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1 CENTERS PLAN FOR HEALTHY LIVING 中央計劃管理式長期護理護士服務 CENTERS PLAN ADVANTAGE CARE (HMO) CENTERS PLAN CARE COMPLETE (MMP) Centers Plan for FIDA Care Complete Medicare-Medicaid計劃 2016年承保藥物清單 處方一覽表 本處方一覽表更新於7/1/2016 如果您有任何疑問 請致電Centers Plan for FIDA Care Complete 電話是 每週七天 每天早8點至晚8點 TTY使用者請致電 此電話 免費 We CARE... about your CARE H3018_16702_CY2016_Drug_List_CH

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3 Centers Plan for FIDA Care Complete (Medicare-Medicaid 計劃 ) 2016 年承保藥物清單 本處方一覽表更新於 1/7/2016 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , 每週七天, 每天早 8 點至晚 8 點 TTY 使用者請致電 此電話免費 更多資訊, 請瀏覽 生效日期 年 1 月 1 日最後更新 :1/7/2016 處方一覽表 ID:16507, 第 16 版本 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD iii

4 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD iv

5 Centers Plan for FIDA Care Complete 2016 年承保藥物清單 ( 處方一覽表 ) 這是會員透過 Centers Plan for FIDA Care Complete 可獲得的一份藥物清單 Centers Plan for FIDA Care Complete (Medicare-Medicaid 計劃 ) 是由 Medicare 與紐約州衛生部 (Medicaid) 共同簽署的一份統籌保健計劃, 旨在透過 Fully Integrated Duals Advantage (FIDA) 計劃展示為會員同時提供 Medicare 和 Medicaid 的福利 承保藥物清單及 / 或藥店和醫療提供者網絡在全年內可能發生變化 在我們做出影響到您的修改之前, 我們將 向您傳送通知 福利可能在每年的 1 月 1 日發生變化 您可隨時線上檢視 Centers Plan for FIDA Care Complete 的最新承保藥物清單, 網址為 或者致電 Centers Plan for FIDA Care Complete 會員服務部, 電話是 限制和約束可能適用 有關詳細諮詢, 請致電 Centers Plan for FIDA Care Complete 會員服務部, 或閱讀 Centers Plan for FIDA Care Complete 會員手冊 任何承保藥物無自付費用 您可以其他格式 ( 大字型印刷 布拉耶點字法或音訊 ) 免費獲得此資訊 請在我們的工作時間內致電 ,TTY/TDD 使用者可致電 , 我們的工作時間是 : 每週 7 天 每天早 8 點至晚 8 點 此電話免費 You can get this information for free in other languages. Call , and TTY/TDD users call , during our hours of operation: 8 am to 8pm, seven days a week. The call is free. 您可以免費獲得我們用其他語言提供的該資訊 請在我們的工作時間內致電 ,TTY/TDD 使用者可致電 , 我們的工作時間是 : 每週 7 天 每天早 8 點至晚 8 點 致電是免費的 Ou ka jwenn enfòmasyon sa a gratis nan lòt lang yo. Rele , e itilizatè TTY/TDD yo ka rele , pandan lè fonksyonman: 8 am a 8pm, sèt jou pa semèn. Apèl la gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare x il numero e per gli utenti TTY/TDD negli orari di lavoro: dalle 08:00 alle 20:00, 7 giorni su 7. La chiamata è gratuita. 이정보를다른언어로무료로받아보실수있습니다 번으로전화주시고, TTY/TDD 사용자들은 번으로영업시간동안전화주십시오 : 오전 8시 ~ 오후 8시, 매주 7일간본전화료는무료입니다 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD v

6 Вы можете получить эту информацию бесплатно на других языках. Звоните по номеру , пользователи телетайпа/текстового телефона по номеру , во время наших часов работы: 08:00 20:00, семь дней в неделю. Звонок является бесплатным. Puede obtener esta información en otros idiomas de manera gratuita. Llame al , y los usuarios de TTY/TDD pueden llamar al , durante nuestras horas de operación: 8 a.m. a 8 p.m., los siete días de la semana. La llamada es gratuita. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Centers Plan for FIDA Care Complete. ICAN may be reached toll-free at or online at icannys.org. 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD vi

7 常見問題 (FAQ) 如果您對於承保藥物清單有任何疑問, 請在此尋找答案 您可以閱讀所有常見問題 (FAQ) 以瞭解更多資訊, 或 尋找一個問題和答案 1. 承保藥物清單上包含哪些處方藥? ( 我們將承保藥物清單簡稱為藥物清單 ) 承保藥物清單 3 頁開始所列的各藥物為 Centers Plan for FIDA Care Complete 承保藥物 這些藥物均可在我們網 絡藥房內獲得 如果藥房與我們簽訂合作協定並向您提供服務, 則藥房在我們網絡內 我們把這些藥房稱為 網絡藥房 Centers Plan for FIDA Care Complete 將承保藥物清單上的所有藥物, 如果 : 您的醫生或其他開藥醫生表示您需要這些藥物以康復或維持健康, 藥物對治療您的病症具有醫療必要性, 以及 您在 Centers Plan for FIDA Care Complete 網絡藥房內配藥 Centers Plan for FIDA Care Complete 可能在獲得某些藥物上需要採取其他步驟 ( 請檢視以下第 5 個問題 ) 在一些情況下, 您在獲得藥物之前可能需要做其他事, 例如先嘗試其他藥物 查看最新承保藥物清單, 您可瀏覽我們網站 或致電會員服務部, 電話是 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD vii

8 2. 藥物清單是否會變更? 是 一年當中 Centers Plan for FIDA Care Complete 可能會新增或移除藥物清單中的某些藥物 通常, 只有在以下情況下藥物清單會有所變更 : 現在出現了一種新藥物, 其藥效與藥物清單上的藥物效果相同, 或者 我們瞭解到一種藥物並不安全 我們可能也會變更我們的藥物規則 例如, 我們可以 : 決定一種藥物是否需要事先核准 ( 事先核准是指在您可獲得藥物之前, 您需獲得 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 的許可 ) 新增或變更您可獲得的藥量 ( 稱為 數量限制 ) 增加或變更藥物逐步治療限制 ( 逐步治療指在我們會承保其他藥物之前, 您必須先試用其他藥物 ) ( 有關這些藥物規則的更多資訊, 請參閱第 ix 頁 ) 一旦您正在服用的藥物從藥物清單上除名, 我們將告知您 一旦我們變更藥物的承保規則, 我們將告知您 以下第 3 4 以及 7 個問題就藥物清單變更會發生什麼的問題有更多闡述 您可總是線上查看 Centers Plan for FIDA Care Complete 的最新藥物清單, 網址是 您可致電會員服務部, 瞭解現行版本的藥物清單, 電話是 如果現在出現了一種與藥物清單上藥物效果相同且價格更低的新藥, 會發生什麼? 如果現出現了一種與藥物清單上藥物效果相同的新藥 : 您的藥劑師可能在您下次配藥時向您提供較便宜的藥物 如果您和您的提供者認定便宜的藥物對您並不適用, 您的提供者可讓藥劑師繼續向您提供您正在服用的藥物 Centers Plan for FIDA Care Complete 可能決定將較貴的藥物從藥物清單上移除 如果我們因為新藥具有相同藥效而將您在服用的一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除前至少 60 天前或在您要求續配藥時通知您 隨後您可在藥物清單變更前購買 60 天的藥 如果我們決定將一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除前至少 60 天以書面形式以及 / 或者電話方式通知您 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD viii

