VillageCareMAX Full Advantage FIDA 計劃 206 年涵蓋藥品目錄 ( 處方一覽表 ) 這是參與者可在 VillageCareMAX Full Advantage FIDA 計劃中獲得藥品的清單 VillageCareMAX Full Advantage FIDA 計

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1 H9345_MBR6_03c CMS Approved VillageCareMAX Full Advantage FIDA 計劃 (Medicare-Medicaid Plan, 即 醫療保險 紐約州衛生署計劃 ) 206 年給付藥品目錄 ( 處方一覽表 ) 該給付藥品清單已在 0/0/206 更新 欲了解更多最新信息或其他問題, 請撥打 VillageCareMAX 全部優勢 FIDA 計劃服務熱線 , 聽障者電話 (TTY) 用戶請撥打 7, 辦公時間為上午 8 時到下午 8 時, 每週 7 天 或訪問 Formulary ID: , Version 9

2 VillageCareMAX Full Advantage FIDA 計劃 206 年涵蓋藥品目錄 ( 處方一覽表 ) 這是參與者可在 VillageCareMAX Full Advantage FIDA 計劃中獲得藥品的清單 VillageCareMAX Full Advantage FIDA 計劃是一項管理式醫療計劃, 與醫療保險部門及紐約州衛生署簽訂合約, 以全面整合雙重優勢 (FIDA - 全面整合雙重優勢 ) 方案來為參與者同時提供兩項計劃的福利 給付藥品清單以及 / 可能會在一年之中作出更改 當我們作出的變更會影響到您之前, 我們會向您發送通知 福利可能會在每年的 0 月 0 日作出更改 您可上網 ( 查看 VillageCareMAX Full Advantage FIDA 計劃的最新給付藥品清單, 或撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線 隨時核查 聽障者電話 (TTY) 用戶請撥打 7 請注意可能存在的局限性和限制 若需要進一步的資訊, 請撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線或閱讀 VillageCareMAX Full Advantage FIDA 參與者手冊 對於任何給付藥品都無需承擔自付額 ( 被保險人用於就醫或配藥所支付的小額費用 ) 您還可以免費索取大字版, 點字或語音等格式, 請撥打免付費專線 和 7, 上午 8 時至晚上 8 時, 每週 7 天 You can get this information for free in other languages. Call and TTY users should call 7, during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español.Llame a Servicios del Participante al durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 7.La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 7. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a gratis nan kreyòl Ayisyen. Rele sèvis patisipan nan pandan lè 8:00 am jiska 8:00 pm, 7 jou pà semèn. Itilisatè ATS yo dwe rele nan 7. Apèl sa a gratis. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : ii

3 Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону с 8:00 до 20:00, без выходных. Пользователи TTY звоните по телефону 7. Звонок бесплатный. 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 , 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽障者電話服務專線 (TTY) 用戶請撥打 7 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 번 (TTY 사용자는 7 번 ) 으로문의해주십시오. 통화는무료입니다. 紐約州備有參與者申訴方案稱為獨立消費者倡權網路 (ICAN), 可為參與者提供 VillageCareMAX Full Advantage FIDA 計劃的免費 保密協助 若需要使用參與者申訴服務 (ICAN), 請撥打免付費電話 : , 或造訪網站 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : iii

4 常見問題 (FAQ) 您可在此處查找有關給付藥品清單疑問的答案 您可以閱讀所有的常見問題瞭解更多資訊, 也可以查找問題和答案. 給付藥品清單上有什麼處方藥? ( 此處我們將給付藥品清單簡稱為 藥品清單 ) 從給付藥品清單第一頁開始的所有藥品均為 VillageCareMAX Full Advantage FIDA 計劃給付藥品 這些藥品在我們藥房網路中的所有藥店內有售 如果一個藥房與我們簽署了合作為您提供服務的合約, 那麼這個藥房就在我們網路中 我們將這個藥房稱為 網路藥房 如果符合以下情況,VillageCareMAX Full Advantage FIDA 計劃將給付藥品清單上的所有藥品 : 您的醫生或其他處方開立者認為您需要這些藥品來獲得好轉或保持健康, 您需要此藥品治療病情, 且 您在 VillageCareMAX Full Advantage FIDA 計劃網路藥房內補藥 在獲得某些藥品的過程中,VillageCareMAX Full Advantage FIDA 計劃可能會採取額外的步驟 ( 詳見下文中的問題 5) 在某些情況下, 您在獲得某種藥品前可能必須先進行其它步驟, 比如先嘗試其它藥品等 您也可以前往我們的網站 或者撥打參與者服務熱線 獲得最新的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 2. 藥品清單是否會不斷變化? 是 VillageCareMAX Full Advantage FIDA 計劃可能會隨時增加或減少藥品清單上的藥品 一般來說, 藥品清單只會在以下情況下更改 : 出現了一種與藥品清單上現有藥品效果一樣好的新藥, 或者 我們瞭解到清單上的某種藥品不安全 我們也有可能會更改有關藥品的規定 比如說, 我們可能會 : 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : iv

5 要求或取消要求某種藥物的事先許可 ( 事先許可即在您獲得某種藥品前, 來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的跨學科專業團隊 (Interdisciplinary Team,IDT) 的許可 ) 增加或更改您可獲得某種藥品的數量 ( 被稱為 限量 ) 增加或更改某種藥品的階段療法限制 ( 階段療法是指您在獲得某種藥品前必須先嘗試另一種藥品 ) ( 有關這些藥品規定的進一步資訊請參閱第 vi 頁 ) 當您正在使用的某種藥物被從藥品清單中移除時, 我們會通知您 當我們對某種藥品的給付規定進行更改時, 也會通知您 有關藥品清單更改時狀況的進一步資訊請查看下文中的問題 3 4 和 7 您可隨時上網 ( 查看 VillageCareMAX Full Advantage FIDA 計劃的最新藥品清單 您也可撥打參與者服務熱線 核查現行的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 3. 當出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥時, 會如何處理? 如果出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥 : 當您下次補藥時, 您的藥師可能會給您比較便宜的那一款藥品 如果您和您的處方提供者認為便宜的那一款藥品不適合您, 那麼您的處方提供者可致電藥師, 請他 / 她繼續給您現在正在服用的這種藥品 VillageCareMAX Full Advantage FIDA 計劃部門可能會決定將比較貴的那一款藥品從藥品清單中移除 如果您正在服用的某種藥品因為存在效果同樣好且比較便宜的藥品上市而從藥品清單上被移除, 我們將會在將其從藥品清單上移除前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 當您正在使用的某種藥物自藥品清單中移除時,VillageCareMAX Full Advantage FIDA 計劃部門會寄信通知您 我們的網站上列有關於藥品清單的最新資訊 如有任何疑問, 您可以隨時上網 ( 查看或者撥打參與者服務熱線諮詢 我們的電話號碼為 聽障者電話 (TTY) 用戶請撥打 7 我們的營業時間為每週 7 天, 上午 8:00 至晚上 8:00 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : v

6 4. 當我們發現某種藥品不安全時, 會如何處理? 如果美國食品藥物管理局 (FDA) 指出您正在服用的藥品不安全, 我們會直接將其從藥品清單上移除 我們也會寄信和致電給您, 讓您得知這種不安全藥物已從藥品清單上移除 如果您正在服用某種已由 FDA 確認為不安全的藥物, 請與您的醫生談一談 您的醫生可以開立另一種藥物來取代不再供應的藥物 5. 藥品給付是否存在任何限制或局限性? 或者說, 如要獲得某些藥品, 是否要求採取某些行動? 是的, 部分藥品具有給付規定或限量規定 在某些情況下, 在獲得藥品前您或您的醫生或其他處方開立者必須先進行其它步驟 例如 : 獲得事先許可 ( 或事先授權 ): 對於某些藥品, 在您獲得藥品前, 您或您的醫生或其他處方開立者必須先獲得來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的多專業團隊 (Interdisciplinary Team,IDT) 的許可 若您未獲得許可, 則 VillageCareMAX Full Advantage FIDA 計劃將不會為您給付此藥品 數量限制 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會限制您可獲得藥品的數量 階段療法 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會要求您進行階段療法 也就是說, 在病情治療過程中, 您將必須以某種特定順序嘗試不同藥品 您可能得在獲得某種藥品前, 先嘗試另一種藥品 若您的醫生認為第一種藥品對您無效, 那麼我們將為您給付第二種藥品 您可以在從開始自第一頁的表格中瞭解您的藥品是否有任何附加要求或限制 您也可以上網 ( 瞭解更多資訊 我們已在網站上公佈了一些文件來說明我們的事先授權和階段步驟療法限制 您也可以要求我們寄送一份至貴府 對於這些限制, 您可以請求 規則豁免 有關規則豁免的進一步資訊, 請查看問題 如果您在護理機構或其它長照機構中, 且需要某種不在藥品清單上的藥品或者無法輕易獲得所需藥品, 我們可以向您提供幫助 無論您是否為 VillageCareMAX Full Advantage FIDA 計劃的新參與者, 我們都將為您提供所需藥品的 3 天緊急藥品供應給付 ( 除非您已持有需用藥天數少於此天數的處方 ) 這可以讓您有充分的時間和您的醫生或其他處方開立者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : vi

7 6. 您將如何得知您所需藥品是否有限制, 或者在獲得藥品前是否要求採取某些行動? 第 頁上的給付藥品清單中, 有一欄為 使用時的必要行動 限制或局限性 7. 如果我們更改了有關如何給付某些藥品的規定 ( 例如, 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量 及 / 或階段療法限制等場合 ), 會發生什麼情況? 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量及 / 或階段步驟療法限制, 我們將通知您 我們將會在增加限制前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 這可以讓您有充分時間與您的醫生或其它處方提供者商量下一步行動 8. 您如何在藥品清單上查找某種藥品? 有兩種查找藥品的方法 : 您可以按照首字母順序檢索 ( 如果您知道如何拼寫該藥品的英文名稱 ), 或者 根據醫療狀況查找 如果您要按照首字母順序進行檢索, 請查看第 I- 頁中的首字母順序排列部分 然後在清單中查找您所需藥品的名稱 如果您要按照醫療狀況查找, 請找到第 頁中的 根據醫療狀況分類的藥品清單 部分 在該部分, 藥物將根據它們被用於治療的醫療的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物 9. 如果您要服用的藥品未列在藥品清單上, 該怎麼辦? 如果您未在藥品清單上找到所需藥品, 請撥打參與者服務熱線 並諮詢相關情況 聽障者電話 (TTY) 用戶請撥打 7 如果您得知 VillageCareMAX Full Advantage FIDA 計劃不會給付該藥品, 您可以採取以下行動之一 : 向參與者服務熱線工作人員索取一份您想服用藥品的相似藥品清單 然後將這份清單給您的醫生或其它處方提供者過目 他或她可以為您開立與您想服用藥品的相似藥品處方, 或者 您可以向本計劃工作人員或您的跨學科專業團隊 (IDT) 請求規則豁免, 來給付您的藥品 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : vii

8 0. 如果您是 VillageCareMAX Full Advantage FIDA 計劃的新成員, 且無法在藥品清單上找到您所需藥品或在獲取藥品的過程中出現了問題, 該怎麼辦? 我們能幫助您 在您成為 VillageCareMAX Full Advantage FIDA 計劃參與者的前 90 天中, 我們必須根據需要為您提供最多 90 天的臨時藥品供應服務 這可以讓您有充分的時間和您的醫生或其他處方提供者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 如符合以下情況, 我們將為您提供最多 90 天的臨時藥品供應服務 : 您正在使用不在我們藥品清單中的藥品 ; 或者 根據健康計劃規定, 您無法獲得您的處方提供者要求的藥品數量 ; 或 此藥品要求來自 VillageCareMAX Full Advantage FIDA 計劃或者您的跨學科專業團隊 (IDT) 的事先許可 ; 或 您正在服用的藥品屬於階段療法限制藥品 如果您生活在護理機構或其它長照機構中, 您可根據處方領取多達 98 天劑量的藥品 您可以在該計劃的頭 90 天內多次補藥 這可以讓您的處方開立者有足夠的時間將您使用的藥品更改為藥品清單上的藥品, 或者請求規則豁免 VillageCareMAX Full Advantage FIDA 計劃擁有一個過渡流程來確保向新進和目前的 D 部分 ( 聯邦醫療保險處方藥計劃 ) 成員提供持續的藥品給付服務 有時候, 您會經歷諸如入住或搬出長照機構 住院或出院等照護等級方面的變化 在這些情況下, VillageCareMAX Full Advantage FIDA 計劃將向您提供一次性的非處方藥物緊急供應 非處方藥品同時包括不在本計劃處方一覽表上的 D 部分藥品, 以及列於本計劃處方一覽表中 但根據本計劃使用管理規定需要獲得事先許可或進行階段療法的 D 部分藥品 如您有任何問題, 請致電參與者服務中心 您可在每週 7 天, 上午 8:00 至晚上 8:00 間撥打 聽障者電話 (TTY) 用戶請撥打 7. 您是否可以請求規則豁免來報銷藥品? 是 您可以向 VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 請求規則豁免來給付不在藥品清單上的藥品 你也可以請求 VillageCareMAX Full Advantage FIDA 計劃部門或者您的 IDT 來更改有關您所需藥品的規定 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : viii

9 例如,VillageCareMAX Full Advantage FIDA 計劃會限制可給付藥品量 如果您所需藥品有限量規定, 您可以要求我們或您的 IDT 團隊更改數量限制並給付更多藥品 其它例子 : 您可以要求我們或您的 IDT 取消階段療法限制或事先許可要求 2. 獲得規則豁免需要多長時間? 首先,VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 必須從您的處方提供者收到支援您規則豁免請求的聲明 在我們受到聲明之後, 您將在 72 小時內收到有關您規則豁免請求的判定 如果您或者您的處方提供者認為花費 72 小時等待決定將對您的健康產生傷害, 您可以要求加急 此為更快的判定 如果您的處方提供者支援您的請求, 您將在收到您的處方提供者支援聲明的 24 小時內獲得判定 3. 您需如何請求規則豁免? 如需請求規則豁免, 請致電您的醫療管理人員 您的醫療管理人員將和您及您的處方提供者一起幫您請求規則豁免 4. 什麼是仿學名藥? 學名藥是指由與品牌藥品相同成分製成的藥品 它們通常比品牌藥品價格更低廉且並無廣為人知的品名 學名藥由食品藥物管理局 (FDA) 審查核准 VillageCareMAX Full Advantage FIDA 計劃可同時給付品牌藥和學名藥 5. 什麼是 OTC 藥品? OTC 的意思是 成藥 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可給付部分非處方 (OTC) 藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可給付的非處方藥品 非處方藥品位於第 4 級中 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : ix

10 6. VillageCareMAX Full Advantage FIDA 計劃是否可給付非藥物類非處方產品? 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可報銷部分非藥物類非處方產品 樣例包括 : 紗布墊 酒精棉 / 墊 胰島素注射器和針頭等非處方類糖尿病用品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非處方藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非藥物類非處方產品 7. 你們的自付醫療費用如何計算? 您無需為藥品清單上的藥品承擔自付款 8. 什麼是藥品? 在 VillageCareMAX Full Advantage FIDA 計劃處方一覽表中, 您可以看到共有 4 種藥品等級 類別 的藥品為由醫療保險部門給付的學名藥 類別 2 的藥品為由醫療保險部門給付的品牌藥和專科用藥 類別 3 的藥品為由紐約衛生署給付的非 D 部分藥品和品牌藥 類別 4 的藥品為由紐約衛生署給付的非處方 (OTC) 藥品 作為我們計劃的成員, 您無需為這四類藥品承擔任何自付款 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : x

11 給付藥品清單 下文第 頁中的給付藥品清單向您提供了有關可由 VillageCareMAX Full Advantage FIDA 計劃給付藥品的資訊 如果您無法在清單中找到所需藥品, 請使用由第 I- 頁開始的索引 圖表中的第一列為藥品名稱 品牌藥品為大寫 ( 例如 : 立普妥 [LIPITOR]), 而學名藥為小寫斜體 ( 例 : 布洛芬 [ibuprofen]) 必要行動 限制或局限性一欄中資訊可讓您瞭解 VillageCareMAX Full Advantage FIDA 計劃是否對給付您的藥物設立任何規定 描述指南 此藥品清單採用以下縮寫和符號 : 縮寫 / 符號 描述 解釋說明 使用管理限制 在領取藥物前, 您 ( 或您的醫師 ) 需要獲得來自 VillageCareMAX Full PA Advantage FIDA 計劃的事先授權 若事先授權限制無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此 藥品 根據醫療保險部門的 Part B 或 Part D 保險計劃, 此藥品可能需要支付款項 在領取藥品前, 您 ( 或您的醫師 ) 需要 Part B 和 Part D 保險獲得來自 VillageCareMAX Full 計劃測定的事先授權 Advantage FIDA 計劃的事先授權來確 定此藥品是否可根據醫療保險部門的 Part D 保險計劃報銷 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 此藥已被 CMS 認為是潛在有害的, 因 PA-HRM 此,65 歲或以的上 Medicare 醫療保險高風險藥物的事先授權參加者要得到 VillageCareMAX Full 限制 Advantage FIDA 計劃的事先許可高風 險服藥的要求之後才得到此處方藥 若 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xi

12 縮寫 / 符號 描述 解釋說明無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 PA NSO 僅針對新開方藥品的事先授權限制 如果您是新成員或您之前未服用過此藥品, 在領取藥物前, 您 ( 或您的醫師 ) 需獲得來自 VillageCareMAX Full Advantage FIDA 計劃的事先授權 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 VillageCareMAX Full Advantage FIDA QL 計劃限制了此藥品每次按處方領取的報數量限制規定銷數量, 或者特定時間框架內的數量 ST 階段療法限制 在 VillageCareMAX Full Advantage FIDA 計劃為此藥物提供報銷之前, 您必須首先嘗試另一種藥品來治療您的病情 在其它藥品對您無效的情況下, 才可報銷此藥品 其它保險相關縮寫 此藥方可能僅可在某些特定藥房中領取 藥品 欲知更多資訊, 請查看您的藥劑 目錄或在每天上午 8:00 至晚上 8:00 LA 藥品獲取限制間, 每週 7 天撥打我們的會員服務熱線 此為免費電話 聽障 者電話 TTY 用戶請撥打 7 您也許能夠獲得大多數的藥物多於 對 月的供應通過郵購處方以降低成本的份 NM 非郵購藥品額 如藥物無法通過郵購, 您處方的要 求 / 限制列中記下 NM * 非 Part D 藥品 此藥品不是可由醫療保險部門報銷的 Part D 藥品, 或者 OTC 藥品或產品 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xii

13 注 : 所有類別 3 和類別 4 中的藥品均為非 Part D 藥品 這些藥品具有不同的申訴規定 申訴是一種在您認為有錯誤存在的情況下請求審核並更改保險決定的正式途徑 例如, VillageCareMAX Full Advantage FIDA 計劃或您的跨學科專業團隊 (IDT) 可能會規定您所需藥品不在受保範圍內, 或者決定不再由醫療保險部門或紐約州衛生署報銷此藥品 如果您或您的醫生或其他處方提供者不同意這項決定, 則您可進行申訴 如需有關如何申訴的指導, 請撥打參與者服務熱線 或獨立消費者倡權網路 (ICAN) 的電話 您也可以通過閱讀參與者手冊來瞭解如何就某項決策進行申訴 藥品名單 - 按醫療狀況的類型分類 在本節中藥物將根據它們被用於治療的醫療狀況的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xiii

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15 Table of Contents Analgesics... 3 Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents... 5 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

16 Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products... 5 Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206 2

17 Analgesics Analgesics, Miscellaneous acephen 20 mg suppository outer 20 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 20 mg suppos outer 20 mg * acetaminophen 60 mg rapid tab 60 mg * acetaminophen 60 mg/5 ml elx 60 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 20 mg-2 mg/5 ml solution 20-2 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /2.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) $0 $0 $0 $0 $0 QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (80 per 30 days) 3

18 ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fiorinal with Codeine #3) (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) $0 $0 $0 $0 (Tencon) $0 (Esgic) $0 (Esgic) $0 (Fiorinal) $0 capacet oral capsule mg (Esgic) $0 child non-aspirin 60 mg/5 ml children's 60 mg/5 ml * (Acetaminophen) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) ST; QL (60 per 30 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) 4

19 child pain-fever 60 mg/5 ml QL (240 per 30 days) (Infants' Tylenol) a/f,gluten/f,cherry 60 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 5 mg, 30 QL (80 per 30 days) (Codeine Sulfate) $0 mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 60 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) endocet oral tablet mg, 2.5- QL (360 per 30 days) (Xolox) $0 325 mg, mg, mg endodan oral tablet mg (Percodan) $0 QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 (Actiq) $0 PA; QL (20 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) $0 QL (0 per 30 days) feverall 20 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 20 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution mg/5 ml(5 ml), mg/5 ml, mg/5 ml (Hycet) $0 5

20 hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg, mg hydromorphone (pf) injection solution 0 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection syringe 2 mg/ml (Norco) $0 (Norco) $0 (Ibudone) $0 (Dilaudid-HP) $0 (Dilaudid) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (50 per 30 days) (Hydromorphone HCl) $0 (Hydromorphone HCl) $0 hydromorphone oral liquid mg/ml (Dilaudid) $0 QL (200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (80 per 30 days) (Dilaudid) $0 mg hydromorphone oral tablet 8 mg (Dilaudid) $0 QL (240 per 30 days) HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG junior mapap 60 mg rapid tab 60 mg * LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY (Acetaminophen) QL (30 per 30 days) PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) $0 325 mg lorcet hd oral tablet mg (Norco) $0 QL (360 per 30 days) lorcet plus oral tablet mg (Norco) $0 QL (360 per 30 days) 6

21 mapap 60 mg/5 ml elixir 60 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 60 mg/5 ml suspension 60 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/5 ml liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (80 per 30 days) (Tylenol Arthritis) mg * PA-HRM; QL (80 per margesic oral capsule (Esgic) $0 30 days); AGE (Max mg 64 Years) methadone injection solution 0 mg/ml (Methadone HCl) $0 methadone oral solution 0 mg/5 QL (800 per 30 days) (Methadone HCl) $0 ml, 5 mg/5 ml methadone oral tablet 0 mg, 5 mg (Diskets) $0 QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) $0 QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% $0 syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 0 mg/ml carpuject 0 mg/ml (Morphine Sulfate) $0 morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) $0 morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) $0 morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) $0 morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) $0 00 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) $0 7

22 morphine in dextrose 5 % injection pt controlled analgesia syring 00 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 5 mg/ml, 8 mg/ml morphine injection syringe 0 mg/ml morphine intramuscular pen injector 0 mg/0.7 ml morphine intravenous cartridge 5 mg/ml morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 morphine oral solution 0 mg/5 ml (Morphine Sulfate) $0 QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) $0 (4 mg/ml) MORPHINE ORAL TABLET 5 QL (80 per 30 days) MG, 30 MG morphine oral tablet extended QL (20 per 30 days) (MS Contin) $0 release 00 mg, 30 mg, 60 mg morphine oral tablet extended QL (80 per 30 days) (MS Contin) $0 release 5 mg, 200 mg morphine rectal suppository 0 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) $0 non-aspirin x-str 67 mg/5 ml 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG 8

23 NUCYNTA ORAL TABLET 00 QL (8 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (80 per 30 days) (Oxycodone HCl) $0 mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) $0 QL (300 per 30 days) oxycodone oral tablet 0 mg, 5 mg, QL (80 per 30 days) (Roxicodone) $0 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.2 hr 0 mg, 5 mg, 20 (Oxycontin) $0 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral QL (20 per 30 days) (Oxycontin) only,ext.rel.2 hr 80 mg (Oxycodone QL (800 per 30 days) oxycodone-acetaminophen oral HCl/Acetaminophe $0 solution mg/5 ml n) oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) $0 mg, mg oxycodone-acetaminophen oral QL (80 per 30 days) (Xolox) $0 tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) $0 tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) $ mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (20 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg, 5 QL (80 per 30 days) (Opana) $0 mg oxymorphone oral tablet extended QL (60 per 30 days) release 2 hr 0 mg, 5 mg, 20 mg, (Opana ER) $0 5 mg, 7.5 mg 9

24 oxymorphone oral tablet extended QL (20 per 30 days) (Opana ER) $0 release 2 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (80 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 60 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 60 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 60 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 60 mg * reprexain oral tablet mg, QL (50 per 30 days) (Ibudone) $ mg, mg (Oxycodone QL (800 per 30 days) roxicet oral solution mg/5 ml HCl/Acetaminophe n) $0 silapap infant's drops infant 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (80 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 60 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * 0

