 % 2 $0 MO adapalene topical gel with pump 2 $0 MO amnesteem 2 $0 MO benzoyl peroxide topical gel 10 %, 5 % 4 $0 MO; [*] clindamycin phosphate topical 2 $0 MO DIFFERIN TOPICAL GEL 0.3 % 2 $0 MO DIFFERIN TOPICAL GEL WITH PUMP 2 $0 MO ery pads 2 $0 MO erythromycin with ethanol 2 $0 MO erythromycin-benzoyl peroxide 2 $0 MO metronidazole topical cream 2 $0 MO metronidazole topical gel 0.75 % 2 $0 MO metronidazole topical lotion 2 $0 MO persa-gel 4 $0 [*] rosadan topical cream 2 $0 MO TAZORAC 2 $0 PAR; MO tretinoin topical cream 2 $0 MO; QLL (45 per 30 days) tretinoin topical gel 0.01 %, % 2 $0 MO; QLL (45 per 30 days) TRETIN-X CREAM KIT TOPICAL COMBO PACK 0.05 %, 0.1 % TOPICAL ANESTHETICS 2 $0 MO anti-itch (benz-resor) 4 $0 [*] calagesic 4 $0 [*] CALDYPHEN TOPICAL LOTION 1-8 % 4 $0 [*] lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) 2 $0 MO ENYDMEM

62 lidocaine (pf) injection solution 15 mg/ml (1.5 %) 2 $0 lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 2 $0 MO lidocaine hcl laryngotracheal 2 $0 MO lidocaine hcl mucous membrane gel 2 $0 MO lidocaine hcl mucous membrane jelly in applicator 2 $0 MO lidocaine hcl mucous membrane solution 2 % 2 $0 lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 2 $0 MO lidocaine hcl urethral 2 $0 lidocaine topical adhesive patch,medicated 2 $0 PAR; MO; QLL (90 per 30 days) lidocaine topical ointment 2 $0 MO lidocaine viscous 2 $0 MO lidocaine-prilocaine 2 $0 MO vagicaine topical cream 5-2 % 4 $0 [*] vagicream topical cream 5-2 % 4 $0 [*] TOPICAL ANTIBACTERIALS ANTIBIOTIC (BACITRACIN ZINC) 4 $0 [*] antibiotic (neomy-bacit-polym) 4 $0 [*] ANTIBIOTIC + PAIN RELIEF 4 $0 [*] ANTIBIOTIC PLUS (PRAMOXINE) 4 $0 [*] antiseptic solution 4 $0 [*] bacitracin topical ointment 4 $0 MO; [*] bacitracin topical packet 4 $0 [*] bacitracin zinc topical ointment 4 $0 MO; [*] bacitracin zinc topical packet 4 $0 [*] bacitracin-polymyxin b topical ointment 4 $0 MO; [*] bacitracin-polymyxin b topical packet 4 $0 [*] bacitraycin plus topical ointment 500 unit/gram 4 $0 [*] DOUBLE ANTIBIOTIC 4 $0 [*] first aid abx pain relief 4 $0 [*] ENYDMEM

63 first aid antiseptic topical solution 4 $0 [*] gentamicin topical 2 $0 MO grx dyne topical solution 10 % 4 $0 [*] multi antibiotic plus 4 $0 [*] mupirocin ointment 2 $0 MO poly bacitracin 4 $0 [*] povidone-iodine topical liquid in packet 4 $0 [*] povidone-iodine topical ointment 4 $0 MO; [*] povidone-iodine topical solution 10 % 4 $0 [*] povidone-iodine topical spray,non-aerosol 4 $0 [*] sulfacetamide sodium (acne) 2 $0 MO SULFAMYLON TOPICAL CREAM 2 $0 MO tri-biozene 4 $0 [*] triple antibiotic (pram) extra 4 $0 [*] triple antibiotic plus 4 $0 [*] triple antibiotic topical ointment 4 $0 MO; [*] triple antibiotic topical ointment in packet 4 $0 MO; [*] TOPICAL ANTIFUNGALS af 4 $0 [*] aloe vesta topical ointment 2 % 4 $0 [*] ANTIFUNGAL (CLOTRIMAZOLE) 4 $0 [*] antifungal (tolnaftate) topical aerosol,spray 4 $0 [*] ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM 4 $0 [*] antifungal (tolnaftate) topical powder 4 $0 MO; [*] antifungal spray 4 $0 [*] athlete's foot (terbinafine) 4 $0 [*] athlete's foot (tolnaftate) 4 $0 [*] baza antifungal 4 $0 MO; [*] ciclodan topical solution 2 $0 PAR; MO ciclopirox topical cream 2 $0 MO ENYDMEM

64 ciclopirox topical gel 2 $0 MO ciclopirox topical shampoo 2 $0 MO ciclopirox topical solution 2 $0 PAR; MO ciclopirox topical suspension 2 $0 MO clotrim antifungal 4 $0 [*] clotrimazole af 4 $0 [*] clotrimazole foot 4 $0 [*] clotrimazole topical 2 $0 MO clotrimazole-betamethasone 2 $0 MO critic-aid clear af 4 $0 MO; [*] econazole topical 2 $0 MO ELON DUAL DEFENSE 4 $0 [*] FUNGI-NAIL TOPICAL SOLUTION 4 $0 [*] fungoid-d 4 $0 [*] inzo antifungal 4 $0 [*] jock itch (terbinafine) 4 $0 [*] ketoconazole topical 2 $0 MO lotrimin af jock itch powder 4 $0 [*] lotrimin af powder 4 $0 MO; [*] micatin 4 $0 [*] miconazole nitrate topical aerosol powder 4 $0 [*] miconazole nitrate topical cream 4 $0 MO; [*] miconazorb af 4 $0 [*] micro-guard 4 $0 MO; [*] MYCO NAIL A 4 $0 [*] nuzole 4 $0 [*] nystatin topical 2 $0 MO nystatin-triamcinolone 2 $0 MO nystop 2 $0 MO podactin 4 $0 [*] ENYDMEM

65 REMEDY ANTIFUNGAL TOPICAL POWDER 4 $0 [*] terbinafine hcl topical 4 $0 MO; [*] tinactin topical powder 4 $0 MO; [*] tolnaftate topical aerosol powder 4 $0 [*] tolnaftate topical cream 4 $0 [*] tolnaftate topical powder 4 $0 [*] tolnaftate topical solution 4 $0 MO; [*] triple paste af 4 $0 MO; [*] zeasorb (miconazole) 4 $0 MO; [*] TOPICAL ANTIVIRALS ABREVA 4 $0 MO; [*] acyclovir topical 2 $0 MO; QLL (30 per 30 days) DENAVIR 2 $0 MO; QLL (5 per 1 day) TOPICAL CORTICOSTEROIDS ala-cort topical cream 2 $0 MO alclometasone 2 $0 MO amcinonide 2 $0 MO anti-itch (hc) topical cream 4 $0 [*] anti-itch (hc) topical ointment 4 $0 [*] betamethasone dipropionate 2 $0 MO betamethasone valerate topical cream 2 $0 MO betamethasone valerate topical lotion 2 $0 MO betamethasone valerate topical ointment 2 $0 MO betamethasone, augmented 2 $0 MO CAPEX 2 $0 MO clobetasol topical cream 2 $0 MO clobetasol topical foam 2 $0 MO clobetasol topical gel 2 $0 MO clobetasol topical ointment 2 $0 MO clobetasol topical solution 2 $0 MO ENYDMEM

66 clobetasol-emollient topical cream 2 $0 MO cormax topical solution 2 $0 MO cortaid topical cream 4 $0 MO; [*] cortisone (hydrocortisone) 4 $0 [*] cortizone-10 plus 4 $0 [*] cortizone-10 topical cream 4 $0 [*] cortizone-10 topical ointment 4 $0 [*] desonide 2 $0 MO desoximetasone 2 $0 MO diflorasone 2 $0 MO fluocinolone 2 $0 MO fluocinolone-shower cap 2 $0 MO fluocinonide topical cream 0.05 % 2 $0 MO fluocinonide topical gel 2 $0 MO fluocinonide topical ointment 2 $0 MO fluocinonide topical solution 2 $0 MO fluocinonide-e 2 $0 MO fluticasone topical 2 $0 MO halobetasol propionate 2 $0 MO HALOG 2 $0 MO hydrocortisone acetate topical 4 $0 [*] hydrocortisone plus 4 $0 [*] hydrocortisone topical cream 0.5 % 4 $0 MO; [*] hydrocortisone topical cream 1 %, 2.5 % 2 $0 MO hydrocortisone topical lotion 1 % 4 $0 MO; [*] hydrocortisone topical lotion 2.5 % 2 $0 MO hydrocortisone topical ointment 0.5 % 4 $0 MO; [*] hydrocortisone topical ointment 1 %, 2.5 % 2 $0 MO hydrocortisone valerate 2 $0 MO hydrocortisone-aloe vera topical cream 1 % 4 $0 MO; [*] ENYDMEM

67 hydrocortisone-min oil-wht pet 2 $0 MO mometasone 2 $0 MO noble formula hc topical cream 4 $0 [*] recort plus 4 $0 [*] scalpicin anti-itch 4 $0 MO; [*] soothing care (hydrocortisone) 4 $0 [*] triamcinolone acetonide topical cream 2 $0 MO triamcinolone acetonide topical lotion 2 $0 MO triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % 2 $0 MO trianex 2 $0 MO triderm topical cream 2 $0 MO TOPICAL ENZYMES SANTYL 2 $0 MO; QLL (30 per 30 days) TOPICAL SCABICIDES / PEDICULICIDES lice complete kit $0 [*] LICE CREAM RINSE 4 $0 [*] lice killing 4 $0 [*] LICE KILLING (PERMETHRIN) 4 $0 [*] lice pyrinyl shampoo 4 $0 [*] LICE SOLUTION 4 $0 [*] LICE TREATMENT (PERMETHRIN) 4 $0 [*] lice treatment topical liquid 1 % 4 $0 [*] lice treatment topical shampoo 4 $0 [*] lindane 2 $0 MO permethrin topical cream 2 $0 MO permethrin topical liquid 4 $0 MO; [*] pyrethrin lice treatment m 4 $0 [*] RID COMPLETE LICE ELIM KIT TOPICAL 4 $0 [*] RID LICE KILLING 4 $0 [*] ENYDMEM

68 DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine intravenous 2 $0 B/D PAR; MO IRRIGATING SOLUTIONS lactated ringers irrigation 2 $0 B/D PAR; MO neomycin-polymyxin b gu 2 $0 MO ringers irrigation 2 $0 B/D PAR; MO MISCELLANEOUS AGENTS ADAGEN 2 $0 MO alendronate oral tablet 40 mg 1 $0 MO; QLL (30 per 30 days) anagrelide 2 $0 MO ARALAST NP 2 $0 PAR; MO; LA BUPHENYL ORAL TABLET 2 $0 PAR; MO cevimeline 2 $0 MO CLINIMIX 4.25%/D5W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 2.75%/D10W SUL FREE 2 $0 B/D PAR CLINIMIX E 2.75%/D5W SULF FREE 2 $0 B/D PAR d10 % & 0.45 % sodium chloride 2 $0 B/D PAR d2.5 %-0.45 % sodium chloride 2 $0 B/D PAR d5 % and 0.9 % sodium chloride 2 $0 B/D PAR; MO d5 %-0.45 % sodium chloride 2 $0 B/D PAR; MO dex4 glucose bits 4 $0 [*] dex4 glucose oral tablet,chewable 4 $0 MO; [*] dex4 glucose pouch pack 4 $0 [*] dex4 glucose quick dissolve 4 $0 [*] dextrose 10 % and 0.2 % nacl 2 $0 B/D PAR dextrose 10 % in water (d10w) intravenous parenteral solution 2 $0 B/D PAR; MO dextrose 25 % in water (d25w) 2 $0 B/D PAR dextrose 30 % in water (d30w) 2 $0 B/D PAR ENYDMEM

69 dextrose 40 % in water (d40w) 2 $0 B/D PAR dextrose 5 % in water (d5w) 2 $0 B/D PAR; MO dextrose 5 %-lactated ringers 2 $0 B/D PAR; MO dextrose 5%-0.2 % sod chloride 2 $0 B/D PAR dextrose 5%-0.3 % sod.chloride 2 $0 B/D PAR dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe 2 $0 B/D PAR; MO 2 $0 B/D PAR dextrose 70 % in water (d70w) 2 $0 B/D PAR; MO dextrose oral gel 4 $0 [*] dextrose with sodium chloride 2 $0 B/D PAR disulfiram 2 $0 MO EXJADE 2 $0 PAR; MO; LA gerber good start glucose 4 $0 [*] GLUCO BURST 4 $0 [*] glucose bits 4 $0 [*] glucose gel 4 $0 [*] glucose oral tablet,chewable 4 $0 [*] glucose oral tablet,chewable 4 gram 4 $0 MO; [*] INCRELEX 2 $0 PAR; MO; LA insta-glucose 4 $0 MO; [*] levocarnitine (with sugar) 2 $0 B/D PAR; MO levocarnitine oral tablet 2 $0 B/D PAR; MO midodrine 2 $0 MO ORFADIN 2 $0 LA pilocarpine hcl oral 2 $0 MO POLYETHYLENE GLYCOL $0 MO; [*] RENAGEL 2 $0 ST; MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM 2 $0 MO; QLL (180 per 30 days) ENYDMEM

70 RENVELA ORAL POWDER IN PACKET 2.4 GRAM 2 $0 MO; QLL (90 per 30 days) RENVELA ORAL TABLET 2 $0 MO; QLL (270 per 30 days) riluzole 2 $0 MO sodium chloride 0.9 % intravenous 2 $0 MO sodium chloride irrigation 2 $0 MO sodium polystyrene (sorb free) 2 $0 sodium polystyrene sulfonate oral powder 2 $0 MO sodium polystyrene sulfonate oral suspension 2 $0 sodium polystyrene sulfonate rectal 2 $0 SODIUM POLYSTYRENE SULFONATE RECTAL 2 $0 sps oral 2 $0 MO sps rectal 2 $0 SYPRINE 2 $0 MO water for irrigation, sterile 2 $0 B/D PAR; MO ZEMAIRA 2 $0 PAR; MO; LA MISCELLANEOUS DEVICES ALCOHOL, RUBBING 4 $0 [*] isopropyl alcohol solution 70 % 4 $0 MO; [*] isopropyl alcohol, rubbing 4 $0 MO; [*] SMOKING DETERRENTS buproban 2 $0 MO; QLL (60 per 30 days) CHANTIX 2 $0 PAR; MO; QLL (60 per 30 days) CHANTIX CONTINUING MONTH BOX 2 $0 PAR; MO; QLL (56 per 28 days) CHANTIX STARTING MONTH BOX 2 $0 PAR; MO; QLL (53 per 365 days) nicorelief buccal gum 4 $0 MO; [*] nicotine (polacrilex) buccal gum 4 $0 MO; [*] nicotine (polacrilex) buccal lozenge 4 $0 MO; [*]; QLL (20 per 1 day) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr 4 $0 MO; [*]; QLL (30 per 30 days) ENYDMEM

71 nicotine transdermal patch, td daily, sequential 4 $0 MO; [*] NICOTROL NS 2 $0 MO; QLL (120 per 30 days) nts step 1 4 $0 [*]; QLL (30 per 30 days) quit 2 buccal gum 4 $0 [*] quit 4 buccal gum 4 $0 [*] stop smoking aid buccal lozenge 4 $0 [*]; QLL (20 per 1 day) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS anefrin 4 $0 [*] ayr saline nasal drops 4 $0 MO; [*] azelastine nasal 2 $0 MO; QLL (30 per 25 days) baby ayr saline 4 $0 [*] chlorhexidine gluconate mucous membrane 2 $0 MO cough drops mucous membrane lozenge 10 mg 4 $0 [*] COUGH DROPS MUCOUS MEMBRANE LOZENGE 2.7 MG, 5 MG, 5.8 MG, 6.1 MG, 8 MG, 9.1 MG 4 $0 [*] dristan long lasting 4 $0 [*] ipratropium bromide nasal 2 $0 MO; QLL (30 per 30 days) MENTHOL COUGH MUCOUS MEMBRANE LOZENGE 6.1 MG 4 $0 [*] nasal decongestant (oxymetazl) 4 $0 [*] NASAL RELIEF 4 $0 [*] nasal spray (oxymetazoline) 4 $0 [*] nrs nasal relief 4 $0 [*] original nasal spray 4 $0 [*] oxymetazoline 4 $0 [*] paroex oral rinse 2 $0 MO periogard 2 $0 MO sinus nasal spray 4 $0 [*] sinus relief (oxymetazoline) 4 $0 [*] ENYDMEM

72 SORE THROAT (MENTHOL) 4 $0 [*] triamcinolone acetonide dental 2 $0 MO TYZINE NASAL DROPS 0.05 % 2 $0 MO MISCELLANEOUS OTIC PREPARATIONS acetic acid otic 2 $0 MO acetic acid-aluminum acetate 2 $0 MO fluocinolone acetonide oil 2 $0 MO hydrocortisone-acetic acid 2 $0 MO ofloxacin otic 2 $0 MO OTIC STEROID / ANTIBIOTIC CIPRODEX 2 $0 MO COLY-MYCIN S 2 $0 MO neomycin-polymyxin-hc otic 2 $0 MO ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. 2 $0 PAR; MO cortisone 2 $0 MO dexamethasone 2 $0 MO dexamethasone sodium phos (pf) 2 $0 MO dexamethasone sodium phosphate injection 2 $0 MO fludrocortisone 2 $0 MO hydrocortisone oral 2 $0 MO methylprednisolone acetate 2 $0 MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg 2 $0 MO methylprednisolone sodium succ intravenous 2 $0 MO methylprednisolone tablets 2 $0 MO prednisolone oral solution 15 mg/5 ml 2 $0 MO prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) 2 $0 MO ENYDMEM