9 4. 如果我們發現一種藥物並不安全, 會發生什麼? 如果食品和藥品管理局 (FDA) 表示您服用的藥物並不安全, 我們會立即將此藥從藥物清單上移除 我們亦將發函通知您這種不安全的藥物已從藥物清單上移除 在接收此信函以及 / 或者電話後, 請致電您的醫生並且請他或她開立一種替代藥 5. 藥物承保是否有約束或限制? 或者為取得某些藥品是否要求採取一些措施? 是, 一些藥物有承保規則或限制您所能取得的藥量 一些情況下, 您 您的醫生或其他開藥醫生在取得藥物之前必須先做某件事情 例如 : 事先核准 ( 或事先核准 ): 對於一些藥品, 您或您的醫生或其他開藥醫生必須在您配藥之前獲得 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 的核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 數量限制 : 有時,Centers Plan for FIDA Care Complete 限制您能獲得的藥量 階段治療 : 有時 Centers Plan for FIDA Care Complete 要求您採取逐步治療 這意味著在應對您的醫療病症時, 您將必須按一定順序試用藥物 在我們會承保其他藥物之前, 您可能需要先試用其他藥物 如果您的醫生認為第一種藥物對您並不適用, 之後我們將承保第二種藥物 瞭解您的藥物是否有其他額外要求或限制, 您可從 xvi 頁開始查看各表格 您亦可透過瀏覽我們網站瞭解更多資訊, 網址為 我們發佈線上文件, 解釋我們的事先核准和逐步治療限制 您也可以要求我們向您傳送一份副本 您可對這些限制要求進行 例外處理 瞭解例外處理的更多資訊, 請查看第 11 個問題 如果您在護理設施或其他長期護理設施內, 並且需要藥物清單外的一種藥物, 或者如果您取得所需藥物並不方便, 我們可提供協助 我們將承保一次 31 天急救藥物用量 ( 除非您處方箋上註明的天數較少 ), 不論您是否為 Centers Plan for FIDA Care Complete 新會員 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可説明您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 瞭解例外處理的更多資訊, 請查看第 11 個問題 6. 您將如何得知您想要的藥物是否有限制或取得藥物是否需要採取行動? 第 18 頁的承保藥物清單有一張柱狀圖, 標題是 必要行動 約束或使用限制 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD ix

10 7. 如果我們變更了藥物承保方式的規則, 會發生什麼? 例如, 如果我們增加了一種藥物的事先核准 ( 核准 ) 數量限制 以及 / 或者逐步治療 我將向您告知如果我們增加藥物的事先核准 數量限制, 以及 / 或者逐步治療限制 我們將在增加限制或在您要 求下次續配藥之前至少提前 60 天通知您 隨後您可在藥物清單變更前購買 60 天的藥 這將給您與您的醫生或其 他開藥醫生商討下一步操作的時間 8. 您如何在藥品清單上尋找一種藥物? 尋找藥物有兩個方法 : 您可按字母尋找 ( 如果您知道藥物名稱如何拼字 ), 或者 您可按醫療病症查詢 按字母查詢, 請翻至 I-1 頁檢視字母清單部分 然後在清單上尋找您的藥物的名稱 按醫療病症查詢, 請翻至第 18 頁查看 按醫療病症排列藥物清單 這一小節中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 如果您心臟有問題, 您應該尋找心血管藥物類別 您可在那裏找到應對心臟問題的藥物 9. 如果您想服用的藥品未在藥物清單上, 該怎麼辦? 如果您在藥物清單上並未看到您的藥物, 請致電 , 連絡會員服務部詢問情況 如果您瞭解到 Centers Plan for FIDA Care Complete 將不會對藥物進行承保, 您可採取以下一項操作 : 向會員服務部索取一份您想要服用的藥物清單 然後將清單給您的醫生或其他開藥醫生看 他或她可向您開立類似您想要服用且在藥物清單上的藥物 或 您可要求計劃或您的跨學科小組 (IDT) 作例外處理, 承保您的藥物 瞭解例外處理的更多資訊, 請查看第 11 個問題 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD x

11 10. 如果您新加入 Centers Plan for FIDA Care Complete, 並且在藥物清單上找不到或很難找到您的藥物, 您該怎麼辦? 我們竭誠相助 我們必須按需要承保在您成為 Centers Plan for FIDA Care Complete 會員最初 90 天的藥物暫時用 量 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可説明您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 我們將向您承保最多 90 天的暫時藥物用量, 如果 : 您在服用的藥物並不在我們的藥物清單上, 或者 健康計劃規則並不能讓您獲得您的開藥醫生開立的藥量, 或者 藥物需要 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 事先核准, 或者 您所服用的藥物為逐步治療限制的一部分 如果您在護理設施或其他長期護理設施內, 您可獲得的再次配藥藥量為至多 98 天 在您的計劃的最初 90 天期間, 您可以多次續配藥 這給予您的開藥醫生留出時間將您的藥物改為藥物清單上的藥物或者要求例外處理 如果下列一個護理等級變更情況適用於您, 您可能有資格獲得您目前正在服用的藥物的過渡用量 : 如果您從醫院或其他機構轉到長期護理機構 如果您離開長期護理機構回家 如果您出院回家 如果您從專業護理機構出院 如果您的狀態從安寧照護變為非安寧照護 如果您從精神病院出院並且具有個性化藥物計劃 以上所列的護理等級變更只是您可能有資格獲得過渡用量的一些原因, 有關更多資訊, 請連絡會員服務 部, 電話為 TTY 使用者請致電 代表工作時間為每週七天, 早 8 點至晚 8 點 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xi

12 11. 您是否能夠要求例外處理以承保您的藥物? 是 您可要求 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 作例外處理, 承保未在藥物清單上的藥物 您亦可要求 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 變更藥物規則 例如,Centers Plan for FIDA Care Complete 可能限制了我們將承保的藥物劑量 如果您的藥物有限制, 您可要求我們或您的 IDT 變更限制或承保更多劑量 其他範例 : 您可要求我們或您的跨學科小組 (IDT) 擯棄逐步治療限制或事先核准要求 12. 獲得例外處理需要多少時間? 首先,Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 必須收到來自您的開藥醫生支援您例外處理要求的聲明 您將在我們收到聲明後 72 小時內獲得我們對於您的例外處理要求的決定 如果您或您的開藥醫生認為如果 72 小時的必須等待可能有損您的健康, 您可要求加快例外處理 這就是快速決定 如果您的開藥醫生支援您的要求, 您將在我們收到您的開藥醫生的支援性聲明後 24 小時內獲得決定 13. 您如何要求進行例外處理? 要求例外處理, 您可致電您的保健管理員 您的保健管理員將協助您和您的提供者協助您要求例外處理 14. 什麼是普通藥物? 普通藥物成分與品牌藥物相同 它們通常比品牌藥價格更低且藥名並不被熟知 普通藥獲食品與藥品管理局 (FDA) 核准 Centers Plan for FIDA Care Complete 承保品牌藥品和普通藥品 15. 什麼是非處方 (OTC) 藥物? OTC 表示 非處方藥 當非處方藥是由您的提供者開立時,Centers Plan for FIDA Care Complete 將承保這些非處方藥 您可閱讀 Centers Plan for FIDA Care Complete 藥物清單, 瞭解哪些非處方藥在承保之列 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xii

13 16. Centers Plan for FIDA Care Complete 是否承保非處方藥非藥劑產品? 當非處方非藥劑產品是由您的提供者開立時,Centers Plan for FIDA Care Complete 將承保這些產品 非處方非 藥劑產品包括諸如酒精棉簽和紗布墊等物品 您可閱讀 Centers Plan for FIDA Care Complete 藥物清單, 瞭解哪些非處方非藥劑產品在承保之列 Centers Plan for FIDA Care Complete 同樣為會員提供每個月 $25 的補充非處方藥 (OTC) 福利, 以用於 Medicare 和 Medicaid 不承保的非處方藥清單上的項目 當月未用完的餘額不可轉入下個月 請參閱 會員手冊 第 4 章瞭解更多資訊, 或者致電會員服務部 : (TTY 使用者請致電 ), 工作時間是每週 7 天, 每天早 8 點至晚 8 點 17. 什麼是您的自付費用? 藥物清單上的藥物您無需支付自付費用 18. 什麼是藥物層級? 層級就是藥物組 所有計劃藥物清單上的藥物均為四 (4) 層級之一 您無需支付任一一層的藥物費用 第 1 層級為 Medicare 承保的普通藥物 這是最低一級 第 2 層級為 Medicare 承保的品牌藥物和專用藥物 第 3 層級為 Medicaid 承保的非 D 部分藥物 第 4 層級為 Medicaid 承保的非處方 (OTC) 藥 這是最高一級 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xiii