25 tencon oral tablet mg (Tencon) $0 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) $0 QL (240 per 30 days) tramadol-acetaminophen oral tablet mg (Ultracet) $0 QL (240 per 30 days) vicodin es oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 0 oral tablet mg (Ibudone) $0 QL (50 per 30 days) zebutal oral capsule mg (Esgic) $0 Nonsteroidal Anti- Inflammatory Agents ADVIL 00 MG TABLET JR STRENGTH,COATED 00 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 00 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 00 MG * aspirin 300 mg suppository 300 mg * (Aspirin) aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg * (Aspirin) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years)

26 aspirin 8 mg chewable tablet 8 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 8 mg tablet low dose 8 (Ecotrin) mg * aspir-low ec 8 mg tablet 8 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML) celecoxib oral capsule 00 mg, 200 (Celebrex) $0 mg, 400 mg, 50 mg CHILDREN'S ADVIL 00 MG/5 ML A/F (OTC) 00 MG/5 ML * $0 cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * $0 diclofenac sodium oral tablet (Voltaren-XR) $0 extended release 24 hr 00 mg diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, $0 Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) $0 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) $0 mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) $0 ecpirin ec 325 mg tablet 325 mg * (Ecotrin) bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral diclofenac potassium oral tablet 50 (Aspirin/Calcium (Choline Sal/Mag (Diclofenac mg * liquid 500 mg/5 ml mg Carbonate/Mag) Salicylate) Potassium) QL (60 per 30 days) 2

27 etodolac oral capsule 200 mg, 300 mg (Etodolac) $0 etodolac oral tablet 400 mg, 500 mg (Etodolac) $0 etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) $0 mg fenoprofen oral capsule 200 mg (Nalfon) $0 fenoprofen oral tablet 600 mg (Fenoprofen Calcium) $0 FLECTOR TRANSDERMAL PA PATCH 2 HOUR.3 % flurbiprofen oral tablet 00 mg, 50 mg (Flurbiprofen) $0 gnp ibuprofen jr str 00 mg tb 00 mg * (Advil) ibuprofen 00 mg/5 ml susp children's (otc) 00 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 00 mg/5 ml (Ibuprofen) $0 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) $0 indomethacin oral capsule 25 mg (Indomethacin) $0 QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) $0 QL (20 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) $0 release 75 mg indomethacin sodium intravenous (Indomethacin recon soln mg Sodium) $0 infant ibuprofen 50 mg/.25 ml d/f,a/f,non-staining 50 mg/.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) $0 3

28 ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) $0 ketorolac oral tablet 0 mg (Ketorolac Tromethamine) $0 mefenamic acid oral capsule 250 mg (Ponstel) $0 meloxicam oral suspension 7.5 mg/5 ml (Mobic) $0 meloxicam oral tablet 5 mg, 7.5 mg (Mobic) $0 nabumetone oral tablet 500 mg, 750 mg (Nabumetone) $0 naproxen oral suspension 25 mg/5 ml (Naprosyn) $0 naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) $0 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg $0 naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) $0 piroxicam oral capsule 0 mg, 20 mg (Feldene) $0 ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 00 mg tablet junior (Advil) strength 00 mg * st. joseph aspirin 8 mg chew (Bayer Chewable orange 8 mg * Aspirin) st. joseph aspirin ec 8 mg tb enteric coated 8 mg * (Ecotrin) sulindac oral tablet 50 mg, 200 mg (Sulindac) $0 tolmetin oral capsule 400 mg (Tolmetin Sodium) $0 tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) $0 VOLTAREN TOPICAL GEL % $0 wal-profen 200 mg softgel softgel 200 mg * Anesthetics Local Anesthetics (Advil) QL (20 per 30 days) 4

29 glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) $0 lidocaine (pf) injection solution 5 mg/ml (.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) $0 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) $0 lidocaine hcl injection solution 0 mg/ml ( %), 20 mg/ml (2 %) (Xylocaine) $0 lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) $0 lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) $0 lidocaine topical adhesive patch,medicated 5 % (Lidoderm) $0 lidocaine topical ointment 5 % (Lidocaine) $0 lidocaine-prilocaine topical cream % (EMLA) $0 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg bupropion hcl sr 50 mg tablet f/c 50 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) $0 $0 $0 (Zyban) $0 PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (68 per 84 days) QL (68 per 84 days) 5

30 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) $0 naloxone injection solution 0.4 mg/ml (Naloxone HCl) $0 naloxone injection syringe 0.4 mg/ml, mg/ml (Naloxone HCl) $0 naltrexone oral tablet 50 mg (Revia) $0 NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 4 MG/24HR PATCH 4 MG/24 HR * NICODERM CQ 2 MG/24HR PATCH 2 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 4 mg/24hr patch outer (otc) 4 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 2 mg/24hr patch step (otc) 2 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) QL (53 per 28 days) QL (4 per 30 days) QL (68 per 365 days) QL (68 per 365 days) QL (80 per 365 days) QL (68 per 365 days) QL (68 per 365 days) 6

31 nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * NICOTROL INHALATION CARTRIDGE 0 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 (Nicoderm Cq) QL (80 per 365 days) QL (008 per 90 days) PA; QL (90 per 30 days) QL (20 per 30 days) (Xanax) $0 mg, mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (20 per 30 days) $0 0 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, mg (Klonopin) $0 QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) $0 QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg, 0.25 mg, 0.5 mg, mg (Clonazepam) $0 QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) $0 tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (20 per 30 days) (Tranxene T-Tab) $0 5 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) $ mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) $0 QL (0 per 28 days) diazepam intensol oral concentrate QL (200 per 30 days) (Diazepam) $0 5 mg/ml diazepam oral solution 5 mg/5 ml ( QL (200 per 30 days) (Diazepam) $0 mg/ml) diazepam oral tablet 0 mg, 2 mg, 5 QL (20 per 30 days) (Valium) $0 mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) $0 lorazepam oral tablet 0.5 mg, mg, QL (90 per 30 days) (Ativan) $0 2 mg 7

32 ONFI ORAL SUSPENSION 2.5 MG/ML Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) $0 (Gentamicin Sulfate) $0 (Gentamicin Sulfate/PF) $0 (Gentamicin Sulfate/PF) $0 neomycin oral tablet 500 mg (Neomycin Sulfate) $0 streptomycin intramuscular recon (Streptomycin soln gram Sulfate) $0 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/00 ml tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (Tobi) $0 (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) $0 $0 (Bacitracin) $0 PA NSO; QL (480 per 30 days) QL (224 per 28 days) 8

33 chloramphenicol sod succinate (Chloramphenicol intravenous recon soln gram Sod Succ) $0 clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) $0 clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg (Cleocin HCl) $0 clindamycin in 5 % dextrose (Cleocin Phosphate intravenous piggyback 300 mg/50 In D5w) ml, 600 mg/50 ml, 900 mg/50 ml $0 clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Palmitate) $0 clindamycin phosphate injection (Cleocin solution 50 mg/ml Phosphate) $0 clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) $0 colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 mg Parenteral) $0 CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) $0 linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) $0 linezolid oral suspension for reconstitution 00 mg/5 ml (Zyvox) $0 linezolid oral tablet 600 mg (Zyvox) $0 methenamine hippurate oral tablet gram (Hiprex) $0 metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/00 dium Chloride) ml $0 metronidazole oral capsule 375 mg (Flagyl) $0 metronidazole oral tablet 250 mg, 500 mg (Flagyl) $0 9

34 nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (75/25) (Macrodantin) $0 (Macrobid) $0 (Macrobid) $0 polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) $0 SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg (Trimethoprim) $0 vancomycin hcl g/200 ml bag (Vancomycin Hcl gram/200 ml In Dextrose 5 %) $0 vancomycin intravenous recon soln,000 mg, 0 gram, 750 mg (Vancomycin HCl) $0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) 20

35 vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) $0 vancomycin oral capsule 25 mg, 250 mg (Vancocin HCl) $0 XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) $0 cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 (Cefaclor) $0 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) $0 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) $0 mg/5 ml cefadroxil oral tablet gram (Cefadroxil) $0 cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback gram/50 Sodium/Dextrose, $0 ml, 2 gram/50 ml Iso) cefazolin injection recon soln gram, 0 gram, 500 mg (Cefazolin Sodium) $0 cefdinir oral capsule 300 mg (Cefdinir) $0 cefdinir oral suspension for reconstitution 25 mg/5 ml, 250 (Cefdinir) $0 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) $0 CEFEPIME 2 GM INJECTION 2 GRAM/00 ML PA; QL (9 per 30 days) PA 2

36 CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln gram, 2 gram cefotaxime injection recon soln gram, 0 gram, 2 gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml (Maxipime) $0 (Claforan) $0 (Cefoxitin Sodium/Dextrose, Iso) $0 cefoxitin intravenous recon soln gram, 0 gram, 2 gram (Cefoxitin Sodium) $0 cefpodoxime oral suspension for (Cefpodoxime reconstitution 00 mg/5 ml, 50 mg/5 Proxetil) ml $0 cefpodoxime oral tablet 00 mg, 200 (Cefpodoxime mg Proxetil) $0 cefprozil oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml (Cefprozil) $0 cefprozil oral tablet 250 mg, 500 mg (Cefprozil) $0 ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) $0 ceftibuten oral capsule 400 mg (Cedax) $0 ceftibuten oral suspension for reconstitution 80 mg/5 ml (Cedax) $0 ceftriaxone gm piggyback 50ml (Ceftriaxone galaxycontainer gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone gm vial 0's, fliptop,l/f gram (Rocephin) $0 ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone injection recon soln 0 gram, 250 mg, 500 mg (Rocephin) $0 ceftriaxone intravenous recon soln (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) $0 22

37 cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) $0 cefuroxime sodium injection recon soln.5 gram, 750 mg (Zinacef) $0 cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) $0 cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) $0 cephalexin oral suspension for reconstitution 25 mg/5 ml, 250 (Cephalexin) $0 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) $0 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) $0 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) $0 azithromycin oral packet gram (Zithromax) $0 azithromycin oral suspension for reconstitution 00 mg/5 ml, 200 (Zithromax) $0 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) $0 azithromycin oral tablet 500 mg (Zithromax) $0 23

38 clarithromycin oral suspension for reconstitution 25 mg/5 ml, 250 (Biaxin) $0 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) $0 clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) $0 DIFICID ORAL TABLET 200 MG QL (20 per 0 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) $0 e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) $0 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg (Erythromycin Base) (Erythromycin Stearate) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) $0 $0 $0 $0 $0 (Azactam) $0 (Primaxin) $0 LA 24

39 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln 500 mg meropenem iv gm vial outer, latexfree gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 25 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 2 hr, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 0's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml (Merrem) $0 (Merrem) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Augmentin) $0 (Augmentin) $0 (Augmentin XR) $0 (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) $0 $0 $0 $0 25

40 ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln 2 gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml (Ampicillin Sodium) (Ampicillin Sodium) $0 $0 (Unasyn) $0 (Dicloxacillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 (Oxacillin Sodium) $0 (Oxacillin Sodium/Dextrose, Iso) $0 (Oxacillin Sodium) $0 (Oxacillin Sodium) $0 (Pen G Pot/Dextrose- Water) $0 26

41 penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 25 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 25 mg/ml (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) $0 $0 $0 $0 $0 $0 (Zosyn) $0 (Zosyn) $0 (Cipro) $0 (Cipro I.V.) $0 (Ciprofloxacin Lactate) $0 (Cipro) $0 (Cipro I.V.) $0 (Levaquin) $0 (Levofloxacin) $0 27

42 levofloxacin oral solution 250 mg/0 ml (Levaquin) $0 levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) $0 moxifloxacin oral tablet 400 mg (Avelox) $0 ofloxacin oral tablet 400 mg (Ofloxacin) $0 Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) $0 sulfamethoxazole-trimethoprim intravenous solution mg/5 ml (Sulfamethoxazole/ Trimethoprim) $0 sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension mg/5 ml Trimethoprim) $0 sulfamethoxazole-trimethoprim oral tablet mg, mg (Bactrim) $0 sulfasalazine oral tablet 500 mg (Azulfidine) $0 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) $0 sulfatrim oral suspension (Sulfamethoxazole/ mg/5 ml Trimethoprim) $0 Tetracyclines doxy-00 intravenous recon soln (Doxycycline 00 mg Hyclate) $0 doxycycline hyclate 00 mg cap 00 mg (Morgidox) $0 doxycycline hyclate 00 mg tab 00 mg (Doryx) $0 doxycycline hyclate intravenous (Doxycycline recon soln 00 mg Hyclate) $0 doxycycline hyclate oral capsule 00 mg (Adoxa) $0 doxycycline hyclate oral capsule 50 mg (Morgidox) $0 doxycycline hyclate oral tablet 00 mg, 50 mg (Avidoxy) $0 28

43 doxycycline hyclate oral tablet 20 mg doxycycline mono 00 mg cap 00 mg doxycycline mono 00 mg tablet f/c 00 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 50 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 0 mg, 20 mg, 50 mg adriamycin intravenous solution 0 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml (Doryx) $0 (Adoxa) $0 (Avidoxy) $0 (Avidoxy) $0 (Adoxa) $0 (Vibramycin) $0 (Avidoxy) $0 (Minocin) $0 (Minocycline HCl) $0 (Tetracycline HCl) $0 (Doxorubicin HCl) $0 (Doxorubicin HCl) $0 (Fluorouracil) $0 PA NSO; QL (4 per 2 days) 29

44 adrucil intravenous solution 500 mg/0 ml (Fluorouracil) $0 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet mg (Arimidex) $0 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) azacitidine injection recon soln 00 mg (Vidaza) $0 BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) $0 bicalutamide oral tablet 50 mg (Casodex) $0 bleomycin injection recon soln 30 (Bleomycin unit Sulfate) $0 bleomycin sulfate 5 unit vial latexfree 5 unit Sulfate) (Bleomycin $0 BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG PA NSO; QL (2 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (40 per 365 days) PA NSO; QL (20 per 30 days) PA NSO; QL (30 per 30 days) 30

45 CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG (Cyclophosphamid e) (Cyclophosphamid e) $0 $0 (Dactinomycin) $0 (Dacogen) $0 (Doxil) $0 PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (2 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO PA NSO; LA 3

46 ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 mg/ml (Etoposide) $0 exemestane oral tablet 25 mg (Aromasin) $0 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) $0 fluorouracil 5,000 mg/00 ml latexfree 5 gram/00 ml (Fluorouracil) $0 fluorouracil intravenous solution gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) $0 mg/0 ml flutamide oral capsule 25 mg (Flutamide) $0 QL ( per 84 days) QL ( per 2 days) QL ( per 68 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 32

47 GAZYVA INTRAVENOUS SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) $0 IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG ifosfamide gm/20 ml vial suv gram/20 ml ifosfamide intravenous recon soln gram ifosfamide-mesna intravenous kit - gram, 3,000-,000 mg (Ifex) $0 (Ifex) $0 (Ifosfamide/Mesna ) $0 imatinib oral tablet 00 mg (Gleevec) $0 imatinib oral tablet 400 mg (Gleevec) $0 IMBRUVICA ORAL CAPSULE 40 MG IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) 33

48 INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 5 MG KIT WITH DILUENT 5 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) $0 LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit (Leuprolide mg/0.2 ml Acetate) $0 lipodox 50 intravenous suspension 2 mg/ml (Doxil) $0 PA NSO; QL (80 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (6 per 28 days) PA NSO 34

49 lipodox intravenous suspension 2 mg/ml lomustine oral capsule 0 mg, 00 mg, 40 mg LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Doxil) $0 (Lomustine) $0 (Megestrol Acetate) $0 MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) $0 methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml (Methotrexate $0 Sodium) PA NSO; QL (00 per 28 days) PA NSO; QL (80 per 28 days) QL ( per 84 days) QL ( per 84 days) QL ( per 68 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) 35

50 methotrexate sodium (pf) injection (Methotrexate recon soln gram Sodium/PF) $0 methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) $0 methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) $0 mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) $0 NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg (Nilandron) $0 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML ; ST PA NSO; QL (20 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (00 per 2 days) PA NSO; LA PA NSO 36

51 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 0 mg, 20 mg (Tamoxifen Citrate) $0 TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 MG/ML) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (20 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (2 per 28 days) PA NSO; QL (20 per 2 days) 37

52 TEMODAR INTRAVENOUS RECON SOLN 00 MG thiotepa injection recon soln 5 mg (Thiotepa) $0 toposar intravenous solution 20 mg/ml (Etoposide) $0 TREANDA 25 MG VIAL 25 MG TREANDA INTRAVENOUS RECON SOLN 00 MG TREANDA INTRAVENOUS SOLUTION 80 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 mg (Tretinoin) $0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA NSO; (vial only) QL ( per 68 days) QL ( per 68 days) QL ( per 84 days) (capsule: 0mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA 38

53 vinorelbine intravenous solution 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG (Navelbine) $0 XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0. mg/ml propantheline oral tablet 5 mg (Atropine Sulfate) $0 (Atropine Sulfate) $0 (Propantheline Bromide) $0 PA NSO; QL (20 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (20 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL ( per 84 days) QL ( per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (40 per 28 days) PA NSO; QL (20 per 30 days) 39

54 STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 2 hr 00 mg, 200 mg, (Carbatrol) $0 300 mg carbamazepine oral suspension 00 mg/5 ml (Tegretol) $0 carbamazepine oral tablet 200 mg (Tegretol) $0 carbamazepine oral tablet extended release 2 hr 00 mg, 200 mg, 400 (Tegretol XR) $0 mg carbamazepine oral tablet,chewable 00 mg (Carbamazepine) $0 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG $0 divalproex oral capsule, sprinkle 25 mg (Depakote Sprinkle) $0 QL (4 per 28 days) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 40

55 divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) $0 divalproex oral tablet,delayed release (dr/ec) 25 mg, 250 mg, 500 (Depakote) $0 mg epitol oral tablet 200 mg (Tegretol) $0 ethosuximide oral capsule 250 mg (Zarontin) $0 ethosuximide oral solution 250 mg/5 ml (Zarontin) $0 felbamate oral suspension 600 mg/5 ml (Felbatol) $0 felbamate oral tablet 400 mg, 600 mg (Felbatol) $0 fosphenytoin 500 mg pe/0 ml 0's,sdv,latex-free 500 mg pe/0 ml (Cerebyx) $0 fosphenytoin injection solution 00 mg pe/2 ml (Cerebyx) $0 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg (Neurontin) $0 gabapentin oral solution 250 mg/5 ml (Neurontin) $0 gabapentin oral tablet 600 mg, 800 mg (Neurontin) $0 GABITRIL ORAL TABLET 2 MG, 6 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg (Lamictal) $0 ST ST 4

56 lamotrigine oral tablet extended release 24hr 00 mg, 200 mg, 25 (Lamictal XR) $0 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) $0 lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) $0 levetiracetam intravenous solution 500 mg/5 ml (Keppra) $0 levetiracetam oral solution 00 mg/ml (Keppra) $0 levetiracetam oral tablet,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) $0 levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) $0 LYRICA ORAL CAPSULE 00 QL (90 per 30 days) MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) $0 oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg (Trileptal) $0 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (500 per 30 days) (Phenobarbital) $0 (4 mg/ml) phenobarbital oral tablet 00 mg, QL (90 per 30 days) 5 mg, 6.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) $0 phenobarbital oral tablet 30 mg (Phenobarbital) $0 QL (200 per 30 days) 42

57 phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) $0 solution 30 mg/ml, 65 mg/ml Sodium) phenytoin oral suspension 25 mg/5 ml (Dilantin-25) $0 phenytoin oral tablet,chewable 50 mg (Dilantin) $0 phenytoin sodium extended oral capsule 00 mg, 200 mg, 300 mg (Dilantin) $0 phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) $0 phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) $0 POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) $0 ROWEEPRA ORAL TABLET 500 MG $0 SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) $0 topiragen oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 topiramate oral capsule, sprinkle 5 mg, 25 mg (Topamax) $0 topiramate oral capsule,sprinkle,er 24hr 00 mg, 50 mg, 200 mg, 25 (Qudexy XR) $0 mg, 50 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 days) ST; QL (20 per 30 days) 43

58 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 00 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) (Depacon) $0 valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) $0 valproic acid oral capsule 250 mg (Depakene) $0 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00 mg, 25 mg, 50 mg (Zonegran) $0 Antidementia Agents Antidementia Agents donepezil oral tablet 0 mg, 23 mg, ST QL (200 per 5 days) QL (200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) $0 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) $0 0 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) $0 pellets 24 hr 6 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) $0 QL (200 per 30 days) galantamine oral tablet 2 mg, 4 QL (60 per 30 days) (Razadyne) $0 mg, 8 mg memantine oral solution 2 mg/ml (Namenda) $0 QL (360 per 30 days) memantine oral tablet 0 mg, 5 mg (Namenda) $0 QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) $0 0 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG 44

59 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG buproban oral tablet extended release 50 mg bupropion hcl (smoking deter) oral tablet extended release 50 mg bupropion hcl oral tablet 00 mg, 75 mg bupropion hcl oral tablet extended release 00 mg, 50 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg, 300 mg citalopram oral solution 0 mg/5 ml citalopram oral tablet 0 mg, 20 mg, 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg (Exelon) $0 (Exelon) $0 (Amitriptyline HCl) $0 (Amoxapine) $0 (Wellbutrin SR) $0 (Wellbutrin SR) $0 (Wellbutrin) $0 (Wellbutrin SR) $0 (Wellbutrin XL) $0 (Citalopram Hydrobromide) $0 (Celexa) $0 (Anafranil) $0 QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA NSO-HRM ST QL (30 per 30 days) PA NSO-HRM 45

60 desipramine oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg (Norpramin) $0 doxepin oral capsule 0 mg, 00 PA NSO-HRM (Doxepin HCl) $0 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml (Doxepin HCl) $0 PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) $0 release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) $0 release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) $0 release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) $0 escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg (Lexapro) $0 FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0 mg, 20 mg, 40 mg (Prozac) $0 fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) $0 fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) $0 fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) $0 fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 00 mg, 50 mg Maleate) $0 fluvoxamine oral tablet 00 mg, 25 (Fluvoxamine mg, 50 mg Maleate) $0 46

61 imipramine hcl oral tablet 0 mg, 25 (Tofranil) mg, 50 mg $0 imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg (Tofranil-Pm) $0 maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) $0 MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg (Remeron) $0 mirtazapine oral tablet,disintegrating 5 mg, 30 mg, (Remeron) $0 45 mg nefazodone oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg (Nefazodone HCl) $0 nortriptyline oral capsule 0 mg, 25 mg, 50 mg, 75 mg (Pamelor) $0 nortriptyline oral solution 0 mg/5 ml (Nortriptyline HCl) $0 olanzapine-fluoxetine oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 (Symbyax) $0 mg, 6-50 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg (Paxil) $0 paroxetine hcl oral tablet extended release 24 hr 2.5 mg, 25 mg, 37.5 (Paxil CR) $0 mg PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine-amitriptyline oral (Perphenazine/Ami tablet 2-0 mg, 2-25 mg, 4-0 mg, triptyline HCl) 4-25 mg, 4-50 mg $0 phenelzine oral tablet 5 mg (Nardil) $0 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG, 25 MG, 50 MG PA NSO-HRM PA NSO-HRM PA NSO-HRM ST; QL (30 per 30 days) 47

62 protriptyline oral tablet 0 mg, 5 mg (Protriptyline HCl) $0 sertraline oral concentrate 20 mg/ml (Zoloft) $0 sertraline oral tablet 00 mg, 25 mg, 50 mg (Zoloft) $0 SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG tranylcypromine oral tablet 0 mg (Parnate) $0 trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg (Trazodone HCl) $0 trimipramine oral capsule 00 mg, (Trimipramine 25 mg, 50 mg Maleate) $0 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 50 mg, 37.5 mg, 75 (Effexor XR) $0 mg venlafaxine oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Venlafaxine HCl) $0 venlafaxine oral tablet extended release 24hr 50 mg, 37.5 mg, 75 (Venlafaxine HCl) $0 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23), 0 MG (7)-20 MG (7)-40 MG (6) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG (Precose) $0 QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST QL (90 per 30 days) QL (80 per 30 days) 48

63 GLYXAMBI ORAL TABLET 0-5 ST MG, 25-5 MG INVOKAMET ORAL TABLET ST 50-,000 MG, MG, 50-,000 MG, MG INVOKAMET XR ORAL ST TABLET, IR - ER, BIPHASIC 24HR 50-,000 MG, MG, 50-,000 MG, MG INVOKANA ORAL TABLET 00 ST MG, 300 MG JANUMET ORAL TABLET 50-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 0 ST MG, 25 MG JENTADUETO ORAL TABLET 2.5-,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG, 5-,000 MG KORLYM ORAL TABLET 300 PA; QL (2 per 28 MG days) metformin oral tablet,000 mg (Glucophage) $0 QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) $0 QL (50 per 30 days) metformin oral tablet 850 mg (Glucophage) $0 QL (90 per 30 days) metformin oral tablet extended QL (20 per 30 days) (Glucophage XR) $0 release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) $0 release 24 hr 750 mg 49