73 prednisolone sodium phosphate oral tablet,disintegrating 2 $0 MO prednisone intensol 2 $0 MO prednisone oral solution 2 $0 MO prednisone oral tablet 1 $0 MO prednisone oral tablets,dose pack 1 $0 MO triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS 2 $0 MO 2 $0 methimazole oral tablet 10 mg, 5 mg 2 $0 MO propylthiouracil 2 $0 MO DIABETES THERAPY acarbose oral tablet 100 mg 2 $0 MO; QLL (90 per 30 days) acarbose oral tablet 25 mg 2 $0 MO; QLL (360 per 30 days) acarbose oral tablet 50 mg 2 $0 MO; QLL (180 per 30 days) alcohol pads 1 $0 MO BYDUREON 2 $0 MO; QLL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 2 $0 MO; QLL (2.4 per 30 days) 2 $0 MO; QLL (1.2 per 30 days) CYCLOSET 2 $0 ST; MO; QLL (180 per 30 days) GAUZE PADS 2 X 2 1 $0 MO; QLL (200 per 30 days) glimepiride oral tablet 1 mg 1 $0 MO; QLL (240 per 30 days) glimepiride oral tablet 2 mg 1 $0 MO; QLL (120 per 30 days) glimepiride oral tablet 4 mg 1 $0 MO; QLL (60 per 30 days) glipizide oral tablet 10 mg 1 $0 MO; QLL (120 per 30 days) glipizide oral tablet 5 mg 1 $0 MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg 1 $0 MO; QLL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg 1 $0 MO; QLL (240 per 30 days) ENYDMEM

74 glipizide oral tablet extended release 24hr 5 mg 1 $0 MO; QLL (120 per 30 days) glipizide-metformin oral tablet mg 1 $0 MO; QLL (240 per 30 days) glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT 2 $0 MO GLUCAGON EMERGENCY KIT (HUMAN) 2 $0 MO HUMALOG KWIKPEN 2 $0 MO HUMALOG MIX $0 MO HUMALOG MIX KWIKPEN 2 $0 MO HUMALOG MIX $0 MO HUMALOG MIX KWIKPEN 2 $0 MO HUMALOG SUBCUTANEOUS CARTRIDGE 2 $0 MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) 1 $0 MO; QLL (120 per 30 days) 2 $0 MO 2 $0 HUMULIN 70/30 2 $0 MO HUMULIN 70/30 KWIKPEN 2 $0 MO HUMULIN N 2 $0 MO HUMULIN N KWIKPEN 2 $0 MO HUMULIN R 2 $0 MO HUMULIN R U-500 (CONCENTRATED) 2 $0 MO INSULIN PEN NEEDLE 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U ML 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U ML 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1/2 ML 1 $0 MO; QLL (200 per 30 days) JANUMET 2 $0 MO; QLL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (60 per 30 days) JANUVIA ORAL TABLET 100 MG 2 $0 MO; QLL (30 per 30 days) ENYDMEM

75 JANUVIA ORAL TABLET 25 MG 2 $0 MO; QLL (120 per 30 days) JANUVIA ORAL TABLET 50 MG 2 $0 MO; QLL (60 per 30 days) JARDIANCE 2 $0 PAR; MO; QLL (30 per 30 days) JENTADUETO 2 $0 MO; QLL (60 per 30 days) KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, MG 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) LANTUS 2 $0 MO LANTUS SOLOSTAR 2 $0 MO LEVEMIR 2 $0 MO LEVEMIR FLEXTOUCH 2 $0 MO metformin oral tablet 1,000 mg 1 $0 MO; QLL (76 per 30 days) metformin oral tablet 500 mg 1 $0 MO; QLL (153 per 30 days) metformin oral tablet 850 mg 1 $0 MO; QLL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg 1 $0 MO; QLL (120 per 30 days) 1 $0 MO; QLL (80 per 30 days) 1 $0 MO; QLL (75 per 30 days) 1 $0 MO; QLL (150 per 30 days) nateglinide oral tablet 120 mg 2 $0 MO; QLL (90 per 30 days) nateglinide oral tablet 60 mg 2 $0 MO; QLL (180 per 30 days) NEEDLES, INSULIN DISP.,SAFETY 1 $0 MO; QLL (200 per 30 days) ONGLYZA ORAL TABLET 2.5 MG 2 $0 MO; QLL (60 per 30 days) ONGLYZA ORAL TABLET 5 MG 2 $0 MO; QLL (30 per 30 days) pioglitazone oral tablet 15 mg 1 $0 MO; QLL (90 per 30 days) pioglitazone oral tablet 30 mg 1 $0 MO; QLL (45 per 30 days) pioglitazone oral tablet 45 mg 1 $0 MO; QLL (30 per 30 days) pioglitazone-glimepiride 2 $0 MO; QLL (30 per 30 days) ENYDMEM

76 pioglitazone-metformin 2 $0 MO; QLL (90 per 30 days) PRANDIMET 2 $0 MO; QLL (150 per 30 days) PROGLYCEM 2 $0 MO SYMLINPEN $0 PAR; MO; QLL (11 per 30 days) SYMLINPEN 60 2 $0 PAR; MO; QLL (6 per 30 days) TANZEUM 2 $0 MO; QLL (4 per 28 days) tolazamide oral tablet 250 mg 1 $0 MO; QLL (120 per 30 days) tolazamide oral tablet 500 mg 1 $0 MO; QLL (60 per 30 days) tolbutamide 1 $0 MO; QLL (180 per 30 days) TOUJEO SOLOSTAR 2 $0 MO TRADJENTA 2 $0 MO; QLL (30 per 30 days) TRULICITY 2 $0 MO; QLL (2 per 28 days) VICTOZA 2-PAK 2 $0 MO; QLL (9 per 30 days) VICTOZA 3-PAK 2 $0 MO; QLL (9 per 30 days) MISCELLANEOUS HORMONES ALDURAZYME 2 $0 PAR; MO ANDRODERM 2 $0 PAR; MO; QLL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) 2 $0 PAR; MO; QLL (300 per 30 days) 2 $0 PAR; MO; QLL (150 per 30 days) 2 $0 PAR; MO; QLL (300 per 30 days) 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) androxy 2 $0 PAR; MO cabergoline 2 $0 MO calcitonin (salmon) 2 $0 MO; QLL (4 per 30 days) ENYDMEM

77 calcitriol intravenous solution 1 mcg/ml 2 $0 B/D PAR; MO calcitriol oral 2 $0 B/D PAR; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 2 $0 PAR; MO danazol oral 2 $0 MO desmopressin injection 2 $0 MO desmopressin nasal 2 $0 MO desmopressin oral 2 $0 MO doxercalciferol intravenous 2 $0 B/D PAR doxercalciferol oral 2 $0 B/D PAR; MO ELAPRASE 2 $0 PAR; MO FABRAZYME 2 $0 PAR; MO HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML) HECTOROL INTRAVENOUS SOLUTION 4 MCG/2 ML 2 $0 PAR 2 $0 PAR; MO HECTOROL ORAL 2 $0 PAR; MO KUVAN ORAL TABLET,SOLUBLE 2 $0 PAR; MO MYOZYME 2 $0 PAR; MO NAGLAZYME 2 $0 PAR; MO; LA oxandrolone oral tablet 10 mg 2 $0 PAR; MO; QLL (60 per 30 days) oxandrolone oral tablet 2.5 mg 2 $0 PAR; MO; QLL (120 per 30 days) pamidronate 2 $0 B/D PAR; MO paricalcitol oral 2 $0 B/D PAR; MO SENSIPAR ORAL TABLET 30 MG, 60 MG 2 $0 MO; QLL (60 per 30 days) SENSIPAR ORAL TABLET 90 MG 2 $0 MO; QLL (120 per 30 days) SOMAVERT 2 $0 PAR; MO; LA STIMATE 2 $0 MO SYNAREL 2 $0 PAR; MO TESTIM 2 $0 PAR; MO; QLL (300 per 30 days) testosterone cypionate 2 $0 MO ENYDMEM

78 testosterone enanthate 2 $0 MO testosterone transdermal gel in packet 2 $0 PAR; MO; QLL (300 per 30 days) ZAVESCA 2 $0 PAR; MO; LA ZEMPLAR INTRAVENOUS 2 $0 B/D PAR; MO zoledronic acid intravenous recon soln 2 $0 PAR zoledronic acid intravenous solution 2 $0 PAR; MO ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORMONES 2 $0 PAR; MO levothyroxine oral 2 $0 MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 2 $0 MO liothyronine oral 2 $0 MO SYNTHROID 2 $0 MO unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS 2 $0 MO anti-diarrheal (loperamide) oral capsule 4 $0 [*] ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 4 $0 [*] anti-diarrheal (loperamide) oral tablet 4 $0 MO; [*] atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2 $0 bismatrol oral suspension 262 mg/15 ml 4 $0 MO; [*] bismatrol oral suspension 525 mg/15 ml 4 $0 [*] bismatrol oral tablet,chewable 4 $0 [*] bismuth 4 $0 [*] bismuth maximum strength 4 $0 [*] diamode 4 $0 [*] diarrhea relief (bismuth subs) 4 $0 [*] ENYDMEM

79 dicyclomine oral capsule 2 $0 MO dicyclomine oral solution 2 $0 MO dicyclomine oral tablet 2 $0 MO diotame 4 $0 [*] diphenoxylate-atropine 2 $0 MO glycopyrrolate oral 2 $0 MO kaopectate (bismuth subsalicy) 4 $0 MO; [*] KAOPECTATE CHILD(BIS SSALICYL) 4 $0 [*] kaopectate ex str (bismuth ss) 4 $0 [*] kao-tin (bismuth subsalicylat) 4 $0 [*] k-pec antidiarrheal (bism sub) 4 $0 [*] loperamide oral capsule 2 $0 MO loperamide oral liquid 1 mg/5 ml 4 $0 MO; [*] loperamide oral liquid 1 mg/7.5 ml 4 $0 [*] loperamide oral tablet 4 $0 [*] medi-bismuth 4 $0 [*] opium tincture oral tincture 2 $0 MO peptic relief 4 $0 [*] pepto-bismol oral tablet,chewable 4 $0 MO; [*] pepto-bismol to-go 4 $0 [*] pink bismuth maximum strength 4 $0 [*] pink bismuth oral suspension 4 $0 [*] pink bismuth oral tablet 4 $0 [*] pink bismuth oral tablet,chewable 4 $0 MO; [*] soothe (bismuth subsalicylate) 4 $0 [*] MISCELLANEOUS GASTROINTESTINAL AGENTS ADVANCED ANTACID-ANTIGAS 4 $0 [*] almacone oral suspension 4 $0 [*] almacone-2 4 $0 [*] alophen 4 $0 [*] ENYDMEM

80 alosetron 2 $0 PAR; MO; QLL (60 per 30 days) aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml 4 $0 MO; [*] 4 $0 [*] AMITIZA 2 $0 MO antacid anti-gas double str 4 $0 [*] ANTACID ANTI-GAS ORAL SUSPENSION 4 $0 [*] antacid liquid 4 $0 [*] antacid plus anti-gas 4 $0 [*] ANTACID WITH SIMETHICONE ORAL SUSPENSION 4 $0 [*] ANTACID-ANTIGAS 4 $0 [*] antacid-simethicone 4 $0 [*] antacid-simethicone ds 4 $0 [*] anti-gas ultra strength 4 $0 [*] anti-nausea 4 $0 [*] APRISO 2 $0 MO ASACOL HD 2 $0 MO balsalazide 2 $0 MO bisac-evac 4 $0 MO; [*] bisacodyl oral 4 $0 MO; [*] bisacodyl rectal 4 $0 MO; [*] bisa-lax 4 $0 [*] biscolax 4 $0 MO; [*] budesonide oral 2 $0 MO CANASA 2 $0 MO child suppository 4 $0 [*] children's pepto 4 $0 [*] CIMZIA 2 $0 PAR; MO; QLL (6 per 28 days) CIMZIA POWDER FOR RECONST 2 $0 PAR; MO; QLL (6 per 28 days) ENYDMEM

81 CIMZIA STARTER KIT 2 $0 PAR; MO; QLL (6 per 28 days) CITRATE OF MAGNESIA 4 $0 [*] citroma 4 $0 [*] CLEARLAX ORAL POWDER 4 $0 MO; [*] colocort 2 $0 MO col-rite 4 $0 [*] comfort gel 4 $0 [*] comfort gel extra strength 4 $0 [*] compro 2 $0 PAR; MO constulose 2 $0 MO CREON 2 $0 MO CYSTADANE 2 $0 MO DELZICOL 2 $0 MO dimenhydrinate oral 4 $0 MO; [*] diocto oral liquid 4 $0 [*] diocto oral syrup 4 $0 MO; [*] dioctyl 4 $0 [*] DIPENTUM 2 $0 MO disposable enema 4 $0 [*] doc-q-lace 4 $0 MO; [*] doc-q-lax 4 $0 MO; [*] docu 4 $0 MO; [*] docuprene 4 $0 [*] docusate calcium 4 $0 MO; [*] docusate sodium oral capsule 4 $0 MO; [*] docusate sodium oral liquid 4 $0 MO; [*] docusate sodium oral tablet 4 $0 [*] docusil 4 $0 [*] dok oral capsule 100 mg 4 $0 MO; [*] dok oral capsule 250 mg 4 $0 [*] ENYDMEM

82 dok oral tablet 4 $0 MO; [*] dok plus 4 $0 [*] dramamine oral tablet 4 $0 MO; [*] driminate 4 $0 [*] dronabinol 2 $0 B/D PAR; MO; QLL (120 per 30 days) ducodyl 4 $0 [*] dulcolax stool softener (dss) 4 $0 MO; [*] EMEND ORAL CAPSULE 125 MG 2 $0 B/D PAR; MO; QLL (4 per 30 days) EMEND ORAL CAPSULE 40 MG 2 $0 B/D PAR; MO; QLL (1 per 1 day) EMEND ORAL CAPSULE 80 MG 2 $0 B/D PAR; MO; QLL (8 per 30 days) EMEND ORAL CAPSULE,DOSE PACK 2 $0 B/D PAR; MO; QLL (12 per 30 days) enema disposable 4 $0 [*] enema rectal 4 $0 [*] ENEMA RECTAL 4 $0 [*] enulose 2 $0 MO EPSOM SALT 4 $0 [*] fiber (calcium polycarbophil) 4 $0 MO; [*] fiber (psyllium husk) 4 $0 [*] FIBER (PSYLLIUM HUSK/SUGAR) 4 $0 [*] FIBER (WITH ASPARTAME) 4 $0 [*] fiber laxative (ca polycarbo) 4 $0 [*] fiber laxative (husk/sugar) 4 $0 [*] fiber laxative (methylcellulo) 4 $0 [*] fiber laxative (psyllium husk) 4 $0 [*] fiber laxative (psyllium) s/f 4 $0 [*] FIBER ORAL POWDER 4 $0 [*] fiber smooth 4 $0 [*] FIBER SMOOTH (SUCROSE) 4 $0 [*] fiber therapy 4 $0 [*] ENYDMEM

83 fiber therapy (ca polycarboph) 4 $0 [*] fiber therapy (psyllium seed) 4 $0 [*] fiber therapy (psyllium) 4 $0 [*] fiber therapy laxative (husk) 4 $0 [*] fiber therapy sugar free 4 $0 [*] FIBER-CAPS 4 $0 [*] fiber-lax 4 $0 MO; [*] fiber-tabs 4 $0 [*] flanax antacid 4 $0 [*] foaming antacid extra strength 4 $0 [*] foaming antacid oral suspension 4 $0 [*] formula em 4 $0 [*] gas relief extra strength oral capsule 4 $0 [*] gas relief oral capsule 4 $0 [*] gas relief ultra strength 4 $0 [*] gavilax oral powder 4 $0 MO; [*] gavilyte-c 2 $0 MO gavilyte-g 2 $0 MO gavilyte-n 2 $0 MO generlac 2 $0 MO gentle laxative 4 $0 [*] gentlelax 4 $0 [*] geri-kot 4 $0 [*] geri-lanta 4 $0 [*] geri-mox antacid-antigas 4 $0 [*] GERI-MUCIL 4 $0 [*] glycerin (adult) 4 $0 [*] glycerin (child) 4 $0 [*] glycolax oral powder 4 $0 [*] healthylax 4 $0 [*] ENYDMEM

84 heartburn relief (magnesium carbonate/aluminum hydroxide) tab chews 4 $0 [*] HEMORRHOID RECTAL OINTMENT 4 $0 [*] hemorrhoidal cream 4 $0 [*] hemorrhoidal rectal cream % 4 $0 [*] hemorrhoidal rectal ointment 4 $0 MO; [*] HEMORRHOIDAL RECTAL OINTMENT %, % 4 $0 [*] hydrocortisone acetate rectal suppository 4 $0 MO; [*] hydrocortisone rectal enema 2 $0 MO kao-tin (docusate calcium) 4 $0 [*] konsyl (sugar) oral powder 3.4 gram/11 gram 4 $0 [*] konsyl (sugar) oral powder 3.4 gram/12 gram 4 $0 MO; [*] konsyl easy mix 4 $0 [*] konsyl fiber 4 $0 [*] konsyl formula-d 4 $0 MO; [*] konsyl sugar-free (aspartame) oral powder 4 $0 [*] konsyl sugar-free oral capsule 4 $0 MO; [*] konsyl sugar-free oral powder 4 $0 MO; [*] lactulose 2 $0 MO laxa clear 4 $0 [*] laxacin 4 $0 [*] laxative (glycerin-pediatric) 4 $0 [*] laxative peg 3350 oral powder 4 $0 [*] laxative-senna 4 $0 [*] LIALDA 2 $0 MO LINZESS 2 $0 MO liquid antacid 4 $0 [*] LOTRONEX 2 $0 PAR; MO; QLL (60 per 30 days) mag-al plus 4 $0 [*] mag-al plus extra strength 4 $0 [*] ENYDMEM

85 magnesium citrate oral solution 4 $0 MO; [*] meclizine oral tablet 12.5 mg, 25 mg 2 $0 MO meclizine oral tablet,chewable 4 $0 [*] mesalamine rectal 2 $0 MO mesalamine with cleansing wipe 2 $0 MO metoclopramide hcl injection solution 2 $0 MO metoclopramide hcl injection syringe 2 $0 metoclopramide hcl oral solution 2 $0 MO metoclopramide hcl oral tablet 2 $0 MO mi-acid oral suspension 4 $0 MO; [*] mi-acid oral tablet,chewable 4 $0 [*] milk of magnesia 4 $0 MO; [*] milk of magnesia concentrated 4 $0 MO; [*] mineral oil extra heavy oral 4 $0 [*] mineral oil heavy oral 4 $0 MO; [*] mineral oil laxative 4 $0 MO; [*] mineral oil oral 4 $0 MO; [*] mineral oil rectal 4 $0 [*] mintox 4 $0 MO; [*] mintox maximum strength 4 $0 MO; [*] mintox plus 4 $0 MO; [*] motion relief (meclizine) 4 $0 [*] MOTION SICKNESS (MECLIZINE) 4 $0 [*] motion sickness relief(mecliz) 4 $0 [*] natural fiber laxative 4 $0 [*] natural fiber laxative (sugar) 4 $0 [*] natural fiber laxative s/f 4 $0 [*] natural fiber laxative smooth 4 $0 [*] natural fiber laxative therapy 4 $0 [*] natural fiber laxative(aspart) 4 $0 [*] ENYDMEM