14 承保藥物清單 18 頁開始的承保藥物清單向您提供 Centers Plan for FIDA Care Complete 承保的藥物資訊 如果您在藥物清單上找藥物有困難, 請翻至 I-1 頁, 開始閱讀索引部分 圖示第一柱列出了藥物名稱 品牌藥名稱大寫 ( 如 :NORTHERA), 普通藥為斜體小寫 ( 如 :clonidine) 必要行動 約束或使用限制柱狀圖向您說明您藥物的 Centers Plan for FIDA Care Complete 承保規則 文件文字部分可能會有以下使用管理縮寫承保註釋縮寫 縮寫說明解釋 使用管理約束 PA PA-HRM PA NSO 事前核准約束事前核准約束用於 B 部分及 D 部分判定 B 部分及 D 部分判定的高危藥品 B 部分及 D 部分判定的僅限於紐約州 在您獲得此藥配藥之前, 您 ( 或者您的醫生 ) 必須首先獲得 Centers Plan for FIDA Care Complete 的事前核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 在 Medicare B 部分或者 D 部分承保下, 該藥物可能符合支付資格 您 ( 或您的醫生 ) 必須在您獲得此藥配藥之前取得 Centers Plan for FIDA Care Complete 關於此藥在 Medicare D 部分承保下的事先核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 本藥品已經被 CMS 視為潛在有害藥品, 因此針對 Medicare65 周歲及以上受益者是高危藥品 65 周歲或以上參與者必須在您獲得此藥配藥之前首先獲得 Centers Plan for FIDA Care Complete 的事前核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 如果您是名新參與者或者如果您之前未曾服用過此藥, 您 ( 或您的醫生 ) 必須在您為此藥配藥之前獲得 Centers Plan for FIDA Care Complete 的事先核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xiv

15 縮寫說明解釋 QL ST 數量限制約束 逐步治療約束 Centers Plan for FIDA Care Complete 限制每份處方或某指定期間所承保的藥量 在 Centers Plan for FIDA Care Complete 將為此藥提供承保之前, 您必須首先使用其他藥物以應對您的醫療病症 只有當其他藥物對您並不起作用的情況下, 此藥才可能獲得承保 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xv

16 文件文字部分可能會有以下承保註釋縮寫 其他特殊承保要求 縮寫說明解釋 LA NM 獲得管道有限的藥物 非來信訂購藥品 該處方可能只能在一些藥房配藥 欲瞭解更多訊息, 請參閱您的 藥房名錄 或致電會員服務部 : , 工作時間為每週七天, 早 8 點至晚 8 點 TTY/TDD 使用者應致電 您可能在您的處方表中按折扣藥品分擔費用郵購多數藥品的 1 個月以上供給量 透過郵購福利無法獲得的藥品在您處方一覽表中的要求 / 限制一欄中以 NM 標註 * 不是 D 部分藥物 這種藥是一份非 D 部分藥物或一份非處方藥物或產品 注意 : 藥品邊上的 (*) 表示此藥並非 D 部分藥品 這些藥品有不同的上訴規則 上訴即要求我們審核並且在您認為存在錯誤的情況下變更承保決定的正式方式 例如,Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 可能決定您想要的藥物並未或不再受到 Medicare or Medicaid 承保 如果您或您的醫生或其他開藥醫生對該決定有異議, 您可提起上訴 瞭解如何上訴的指令, 請致電會員服務部, 電話是 或者致電獨立消費者宣導組織 (ICAN), 電話是 您亦可閱讀會員手冊, 瞭解如何對決定提起上訴 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xvi

17 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals 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

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

19 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 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 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 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 (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) (Buprenorphine HCl) (Fiorinal with Codeine #3) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 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 (180 per 30 days) PA-HRM; QL (180 per 30 days) ST; QL (60 per 30 days) PA-HRM; QL (180 per 30 days) 3

20 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 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain & fever 160 mg/5 ml a/f,gluten/f,cherry 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg * children's mapap 80 mg rapid 80 mg * children's silapap elixir 160 mg/5 ml * codeine sulfate oral tablet 15 mg, 30 mg, 60 mg cvs child non-asa 80 mg tb chw 80 mg * cvs non-aspirin jr tab chew 160 mg * cvs pain relief adult liquid 500 mg/15 ml * endocet oral tablet mg, mg, mg, mg (Acetaminophen) (Infants' Tylenol) (Acetaminophen) (Acetaminophen) (Tylenol Sore Throat) (Codeine Sulfate) (Acetaminophen) (Acetaminophen) (Tylenol Sore Throat) (Xolox) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (4 per 28 days) PA-HRM; QL (180 per 30 days) QL (240 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (120 per 30 days) QL (360 per 30 days) 4

21 endodan oral tablet mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 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 solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml 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 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection syringe 2 mg/ml (Hycet) (Norco) (Norco) (Ibudone) (Dilaudid-HP) (Dilaudid) QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg 5

22 hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 QL (240 per 30 days) ml * mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (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/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Acetaminophen) mg * margesic oral capsule PA-HRM; QL (180 per (Esgic) mg 30 days) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 50 mg/25 ml (2 mg/ml) (Morphine Sulfate/0.9% Nacl/PF) 6

23 morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) morphine in dextrose 5 % injection pt controlled analgesia syring 100 (Morphine mg/50 ml (2 mg/ml), 50 mg/25 ml (2 Sulfate/D5W) mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml (Morphine Sulfate) morphine intramuscular pen injector 10 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) 7

24 non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 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 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral QL (120 per 30 days) (Oxycontin) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) 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.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG 8

25 oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 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 (180 per 30 days) (Acetaminophen) 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 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 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 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet mg, QL (150 per 30 days) (Ibudone) mg, mg (Oxycodone QL (1800 per 30 days) roxicet oral solution mg/5 ml HCl/Acetaminophe n) silapap infant's drops infant's 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Acetaminophen) 650 mg * sm pain rel jr str tab chew 160 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) 9

26 tactinal 500 mg tablet extra-strength 500 mg * (Tylenol) QL (240 per 30 days) tencon oral tablet mg (Tencon) PA-HRM; QL (180 per 30 days) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet mg (Ultracet) QL (240 per 30 days) vicodin es oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) zebutal oral capsule mg (Esgic) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg * (Aspirin) aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 mg * (Bayer Chewable Aspirin) PA-HRM; QL (180 per 30 days) 10

27 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 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 100 mg diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 (Etodolac) mg etodolac oral tablet 400 mg, 500 mg (Etodolac) 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) 11

28 etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Etodolac) (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) indomethacin oral capsule 50 mg (Indomethacin) indomethacin oral capsule, extended (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) PA PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) PA-HRM QL (20 per 30 days) 12

29 meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) 13

30 lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl laryngotracheal solution 4 % (Xylocaine) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine hcl urethral gel 2 % (Lidocaine HCl) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) 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 150 mg tablet f/c 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) (Zyban) PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) 14

31 disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * NICODERM CQ 21 MG/24HR PATCH 21 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 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 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) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG QL (4 per 30 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) 15

32 ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 PA; QL (90 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, QL (90 per 30 days) (Ativan) 2 mg ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) Antibacterials Aminoglycosides 16

33 BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial 25's,pedi,latex-free 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) 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/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Tobi) (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) (Cleocin HCl) QL (224 per 28 days) 17