64 metformin oral tablet extended release 24hr,000 mg (Fortamet) $0 metformin oral tablet extended release 24hr 500 mg (Fortamet) $0 miglitol oral tablet 00 mg, 25 mg, 50 mg (Glyset) $0 nateglinide oral tablet 20 mg, 60 mg (Starlix) $0 pioglitazone oral tablet 5 mg, 30 mg, 45 mg (Actos) $0 pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg (Duetact) $0 pioglitazone-metformin oral tablet mg, mg (Actoplus Met) $0 repaglinide oral tablet 0.5 mg, mg, (Prandin) 2 mg $0 repaglinide-metformin oral tablet mg, mg (Prandimet) $0 SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET 2.5-,000 MG, MG, 5-,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA Insulins QL (60 per 30 days) QL (50 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (240 per 30 days) QL (50 per 30 days) PA; QL (0.8 per 28 days) PA; QL (6 per 28 days) ST 50

65 HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) QL (24 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) 5

66 Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) $0 QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) $0 QL (60 per 30 days) glipizide oral tablet 0 mg (Glucotrol) $0 QL (20 per 30 days) glipizide oral tablet 5 mg (Glucotrol) $0 QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) $0 release 24hr 0 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) $0 release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) $0 250 mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (20 per 30 days) $0 500 mg, mg in HCl) glyburide micronized oral tablet.5 PA-HRM; AGE (Max (Glynase) $0 mg, 3 mg, 6 mg 64 Years) glyburide oral tablet.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) $0 mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) $ mg, mg, mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) $0 QL (20 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) $0 QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) $0 QL (80 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * (Miconazole Nitrate) AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg (Amphotericin B) $0 anti-fungal % powder % * (Tolnaftate) antifungal 2% cream 2 % * (Nuzole) 52

67 baza antifungal 2% cream 2's 2 % (Nuzole) * blis-to-sol % liquid % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) $0 ciclopirox topical gel 0.77 % (Loprox) $0 ciclopirox topical shampoo % (Loprox) $0 ciclopirox topical solution 8 % (Penlac) $0 ciclopirox topical suspension 0.77 (Ciclopirox $0 % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) $0 topical solution 8 % clotrim % vaginal cream % * (Gyne-Lotrimin) clotrimazole % cream (otc) % * (Lotrimin AF) clotrimazole % solution (otc) % (Clotrimazole) * clotrimazole insert 00 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) $0 troche 0 mg clotrimazole topical cream % (Clotrimazole) $0 clotrimazole topical solution % (Clotrimazole) $0 clotrimazole-7 cream % * (Gyne-Lotrimin) clotrimazole-betamethasone topical (Lotrisone) $0 cream % $0 cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af % spray powder % * (Tinactin) cvs miconazole 3 combo pack 3pref (Miconazole applic w/cream 4 % (200 mg)- 2 % Nitrate) (9 gram) * (Miconazole dermafungal 2% ointment 2 % * Nitrate) clotrimazole-betamethasone topical critic-aid clear af 2% oint 2's, w/ (Clotrimazole/Beta (Miconazole lotion % antifungal 2 % * methasone Dip) Nitrate) 53

68 econazole topical cream % (Econazole Nitrate) $0 elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml $0 fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 200 mg/00 ml (Fluconazole In Nacl,Iso-Osm) $0 fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml (Diflucan) $0 fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg (Diflucan) $0 fluconazole-nacl 400 mg/200 ml (Fluconazole In 0's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) $0 flucytosine oral capsule 250 mg, 500 mg (Ancobon) $0 fungi cure intensive % spray % * (Clotrimazole) FUNGI-NAIL TINCTURE * fungoid-d % cream % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet 500 mg (Grifulvin V) $0 inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 00 mg (Sporanox) $0 ketoconazole oral tablet 200 mg (Ketoconazole) $0 ketoconazole topical cream 2 % (Ketoconazole) $0 ketoconazole topical shampoo 2 % (Nizoral) $0 lamisil af defens % spray pwd % * (Tinactin) lamisil af defense % powder % * (Tolnaftate) LAMISIL ANTIFUNGAL % SPRAY FOR ATHLETES FOOT % * LAMISIL AT % GEL % * 54

69 micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole 7 00 mg vag supp 00 (Miconazole mg * Nitrate) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole $0 200 mg Nitrate) MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 (Nystatin) $0 unit/gram nystatin oral suspension 00,000 (Nystatin) $0 unit/ml nystatin oral tablet 500,000 unit (Nystatin) $0 nystatin topical cream 00,000 (Nystatin) $0 unit/gram nystatin topical ointment 00,000 (Nystatin) $0 unit/gram nystatin topical powder 00,000 (Nystatin) $0 unit/gram $0 nystatin-triamcinolone topical (Nystatin/Triamcin cream 00, unit/g-% ) 55

70 nystatin-triamcinolone topical (Nystatin/Triamcin $0 ointment 00, unit/gram-% ) nystop topical powder 00,000 (Nystatin) $0 unit/gram pv foot odor control % powder % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal % liquid spray liquid (Tolnaftate) spray % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine % cream % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) $0 tolnaftate % cream % * (Tinactin) tolnaftate % solution % * (Tolnaftate) (Miconazole triple paste af 2% ointment 2 % * Nitrate) voriconazole intravenous solution (Vfend IV) $0 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) $0 mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) $0 mg Antihistamines Antihistamines alavert 0 mg odt non-drowsy, mint (Claritin) 0 mg * alavert d-2 allergy-sinus tab 5-20 mg * ALLEGRA ALLERGY 80 MG TABLET 80 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * (Claritin-D 2 Hour) 56

71 aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-2hr tablet 5-20 mg * (Claritin-D 2 Hour) allerclear d-24hr er tablet nondrowsy mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-.34 mg tablet.34 mg * (Clemastine Fumarate) aller-tec d 5-20 mg tablet 5-20 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet mg * (Triprolidine/Pseud oephedrine) banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 2.5 mg/5 ml a/f 2.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl mg/ ml soln children, s/f, grape (otc) mg/ml * (Children'S Zyrtec) cetirizine hcl 0 mg tablet indoor & outdoor 0 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er 5-20 mg tab 5-20 mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * 57

72 child triaminic cold & allergy -2.5 mg/5 ml * child wal-tap cold-allergy elx -2.5 mg/5 ml * CHILD ZYRTEC MG/ML SOLUTION D/F,S/F,GRAPE MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 0 MG ODT 0 MG * child's aller-tec mg/ml soln mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-dryl 2.5 mg/5 ml a/f,s/f,d/f,bubb gum 2.5 mg/5 ml * child's wal-zyr 0 mg chew tab 0 mg * CLARITIN 0 MG LIQUI-GEL CAP 0 MG * CLARITIN 0 MG REDITABS 0 MG * CLARITIN 0 MG TABLET (OTC) 0 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 0 mg sftgl 0 mg * (Dimetapp) (Dimetapp) (Children'S Zyrtec) (Zzzquil) (Zyrtec) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) 58

73 cvs child allergy 0 mg chw tb 24 hr,indoor/outdoor 0 mg * cvs cold & cough nighttime liq mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-.34 mg tablet.34 mg * dayhist allergy.34 mg tablet 2 hr relief.34 mg * dimaphen elixir a/f, grape, gluten-f -2.5 mg/5 ml * dimetapp cold & congest liquid mg/5 ml * (Zyrtec) (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) $0 $0 (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 2.5 mg/5 ml soln 2.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine $0 solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-0 mg tablet 4-0 mg (Chlorpheniramine/ * Phenylephrine) 59

74 fexofenadine hcl 80 mg tablet (Allegra Allergy) 24hr,original str (otc) 80 mg * fexofenadine hcl 30 mg/5 ml 30 (Fexofenadine mg/5 ml * HCl) fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) $0 ml levocetirizine oral tablet 5 mg (Xyzal) $0 loratadine 0 mg tablet 0 mg * (Claritin) loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S s/f 5 mg/5 ml * Claritin) loratadine-d 2 hour tablet nondrowsy 5-20 mg * Hour) (Claritin-D 2 loratadine-d 24hr tablet mg (Claritin-D 24 * Hour) $0 q-dryl 2.5 mg/5 ml liquid a/f 2.5 (Zzzquil) mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 2.5 mg/5 ml liquid 2.5 (Zzzquil) mg/5 ml * (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 sm allergy relief.34 mg tab.34 sm sinus and allergy tablet (Promethazine (Diphenhydramine (Diphenhydramine (Clemastine (Chlorpheniramine/ ml mg * mg * mg * maximum strength 4-60 mg * HCl) HCl) HCl) Fumarate) Pseudoephed) PA-HRM; AGE (Max 64 Years) 60

75 sm z-sleep 50 mg/30 ml liquid (Zzzquil) berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE MG/5 ML * unisom 50 mg sleepgels softgel 50 (Zzzquil) mg * wal-act d cold & allergy tab (Triprolidine/Pseud mg * oephedrine) wal-dryl allergy 25 mg capsule 25 (Zzzquil) mg * wal-dryl allergy 25 mg minitab (Diphenhydramine minitab, coated 25 mg * HCl) wal-fex allergy 80 mg tablet 80 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 0 mg odt non-drowsy 0 (Claritin) mg * wal-itin 0 mg tablet non-drowsy 0 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 2 wal-itin d 2 hour tablet 5-20 mg * Hour) wal-itin d 24 hour tablet mg (Claritin-D 24 * Hour) wal-phed pe sinus-allergy tab 4-0 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 6

76 wal-sleep z 25 mg odt 25 mg * (Unisom Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * (Zzzquil) wal-som 25 mg tablet 25 mg * (Doxylamine Succinate) wal-som 50 mg softgel softgel 50 mg * (Zzzquil) wal-tap elixir -2.5 mg/5 ml * (Dimetapp) wal-zyr 0 mg tablet 0 mg * (Zyrtec) wal-zyr d tablet 2 hr 5-20 mg * (Zyrtec-D) wal-zyr solution children's, a/f mg/ml * (Children'S Zyrtec) ZYRTEC 0 MG LIQUID GELS 0 MG * ZYRTEC 0 MG ODT 0 MG * ZYRTEC 0 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 0 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 0% CREAM 0 % * AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) $0 metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) $0 terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) $0 terconazole vaginal suppository 80 mg (Terconazole) $0 Antimigraine Agents 62

77 Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) $0 solution mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) $0 ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet mg, 2.5 mg (Amerge) $0 QL (8 per 28 days) rizatriptan oral tablet 0 mg, 5 mg (Maxalt) $0 QL (8 per 28 days) rizatriptan oral tablet,disintegrating QL (8 per 28 days) (Maxalt Mlt) $0 0 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng p/f,dehp/f,pvc/f 6 mg/0.5 ml sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials (Sumatriptan Succinate) $0 (Imitrex) $0 (Imitrex) $0 (Sumatriptan Succinate) $0 (Imitrex) $0 (Sumatriptan Succinate) (Sumatriptan Succinate) $0 $0 (Imitrex) $0 (Zomig) $0 (Zomig Zmt) $0 QL (4 per 28 days) QL (2 per 28 days) QL (8 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (2 per 28 days) QL (2 per 28 days) 63

78 CAPASTAT INJECTION RECON SOLN GRAM dapsone oral tablet 00 mg, 25 mg (Dapsone) $0 ethambutol oral tablet 00 mg, 400 mg (Myambutol) $0 isoniazid oral solution 50 mg/5 ml (Isoniazid) $0 isoniazid oral tablet 00 mg, 300 mg (Isoniazid) $0 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) $0 rifabutin oral capsule 50 mg (Mycobutin) $0 rifampin intravenous recon soln 600 mg (Rifadin) $0 rifampin oral capsule 50 mg, 300 mg (Rifadin) $0 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300- PA; QL (88 per 68 days) 0.5 MG compro rectal suppository 25 mg (Compazine) $0 cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml $0 dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) 64

79 dronabinol oral capsule 0 mg, 2.5 mg, 5 mg (Marinol) $0 EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 50 MG EMEND ORAL CAPSULE 25 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 25 MG ()- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous (Granisetron solution 00 mcg/ml HCl/PF) $0 granisetron hcl intravenous solution mg/ml ( ml) (Granisetron HCl) $0 granisetron hcl oral tablet mg (Granisetron HCl) $0 meclizine 2.5 mg caplet caplet (otc) 2.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 2.5 mg, 25 mg (Meclizine HCl) $0 motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) $0 ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) $0 ondansetron hcl oral solution 4 (Zofran) $0 mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) $0 mg, 8 mg ondansetron oral (Zofran Odt) $0 tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 2.5 PA-HRM; AGE (Max (Phenergan) $0 mg, 25 mg 64 Years) 65

80 prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral tablet 2.5 mg, 25 mg, 50 mg promethazine rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 2.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY.5 MG ( MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Prochlorperazine Edisylate) $0 (Compazine) $0 (Compazine) $0 (Promethazine HCl) $0 (Phenergan) $0 (Phenergan) $0 (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) $0 atovaquone-proguanil oral tablet mg, mg (Malarone) $0 chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) $0 COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (0 per 30 days) 66

81 EMVERM ORAL TABLET,CHEWABLE 00 MG $0 hydroxychloroquine oral tablet 200 mg (Plaquenil) $0 ivermectin oral tablet 3 mg (Stromectol) $0 mefloquine oral tablet 250 mg (Mefloquine HCl) $0 NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) $0 PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (6 per 2 days) QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) $0 PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 mg (Amantadine HCl) $0 amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) $0 amantadine hcl oral tablet 00 mg (Amantadine HCl) $0 APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML AZILECT ORAL TABLET 0.5 MG, MG benztropine oral tablet 0.5 mg, (Benztropine mg, 2 mg Mesylate) $0 bromocriptine oral capsule 5 mg (Parlodel) $0 bromocriptine oral tablet 2.5 mg (Parlodel) $0 cabergoline oral tablet 0.5 mg (Cabergoline) $0 carbidopa oral tablet 25 mg (Lodosyn) $0 carbidopa-levodopa oral tablet 0-00 mg, mg, mg (Sinemet CR) $0 carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) $0 mg QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 67

82 carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg (Stalevo 50) $0 entacapone oral tablet 200 mg (Comtan) $0 NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg (Mirapex) $0 ropinirole oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) $0 ropinirole oral tablet extended release 24 hr 2 mg, 2 mg, 4 mg, 6 (Requip XL) $0 mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) $0 selegiline hcl oral tablet 5 mg (Selegiline HCl) $0 trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) $0 trihexyphenidyl oral tablet 2 mg, 5 (Trihexyphenidyl mg HCl) $0 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL ( per 28 days) 68

83 ABILIFY MAINTENA QL ( per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution mg/ml (Abilify) $0 QL (900 per 30 days) aripiprazole oral tablet 0 mg, 5 QL (30 per 30 days) (Abilify) $0 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) $0 QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 0 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 5 mg ARISTADA INTRAMUSCULAR QL (.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) $0 chlorpromazine oral tablet 0 mg, (Chlorpromazine 00 mg, 200 mg, 25 mg, 50 mg HCl) $0 clozapine oral tablet 00 mg (Clozaril) $0 QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) $0 QL (35 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) $0 QL (90 per 30 days) clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 50 mg, 200 mg, (Fazaclo) $0 ST 25 mg FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG ST; QL (60 per 30 days) 69

84 FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 00 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/2.625 ML (Fluphenazine Decanoate) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) $0 $0 $0 $0 $0 $0 $0 $0 $0 (Haloperidol) $0 ST; QL (8 per 28 days) QL (6 per 28 days) 70

85 LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 0 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) $0 molindone oral tablet 0 mg (Molindone HCl) $0 QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) $0 QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) $0 QL (20 per 30 days) NUPLAZID ORAL TABLET 7 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) $0 0 mg olanzapine oral tablet 0 mg, 5 QL (30 per 30 days) (Zyprexa) $0 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) $0 0 mg, 5 mg, 5 mg olanzapine oral tablet,disintegrating QL (3 per 30 days) (Zyprexa Zydis) $0 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) $0 release 24hr.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) $0 release 24hr 6 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg (Perphenazine) $0 pimozide oral tablet mg, 2 mg (Orap) $0 quetiapine oral tablet 00 mg, 200 QL (90 per 30 days) (Seroquel) $0 mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (20 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML 7

86 risperidone oral solution mg/ml (Risperdal) $0 QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) $0 mg, mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, mg, 2 mg (Risperdal M-Tab) $0 risperidone oral QL (20 per 30 days) (Risperdal M-Tab) $0 tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG ST; QL (60 per 30 days) thioridazine oral tablet 0 mg, 00 PA NSO-HRM (Thioridazine HCl) $0 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 (Thiothixene) $0 mg, 2 mg, 5 mg trifluoperazine oral tablet mg, 0 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG (Trifluoperazine HCl) $0 (Geodon) $0 Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) $0 ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 72

87 abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG (Trizivir) $0 (Videx EC) $0 73

88 INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 mg/ml (Epivir) $0 lamivudine oral tablet 00 mg, 50 mg, 300 mg (Epivir) $0 lamivudine-zidovudine oral tablet mg (Combivir) $0 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) $0 nevirapine oral tablet 200 mg (Viramune) $0 nevirapine oral tablet extended release 24 hr 00 mg, 400 mg (Viramune XR) $0 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG 74

89 PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 50 MG, 300 MG stavudine oral capsule 5 mg, 20 mg, 30 mg, 40 mg (Zerit) $0 stavudine oral recon soln mg/ml (Zerit) $0 STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG 75

90 VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 50 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg (Retrovir) $0 zidovudine oral syrup 0 mg/ml (Retrovir) $0 zidovudine oral tablet 300 mg (Zidovudine) $0 Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) $0 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 mg (Flumadine) $0 SYNAGIS 00 MG/ ML VIAL 00 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG QL (84 per 80 days) QL (48 per 80 days) 76

91 TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 50 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 2.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG ZEPATIER ORAL TABLET MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 0 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION RECON SOLN 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML QL (42 per 80 days) QL (540 per 80 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (2 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO PA NSO PA NSO 77

92 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 20 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) $0 acyclovir oral suspension 200 mg/5 ml (Zovirax) $0 acyclovir oral tablet 400 mg, 800 mg (Zovirax) $0 acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) $0 adefovir oral tablet 0 mg (Hepsera) $0 entecavir oral tablet 0.5 mg, mg (Baraclude) $0 famciclovir oral tablet 25 mg, 250 mg, 500 mg (Famvir) $0 ganciclovir sodium intravenous recon soln 500 mg (Cytovene) $0 ribasphere oral capsule 200 mg (Rebetol) $0 ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) $0 TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet gram, 500 mg (Valtrex) $0 PA PA PA PA PA NSO; QL (4 per 28 days) 78

93 valganciclovir oral tablet 450 mg (Valcyte) $0 VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 00 mg/ml, 20 mg/0.8 ml, 50 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 0 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 2,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml) (Lovenox) $0 (Lovenox) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) $0 $0 QL (24 per 30 days) QL (5 per 30 days) QL (2 per 30 days) QL (8 per 30 days) 79

94 heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (00 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (00 units/ml) bag excel container 25,000 unit/250 ml(00 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 5 MG jantoven oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) $0 $0 $0 $0 $0 $0 (Coumadin) $0 (Coumadin) $0 PA; QL (24 per 28 days) ST; QL (60 per 30 days) PA 80

95 EPOGEN 0,000 UNITS/ML VIAL SDV, P/F, OUTER 0,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 00 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 0,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (0.6 per 28 days) PA; QL (2 per 28 days) 8

96 PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet,000 mg, 500 mg anagrelide oral capsule 0.5 mg, mg protamine intravenous solution 0 mg/ml tranexamic acid intravenous solution,000 mg/0 ml (00 (Aminocaproic Acid) (Aminocaproic Acid) $0 $0 (Agrylin) $0 (Protamine Sulfate) $0 (Tranexamic Acid) $0 PA; QL (2 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) $0 QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 2 hr mg (Aggrenox) $0 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg (Pletal) $0 clopidogrel oral tablet 300 mg, 75 mg (Plavix) $0 dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) $0 82

97 EFFIENT ORAL TABLET 0 MG, 5 MG pentoxifylline oral tablet extended release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % (Pentoxifylline) $0 QL (30 per 30 days) AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % 83

98 AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 84

99 CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 85

100 CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 0 % in water (d0w) intravenous solution dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % (Cysteine HCl) $0 (Dextrose) (Dextrose 0 % in Water) (Dextrose 0 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) $0 $0 $0 $0 $0 dextrose 5 % in ringers intravenous (Dextrose 5 % In parenteral solution 5 % Ringers) $0 dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous parenteral solution Water) $0 dextrose 50 % in water (d50w) (Dextrose 50 % in $0 intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in $0 intravenous syringe Water) 86

101 dextrose 70 % in water (d70w) (Dextrose 70 % in $0 intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, (Dextrose) caffeine free 4 gram * glucose 40% gel tropical fruit 40 % (Dextrose) * glutose 5 gel 3 pak, outer, u-d 40 (Dextrose) % * HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/3 gram * insta-glucose gel 24 gram/3 gram (Dextrose/Dextrin/ * Maltose) INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % 87

102 PREMASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0. mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.-5 mg, mg, mg doxazosin oral tablet mg, 2 mg, 4 mg, 8 mg (Fat Emul/Soy/Mct/Oli v/fish Oil) (Catapres) $0 (Catapres-Tts ) $0 (Catapres-Tts ) $0 (Clonidine HCl/Chlorthalidon e) $0 (Cardura) $0 QL (4 per 28 days) QL (8 per 28 days) 88

103 guanfacine oral tablet mg, 2 mg (Tenex) $0 midodrine oral tablet 0 mg, 2.5 mg, (Midodrine HCl) 5 mg $0 NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG phenylephrine hcl injection solution 0 mg/ml (Vazculep) $0 prazosin oral capsule mg, 2 mg, 5 mg (Minipress) $0 Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 6 mg, 32 mg, 4 mg, 8 mg (Atacand) $0 candesartan-hydrochlorothiazid oral tablet mg, mg, (Atacand HCT) $ mg ENTRESTO ORAL TABLET MG, 49-5 MG, MG irbesartan oral tablet 50 mg, 300 mg, 75 mg (Avapro) $0 irbesartan-hydrochlorothiazide oral tablet mg, mg (Avalide) $0 losartan oral tablet 00 mg, 25 mg, 50 mg (Cozaar) $0 losartan-hydrochlorothiazide oral tablet mg, mg, 50- (Hyzaar) $0 2.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) $0 PA-HRM; AGE (Max 64 Years) PA; QL (80 per 30 days) PA; QL (60 per 30 days) 89

104 telmisartan-hydrochlorothiazid oral tablet mg, mg, mg TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution.25 mg/ml enalapril-hydrochlorothiazide oral tablet 0-25 mg, mg fosinopril oral tablet 0 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Micardis HCT) $0 (Diovan) $0 (Diovan HCT) $0 (Lotensin) $0 (Lotensin HCT) $0 (Captopril) $0 (Captopril/Hydroch lorothiazide) $0 (Vasotec) $0 (Enalaprilat Dihydrate) $0 (Vaseretic) $0 (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) $0 $0 (Zestril) $0 ST 90

105 lisinopril-hydrochlorothiazide oral tablet mg, mg, 20- (Zestoretic) $0 25 mg moexipril oral tablet 5 mg, 7.5 mg (Moexipril HCl) $0 moexipril-hydrochlorothiazide oral tablet mg, 5-25 mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 0 mg, 20 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 00 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 00 mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide oral tablet 00 mg, 50 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 50 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG (Moexipril/Hydroc hlorothiazide) $0 (Aceon) $0 (Accupril) $0 (Accuretic) $0 (Altace) $0 (Mavik) $0 (Cordarone) $0 (Norpace) $0 (Tikosyn) $0 (Tambocor) $0 (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) $0 $0 (Mexiletine HCl) $0 9

106 pacerone oral tablet 00 mg, 200 mg, 400 mg (Cordarone) $0 procainamide injection solution 00 (Procainamide mg/ml, 500 mg/ml HCl) $0 propafenone oral capsule,extended release 2 hr 225 mg, 325 mg, 425 mg (Rythmol SR) $0 propafenone oral tablet 50 mg, 225 (Rythmol) mg, 300 mg $0 quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) $0 quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) $0 quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) $0 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) $0 atenolol oral tablet 00 mg, 25 mg, 50 mg (Tenormin) $0 atenolol-chlorthalidone oral tablet mg, mg (Tenoretic 50) $0 betaxolol oral tablet 0 mg, 20 mg (Betaxolol HCl) $0 bisoprolol fumarate oral tablet 0 mg, 5 mg (Zebeta) $0 bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) $ mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg (Coreg) $0 esmolol intravenous solution 00 mg/0 ml (0 mg/ml) (Brevibloc) $0 92