86 natural fiber supplement oral powder in packet 4 $0 [*] natural laxative 4 $0 [*] NATURAL PSYLLIUM FIBER 4 $0 [*] NATURAL VEGETABLE 4 $0 [*] NATURAL VEGETABLE (PSYLLIUM) 4 $0 [*] natural vegetable powder 4 $0 [*] nausea control 4 $0 [*] nausea relief 4 $0 [*] ondansetron hcl (pf) injection solution 2 $0 MO ondansetron hcl (pf) injection syringe 2 $0 ondansetron hcl intravenous solution 2 $0 MO ondansetron hcl oral solution 2 $0 B/D PAR; MO; QLL (450 per 30 days) ondansetron hcl oral tablet 24 mg 2 $0 B/D PAR; QLL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg 2 $0 B/D PAR; MO; QLL (90 per 30 days) ondansetron odt 2 $0 B/D PAR; MO; QLL (90 per 30 days) oral saline laxative oral liquid 4 $0 [*] p-col rite 4 $0 [*] peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram 2 $0 MO 2 $0 peg-3350 with flavor packs 2 $0 peg-electrolyte soln 2 $0 PENTASA 2 $0 MO perdiem overnight relief 4 $0 MO; [*] peri-colace 4 $0 MO; [*] PHOSPHATE LAXATIVE 4 $0 [*] polyethylene glycol 3350 oral 2 $0 MO ENYDMEM

87 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 2 $0 PAR; MO prochlorperazine maleate oral 2 $0 PAR; MO prochlorperazine maleate rectal 2 $0 PAR; MO procto-pak 2 $0 MO proctosol hc 2 $0 MO proctozone-hc 2 $0 MO promolaxin 4 $0 [*] psyllium husk oral capsule 4 $0 [*] purelax 4 $0 [*] ready-to-use enema 4 $0 [*] ready-to-use enema (min oil) 4 $0 [*] reguloid oral capsule 4 $0 [*] reguloid oral powder 4 $0 MO; [*] reguloid, sugar free 4 $0 [*] RELISTOR SUBCUTANEOUS SOLUTION 2 $0 PAR; MO RELISTOR SUBCUTANEOUS SYRINGE 2 $0 PAR; MO REMICADE 2 $0 PAR; MO ri-gel 4 $0 [*] ri-gel ii 4 $0 [*] ri-mox 4 $0 [*] ri-mox plus 4 $0 [*] SANI-SUPP (ADULT) 4 $0 MO; [*] sani-supp (infant) 4 $0 MO; [*] senexon 4 $0 MO; [*] senexon-s 4 $0 MO; [*] senna lax 4 $0 MO; [*] senna laxative 4 $0 [*] senna oral syrup 8.8 mg/5 ml 4 $0 MO; [*] SENNA ORAL TABLET 4 $0 [*] senna plus 4 $0 MO; [*] ENYDMEM

88 SENNA PROMPT 4 $0 [*] senna with docusate sodium 4 $0 [*] senna-extra 4 $0 [*] senna-gen 4 $0 MO; [*] senna-s 4 $0 MO; [*] senno 4 $0 [*] sennosides-docusate sodium 4 $0 [*] SENOKOTXTRA 4 $0 MO; [*] sen-o-tab 4 $0 [*] silace oral liquid 4 $0 MO; [*] silace oral syrup 4 $0 [*] simethicone oral capsule 180 mg 4 $0 [*] sodium bicarbonate oral 4 $0 MO; [*] sof-lax 4 $0 [*] soluble fiber 4 $0 [*] STIMULANT LAXATIVE PLUS 4 $0 [*] stool softener oral capsule 100 mg, 240 mg 4 $0 MO; [*] STOOL SOFTENER ORAL CAPSULE 250 MG 4 $0 MO; [*] stool softener oral capsule 50 mg 4 $0 [*] stool softener oral liquid 4 $0 [*] stool softener oral syrup 4 $0 [*] stool softener oral tablet 4 $0 [*] stool softener-laxative 4 $0 [*] stool softener-stimulant laxat 4 $0 [*] sulfasalazine 2 $0 MO sulfazine 2 $0 MO sulfazine ec 2 $0 MO suppository adult 4 $0 [*] surfak 4 $0 MO; [*] travel sickness (meclizine) 4 $0 MO; [*] ENYDMEM

89 ursodiol 2 $0 MO vegetable laxative 4 $0 [*] WOMEN'S GENTLE LAXATIVE(BISAC) 4 $0 [*] women's laxative (bisacodyl) 4 $0 [*] ULCER THERAPY acid control (ranitidine) oral tablet 150 mg 4 $0 [*] ACID REDUCER (CIMETIDINE) 4 $0 [*] acid reducer (famotidine) 4 $0 [*] ACID REDUCER (RANITIDINE) 4 $0 [*] acid reducer complete (famot) 4 $0 [*] acid relief (cimetidine) 4 $0 [*] cimetidine oral tablet 200 mg 4 $0 MO; [*] DEXILANT 2 $0 ST; MO; QLL (30 per 30 days) DUAL ACTION COMPLETE 4 $0 [*] famotidine (pf) 2 $0 MO famotidine (pf)-nacl (iso-os) 2 $0 famotidine intravenous 2 $0 MO famotidine oral suspension 2 $0 MO famotidine oral tablet 10 mg 4 $0 MO; [*] famotidine oral tablet 20 mg, 40 mg 2 $0 MO heartburn relief (famotidine) 4 $0 [*] HEARTBURN RELIEF (LANSOPRAZOLE) ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG heartburn relief (ranitidine) 4 $0 [*] 4 $0 [*]; QLL (30 per 30 days) lansoprazole oral capsule,delayed release(dr/ec) 2 $0 MO; QLL (30 per 30 days) misoprostol 2 $0 MO omeprazole magnesium 4 $0 [*] omeprazole oral capsule,delayed release(dr/ec) 2 $0 MO; QLL (30 per 30 days) omeprazole oral tablet,delayed release (dr/ec) 4 $0 MO; [*] pantoprazole oral 2 $0 MO; QLL (30 per 30 days) ENYDMEM

90 pepcid ac oral tablet 20 mg 4 $0 MO; [*] PRILOSEC OTC 4 $0 MO; [*] ranitidine hcl injection 2 $0 MO ranitidine hcl oral syrup 2 $0 MO ranitidine hcl oral tablet 150 mg, 300 mg 2 $0 MO ranitidine hcl oral tablet 75 mg 4 $0 MO; [*] sucralfate oral tablet 2 $0 MO tagamet hb 4 $0 MO; [*] IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 2 $0 PAR; MO ARANESP (IN POLYSORBATE) 2 $0 PAR; MO ARCALYST 2 $0 PAR; MO AVONEX (WITH ALBUMIN) 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 2 $0 PAR; MO; QLL (4 per 28 days) EXTAVIA SUBCUTANEOUS KIT 2 $0 PAR; MO EXTAVIA SUBCUTANEOUS RECON SOLN 2 $0 PAR GENOTROPIN 2 $0 PAR; MO GENOTROPIN MINIQUICK 2 $0 PAR; MO HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) 2 $0 PAR; MO ILARIS (PF) 2 $0 PAR; MO; LA INTRON A INJECTION 2 $0 PAR; MO LEUKINE INJECTION RECON SOLN 2 $0 PAR; MO MOZOBIL 2 $0 PAR; MO NEULASTA SUBCUTANEOUS SYRINGE 2 $0 PAR; MO; QLL (2 per 28 days) NEUMEGA 2 $0 PAR; MO; QLL (21 per 21 days) NEUPOGEN 2 $0 PAR; MO ENYDMEM

91 NORDITROPIN FLEXPRO 2 $0 PAR; MO PEGASYS 2 $0 PAR; MO PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML 2 $0 PAR; MO PEGINTRON 2 $0 PAR; MO PEGINTRON REDIPEN 2 $0 PAR; MO PROCRIT 2 $0 PAR; MO; QLL (12 per 28 days) PROLEUKIN 2 $0 B/D PAR; MO REBIF (WITH ALBUMIN) 2 $0 PAR; MO REBIF REBIDOSE 2 $0 PAR; MO REBIF TITRATION PACK 2 $0 PAR; MO SYLATRON 2 $0 PAR; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) 1 $0 MO ADACEL(TDAP ADOLESN/ADULT)(PF) 1 $0 MO ATGAM 2 $0 B/D PAR BCG VACCINE, LIVE (PF) 2 $0 MO BEXSERO (PF) 2 $0 MO BOOSTRIX TDAP 1 $0 MO CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM 2 $0 PAR; MO CERVARIX VACCINE (PF) 1 $0 MO COMVAX (PF) 1 $0 MO DAPTACEL (DTAP PEDIATRIC) (PF) 1 $0 MO ENGERIX-B (PF) 1 $0 B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 1 $0 B/D PAR; MO 1 $0 B/D PAR GAMASTAN S/D 2 $0 PAR; MO GAMMAGARD LIQUID 2 $0 PAR; MO ENYDMEM

92 GAMMAGARD S-D (IGA < 1 MCG/ML) 2 $0 PAR; MO GAMMAPLEX 2 $0 PAR; MO GAMUNEX-C 2 $0 PAR; MO GARDASIL (PF) 2 $0 MO GARDASIL 9 (PF) 2 $0 MO HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML 1 $0 MO 1 $0 MO 1 $0 IMOVAX RABIES VACCINE (PF) 2 $0 MO INFANRIX (DTAP) (PF) 2 $0 MO IPOL INJECTION SUSPENSION 1 $0 MO IPOL INJECTION SYRINGE 1 $0 IXIARO (PF) 2 $0 MO MENACTRA (PF) INTRAMUSCULAR SOLUTION 2 $0 MO MENOMUNE - A/C/Y/W $0 MENOMUNE - A/C/Y/W-135 (PF) 2 $0 MO MENVEO A-C-Y-W-135-DIP (PF) 2 $0 MO M-M-R II (PF) 1 $0 MO PEDVAX HIB (PF) 1 $0 MO PROQUAD (PF) 2 $0 QUADRACEL (PF) 2 $0 RABAVERT (PF) 2 $0 MO RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX 2 $0 1 $0 B/D PAR; MO 1 $0 B/D PAR; MO 1 $0 B/D PAR ENYDMEM

93 ROTATEQ VACCINE 1 $0 MO TETANUS,DIPHTHERIA TOX PED(PF) 2 $0 MO TETANUS-DIPHTHERIA TOXOIDS-TD 1 $0 MO THYMOGLOBULIN 2 $0 B/D PAR TICE BCG 2 $0 MO TRUMENBA 2 $0 TWINRIX (PF) 1 $0 MO TYPHIM VI INTRAMUSCULAR SOLUTION 2 $0 TYPHIM VI INTRAMUSCULAR SYRINGE 2 $0 MO VAQTA (PF) INTRAMUSCULAR SUSPENSION 2 $0 MO VAQTA (PF) INTRAMUSCULAR SYRINGE 2 $0 VARIVAX (PF) 2 $0 MO VARIZIG INTRAMUSCULAR RECON SOLN 2 $0 MO VARIZIG INTRAMUSCULAR SOLUTION 2 $0 YF-VAX (PF) 2 $0 MO ZOSTAVAX (PF) 2 $0 MO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 $0 MO colchicine-probenecid 2 $0 MO COLCRYS 2 $0 MO probenecid 2 $0 MO ULORIC 2 $0 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution 2 $0 MO; QLL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg 1 $0 MO; QLL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg 1 $0 MO; QLL (4 per 28 days) BONIVA INTRAVENOUS 2 $0 B/D PAR; MO EVISTA 2 $0 MO; QLL (30 per 30 days) ENYDMEM

94 FORTEO 2 $0 PAR; MO; QLL (3 per 28 days) ibandronate intravenous solution 2 $0 B/D PAR; MO ibandronate intravenous syringe 2 $0 MO ibandronate oral 2 $0 MO; QLL (1 per 28 days) PROLIA 2 $0 PAR; MO; QLL (2 per 365 days) raloxifene 2 $0 MO; QLL (30 per 30 days) OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS 2 $0 PAR; MO DEPEN TITRATABS 2 $0 MO ENBREL SUBCUTANEOUS RECON SOLN 2 $0 PAR; MO; QLL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) 2 $0 PAR; MO; QLL (4.08 per 28 days) 2 $0 PAR; MO; QLL (8 per 28 days) ENBREL SURECLICK 2 $0 PAR; MO; QLL (8 per 28 days) HUMIRA PEDIATRIC CROHN'S START 2 $0 PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN 2 $0 PAR; MO; QLL (3.2 per 28 days) HUMIRA PEN CROHN'S-UC-HS START 2 $0 PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN PSORIASIS STARTER 2 $0 PAR; MO; QLL (3.2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 2 $0 PAR; MO; QLL (2 per 28 days) 2 $0 PAR; MO; QLL (3.2 per 28 days) KINERET 2 $0 PAR; MO; QLL (28 per 28 days) leflunomide 2 $0 MO RIDAURA 2 $0 MO SAVELLA ORAL TABLET 100 MG 2 $0 MO; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG 2 $0 MO; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG 2 $0 MO; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG 2 $0 MO; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (1 per 365 days) SIMPONI 2 $0 PAR; MO; QLL (1 per 28 days) ENYDMEM

95 OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila 2 $0 MO DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML 2 $0 MO errin 2 $0 MO ESTRACE VAGINAL 2 $0 MO estradiol oral 2 $0 PAR; MO estradiol transdermal patch weekly 2 $0 PAR; MO; QLL (4 per 28 days) ESTRING 2 $0 MO; QLL (1 per 90 days) lyza 2 $0 MO medroxyprogesterone 2 $0 MO MENEST 2 $0 PAR; MO nora-be 2 $0 MO norethindrone (contraceptive) 2 $0 MO norethindrone acetate 2 $0 MO PREMARIN ORAL 2 $0 MO PREMARIN VAGINAL 2 $0 MO progesterone micronized 2 $0 ST; MO VAGIFEM 2 $0 MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal 2 $0 MO clotrimazole 3 day 4 $0 MO; [*] clotrimazole vaginal cream 4 $0 MO; [*] clotrimazole-3 4 $0 [*] clotrimazole-7 4 $0 [*] metronidazole vaginal 2 $0 MO miconazole 7 4 $0 MO; [*] miconazole nitrate vaginal comb pack,prefill appl & cream 4 $0 [*] miconazole nitrate vaginal cream 4 $0 MO; [*] ENYDMEM

96 MICONAZOLE NITRATE VAGINAL KIT 1,200-2 MG-% 4 $0 [*] miconazole nitrate vaginal suppository 4 $0 [*] miconazole-3 vaginal kit 4 $0 [*] miconazole-3 vaginal suppository 2 $0 MO; QLL (6 per 30 days) NUVARING 2 $0 MO terconazole 2 $0 MO tioconazole 4 $0 [*] tioconazole-1 4 $0 [*] tranexamic acid oral 2 $0 MO vagistat-3 4 $0 [*] XULANE 2 $0 MO zazole vaginal cream 0.4 % 2 $0 ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) 2 $0 MO alyacen 1/35 (28) 2 $0 MO alyacen 7/7/7 (28) 2 $0 MO apri 2 $0 MO aranelle (28) 2 $0 MO aviane 2 $0 MO azurette (28) 2 $0 MO caziant (28) 2 $0 MO cryselle (28) 2 $0 MO drospirenone-ethinyl estradiol oral tablet mg 2 $0 MO elinest 2 $0 MO ELLA 2 $0 MO enpresse 2 $0 MO falmina (28) 2 $0 MO gildagia 2 $0 MO gildess fe 2 $0 MO ENYDMEM

97 junel 1.5/30 (21) 2 $0 MO junel 1/20 (21) 2 $0 MO junel fe 1.5/30 (28) 2 $0 MO junel fe 1/20 (28) 2 $0 MO kariva (28) 2 $0 MO kelnor 1/35 (28) 2 $0 MO lessina 2 $0 MO levonest (28) 2 $0 MO levonorgestrel oral tablet 1.5 mg 4 $0 [*] levonorgestrel-ethinyl estrad oral tablet mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 2 $0 MO 2 $0 MO low-ogestrel (28) 2 $0 MO lutera (28) 2 $0 MO marlissa 2 $0 MO microgestin 1.5/30 (21) 2 $0 MO microgestin 1/20 (21) 2 $0 MO microgestin fe 1.5/30 (28) 2 $0 MO microgestin fe 1/20 (28) 2 $0 MO mono-linyah 2 $0 MO mononessa (28) 2 $0 MO my way 4 $0 [*] myzilra 2 $0 MO necon 0.5/35 (28) 2 $0 MO necon 1/35 (28) 2 $0 MO necon 1/50 (28) 2 $0 MO necon 10/11 (28) 2 $0 MO necon 7/7/7 (28) 2 $0 MO next choice one dose 4 $0 [*] norgestimate-ethinyl estradiol 2 $0 MO ENYDMEM

98 nortrel 0.5/35 (28) 2 $0 MO nortrel 1/35 (21) 2 $0 MO nortrel 1/35 (28) 2 $0 MO nortrel 7/7/7 (28) 2 $0 MO ocella 2 $0 MO ogestrel (28) 2 $0 MO PLAN B ONE-STEP 4 $0 MO; [*] portia 2 $0 MO previfem 2 $0 MO reclipsen (28) 2 $0 MO sprintec (28) 2 $0 MO syeda 2 $0 MO tri-previfem (28) 2 $0 MO tri-sprintec (28) 2 $0 MO trivora (28) 2 $0 MO velivet triphasic regimen (28) 2 $0 MO viorele (28) 2 $0 MO zarah 2 $0 MO zenchent (28) 2 $0 MO zovia 1/35e (28) 2 $0 MO zovia 1/50e (28) 2 $0 MO OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac 2 $0 MO bacitracin ophthalmic 2 $0 MO bacitracin-polymyxin b ophthalmic 2 $0 MO ciprofloxacin hcl ophthalmic 1 $0 MO erythromycin ophthalmic 2 $0 MO gentak ophthalmic ointment 2 $0 MO gentamicin ophthalmic 2 $0 MO ENYDMEM