34 clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg CUBICIN INTRAVENOUS RECON SOLN 500 MG linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml (Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate) (Coly-Mycin M Parenteral) (Zyvox) (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg (Macrodantin) nitrofurantoin macrocrystal oral capsule 50 mg (Macrodantin) PA-HRM; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) 18

35 nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrobid) (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin gram/200 ml HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA; QL (9 per 30 days) PA 19

36 cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram (Maxipime) cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg (Claforan) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) 20

37 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback 50ml (Ceftriaxone galaxycontainer 1 gram/50 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram (Rocephin) ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg (Rocephin) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cephalexin) cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 21

38 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG 22

39 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 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 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg (Erythromycin Stearate) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) LA 23

40 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 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam 1.5 gm vl p/f, latex-free 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Unasyn) (Unasyn) 24

41 dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram (Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) 25

42 piperacil-tazobact 40.5 gram p/f, pharmacy bulk 40.5 gram (Zosyn) Quinolones ciprofloxacin 200 mg/20 ml vl (Ciprofloxacin sdv,latex-free 200 mg/20 ml Lactate) ciprofloxacin hcl oral tablet 100 mg, (Cipro) 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml (Cipro I.V.) ciprofloxacin lactate intravenous (Ciprofloxacin solution 400 mg/40 ml Lactate) ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 (Levaquin) mg/150 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) levofloxacin oral solution 250 mg/10 ml (Levaquin) levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg (Sulfamethoxazole/ Trimethoprim) (Sulfamethoxazole/ Trimethoprim) (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) 26

43 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines doxy 100 vial 10's, p/f 100 mg doxycycline hyclate 100 mg cap 100 mg doxycycline hyclate 100 mg tab f/c 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline mono 100 mg cap 100 mg doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg (Azulfidine) (Sulfamethoxazole/ Trimethoprim) (Doxycycline Hyclate) (Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy) (Doryx) (Adoxa) (Avidoxy) (Avidoxy) (Adoxa) (Vibramycin) (Avidoxy) (Minocin) (Minocycline HCl) 27

44 tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 10 mg, 20 mg, 50 mg adriamycin intravenous solution 10 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Tetracycline HCl) (Doxorubicin HCl) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG (Vidaza) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO 28

45 BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 30 (Bleomycin unit Sulfate) bleomycin sulfate 15 unit vial latexfree 15 unit Sulfate) (Bleomycin BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous (Cyclophosphamid recon soln 1 gram, 2 gram, 500 mg e) CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 (Cyclophosphamid mg, 50 mg e) PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST 29

46 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg (Dactinomycin) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 30

47 floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) fluorouracil intravenous solution 2.5 gram/50 ml (Fluorouracil) flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial sd polymer vial 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg IMBRUVICA ORAL CAPSULE 140 MG (Ifex) (Ifex) (Ifosfamide/Mesna ) PA NSO 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 (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO 31

48 IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 15 MG KIT WITH DILUENT 15 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 (Leuprolide mg/0.2 ml Acetate) lipodox intravenous suspension 2 mg/ml (Doxil) PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (6 per 28 days) PA NSO 32

49 lomustine oral capsule 10 mg, 100 mg, 40 mg LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Lomustine) (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml Sodium) (Methotrexate methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) 33

50 methotrexate sodium oral tablet 2.5 mg mitoxantrone intravenous concentrate 2 mg/ml NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG 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 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG (Methotrexate Sodium) (Mitoxantrone HCl) SPRYCEL ORAL TABLET 20 MG ; ST PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) 34

51 STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) TREANDA 25 MG VIAL 25 MG TREANDA INTRAVENOUS RECON SOLN 100 MG PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO; (vial only) 35

52 TREANDA INTRAVENOUS SOLUTION 180 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE WITH MIXJECT 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) (capsule: 10mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) 36

53 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg 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 (Atropine Sulfate) (Atropine Sulfate) (Propantheline Bromide) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) QL (4 per 28 days) ST ST 37

54 BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) ST PA NSO; QL (80 per 30 days) PA NSO; QL (600 per 30 days) PA NSO; QL (60 per 30 days) 38

55 felbamate oral tablet 400 mg, 600 mg fosphenytoin 500 mg pe/10 ml 10's,sdv,latex-free 500 mg pe/10 ml fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablets,dose pack 25 mg (35) levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Felbatol) (Cerebyx) (Cerebyx) (Neurontin) (Neurontin) (Neurontin) (Lamictal) (Lamictal XR) (Lamictal) (Lamictal (Blue)) (Keppra) (Keppra) (Keppra) (Keppra XR) ST 39

56 LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution 130 mg/ml, 65 mg/ml Sodium) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) 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) SABRIL ORAL POWDER IN PACKET 500 MG 40

57 SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiragen oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, 5 mg (Aricept) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) 41

58 donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG rivastigmine tartrate oral capsule QL (60 per 30 days) (Exelon) 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 QL (30 per 30 days) hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr (Exelon) Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 (Amitriptyline PA NSO-HRM mg, 150 mg, 25 mg, 50 mg, 75 mg HCl) amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg (Amoxapine) BRINTELLIX ORAL TABLET 10 ST MG, 20 MG, 5 MG buproban oral tablet extended release 150 mg (Wellbutrin SR) bupropion hcl oral tablet 100 mg, 75 mg (Wellbutrin) 42

59 bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg (Wellbutrin XL) citalopram oral solution 10 mg/5 ml (Citalopram Hydrobromide) citalopram oral tablet 10 mg, 20 QL (30 per 30 days) (Celexa) mg, 40 mg clomipramine oral capsule 25 mg, PA NSO-HRM (Anafranil) 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 PA NSO-HRM (Doxepin HCl) mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) 43

60 fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 100 mg, 150 mg Maleate) fluvoxamine oral tablet 100 mg, 25 (Fluvoxamine mg, 50 mg Maleate) imipramine hcl oral tablet 10 mg, 25 (Tofranil) mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg (Tofranil-Pm) maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg (Remeron) mirtazapine oral tablet,disintegrating 15 mg, 30 mg, (Remeron) 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg (Nefazodone HCl) nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) nortriptyline oral solution 10 mg/5 ml (Nortriptyline HCl) olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 (Symbyax) mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg (Paxil) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 (Paxil CR) mg PAXIL ORAL SUSPENSION 10 MG/5 ML PA NSO-HRM PA NSO-HRM 44

61 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg (Perphenazine/Ami triptyline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg (Trazodone HCl) trimipramine oral capsule 100 mg, (Trimipramine 25 mg, 50 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 (Effexor XR) mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Antidiabetic Agents (Venlafaxine HCl) (Venlafaxine HCl) PA NSO-HRM ST; QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST 45

62 Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG KORLYM ORAL TABLET 300 (Precose) QL (90 per 30 days) QL (180 per 30 days) ST ST ST ST PA; QL (112 per 28 days) MG metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg (Glucophage XR) (Glucophage XR) (Fortamet) QL (120 per 30 days) QL (90 per 30 days) QL (60 per 30 days) 46

63 metformin oral tablet extended release 24hr 500 mg miglitol oral tablet 100 mg, 25 mg, 50 mg nateglinide oral tablet 120 mg, 60 mg pioglitazone oral tablet 15 mg, 30 mg, 45 mg pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg repaglinide oral tablet 0.5 mg, 1 mg, 2 mg repaglinide-metformin oral tablet mg, mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) (Fortamet) (Glyset) (Starlix) (Actos) (Duetact) (Actoplus Met) (Prandin) (Prandimet) QL (150 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 (150 per 30 days) PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) ST QL (24 per 28 days) 47

64 HUMULIN R U-500 QL (40 per 28 days) (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) 48

65 glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg glyburide micronized oral tablet 1.5 mg glyburide micronized oral tablet 3 mg glyburide micronized oral tablet 6 mg (Glucotrol XL) (Glucotrol XL) (Glipizide/Metform in HCl) (Glipizide/Metform in HCl) (Glynase) (Glynase) (Glynase) glyburide oral tablet 1.25 mg (Glyburide) glyburide oral tablet 2.5 mg (Glyburide) glyburide oral tablet 5 mg (Glyburide) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (120 per 30 days) PA-HRM; QL (400 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (280 per 30 days) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) glyburide-metformin oral tablet mg (Glucovance) glyburide-metformin oral tablet mg, mg (Glucovance) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG (Miconazole Nitrate) 49