107 labetalol intravenous solution 5 mg/ml (Labetalol HCl) $0 labetalol oral tablet 00 mg, 200 mg, 300 mg (Trandate) $0 metoprolol succinate oral tablet extended release 24 hr 00 mg, 200 (Toprol XL) $0 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, mg (Lopressor HCT) $0 metoprolol tartrate intravenous (Metoprolol solution 5 mg/5 ml Tartrate) $0 metoprolol tartrate intravenous (Metoprolol syringe 5 mg/5 ml Tartrate) $0 metoprolol tartrate oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Lopressor) $0 nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg $0 pindolol oral tablet 0 mg, 5 mg (Pindolol) $0 propranolol intravenous solution mg/ml (Propranolol HCl) $0 propranolol oral capsule,extended release 24 hr 20 mg, 60 mg, 60 (Inderal LA) $0 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) $0 propranolol oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) $0 propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet mg, mg chlorothiazid) $0 sorine oral tablet 20 mg, 60 mg, 240 mg, 80 mg (Betapace) $0 sotalol 20 mg tablet 20 mg (Betapace) $0 sotalol af oral tablet 20 mg (Betapace) $0 sotalol oral tablet 60 mg, 240 mg, 80 mg (Betapace) $0 93

108 timolol maleate oral tablet 0 mg, 20 mg, 5 mg (Timolol Maleate) $0 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 20 mg, 80 mg, 240 (Cardizem CD) $0 mg, 300 mg diltiazem 24hr er 80 mg cap 80 mg (Cardizem CD) $0 diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) $0 diltiazem hcl intravenous recon soln 00 mg (Cardizem CD) $0 diltiazem hcl intravenous solution 5 mg/ml (Cardizem CD) $0 diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg (Cardizem CD) $0 diltiazem hcl oral capsule,extended release 2 hr 20 mg, 60 mg, 90 mg (Cardizem CD) $0 diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 (Cardizem CD) $0 mg diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg (Cardizem CD) $0 diltiazem hcl oral tablet extended release 24 hr 80 mg, 240 mg, 300 (Cardizem LA) $0 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release (Cardizem CD) degradable 20 mg, 80 mg, 240 mg $0 matzim la oral tablet extended release 24 hr 80 mg, 240 mg, 300 (Cardizem CD) $0 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 20 mg, 80 mg, 240 mg, (Cardizem CD) $0 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml (Verapamil HCl) $0 94

109 verapamil oral capsule, 24 hr er pellet ct 00 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 20 mg, 80 mg, 240 mg, 360 mg verapamil oral tablet 20 mg, 40 mg, 80 mg verapamil oral tablet extended release 20 mg, 80 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Verelan Pm) $0 (Verelan) $0 (Calan) $0 (Calan SR) $0 digitek oral tablet 25 mcg (Lanoxin) $0 digitek oral tablet 250 mcg (Lanoxin) $0 digox 25 mcg tablet 25 mcg (Lanoxin) $0 ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) 95

110 digox 250 mcg tablet 250 mcg (Lanoxin) $0 digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) $0 (Digoxin) $0 digoxin oral tablet 25 mcg (Lanoxin) $0 digoxin oral tablet 250 mcg (Lanoxin) $0 dobutamine in d5w intravenous parenteral solution,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (2.5 mg/ml) (Dobutamine HCl/D5W) $0 (Dobutamine HCl) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 96

111 dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution mg/ml ( ml) epinephrine injection auto-injector 0.5 mg/0.5 ml, 0.3 mg/0.3 ml epinephrine injection solution mg/ml ( ml) epinephrine injection syringe 0. mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg (Dopamine HCl/D5W) $0 (Dopamine HCl) $0 (Ephedrine Sulfate) $0 (Epinephrine HCl/PF) $0 (Adrenaclick) $0 (Epinephrine) $0 (Epinephrine) $0 (Ethanolamine Oleate) $0 (Hydralazine HCl) $0 (Hydralazine HCl) $0 97

112 LANOXIN ORAL TABLET 87.5 MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/00 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution mg/ml norepinephrine bitartrate intravenous solution mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 50 mg RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 0 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule 0-20 mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg (Milrinone Lactate/D5W) $0 (Milrinone Lactate) $0 (Levophed Bitartrate) $0 (Papaverine HCl) $0 (Papaverine HCl) $0 (Adalat CC) $0 (Norvasc) $0 (Lotrel) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA PA 98

113 amlodipine-valsartan oral tablet 0-60 mg, mg, 5-60 mg, 5- (Exforge) $0 320 mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) $ mg AZOR ORAL TABLET 0-20 MG, 0-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/00 ML felodipine oral tablet extended release 24 hr 0 mg, 2.5 mg, 5 mg (Felodipine) $0 isradipine oral capsule 2.5 mg, 5 mg (Isradipine) $0 nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) $0 nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) $0 nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) $0 Diuretics amiloride oral tablet 5 mg (Amiloride HCl) $0 amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) $0 bumetanide injection solution 0.25 mg/ml (Bumetanide) $0 bumetanide oral tablet 0.5 mg, mg, 2 mg (Bumetanide) $0 chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) $0 chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) $0 ST 99

114 chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) $0 DYRENIUM ORAL CAPSULE 00 MG, 50 MG furosemide injection solution 0 mg/ml (Furosemide) $0 furosemide injection syringe 0 mg/ml (Furosemide) $0 furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) $0 furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) $0 hydrochlorothiazide oral capsule 2.5 mg (Microzide) $0 hydrochlorothiazide oral tablet 2.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) $0 indapamide oral tablet.25 mg, 2.5 mg (Indapamide) $0 methyclothiazide oral tablet 5 mg (Methyclothiazide) $0 metolazone oral tablet 0 mg, 2.5 mg, 5 mg (Zaroxolyn) $0 torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg (Demadex) $0 triamterene-hydrochlorothiazid oral capsule mg, mg (Dyazide) $0 triamterene-hydrochlorothiazid oral tablet mg, mg (Maxzide) $0 Dyslipidemics amlodipine-atorvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg, mg, mg, (Caduet) $0 mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Lipitor) $0 00

115 cholestyramine light oral powder 4 (Cholestyramine/A gram spartame) $0 cholestyramine light oral powder in packet 4 gram (Questran) $0 cholestyramine packet 4 gram (Questran) $0 colestipol hcl granules packet 5 gram (Colestid) $0 colestipol oral granules 5 gram (Colestid) $0 colestipol oral tablet gram (Colestid) $0 endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 (Lofibra) $0 mg fenofibrate nanocrystallized oral tablet 45 mg, 48 mg (Tricor) $0 fenofibrate oral tablet 20 mg, 60 mg, 40 mg, 54 mg (Lofibra) $0 fenofibric acid (choline) oral capsule,delayed release(dr/ec) 35 (Trilipix) $0 mg, 45 mg fenofibric acid oral tablet 05 mg, 35 mg (Fibricor) $0 gemfibrozil oral tablet 600 mg (Lopid) $0 JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET MG, 2 MG, 4 MG lovastatin oral tablet 0 mg, 20 mg, 40 mg (Mevacor) $0 niacin 50 mg tablet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) niacin 500 mg tablet 500 mg * (Slo-Niacin) PA PA; QL (4 per 28 days) QL (30 per 30 days) 0

116 niacin oral tablet extended release 24 hr,000 mg, 500 mg, 750 mg (Niaspan) $0 niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) $0 omega-3 acid ethyl esters oral capsule gram (Lovaza) $0 PRALUENT PEN PA; QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML PRALUENT SYRINGE PA; QL (2 per 28 days) SUBCUTANEOUS SYRINGE 50 MG/ML, 75 MG/ML pravastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Pravachol) $0 prevalite oral powder 4 gram (Cholestyramine/A spartame) $0 prevalite packet outer 4 gram (Cholestyramine/A spartame) $0 REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE PA; QL (3.5 per 28 days) INJECTOR 420 MG/3.5 ML REPATHA SURECLICK PA; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML PA; QL (3 per 28 days) rosuvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Crestor) $0 simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Zocor) $0 simvastatin oral tablet 80 mg (Zocor) $0 QL (30 per 30 days) 02

117 VASCEPA ORAL CAPSULE GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 0 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) $0 spironolactone oral tablet 00 mg, 25 mg, 50 mg (Aldactone) $0 spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg $0 Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg (Isochron) $0 isosorbide dinitrate oral tablet extended release 40 mg (Isochron) $0 isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) $0 isosorbide mononitrate oral tablet (Isosorbide 0 mg, 20 mg Mononitrate) $0 isosorbide mononitrate oral tablet extended release 24 hr 20 mg, 30 (Imdur) $0 mg, 60 mg minitran transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) $0 minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) $0 minoxidil oral tablet 0 mg, 2.5 mg (Minoxidil) $0 NITRO-BID TRANSDERMAL OINTMENT 2 % $0 QL (30 per 30 days) QL (60 per 30 days) 03

118 nitroglycerin in 5 % dextrose intravenous solution 00 mg/250 ml (400 mcg/ml), 25 mg/250 ml (00 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/0 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (25 mg/ml caffeine) clonidine hcl oral tablet extended release 2 hr 0. mg dexmethylphenidate oral tablet 0 mg, 2.5 mg, 5 mg (Nitroglycerin/D5 W) $0 (Nitroglycerin) $0 (Nitrostat) $0 (Nitro-Dur) $0 (Nitro-Dur) $0 (Cafcit) $0 (Cafcit) $0 (Caffeine/Sodium Benzoate) $0 (Kapvay) $0 (Focalin) $0 QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) QL (60 per 30 days) 04

119 dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg dextroamphetamine oral tablet 0 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 0 mg, 5 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0. mg/ml guanfacine oral tablet extended release 24 hr mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg (Dexedrine) $0 (Dexedrine) $0 (Adderall XR) $0 (Adderall XR) $0 (Adderall) $0 (Romazicon) $0 (Intuniv) $0 (Lithium Carbonate) $0 (Lithobid) $0 (Lithobid) $0 (Lithium Citrate) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 QL (20 per 30 days) QL (80 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) 05

120 methylphenidate oral capsule,er biphasic mg, 40 mg (Metadate Cd) $0 methylphenidate oral solution 0 mg/5 ml, 5 mg/5 ml (Methylin) $0 methylphenidate oral tablet 0 mg, 20 mg, 5 mg (Ritalin) $0 methylphenidate oral tablet (Methylphenidate extended release 0 mg, 20 mg HCl) $0 methylphenidate oral tablet extended release 24hr 8 mg, 27 (Concerta) $0 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) $0 NUEDEXTA ORAL CAPSULE 20-0 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) $0 SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 2.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 2.5 mg, 25 mg (Xenazine) $0 Contraceptives Contraceptives AFTERA.5 MG TABLET.5 MG * 3 $0 altavera (28) oral tablet mg (Amethyst) $0 QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (2 per 28 days) QL (6 per 365 days) 06

121 alyacen /35 (28) oral tablet -35 mg-mcg (Modicon) $0 alyacen 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 amethia lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (7) (Seasonique) $0 amethia oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) apri oral tablet mg (Desogen) $0 aranelle (28) oral tablet 0.5// mg-mcg (Modicon) $0 ashlyna oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) aubra oral tablet mg-mcg (Amethyst) $0 aviane oral tablet mg-mcg (Amethyst) $0 azurette (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 balziva (28) oral tablet mgmcg (Modicon) $0 bekyree (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 blisovi 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 blisovi fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 blisovi fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 briellyn oral tablet mg-mcg (Modicon) $0 camila oral tablet 0.35 mg (Nor-Q-D) $0 camrese lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (Seasonique) $0 (7) QL (9 per 84 days) QL (9 per 84 days) QL (9 per 84 days) 07

122 camrese oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) caziant (28) oral tablet 0./.25/.5-25 mg-mcg cryselle (28) oral tablet mgmcg cyclafem /35 (28) oral tablet -35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Seasonique) $0 (Desogen) $0 (Norgestrel-Ethinyl Estradiol) $0 (Modicon) $0 (Modicon) $0 cyred oral tablet mg (Desogen) $0 dasetta /35 (28) oral tablet -35 mg-mcg (Modicon) $0 dasetta 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 daysee oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 deblitane oral tablet 0.35 mg (Nor-Q-D) $0 delyla (28) oral tablet mgmcg (Amethyst) $0 desog-e.estradiol/e.estradiol oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 desogestrel-ethinyl estradiol oral tablet mg (Desogen) $0 drospirenone-ethinyl estradiol oral tablet mg, mg (Yaz) $0 econtra ez.5 mg tablet inner.5 mg * (Aftera) QL (9 per 84 days) QL (9 per 84 days) QL (6 per 365 days) (Norgestrel-Ethinyl elinest oral tablet mg-mcg $0 Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg (Desogen) $0 enpresse oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 08

123 enskyce oral tablet mg (Desogen) $0 errin oral tablet 0.35 mg (Nor-Q-D) $0 estarylla oral tablet mg-mcg (Ortho-Cyclen) $0 fallback solo.5 mg tablet inner.5 mg * (Aftera) falmina (28) oral tablet mgmcg (Amethyst) $0 gianvi (28) oral tablet mg (Yaz) $0 gildagia oral tablet mg-mcg (Modicon) $0 gildess.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg $0 gildess /20 (2) oral tablet -20 mg-mcg (Loestrin) $0 gildess 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 gildess fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 gildess fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 heather oral tablet 0.35 mg (Nor-Q-D) $0 introvale oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jencycla oral tablet 0.35 mg (Nor-Q-D) $0 jolessa oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jolivette oral tablet 0.35 mg (Nor-Q-D) $0 juleber oral tablet mg (Desogen) $0 junel.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 junel /20 (2) oral tablet -20 mgmcg (Loestrin) $0 junel fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 junel fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 QL (6 per 365 days) QL (9 per 84 days) QL (9 per 84 days) 09

124 junel fe 24 oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 kariva (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 kelnor /35 (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 kimidess (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 kurvelo oral tablet mg (Amethyst) $0 l norgest/e.estradiol-e.estrad oral QL (9 per 84 days) tablets,dose pack,3 month 0.0 mg- 20 mcg (84)/0 mcg (7), 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 larin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 larin /20 (2) oral tablet -20 mgmcg (Loestrin) $0 larin 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 larin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 larin fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 larissia oral tablet mg-mcg (Amethyst) $0 leena 28 oral tablet 0.5// mg-mcg (Modicon) $0 lessina oral tablet mg-mcg (Amethyst) $0 levonest (28) oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 levonor-eth estrad outer QL (9 per 84 days) (Amethyst) $ mg levonorgestrel.5 mg tablet (otc) QL (6 per 365 days) (Aftera).5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) $0 QL (2 per 365 days) levonorgestrel oral tablet.5 mg (Plan B One-Step) $0 QL (6 per 365 days) 0

125 levonorgestrel-ethinyl estrad oral tablet mg-mcg (Amethyst) $0 levonorgestrel-ethinyl estrad oral QL (9 per 84 days) tablets,dose pack,3 month 0.5 mg- 30 mcg (Amethyst) $0 levonorg-eth estrad triphasic oral QL (9 per 84 days) tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 levora-28 oral tablet mg (Amethyst) $0 lomedia 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 loryna (28) oral tablet mg (Yaz) $0 low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) $0 lutera (28) oral tablet mgmcg (Amethyst) $0 lyza oral tablet 0.35 mg (Nor-Q-D) $0 marlissa oral tablet mg (Amethyst) $0 microgestin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 microgestin /20 (2) oral tablet - 20 mg-mcg (Loestrin) $0 microgestin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 microgestin fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) (Loestrin Fe) $0 mono-linyah oral tablet mgmcg (Ortho-Cyclen) $0 mononessa (28) oral tablet mg-mcg (Ortho-Cyclen) $0 my way.5 mg tablet (otc).5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 necon 0.5/35 (28) oral tablet mg-mcg (Modicon) $0

126 necon /35 (28) oral tablet -35 mgmcg (Modicon) $0 necon /50 (28) oral tablet -50 mgmcg (Norinyl +50) $0 necon 0/ (28) oral tablet /-35 mg-mcg/mg-mcg (Modicon) $0 necon 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 next choice one dose.5 mg tb (otc).5 mg * (Aftera) next choice one dose oral tablet.5 mg (Plan B One-Step) $0 nikki (28) oral tablet mg (Yaz) $0 nora-be oral tablet 0.35 mg (Nor-Q-D) $0 norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) $0 norethindrone ac-eth estradiol oral tablet -20 mg-mcg (Loestrin) $0 norethindrone-e.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 norg-ee / x28 day regimen 0.8/0.25/0.25 mg-35 (Ortho-Cyclen) $0 mcg (28) norgestimate-ethinyl estradiol oral tablet 0.8/0.25/0.25 mg-25 mcg, (Ortho-Cyclen) $ mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) $0 nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg $0 nortrel /35 (2) oral tablet -35 mg-mcg (Modicon) $0 nortrel /35 (28) oral tablet -35 mg-mcg (Modicon) $0 nortrel 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 QL (6 per 365 days) QL (6 per 365 days) 2

127 NUVARING VAGINAL RING ST; QL ( per 28 days) MG/24 HR ocella oral tablet mg (Yaz) $0 ogestrel (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl $0 opcicon one-step.5 mg tablet.5 QL (6 per 365 days) (Aftera) mg * option 2.5 mg tablet.5 mg * (Aftera) QL (6 per 365 days) orsythia oral tablet mg-mcg (Amethyst) $0 philith oral tablet mg-mcg (Modicon) $0 pimtrea (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 pirmella oral tablet 0.5/0.75/ mg- 35 mcg, -35 mg-mcg (Modicon) $0 PLAN B ONE-STEP.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC).5 MG * portia oral tablet mg (Amethyst) $0 previfem oral tablet mg-mcg (Ortho-Cyclen) $0 quasense oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) react.5 mg tablet.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet mg (Desogen) $0 setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) $0 sprintec (28) oral tablet mgmcg (Ortho-Cyclen) $0 sronyx oral tablet mg-mcg (Amethyst) $0 syeda oral tablet mg (Yaz) $0 tarina fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 tilia fe oral tablet -20(5)/-30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-estarylla oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 3

128 tri-legest fe oral tablet -20(5)/- 30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-linyah oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-lo-estarylla oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-marzia oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-sprintec oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 trinessa (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-previfem (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-sprintec (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 trivora (28) oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 velivet triphasic regimen (28) oral tablet 0./.25/.5-25 mg-mcg (Desogen) $0 vestura (28) oral tablet mg (Yaz) $0 vienva oral tablet mg-mcg (Amethyst) $0 viorele (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 vyfemla (28) oral tablet mgmcg (Modicon) $0 wera (28) oral tablet mg-mcg (Modicon) $0 xulane transdermal patch weekly mcg/24 hr (Ortho Evra) $0 zarah oral tablet mg (Yaz) $0 zenchent (28) oral tablet mgmcg (Modicon) $0 zovia /35e (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 zovia /50e (28) oral tablet -50 mg-mcg (Demulen -50-2) $0 QL (3 per 28 days) 4

129 Cough And Cold Products Cough And Cold Products 5dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-50gfn-5dm liquid mg/5 ml * 30pse-3brm-5dm oral liquid mg/5 ml * 3brm-5dm-30pse liquid mg/5 ml * 3brm-30dm-50pse liquid (otc) mg/5 ml * 50pse-3brm-30dm oral liquid mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin linger cold syr 5 mg/5 ml * adt robitussin peak cld dm max mg/5 ml * adult robitussin peak cold liq nondrowsy 0-00 mg/5 ml * adult wal-tussin dm max liq a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup a/f,cherry,adult 0-00 mg/5 ml * adult wal-tussin liquid 00 mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) (Neo Dm) (Neo Dm) (Neo Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) (G-Zyncof) (G-Zyncof) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) alka-seltzer plus mucus-conges 0- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 0peh-4cpm-20dm tablet 4-0- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) 5

130 ambi 40pse-400gfn-20dm tablet mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 00 mg capsule 00 mg * (Zonatuss) 3 $0 benzonatate 50 mg capsule 50 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid mg/5 ml * (Neo Dm) bionel pediatric liquid mg/5 ml * (Trispec Pse) biospec dmx liquid 5-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (otc) mg/5 ml * (Neo Dm) bromfed dm cough syrup (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 bromphenir-pseudoephed-dm syr (Brompheniramine/ (rx) mg/5 ml * Pseudoephed/Dm) brom-pse-dm cough syrup butter (Brompheniramine/ scotch (otc) mg/5 ml * Pseudoephed/Dm) centergy dm pediatric drops -2-3 (Chlorpheniramine/ mg/ml * Phenyleph/Dm) cheracol d cough formula 0-00 mg/5 ml * (G-Zyncof) cheratussin dac syrup mg/5 ml * (Tusnel C) child sudafed pe cough-cold lq (Dextromethorphan mg/5 ml * /Phenylephrine) child triaminic cgh-congst syr 5-00 (Cough Formula mg/5 ml * Dm) 6

131 (Dextromethorphan child wal-tussin 7.5 mg odt 7.5 mg * Hbr) children's mucinex cough liq a/f 5- (G-Zyncof) 00 mg/5 ml * children's silfedrine liq 5 mg/5 ml (Pseudoephedrine * HCl) (Robitussin chl mucinex chest congest liq a/f Mucus-Chest 00 mg/5 ml * Congest) cold multi-symptom day-night (Dm pseudoephedrine-free Hb/Pe/Acetaminop mg * hen/chlorph) (Dm cold relief multi-symp caplet cplt,2 Hb/Pe/Acetaminop day,2 night mg * hen/chlorph) (Dcold-flu relief liquid ,000 Methorphan/Aceta mg/30 ml * min/doxylamn) congestac tablet mg * (Poly-Vent Ir) congest-eze mg caplet 60- (Poly-Vent Ir) 400 mg * childs sudafed 5 mg/5 ml liq nondrowsy,a/f,s/f 5 mg/5 ml * chld triaminic cgh-sor thr sus 60-5 codituss dm syrup mg/5 cold-flu relief d/n softgel 0-5- (Pseudoephedrine (Child Tylenol Plus (Pyrilamine/Pe/De (Vicks Dayquilmg/5 ml * ml * 325mg(d)/ mg * HCl) Cough-Sore) xtromethorphan) Nyquil) coricidin hbp cold-multi sympt mg/5 ml * coricidin hbp softgel mg * cough & cold syrup mg/5 ml * (D- Methorphan/Aceta min/doxylamn) (Guaifenesin/Dextr omethorphan) (Maxiphen Dmx) 7

132 cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab mg * (Maxiphen) cvs chest congest relief dm tb mg * (Allfen Dm) cvs child cold-cough day liq (Dextromethorphan mg/5 ml * /Phenylephrine) (Robitussin cvs child's chest congest liq 00 Mucus-Chest mg/5 ml * Congest) cvs cough & sore throat susp 60-5 (Child Tylenol Plus mg/5 ml * Cough-Sore) cvs daytime-nighttime cold-flu multi-symp,twin pack mg/5 ml * cvs tussin cgh 5 mg liq gels nondrowsy, liq gels 5 mg * cvs tussin dm cough-chest liq mg/5 ml * daytime cold & cough liquid, mg/30 ml * daytime cold-flu liquid a/f, glutenfree mg/5 ml * (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) (Triaminic) (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (Dextromethorphan Hb/Doxylamine) daytime cough liquid a/f, gluten-free 5 mg/5 ml * daytime-nighttime cough liquid 5mg/5ml(d)/ mg/30ml * delsym cough+chest cngst dm lq 5-00 mg/5 ml * (G-Zyncof) despec-dm tablet mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 0-00 mg/5 ml * (G-Zyncof) 8

133 diabetic tussin dm max-str liq mg/5 ml * (G-Zyncof) ed bron gp liquid 5-00 mg/5 ml * (Despec) entre-cough liquid mg/5 ml * (Trispec Pse) expectorant 00 mg/5 ml syrup 00 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold 30-5 mg/5 ml * geri-tussin dm syrup 0-00 mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution mg/5 ml * guaifenesin er 600 mg tablet 600 mg * head congestion day-night pack mg * hydrocodone-chlorphen er susp 0-8 mg/5 ml * hydrocodone-homatropine 5-.5 mg tablet 5-.5 mg * hydromet syrup 5-.5 mg/5 ml * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) (Tussionex) 3 $0 (Tussigon) 3 $0 (Hydrocodone Bit/Homatrop Me- Br) 3 $0 liquibid d-r tablet mg * (Maxiphen) lohist-dm syrup mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid mg/5 ml (Tusnel C) * mar-cof bp liquid mg/5 ml * (Bromphenira/Pseu doephed/codein) 3 $0 9