99 NATACYN 2 $0 MO neomycin-bacitracin-polymyxin 2 $0 MO neomycin-polymyxin-gramicidin 2 $0 MO neo-polycin 2 $0 MO ofloxacin ophthalmic 2 $0 MO polycin 2 $0 polymyxin b sulf-trimethoprim 2 $0 MO tobramycin 2 $0 MO VIGAMOX 2 $0 MO ANTIVIRALS trifluridine 2 $0 MO ZIRGAN 2 $0 MO BETA-BLOCKERS betaxolol ophthalmic 2 $0 MO carteolol 2 $0 MO levobunolol ophthalmic drops 0.5 % 2 $0 MO metipranolol 2 $0 MO timolol maleate ophthalmic 2 $0 MO TIMOPTIC OCUDOSE (PF) 2 $0 MO CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 $0 MO CYCLOPLEGIC MYDRIATICS tropicamide ophthalmic 2 $0 MO MISCELLANEOUS OPHTHALMOLOGICS alaway 4 $0 MO; [*] allergy eye (ketotifen) 4 $0 [*] altachlore 4 $0 [*] artificial tears 4 $0 [*] artificial tears (petro/min) 4 $0 MO; [*] artificial tears (pf) 4 $0 [*] ENYDMEM

100 artificial tears (polyvin alc) 4 $0 MO; [*] artificial tears(glycerin-peg) 4 $0 [*] artificial tears(hypromellose) 4 $0 [*] azelastine ophthalmic 2 $0 MO CHILDREN'S ALAWAY 4 $0 [*] cromolyn ophthalmic 2 $0 MO dry eye relief 4 $0 [*] ketotifen fumarate 4 $0 MO; [*] moisture drops 4 $0 [*] MURO $0 MO; [*] natural tears (pf) 4 $0 [*] nature's tears 4 $0 [*] PATADAY 2 $0 MO PATANOL 2 $0 MO PAZEO 2 $0 MO RESTASIS 2 $0 MO sodium chloride ophthalmic 4 $0 MO; [*] tears pure 4 $0 [*] VISINE TEARS 4 $0 MO; [*] NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen sodium 2 $0 MO ILEVRO 2 $0 MO ketorolac ophthalmic 2 $0 MO NEVANAC 2 $0 MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral 2 $0 MO acetazolamide sodium 2 $0 MO methazolamide oral 2 $0 MO OTHER GLAUCOMA DRUGS AZOPT 2 $0 MO ENYDMEM

101 bimatoprost 2 $0 MO COMBIGAN 2 $0 MO dorzolamide 2 $0 MO dorzolamide-timolol 2 $0 MO latanoprost 2 $0 MO LUMIGAN OPHTHALMIC DROPS 0.01 % 2 $0 MO TRAVATAN Z 2 $0 MO; QLL (5 per 30 days) travoprost (benzalkonium) 2 $0 MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc 2 $0 MO neomycin-polymyxin b-dexameth 2 $0 MO neomycin-polymyxin-hc ophthalmic 2 $0 MO neo-polycin hc 2 $0 tobramycin-dexamethasone 2 $0 MO STEROIDS dexamethasone sodium phosphate ophthalmic 2 $0 MO fluorometholone 2 $0 MO prednisolone acetate 2 $0 MO prednisolone sodium phosphate ophthalmic 2 $0 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. 2 $0 MO sulfacetamide-prednisolone 2 $0 MO SULFONAMIDES sulfacetamide sodium ophthalmic drops 2 $0 MO SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % 2 $0 MO apraclonidine 2 $0 MO brimonidine 2 $0 MO VASOCONSTRICTOR DECONGESTANTS ALLERGY EYE (NAPHAZOLINE-PHEN) 4 $0 [*] ENYDMEM

102 altazine 4 $0 [*] eye drops (with povidone) 4 $0 [*] naphazoline 2 $0 MO opti-clear 4 $0 [*] sterile eye drops ophthalmic drops 0.05 % 4 $0 [*] tetrahydrozoline ophthalmic 4 $0 [*] VISINE 4 $0 [*] visine-a 4 $0 MO; [*] RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS acta-tabs pe 4 $0 [*] adult cough formula dm max 4 $0 [*] adult tussin chest congestion 4 $0 [*] ADULT TUSSIN COUGH CONGEST DM 4 $0 [*] ADULT TUSSIN DM 4 $0 [*] ala-hist ir 4 $0 MO; [*] ALL DAY ALLERGY (CETIRIZINE) ORAL CAPSULE 4 $0 [*] all day allergy (cetirizine) oral solution 4 $0 [*]; QLL (300 per 30 days) all day allergy (cetirizine) oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) all day allergy (cetirizine) oral tablet,chewable 10 mg 4 $0 MO; [*] all day allergy relief(cetir) 4 $0 [*]; QLL (30 per 30 days) all day allergy-d 4 $0 MO; [*] allergy (chlorpheniramine) 4 $0 MO; [*] allergy (diphenhydramine) 4 $0 [*] ALLERGY COMPLETE-D 4 $0 [*] allergy multi-symptom 4 $0 [*] allergy plus severe sinus ha 4 $0 [*] allergy relief (cetirizine) oral capsule 4 $0 [*] allergy relief (cetirizine) oral tablet 4 $0 [*]; QLL (30 per 30 days) ENYDMEM

103 ALLERGY RELIEF (CLEMASTINE) 4 $0 MO; [*] allergy relief (fexofenadine) 4 $0 [*] allergy relief (loratadine) oral solution 4 $0 [*] allergy relief (loratadine) oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING allergy relief multi-symptom 4 $0 [*] allergy relief(chlorpheniramn) 4 $0 [*] allergy relief(diphenhydramin) 4 $0 [*] allergy relief-d (cetirizine) 4 $0 [*] ALLERGY RELIEF-D (LORATADINE) 4 $0 [*] ALLERGY RELIEF-SINUS HEADACHE 4 $0 [*] ALLERGY SINUS HEADACHE (PE) ORAL TABLET MG 4 $0 [*]; QLL (30 per 30 days) 4 $0 [*] allergy sinus pe 4 $0 [*] aller-tec 4 $0 [*]; QLL (30 per 30 days) aller-tec d 4 $0 [*] allfen 4 $0 [*] allfen dm 4 $0 MO; [*] ALL-NITE COLD-FLU ORAL LIQUID MG/15 ML 4 $0 [*] ambi 10peh-4cpm 4 $0 [*] ambi 60pse-4cpm 4 $0 [*] antitussive dm 4 $0 [*] ap-hist dm 4 $0 [*] aprodine 4 $0 MO; [*] arbinoxa 2 $0 PAR; MO banophen allergy 4 $0 MO; [*] banophen oral capsule 25 mg 4 $0 MO; [*] banophen oral capsule 50 mg 4 $0 [*] banophen oral liquid 4 $0 MO; [*] ENYDMEM

104 banophen oral tablet 4 $0 [*] benzonatate oral capsule 100 mg, 200 mg 3 $0 MO; [*] biocotron 4 $0 [*] BIOSPEC DMX 4 $0 [*] brohist d 4 $0 [*] brompheniramine-pseudoeph-dm oral syrup 4 $0 MO; [*] brotapp 4 $0 MO; [*] cetiri-d 4 $0 [*] cetirizine oral solution 1 mg/ml 4 $0 MO; [*]; QLL (300 per 30 days) cetirizine oral solution 5 mg/5 ml 4 $0 [*] cetirizine oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) CETIRIZINE ORAL TABLET 4 $0 MO; [*]; QLL (30 per 30 days) cetirizine oral tablet,chewable 4 $0 MO; [*] cetirizine-pseudoephedrine 4 $0 MO; [*] CHEST CONGESTION RELIEF + DM 4 $0 [*] CHEST CONGESTION RELIEF ORAL TABLET 4 $0 [*] CHEST CONGESTION RELIEF PE 4 $0 [*] chest congestion-cough relief 4 $0 [*] chest-sinus congestion relief 4 $0 [*] child allergy relf(cetirizine) oral solution 4 $0 [*]; QLL (300 per 30 days) CHILD ALLERGY RELF(CETIRIZINE) ORAL TABLET,CHEWABLE 4 $0 [*] child chest congestion + cough 4 $0 [*] child mucinex chest congestion 4 $0 [*] child mucus relief cough 4 $0 [*] child mucus relief expectorant 4 $0 [*] children night time cold-cough 4 $0 [*] children's allergy (diphenhyd) oral elixir 4 $0 [*] children's allergy (diphenhyd) oral liquid 4 $0 [*] children's allergy relief(lor) 4 $0 [*] children's allergy(cetirizine) 4 $0 [*]; QLL (300 per 30 days) ENYDMEM

105 children's aller-tec 4 $0 [*]; QLL (300 per 30 days) children's cetirizine oral solution 4 $0 [*]; QLL (300 per 30 days) children's cetirizine oral tablet,chewable 4 $0 MO; [*] children's chest congestion 4 $0 [*] children's cold & cough dm 4 $0 [*] children's cold-allergy (pe) 4 $0 [*] children's dibromm cold & alle 4 $0 [*] children's dibromm dm cold & c 4 $0 [*] children's mucinex cough 4 $0 [*] children's silfedrine 4 $0 [*] child's all day allergy(cetir) 4 $0 [*]; QLL (300 per 30 days) childs triacting cold & cough 4 $0 [*] chlorpheniramine maleate oral tablet 4 $0 [*] chlorpheniramine maleate oral tablet extended release 4 $0 MO; [*] chlortabs 4 $0 [*] clemastine oral tablet 1.34 mg 4 $0 MO; [*] clemastine oral tablet 2.68 mg 2 $0 PAR; MO COLD & ALLERGY PE 4 $0 [*] COLD & COUGH DM 4 $0 [*] cold & cough elixir 4 $0 [*] COLD & FLU SEVERE 4 $0 [*] cold & sinus pain relief 4 $0 [*] COLD HEAD CONGESTION DAY/NITE 4 $0 [*] COLD HEAD CONGESTION DAYTIME 4 $0 [*] cold head congestion nighttime 4 $0 [*] cold head congestion sever day 4 $0 [*] cold multi-symptom 4 $0 [*] COLD MULTI-SYMPTOM (CHLORPHEN) 4 $0 [*] COLD MULTI-SYMPTOM DAY/NIGHT 4 $0 [*] COLD MULTI-SYMPTOM NIGHTTIME 4 $0 [*] ENYDMEM

106 cold relief m/s day/night 4 $0 [*] COLD-COUGH SINUS RELIEF PE 4 $0 [*] cold-flu relief, day/night 4 $0 [*] cold-sinus relief 4 $0 [*] CORICIDIN HBP COLD-MULTI SYMPT 4 $0 [*] cough control (guaifenesin) 4 $0 [*] cough control dm 4 $0 [*] COUGH CONTROL DM MAX 4 $0 [*] cough dm er 4 $0 [*] COUGH DROPS (WITH EUCALYPTUS) MUCOUS MEMBRANE LOZENGE, 3.1 MG, 7.6 MG cough drops (with eucalyptus) mucous membrane lozenge 7 mg, 8 mg 4 $0 [*] 4 $0 [*] cough drops mucous membrane lozenge 5.4 mg 4 $0 [*] cough formula dm 4 $0 [*] cough suppressant-expectorant 4 $0 [*] cough syrup 4 $0 [*] cough syrup dm 4 $0 [*] cough-sore throat night 4 $0 [*] DAY TIME PE 4 $0 [*] DAYTIME & NIGHTTIME COLD 4 $0 [*] DAYTIME COLD & FLU RELIEF (PE) 4 $0 [*] DAYTIME COLD-FLU 4 $0 [*] day-time cough 4 $0 [*] DAYTIME SINUS 4 $0 [*] daytime-nighttime 4 $0 [*] dextromethorphan polistirex 4 $0 [*] dextromethorphan-guaifenesin 4 $0 [*] diabetic siltussin das-na 4 $0 [*] diabetic siltussin-dm 4 $0 [*] ENYDMEM

107 diabetic siltussin-dm max str 4 $0 [*] DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML 4 $0 MO; [*] diabetic tussin dm oral liquid mg/5 ml 4 $0 [*] DIABETIC TUSSIN EX ORAL LIQUID 4 $0 MO; [*] diabetic tussin max st 4 $0 MO; [*] dimaphen (pe) 4 $0 [*] dimaphen dm 4 $0 MO; [*] dimetapp cold-congestion 4 $0 [*] dimetapp dm cold-cough (pe) 4 $0 [*] diphenhydramine hcl injection solution 50 mg/ml 2 $0 PAR; MO diphenhydramine hcl injection syringe 2 $0 PAR; MO diphenhydramine hcl oral capsule 4 $0 MO; [*] diphenhydramine hcl oral elixir 4 $0 [*] diphenhydramine hcl oral liquid 4 $0 [*] diphenhydramine hcl oral syrup 4 $0 [*] diphenhydramine hcl oral tablet 25 mg 4 $0 [*] dm max 4 $0 [*] dristan cold 4 $0 [*] endacof - dm 4 $0 [*] entre-hist pse 4 $0 [*] epinephrine injection solution 1 mg/ml (1:1,000) 2 $0 MO epinephrine injection syringe 0.1 mg/ml (1:10,000) 2 $0 MO EPIPEN 2-PAK 2 $0 MO; QLL (2 per 1 day) EPIPEN JR 2-PAK 2 $0 MO; QLL (2 per 1 day) expectorant cough syrup 4 $0 [*] EXPECTORANT ORAL LIQUID 4 $0 [*] fenesin ir 4 $0 [*] fenesin pe ir 4 $0 [*] fexofenadine oral tablet 180 mg, 60 mg 4 $0 MO; [*] FLU & SEVERE COLD-DAYTIME 4 $0 [*] ENYDMEM

108 flu & severe cold-nighttime 4 $0 [*] FLU & SORE THROAT RELIEF 4 $0 [*] flu relief therapy daytime 4 $0 [*] flu relief therapy nighttime 4 $0 [*] geri-tussin 4 $0 [*] g-tron 4 $0 [*] guaifenesin oral liquid 4 $0 [*] guaifenesin oral tablet 200 mg 4 $0 MO; [*] guaifenesin oral tablet extended release 12hr 4 $0 MO; [*] GUAIFENESIN-DM 4 $0 [*] HEAD CONGESTION COLD RELIEF 4 $0 [*] hist-pse 4 $0 [*] hot steam liquid 4 $0 [*] hydrocodone compound syrup 3 $0 [*] hydrocodone-chlorpheniramine 3 $0 MO; [*] hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) 3 $0 MO; [*] 3 $0 [*] hydrocodone-homatropine oral tablet 3 $0 MO; [*] hydromet 3 $0 MO; [*] IBUPROFEN COLD 4 $0 [*] IBUPROFEN COLD-SINUS(WITH PSE) 4 $0 [*] iophen dm-nr 4 $0 MO; [*] iophen-nr 4 $0 MO; [*] kidkare cough/cold 4 $0 [*] levocetirizine oral tablet 2 $0 MO; QLL (30 per 30 days) liquibid d-r 4 $0 [*] lohist - d 4 $0 MO; [*] lohist peb dm 4 $0 [*] lohist-peb 4 $0 [*] ENYDMEM

109 loradamed 4 $0 MO; [*]; QLL (30 per 30 days) lorata-d 4 $0 [*] lorata-dine d 4 $0 [*] loratadine oral solution 4 $0 MO; [*] loratadine oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) loratadine oral tablet,disintegrating 4 $0 MO; [*]; QLL (30 per 30 days) loratadine-d 4 $0 MO; [*] mapap cold formula 4 $0 [*] mapap sinus max strength (pe) 4 $0 [*] medicidin-d 4 $0 [*] medikoff drops 4 $0 [*] menthol cough drops 4 $0 [*] menthol cough mucous membrane lozenge 6.5 mg 4 $0 [*] menthol drops 4 $0 [*] mucaphed 4 $0 [*] MUCINEX COUGH MINI-MELTS 4 $0 MO; [*] mucinex dm 4 $0 MO; [*] mucinex fast-max cold-flu-thrt oral tablet 4 $0 [*] mucinex fast-max dm max 4 $0 [*] mucinex fast-max severe cold oral tablet 4 $0 [*] mucinex oral tablet extended release 12hr 600 mg 4 $0 MO; [*] mucosa 4 $0 [*] mucosa dm 4 $0 [*] mucus dm 4 $0 [*] mucus relief chest 4 $0 [*] MUCUS RELIEF COLD-FLU-SORE THR ORAL TABLET 4 $0 [*] MUCUS RELIEF COUGH 4 $0 [*] mucus relief d (phenylephrine) 4 $0 [*] mucus relief dm 4 $0 MO; [*] mucus relief dm max 4 $0 [*] ENYDMEM

110 mucus relief er oral tablet extended release 12hr 4 $0 [*] mucus relief oral tablet 400 mg 4 $0 MO; [*] mucus relief pe 4 $0 [*] mucus relief plus 4 $0 [*] MUCUS RELIEF SEV CONGEST-COLD 4 $0 [*] mucus relief sinus 4 $0 [*] multi-symptom cold (pe & cpm) 4 $0 [*] multi-symptom cold (pe) 4 $0 [*] multi-symptom cold daytime 4 $0 [*] multi-symptom cold night time 4 $0 [*] nasal decongestant (pe) oral tablet 10 mg 4 $0 [*] nasal decongestant (pseudoeph) 4 $0 [*] NIGHT TIME COLD & FLU RELIEF 4 $0 [*] night time cold oral tablet 4 $0 [*] NIGHT TIME COLD-FLU ORAL LIQUID 4 $0 [*] NIGHT TIME COLD-FLU RELIEF ORAL LIQUID ,000 MG/30 ML 4 $0 [*] night time cough & sore throat 4 $0 [*] nightime sleep 4 $0 [*] nighttime cold-flu 4 $0 [*] NIGHTTIME COLD-FLU RELIEF 4 $0 [*] nighttime cough 4 $0 [*] nighttime cough-cold 4 $0 [*] nighttime sinus 4 $0 [*] nighttime sleep aid (diphen) 4 $0 [*] NITE TIME COLD-FLU 4 $0 [*] nite time cold-flu formula 4 $0 [*] NITE TIME COLD-FLU RELIEF 4 $0 [*] NITE TIME COUGH 4 $0 [*] NITE TIME-D COLD-FLU RELIEF 4 $0 [*] NITE-TIME COLD-FLU 4 $0 [*] ENYDMEM