66 amphotericin b injection recon soln (Amphotericin B) 50 mg anti-fungal 1% powder 1 % * (Tolnaftate) baza antifungal 2% cream 12's 2 % (Nuzole) * blis-to-sol 1% liquid 1 % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % (Loprox) ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Ciclopirox % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) topical solution 8 % clotrim 1% vaginal cream 1 % * (Gyne-Lotrimin) clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) clotrimazole 1% solution (otc) 1 % (Clotrimazole) * clotrimazole insert 100 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) troche 10 mg clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Clotrimazole) clotrimazole-7 cream 1 % * (Gyne-Lotrimin) clotrimazole-betamethasone topical (Lotrisone) cream % cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af 1% spray powder 1 % * (Tinactin) cvs antifungal 25% liquid 25 % * (Undecylenic Acid) clotrimazole-betamethasone topical critic-aid clear af 2% oint 12's, w/ (Clotrimazole/Beta (Miconazole lotion % antifungal 2 % * methasone Dip) Nitrate) 50

67 cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) * (Miconazole Nitrate) dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream 1 % (Econazole Nitrate) elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml (Fluconazole In Nacl,Iso-Osm) fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) fluconazole-nacl 400 mg/200 ml (Fluconazole In 10's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * (Clotrimazole) FUNGI-NAIL TINCTURE * fungoid-d 1% cream 1 % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet 500 mg (Grifulvin V) inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % * (Tinactin) lamisil af defense 1% powder 1 % * (Tolnaftate) 51

68 LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole mg vag supp 100 (Miconazole mg * Nitrate) miconazole nitrate 2% cream 2 % * (Nuzole) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole 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) 100 MG nyamyc topical powder 100,000 (Nystatin) unit/gram nystatin oral suspension 100,000 (Nystatin) unit/ml nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 100,000 (Nystatin) unit/gram nystatin topical ointment 100,000 (Nystatin) unit/gram nystatin topical powder 100,000 (Nystatin) unit/gram 52

69 nystatin-triamcinolone topical (Nystatin/Triamcin cream 100, unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin ointment 100, unit/gram-% ) nystop topical powder 100,000 (Nystatin) unit/gram pv foot odor control 1% powder 1 % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal 1% liquid spray liquid (Tolnaftate) spray 1 % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine 1% cream 1 % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Tolnaftate) (Miconazole triple paste af 2% ointment 2 % * Nitrate) voriconazole intravenous solution (Vfend IV) 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) mg Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint (Claritin) 10 mg * ALLEGRA ALLERGY 180 MG TABLET 180 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * alavert d-12 allergy-sinus tab (Claritin-D 12 mg * Hour) 53

70 aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-12hr tablet mg * (Claritin-D 12 Hour) allerclear d-24hr er tablet nondrowsy mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d mg tablet 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 12.5 mg/5 ml a/f 12.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl 1 mg/1 ml soln children, s/f, grape (otc) 1 mg/ml * (Children'S Zyrtec) cetirizine hcl 10 mg tablet indoor & outdoor 10 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er mg tab 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 * child triaminic cold & allergy mg/5 ml * (Dimetapp) 54

71 child wal-tap cold-allergy elx mg/5 ml * CHILD ZYRTEC 1 MG/ML SOLUTION D/F,S/F,GRAPE 1 MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-dryl 12.5 mg/5 ml a/f,s/f,d/f,bubb gum 12.5 mg/5 ml * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 10 MG REDITABS 10 MG * CLARITIN 10 MG TABLET (OTC) 10 MG * CLARITIN 5 MG REDITABS 5 MG * clemastine fum 1.34 mg tablet (otc) 1.34 mg * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs child allergy 10 mg chw tb 24 hr,indoor/outdoor 10 mg * (Dimetapp) (Allegra Allergy) (Children'S Zyrtec) (Zzzquil) (Zyrtec) (Clemastine Fumarate) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) (Zyrtec) 55

72 cvs cold & cough nighttime liq mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f mg/5 ml * dimetapp cold & congest liquid mg/5 ml * (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 12.5 mg/5 ml soln 12.5 (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 solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/ * Phenylephrine) fexofenadine hcl 180 mg tablet (Allegra Allergy) 24hr,original str (otc) 180 mg * fexofenadine hcl 30 mg/5 ml 30 (Fexofenadine mg/5 ml * HCl) 56

73 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) ml levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Claritin) loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S s/f 5 mg/5 ml * Claritin) loratadine-d 12 hour tablet nondrowsy mg * Hour) (Claritin-D 12 loratadine-d 24hr tablet mg (Claritin-D 24 * Hour) q-dryl 12.5 mg/5 ml liquid a/f 12.5 (Zzzquil) mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 (Zzzquil) mg/5 ml * (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) sm z-sleep 50 mg/30 ml liquid (Zzzquil) berry,gluten-free 50 mg/30 ml * TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE MG/5 ML * unisom 50 mg sleepgels softgel 50 (Zzzquil) mg * promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 sm sinus and allergy tablet sudogest sinus & allergy tab 4-60 (Promethazine (Diphenhydramine (Diphenhydramine (Chlorpheniramine/ (Chlorpheniramine/ ml mg * mg * maximum strength 4-60 mg * mg * HCl) HCl) HCl) Pseudoephed) Pseudoephed) PA-HRM 57

74 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 180 mg tablet 180 (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 10 mg odt non-drowsy 10 (Claritin) mg * wal-itin 10 mg tablet non-drowsy 10 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 12 wal-itin d 12 hour tablet mg * Hour) wal-itin d 24 hour tablet mg (Claritin-D 24 * Hour) (Unisom wal-sleep z 25 mg odt 25 mg * Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid (Zzzquil) berry, a/f, d/f, s/f 50 mg/30 ml * (Doxylamine wal-som 25 mg tablet 25 mg * Succinate) wal-som 50 mg softgel softgel 50 mg (Zzzquil) * wal-tap elixir mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr mg * (Zyrtec-D) wal-phed pe sinus & allergy tb 4-10 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 58

75 wal-zyr solution children's, a/f 1 mg/ml * (Children'S Zyrtec) ZYRTEC 10 MG LIQUID GELS 10 MG * ZYRTEC 10 MG ODT 10 MG * ZYRTEC 10 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt Mlt) 10 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng (Sumatriptan QL (4 per 28 days) p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) 59

76 sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 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 CAPASTAT INJECTION RECON SOLN 1 GRAM (Imitrex) (Imitrex) (Sumatriptan Succinate) (Imitrex) (Sumatriptan Succinate) (Sumatriptan Succinate) (Imitrex) (Zomig) (Zomig Zmt) dapsone oral tablet 100 mg, 25 mg (Dapsone) ethambutol oral tablet 100 mg, 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 100 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) QL (12 per 28 days) QL (18 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 (12 per 28 days) QL (12 per 28 days) 60

77 rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300- (Rifadin) PA; QL (188 per 168 days) 0.5 MG compro rectal suppository 25 mg (Compazine) cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg (Marinol) EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 115 MG, 150 MG EMEND ORAL CAPSULE 125 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) granisetron (pf) intravenous (Granisetron solution 100 mcg/ml HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) granisetron hcl oral tablet 1 mg (Granisetron HCl) meclizine 12.5 mg caplet caplet (otc) 12.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) 61