134 mar-cof cg liquid mg/5 ml * (M-Clear Wc) 3 $0 M-END DM SYRUP MG/5 ML * mesehist dm oral syrup (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) mucus dm mg tablet mg * (Mucinex Dm) mucus dm max tablet 60-,200 mg * (Mucinex Dm) mucus relief 400 mg tablet d/f 400 mg * (Allfen) nasal-sinus decongest tab 30 mg * (Sudafed 2-Hour) nasohist dm pediatric drops -2-3 (Chlorpheniramine/ mg/ml * Phenyleph/Dm) NEO DM SYRUP MG/5 ML * neo-tuss liquid mg/5 ml * (G-Zyncof) NEXAFED 30 MG TABLET 30 MG * night time cold med liquid mg/5 ml * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM MG * night time cough & sore throat ,000 mg/30 ml * nighttime cough liquid gluten-free, cherry mg/5 ml * nohist-dm liquid mg/5 ml * pecgen dmx 25-5 mg/5 ml liq 5-25 mg/5 ml * pedia relief cough-cold liquid a/f, cherry -5-5 mg/5 ml * (Dm/P- Ephed/Acetaminop h/doxylam) (D- Methorphan/Aceta min/doxylamn) (Dextromethorphan Hb/Doxylamine) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) 20

135 pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * poly-tussin liquid mg/5 ml * promethazine vc-codeine syrup mg/5 ml * promethazine-codeine syrup mg/5 ml * promethazine-dm syrup mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime mg/5 ml * pv night-time softgel multisympt.,softgel mg * (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 (Sudafed 2-Hour) (Sudafed 2-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid 5-00 mg/5 ml * (Despec) q-tapp dm elixir -5-5 mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 00 mg/5 ml solution a/f, Mucus-Chest non-drowsy 00 mg/5 ml * Congest) q-tussin dm syrup 0-00 mg/5 ml * ra child plus cough-runny nose pseudoephedrine free mg/5 ml * (Cough Formula Dm) (Dextromethorphn/ Acetaminoph/Cp) 2

136 ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra maximum strength flu tablet mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) (Dextromethorphan ra tussin dm syrup a/f 0-00 mg/5 ml * ra tussin max strn cough syrup 5 mg/5 ml * Hbr) refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet mg * (Maxiphen) relcof c liquid mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * robafen 00 mg/5 ml syrup 00 mg/5 ml * robafen cough 5 mg liquidgel nondrowsy,liquidgel 5 mg * robafen-dm syrup 0-00 mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ -7.5 MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid mg/5 ml * (Robitussin Mucus-Chest Congest) 3 $0 (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) 22

137 rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid 0-00 mg/5 ml * scot-tussin 00 mg/5 ml liq 00 mg/5 ml * scot-tussin dm s-f liquid 2-5 mg/5 ml * siltussin sa 00 mg/5 ml syr 00 mg/5 ml * sm adult nasal decongestant lq 5 mg/5 ml * sm childrens plus cold susp grape,multi-symptom mg/5 ml * sm cold-cough child elixir -5-5 mg/5 ml * sm cough & runny nose liquid -5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm mucus relief cough liquid childrens, a/f 5-00 mg/5 ml * sm nite time cold-flu liquid ,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) 23

138 sm pedia relief liquid -5-5 mg/5 (Chlorpheniramin/ ml * Pseudoephed/Dm) sm severe cold m-s caplet (Dm/Pseudoephed/ mg * Acetaminophen) sm tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) sudafed 30 mg tablet nondrowsy,max-str 30 mg * (Sudafed 2-Hour) sudogest 30 mg tablet boxed 30 mg * (Sudafed 2-Hour) sudogest 60 mg tablet 60 mg * (Sudafed 2-Hour) suphedrin liquid 5 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER MG * THERAFLU MULTI-SYMP COLD CPLT MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S 60-5 MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry mg/5 ml * /Phenylephrine) tri-dex pe oral syrup mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) 0-00 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * TUSNEL PEDIATRIC LIQUID (RX) MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * 24

139 tussin cf cough-cold syrup a/f mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap mg * seudoephedrine) tussin dm syrup 5-00 mg/5 ml * (Cough Formula Dm) VANACOF LIQUID MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) (Dvicks dayquil liquicaps cold & flu 5- Methorphan/Pe/Ac mg * etaminophen) vicks nature fusion cough liq 5 mg/5 (Dextromethorphan ml * Hbr) vicks nyquil severe cold-flu (Dm/Pe/Acetamino mg/5 ml * phen/doxylamine) virdec dm drops mg/ml * (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid 0-00 mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp (Dm/Pseudoephed/ mg/.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq -5-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 2-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free mg * Dm/Acetamin/Gg) wal-tussin cough 5 mg softgel 5 mg * (Robitussin) 25

140 wal-tussin cough 5 mg/5 ml 5 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 2-Hour) ZONATUSS 50 MG CAPSULE 50 MG * 3 $0 zyncof mg/5 ml liquid mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) $0 chlorhexidine gluconate mucous membrane mouthwash 0.2 % oralone dental paste 0. % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE.-5 % triamcinolone acetonide dental paste 0. % (Peridex) $0 (Triamcinolone Acetonide) $0 (Peridex) $0 (Salagen) $0 (Triamcinolone Acetonide) $0 $0 Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 0 MG acitretin oral capsule 0 mg, 7.5 mg, 25 mg (Soriatane) $0 acne medication 0% lotion 0 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acneclear gel 0 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) $0 QL (30 per 30 days) 26

141 ALCOHOL PADS TOPICAL PADS, MEDICATED $0 ALCOHOL PREP PADS $0 amlactin 2% lotion 2 % * (Ammonium Lactate) ammonium lactate 2% cream (Ammonium fragrance free (otc) 2 % * Lactate) ammonium lactate 2% lotion (otc) (Ammonium 2 % * Lactate) ammonium lactate topical cream 2 % (Lac-Hydrin) $0 ammonium lactate topical lotion 2 % (Lac-Hydrin) $0 ANACAINE TOPICAL OINTMENT 0 % benzoyl peroxide 0% gel aqueous (otc) 0 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % (Calcipotriene) $0 calcipotriene topical cream % (Dovonex) $0 calcipotriene topical ointment % (Calcipotriene) $0 calcitrene topical ointment % (Calcipotriene) $0 calcitriol topical ointment 3 mcg/gram (Vectical) $0 CASTELLANI PAINT MODIFIED.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (50 MG/ML) 300 MG DOSE-2 PENS 50 MG/ML COSENTYX (50 MG/ML) 300 MG DOSE-2 SYRINGES 50 MG/ML PA PA 27

142 COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML cvs skin treatment body lotion 2 % * fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % geri-hydrolac 2% lotion 2 % * geri-hydrolac 5% lotion 5 % * (Ammonium Lactate) (Carac) $0 (Fluorouracil) $0 (Ammonium Lactate) (Ammonium Lactate) imiquimod topical cream in packet 5 (Aldara) % $0 LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 0 PA PA PA NSO; QL (24 per 30 days) mg (Oxsoralen-Ultra) $0 PANRETIN TOPICAL GEL 0. % persa-gel 0% 2's,max-strength 0 % * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.05 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podocon topical liquid 25 % (Podophyllum Resin) $0 podofilox topical solution 0.5 % (Condylox) $0 potassium hydroxide topical (Potassium solution 5 % Hydroxide) $0 pv acne pimple 0% gel 0 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 28

143 TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.06 % zenatane oral capsule 0 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg $0 zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (5 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel % (Cleocin T) $0 clindamycin phosphate topical lotion % (Cleocin T) $0 clindamycin phosphate topical solution % (Cleocin T) $0 clindamycin phosphate topical swab % cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % (Cleocin T) $0 (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) $0 (Erygel) $0 (Erythromycin Base/Ethanol) $0 29

144 erythromycin with ethanol topical (Erythromycin swab 2 % Base/Ethanol) $0 gentamicin topical cream 0. % (Gentamicin Sulfate) $0 gentamicin topical ointment 0. % (Gentamicin Sulfate) $0 metronidazole topical cream 0.75 % (Metrocream) $0 metronidazole topical gel 0.75 %, % (Rosadan) $0 metronidazole topical lotion 0.75 % (Metrolotion) $0 mupirocin calcium topical cream 2 % (Bactroban) $0 mupirocin topical ointment 2 % (Centany) $0 neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) $0 (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) $0 selenium sulfide topical lotion 2.5 % (Selenium Sulfide) $0 selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) $0 silver nitrate topical ointment 0 % (Silver Nitrate) $0 silver nitrate topical solution 0.5 %, 0 %, 25 %, 50 % (Silver Nitrate) $0 silver sulfadiazine topical cream % (Silvadene) $0 ssd topical cream % (Silvadene) $0 sulfacetamide sodium (acne) topical suspension 0 % (Klaron) $0 (Neomycin triple antibiotic ointment carton Su/Bacitrac 3.5mg-400 unit- 5,000 unit/gram * Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream % (Anusol-HC) $0 30

145 ala-scalp topical lotion 2 % (Scalacort) $0 (Alclometasone alclometasone topical cream 0.05 % $0 Dipropionate) alclometasone topical ointment 0.05 (Alclometasone $0 % Dipropionate) aquanil hc % lotion % * (Cortizone-0) beta hc % lotion % * (Cortizone-0) $0 $0 $0 $0 betamethasone valerate topical (Luxiq) $0 foam 0.2 % $0 $0 betamethasone, augmented topical (Diprolene AF) $0 cream 0.05 % $0 betamethasone, augmented topical (Diprolene) $0 lotion 0.05 % betamethasone, augmented topical (Diprolene) $0 ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) $0 (Clobetasol clobetasol scalp solution 0.05 % $0 Propionate) clobetasol topical foam 0.05 % (Olux) $0 (Clobetasol clobetasol topical gel 0.05 % $0 Propionate) clobetasol topical lotion 0.05 % (Clobex) $0 betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0. % lotion 0. % ointment 0. % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 3

146 clobetasol topical ointment 0.05 % (Temovate) $0 clobetasol topical shampoo 0.05 % (Clobex) $0 clobetasol-emollient topical cream 0.05 % (Temovate) $0 clocortolone pivalate topical cream 0. % (Cloderm) $0 colocort rectal enema 00 mg/60 ml (Cortenema) $0 cormax scalp solution 0.05 % (Clobetasol Propionate) $0 cortizone-0 % creme maximum strength % * (Hydrocortisone) CORTIZONE-0 % LOTION % * cortizone-0 % ointment % * (Hydrocortisone) dermarest eczema % lotion % * (Cortizone-0) desonide topical cream 0.05 % (Desowen) $0 desonide topical ointment 0.05 % (Desonide) $0 desoximetasone topical cream 0.05 %, 0.25 % (Topicort) $0 desoximetasone topical gel 0.05 % (Topicort) $0 desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) $0 ELIDEL TOPICAL CREAM % fluocinonide topical cream 0.05 % (Vanos) $0 fluocinonide topical gel 0.05 % (Fluocinonide) $0 fluocinonide topical ointment 0.05 % (Fluocinonide) $0 fluocinonide topical solution 0.05 % (Fluocinonide) $0 fluticasone topical cream 0.05 % (Cutivate) $0 fluticasone topical ointment % (Fluticasone Propionate) $0 halobetasol propionate topical cream 0.05 % (Ultravate) $0 halobetasol propionate topical ointment 0.05 % (Ultravate) $0 hydro skin % lotion % * (Cortizone-0) 32

147 hydrocortisone 0.5% cream (otc) (Hydrocortisone) 0.5 % * hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone % cream maximum (Hydrocortisone) strength (otc) % * hydrocortisone % cream maximum (Hydrocortisone strength % * Acetate) hydrocortisone % lotion (otc) % (Cortizone-0) 3 $0 * hydrocortisone % ointment carton (Hydrocortisone) (otc) % * hydrocortisone acet-aloe vera (Hydrocortisone $0 topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.% cream 0. (Hydrocortisone $0 % Butyrate) hydrocortisone butyrate topical (Locoid) $0 ointment 0. % hydrocortisone butyrate topical (Locoid) $0 solution 0. % $0 hydrocortisone rectal enema 00 (Cortenema) $0 mg/60 ml hydrocortisone topical cream %, (Anusol-HC) $0 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) $0 hydrocortisone topical ointment (Hydrocortisone) $0 %, 2.5 % $0 hydrocortisone valerate topical (Westcort) $0 ointment 0.2 % mometasone topical cream 0. % (Elocon) $0 mometasone topical ointment 0. % (Elocon) $0 mometasone topical solution 0. % (Elocon) $0 hydrocortisone butyr-emollient hydrocortisone valerate topical (Hydrocortisone (Hydrocortisone topical cream 0. % cream 0.2 % Butyrate) Valerate) 33

148 neosporin % anti-itch cream % * (Hydrocortisone) ONFI ORAL TABLET 0 MG, 20 MG prednicarbate topical cream 0. % (Dermatop) $0 prednicarbate topical ointment 0. % (Dermatop) $0 preparation h hc % cream % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) $0 procto-pak topical cream with perineal applicator % (Anusol-HC) $0 proctosol hc rectal cream 2.5 % (Hydrocortisone) $0 proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) $0 proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) $0 recort plus % cream % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0. % (Protopic) $0 triamcinolone acetonide topical (Triamcinolone cream %, 0. %, 0.5 % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone lotion %, 0. % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone ointment %, 0. %, 0.5 % Acetonide) $0 trianex topical ointment 0.05 % (Triamcinolone Acetonide) $0 u-cort topical cream -0 % (Hydrocortisone Acetate/Urea) $0 Dermatological Retinoids adapalene topical cream 0. % (Differin) $0 adapalene topical gel 0. % (Differin) $0 TAZORAC TOPICAL CREAM 0.05 %, 0. % tretinoin gel micro 0.04% tube 0.04 % (Retin-A Micro) $0 tretinoin gel micro 0.% tube 0. % (Retin-A Micro) $0 PA PA NSO; QL (60 per 30 days) PA 34

149 tretinoin microspheres topical gel with pump 0.04 %, 0. % tretinoin topical cream %, 0.05 %, 0. % tretinoin topical gel 0.0 %, %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * (Retin-A Micro) $0 (Retin-A) $0 (Retin-A) $0 (Piperonyl Butoxide/Pyrethrin s) cvs permethrin % lotion % * (Nix) malathion topical lotion 0.5 % (Ovide) $0 NIX % CREME RINSE LIQUID W/ NIT COMB % * permethrin topical cream 5 % (Elimite) $0 ra lice treatment % crm rinse 2x59ml, 2 combs % * (Nix) sm lice treatment permethrin 2's % * (Nix) v-r lice cream rinse % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" $0 BD INSULIN SYR 0.3 ML 3GX5/6 0.3 ML 3 GAUGE X $0 5/6 BD INSULIN SYR 0.5 ML 3GX5/6" 0.5 ML 3 GAUGE X $0 5/6 BD INSULIN SYR ML 3GX5/6" ML 3 GAUGE X 5/6 $0 PA PA PA 35

150 BD ULTRA-FINE PEN NDL 8MMX3G SHORT 3 GAUGE X 5/6" INSULIN SYRINGE-NEEDLE U- 00 SYRINGE 0.3 ML 29 GAUGE, ML 29 GAUGE X /2", /2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X /2" $0 $0 $0 VGO 40 DISPOSABLE DEVICE $0 Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN.5 MG, 7.5 MG 36

151 FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 00 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-7,000-27,000 unit PULMOZYME INHALATION SOLUTION MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 00 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML ( MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 00 MG (Zenpep) $0 PA PA; LA PA QL (90 per 30 days) 37

152 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT, 5,000-7,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) $0 altacaine ophthalmic drops 0.5 % (Tetravisc) $0 altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % (Iopidine) $0 artificial tears.4 % drops.4 % * (Polyvinyl Alcohol) (Dextran artificial tears drops p/f, sterile /Hypromellose/P 0.3 % * F) artificial tears eye drops strl % * (Tears Naturale) artificial tears eye ointment 83-5 % (Genteal Pm) * atropine ophthalmic drops % (Isopto Atropine) $0 atropine ophthalmic ointment % (Atropine Sulfate) $0 atropine-care ophthalmic drops % (Isopto Atropine) $0 ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) 38

153 azelastine nasal aerosol,spray 37 mcg (0. %) (Astepro) $0 azelastine ophthalmic drops 0.05 % (Azelastine HCl) $0 (Dextran bion tears eye drops % * 70/Hypromellose/P F) carteolol ophthalmic drops % (Carteolol HCl) $0 cromolyn ophthalmic drops 4 % (Cromolyn Sodium) $0 cvs artificial tears drops sterile - (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf % % * (Carboxymethylcel lulose Sodium) cvs lubricant eye ointment p/f (Genteal Pm) 42.5 % * cvs lubricant gel eye drops % * cvs lubricating eye drops dry eye soln % * cvs natural tears drops % * (Carboxymethylcel l/hypromellose) (Refresh Optive) (Dextran 70/Hypromellose/P F) cyclopentolate ophthalmic drops 0.5 (Cyclogyl) $0 %, %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) $0 (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) QL (30 per 25 days) 39

154 flucaine ophthalmic drops (Proparacaine/Fluo $0 % rescein Sod) GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.%-0.3% drop 0.- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % $0 Homatropine) $0 ipratropium bromide nasal (Atrovent) $0 spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) $0 spray,non-aerosol 0.06 % (Genteal Mild To isopto tears 0.5% eye drops 0.5 % * Moderate) LACRISERT OPHTHALMIC INSERT 5 MG lubricant % eye drops 0.5- (Refresh Optive) 0.9 % * lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment 83-5 % (Genteal Pm) * muro-28 2% eye drops 2 % * (Sodium Chloride) muro-28 5% eye drops 5 % * (Sodium Chloride) muro-28 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0. % (Naphazoline HCl) $0 homatropine hbr ophthalmic drops lubricant % eye drops 0.5- (Isopto (Carboxymethylcel 5 % 0.9 % * Homatropine) l/glycerin/pf) QL (30 per 28 days) QL (5 per 0 days) 40

155 nasal decongestant 0.05% spray (Afrin) 0.05 % * (Genteal Mild To natural balance tears drops 0.4 % * Moderate) (Genteal Mild To nature's tears drops 0.4 % * Moderate) neo-synephrine 2 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0. % (Patanol) $0 PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops (Mydfrin) $0 0 %, 2.5 % proparacaine ophthalmic drops 0.5 (Proparacaine HCl) $0 % pure & gentle eye drops lubricant (Genteal Mild To 0.3 % * Moderate) (Genteal Mild To pv artificial tears 0.4 % * Moderate) pv lubricant.4 % eye drops.4 % (Polyvinyl * Alcohol) REFRESH CELLUVISC % EYE DROPS % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * pv pure-gentle eye drops sterile 0.3 (Genteal Mild To % * Moderate) REFRESH OPTIVE EYE DROPS % * retaine cmc 0.5% eye drops 0.5 % * saline mist 0.65% nose spry 0.65 % * (Carboxymethylcel lulose Sodium) (Little Remedies) ST 4

156 sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl % * (Systane) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE % EYE DROPS % * SYSTANE GEL EYE DROPS % * tears again.4 % drops.4 % * (Polyvinyl Alcohol) tears again eye ointment % * (Genteal Pm) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f % * F) tetracaine hcl (pf) ophthalmic drops (Tetracaine 0.5 % HCl/PF) $0 ultra fresh pm ointment * (Lanolin/Mineral Oil/Petrolatum) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 2 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) $0 bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) $0 bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment 500-0,000 unit/gram xin B Sulfate) $0 bleph-0 ophthalmic drops 0 % (Sulfacetamide Sodium) $0 CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) $0 42

157 ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) $0 COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) $0 gatifloxacin ophthalmic drops 0.5 % (Zymaxid) $0 gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 gentamicin ophthalmic drops 0.3 % (Garamycin) $0 gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 levofloxacin ophthalmic drops 0.5 % (Levofloxacin) $0 MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment ,000 Zn/Poly/HC) mg-unit/g-% $0 neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-0,000-0 mgunit-mg/ml (Neomycin Su/Bacitra/Polymy xin) $0 (Maxitrol) $0 (Maxitrol) $0 (Neosporin) $0 (Neomycin/Polymy xin B Sulf/HC) $0 43

158 neomycin-polymyxin-hc otic drops,suspension 3.5-0,000- mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-0,000- mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-% (Neomycin/Polymy xin B Sulf/HC) $0 (Cortisporin) $0 (Neomycin Su/Baci Zn/Poly/HC) $0 (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy ,000 mg-unit-unit/g xin) $0 ofloxacin ophthalmic drops 0.3 % (Floxin) $0 ofloxacin otic drops 0.3 % (Floxin) $0 polymyxin b sulf-trimethoprim ophthalmic drops 0,000 unit- mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic drops 0 % sulfacetamide sodium ophthalmic ointment 0 % sulfacetamide-prednisolone ophthalmic drops 0 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % (Polytrim) $0 (Sulfacetamide Sodium) (Sulfacetamide Sodium) (Sulfacetamide/Pre dnisolone Sp) $0 $0 $0 tobramycin ophthalmic drops 0.3 % (Tobrex) $0 tobramycin-dexamethasone ophthalmic drops,suspension (Tobradex) $0 % trifluridine ophthalmic drops % (Viroptic) $0 VIGAMOX OPHTHALMIC DROPS 0.5 % 44

159 ZIRGAN OPHTHALMIC GEL 0.5 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0. % diclofenac sodium ophthalmic drops 0. % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0. % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0. % (Bromfenac Sodium) $0 (Dexasol) $0 (Diclofenac Sodium) $0 (Flunisolide) $0 (FML) $0 (Ocufen) $0 (Fluticasone Propionate) $0 (Acular) $0 ST QL (50 per 25 days) 45

160 prednisolone acetate ophthalmic drops,suspension % prednisolone sodium phosphate ophthalmic drops % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 25 mg tablet 25 mg (Omnipred) $0 (Prednisolone Sod Phosphate) $0 * (Simethicone) cvs gas relief 25 mg chew tab extra strength 25 mg * (Gas-X) cvs gas relief 25 mg softgel softgel 25 mg * (Phazyme) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 25 mg chew tablet max str,lactose-free 25 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 80 mg * (Phazyme) inf gas rel 20 mg/0.3 ml drop (Simethicone) 20mg/0.3ml, dye free 40 mg/0.6 ml * mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 25 mg tab 25 mg * (Gas-X) simethicone 80 mg softgel 80 mg * (Phazyme) QL (60 per 30 days) PA; QL (60 per 30 days) 46

161 v-r anti-gas 66 mg softgel 66 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack mg $0 CARAFATE ORAL SUSPENSION 00 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) $0 cimetidine oral tablet 200 mg, 300 (Rx Product Only) (Cimetidine) $0 mg, 400 mg, 800 mg cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) $0 famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) $0 famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) $0 famotidine 40 mg/4 ml vial 25's,outer 0 mg/ml (Famotidine) $0 famotidine oral tablet 20 mg, 40 mg (Pepcid) $0 (Rx Product Only) gnp acid reducer 0 mg tablet 0 mg * (Pepcid Ac) lansoprazole dr 5 mg capsule na/f (otc) 5 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) $0 release(dr/ec) 5 mg, 30 mg misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) $0 omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 4-days course 20 mg * Magnesium) 47

162 omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg, 40 mg (Prilosec) $0 omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) $0 oral capsule 20-. mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg $0 pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) $0 PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ra omeprazole-bicarb 20-,00 3x4 day course (otc) 20-. mggram (Zegerid Otc) * ranitidine 50 mg tablet maximum strength (otc) 50 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl injection solution 50 (Rx Product Only) (Ranitidine HCl) $0 mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 50 mg, (Rx Product Only) (Ranitidine HCl) $0 300 mg ranitidine hcl oral syrup 5 mg/ml (Ranitidine HCl) $0 (Rx Product Only) ranitidine hcl oral tablet 50 mg, (Rx Product Only) (Zantac) $0 300 mg sucralfate oral suspension 00 mg/ml (Sucralfate) $0 sucralfate oral tablet gram (Carafate) $0 wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 50 MG TABLET TWIN PACK(2X45TABS) (OTC) 50 MG * 48

163 ZANTAC 50 MG TABLET TWIN PK, MAX STRGTH (OTC) 50 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid mg/5 ml * almacone liquid mg/5 ml * almacone-2 liquid mg/5 ml * aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG antacid plus x-stren susp mg/5 ml * antacid ultra tablet chew 400 mg (,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * antacid-antigas liquid mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/5 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (,250 mg) * (Gaviscon) (Maalox Maximum Strength) (Maalox Maximum Strength) (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) (Maalox Maximum Strength) (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) QL (60 per 30 days) 49

164 calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * comfort gel suspension regular str, cherry mg/5 ml * constulose oral solution 0 gram/5 ml cromolyn oral concentrate 00 mg/5 ml cvs antacid-antigas tab chew, mg * (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) $0 (Gastrocrom) $0 (Calcium Carbonate/Simethi cone) cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/5 ml * (Pepto-Bismol) cvs loperamide mg/7.5 ml liq mint mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 0 mg (Bentyl) $0 dicyclomine oral solution 0 mg/5 ml (Dicyclomine HCl) $0 50