111 nitetime multi-symptom 4 $0 [*] nohist-dm 4 $0 MO; [*] nohist-lq 4 $0 [*] non-pseudo sinus pain-pressure 4 $0 [*] nyquil d 4 $0 [*] organ-i nr 4 $0 MO; [*] ormir 4 $0 [*] pedia relief cough-cold 4 $0 [*] pediacare multi-symptom cold 4 $0 [*] pediatric cough & cold oral liquid mg/5 ml 4 $0 [*] pharbechlor 4 $0 [*] pharbedryl 4 $0 [*] POLY HIST FORTE (DOXYLAMINE) 4 $0 MO; [*] promethazine injection solution 2 $0 PAR; MO promethazine vc-codeine 3 $0 MO; [*] promethazine-codeine 3 $0 MO; [*] promethazine-dm 3 $0 MO; [*] promethazine-phenyleph-codeine 3 $0 [*] promethegan rectal suppository 12.5 mg 2 $0 PAR; MO pseudoephedrine hcl oral liquid 4 $0 MO; [*] pseudoephedrine hcl oral tablet 30 mg 4 $0 MO; [*] pseudoephedrine hcl oral tablet 60 mg 4 $0 [*] pseudoephedrine hcl oral tablet extended release 4 $0 MO; [*] pyrilamine-phenylephrine 4 $0 [*] q-dryl oral capsule 4 $0 [*] q-dryl oral liquid 4 $0 MO; [*] q-tapp 4 $0 MO; [*] q-tussin 4 $0 [*] q-tussin dm 4 $0 [*] quenalin 4 $0 [*] ENYDMEM

112 refenesen 4 $0 [*] refenesen dm 4 $0 [*] refenesen pe 4 $0 [*] ri-tussin 4 $0 [*] ri-tussin dm 4 $0 [*] robafen 4 $0 MO; [*] robafen dm 4 $0 MO; [*] robafen dm cough 4 $0 [*] RU-HIST D 4 $0 MO; [*] rydex 4 $0 [*] rynex dm 4 $0 [*] rynex pe 4 $0 [*] rynex pse 4 $0 [*] SEVERE ALLERGY-SINUS HEADACHE 4 $0 [*] SEVERE COLD (DIPHEN-PE-ACETAM) 4 $0 [*] SEVERE COLD MULTI-SYMPTOM 4 $0 [*] SEVERE COLD PE 4 $0 [*] siladryl sa 4 $0 [*] silphen cough 4 $0 [*] siltussin dm das 4 $0 [*] siltussin sa 4 $0 MO; [*] siltussin-dm 4 $0 [*] sinus & allergy non-drowsy 4 $0 [*] SINUS & ALLERGY PE 4 $0 [*] SINUS & ALLERGY(PHENYLEPHRINE) 4 $0 [*] sinus cong & pain day-night 4 $0 [*] SINUS CONGESTION&PAIN(CHLORPH) 4 $0 [*] sinus decongestant (pe) 4 $0 [*] SINUS HEADACHE PE 4 $0 [*] SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG 4 $0 [*] ENYDMEM

113 sleep aid (diphenhydramine) oral tablet 4 $0 [*] SLEEP AID MAX STR (DIPHENHYDR) 4 $0 [*] sleep tablet (diphenhydramine) 4 $0 [*] SUDAFED 24 HOUR 4 $0 MO; [*] sudogest 4 $0 MO; [*] sudogest 12-hour 4 $0 MO; [*] sudogest cold & allergy 4 $0 [*] sudogest pe 4 $0 MO; [*] sudogest sinus & allergy 4 $0 [*] suphedrin 4 $0 [*] suphedrin 12 hour 4 $0 [*] SUPHEDRINE 4 $0 [*] SUPHEDRINE 12 HOUR 4 $0 [*] SUPHEDRINE PE 4 $0 [*] suphedrine pe cold & allergy 4 $0 [*] suphedrine pe sinus & allergy 4 $0 [*] suphedrine pe sinus headache 4 $0 [*] tl-hist dm 4 $0 [*] tusnel diabetic 4 $0 [*] tussi pres-b oral liquid mg/5 ml 4 $0 [*] tussigon 3 $0 MO; [*] TUSSIN 4 $0 [*] tussin chest congestion 4 $0 [*] tussin cough &chest congestion 4 $0 [*] tussin cough dm 4 $0 [*] TUSSIN DM CLEAR 4 $0 [*] tussin dm cough 4 $0 [*] tussin dm cough & chest oral liquid mg/5 ml 4 $0 [*] tussin dm cough & chest oral syrup 4 $0 [*] ENYDMEM

114 TUSSIN DM MAX ORAL LIQUID MG/5 ML 4 $0 [*] tussin dm oral liquid 4 $0 [*] tussin dm oral syrup mg/5 ml 4 $0 [*] tussin dm oral tablet 4 $0 [*] tussin expectorant 4 $0 [*] tussin honey 4 $0 [*] tussin maximum strength 4 $0 [*] tussin maximum strength cough 4 $0 [*] vaporizing steam 4 $0 [*] VAZOTAB (PYRILAMINE) 4 $0 [*] PULMONARY AGENTS acetylcysteine 2 $0 B/D PAR; MO ADVAIR DISKUS 2 $0 MO; QLL (60 per 30 days) ADVAIR HFA 2 $0 MO; QLL (12 per 30 days) AEROSPAN 2 $0 MO; QLL (18 per 30 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 1 $0 MO albuterol sulfate oral tablet 2 $0 MO albuterol sulfate oral tablet extended release 12 hr 2 $0 MO 1 $0 B/D PAR; MO; QLL (360 per 30 days) 1 $0 B/D PAR; MO; QLL (60 per 30 days) ANORO ELLIPTA 2 $0 MO; QLL (60 per 30 days) ARNUITY ELLIPTA 2 $0 MO; QLL (30 per 30 days) ASMANEX HFA 2 $0 MO; QLL (13 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) 2 $0 MO; QLL (0.14 per 30 days) 2 $0 ENYDMEM

115 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) 2 $0 MO; QLL (0.24 per 30 days) ATROVENT HFA 2 $0 MO; QLL (26 per 30 days) BREO ELLIPTA 2 $0 MO; QLL (60 per 30 days) COMBIVENT RESPIMAT 2 $0 MO; QLL (8 per 30 days) cromolyn inhalation 2 $0 B/D PAR; MO; QLL (240 per 30 days) cromolyn nasal 4 $0 MO; [*] DALIRESP 2 $0 PAR; MO; QLL (30 per 30 days) DULERA 2 $0 MO; QLL (13 per 30 days) FIRAZYR 2 $0 PAR; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (12 per 30 days) 2 $0 MO; QLL (24 per 30 days) 2 $0 MO; QLL (11 per 30 days) 2 $0 MO; QLL (75 per 30 days) fluticasone nasal 2 $0 MO; QLL (16 per 30 days) FORADIL AEROLIZER 2 $0 MO; QLL (60 per 30 days) ipratropium bromide inhalation 2 $0 B/D PAR; MO ipratropium-albuterol 2 $0 B/D PAR; MO; QLL (540 per 30 days) KALYDECO ORAL TABLET 2 $0 PAR; MO; QLL (60 per 30 days) LETAIRIS 2 $0 PAR; MO; LA; QLL (30 per 30 days) ENYDMEM

116 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol oral 2 $0 MO 2 $0 B/D PAR; MO; QLL (270 per 30 days) 2 $0 B/D PAR; MO; QLL (540 per 30 days) montelukast 2 $0 MO; QLL (30 per 30 days) NASONEX 2 $0 MO; QLL (17 per 30 days) PERFOROMIST 2 $0 B/D PAR; MO; QLL (120 per 30 days) PROAIR HFA 2 $0 MO; QLL (18 per 30 days) PROAIR RESPICLICK 2 $0 MO; QLL (2 per 30 days) PULMOZYME 2 $0 B/D PAR; MO QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION 2 $0 MO; QLL (9 per 30 days) 2 $0 MO; QLL (18 per 30 days) SEREVENT DISKUS 2 $0 MO; QLL (60 per 30 days) sildenafil oral 2 $0 PAR; MO; QLL (90 per 30 days) SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION 2 $0 MO; QLL (4 per 30 days) SPIRIVA WITH HANDIHALER 2 $0 MO; QLL (30 per 30 days) STIOLTO RESPIMAT 2 $0 MO; QLL (4 per 30 days) terbutaline oral 2 $0 MO terbutaline subcutaneous 2 $0 MO theophylline oral tablet extended release 2 $0 MO theophylline oral tablet extended release 12 hr 2 $0 MO TRACLEER 2 $0 PAR; MO; LA; QLL (60 per 30 days) VENTAVIS 2 $0 PAR; MO XOLAIR 2 $0 PAR; MO; LA; QLL (6 per 28 days) zafirlukast 2 $0 MO; QLL (60 per 30 days) UROLOGICALS ENYDMEM

117 ANTICHOLINERGICS / ANTISPASMODICS MYRBETRIQ 2 $0 MO; QLL (30 per 30 days) oxybutynin chloride oral syrup 2 $0 MO; QLL (600 per 30 days) oxybutynin chloride oral tablet 2 $0 MO; QLL (120 per 30 days) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) tolterodine oral capsule,extended release 24hr 2 $0 MO; QLL (30 per 30 days) tolterodine oral tablet 2 $0 MO; QLL (60 per 30 days) TOVIAZ 2 $0 MO; QLL (30 per 30 days) trospium oral tablet 2 $0 MO; QLL (60 per 30 days) VESICARE 2 $0 MO; QLL (30 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin 2 $0 MO finasteride oral tablet 5 mg 2 $0 MO tamsulosin 2 $0 MO CHOLINERGIC STIMULANTS bethanechol chloride 2 $0 MO MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG 2 $0 PAR; MO; QLL (30 per 30 days) CYSTAGON 2 $0 MO; LA potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS 2 $0 MO azo 4 $0 [*] AZO URINARY PAIN RELIEF ORAL TABLET 95 MG 4 $0 [*] azo-dine oral tablet 95 mg 4 $0 [*] azo-tabs 4 $0 [*] urinary pain relief oral tablet 95 mg 4 $0 [*] ENYDMEM

118 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES alcalak 4 $0 [*] ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG) 4 $0 [*] calcium d (d3) 4 $0 [*] calcium d oral tablet 500 mg(1,250mg) -200 unit calcium d oral tablet 500 mg(1,250mg) -400 unit 4 $0 MO; [*] 4 $0 [*] CALCIUM 500 ORAL TABLET 4 $0 [*] calcium 500 with d 4 $0 MO; [*] calcium $0 [*] calcium d(3) oral tablet 600 mg(1,500mg) unit, 600 mg(1,500mg) -400 unit CALCIUM D(3) ORAL TABLET MG-UNIT 4 $0 MO; [*] 4 $0 [*] calcium 600 with vitamin d3 oral tablet 4 $0 [*] calcium acetate oral capsule 1 $0 MO calcium antacid oral tablet,chewable 200 mg calcium (500 mg) calcium antacid oral tablet,chewable 300 mg (750 mg), 320 mg (750 mg) CALCIUM ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) 4 $0 MO; [*] 4 $0 [*] 4 $0 [*] calcium antacid tropical 4 $0 [*] calcium antacid ultra max st 4 $0 [*] calcium carbonate oral suspension 4 $0 MO; [*] calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg) 4 $0 MO; [*] 4 $0 [*] ENYDMEM

119 calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit 4 $0 [*] 4 $0 MO; [*] calcium citrate + 4 $0 [*] calcium citrate + d 4 $0 [*] calcium citrate + d with mag 4 $0 [*] calcium citrate-vitamin d2 4 $0 [*] calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mgunit CALCIUM CITRATE-VITAMIN D3 ORAL TABLET MG-UNIT 4 $0 [*] 4 $0 MO; [*] 4 $0 MO; [*] calcium+d oral tablet 500 mg(1,250mg) -200 unit 4 $0 [*] CITRACAL REGULAR 4 $0 MO; [*] citrus calcium oral tablet 200 mg calcium -250 unit 4 $0 [*] citrus calcium oral tablet mg-unit 4 $0 MO; [*] copper chloride 3 $0 MO; [*] dextrose-kcl-nacl 2 $0 B/D PAR hi-cal plus vit d 4 $0 [*] high potency calcium 4 $0 [*] klor-con 10 2 $0 MO klor-con 8 2 $0 MO klor-con m10 2 $0 MO klor-con m15 2 $0 MO klor-con m20 2 $0 MO K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ 2 $0 lactated ringers intravenous 2 $0 B/D PAR; MO ENYDMEM

120 mag 64 4 $0 MO; [*] mag-delay 4 $0 MO; [*] mag-g 4 $0 MO; [*] magnesium gluconate oral tablet 27 mg (500 mg) 4 $0 MO; [*] magnesium gluconate oral tablet 27.5 mg (500 mg) 4 $0 [*] magnesium oxide oral tablet 400 mg, 420 mg 4 $0 MO; [*] magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) 2 $0 2 $0 2 $0 MO magnesium sulfate injection solution 2 $0 MO magnesium sulfate injection syringe 2 $0 manganese chloride 3 $0 [*] NORMOSOL-R 2 $0 B/D PAR NORMOSOL-R IN 5 % DEXTROSE 2 $0 B/D PAR oral electrolytes 4 $0 [*] oralyte 4 $0 [*] oysco 500/d oral tablet 4 $0 MO; [*] oysco d 4 $0 MO; [*] oysco $0 MO; [*] oyst-cal $0 MO; [*] oyster shell + d3 4 $0 [*] oyster shell calcium 4 $0 MO; [*] oyster shell calcium $0 MO; [*] oyster shell calcium-vit d3 4 $0 MO; [*] oystercal-d 4 $0 [*] pedialyte freezer pops 4 $0 [*] PEDIALYTE ORAL POWDER IN PACKET MEQ/8.5 GRAM 4 $0 MO; [*] ENYDMEM

121 pedialyte oral solution 4 $0 MO; [*] pedialyte singles 4 $0 [*] pediatric electrolyte 4 $0 [*] pediatric freezer pops 4 $0 [*] potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO potassium chloride intravenous solution 2 $0 B/D PAR; MO potassium chloride oral capsule, extended release 2 $0 MO potassium chloride oral tablet extended release 2 $0 MO potassium chloride oral tablet,er particles/crystals 2 $0 MO potassium chloride-0.45 % nacl 2 $0 B/D PAR potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO ENYDMEM

122 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l 2 $0 B/D PAR ringers intravenous 2 $0 B/D PAR sodium chloride 0.45 % intravenous parenteral solution 2 $0 MO sodium chloride 0.45 % intravenous piggyback 2 $0 sodium chloride 3 % 2 $0 MO sodium chloride 5 % 2 $0 sodium chloride intravenous 2 $0 B/D PAR; MO TPN ELECTROLYTES 2 $0 B/D PAR ULTRA STRENGTH ANTACID 4 $0 [*] ultra strength calcium antacid 4 $0 [*] zinc chloride intraveneous solution 3 $0 MO; [*] MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % 2 $0 B/D PAR AMINOSYN 8.5 %-ELECTROLYTES 2 $0 B/D PAR AMINOSYN II 10 % 2 $0 B/D PAR AMINOSYN II 7 % 2 $0 B/D PAR AMINOSYN II 8.5 % 2 $0 B/D PAR AMINOSYN II 8.5 %-ELECTROLYTES 2 $0 B/D PAR AMINOSYN M 3.5 % 2 $0 B/D PAR AMINOSYN-HBC 7% 2 $0 B/D PAR AMINOSYN-PF 10 % 2 $0 B/D PAR AMINOSYN-PF 7 % (SULFITE-FREE) 2 $0 B/D PAR CLINIMIX 5%/D15W SULFITE FREE 2 $0 B/D PAR CLINIMIX 5%/D25W SULFITE-FREE 2 $0 B/D PAR CLINIMIX 2.75%/D5W SULFIT FREE 2 $0 B/D PAR CLINIMIX 4.25%/D10W SULF FREE 2 $0 B/D PAR CLINIMIX 4.25%-D20W SULF-FREE 2 $0 B/D PAR CLINIMIX 4.25%-D25W SULF-FREE 2 $0 B/D PAR CLINIMIX 5%-D20W(SULFITE-FREE) 2 $0 B/D PAR ENYDMEM

123 CLINIMIX E 4.25%/D10W SUL FREE 2 $0 CLINIMIX E 4.25%/D25W SUL FREE 2 $0 B/D PAR CLINIMIX E 4.25%/D5W SULF FREE 2 $0 B/D PAR CLINIMIX E 5%/D15W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 5%/D20W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 5%/D25W SULFIT FREE 2 $0 B/D PAR CLINISOL SF 15 % 2 $0 B/D PAR; MO freamine iii 10 % 2 $0 B/D PAR HEPATAMINE 8% 2 $0 B/D PAR intralipid intravenous emulsion 20 % 2 $0 B/D PAR; MO ISOLYTE-P IN 5 % DEXTROSE 2 $0 B/D PAR NORMOSOL-M IN 5 % DEXTROSE 2 $0 B/D PAR NORMOSOL-R PH $0 B/D PAR PLASMA-LYTE $0 B/D PAR PLASMA-LYTE-56 IN 5 % DEXTROSE 2 $0 B/D PAR travasol 10 % 2 $0 B/D PAR; MO TROPHAMINE 10 % 2 $0 B/D PAR; MO TROPHAMINE 6% 2 $0 B/D PAR VITAMINS / HEMATINICS a thru z 4 $0 [*] a thru z advanced formula 4 $0 [*] a thru z high potency oral tablet 4 $0 [*] adults' daily formula 4 $0 [*] animal chews 4 $0 [*] animal shape vitamins 4 $0 [*] ANIMAL SHAPES COMPLETE ORAL TABLET,CHEWABLE 4 $0 [*] AQUASOL A 3 $0 MO; [*] ascorbic acid oral tablet 4 $0 [*] ascorbic acid oral tablet extended release 1,000 mg 4 $0 MO; [*] ENYDMEM