78 meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) ondansetron hcl oral solution 4 mg/5 ml (Zofran) ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg (Zofran) ondansetron oral tablet,disintegrating 4 mg, 8 mg (Zofran Odt) phenadoz rectal suppository 12.5 mg, 25 mg (Phenergan) prochlorperazine edisylate injection (Prochlorperazine solution 10 mg/2 ml (5 mg/ml) Edisylate) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) prochlorperazine rectal suppository 25 mg (Compazine) promethazine oral tablet 12.5 mg, (Promethazine 25 mg, 50 mg HCl) promethazine rectal suppository 12.5 mg, 25 mg, 50 mg (Phenergan) promethegan rectal suppository 12.5 mg, 25 mg, 50 mg (Phenergan) TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG PA-HRM PA-HRM PA-HRM PA-HRM QL (10 per 30 days) 62

79 ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg, mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 (Plaquenil) mg ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG (Paromomycin Sulfate) QL (6 per 21 days) QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 100 mg (Amantadine HCl) APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML QL (60 per 30 days) 63

80 AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine oral tablet 0.5 mg, 1 (Benztropine mg, 2 mg Mesylate) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet mg, mg, mg (Sinemet CR) carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, (Stalevo 50) mg, mg, mg entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) trihexyphenidyl oral tablet 2 mg, 5 mg (Trihexyphenidyl HCl) PA-HRM PA-HRM PA-HRM 64

81 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG QL (1 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml (Abilify) QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) chlorpromazine oral tablet 10 mg, (Chlorpromazine 100 mg, 200 mg, 25 mg, 50 mg HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) 65

82 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 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, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML (Fazaclo) (Fluphenazine Decanoate) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) (Haloperidol) ST ST; QL (60 per 30 days) ST; QL (8 per 28 days) QL (6 per 28 days) 66

83 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) molindone oral tablet 10 mg (Moban) QL (240 per 30 days) molindone oral tablet 25 mg (Moban) QL (270 per 30 days) molindone oral tablet 5 mg (Moban) QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating QL (31 per 30 days) (Zyprexa Zydis) 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg (Perphenazine) pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (120 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG 67

84 RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) risperidone oral (Risperdal M-Tab) QL (120 per 30 days) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG Antivirals (Systemic) (Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl) (Geodon) ST; QL (60 per 30 days) PA NSO-HRM ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 68

85 Antiretrovirals abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine-zidovudine oral tablet mg (Trizivir) APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 (Videx EC) mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 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 100 MG, 200 MG, 25 MG 69

86 INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG 70

87 PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 10 MG/ML (FINAL) 71

88 VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS 100 MG/1 ML VIAL 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals QL (84 per 180 days) QL (48 per 180 days) QL (42 per 180 days) QL (540 per 180 days) 72

89 DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG ZEPATIER ORAL TABLET MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 10 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML 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 (112 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO PA NSO PA NSO PA PA PA PA 73

90 SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg (Famvir) ganciclovir sodium intravenous recon soln 500 mg (Cytovene) ribasphere oral capsule 200 mg (Rebetol) ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) 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 (Lovenox) PA NSO; QL (4 per 28 days) 74

91 enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml 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 12,500 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(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 10,000 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 (100 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container 25,000 unit/250 ml(100 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) PA; QL (24 per 28 days) 75

92 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML (Coumadin) (Coumadin) ST; QL (60 per 30 days) PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 76

93 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/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 10,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 10,000 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 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet 1,000 mg, 500 mg anagrelide oral capsule 0.5 mg, 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) (Aminocaproic Acid) (Aminocaproic Acid) (Agrylin) (Protamine Sulfate) (Tranexamic Acid) PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) 77

94 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg (Pletal) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 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 % QL (30 per 30 days) 78

95 AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % 79

96 CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 80

97 CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringers intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution (Cysteine HCl) (Dextrose) (Dextrose 10 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5 % In Ringers) (Dextrose 5 % in Water) 81

98 dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous syringe Water) dextrose 70 % in water (d70w) (Dextrose 70 % in intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, (Dextrose) caffeine free 4 gram * glucose 40% gel tropical fruit 40 % * glutose 15 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/31 gram (Dextrose/Dextrin/ * Maltose) INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % LIPOSYN II INTRAVENOUS EMULSION 20 % LIPOSYN III INTRAVENOUS EMULSION 10 %, 20 %, 30 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % 82

99 NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet mg, mg, mg (Catapres) (Catapres-Tts 1) (Catapres-Tts 1) (Clonidine HCl/Chlorthalidon e) QL (4 per 28 days) QL (8 per 28 days) doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Cardura) guanfacine oral tablet 1 mg, 2 mg (Tenex) PA-HRM 83

100 midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg ENTRESTO ORAL TABLET MG, MG, MG irbesartan oral tablet 150 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet mg, mg, mg (Midodrine HCl) (Vazculep) (Minipress) (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) PA; QL (180 per 30 days) PA; QL (60 per 30 days) 84

101 TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet mg, mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg (Diovan) (Diovan HCT) (Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydroch lorothiazide) (Vasotec) (Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) (Zestril) (Zestoretic) moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) ST 85

102 moexipril-hydrochlorothiazide oral tablet mg, mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg (Moexipril/Hydroc hlorothiazide) (Aceon) (Accupril) (Accuretic) (Altace) (Mavik) (Cordarone) (Norpace) (Tambocor) (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) (Mexiletine HCl) (Cordarone) (Procainamide HCl) (Rythmol SR) 86

103 propafenone oral tablet 150 mg, 225 (Rythmol) mg, 300 mg quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet mg, mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg (Kerlone) bisoprolol fumarate oral tablet 10 mg, 5 mg (Zebeta) bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 100 mg, 200 mg, 300 mg (Trandate) metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 (Toprol XL) mg, 25 mg, 50 mg 87

104 metoprolol ta-hydrochlorothiaz oral tablet mg, mg, (Lopressor HCT) mg metoprolol tartrate intravenous solution 5 mg/5 ml (Lopressor) metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Lopressor) nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg pindolol oral tablet 10 mg, 5 mg (Pindolol) propranolol intravenous solution 1 mg/ml (Propranolol HCl) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 (Inderal LA) mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet mg, mg chlorothiazid) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg (Betapace) sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 10 mg, 20 mg, 5 mg (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 (Cardizem CD) mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg (Cardizem CD) diltiazem 24hr er 360 mg cap once a (Cardizem CD) day dosage 360 mg 88

105 diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem LA) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Verapamil HCl) (Verelan Pm) (Verelan) (Calan) (Calan SR) 89

106 CORLANOR ORAL TABLET 5 ST MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG digitek oral tablet 125 mcg (Lanoxin) QL (30 per 30 days) digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 days) digox 125 mcg tablet 125 mcg (Lanoxin) QL (30 per 30 days) digox 250 mcg tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 days) digoxin 0.25 mg/ml syringe 250 PA-HRM (Digoxin) mcg/ml digoxin injection solution 250 PA-HRM (Digoxin) mcg/ml DIGOXIN ORAL SOLUTION 50 PA-HRM; QL (300 per MCG/ML 30 days) digoxin oral tablet 125 mcg (Lanoxin) QL (30 per 30 days) digoxin oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 days) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (Dobutamine (4,000 mcg/ml), 250 mg/250 ml (1 HCl/D5W) mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) 250 mg/20 ml (12.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) ephedrine sulfate injection solution 50 mg/ml (Dopamine HCl/D5W) (Dopamine HCl) (Ephedrine Sulfate) 90

107 epinephrine hcl (pf) intravenous solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN ORAL TABLET MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 150 mg (Epinephrine HCl/PF) (Adrenaclick) (Epinephrine) (Epinephrine) (Ethanolamine Oleate) (Hydralazine HCl) (Hydralazine HCl) (Milrinone Lactate/D5W) (Milrinone Lactate) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl) PA-HRM; QL (30 per 30 days) QL (30 per 30 days) PA PA 91