165 dicyclomine oral tablet 20 mg (Bentyl) $0 diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) $0 diphenoxylate-atropine oral tablet mg (Lomotil) $0 enulose oral solution 0 gram/5 ml (Lactulose) $0 flanax antacid liquid (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid mg/5 ml * (Gaviscon) GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400- (Maalox Maximum mg/5 ml * Strength) gelusil tablet chewable cool mint mg * (Almacone) generlac oral solution 0 gram/5 ml (Lactulose) $0 glycopyrrolate injection solution 0.2 mg/ml $0 glycopyrrolate oral tablet mg, 2 mg (Robinul) $0 imodium a-d mg/7.5 ml liquid mint (Loperamide HCl) mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/5 ml susp vanilla flavor 262 mg/5 ml * (Pepto-Bismol) (Sodium kionex 5 gm/60 ml suspension 5- Polystyrene 9.3 gram/60 ml Sulfon/Sorb) $0 (Sodium kionex oral powder Polystyrene $0 Sulfon/Sorb) PA PA 5

166 lactulose oral solution 0 gram/5 (Lactulose) $0 ml LINZESS ORAL CAPSULE 45 MCG, 290 MCG loperamide mg/5 ml liquid mg/5 (Loperamide HCl) ml * loperamide oral capsule 2 mg (Loperamide HCl) $0 LOTRONEX ORAL TABLET 0.5 MG, MG maalox advanced suspension (Maalox Maximum regular strength mg/5 Strength) ml * MAGNEBIND 300 TABLET MG * magnesium 500 mg capsule s/f,na/f (Uromag) 500 mg * magnesium oxide 250 mg tablet 250 (Magox 400) mg * magnesium oxide 400 mg tablet (Magox 400) s/f,p/f,gluten-free 400 mg * magnesium oxide 500 mg tablet (Magox 400) p/f,s/f,lactose-free 500 mg * masanti liquid mg/5 ml (Maalox Maximum * Strength) $0 $0 $0 metoclopramide hcl oral tablet 0 (Reglan) $0 mg, 5 mg mgo 400 mg tablet 400 mg * (Magox 400) medi-first pep-t-med tab chew 262 methscopolamine oral tablet 2.5 mg, metoclopramide hcl injection metoclopramide hcl oral solution 5 (Pepto-Bismol To- (Methscopolamine (Metoclopramide (Metoclopramide mg * 5 mg solution 5 mg/ml mg/5 ml Go) Bromide) HCl) HCl) QL (30 per 30 days) 52

167 mi acid suspension (Maalox Maximum mg/5 ml, mg/5 ml * Strength) mi-acid ds tablet mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme mg/5 Strength) ml * mintox plus tablet chewable mg * (Almacone) mintox suspension mint creme 200- (Maalox Maximum mg/5 ml * Strength) MOVANTIK ORAL TABLET 2.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 0 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide mg/7.5 ml susp mint (Loperamide HCl) mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID. GRAM/ML RELISTOR ORAL TABLET 50 MG RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension (Maalox Maximum mg/5 ml * Strength) ri-mox suspension mg/5 (Maalox Maximum ml * Strength) QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 53

168 sm foaming antacid tablet chew mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 0 gr 650 mg * sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/20 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/5 ml suspension s/f,cherry 262 mg/5 ml * sps (with sorbitol) oral suspension 5-20 gram/60 ml (Gaviscon) (Bismuth Subsalicylate) (Sodium Bicarbonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) $0 $0 (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) $0 ursodiol oral capsule 300 mg (Actigall) $0 ursodiol oral tablet 250 mg, 500 mg (Urso) $0 VIBERZI ORAL TABLET 00 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 0 mg suppository 0 mg * (Dulcolax) bisacodyl 0 mg suppository 0 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 0 mg suppository 0 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 00 MG CAPSULE 00 MG * ST; QL (60 per 30 days) 54

169 cvs enema disposable 9-7 gram/8 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 00 mg mini enema 00 mg/5 ml * (Docusate Sodium) cvs purelax powder 4 once-daily doses 7 gram/dose * (Gavilax) cvs purelax powder packet s/f, 0 daily doses 7 gram * (Miralax) cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 mg * (Surfak) doc-q-lace 00 mg softgel 00 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml * (Docusate Sodium) docusate sodium 00 mg tablet crushable 00 mg * (Docusate Sodium) docusate sodium-senna tablet (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 00 mg softgel softgel 00 mg * (Colace) dok 00 mg tablet 00 mg * (Docusate Sodium) dulcolax ss 00 mg softgel 00 mg * (Colace) enema disposable 9-7 gram/8 ml * (Enema) enema ready to use latex-free 9-7 gram/8 ml * (Enema) enemeez mini enema 5cc tubes, outer 283 mg/5 ml * (Docusate Sodium) enemeez plus mini enema outer mg/5 ml * (Docusol Plus) eq fiber therapy powder * (Psyllium Seed (With Sugar)) 55

170 equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy (psyllium) oral powder (Psyllium Seed) * fiber therapy powder 2 gram/9 (Citrucel) gram * fiber-lax captabs 500mg (Fibercon) polycarbophil 625 mg * fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 0 MG ENEMA 0 MG/30 ML * gavilyte-c oral recon soln 240- (Golytely) $ gram gavilyte-g oral recon soln 236- (Golytely) $ gram (Nulytely with gavilyte-n oral recon soln 420 gram $0 Flavor Packs) gentlelax powder 30 once-daily (Gavilax) doses 7 gram/dose * glycolax powder 7 doses (otc) 7 (Gavilax) 3 $0 gram/dose * healthylax powder packet 4x7gm, (Miralax) outer 7 gram * hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * magic bullet 0 mg suppos 0 mg * (Dulcolax) mineral oil laxative * (Mineral Oil) konsyl psyllium fiber packet orange, milk of magnesia suspension 400 (Psyllium Husk (Milk Of gluten free 3.4 gram * mg/5 ml * (With Sugar)) Magnesia) 56

171 MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon gram/5 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln gram, gram (Golytely) $0 peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) $0 peri-colace tablet mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 00 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon gram/5 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 7 gram/dose Glycol 3350) $0 polyethylene glycol 3350 oral (Polyethylene powder in packet 7 gram Glycol 3350) $0 polyethylene glycol 3350 powd 4 once-daily doses (otc) 7 gram/dose (Gavilax) * polyethylene glycol 3350 powd 7 grams pkts,outer (otc) 7 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 7 gram * (Miralax) promolaxin 00 mg tablet 00 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 9-7 gram/8 ml * (Enema) ra laxative peg 3350 powder 4 once-daily doses 7 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) 57

172 senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/5 ml syrup 60 mg/5 ml * (Docusate Sodium) sm clearlax powder 4 once-daily doses 7 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 0 oncedaily doses 7 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) $0 Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) $0 calcium acetate oral tablet 667 mg (Calcium Acetate) $0 calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) $0 (Calcium magnebind 400 oral tablet Carbonate/Mag mg Carb/Fa) $0 PHOSLYRA ORAL SOLUTION 667 MG (69 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM 58

173 RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin Chloride) $0 oxybutynin chloride oral tablet 5 mg (Oxybutynin Chloride) $0 oxybutynin chloride oral tablet extended release 24hr 0 mg, 5 (Ditropan XL) $0 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) $0 tolterodine oral tablet mg, 2 mg (Detrol) $0 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended (Trospium release 24hr 60 mg Chloride) $0 trospium oral tablet 20 mg (Trospium Chloride) $0 Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 0 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule mg, 0 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg (Uroxatral) $0 (Flomax) $0 (Terazosin HCl) $0 (Desferal) $0 59

174 DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 25 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 00 MG/ML FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM),.62 % (40.5 MG/2.5 GRAM) (Sodium Thiosulfate) $0 androxy oral tablet 0 mg (Fluoxymesterone) $0 danazol oral capsule 00 mg, 200 mg, 50 mg (Danazol) $0 oxandrolone oral tablet 0 mg, 2.5 mg (Oxandrin) $0 testosterone cypionate (Depointramuscular oil 00 mg/ml, 200 Testosterone) mg/ml $0 PA; QL (30 per 30 days) PA; QL (50 per 30 days) PA; QL (50 per 30 days) PA 60

175 testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram ( %) testosterone transdermal gel in metered-dose pump.25 gram/ actuation ( %) testosterone transdermal gel in packet % (25 mg/2.5gram) testosterone transdermal gel in packet % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0. mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0. mg/24 hr estradiol valerate intramuscular oil 0 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg (Testosterone Enanthate) $0 (Testim) $0 (Vogelxo) $0 (Androgel) $0 (Testim) $0 (Activella) $0 (Estrace) $0 (Vivelle-Dot) $0 (Climara) $0 (Delestrogen) $0 (Activella) $0 PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 6

176 estropipate oral tablet 0.75 mg,.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0. MG/24 HR MENEST ORAL TABLET 0.3 MG, MG,.25 MG, 2.5 MG (Estropipate) $0 mimvey lo oral tablet mg (Activella) $0 mimvey oral tablet -0.5 mg (Activella) $0 PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 mg (Evista) $0 VAGIFEM VAGINAL TABLET 0 MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 00 (Hydrocortisone mg Sod Succinate) $0 betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) $0 cortisone oral tablet 25 mg (Cortisone Acetate) $0 dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) $0 ml PA-HRM; AGE (Max 64 Years) QL ( per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (8 per 28 days) 62

177 dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 0 mg/ml, 4 mg/ml fludrocortisone oral tablet 0. mg (Dexamethasone) $0 (Dexamethasone Sod Phosphate) (Fludrocortisone Acetate) $0 $0 hydrocortisone oral tablet 0 mg, 20 (Cortef) $0 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) $0 methylprednisolone oral tablet 6 (Medrol) $0 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) $0 tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 25 mg, 40 mg (Solu-Medrol) $0 methylprednisolone ss gm vl mdv,latex-free,000 mg (Solu-Medrol) $0 prednisolone sodium phosphate oral solution 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) $0 prednisone oral solution 5 mg/5 ml (Prednisone) $0 prednisone oral tablet mg, 2.5 mg, (Prednisone) $0 20 mg, 5 mg, 50 mg prednisone oral tablet 0 mg (Prednisone) $0 prednisone oral tablets,dose pack 0 mg, 0 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) $0 SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML triamcinolone acetonide injection (Triamcinolone suspension 0 mg/ml, 40 mg/ml Acetonide) $0 Pituitary 63

178 desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0. mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 2 MG/ML (36 UNIT/ML), 5 MG/ML (5 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,0 50 mcg/ml ( ml) (Desmopressin Acetate) $0 (DDAVP) $0 (Desmopressin Acetate) $0 (DDAVP) $0 (Octreotide Acetate) $0 QL (5 per 30 days) QL (5 per 30 days) PA PA QL ( per 84 days) PA 64

179 octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 0 MG KIT 0 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 0 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml (Sandostatin) $0 (Octreotide Acetate) (Hydroxyprogester one Caproate) $0 $0 PA PA PA QL ( per 28 days) QL ( per 360 days) QL (0 per 28 days) PA NSO 65

180 medroxyprogesterone intramuscular suspension 50 mg/ml medroxyprogesterone intramuscular syringe 50 mg/ml medroxyprogesterone oral tablet 0 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 00 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 00 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Depo-Provera) $0 (Medroxyprogester one Acetate) $0 (Provera) $0 (Megace Es) $0 (Aygestin) $0 (Progesterone) $0 (Prometrium) $0 (Levothyroxine Sodium) $0 (Levoxyl) $0 (Cytomel) $0 methimazole oral tablet 0 mg, 5 mg (Tapazole) $0 propylthiouracil oral tablet 50 mg (Propylthiouracil) $0 Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG QL ( per 84 days) QL ( per 84 days) 66

181 AUBAGIO ORAL TABLET 4 PA; QL (28 per 28 MG, 7 MG days) azathioprine oral tablet 50 mg (Imuran) $0 azathioprine sodium injection recon (Azathioprine $0 soln 00 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) $0 250 mg/5 ml cyclosporine modified oral capsule (Neoral) $0 00 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) $0 00 mg/ml cyclosporine oral capsule 00 mg, (Sandimmune) $0 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG ( ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, MG, 4 MG 67

182 FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 00 mg, 25 (Neoral) $0 mg, 50 mg gengraf oral solution 00 mg/ml (Neoral) $0 HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- PA UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PA PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS PA SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML, 50 UNIT/ML (0 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (0 %) 68

183 HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 80 MG/.2 ML (50 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML leflunomide oral tablet 0 mg, 20 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 80 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 0 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 25 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 0 % (Arava) $0 (Cellcept) $0 (Cellcept) $0 (Cellcept) $0 (Myfortic) $0 PA PA; QL (8.76 per 28 days) PA PA 69

184 PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, mg, 2 mg tacrolimus oral capsule 0.5 mg, mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML (Rapamune) $0 (Hecoria) $0 PA; LA; QL (5 per 28 days) ; QL (20 per 30 days) 70

185 BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 0'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (.5 per 365 days) QL (.5 per 365 days) 7

186 GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML QL (.5 per 365 days) QL (.5 per 365 days) 72

187 MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG /0.5 ML (FINAL) MENVEO MENCYW-35 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QL (2 per 365 days) QL (2 per 365 days) 73

188 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) ; QL (3 per 365 days) 74

189 TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, mg (Alosetron HCl) $0 QL (2 per 365 days) QL ( per 365 days) 75

190 APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) $0 budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) $0 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet,delayed release (dr/ec) 800 mg (Asacol Hd) $0 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % (Acetic Acid) $0 LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) $0 sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) $0 sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) $0 sorbitol-mannitol urethral solution (Mannitol/Sorbitol g/00 ml Solution) $0 water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) $0 Metabolic Bone Disease Agents Metabolic Bone Disease Agents ST 76

191 alendronate oral solution 70 mg/75 (Alendronate QL (300 per 28 days) $0 ml Sodium) alendronate oral tablet 0 mg, 40 mg, 5 mg (Fosamax) $0 alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) $0 mg calcitonin (salmon) nasal QL (3.7 per 28 days) spray,non-aerosol 200 unit/actuation (Miacalcin) $0 calcitriol intravenous solution mcg/ml (Calcitriol) $0 calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) $0 calcitriol oral solution mcg/ml (Rocaltrol) $0 doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) $0 doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg (Hectorol) $0 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 (Ibandronate QL (3 per 84 days) $0 mg/3 ml Sodium) ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) $0 mg/3 ml ibandronate oral tablet 50 mg (Boniva) $0 QL ( per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PA; QL (2 per 28 days) 77

192 PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 2 MCG/ML, 5 MCG/ML paricalcitol oral capsule mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS $0 (Zemplar) $0 QL ( per 80 days) SYRINGE 60 MG/ML risedronate oral tablet 50 mg (Actonel) $0 QL ( per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) $0 QL (30 per 28 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/00 ml zoledronic acid-mannitol-water intravenous solution 5 mg/00 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/0 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 62 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML (Zometa) $0 (Zoledronic Acid/Mannitol- Water) $0 (Reclast) $0 QL (00 per 300 days) PA PA 78

193 allopurinol oral tablet 00 mg, 300 mg (Zyloprim) $0 amifostine crystalline intravenous recon soln 500 mg (Ethyol) $0 anticoag citrate phos dextrose (Citrate Phosphate solution gram-mg/00ml Dextros Soln) $0 AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 20 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg (Urecholine) $0 buspirone oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg (Buspirone HCl) $0 CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) $0 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER GRAM/.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) $0 dutasteride oral capsule 0.5 mg (Avodart) $0 dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) $0 ST ST ST PA ST PA QL (30 per 30 days) 79

194 ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet mg (Ergoloid Mesylates) $0 EXONDYS 5 INTRAVENOUS SOLUTION 50 MG/ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) $0 fomepizole intravenous solution gram/ml (Fomepizole) $0 FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " $0 GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG guanidine oral tablet 25 mg (Guanidine HCl) $0 hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) $0 hydroxyzine hcl oral solution 0 mg/5 ml (Hydroxyzine HCl) $0 hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg (Hydroxyzine HCl) $0 hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg (Vistaril) $0 KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 2 MG/.2 ML leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg (Leucovorin Calcium) $0 PA; LA ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA NSO; QL (20 per 30 days) PA 80

195 leucovorin calcium injection recon (Leucovorin soln 00 mg, 350 mg, 50 mg Calcium) $0 leucovorin calcium oral tablet 0 (Leucovorin mg, 5 mg, 25 mg, 5 mg Calcium) $0 levocarnitine (with sugar) oral (Levocarnitine solution 00 mg/ml (With Sugar)) $0 levocarnitine oral tablet 330 mg (Carnitor) $0 levoleucovorin intravenous recon soln 50 mg (Fusilev) $0 mesna intravenous solution 00 mg/ml (Mesnex) $0 MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 80 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) $0 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 25 MG/ML ORFADIN ORAL SUSPENSION 4 MG/ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47), 0 MG (4)-20 MG (4)-30 MG(9) PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 8

196 OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 0 MG/0.4 ML, 2.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) $0 probenecid-colchicine oral tablet (Colchicine/Proben mg ecid) $0 PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) $0 pyridostigmine bromide oral tablet extended release 80 mg (Mestinon) $0 qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 0 MG/0.2 ML, 2.5 MG/0.25 ML, 5 MG/0.3 ML, 7.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML ST ST 82

197 REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 00 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SIMPONI ARIA INTRAVENOUS SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 00 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 00 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " $0 summer's eve dche-xtra clns 2's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 2's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML PA QL (60 per 30 days) PA PA PA PA 83

198 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG topical light mineral oil * (Mineral Oil) QL (4 per 30 days) QL (60 per 30 days) PA NSO; QL (60 per 30 days) TYBOST ORAL TABLET 50 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG PA; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG PA; QL (30 per 30 days) ZINBRYTA SUBCUTANEOUS ST SYRINGE 50 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) $0 acetazolamide oral tablet 25 mg, 250 mg (Acetazolamide) $0 acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) $0 ALPHAGAN P OPHTHALMIC DROPS 0. % AZOPT OPHTHALMIC DROPS,SUSPENSION % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) $0 bimatoprost ophthalmic drops 0.03 % (Bimatoprost) $0 84

199 brimonidine ophthalmic drops 0.5 %, 0.2 % (Alphagan P) $0 COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) $0 dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) $0 latanoprost ophthalmic drops % (Xalatan) $0 levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) $0 LUMIGAN OPHTHALMIC DROPS 0.0 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg $0 metipranolol ophthalmic drops 0.3 % (Metipranolol) $0 PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.25 % pilocarpine hcl ophthalmic drops %, 2 %, 4 % (Isopto Carpine) $0 SIMBRINZA OPHTHALMIC DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) $0 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) $0 TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) (Travoprost ophthalmic drops % (Benzalkonium)) $0 Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * (Citracal-Vitamin D) (drops: 0.5%, 0.20%) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (2.5 per 25 days) 85

200 calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium,000 + d3 caplet,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(,250mg) -400 unit * calcium vit d 400 caplet s/f, p/f, caplet 600 mg(,500mg) -400 unit * calcium vit d 400 softgl 600 mg(,500mg) -400 unit * calcium vit d tablet mg-unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(,500mg) -500 unit * calcium 600 mg tablet 600 mg (,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(,500mg) -400 unit * calcium carb,250 mg/5 ml sus 500 mg/5 ml (,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 00 mg/ml (0 %) calcium chloride intravenous syringe 00 mg/ml (0 %) calcium citrate - vit d caplet caplet, coated mg-unit * (Calcium Citrate) (Caltrate 600 Plus D3) (Calcium Vit D) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) $0 (Calcium Chloride) $0 (Citracal-Vitamin D) 86

201 calcium citrate-vit d3 caplet s/f, p/f mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 00 mg/ml (0%) calcium with vit d tablet mg-unit * CALTRATE D SOFT CHEW TAB VANILLA CREME 600 MG (,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(,500MG) -800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(,500mg) -500 unit * cvs calcium vit d 200 tb 500 mg(,250mg) -200 unit * cvs calcium vit d tablet oyster shell 500 mg(,250mg) -25 unit * cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(,500mg) unit * cvs magnesium 250 mg tablet 250 mg * (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) $0 (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d0 %-0.45 % sodium chloride (Dextrose 0 % intravenous parenteral solution and 0.45 % NaCl) $0 87

202 d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 0 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(,500mg) -00 unit * gnp calcium 500-vit d3 600 tab 500mg (,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 0 % and 0.2 % NaCl) (Dextrose 5%- Lactated Ringers) (Dextrose 5 %-0.2 % NaCl) (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Potassium Chloride/D5-0.2%NaCl) $0 $0 $0 $0 $0 $0 $0 $0 $0 (Klor-Con-Ef) $0 (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) $0 88

203 hm calcium citrate-vit d cplt caplet, gluten-free mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq KELP 50 MCG TABLET 50 MCG * KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq (Citracal-Vitamin D) (Klor-Con-Ef) $0 (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 $0 89

204 liquid calcium 600-vit d3 sfgl 600 mg(,500mg) -400 unit * liquid calcium 600-vit d3 sfgl softgel,p/f,gluten-f 600 mg(,500mg) -500 unit * liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) (Magnesium magnesium 300 mg capsule 300 mg Oxide/Mag Aa * Chelate) magnesium chloride injection (Magnesium solution 200 mg/ml (20 %) Chloride) $0 magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium sulf in 0.45% nacl (Magnesium Sulf intravenous solution 20 gram/500 In 0.45% NaCl) ml (40 mg/ml) $0 magnesium sulfate in d5w (Magnesium intravenous piggyback gram/00 Sulfate/D5W) ml, 4 gram/00 ml $0 magnesium sulfate in water intravenous parenteral solution 20 (Magnesium gram/500 ml (4 %), 40 gram/,000 Sulfate in Water) $0 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (Magnesium (4 %), 4 gram/00 ml (4 %), 4 Sulfate in Water) $0 gram/50 ml (8 %) magnesium sulfate injection solution (Magnesium 4 meq/ml (50 %) Sulfate) $0 90

205 magnesium sulfate injection syringe (Magnesium 4 meq/ml Sulfate) $0 natural calcium 500 mg tablet 500 (Calcium mg calcium (,250 mg) * Carbonate) NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 7.5 mg tablet 7.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oysco d tablet mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (,250 mg) * Carbonate) oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 25 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (,250 mg) * oyster shell calcium tablet 500 (Caltrate 600 Plus mg(,250mg) -400 unit * D3) oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(,250mg) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(,250mg) -400 unit * (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) pediatric electrolyte solution * (Pedialyte) 9

206 PHOS-NAK PACKET MG * phospha 250 neutral oral tablet 250 mg PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml, 4 meq/ml potassium bicarb and chloride oral tablet, effervescent 25 meq potassium bicarb-citric acid oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 meq/ml (K-Phos Neutral) $0 (Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) $0 $0 (Klor-Con-Ef) $0 (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 $0 $0 92

207 potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 0 meq (,080 mg), 5 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-,002 mg potassium cl 0 meq/50 ml sol 0 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 0 meq tablet 0 meq (Potassium Chloride) (Potassium Chloride) $0 $0 (Klor-Con) $0 (Klor-Con 0) $0 (Klor-Con 0) $0 (Potassium Chloride) (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) (Potassium Chloride/D5-0.9%NaCl) $0 $0 $0 $0 $0 (Urocit-K) $0 (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 93

208 potassium cl er 0 meq tablet f/c 0 meq (Klor-Con 0) $0 potassium cl er 20 meq tablet 20 (Potassium meq Chloride) $0 (Potassium potassium phosphate m-/d-basic Phos,M-Basic-Dintravenous solution 3 mmol/ml Basic) $0 (Ca/D3/Mag ra cal 600-vit d3-min chew tab 600 Ox/Zinc/Cop/Mang mg calcium- 400 unit-40 mg * /Bor) ra hi-cal plus vitamin d tab 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) (Calcium ra oyster shell-vitamin d tab s/f, p/f Carbonate/Vitamin 250 (625)-25 mg-unit * D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution (Ringers Solution) $0 sm calcium 600-vit d3 800 tab 600 (Caltrate 600 Plus mg(,500mg) -800 unit * D3) sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) $0 sodium bicarbonate intravenous (Sodium solution meq/ml (8.4 %) Bicarbonate) $0 sodium bicarbonate intravenous syringe 0 meq/0 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) $0 8.4 % ( meq/ml) sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution 0.45 % 0.45 %) $0 sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) $0 sodium chloride 3 % intravenous (Sodium Chloride parenteral solution 3 % 3 %) $0 94