124 ascorbic acid oral tablet extended release 1,500 mg, 500 mg 4 $0 [*] ascorbic acid oral tablet,chewable 4 $0 [*] ascorbic acid with rose hips 4 $0 [*] b-12 dots 4 $0 MO; [*] bee-zee 4 $0 [*] biotin oral tablet 300 mcg 4 $0 MO; [*] c 500 timed released 4 $0 [*] c complex 4 $0 [*] c-1000 oral tablet 4 $0 [*] c-1000 oral tablet extended release 4 $0 MO; [*] c-1000 with rose hips 4 $0 [*] c $0 [*] c $0 [*] ca-d3-mag ox-zinc-cop-mang-bor oral tablet 4 $0 [*] calcidol 4 $0 [*] calciferol 4 $0 MO; [*] CALCIUM MAGNESIUM + D ORAL TABLET MG-MG-UNIT 4 $0 [*] calvite p&d 4 $0 [*] central vite with lutein 4 $0 [*] central-vite oral tablet mg-mcg 4 $0 [*] century 4 $0 [*] century adults $0 [*] century ultimate women's oral tablet mgmcg 4 $0 [*] cerovite advanced formula 4 $0 MO; [*] certavite-antioxid (iron gluc) oral liquid 9 mg iron/15 ml 4 $0 MO; [*] certavite-antioxidant 4 $0 MO; [*] chewable multi vitamin 4 $0 [*] chewable vitamin c 4 $0 [*] ENYDMEM

125 chewable-vite 4 $0 MO; [*] children's chewable vitamin 4 $0 [*] children's multivit w/extra c 4 $0 [*] childs chew vite 4 $0 [*] child's vitamin with vitamin c 4 $0 [*] cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit 4 $0 MO; [*] 4 $0 [*] cholecalciferol (vitamin d3) oral drops 400 unit/ml 4 $0 MO; [*] cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit 4 $0 MO; [*] cholecalciferol (vitamin d3) oral tablet 400 unit 4 $0 [*] classic prenatal 4 $0 MO; [*] cyanocobalamin (vitamin b-12) injection 3 $0 MO; [*] cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release 2,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg 4 $0 [*] 4 $0 [*] 4 $0 MO; [*] d $0 MO; [*] daily multiple for men 4 $0 [*] daily multiple for men $0 [*] daily multiple for women $0 [*] daily multiple oral tablet, mg-mcg 4 $0 [*] daily multiple vitamins/iron 4 $0 [*] daily multi-vitamin 4 $0 [*] daily multivitamin with iron 4 $0 [*] daily multivitamin-minerals 4 $0 [*] daily multi-vitamins/iron 4 $0 [*] DAILY PRENATAL 4 $0 [*] ENYDMEM

126 daily vitamin formula 4 $0 [*] daily vitamin formula-minerals 4 $0 [*] daily vitamin with iron 4 $0 [*] daily vites/iron 4 $0 MO; [*] daily-vite 4 $0 MO; [*] delta d3 4 $0 MO; [*] dialyvite $0 MO; [*] dialyvite oral tablet mg-mg-mcg-mg 3 $0 MO; [*] dialyvite vitamin d 4 $0 MO; [*] dino-life 4 $0 [*] dino-life with extra c 4 $0 [*] dino-life with iron-zinc 4 $0 [*] d-vi-sol 4 $0 MO; [*] d-vita 4 $0 [*] ergocalciferol (vitamin d2) oral capsule 3 $0 MO; [*] ergocalciferol (vitamin d2) oral drops 4 $0 MO; [*] ergocalciferol (vitamin d2) oral tablet 400 unit 4 $0 MO; [*] essentia 4 $0 [*] feosol oral tablet 325 mg (65 mg iron) 4 $0 MO; [*] FERAHEME 3 $0 MO; [*] ferocon 3 $0 MO; [*] ferosul oral tablet 4 $0 MO; [*] ferrex $0 MO; [*] ferrocite plus 3 $0 MO; [*] ferro-time 4 $0 MO; [*] ferrous gluconate oral tablet 236 mg (27 mg iron), 256 mg (28 mg iron) 4 $0 [*] ferrous sulfate oral tablet 325 mg (65 mg iron) 4 $0 MO; [*] ferrousul 4 $0 [*] fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) 2 $0 MO ENYDMEM

127 folbee plus oral tablet mg 3 $0 MO; [*] folic acid injection 3 $0 MO; [*] folic acid oral tablet 1 mg 3 $0 MO; [*] folic acid oral tablet 400 mcg, 800 mcg 4 $0 MO; [*] full spectrum b-vitamin c 4 $0 [*] gummi bear multivitamin 4 $0 [*] gummy swirls 4 $0 [*] hematinic plus vit/minerals 3 $0 MO; [*] hydroxocobalamin 3 $0 MO; [*] icaps plus 4 $0 [*] iferex $0 MO; [*] infed 3 $0 MO; [*] iron (dried) 4 $0 [*] iron (ferrous sulfate) 4 $0 [*] iron high potency 4 $0 [*] IRON ORAL TABLET 325 MG (65 MG IRON) 4 $0 [*] iron oral tablet extended release 159 mg (45 mg iron) 4 $0 [*] kid's vitamins + extra c 4 $0 [*] kid's vitamins oral tablet,chewable 4 $0 [*] little animals 4 $0 [*] m.v.i. adult 3 $0 [*] M.V.I. PEDIATRIC 3 $0 [*] M.V.I.-12 (WITHOUT VITAMIN K) 3 $0 [*] men's daily multivit-mineral 4 $0 [*] men's multi-vitamin 4 $0 [*] men's one daily oral tablet 4 $0 [*] multi complete with iron 4 $0 [*] multi-day with iron 4 $0 [*] multi-delyn 4 $0 MO; [*] multiple vitamin essential 4 $0 [*] ENYDMEM

128 multiple vitamin-minerals 4 $0 [*] multiple vitamins 4 $0 [*] multivitamin 4 $0 MO; [*] multivitamin with iron 4 $0 [*] multivitamin with minerals oral tablet 4 $0 MO; [*] multi-vitamins with iron 4 $0 [*] myferon $0 MO; [*] mynephrocaps 3 $0 [*] nephro-vite rx 3 $0 MO; [*] omnicap 4 $0 [*] once daily 4 $0 [*] one daily 50 plus 4 $0 [*] one daily complete 4 $0 [*] one daily energy oral tablet 4 $0 [*] one daily essential oral tablet, 0.4 mg 4 $0 [*] one daily for men 4 $0 [*] one daily for women 4 $0 [*] one daily maximum 4 $0 [*] one daily maximum (with ca) 4 $0 [*] one daily men's 50+ oral tablet mcgmcg-mg 4 $0 [*] one daily multi-vit w-mineral 4 $0 [*] one daily multivitamin oral tablet 4 $0 [*] one daily oral tablet, mg-mcg 4 $0 [*] ONE DAILY ORAL TABLET MG-MG-MCG-MG 4 $0 [*] one daily plus iron 4 $0 [*] one daily plus minerals 4 $0 [*] one daily prenatal oral combo pack mg-mcg-mg 4 $0 [*] one daily with iron 4 $0 [*] ENYDMEM

129 one daily womens 50 plus 4 $0 [*] ONE DAILY WOMEN'S METABOLISM 4 $0 [*] one-a-day essential 4 $0 MO; [*] one-a-day maximum formula 4 $0 [*] one-a-day teen advantage 4 $0 [*] oyster shell calcium with d 4 $0 [*] pnv cmb#95-ferrous fumarate-fa 4 $0 [*] poly-iron 4 $0 MO; [*] poly-vita 4 $0 [*] poly-vitamin 4 $0 [*] poly-vitamins 4 $0 [*] prenatal 4 $0 [*] prenatal + dha oral combo pack 28 mg iron- 975 mcg-200 mg 4 $0 [*] prenatal complete 4 $0 [*] prenatal formula oral tablet, mg 4 $0 [*] prenatal multivitamins 4 $0 [*] prenatal vit#96-ferrous fum-fa 4 $0 MO; [*] PRENATAL VITAMIN ORAL TABLET 2 $0 MO PRENATAL VITAMIN ORAL TABLET MG 4 $0 [*] prenatal vitamin with minerals 4 $0 [*] prenatal vit-iron fumarate-fa 4 $0 [*] pyridoxine injection 3 $0 MO; [*] pyridoxine oral tablet 100 mg 4 $0 [*] quintabs-m iron free 4 $0 [*] renal caps 3 $0 MO; [*] rena-vite 4 $0 MO; [*] rena-vite rx 3 $0 MO; [*] reno caps 3 $0 MO; [*] risacal-d 4 $0 MO; [*] ENYDMEM

130 slow release iron oral tablet extended release 142 mg (45 mg iron), 47.5 mg iron 4 $0 [*] sodium fluoride oral tablet 2 $0 MO sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) spectravite advanced formula oral tablet mg-mcg 2 $0 MO 4 $0 [*] spectravite ultra women 4 $0 [*] stress formula advanced 4 $0 [*] tab-a-vite 4 $0 MO; [*] tab-a-vite/iron 4 $0 MO; [*] tab-a-vite-minerals 4 $0 [*] thera-d 4 $0 [*] theralogix companion 4 $0 [*] thiamine hcl injection 3 $0 MO; [*] thiamine hcl oral tablet 100 mg, 250 mg, 50 mg 4 $0 [*] thiamine mononitrate 4 $0 [*] tl icon 3 $0 MO; [*] tricon 3 $0 MO; [*] triphrocaps 3 $0 MO; [*] TRI-VI-SOL 4 $0 MO; [*] tri-vita 4 $0 [*] tri-vitamin 4 $0 MO; [*] VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML VENOFER INTRAVENOUS SOLUTION 50 MG IRON/2.5 ML 3 $0 MO; [*] 3 $0 [*] vitalee 4 $0 [*] vitamin a oral capsule 10,000 unit 4 $0 MO; [*] vitamin a oral capsule 25,000 unit, 8,000 unit 4 $0 [*] VITAMIN A PALMITATE ORAL CAPSULE 4 $0 [*] vitamin b-1 4 $0 MO; [*] ENYDMEM

131 VITAMIN B-1 (MONONITRATE) 4 $0 [*] vitamin b-12 oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg vitamin b-12 oral tablet extended release 2,000 mcg 4 $0 MO; [*] 4 $0 [*] vitamin b-12 sublingual tablet 1,000 mcg 4 $0 [*] vitamin b-6 oral tablet 100 mg 4 $0 MO; [*] vitamin c cough drops 4 $0 [*] VITAMIN C DROPS 4 $0 [*] vitamin c oral capsule, extended release 4 $0 MO; [*] VITAMIN C ORAL LOZENGE 4 $0 [*] vitamin c oral syrup 4 $0 MO; [*] vitamin c oral tablet 1,000 mg, 250 mg, 500 mg 4 $0 MO; [*] vitamin c oral tablet 100 mg 4 $0 [*] vitamin c oral tablet extended release 1,000 mg 4 $0 [*] VITAMIN C ORAL TABLET EXTENDED RELEASE 500 MG 4 $0 MO; [*] vitamin c oral tablet,chewable 250 mg, 500 mg 4 $0 MO; [*] VITAMIN C WITH ROSE HIPS ORAL TABLET 4 $0 MO; [*] vitamin c with rose hips oral tablet extended release 4 $0 [*] vitamin d2 3 $0 MO; [*] vitamin d3 oral capsule 1,000 unit, 2,000 unit, 400 unit 4 $0 MO; [*] vitamin d3 oral tablet 1,000 unit, 400 unit 4 $0 MO; [*] vitamin d3 oral tablet 2,000 unit 4 $0 [*] VITAMIN D3 ORAL TABLET 5,000 UNIT 4 $0 [*] vitamin e (dl, acetate) oral capsule 400 unit 4 $0 MO; [*] vitamin e mixed oral capsule 400 unit 4 $0 [*] vol-care rx 3 $0 MO; [*] yelets 4 $0 [*] zoo chews 4 $0 [*] ENYDMEM

132 Index A A & D ZINC OXIDE CREAM A + D (LAN, PET) a thru z a thru z advanced formula a thru z high potency abacavir... 9 abacavir-lamivudine-zidovudine... 9 ABELCET... 9 ABILIFY ABILIFY MAINTENA ABRAXANE ABREVA ABSTRAL acarbose acebutolol acephen acetadryl aceta-gesic acetaminophen... 35, 36 ACETAMINOPHEN EXTRA STRENGTH acetaminophen pain relief acetaminophen pm acetaminophen pm extra str.. 35 acetaminophen-codeine acetazolamide oral acetazolamide sodium acetic acid acetic acid-aluminum acetate 71 acetylcysteine... 67, 113 acid control (ranitidine) ACID REDUCER (CIMETIDINE) acid reducer (famotidine) ACID REDUCER (RANITIDINE) acid reducer complete (famot)88 acid relief (cimetidine) acitretin acne treatment (benzoyl perox) acta-tabs pe ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIMMUNE ACTIQ acyclovir... 9, 10, 64 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 90 ADAGEN adapalene ADASUVE ADDED STRENGTH PAIN RELIEVER adefovir adult cough formula dm max 101 adult low dose aspirin adult tussin chest congestion 101 ADULT TUSSIN COUGH CONGEST DM ADULT TUSSIN DM adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVANCED ANTACID- ANTIGAS AEROSPAN af 62 afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX ak-poly-bac ala-cort ala-hist ir alaway ALBENZA albuterol sulfate alcalak alclometasone alcohol pads ALCOHOL, RUBBING ALDURAZYME alendronate... 67, 92 alfuzosin ALIMTA ALINIA all day allergy (cetirizine) ALL DAY ALLERGY (CETIRIZINE) all day allergy relief(cetir) all day allergy-d allergy (chlorpheniramine). 101 allergy (diphenhydramine) ALLERGY COMPLETE-D 101 allergy cream (diphenhyd, zn) 58 allergy eye (ketotifen) ALLERGY EYE (NAPHAZOLINE-PHEN) allergy multi-symptom allergy plus severe sinus ha. 101 allergy relief (cetirizine) ALLERGY RELIEF (CLEMASTINE) allergy relief (fexofenadine) 102 allergy relief (loratadine) ALLERGY RELIEF (LORATADINE) allergy relief multi-symptom 102 allergy relief(chlorpheniramn) allergy relief(diphenhydramin) allergy relief-d (cetirizine) ALLERGY RELIEF-D (LORATADINE) ALLERGY RELIEF-SINUS HEADACHE ALLERGY SINUS HEADACHE (PE) ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 ) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 H8417_15_20348_T CMS Approved 12/24/2014 ENYDMKT

133 allergy sinus pe aller-tec aller-tec d allfen allfen dm ALL-NITE COLD-FLU allopurinol almacone almacone aloe vesta alophen alosetron ALPHAGAN P alprazolam altachlore altavera (28) altazine aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl ambi 10peh-4cpm ambi 60pse-4cpm AMBISOME... 9 amcinonide amifostine crystalline amikacin amiloride amiloride-hydrochlorothiazide AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b...9 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA anagrelide anastrozole ANDRODERM ANDROGEL androxy anefrin animal chews animal shape vitamins ANIMAL SHAPES COMPLETE ANORO ELLIPTA ANTACID ANTI-GAS antacid anti-gas double str ANTACID CALCIUM antacid liquid antacid plus anti-gas ANTACID WITH SIMETHICONE ANTACID-ANTIGAS antacid-simethicone antacid-simethicone ds ANTIBIOTIC (BACITRACIN ZINC) antibiotic (neomy-bacit-polym) ANTIBIOTIC + PAIN RELIEF ANTIBIOTIC PLUS (PRAMOXINE) anti-diarrheal (loperamide) ANTI-DIARRHEAL (LOPERAMIDE) ANTIFUNGAL (CLOTRIMAZOLE) antifungal (tolnaftate) ANTIFUNGAL (TOLNAFTATE) antifungal spray anti-gas ultra strength anti-itch (benz-resor) anti-itch (diphenhydramine).. 58 anti-itch (hc) anti-itch(diphenhyd) with zinc 58 ANTI-ITCH(DIPHENHYD) WITH ZINC anti-nausea antiseptic solution antitussive dm ap-hist dm APOKYN apraclonidine apri APRISO aprodine APTIOM APTIVUS AQUASOL A ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) arbinoxa ARCALYST aripiprazole... 40, 41 ARNUITY ELLIPTA ARRANON arthritis pain relief (acetam).. 36 artificial tears artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc) artificial tears(glycerin-peg).. 99? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

134 artificial tears(hypromellose) 99 ARZERRA ASACOL HD ascorbic acid , 123 ascorbic acid with rose hips 123 ASMANEX HFA ASMANEX TWISTHALER , 114 aspir aspirin aspirin childrens aspirin low dose aspirin low-strength aspirin, buffered aspirin-dipyridamole aspir-low aspir-trin ASTAGRAF XL atenolol atenolol-chlorthalidone ATGAM athenol athlete's foot (terbinafine) athlete's foot (tolnaftate) atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine ATROVENT HFA AVASTIN aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine AZACTAM IN DEXTROSE (ISO-OSM) azathioprine azelastine... 70, 99 AZILECT azithromycin azo AZO URINARY PAIN RELIEF azo-dine AZOPT AZOR azo-tabs aztreonam azurette (28) B b-12 dots baby ayr saline baciim bacitracin... 61, 97 bacitracin zinc bacitracin-polymyxin b... 61, 97 bacitraycin plus baclofen balsalazide banophen , 103 banophen allergy banophen anti-itch BANZEL BARACLUDE bayer plus extra strength baza antifungal BCG VACCINE, LIVE (PF). 90 bee-zee BELEODAQ benazepril benazepril-hydrochlorothiazide benzonatate benzoyl peroxide benztropine betamethasone dipropionate.. 64 betamethasone valerate betamethasone, augmented betatemp betaxolol... 51, 98 bethanechol chloride bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BICNU BILTRICIDE bimatoprost biocotron BIOSPEC DMX biotin bisac-evac bisacodyl bisa-lax biscolax bismatrol bismuth bismuth maximum strength bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLEPHAMIDE S.O.P BLINCYTO BONIVA BOOSTRIX TDAP BOSULIF BREO ELLIPTA BRILINTA brimonidine BRINTELLIX brohist d bromocriptine brompheniramine-pseudoephdm brotapp budesonide bumetanide BUPHENYL buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl buspirone BUSULFEX butalbital compound w/codeine butorphanol tartrate BYDUREON BYETTA... 72? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