108 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg (Adalat CC) amlodipine oral tablet 10 mg, 2.5 mg, 5 mg (Norvasc) amlodipine-benazepril oral capsule mg, mg, mg, 5- (Lotrel) 10 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg, 5- (Exforge) 320 mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) mg AZOR ORAL TABLET MG, MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg (Felodipine) isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral tablet 5-50 mg (Amiloride/Hydroc hlorothiazide) ST 92

109 bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, 1 mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG furosemide injection solution 10 mg/ml (Furosemide) furosemide injection syringe 10 mg/ml (Furosemide) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) indapamide oral tablet 1.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 10 mg, 2.5 mg, 5 mg (Zaroxolyn) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule mg, mg (Dyazide) triamterene-hydrochlorothiazid oral tablet mg, mg (Maxzide) Dyslipidemics 93

110 amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, (Caduet) mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) cholestyramine light oral powder in packet 4 gram (Questran) cholestyramine packet 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 (Lofibra) mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg (Lofibra) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor) PA PA; QL (4 per 28 days) 94

111 niacin 50 mg tablet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) niacin 500 mg tablet 500 mg * (Slo-Niacin) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg (Niaspan) niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram (Cholestyramine/A spartame) prevalite packet outer 4 gram REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Cholestyramine/A spartame) (Zocor) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM 95

112 WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg (Isochron) isosorbide dinitrate oral tablet extended release 40 mg (Isochron) isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) isosorbide mononitrate oral tablet (Isosorbide 10 mg, 20 mg Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 (Imdur) mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil) NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (Nitroglycerin/D5 (400 mcg/ml), 25 mg/250 ml (100 W) mcg/ml), 50 mg/250 ml (200 mcg/ml) QL (30 per 30 days) QL (60 per 30 days) 96

113 nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin transdermal patch 24 hour 0.1 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 12 HR 10 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 (125 mg/ml caffeine) clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Nitroglycerin) (Nitro-Dur) (Nitro-Dur) (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) (Kapvay) (Focalin) (Dexedrine) (Dexedrine) (Adderall XR) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) 97

114 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0.1 mg/ml guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 150 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 methylphenidate oral capsule,er biphasic mg, 40 mg methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg, 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg (Adderall XR) (Adderall) (Romazicon) (Intuniv) (Lithium Carbonate) (Lithobid) (Lithobid) (Lithium Citrate) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Methylin) (Ritalin) (Methylphenidate HCl) (Concerta) 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) 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) 98

115 methylphenidate oral tablet extended release 24hr 36 mg (Concerta) NUEDEXTA ORAL CAPSULE MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Contraceptives Contraceptives AFTERA 1.5 MG TABLET 1.5 MG * 3 $0 altavera (28) oral tablet mg (Amethyst) alyacen 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (Seasonique) (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) apri oral tablet mg (Desogen) aranelle (28) oral tablet 0.5/1/ mg-mcg (Modicon) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) 99

116 ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet mg-mcg (Amethyst) aviane oral tablet mg-mcg (Amethyst) azurette (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet mgmcg (Modicon) bekyree (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) blisovi fe 1/20 (28) oral tablet 1 mg- (Loestrin Fe) 20 mcg (21)/75 mg (7) briellyn oral tablet mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg cryselle (28) oral tablet mgmcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Seasonique) (Seasonique) (Desogen) (Norgestrel-Ethinyl Estradiol) (Modicon) (Modicon) cyred oral tablet mg (Desogen) dasetta 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) QL (91 per 84 days) QL (91 per 84 days) 100

117 daysee oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet mg (Desogen) drospirenone-ethinyl estradiol oral tablet mg, mg (Yaz) econtra ez 1.5 mg tablet inner 1.5 QL (6 per 365 days) (Aftera) mg * elinest oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg (Desogen) enpresse oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet mg (Desogen) errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet mg-mcg (Ortho-Cyclen) falmina (28) oral tablet mgmcg (Amethyst) gianvi (28) oral tablet mg (Yaz) gildagia oral tablet mg-mcg (Modicon) gildess 1.5/30 (21) oral tablet (Loestrin) mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) heather oral tablet 0.35 mg (Nor-Q-D) 101

118 introvale oral tablets,dose pack,3 (Levonorgestrelmonth mg-mcg Ethin Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 (Levonorgestrelmonth mg-mcg Ethin Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet mg (Desogen) junel 1.5/30 (21) oral tablet mg-mcg (Loestrin) junel 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen ) kimidess (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kurvelo oral tablet mg (Amethyst) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7), 0.15 mg-30 (Seasonique) mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg (Loestrin) larin 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) 102

119 leena 28 oral tablet 0.5/1/ mg-mcg (Modicon) lessina oral tablet mg-mcg (Amethyst) levonest (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) levonor-eth estrad outer QL (91 per 84 days) (Amethyst) mg levonorgestrel 1.5 mg tablet (otc) QL (6 per 365 days) (Aftera) 1.5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (12 per 365 days) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Amethyst) levonorgestrel-ethinyl estrad oral QL (91 per 84 days) tablets,dose pack,3 month mg-mcg (Amethyst) levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet mg (Yaz) low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet mg (Amethyst) microgestin 1.5/30 (21) oral tablet mg-mcg (Loestrin) microgestin 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) (Loestrin Fe) 103

120 mono-linyah oral tablet mgmcg (Ortho-Cyclen) mononessa (28) oral tablet mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet mg-mcg (Modicon) necon 1/35 (28) oral tablet 1-35 mgmcg (Modicon) necon 1/50 (28) oral tablet 1-50 mgmcg (Norinyl 1+50) necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg (Modicon) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) next choice one dose 1.5 mg tb (otc) QL (6 per 365 days) (Aftera) 1.5 mg * next choice one dose oral tablet 1.5 QL (6 per 365 days) (Plan B One-Step) mg nikki (28) oral tablet mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) norg-ee / /0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, (Ortho-Cyclen) mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg 104

121 nortrel 1/35 (21) oral tablet 1-35 mg-mcg (Modicon) nortrel 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) NUVARING VAGINAL RING ST; QL (1 per 28 days) MG/24 HR ocella oral tablet mg (Yaz) ogestrel (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * orsythia oral tablet mg-mcg (Amethyst) philith oral tablet mg-mcg (Modicon) pimtrea (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg (Modicon) PLAN B ONE-STEP 1.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC) 1.5 MG * portia oral tablet mg (Amethyst) previfem oral tablet mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month mg-mcg Ethin Estradiol) react 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet mg (Desogen) setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month mg-mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) sprintec (28) oral tablet mgmcg (Ortho-Cyclen) sronyx oral tablet mg-mcg (Amethyst) syeda oral tablet mg (Yaz) tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) 105

122 tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg (Desogen) vestura (28) oral tablet mg (Yaz) vienva oral tablet mg-mcg (Amethyst) viorele (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) vyfemla (28) oral tablet mgmcg (Modicon) wera (28) oral tablet mg-mcg (Modicon) xulane transdermal patch weekly mcg/24 hr (Ortho Evra) zarah oral tablet mg (Yaz) zenchent (28) oral tablet mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen ) QL (3 per 28 days) 106

123 zovia 1/50e (28) oral tablet 1-50 mg-mcg Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-150gfn-15dm liquid mg/5 ml * 3brm-15dm-30pse liquid mg/5 ml * 3brm-30dm-50pse liquid (otc) mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin linger cold syr 15 mg/5 ml * adt robitussin peak cld dm max mg/5 ml * adult robitussin peak cold liq nondrowsy 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 mg/5 ml * adult wal-tussin liquid 100 mg/5 ml * (Demulen ) (Chlorpheniramine/ Phenyleph/Dm) (Chlophedianol HCl/Guaifenesin) (Trispec Pse) (Brompheniramine/ Pseudoephed/Dm) (Brompheniramine/ Pseudoephed/Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) (G-Zyncof) (G-Zyncof) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 10peh-4cpm-20dm tablet (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet 40- (Guaifenesin/Dm/P mg * seudoephedrine) ambi 60pse-4cpm-20dm tablet (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) 107