209 sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 67 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg v-r calcium d 33 caplet mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE (Sodium Chloride 5 %) $0 (Sodium Chloride) $0 (Sodium Lactate) $0 (Sodium Lactate) $0 (Sodium Phos,M- Basic-D-Basic) $0 (K-Phos Neutral) $0 (Caltrate 600 Plus D3) QL (60 per 30 days) QL (2 per 28 days) QL (60 per 30 days) 95

210 DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) $0 montelukast oral tablet 0 mg (Singulair) $0 montelukast oral tablet,chewable 4 mg, 5 mg (Singulair) $0 zafirlukast oral tablet 0 mg, 20 mg (Accolate) $0 Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 (Albuterol Sulfate) $0 mg/ml albuterol sulfate oral syrup 2 mg/5 ml (Albuterol Sulfate) $0 QL (3 per 28 days) QL (60 per 30 days) QL (20 per 30 days) QL (2 per 28 days) QL (24 per 28 days) QL (2.2 per 28 days) QL (7.4 per 25 days) 96

211 albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 2 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG (Albuterol Sulfate) $0 (Vospire ER) $0 (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) (Metaproterenol Sulfate) (Metaproterenol Sulfate) $0 $0 $0 $0 QL (25.8 per 28 days) QL (8 per 30 days) 97

212 STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution mg/ml theochron oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) acetylcysteine solution 00 mg/ml (0 %), 200 mg/ml (20 %) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) $0 $0 $0 $0 $0 $0 $0 (Acetadote) $0 (Acetadote) $0 QL (2 per 28 days) 98

213 CINQAIR INTRAVENOUS SOLUTION 0 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 50 MG NUCALA SUBCUTANEOUS RECON SOLN 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG ORKAMBI ORAL TABLET MG PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 50 MG (Cromolyn Sodium) $0 (Nasalcrom) (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0 mg, 20 mg (Baclofen) $0 carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 0 mg, 5 mg (Soma) $0 (Parafon Forte DSC) $0 (Fexmid) $0 PA QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL ( per 28 days) PA PA; QL (20 per 30 days) PA PA-HRM; QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 99

214 dantrolene oral capsule 00 mg, 25 mg, 50 mg (Dantrium) $0 metaxall oral tablet 800 mg (Skelaxin) $0 metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Skelaxin) $0 (Robaxin) $0 (Dantrium) $0 (Zanaflex) $0 tizanidine oral tablet 2 mg, 4 mg (Zanaflex) $0 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 50 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG eszopiclone oral tablet mg, 2 mg, 3 mg (Nuvigil) $0 (Lunesta) $0 HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA QL (30 per 30 days) PA-HRM; QL (30 per 30 days); AGE (Max 64 Years) PA LA 200

215 zaleplon oral capsule 0 mg, 5 mg (Sonata) $0 zolpidem oral tablet 0 mg, 5 mg (Ambien) $0 zolpidem oral tablet,ext release multiphase 2.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) $0 ADCIRCA ORAL TABLET 20 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) 20

216 ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg,.5 mg LETAIRIS ORAL TABLET 0 MG, 5 MG (Flolan) $0 OPSUMIT ORAL TABLET 0 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 0.25 MG, MG, 2.5 MG REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 0 mg/2.5 ml (Revatio) $0 sildenafil oral tablet 20 mg (Revatio) $0 TRACLEER ORAL TABLET 25 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (37.5 per day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (240 per 30 days) 202

217 UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z select 50+ formula tb advanced formula mgmcg-mcg * a thru z select men 50+ tablet mcg * a thru z select multivit tab mcg * a thru z select tablet adults 50+,iron-free mg-mcgmcg * a thru z select tablet new formulation * a thru z select women's tablet * abc plus tablet mgmcg-mcg * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals/Lut) (Biocel) (Biocel) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Mv,Fe,Min/Lutein ) (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet mg-mcg-mcg * (Biocel) adults' daily formula tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) PA; QL (200 per 365 days) 203

218 antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula # tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b mcg tablet 500 mcg * (B-2) b-2 dots 500 mcg tablet 500 mcg * (B-2) balance b-00 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-00 tablet * (Vitamin B Complex) balanced b-00 tablet 00 mg * (Vit B Complex 00 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b2 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) 204

219 b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) biosupp liquid * (Multivitamin with Minerals) biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/5 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) centram-care multivit-min liq 9 mg iron/5 ml * centravites 50 plus tablet * centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/5 ml * centrum silver tablet adults mg-mcg-mcg * century adults 50+ tablet gluten free mg-mcg-mcg * century mature tablet * century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * (Multivit- Minerals/Ferrous Gluc) (Multivit with Iron- Minerals) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) 205

220 cerovite liquid 9 mg iron/5 ml * certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/5 ml * certavite-antioxidant tablet mg-mcg * child chew + iron tab chew * (Multivit- Minerals/Ferrous Gluc) (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 5 mg/ml 5 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet mcg * (Biocel) complete multivitamin tab * (Multivit,Th Iron,Other Min) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-00 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-50 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) 206

221 cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs mg-mcg-mcg * (Biocel) cvs spectravite advanced tab (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with Iron) cvs spectravite ultra women tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) cvs super b complx & c cplt caplet, p/f * (Vita-Bee with C) (Vits cvs vision formula tablet,000 unit- A,C,E/Lutein/Mine 200 mg-60 unit-2 mg * rals) 207

222 (Vitamin B cvs vitamin b-00 complx tb * Complex) cvs vitamin c,000 mg tb chw,000 (Ascorbic Acid) mg * cvs vitamin d3,000 unit sfgl softgel (D3-50),000 unit * cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin,000 mcg/ml 25's (Cyanocobalamin 3 $0,000 mcg/ml * (Vitamin B-2)) d3 dots 2,000 unit tablet p/f 2,000 (Vitamin D3) unit * (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) (Multivitamin with daily vite with iron tablet * Iron) dino-life extra c tab chew * (Multivitamin) (Multivit with Irondino-life iron-zinc tb chew * Minerals) daily multivitamin-iron tablet 8- daily vit formula + iron tab (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 208

223 dino-life tablet chewable * (Multivitamin) eldertonic elixir mg * (B,B2,B3,B6,B2 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 8 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet mcg * (Biocel) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet mg * eql one daily men's tablet * ergocalciferol 8,000 units/ml 8,000 unit/ml * essentia tablet mg-mcg * (Tab A Vite) (Multivitamin with Minerals) (Drisdol) (Multivitamin/Iron/ Folic Acid) 209

224 essential balance tablet * essential daily tablet w/iron & calcium mg * ferocon capsule mg * ferretts 325 mg tablet 325 mg (06 mg iron) * ferrex 50 capsule outer, u-d 50 mg iron * ferrex 50 plus capsule mg * (Mv,Fe,Min/Lutein ) (Tab A Vite) (Iron Fum/Vit C/B2-If/Fa) 3 $0 (Ferrous Fumarate) (Pic 200) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (06 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (06 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) 20

225 flintstones with iron tab chew 8 mg iron * (Pedi Mv No.79/Ferrous Fumarate) folic acid mg tablet (rx) mg * (Folic Acid) 3 $0 folic acid,000 mcg tablet p/f,s/f (otc) mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp century mature tablet gluten- (Biocel) free mg-mcg-mcg * gnp century tablet gluten-free 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet (Pnv33/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew (Multivitamin) multivit & minerals * hair vitamins * healthy eyes caplet caplet,000 unit-200 mg-60 unit-2 mg * hemocyte tablet u-u,blister pk 324 mg (06 mg iron) * hi-b complex tablet * hm complete 50+ tablet mg-mcg-mcg * hm one daily with iron tablet glutenfree mg-mcg * (Multivitamin with Iron) (Vits A,C,E/Lutein/Mine rals) (Ferrous Fumarate) (Vitamin B Complex) (Biocel) (Multivitamin/Iron/ Folic Acid) 2

226 hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 50 capsule 50 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/5 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,60 UNIT-3 MG-00 UNIT * MACUVITE TABLET 5, UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * (Multivitamin with multi complete-iron tablet mg-mcg * Minerals/Lut) (Multivitamin/Iron/ Folic Acid) 22

227 multi-day plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 0 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) multivitamin-mineral liquid 9 mg iron/5 ml * (Multivit- Minerals/Ferrous Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.7 chewable, d/f, s/f 0.5 mg with Fluoride) $0 multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * 3 $0 nephplex rx tablet mg-mg-mcg-mg * nephron fa tablet mg * nephro-vite rx tablet mgmg-mcg * (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Iron Fum/Doss/Fa/Vit Bcomp,C) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 3 $0 3 $0 23

228 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 50 capsule 50 mg iron * (Pic 200) ocutabs tablet s/f, w/lutein * (Beta-Carotene(A)- Vits C,E/Mins) oncovite tablet * (Multivitamin,Ther apeutic) one daily complete tablet * (Multivitamin with Minerals) one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- mg Ca,No.72/Iron/Fa) (All Rx Prenatal Vitamins Covered) 24

229 poly-iron 50 mg capsule 50 mg iron * poly-vita drops, unitmg-unit/ml * poly-vita with iron drops,500 unit- 400 unit-0 mg/ml * poly-vitamin drops, unit-mg-unit/ml * (Pic 200) (Pediatric Multivitamin No.20) (Ped Multivit #46/Iron Sulfate) (Pediatric Multivitamin No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops,500 (Ped Multivit unit-400 unit-0 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) mg * No.30/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron * Fumarate/Fa) prenatal vitamins tablet phosphorus (Prenatal) free 28 mg iron- 800 mcg * (Multivitamin with pub multivitamin 50 plus tab * Minerals/Lut) (Vitamin B pv b-00 complex * Complex) (Vitamin B pv b-50 complex * Complex) pv kid's gummy bear tab chew (Multivitamin) chewable * prenatal vitamin plus low iron oral prenatal vitamin tablet 28 mg ironprosight tablet 5, unit-mgunit * (Pnv with (Prenatal Vit/Iron (A/C/E/Zinc/Sod tablet 27 mg iron- mg 800 mcg * Ca,No.72/Iron/Fa) Fumarate/Fa) Selenate/Copper) (All Rx Prenatal Vitamins Covered) 25

230 pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) pv kids vitamins+iron tab chew 5 (Ped Multivit mg iron * #7/Iron Fumarate) pv multivital platinum tablet * (Multivitamin with Minerals/Lut) pv multivital platinum tablet w/lutein & lycopene mcg * (Biocel) pv prenatal formula tablet 28 mg (Prenatal Vit iron- 800 mcg * No.3/Iron/Fa) pv prenatal formula tablet 28 mg (Prenatal Vit/Iron iron- 800 mcg * Fumarate/Fa) pv stress 500 plus zinc tab * (Multivitamin,Stres s Formula/Zn) pyridoxine 00 mg/ml vial 25's 00 mg/ml * (Pyridoxine HCl) 3 $0 qc child complete vit chew tab 8 mg iron * (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 8- (Tab A Vite) 0.4 mg * qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) qc multi-vite tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab (Tab A Vite) mg * (Vitamin B ra balanced b-00 tablet 0.4 mg * Complex/Folic Acid) 26

231 ra b-complex tablet p/f * (Vitamin B Complex) ra b-complex tablet p/f * (Vitamin B Complex) ra central vite select tab p/f * (Multivitamin with Minerals/Lut) ra central-vite select tab p/f * (Multivit with Iron- Minerals) ra central-vite senior tablet mg-mcg-mcg * (Biocel) ra central-vite tablet mg-mcg-mcg * (Biocel) ra central-vite tablet mgmcg * Folic Acid) (Multivitamin/Iron/ ra one daily energy tablet * (Multivitamin with Minerals) ra one daily plus iron tablet * (Multivitamin with Iron) ra one daily tablet p/f * (Multivitamin) ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab mg * (Tab A Vite) ra vit b-2,000 mcg/ml liq,000 (Cyanocobalamin mcg/ml * (Vitamin B-2)) ra vitamin b-2,000 mcg tab timed-release,000 mcg * (B-2) ra vitamin c,000 mg tab sa w/bioflavonoids,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 27

232 scooby-doo one a day tablet * (Multivit with Iron- Minerals) senior tabs mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f mcg * (Biocel) sentry senior tablet mgmcg-mcg * (Biocel) sentry tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) sm airshield effervescent tab 5,000- (Vit A,C,E/Dietary unit-mg-unit * Supp No.2) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) (Vits sm antioxidant vitamins tablet,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral (Multivitamin/Iron/ advanced formula mg-mcg * Folic Acid) sm complete senior formula tab * (Multivit with Iron- Minerals) sm complete senior formula tab mg-mcg-mcg * (Biocel) sm hair, skin and nails caplet caplet, (Multivitamin with gluten-free * Minerals) sm multivitamin w-iron tab * (Multivitamin with Iron) sm natural balanced b-00 tab 00 mg * (Vit B Complex 00 Cmb #2/Herbs) 28

233 sm opti-vitamin tablet,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet mg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-00 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * stress formula with iron tab * stress formula with iron tab 500 mg- 400 mcg- 8 mg iron * stress formula with zinc tab * stress-c with iron tablet 500 mg-400 mcg- 8 mg iron * (Vits A,C,E/Lutein/Mine rals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi M.Vit No.7 with Fluoride) (Vitamin B Complex) (Multivitamin,Stres s Formula/Zn) (Multivitamin,Stres s Formula) (Iron/Mv,Stress Form) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivitamin,Stres s Formula/Zn) (Vit B Comp/C/Fa/Iron/Vi t E) $0 29

234 sunvite tablet 8 mg iron-400 mcg- 25 mcg * (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * super b-50 complex capsule * super b-50 complex plus tab * (B Complex with Vitamin C) (Vitamin B Complex) (Vitamin B Complex) super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet mg (Mv,Ca,Min/Iron iron-66.7 mcg-,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) 220

235 tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 00 mg/ml * (Thiamine HCl) 3 $0 thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops, unit-mgunit/ml * (Pedi Multivit A,C,And D3 No.2) 22

236 tri-vitamin drops, unitmg-unit/ml * ultra b-00 complex tablet * v-c forte capsule mg * vic-forte capsule mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f,000 unit-200 mg-60 unit-2 mg * (Pedi Multivit A,C,And D3 No.2) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) (Vits A,C,E/Lutein/Mine rals) 3 $0 3 $0 vit d2.25 mg (50,000 unit) 50,000 unit * (Drisdol) 3 $0 VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON- MG -50 MG-200 MG vitalets tablet chewable child, (Multivitamin with orange,s/f * Iron) vitamin a 0,000 units capsule soluble 0,000 unit * (Vitamin A) vitamin a 25,000 units capsule softgel 25,000 unit * (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 8 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) 222

237 vitamin b-2,000 mcg tablet,000 mcg * (B-2) vitamin b-2 00 mcg tablet 00 mcg * (B-2) vitamin b mcg tablet 250 mcg * (B-2) vitamin b2 500 mcg tablet 500 mcg * (B-2) vitamin b-2 tr,000 mcg tab (Cyanocobalamin lactose free,000 mcg * (Vitamin B-2)) vitamin b2-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet p/f,no Cmplx C/Rice lactose,cplt mcg-mg * Bran) vitamin c,000 mg tablet,000 mg * (Ascorbic Acid) vitamin c,500 mg tablet sa na/f,s/f,starch/free,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d,000 unit tablet,000 unit * (Vitamin D3) vitamin d3,000 unit tablet s/f,p/f,000 unit * (Vitamin D3) vitamin d3,000 units softgel softgel, p/f, s/f,000 unit * (D3-50) 223

238 vitamin d3 0,000 unit softgel softgel 0,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 00 mcg tablet p/f, glutenfree 00 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-00 tablet * (Vitamin B Complex) yelets tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 224

239 INDEX 3 3 day vaginal pse-50gfn-5dm pse-3brm-5dm day vaginal pse-3brm-30dm MOP A a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA... 68, 69 ABRAXANE ABREVA acamprosate... 5 acarbose acebutolol acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid... 42, 76 acetylcysteine acid gone antacid acid reducer (famotidine) acid relief (cimetidine) acitretin acne medication... 26, 28 ACNE MEDICATION acne-clear ACTEMRA ACTHIB (PF) ACTIMMUNE actinel pediatric... 5 acyclovir... 78, 26 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 70 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil... 29, 30 adt robitussin peak cld dm max... 5 adult multivitamin gummies 203 adult nasal decongestant adult one daily gummies adult robitussin lingering cld 5 adult robitussin peak cold dm... 5 adult wal-tussin... 5 adult wal-tussin dm max... 5 adults 50 plus adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVIL... af 53 afeditab cr AFINITOR AFINITOR DISPERZ AFTERA a-hydrocort airshield AKTEN (PF) AKYNZEO ala-cort ala-scalp... 3 alavert alavert d-2 allergy-sinus ALBENZA albuterol sulfate... 96, 97 alcaine alclometasone... 3 ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate... 76, 77 alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges... 5 ALLEGRA ALLERGY aller-chlor allerclear d-2hr allerclear d-24hr allergy (chlorpheniramine) allergy (diphenhydramine) allergy relief (cetirizine) allergy relief (clemastine) allerhist aller-tec d allopurinol ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 52 I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

240 alophen alosetron ALPHAGAN P alprazolam... 7 ALREX altacaine altamist altavera (28) aluminum hydroxide gel alyacen /35 (28) alyacen 7/7/7 (28) amabelz... 6 amantadine hcl ambi 0peh-4cpm-20dm... 5 ambi 20dm-4cpm... 5 ambi 40pse-400gfn-20dm... 6 ambi 60pse-4cpm ambi 60pse-4cpm-20dm... 6 AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide99 AMINO ACIDS 5 % aminocaproic acid AMINOSYN 0 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone... 9 AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium... 25, 26 ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes plus iron antacid anti-gas antacid anti-gas (ca carb-sim) antacid extra-strength antacid plus extra strength anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide).. 49, 50 antifungal (tolnaftate)... 52, 56 antifungal cream anti-gas maximum strength.. 47 antioxidant antioxidant vitamins apatate forte APOKYN apraclonidine apri APRISO aprodine APTIOM APTIVUS aquanil hc... 3 aranelle (28) ARCALYST aripiprazole ARISTADA armodafinil arthritis pain relief (acetam)... 0 artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc).. 38 artificial tears(dext70-hypro) 38 artificial tears(glycerin-peg). 39 artificial tears(hypromellose) 4 ASACOL HD ascomp with codeine... 4 ascorbic acid (vitamin c) , 223 ashlyna aspirin..., 2 aspirin, buffered... 2 aspirin-dipyridamole aspir-low... 2 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

241 atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 39, 38 atropine-care ATROVENT HFA AUBAGIO aubra AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 205, 22, 220 b-00 complex b-2 dots b-50 complex bacitracin... 8, 29, 42 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 26 balanced b balanced b balanced b-50 complex balsalazide balziva (28) banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) 70 b-complex b-complex with vitamin c , 206, 28, 222, 223 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bekyree (28) BELBUCA... 4 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT BENLYSTA benzonatate... 6 benzoyl peroxide benztropine BETADINE beta-hc... 3 betamethasone acet,sod phos 62 betamethasone dipropionate. 3 betamethasone valerate... 3 betamethasone, augmented.. 3 BETASERON betaxolol... 92, 84 bethanechol chloride BETHKIS... 8 bexarotene BEXSERO (PF) bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx... 6 bion tears (pf) bionel pediatric... 6 biospec dmx... 6 biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP... 7 BOSULIF bp 8 cough... 6 BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm... 6 I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

242 bromfenac bromocriptine brompheniramine-pseudoephdm... 5, 6 budesonide bufferin... 2 bumetanide BUPHENYL buprenorphine hcl... 4, 5 buprenorphine-naloxone... 5 buproban bupropion hcl bupropion hcl (smoking deter)... 5, 45 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC C c complex cabergoline CABOMETYX... 3 ca-d3-mag ox-zinc-cop-mangbor... 88, 94 caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol... 27, 77 calcium d calcium d (d3) calcium calcium d(3) calcium 600 with vitamin d3 90 calcium acetate calcium antacid calcium carbonate... 49, 86 calcium carbonate-vitamin d calcium carbonate-vitamin d , 87, 88, 94 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d3.. 86, 87, 89 calcium gluconate calcium+d CALDOLOR... 2 cal-gest antacid calphron CALTRATE D CALTRATE WITH VITAMIN D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT... 63, 64 CAPRELSA... 3 captopril captopril-hydrochlorothiazide 90 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT MODIFIED CAYSTON caziant (28) cefaclor... 2 cefadroxil... 2 cefazolin... 2 cefazolin in dextrose (iso-os). 2 cefdinir... 2 cefditoren pivoxil... 2 cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM... 2 cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 22 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 22 cefuroxime axetil cefuroxime sodium celecoxib... 2 CELLCEPT INTRAVENOUS CELONTIN centamin centergy dm... 6 central vite with lutein central-vite central-vite for seniors central-vite select , 27 central-vite senior centram-care I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

243 centravites 50 plus centrum centrum complete centrum silver century... 2 century adults century mature , 209, 2 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula certavite senior-antioxidant certavite-antioxid (iron gluc) 206 certavite-antioxidant CERVARIX VACCINE (PF)... 7 cetirizine cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX... 5 CHANTIX CONTINUING MONTH BOX... 5 CHANTIX STARTING MONTH BOX... 6 cheracol d... 6 cheratussin dac... 6 chest congestion relief + dm 8 chest congestion relief pe... 8 chewable multi vitamin child allergy relf(cetirizine) child complete multivitamin 209 child cough and sore throat.. 8 child mucinex chest congestion... 7 child plus cough and runnynose... 2 child triaminic cold-allergy child triaminic cough-congest... 6 child triaminic cough-sore thr... 7 child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 7 CHILDREN'S ADVIL... 2 children's allegra allergy.. 57, 58 children's aller-tec children's chest congestion... 8 children's chewable children's chewable complete children's chewable vitamin. 206 children's chewable w/minerals CHILDREN'S CLARITIN57, 58 children's cold-cough daytime... 8 children's complete vitamin. 26 children's mapap... 5 children's mucinex cough... 7 children's multivit w/extra c. 209 children's non-aspirin... 4, 5 children's pain reliever... 0 children's pain-fever relief... 5 children's pepto childrens plus multi-symp cold children's silfedrine... 7 children's soothe children's sudafed... 7 children's sudafed pe cough. 6 children's tactinal... 5 children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin... 5 chloramphenicol sod succinate... 9 chlordiazepoxide hcl... 7 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm... 5 chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 208, 224 cholestyramine (with sugar). 0 cholestyramine light... 0 choline,magnesium salicylate 2 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 27, 42, 43 ciprofloxacin in 5 % dextrose 27 ciprofloxacin lactate citalopram citracal + d maximum citrus calcium clarithromycin CLARITIN I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

244 CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax CLEVIPREX clindamycin hcl... 9 clindamycin in 5 % dextrose.. 9 clindamycin palmitate hcl... 9 clindamycin pediatric... 9 clindamycin phosphate... 9, 62, 29 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol... 3, 32 clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 7 clonidine clonidine hcl... 88, 04 clopidogrel clorazepate dipotassium... 7 clorpres clotrimazole clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm... 7 COLACE colchicine cold and cough (diphenhydr-pe) cold multi-symptom day/night... 7 cold relief m/s day/night... 7 cold-allergy-sinus cold-flu relief... 7 cold-flu relief, day/night... 7 colestipol... 0 colistin (colistimethate na)... 9 colocort COLY-MYCIN S COMBIGAN COMBIPATCH... 6 COMBIVENT RESPIMAT. 97 COMETRIQ... 3 comfort gel comfort gel extra strength COMPLERA complete complete multi complete multivitamin. 206, 209 complete multivitamin-mineral , 28 complete senior , 28 compoz compro COMVAX (PF)... 7 CONDYLOX congestac... 7 congest-eze... 7 constulose COPAXONE coricidin hbp... 7 coricidin hbp cold-multi sympt... 7 CORLANOR cormax cortisone cortizone CORTIZONE COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 27 COTELLIC... 3 cough and cold... 7, 8 cough and runny nose CREON critic-aid clear af CRIXIVAN cromolyn... 39, 50, 99 cryselle (28) CUBICIN... 9 cyanocobalamin (vitamin b-2) , 208, 27, 223 cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide... 3 CYCLOPHOSPHAMIDE... 3 CYCLOSET I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