135 BYSTOLIC C c 500 timed released c complex c c-1000 with rose hips c c cabergoline ca-d3-mag ox-zinc-cop-mangbor calagesic calcidol calciferol calcipotriene calcitonin (salmon) calcitriol CALCIUM calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) CALCIUM D(3) calcium 600 with vitamin d3 117 calcium acetate calcium antacid CALCIUM ANTACID calcium antacid tropical calcium antacid ultra max st 117 calcium carbonate calcium carbonate-vitamin d calcium citrate calcium citrate + d calcium citrate + d with mag calcium citrate-vitamin d calcium citrate-vitamin d CALCIUM CITRATE- VITAMIN D CALCIUM MAGNESIUM + D calcium+d CALDYPHEN calohist calvite p&d camila CANASA CANCIDAS...9 candesartan candesartan-hydrochlorothiazid CAPASTAT CAPEX CAPRELSA captopril captopril-hydrochlorothiazide 51 carbamazepine carbidopa-levodopa carb-o-philic carboplatin CARIMUNE NF NANOFILTERED carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor cefadroxil... 12, 13 cefazolin cefazolin in dextrose (iso-os). 13 cefdinir cefepime cefoxitin cefoxitin in dextrose, iso-osm. 13 cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os. 13 cefuroxime axetil cefuroxime sodium CELLCEPT CELLCEPT INTRAVENOUS CELONTIN central vite with lutein central-vite century century adults century ultimate women's cephalexin CEREZYME cerovite advanced formula certavite-antioxid (iron gluc) certavite-antioxidant CERVARIX VACCINE (PF) 90 cetiri-d cetirizine CETIRIZINE cetirizine-pseudoephedrine. 103 cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX CHEST CONGESTION RELIEF CHEST CONGESTION RELIEF + DM CHEST CONGESTION RELIEF PE chest congestion-cough relief chest-sinus congestion relief 103 chewable multi vitamin chewable vitamin c chewable-vite child allergy relf(cetirizine). 103 CHILD ALLERGY RELF(CETIRIZINE) child aspirin child chest congestion + cough child ibuprofen child mucinex chest congestion child mucus relief cough child mucus relief expectorant child suppository... 79? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

136 children night time cold-cough children's acetaminophen CHILDREN'S ACETAMINOPHEN CHILDREN'S ALAWAY children's allergy (diphenhyd) children's allergy relief(lor) 103 children's allergy(cetirizine) 103 children's aller-tec children's aspirin children's cetirizine children's chest congestion. 104 children's chewable vitamin 124 children's cold & cough dm 104 children's cold-allergy (pe). 104 children's dibromm cold & alle children's dibromm dm cold & c children's ibuprofen children's mapap children's medi-profen children's medi-tabs children's mucinex cough children's multivit w/extra c 124 children's non-aspirin children's non-aspirin pain children's pain & fever relief. 37 children's pepto children's profen ib children's q-pap children's silapap children's silfedrine child's all day allergy(cetir) 104 childs chew vite childs triacting cold & cough child's vitamin with vitamin c chloramphenicol sod succinate chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine maleate chlorpromazine chlortabs chlorthalidone cholecalciferol (vitamin d3). 124 cholestyramine (with sugar).. 57 cholestyramine light CIALIS ciclodan ciclopirox... 62, 63 cidofovir cilostazol cimetidine CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT CIPRODEX ciprofloxacin (mixture) ciprofloxacin hcl... 18, 97 ciprofloxacin lactate cisplatin citalopram CITRACAL REGULAR CITRATE OF MAGNESIA.. 80 citroma citrus calcium cladribine clarithromycin classic prenatal CLEARLAX clemastine clindamycin hcl clindamycin phosphate.. 15, 60, 94 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) 121 CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient CLOLAR clomipramine clonazepam clonidine hcl clonidine patches clopidogrel clorazepate dipotassium clotrim antifungal clotrimazole... 9, 63, 94 clotrimazole 3 day clotrimazole af clotrimazole foot clotrimazole clotrimazole clotrimazole-betamethasone.. 63 clozapine... 41, 42 colchicine-probenecid COLCRYS... 92? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

137 COLD & ALLERGY PE COLD & COUGH DM cold & cough elixir COLD & FLU SEVERE cold & sinus pain relief COLD HEAD CONGESTION DAY/NITE COLD HEAD CONGESTION DAYTIME cold head congestion nighttime cold head congestion sever day cold multi-symptom COLD MULTI-SYMPTOM (CHLORPHEN) COLD MULTI-SYMPTOM DAY/NIGHT COLD MULTI-SYMPTOM NIGHTTIME cold relief m/s day/night COLD-COUGH SINUS RELIEF PE cold-flu relief, day/night cold-sinus relief colestipol colistin (colistimethate na) colocort col-rite COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT 114 COMETRIQ comfort gel comfort gel extra strength COMPLERA compro COMVAX (PF) constulose COPAXONE 20 MG/ML copper chloride COREG CR CORICIDIN HBP COLD- MULTI SYMPT cormax cortaid cortisone cortisone (hydrocortisone) cortizone cortizone-10 plus COSMEGEN cough control (guaifenesin). 105 cough control dm COUGH CONTROL DM MAX cough dm er cough drops... 70, 105 COUGH DROPS cough drops (with eucalyptus) COUGH DROPS (WITH EUCALYPTUS) cough formula dm cough suppressant-expectorant cough syrup cough syrup dm cough-sore throat night COUMADIN CREON CRESTOR critic-aid clear af CRIXIVAN cromolyn... 99, 114 cryselle (28) cyanocobalamin (vitamin b-12) cyclobenzaprine cyclophosphamide CYCLOSET cyclosporine cyclosporine modified CYRAMZA CYSTADANE CYSTAGON cytarabine cytarabine (pf) D d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 67 dacarbazine daily multiple daily multiple for men daily multiple for men daily multiple for women daily multiple vitamins/iron. 124 daily multi-vitamin daily multivitamin with iron 124 daily multivitamin-minerals. 124 daily multi-vitamins/iron DAILY PRENATAL daily vitamin formula daily vitamin formula-minerals daily vitamin with iron daily vites/iron daily-vite DAKLINZA DALIRESP danazol dantrolene DAPSONE DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM daunorubicin DAUNOXOME DAY TIME PE DAYTIME & NIGHTTIME COLD DAYTIME COLD & FLU RELIEF (PE) DAYTIME COLD-FLU day-time cough DAYTIME SINUS daytime-nighttime decitabine delta d ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

138 DELZICOL demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA 400 MG/ML desipramine desmopressin desonide desoximetasone DESVENLAFAXINE DESVENLAFAXINE FUMARATE dex4 glucose dex4 glucose bits dex4 glucose pouch pack dex4 glucose quick dissolve.. 67 dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 71, 100 DEXILANT dexrazoxane hcl dextroamphetamine dextromethorphan polistirex 105 dextromethorphan-guaifenesin dextrose dextrose 10 % and 0.2 % nacl 67 dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w). 68 dextrose 5 %-lactated ringers 68 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride 68 dextrose-kcl-nacl diabetic siltussin das-na diabetic siltussin-dm diabetic siltussin-dm max str 106 diabetic tussin dm DIABETIC TUSSIN DM DIABETIC TUSSIN EX diabetic tussin max st dialyvite dialyvite dialyvite vitamin d diamode diarrhea relief (bismuth subs) 77 diazepam... 27, 42 diazepam intensol diclofenac potassium diclofenac sodium... 37, 59 dicloxacillin dicyclomine didanosine DIFFERIN diflorasone diflunisal DIGITEK digox digoxin DILANTIN CAPSULES DILANTIN EXTENDED CAPSULES DILANTIN INFATABS diltiazem hcl dilt-xr dimaphen (pe) dimaphen dm dimenhydrinate dimetapp cold-congestion dimetapp dm cold-cough (pe) dino-life dino-life with extra c dino-life with iron-zinc diocto dioctyl diotame DIPENTUM diphenhydramine hcl... 59, 106 diphenhydramineacetaminophen diphenoxylate-atropine disposable enema disulfiram divalproex dm max DOCEFREZ docetaxel doc-q-lace doc-q-lax docu docuprene docusate calcium docusate sodium docusil dok... 80, 81 dok plus donepezil dorzolamide dorzolamide-timolol DOUBLE ANTIBIOTIC doxazosin doxepin doxercalciferol DOXIL doxorubicin DOXY doxycycline hyclate doxycycline monohydrate dramamine driminate dristan cold dristan long lasting dronabinol drospirenone-ethinyl estradiol95 DROXIA dry eye relief... 99? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

139 DUAL ACTION COMPLETE ducodyl dulcolax stool softener (dss).. 81 DULERA duloxetine... 42, 43 duramorph (pf) d-vi-sol d-vita E econazole EDURANT EFFIENT ELAPRASE ELIDEL elinest ELIQUIS ELITEK ELLA ELON DUAL DEFENSE EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide 52 ENBREL ENBREL SURECLICK endacof - dm endocet enema ENEMA enema disposable ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse entacapone entecavir ENTERIC COATED ASPIRIN entre-hist pse enulose epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin epitol EPIVIR EPIVIR HBV eplerenone eprosartan EPSOM SALT EPZICOM EQUETRO ERAXIS(WATER DILUENT).9 ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ery-tab ERYTHROCIN erythrocin (as stearate) erythromycin... 14, 97 erythromycin ethylsuccinate.. 14 erythromycin with ethanol erythromycin-benzoyl peroxide escitalopram oxalate essentia ESTRACE estradiol ESTRING ethambutol ethosuximide etodolac ETOPOPHOS etoposide EVISTA EVOTAZ EXELON exemestane EXJADE EXPECTORANT expectorant cough syrup EXTAVIA eye drops (with povidone) F FABRAZYME falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os). 88 FANAPT FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine fenesin ir fenesin pe ir fenofibrate fenofibrate micronized fenofibrate nanocrystallized.. 57 fenoprofen fentanyl fentanyl citrate FENTORA feosol FERAHEME ferocon ferosul ferrex ferrocite plus ferro-time ferrous gluconate ferrous sulfate ferrousul FETZIMA... 43, 44 fever reducer fever reducer & pain reliever 37 feverall fexofenadine FIBER fiber (calcium polycarbophil) 81 fiber (psyllium husk) FIBER (PSYLLIUM HUSK/SUGAR)... 81? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

140 FIBER (WITH ASPARTAME) fiber laxative (ca polycarbo). 81 fiber laxative (husk/sugar) fiber laxative (methylcellulo). 81 fiber laxative (psyllium husk) 81 fiber laxative (psyllium) s/f fiber smooth FIBER SMOOTH (SUCROSE) fiber therapy fiber therapy (ca polycarboph) fiber therapy (psyllium seed). 82 fiber therapy (psyllium) fiber therapy laxative (husk). 82 fiber therapy sugar free FIBER-CAPS fiber-lax fiber-tabs finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE first aid abx pain relief first aid antiseptic flanax (naproxen) flanax antacid flecainide FLOVENT DISKUS FLOVENT HFA FLU & SEVERE COLD- DAYTIME flu & severe cold-nighttime. 107 FLU & SORE THROAT RELIEF flu relief therapy daytime flu relief therapy nighttime fluconazole... 9 fluconazole in dextrose(iso-o). 9 fluconazole in nacl (iso-osm).. 9 flucytosine... 9 fludarabine fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone-shower cap fluocinonide fluocinonide-e fluoritab fluorometholone fluorouracil... 22, 59 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 65, 114 fluvoxamine foaming antacid foaming antacid extra strength folbee plus folic acid FOLOTYN fondaparinux FORADIL AEROLIZER formula em FORTEO foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FRAGMIN freamine iii 10 % full spectrum b-vitamin c FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief gas relief extra strength gas relief ultra strength GAUZE PADS 2 X gavilax gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK 89 gentak gentamicin...15, 62, 97 gentamicin sulfate (ped) (pf).. 15 gentamicin sulfate (pf) GENTAMICIN SULFATE (PF) gentle laxative gentlelax GEODON gerber good start glucose geri-kot geri-lanta geri-mox antacid-antigas GERI-MUCIL geri-tussin gildagia gildess fe GILENYA GILOTRIF GLATOPA GLEEVEC GLEOSTINE... 22? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

141 glimepiride glipizide... 72, 73 glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCO BURST glucose glucose bits glucose gel glycerin (adult) glycerin (child) glycolax glycopyrrolate gormel griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 grx dyne g-tron guaifenesin GUAIFENESIN-DM guanfacine guanidine gummi bear multivitamin gummy swirls H HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) HEAD CONGESTION COLD RELIEF healthylax heartburn relief (famotidine). 88 HEARTBURN RELIEF (LANSOPRAZOLE) heartburn relief (magnesium carbonate/aluminum hydroxide) tab chews heartburn relief (ranitidine).. 88 HECTOROL hematinic plus vit/minerals HEMORRHOID hemorrhoidal HEMORRHOIDAL hemorrhoidal cream heparin (porcine) heparin (porcine) in 5 % dex. 56 heparin (porcine) in nacl (pf). 56 heparin(porcine) in 0.45% nacl HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HEXALEN hi-cal plus vit d high potency calcium hist-pse hot steam liquid HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS STARTER HUMULIN 70/ HUMULIN 70/30 KWIKPEN 73 HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocodone compound syrup hydrocodone-acetaminophen. 33 hydrocodone-chlorpheniramine hydrocodone-homatropine HYDROCODONE- HOMATROPINE hydrocodone-ibuprofen hydrocortisone...65, 71, 83 hydrocortisone acetate... 65, 83 hydrocortisone plus hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-aloe vera hydrocortisone-min oil-wht pet hydromet hydromorphone hydroxocobalamin hydroxychloroquine hydroxyurea I ibandronate IBRANCE ibu-drops ibuprofen... 37, 38 IBUPROFEN COLD IBUPROFEN COLD- SINUS(WITH PSE) IBUPROFEN IB ibuprofen jr strength ibuprofen pm ibuprofen-diphenhydramine cit ibuprofen-diphenhydramine hcl icaps plus ICLUSIG idarubicin iferex IFEX ifosfamide ILARIS (PF)... 89? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

142 ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) infant fever reducer-pain relf 38 infants ibu-drops infant's ibuprofen infant's medi-profen infant's non-aspirin infants profenib infed INLYTA insta-glucose INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U /2 ML INTELENCE... 10, 11 intralipid INTRON A INTUNIV ER INVANZ INVEGA INVEGA SUSTENNA INVEGA TRINZA... 44, 45 INVIRASE inzo antifungal iophen dm-nr iophen-nr IPOL ipratropium bromide... 70, 114 ipratropium-albuterol i-prin irbesartan irbesartan-hydrochlorothiazide irinotecan iron IRON iron (dried) iron (ferrous sulfate) iron high potency ISENTRESS ISOLYTE-P IN 5 % DEXTROSE isoniazid isopropyl alcohol isopropyl alcohol, rubbing isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX itch relief (diphenhydramine). 59 itch relief (pramoxine-zinc) itraconazole...9 ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA... 73, 74 JARDIANCE JENTADUETO JEVTANA jock itch (terbinafine) jr. acetaminophen junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junior mapap K KADCYLA KALETRA KALYDECO kaopectate (bismuth subsalicy) KAOPECTATE CHILD(BIS SSALICYL) kaopectate ex str (bismuth ss) 78 kao-tin (bismuth subsalicylat) 78 kao-tin (docusate calcium) kariva (28) kelnor 1/35 (28) KEPIVANCE ketoconazole... 9, 63 ketorolac ketotifen fumarate KEYTRUDA KHEDEZLA kidkare cough/cold kid's vitamins kid's vitamins + extra c KINERET klor-con klor-con klor-con m klor-con m klor-con m KOMBIGLYZE XR konsyl (sugar) konsyl easy mix konsyl fiber konsyl formula-d konsyl sugar-free konsyl sugar-free (aspartame) 83 k-pec antidiarrheal (bism sub)78 K-TAB KUVAN L labetalol lactated ringers... 67, 118 lactulose lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR latanoprost LATUDA... 45? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

143 laxa clear laxacin laxative (glycerin-pediatric).. 83 laxative peg laxative-senna LAZANDA leflunomide LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in nacl (iso-os) 28 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin levonest (28) levonorgestrel levonorgestrel-ethinyl estrad. 96 levorphanol tartrate levothyroxine levoxyl LEXIVA LIALDA lice complete kit LICE CREAM RINSE lice killing LICE KILLING (PERMETHRIN) lice pyrinyl shampoo LICE SOLUTION lice treatment LICE TREATMENT (PERMETHRIN) lidocaine lidocaine (pf)... 50, 60, 61 lidocaine hcl lidocaine viscous lidocaine-prilocaine lindane linezolid linezolid-0.9% sodium chloride LINZESS liothyronine liquibid d-r liquid antacid lisinopril lisinopril-hydrochlorothiazide 53 lite coat aspirin lithium carbonate lithium citrate little animals little remedies fever & pain LO-DOSE ASPIRIN lohist - d lohist peb dm lohist-peb LOMUSTINE loperamide loradamed lorata-d loratadine lorata-dine d loratadine-d lorazepam losartan losartan-hydrochlorothiazide. 53 lotrimin af jock itch powder lotrimin af powder LOTRONEX lovastatin low-ogestrel (28) loxapine succinate LUMIGAN LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED lutera (28) LYNPARZA LYRICA... 28, 29 LYSODREN lyza M m.v.i. adult M.V.I. PEDIATRIC M.V.I.-12 (WITHOUT VITAMIN K) MACRODANTIN mag mag-al plus mag-al plus extra strength mag-delay mag-g magnesium citrate magnesium gluconate magnesium oxide magnesium sulfate magnesium sulfate in water. 119 manganese chloride mapap (acetaminophen) mapap arthritis pain mapap cold formula mapap extra strength mapap pm mapap sinus max strength (pe) maprotiline marlissa MARPLAN MATULANE meclizine meclofenamate medi-bismuth medicidin-d medikoff drops medroxyprogesterone mefloquine megestrol... 23, 24 MEKINIST meloxicam melphalan hcl MENACTRA (PF) MENEST... 94? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