245 cyclosporine cyclosporine modified cyproheptadine CYRAMZA... 3 cyred CYSTADANE CYSTARAN cysteine (l-cysteine) D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin... 3 daily gummies daily multiple , 208 daily multi-vitamin daily multivitamin with iron 208 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 208 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF)... 7 daptomycin... 9 DARAPRIM DARZALEX... 3 dasetta /35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough... 8 daytime cold-flu... 8 day-time cough... 8 daytime-nighttime daytime-nighttime cold-flu.. 8 daytime-nighttime cough... 8 deblitane decitabine... 3 decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm... 8 delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine desmopressin... 63, 64 desog-e.estradiol/e.estradiol. 08 desogestrel-ethinyl estradiol 08 desonide desoximetasone despec-dm (pseudoeph-dmguaif)... 8 dex4 glucose dexamethasone... 62, 63 dexamethasone sodium phosphate... 45, 63 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextromethorphan polistirex 8 dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 86 dextrose 5 %-lactated ringers88 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm... 8, 9 diamode diazepam... 7 diazepam intensol... 7 diclofenac potassium... 2 diclofenac sodium... 2, 45 diclofenac-misoprostol... 2 dicloxacillin dicyclomine... 50, 5 didanosine DIFICID diflunisal... 2 digitek digox... 95, 96 I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

246 digoxin DIGOXIN dihydroergotamine... 62, 63 DILANTIN diltiazem hcl dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine... 5 dipyridamole disopyramide phosphate... 9 disulfiram... 6 divalproex... 40, 4 dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide... 9 dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol doxorubicin, peg-liposomal... 3 doxy doxycycline hyclate... 28, 29 doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA... 3 DUAVEE... 6 dulcolax stool softener (dss) 55 DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM E e.c. prin... 2 e.e.s e.e.s. granules econazole econtra ez ed a-hist ed bron gp... 9 ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide 90 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin... 0 enema... 55, 57 enema disposable enemeez enemeez plus ENGERIX-B (PF)... 7 ENGERIX-B PEDIATRIC (PF)... 7 enoxaparin enpresse enskyce entacapone entecavir entre-cough... 9 ENTRESTO enulose... 5 ENVARSUS XR EPCLUSA ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epitol... 4 I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

247 EPIVIR HBV eplerenone EPOGEN... 8 epoprostenol (glycine) EPZICOM eq gentle equalactin ergocalciferol (vitamin d2). 209, 222 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 24, 43 erythromycin ethylsuccinate.. 24 erythromycin with ethanol.. 29, 30 ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 20 essential daily estarylla ESTRACE... 6 estradiol... 6 estradiol valerate... 6 estradiol-norethindrone acet. 6 estropipate eszopiclone ethambutol ethamolin ethosuximide... 4 etodolac... 3 ETOPOPHOS etoposide EVOTAZ exemestane EXJADE EXONDYS expectorant... 9 expectorant dm... 9 expectorant max strength... 9 EXTAVIA extra cleansing douche eye health plus lutein F FABRAZYME fallback solo falmina (28) famciclovir famotidine... 47, 48 famotidine (pf) famotidine (pf)-nacl (iso-os) 47 FANAPT... 69, 70 FARESTON FARYDAK FASLODEX felbamate... 4 felodipine feminine care douche FEMRING fenofibrate... 0 fenofibrate micronized... 0 fenofibrate nanocrystallized. 0 fenofibric acid... 0 fenofibric acid (choline)... 0 fenoprofen... 3 fentanyl... 5 fentanyl citrate... 5 ferocon ferretts ferrex ferrex 50 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate... 20, 22 ferrous sulfate , 20 FETZIMA feverall... 5 fexofenadine fiber (calcium polycarbophil) fiber laxative (methylcellulo)58 fiber smooth fiber therapy (m-cell/sugar).. 56 fiber therapy (m-cellulose) fiber therapy (psyllium) fiber therapy (psyllium/sugar) fiber-lax fibertab finasteride FIRAZYR flanax antacid... 5 FLEBOGAMMA DIF flecainide... 9 FLECTOR... 3 FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron... 2 flintstones/extra c FLOVENT DISKUS FLOVENT HFA floxuridine flu formula daytime-nighttime flu relief therapy daytime... 2 flu severe cold-congestion flucaine fluconazole fluconazole in dextrose(iso-o) 54 fluconazole in nacl (iso-osm). 54 flucytosine fludrocortisone flumazenil flunisolide fluocinonide I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

248 fluorometholone fluorouracil... 32, 28 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen... 3 flurbiprofen sodium flutamide fluticasone... 32, 45 fluvoxamine foaming antacid... 5, 54 folic acid... 2 FOLIC ACID... 2 fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree... 2 fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 4 FREAMINE HBC 6.9 % FREAMINE III 0 % fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA... 4 G gabapentin... 4 GABITRIL... 4 galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF)... 7 GARDASIL 9 (PF) gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL... 5 GATTEX ONE-VIAL... 5 GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas.. 5 gemfibrozil... 0 generlac... 5 gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 8, 30, 43 gentamicin in nacl (iso-osm).. 8 gentamicin sulfate (ped) (pf).. 8 gentamicin sulfate (pf)... 8 GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears gentlelax GENVOYA GEODON geravim... 2 geriaton... 2 geri-hydrolac geri-tussin dm... 9 gianvi (28) gildagia gildess.5/30 (2) gildess /20 (2) gildess 24 fe gildess fe.5/30 (28) gildess fe /20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate... 5 glydo... 4, 5 GLYXAMBI granisetron (pf) granisetron hcl GRANIX... 8 griseofulvin microsize guaifenesin... 9 guaifenesin dac... 9 guanfacine... 89, 05 guanidine gummi bear multivitamin... 2, 25 gummy swirls H hair vitamins... 2 hair,skin and nails... 28, 220 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) I-0 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

249 head congestion day-night... 9 healthy eyes... 2 healthylax heather hemocyte... 2 heparin (porcine) heparin (porcine) in 5 % dex. 79, 80 heparin (porcine) in nacl (pf). 80 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN hi-b complex... 2 HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN... 50, 5 HUMULIN R U-500 (CONCENTRATED)... 5 hydralazine hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine... 9 hydrocodone-homatropine... 9 hydrocodone-ibuprofen... 6 hydrocortisone... 33, 63 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet... 9 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 6 I ibandronate IBRANCE ibuprofen... 2, 3, 4 ibuprofen jr strength... 3 icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d... 5 IMODIUM A-D... 5 IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin... 3 indomethacin sodium... 3 INFANRIX (DTAP) (PF) infants gas relief infant's ibuprofen... 3 INFANT'S MOTRIN... 3 infants' non-aspirin cold INLYTA insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 40, 97 ipratropium-albuterol IPRIVASK irbesartan I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

250 irbesartan-hydrochlorothiazide IRESSA iron high potency ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette jr. acetaminophen... 0 juleber junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe junior mapap... 6 JUXTAPID... 0 K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy)... 5 kariva (28)... 0 k-effervescent kelnor /35 (28)... 0 KELP (IODINE) ketoconazole ketoprofen... 3, 4 ketorolac... 4, 45 KEVEYIS KEYTRUDA kids mini enema kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28)... 0 KINERET KINRIX (PF) kionex... 5 kionex (with sorbitol)... 5 KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM KRYSTEXXA kurvelo... 0 KUVAN KYNAMRO... 0 KYPROLIS L l norgest/e.estradiol-e.estrad 0 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL... 4 LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine... 4, 42 LANOXIN lansoprazole LANTUS... 5 LANTUS SOLOSTAR... 5 larin.5/30 (2)... 0 larin /20 (2)... 0 larin 24 fe... 0 larin fe.5/30 (28)... 0 larin fe /20 (28)... 0 larissia... 0 latanoprost LATUDA... 7 laxative peg LAZANDA... 6 leena leflunomide LEMTRADA LENVIMA lessina... 0 LETAIRIS letrozole leucovorin calcium... 80, 8 LEUKERAN LEUKINE... 8 leuprolide levetiracetam levobunolol levocarnitine... 8 levocarnitine (with sugar)... 8 levocetirizine I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

251 levofloxacin... 27, 28, 43 levofloxacin in d5w levoleucovorin... 8 levonest (28)... 0 levonorgestrel... 0 levonorgestrel-ethinyl estrad0, levonorg-eth estrad triphasic levora levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin).. 35 lidocaine... 5 lidocaine (pf)... 5, 9 lidocaine hcl... 5 lidocaine in 5 % dextrose (pf) 9 lidocaine viscous... 5 lidocaine-prilocaine... 5 life-pack women's linezolid... 9 LINZESS liothyronine lipodox lipodox liquibid d-r... 9 liquid calcium with vitamin d LIQUI-E lisinopril lisinopril-hydrochlorothiazide 9 lithium carbonate lithium citrate little animals little animals-iron LIVALO... 0 lobana bath lohist-dm... 9 lomedia 24 fe... lomustine LONSURF loperamide... 50, 52, 53 loratadine loratadine-d lorazepam... 7 lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex... 9 loryna (28)... losartan losartan-hydrochlorothiazide. 89 LOTEMAX LOTRONEX lovastatin... 0 low-ogestrel (28)... loxapine succinate... 7 lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 40 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 4 lubricant eye (propyl glycol) 40 lubricant eye drops lubricant gel lubricating drops lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28)... LYNPARZA LYRICA lysiplex plus LYSODREN lyza... M maalox advanced MACUVITE MACUVITE EYE CARE mag mag-delay mag-g MAGNEBIND magnebind magnesium... 87, 90 magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide... 52, 53 magnesium sulf in 0.45% nacl magnesium sulfate... 90, 9 magnesium sulfate in d5w magnesium sulfate in water.. 90 malathion mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline mar-cof bp... 9 mar-cof cg margesic... 7 marlissa... MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu meclizine medroxyprogesterone I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

252 mefenamic acid... 4 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol... 35, 66 MEKINIST meloxicam... 4 memantine MENACTRA (PF) M-END DM MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-35 (PF) men's daily gummies men's multi-vitamin men's one daily MENVEO A-C-Y-W-35-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-35 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesalamine mesehist dm mesna... 8 MESNEX... 8 MESTINON... 8 MESTINON TIMESPAN... 8 metaproterenol metaxall metaxalone metformin... 49, 50 methadone... 7 methadose... 7 methazolamide methenamine hippurate... 9 methimazole methocarbamol methotrexate sodium... 35, 36 methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 05, 06 methylprednisolone methylprednisolone acetate.. 63 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 9, 62, 30 metronidazole in nacl (iso-os) 9 mexiletine... 9 mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 53, 54, 55 miconazole microgestin.5/30 (2)... microgestin /20 (2)... microgestin fe.5/30 (28)... microgestin fe /20 (28)... midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil... 82, 84 MINERAL OIL... 8 mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA... 8 mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril... 9 moexipril-hydrochlorothiazide... 9 molindone... 7 mometasone MONISTAT monistat mono-linyah... mononessa (28)... montelukast morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 morphine concentrate... 7 morphine in dextrose 5 %... 8 morrhuate sodium... 8 motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL... 8 mucus dm mucus dm max I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

253 mucus relief... 20, 22 mucus relief cough MULTAQ... 9 multi complete with iron multi-day with iron multi-delyn with iron multiple vitamin-minerals multiple vitamins multiple vitamins with iron.. 23 multi-symptom cold night time multivital platinum multivitamin 50 plus multi-vitamin hp/minerals multivitamin with fluoride multivitamin with iron. 23, 28 multivitamin with minerals.. 23 multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way... myco nail a mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra... N nabumetone... 4 nadolol nafcillin NAGLAZYME naloxone... 6 naltrexone... 6 NAMENDA XR... 44, 45 NAMZARIC naphazoline naproxen... 4 naproxen sodium... 4 naratriptan NARCAN... 6 nasal and sinus decongestant 20 nasal decongestant (oxymetazl)... 4 NASCOBAL nasohist dm NATACYN nateglinide NATPARA natural b natural b-00 complex natural balance... 4 natural calcium... 9 natural fiber laxative therapy 57 natural tears (pf) nature's tears (hypromellose) 4 NEBUPENT necon 0.5/35 (28)... necon /35 (28)... 2 necon /50 (28)... 2 necon 0/ (28)... 2 necon 7/7/7 (28)... 2 nefazodone NEO DM neomycin... 8 neomycin-bacitracin-poly-hc 43 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc... 43, 44 neo-polycin neo-polycin hc neosporin (neo-bac-polym).. 30 neosporin anti-itch neo-synephrine 2 h spr (oxym)... 4 neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA... 8 NEUMEGA... 8 NEUPOGEN... 8 NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR next choice one dose... 2 niacin... 0, 02 niacinamide... 02, 24 niacor nicardipine NICODERM CQ... 6 nicorelief... 6 nicorette... 6 nicotine... 6, 7 nicotine (polacrilex)... 6 NICOTROL... 7 nifedical xl nifedipine night time... 2 night time cold medicine night time cold-flu night time cold-flu relief night time cough-sore throat 20 nighttime cough nikki (28)... 2 NILANDRON nilutamide NINLARO NITE TIME COLD-FLU RELIEF I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

254 NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose 04 NITROSTAT NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength.. 8, 0 non-aspirin flu non-aspirin jr strength... 5 nora-be... 2 NORDITROPIN FLEXPRO 64 norepinephrine bitartrate norethindrone (contraceptive)... 2 norethindrone acetate norethindrone ac-eth estradiol... 2 norethindrone-e.estradiol-iron... 2 norgestimate-ethinyl estradiol... 2 norlyroc... 2 NORMOSOL-M IN 5 % DEXTROSE... 9 NORMOSOL-R PH nortemp... 8 NORTHERA nortrel 0.5/35 (28)... 2 nortrel /35 (2)... 2 nortrel /35 (28)... 2 nortrel 7/7/7 (28)... 2 nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N... 5 NOVOLIN R... 5 NOVOLOG... 5 NOVOLOG FLEXPEN... 5 NOVOLOG MIX NOVOLOG MIX FLEXPEN... 5 NOVOLOG PENFILL... 5 NOXAFIL NUCALA NUCYNTA... 9 NUCYNTA ER... 8 NUEDEXTA nu-iron NULOJIX nu-mag... 9 NUPLAZID... 7 NUTRESTORE NUTRILIPID NUTRILYTE... 9 NUTRILYTE II... 9 NUVARING... 3 nyamyc nystatin nystatin-triamcinolone... 55, 56 nystop nyt-time sleep O OCALIVA ocean nasal... 4 ocella... 3 OCTAGAM octreotide acetate... 64, 65 ocutabs ODEFSEY ODOMZO OFEV ofloxacin... 28, 44 ogestrel (28)... 3 olanzapine... 7 olanzapine-fluoxetine olopatadine... 4 OLYSIO omega-3 acid ethyl esters omeprazole... 47, 48 omeprazole magnesium omeprazole-sodium bicarbonate ONCASPAR oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily... 24, 27 one daily 50 plus one daily complete one daily energy one daily essential 209, 2, 24 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 24 one daily plus iron 2, 24, 27 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula24 one-a-day teen advantage ONFI... 8, 34 opcicon one-step... 3 OPDIVO OPSUMIT option opti-vitamins oral saline laxative oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT... 8 ORENITRAM ORFADIN... 37, 8 ORKAMBI orsythia... 3 OTEZLA... 8 OTEZLA STARTER... 8 I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

255 OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 26 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9, 0 oysco 500/d... 9 oysco d... 9 oysco oyster shell calcium oyster shell calcium-vit d oyster shell calcium-vit d oystercal-d... 9 P pacerone pain relief... 0 pain relief adult... 5 pain reliever jr strength... 0 paliperidone... 7 pancrelipase PANRETIN PANTILINERS pantoprazole papaverine paricalcitol PARICALCITOL paromomycin paroxetine hcl PASER PATADAY... 4 PAXIL pecgen dmx pedia relief pedia relief cough-cold pedia relief infant pediacare multi-symptom cold... 2 PEDIARIX (PF) pediatric electrolyte... 87, 9, 94 pediatric freezer pops pediatric multivitamin.. 23, 28 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 36 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine... 9 periogard permethrin perphenazine... 7 perphenazine-amitriptyline persa-gel pfizerpen-g pharbetol... 0 pharmacist favorite multi-vit 24 phenadoz phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 89, 4 phenylhistine dh... 2 phenytoin phenytoin sodium phenytoin sodium extended philith... 3 phillips phillips liqui-gels PHOSLYRA PHOS-NAK phospha 250 neutral phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k) PICATO pilocarpine hcl... 26, 85 pimozide... 7 pimtrea (28)... 3 pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella... 3 piroxicam... 4 PLAN B ONE-STEP... 3 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podocon podofilox polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-tussin... 2 poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron poly-vitamins POMALYST I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

256 portia... 3 PORTRAZZA potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 92 potassium chlorid-d5-0.45%nacl potassium chloride 92, 93, 94 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 potassium citrate potassium citrate-citric acid. 93 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 46, 63 prednisone PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal... 2, 25, 29 prenatal formula prenatal plus (calcium carb). 24 prenatal tablet prenatal vit#96-ferrous fum-fa prenatal vitamin , 25 prenatal vitamin plus low iron prenatal vitamin with minerals prenatal vit-iron fumarate-fa 25 preparation h hydrocortisone 34 PREVAIL BLADDER CONTROL PAD prevalite PREVIDENT 5000 SENSITIVE previfem... 3 PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT... 8, 82 procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 60, 66 promethazine vc-codeine... 2 promethazine-codeine... 2 promethazine-dm... 2 promethegan promolaxin propafenone propantheline proparacaine... 4 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl... 2 PULMOZYME pure and gentle eye... 4 purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q q-dryl q-pap... 0 q-pap extra strength... 0 q-tapp dm... 2 I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

257 q-tussin... 2 q-tussin dm... 2 QUADRACEL (PF) quasense... 3 quetiapine... 7 QUILLIVANT XR quinapril... 9 quinapril-hydrochlorothiazide 9 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril... 9 RANEXA ranitidine hcl RAPAMUNE RASUVO (PF) RAVICTI react... 3 REBIF (WITH ALBUMIN) 82 REBIF REBIDOSE REBIF TITRATION PACK 83 reclipsen (28)... 3 RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC... 4 REFRESH CLASSIC (PF).. 4 REFRESH LACRI-LUBE... 4 REFRESH OPTIVE... 4 REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 56 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA... 58, 59 repaglinide repaglinide-metformin REPATHA PUSHTRONEX 02 REPATHA SURECLICK REPATHA SYRINGE reprexain... 0 RESCRIPTOR RESTASIS retaine cmc... 4 RETROVIR revive plus REVLIMID revonto REXULTI... 7 REYATAZ REZIRA ribasphere RIDAURA rifabutin rifampin RIFATER ri-gel ii riluzole rimantadine ri-mox ringers... 76, 94 risedronate RISPERDAL CONSTA... 7 risperidone RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA roxicet... 0 ROZEREM rydex rynex dm S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline mist... 4 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs senna... 57, 58 senna lax senna laxative senna with docusate sodium. 55 senokot-s SENSIPAR sentry sentry senior I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

258 SEREVENT DISKUS SEROSTIM sertraline setlakin... 3 sharobel... 3 SIGNIFOR silace siladryl sa silapap... 0 sildenafil SILENOR siltussin sa silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 60 sleep aid (doxylamine) smoflipid smoothlax sodium acetate sodium bicarbonate... 54, 94 sodium chloride... 42, 76, 95, 99 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate sodium thiosulfate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe regular strength sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spectravite spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28)... 3 SPRITAM SPRYCEL sps (with sorbitol) sronyx... 3 ssd st joseph aspirin... 4 st. joseph aspirin... 4 stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin... 8 stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula plus iron stress formula with iron stress formula with zinc STRIBILD STRIVERDI RESPIMAT sucralfate sudafed sudogest sudogest sinus and allergy... 6 sulfacetamide sodium sulfacetamide sodium (acne) 30 sulfacetamide-prednisolone.. 44 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac... 4 sumatriptan sumatriptan succinate summer's eve disposable douche summers eve extra cleansing 83 sunvite super b complex-vitamin c.. 207, 29, 220 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin I-20 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

259 super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURMONTIL SUSTIVA SUTENT syeda... 3 SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYPRINE SYSTANE (PROPYLENE GLYCOL) SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus... 34, 70 tactinal... 0 tactinal extra strength... 0 TAFINLAR TAGRISSO TALTZ AUTOINJECTOR.. 29 TALTZ SYRINGE TAMIFLU... 76, 77 tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe /20 (28)... 3 TASIGNA tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) TECENTRIQ TECFIDERA TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon... TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone... 6 testosterone cypionate testosterone enanthate... 6 TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td 74 tetrabenazine tetracaine hcl (pf) tetracycline THALOMID the magic bullet theochron theophylline theophylline in dextrose 5 % 98 thera m plus (ferrous fumarat) thera vitamin thera-d theradex m THERAFLU DAYTIME COLD-COUGH THERAFLU MULTI- SYMPTOM COLD thera-m therapeutic liquid therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals thera-tabs theratrum complete 50 plus.. 22 theratrum complete 50 plus/lut thiamine hcl (vitamin b) thioridazine thiotepa thiothixene tiagabine TICE BCG tilia fe... 3 timolol maleate... 94, 85 TIVICAY tizanidine TOBI PODHALER... 8 TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl... 8 tobramycin in 0.9 % nacl... 8 tobramycin sulfate... 8 tobramycin-dexamethasone.. 44 TOLAK tolazamide I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

260 tolbutamide tolmetin... 4 tolnaftate tolterodine topiragen topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR... 5 TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... tramadol-acetaminophen... trandolapril... 9 tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres.. 34, 35 TREXALL triacting m-sym cold/cough. 25 triamcinolone acetonide... 26, 34, 63 triaminic cold and cough (pe) TRIAMINIC COLD AND COUGHNT(PE)... 6 TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid trianex TRIBENZOR tri-buffered aspirin... 4 tri-dex pe tri-estarylla... 3 trifluoperazine trifluridine trihexyphenidyl tri-legest fe... 4 tri-linyah... 4 tri-lo-estarylla... 4 tri-lo-marzia... 4 tri-lo-sprintec... 4 trilyte with flavor packets trimethoprim trimipramine trinessa (28)... 4 TRINTELLIX triple antibiotic... 29, 30 triple paste af tri-previfem (28)... 4 tri-sprintec (28)... 4 TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28)... 4 TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL NEW FORMULA 24 TUSNEL PEDIATRIC TUSSI PRES-B tussin cf... 24, 25 tussin cf cough-cold tussin cold-congestion tussin cough (dm only)... 8 tussin dm... 22, 25 tussin dm cough and chest... 8 tussin maximum strength tussin pe... 2 TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U u-cort ULORIC ultra b-00 complex ultra fresh pm ultra strength antacid unisom sleepgels... 6 UNITUXIN UPTRAVI , 203 ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 44 valsartan valsartan-hydrochlorothiazide 90 VALSTAR valu-tapp dm I-22 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

261 VANACOF vancomycin... 20, 2 vancomycin in dextrose 5 %.. 20 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28)... 4 VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil... 94, 95 VERSACLOZ vestura (28)... 4 VGO VIBERZI vic-forte vicks dayquil cold-flu relief. 25 vicks dayquil cough vicks nature fusion cough vicks nyquil severe cold-flu. 25 vicks qlearquil(oxymetazoline) vicks sinex 2-hour vicodin... vicodin es... vicodin hp... VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva... 4 VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine viorele (28)... 4 VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD virt-phos 250 neutral virtussin ac vision vision formula (with lutein) 207, 222 vision plus lutein vit b complex-folic acid VITAFOL FE+ (WITH DOCUSATE) vitalets vitamin a vitamin b complex , 27 vitamin b-00 complex vitamin b2-folic acid vitamin b vitamin c... 27, 223 vitamin d , 223, 224 vitamins and minerals vitamins b complex , 222 vitamins for hair VITEKTA vitrum senior VOLTAREN... 4 voriconazole VOTRIENT VPRIV VRAYLAR vyfemla (28)... 4 W wal-act d cold and allergy... 6 wal-dram wal-dryl allergy... 6 wal-fex allergy... 6 wal-finate... 6 wal-finate-d... 6 wal-itin... 6 wal-itin d... 6 wal-itin d 2 hour... 6 wal-phed... 6, 25 wal-phed pe day-night wal-phed pe sinus and allergy 6 wal-profen... 4 wal-sleep z wal-som (diphenhydramine).. 62 wal-som (doxylamine) wal-tap wal-tussin cough... 25, 26 wal-tussin cough and cold cf 26 wal-tussin dm... 5 wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile WELCHOL wera (28)... 4 womens daily gummies women's daily multivitamin. 26 X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN... 2 XIIDRA XOLAIR XTANDI xulane... 4 xylon 0... XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS I-23 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

262 Z zafirlukast zaleplon ZANTAC... 48, 49 ZANTAC zarah... 4 ZARXIO ZAVESCA zebutal... ZELBORAF ZEMPLAR zenatane zenchent (28)... 4 ZENPEP ZEPATIER zephrex-d ZETIA ZIAGEN zidovudine ZINBRYTA zinc oxide ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia /35e (28)... 4 zovia /50e (28)... 4 ZOVIRAX z-sleep... 60, 6 ZUBSOLV... 7 ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA ZYVOX... 2 I-24 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 9 Effective: December 0, 206

263 Formulary ID: , Version 9