144 MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) men's daily multivit-mineral 126 men's multi-vitamin men's one daily MENSTRUAL COMPLETE 39 menstrual relief menthol cough MENTHOL COUGH menthol cough drops menthol drops MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON MEPRON mercaptopurine meropenem mesalamine mesalamine with cleansing wipe mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metformin methadone methadone intensol methadose methazolamide methenamine hippurate methimazole methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methyclothiazide methylphenidate methylprednisolone acetate methylprednisolone sodium succ methylprednisolone tablets metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metro i.v metronidazole... 15, 60, 94 metronidazole in nacl (iso-os) 15 mexiletine mi-acid micatin miconazole miconazole nitrate... 63, 94, 95 MICONAZOLE NITRATE miconazole miconazorb af microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) micro-guard midodrine MIGRANAL milk of magnesia milk of magnesia concentrated mineral oil mineral oil extra heavy mineral oil heavy mineral oil laxative minocycline minoxidil mintox mintox maximum strength mintox plus mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) modafinil... 45, 46 moexipril moexipril-hydrochlorothiazide moisture drops mometasone mono-linyah mononessa (28) montelukast morphine... 34, 35 MORPHINE morphine (pf) morphine concentrate motion relief (meclizine) MOTION SICKNESS (MECLIZINE) motion sickness relief(mecliz) 84 moxifloxacin MOZOBIL mucaphed mucinex MUCINEX COUGH MINI- MELTS mucinex dm mucinex fast-max cold-flu-thrt mucinex fast-max dm max mucinex fast-max severe cold mucosa mucosa dm mucus dm mucus relief mucus relief chest MUCUS RELIEF COLD-FLU- SORE THR MUCUS RELIEF COUGH. 108 mucus relief d (phenylephrine) mucus relief dm mucus relief dm max mucus relief er mucus relief pe mucus relief plus MUCUS RELIEF SEV CONGEST-COLD mucus relief sinus MULTAQ multi antibiotic plus multi complete with iron ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

145 multi-day with iron multi-delyn multiple vitamin essential multiple vitamin-minerals multiple vitamins multi-symptom cold (pe & cpm) multi-symptom cold (pe) multi-symptom cold daytime 109 multi-symptom cold night time multivitamin multivitamin with iron multivitamin with minerals. 127 multi-vitamins with iron mupirocin ointment MURO MUSTARGEN my way MYCO NAIL A MYCOBUTIN mycophenolate mofetil mycophenolate sodium myferon mynephrocaps MYOZYME MYRBETRIQ myzilra N nabumetone nadolol nadolol-bendroflumethiazide. 53 nafcillin NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium nasal decongestant (oxymetazl) nasal decongestant (pe) nasal decongestant (pseudoeph) NASAL RELIEF nasal spray (oxymetazoline).. 70 NASONEX NATACYN nateglinide natural fiber laxative natural fiber laxative (sugar). 84 natural fiber laxative s/f natural fiber laxative smooth. 84 natural fiber laxative therapy. 84 natural fiber laxative(aspart). 84 natural fiber supplement natural laxative NATURAL PSYLLIUM FIBER natural tears (pf) NATURAL VEGETABLE NATURAL VEGETABLE (PSYLLIUM) natural vegetable powder nature's tears nausea control nausea relief NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin neomycin-bacitracin-poly-hc100 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc 71, 100 neo-polycin neo-polycin hc nephro-vite rx NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR next choice one dose niacin NIACIN (INOSITOL NIACINATE) NIACOR nicardipine nicorelief nicotine... 69, 70 nicotine (polacrilex) NICOTROL NS nifedical xl nifedipine night time cold NIGHT TIME COLD & FLU RELIEF NIGHT TIME COLD-FLU. 109 NIGHT TIME COLD-FLU RELIEF night time cough & sore throat nightime sleep nighttime cold-flu NIGHTTIME COLD-FLU RELIEF nighttime cough nighttime cough-cold nighttime sinus nighttime sleep aid (diphen) 109 NILANDRON nimodipine NIPENT NITE TIME COLD-FLU ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

146 nite time cold-flu formula NITE TIME COLD-FLU RELIEF NITE TIME COUGH NITE TIME-D COLD-FLU RELIEF NITE-TIME COLD-FLU nitetime multi-symptom nitro-bid nitrofurantoin macrocrystal.. 19 nitroglycerin NITROSTAT noble formula hc nohist-dm nohist-lq non-pseudo sinus pain-pressure nora-be NORDITROPIN FLEXPRO. 90 norethindrone (contraceptive) 94 norethindrone acetate norgestimate-ethinyl estradiol 96 NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTEMP nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOXAFIL... 9 nrs nasal relief nts step NUEDEXTA NULOJIX NUVARING nuzole nyquil d nystatin...9, 63 nystatin-triamcinolone nystop O ocella octreotide acetate ofloxacin... 18, 71, 98 ogestrel (28) olanzapine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omnicap ONCASPAR once daily ondansetron hcl ondansetron hcl (pf) ondansetron odt one daily ONE DAILY one daily 50 plus one daily complete one daily energy one daily essential one daily for men one daily for women one daily maximum one daily maximum (with ca) one daily men's one daily multi-vit w-mineral one daily multivitamin one daily plus iron one daily plus minerals one daily prenatal one daily with iron one daily womens 50 plus ONE DAILY WOMEN'S METABOLISM one-a-day essential one-a-day maximum formula128 one-a-day teen advantage ONFI ONGLYZA OPDIVO opium tincture opti-clear oral electrolytes oral saline laxative oralyte ORAP ORFADIN organ-i nr original nasal spray ormir oxacillin oxaliplatin oxandrolone oxaprozin oxcarbazepine OXSORALEN OXTELLAR XR oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oxymetazoline oysco 500/d oysco d oysco oyst-cal oyster shell + d oyster shell calcium oyster shell calcium oyster shell calcium with d oyster shell calcium-vit d oystercal-d P pacerone paclitaxel pain-off pamidronate pamprin max PANRETIN pantoprazole paricalcitol paroex oral rinse paromomycin paroxetine hcl PASER... 16? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

147 PATADAY PATANOL PAXIL PAZEO p-col rite pedia relief cough-cold pediacare fever reducer pediacare multi-symptom cold pedialyte PEDIALYTE pedialyte freezer pops pedialyte singles pediatric cough & cold pediatric electrolyte pediatric freezer pops PEDVAX HIB (PF) peg 3350-electrolytes peg-3350 with flavor packs PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM PENTASA pentoxifylline pepcid ac peptic relief pepto-bismol pepto-bismol to-go percogesic percogesic extra strength perdiem overnight relief PERFOROMIST peri-colace perindopril erbumine periogard PERJETA permethrin perphenazine persa-gel pharbechlor pharbedryl pharbetol phenelzine phenobarbital phenytoin phenytoin sodium phenytoin sodium extended PHOSPHATE LAXATIVE PHOSPHOLINE IODIDE pilocarpine hcl pindolol pink bismuth pink bismuth maximum strength pin-x PIN-X pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam PLAN B ONE-STEP PLASMA-LYTE PLASMA-LYTE-56 IN 5 % DEXTROSE pnv cmb#95-ferrous fumarate-fa podactin podofilox poly bacitracin POLY HIST FORTE (DOXYLAMINE) polycin polyethylene glycol POLYETHYLENE GLYCOL poly-iron polymyxin b sulf-trimethoprim98 poly-vita poly-vitamin poly-vitamins POMALYST portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl , 121 potassium citrate POTIGA povidone-iodine PRADAXA pramipexole PRANDIMET pravastatin prazosin prednisolone prednisolone acetate prednisolone sodium phosphate... 71, 72, 100 prednisone prednisone intensol PREMARIN prenatal prenatal + dha prenatal complete prenatal formula prenatal multivitamins prenatal vit#96-ferrous fum-fa PRENATAL VITAMIN PRENATAL VITAMIN ORAL TABLET ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

148 prenatal vitamin with minerals prenatal vit-iron fumarate-fa128 prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PROAIR HFA PROAIR RESPICLICK probenecid procainamide prochlorperazine edisylate prochlorperazine maleate prochlorperazine maleate rectal PROCRIT procto-pak proctosol hc proctozone-hc progesterone micronized PROGLYCEM PROGRAF PROLEUKIN PROLIA PROMACTA promethazine promethazine vc-codeine promethazine-codeine promethazine-dm promethazine-phenylephcodeine promethegan promolaxin propafenone propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROTOPIC protriptyline provil pseudoephedrine hcl psyllium husk PULMOZYME purelax PURIXAN pyrazinamide pyrethrin lice treatment m pyridostigmine bromide pyridoxine pyrilamine-phenylephrine Q q-dryl q-pap q-pap extra strength q-tapp q-tussin q-tussin dm QUADRACEL (PF) quenalin quetiapine quinapril quinapril-hydrochlorothiazide54 quinidine sulfate tablets quintabs-m iron free quit quit QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE ready-to-use enema ready-to-use enema (min oil). 86 REBIF (WITH ALBUMIN).. 90 REBIF REBIDOSE REBIF TITRATION PACK.. 90 reclipsen (28) RECOMBIVAX HB (PF) recort plus reese's pinworm medicine refenesen refenesen dm refenesen pe reguloid reguloid, sugar free RELENZA DISKHALER RELISTOR REMEDY ANTIFUNGAL REMICADE RENAGEL renal caps rena-vite rena-vite rx reno caps RENVELA... 68, 69 RESCRIPTOR RESTASIS RETROVIR REVLIMID REXULTI REYATAZ ribasphere ribavirin RID COMPLETE LICE ELIM KIT RID LICE KILLING RIDAURA rifabutin rifampin RIFATER ri-gel ri-gel ii riluzole rimantadine ri-mox ri-mox plus ringers... 67, 121 risacal-d RISPERDAL CONSTA risperidone... 47, 48 ri-tussin ri-tussin dm RITUXAN... 25? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

149 rivastigmine tartrate oral capsule rivastigmine transdermal patch rizatriptan robafen robafen dm robafen dm cough ropinirole rosadan ROTARIX ROTATEQ VACCINE ROZEREM RUBBING ALCOHOL (ETHANOL) RU-HIST D rydex rynex dm rynex pe rynex pse S SABRIL SANI-SUPP (ADULT) sani-supp (infant) SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scalpicin anti-itch selegiline hcl selenium sulfide SELZENTRY senexon senexon-s senna SENNA senna lax senna laxative senna plus SENNA PROMPT senna with docusate sodium.. 87 senna-extra senna-gen senna-s senno sennosides-docusate sodium.. 87 SENOKOTXTRA sen-o-tab SENSIPAR SEREVENT DISKUS SEROQUEL XR sertraline SEVERE ALLERGY-SINUS HEADACHE SEVERE COLD (DIPHEN-PE- ACETAM) SEVERE COLD MULTI- SYMPTOM SEVERE COLD PE silace siladryl sa silapap sildenafil silphen cough siltussin dm das siltussin sa siltussin-dm silver sulfadiazine simethicone SIMPONI SIMULECT simvastatin sinus & allergy non-drowsy. 111 SINUS & ALLERGY PE SINUS & ALLERGY(PHENYLEPHRI NE) sinus cong & pain day-night 111 SINUS CONGESTION&PAIN(CHL ORPH) sinus decongestant (pe) SINUS HEADACHE PE sinus nasal spray sinus relief (oxymetazoline) sirolimus sleep aid (diphenhydramine) 112 SLEEP AID (DIPHENHYDRAMINE) 111 sleep aid (doxylamine) SLEEP AID MAX STR (DIPHENHYDR) sleep tablet (diphenhydramine) slow release iron sodium bicarbonate sodium chloride... 69, 99, 121 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium polystyrene (sorb free) sodium polystyrene sulfonate. 69 SODIUM POLYSTYRENE SULFONATE sof-lax SOLTAMOX soluble fiber SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate)78 soothing care (hydrocortisone) SORE THROAT (MENTHOL) sorine sotalol sotalol af SOVALDI spectravite advanced formula spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28) SPRYCEL sps ssd stavudine... 11? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

150 sterile eye drops STIMATE STIMULANT LAXATIVE PLUS STIOLTO RESPIMAT STIVARGA stool softener STOOL SOFTENER stool softener-laxative stool softener-stimulant laxat 87 stop smoking aid STRATTERA STREPTOMYCIN stress formula advanced STRIBILD STROMECTOL SUBOXONE SUBSYS sucralfate SUDAFED 24 HOUR sudogest sudogest 12-hour sudogest cold & allergy sudogest pe sudogest sinus & allergy sulfacetamide sodium sulfacetamide sodium (acne). 62 sulfacetamide-prednisolone 100 sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulfazine sulfazine ec sulindac sumatriptan succinate suphedrin suphedrin 12 hour SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE suphedrine pe cold & allergy suphedrine pe sinus & allergy suphedrine pe sinus headache suppository adult surfak SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus... 25, 59 TAFINLAR tagamet hb TAMIFLU tamoxifen tamsulosin TANZEUM TARCEVA TARGRETIN TASIGNA TASMAR TAZORAC taztia xt tears pure TECFIDERA TEFLARO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam terazosin terbinafine hcl... 9, 64 terbutaline terconazole TESTIM testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline tetrahydrozoline THALOMID theophylline thera-d theralogix companion thiamine hcl thiamine mononitrate thioridazine thiotepa thiothixene THYMOGLOBULIN tiagabine TICE BCG TIKOSYN timolol maleate... 54, 98 TIMOPTIC OCUDOSE (PF). 98 tinactin tioconazole tioconazole TIVICAY tizanidine tl icon tl-hist dm tobramycin tobramycin in % nacl tobramycin sulfate tobramycin-dexamethasone. 100 tolazamide... 75? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

151 tolbutamide tolcapone tolmetin tolnaftate tolterodine topiramate toposar topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid... 56, 95 tranylcypromine travasol 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin tretinoin (chemotherapy) TRETIN-X CREAM KIT TREXALL triamcinolone acetonide. 66, 71, 72 triamterene-hydrochlorothiazid trianex TRIBENZOR tri-biozene tri-buffered aspirin tricon triderm trifluoperazine trifluridine trimethoprim triphrocaps triple antibiotic triple antibiotic (pram) extra. 62 triple antibiotic plus triple paste af tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ TRI-VI-SOL tri-vita tri-vitamin trivora (28) TRIZIVIR TROPHAMINE 10 % TROPHAMINE 6% tropicamide trospium TRULICITY TRUMENBA TRUVADA tusnel diabetic tussi pres-b tussigon TUSSIN tussin chest congestion tussin cough &chest congestion tussin cough dm tussin dm TUSSIN DM CLEAR tussin dm cough tussin dm cough & chest TUSSIN DM MAX tussin expectorant tussin honey tussin maximum strength tussin maximum strength cough TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA TYZINE U U-CORT ULORIC ultra sleep (doxylamine succ) 49 ULTRA STRENGTH ANTACID ultra strength calcium antacid unithroid UNITUXIN urea ureacin urinary pain relief ursodiol UVADEX V vagicaine vagicream VAGIFEM vagistat valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 30 valsartan... 54, 55 valsartan-hydrochlorothiazide vancomycin VANCOMYCIN IN D5W VANCOMYCIN IN DEXTROSE ISO-OSM vaporizing steam VAQTA (PF) VARIVAX (PF) VARIZIG VAZOTAB (PYRILAMINE) VECAMYL... 58? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

152 VECTIBIX vegetable laxative VELCADE velivet triphasic regimen (28) 97 venlafaxine VENLAFAXINE VENOFER VENTAVIS verapamil VERSACLOZ VESICARE VICTOZA 2-PAK VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMPAT vinblastine vincasar pfs vincristine vinorelbine viorele (28) VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VISINE VISINE TEARS visine-a vitalee vitamin a vitamin a & d diaper rash vitamin a and d VITAMIN A PALMITATE 129 vitamin b VITAMIN B-1 (MONONITRATE) vitamin b vitamin b vitamin c VITAMIN C vitamin c cough drops VITAMIN C DROPS vitamin c with rose hips VITAMIN C WITH ROSE HIPS vitamin d vitamin d VITAMIN D vitamin e (dl, acetate) vitamin e mixed vitamin k VITAMIN K vitamin k VITAMIN K VITEKTA vits a and d-white pet-lanolin. 59 vol-care rx VOLTAREN GEL voriconazole...9 VOTRIENT W warfarin water for irrigation, sterile WELCHOL WOMEN'S GENTLE LAXATIVE(BISAC) women's laxative (bisacodyl). 88 X XALKORI XARELTO XENAZINE XGEVA XIFAXAN XOLAIR XTANDI XULANE XYREM Y yelets YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP ZANOSAR zarah ZAVESCA zazole zeasorb (miconazole) ZELBORAF ZEMAIRA ZEMPLAR zenchent (28) zenzedi... 49, 50 ZETIA ZIAGEN zidovudine zinc chloride intraveneous solution zinc oxide ZINC OXIDE DIAPER CREAM ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolmitriptan zolpidem ZOMETA ZOMIG zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA ZYVOX... 16? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

153 ? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 ( 聽 語 障 用 戶 請 致 電 )(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 ENYDMEM

154 存 在 疑 問 嗎? 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 下 午 8 點, 撥 打 免 費 電 話 (TTY 711) 與 我 們 聯 絡 或 瀏 覽 網 站 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 為 一 項 照 護 管 理 計 劃, 與 Medicare 及 紐 約 州 衛 生 署 (Medicaid) 簽 約, 透 過 Fully Integrated Duals Advantage (FIDA) Demonstration 為 參 與 者 提 供 雙 重 計 劃 福 利 Empire BlueCross BlueShield HealthPlus 是 HealthPlus, LLC 的 商 標 名 稱, 該 公 司 屬 Blue Cross and Blue Shield Association 的 獨 立 持 照 組 織 福 利 給 付 藥 物 清 單 和 網 路 內 藥 房 以 及 醫 療 服 務 提 供 者 可 能 於 每 年 1 月 1 日 或 全 年 內 隨 時 變 動 有 關 Empire FIDA Plan 的 詳 細 資 訊, 請 聯 絡 Empire FIDA Plan 或 紐 約 州 參 保 者 經 紀 人 若 要 參 與 此 計 畫 或 其 他 醫 療 保 健 計 畫, 請 聯 絡 紐 約 州 參 保 者 經 紀 人, 電 話 號 碼 為 FIDA (TTY ), 週 一 至 週 五 上 午 8:30 至 下 午 8 點, 及 週 六 上 午 10 點 至 下 午 6 點, 或 瀏 覽 網 站 紐 約 州 建 立 了 一 個 參 與 者 監 察 員 計 劃, 稱 Independent Consumer Advocacy Network (ICAN), 提 供 參 與 者 任 何 Empire FIDA Plan 之 服 務 相 關 的 免 費 保 密 協 助 您 可 以 撥 打 電 話 或 上 網 從 網 站 icannys.org 聯 絡 Participant Ombudsman( 參 與 者 監 察 員 ) 您 可 以 索 取 不 同 格 式 的 處 方 藥 物 清 單, 如 點 字 或 大 型 字 體 版 本 請 致 電 (TTY 711), 週 一 至 週 五 上 午 8 點 至 下 午 8 點 處 方 藥 物 ID 版 本..14 發 佈 時 間 11/01/2015