124 benzonatate 100 mg capsule 100 mg * (Zonatuss) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid mg/5 (Brompheniramine/ ml * Pseudoephed/Dm) bionel pediatric liquid mg/5 ml * (Trispec Pse) biospec dmx liquid 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 (Brompheniramine/ (otc) mg/5 ml * Pseudoephed/Dm) bromfed dm cough syrup (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 bromphenex dm syrup (otc) (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 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 (Chlorpheniramine/ mg/ml * Phenyleph/Dm) cheracol d cough formula 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 (Cough Formula mg/5 ml * Dm) child wal-tussin 7.5 mg odt 7.5 mg * (Dextromethorphan Hbr) children's mucinex cough liq a/f mg/5 ml * (G-Zyncof) 108

125 children's silfedrine liq 15 mg/5 ml (Pseudoephedrine * HCl) (Robitussin chl mucinex chest congest liq a/f Mucus-Chest 100 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,12 Hb/Pe/Acetaminop day,12 night mg * hen/chlorph) (Dcold-flu relief liquid ,000 Methorphan/Aceta mg/30 ml * min/doxylamn) (Guaifenesin/Pseud congestac tablet mg * oephedrne HCl) (Dcoricidin hbp cold-multi sympt Methorphan/Aceta mg/15 ml * min/doxylamn) (Guaifenesin/Dextr coricidin hbp softgel mg * omethorphan) cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab (Maxiphen) mg * cvs chest congest relief dm tb 20- (Allfen Dm) 400 mg * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * codituss dm syrup mg/5 cold-flu relief d/n softgel congest-eze mg caplet 60- cvs child cold-cough day liq (Pseudoephedrine (Pyrilamine/Pe/De (Vicks Dayquil- (Guaifenesin/Pseud (Dextromethorphan ml * 325mg(d)/ mg * 400 mg * mg/5 ml * HCl) xtromethorphan) Nyquil) oephedrne HCl) /Phenylephrine) 109

126 cvs child's chest congest liq 100 mg/5 ml * cvs cough & sore throat susp mg/5 ml * cvs cough relief liquid a/f, grape 15 mg/5 ml * cvs daytime-nighttime cold-flu multi-symp,twin pack mg/15 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq mg/5 ml * cvs tussin max-str syrup 15 mg/5 ml * daytime cold & cough liquid 1, mg/30 ml * daytime cold & flu liquid a/f, glutenfree mg/15 ml * (Robitussin Mucus-Chest Congest) (Acetaminophen/D extromethorphan) (Dextromethorphan Hbr) (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) (Dextromethorphan Hbr) (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 15mg/15ml(d)/ mg/30ml * delsym cough+chest cngst dm lq mg/5 ml * (G-Zyncof) despec-dm tablet mg * (Guaifenesin/Dm/P seudoephedrine) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq mg/5 ml * (G-Zyncof) ed bron gp liquid mg/5 ml * (Despec) entre-cough liquid mg/5 ml * (Trispec Pse) 110

127 expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold mg/5 ml * geri-tussin dm syrup 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 * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) hydrocodone-chlorphen er susp 10- (Tussionex) 3 $0 8 mg/5 ml * hydrocodone-homatropine mg (Tussigon) 3 $0 tablet mg * (Hydrocodone hydromet syrup mg/5 ml * Bit/Homatrop Me- 3 $0 Br) 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 3 $0 * doephed/codein) mar-cof cg liquid mg/5 ml * (M-Clear Wc) 3 $0 mucus dm mg tablet (Mucinex Dm) mg * mucus dm max tablet 60-1,200 mg * (Mucinex Dm) mesehist dm oral syrup (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) 111

128 mucus relief 400 mg tablet d/f 400 mg * (Allfen) nasal-sinus decongest tab 30 mg * (Pseudoephedrine HCl) nasohist dm pediatric drops (Chlorpheniramine/ mg/ml * Phenyleph/Dm) neo-tuss liquid mg/5 ml * (G-Zyncof) NEXAFED 30 MG TABLET 30 MG * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM MG * (Dnight time cough & sore throat Methorphan/Aceta 30-1,000 mg/30 ml * min/doxylamn) nighttime cough liquid gluten-free, (Dextromethorphan cherry mg/15 ml * Hb/Doxylamine) nighttime d cold-flu rlf liq multisymptom,cherry mg/15 ml * nohist-dm liquid mg/5 ml * pecgen dmx mg/5 ml liq mg/5 ml * pedia relief cough-cold liquid a/f, cherry mg/5 ml * 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 * (Dm/P- Ephed/Acetaminop h/doxylam) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) 3 $0 3 $

129 promethazine-dm syrup (Promethazine/Dex mg/5 ml * tromethorphan) 3 $0 pseudoephed 30 mg/5 ml soln 30 (Pseudoephedrine mg/5 ml * HCl) pseudoephedrine 30 mg tablet 30 (Pseudoephedrine mg * HCl) pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * HCl) (Pseudoephedrine (Dpv flu relief therapy liquid daytime Methorphan/Pe/Ac mg/15 ml * etaminophen) (Dm/Ppv night-time softgel multisympt.,softgel mg * Ephed/Acetaminop h/doxylam) pv tussin pe liquid mg/5 ml * (Despec) q-tapp dm elixir mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 100 mg/5 ml solution a/f, Mucus-Chest non-drowsy 100 mg/5 ml * Congest) q-tussin dm syrup mg/5 ml * (Cough Formula Dm) ra child plus cough-runny nose pseudoephedrine free mg/5 ml * 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 * (Dextromethorphn/ Acetaminoph/Cp) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) 113

130 ra tussin dm syrup a/f mg/5 (Cough Formula ml * Dm) 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 * 3 $0 robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid mg/5 ml * rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin dm cough syrup mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * sm adult nasal decongestant lq 15 mg/5 ml * (Robitussin Mucus-Chest Congest) (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) (Pseudoephedrine HCl) 114

131 sm childrens plus cold susp grape,multi-symptom mg/5 ml * sm cold-cough child elixir mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm mucus relief cough liquid childrens, a/f 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 * sm pedia relief liquid mg/5 ml * sm severe cold m-s caplet mg * sm tussin cf syrup mg/5 ml * sudafed 30 mg tablet nondrowsy,max-str 30 mg * sudogest 30 mg tablet boxed 30 mg * sudogest 60 mg tablet 60 mg * suphedrin liquid 15 mg/5 ml * (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) (Chlorpheniramin/ Pseudoephed/Dm) (Dm/Pseudoephed/ Acetaminophen) (Guaifenesin/Dm/P seudoephedrine) (Pseudoephedrine HCl) (Pseudoephedrine HCl) (Pseudoephedrine HCl) 115

132 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 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) 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 * tussin cf cough & cold syrup a/f 5- (Tussi-Pres mg/5 ml * Pediatric) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap mg * seudoephedrine) tussin dm syrup 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 ml * (Dextromethorphan Hbr) 116

133 vicks nyquil severe cold-flu (Dm/Pe/Acetamino mg/15 ml * phen/doxylamine) virdec dm drops mg/ml * (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp (Dm/Pseudoephed/ mg/1.6 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 (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 (Pseudoephedrine 30 mg * HCl) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free mg * Dm/Acetamin/Gg) wal-tussin cough & cold cf (Tussi-Pres pseudoephedrine free Pediatric) mg/5 ml * wal-tussin cough 15 mg softgel 15 mg * (Robitussin) wal-tussin cough 15 mg/5 ml 15 mg/5 ml * zephrex-d 30 mg tablet 30 mg * ZONATUSS 150 MG CAPSULE 150 MG * zyncof mg/5 ml liquid mg/5 ml * (Dextromethorphan Hbr) (Pseudoephedrine HCl) 3 $0 (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane mouthwash 0.12 % (Peridex) 117

134 oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE % sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg) triamcinolone acetonide dental paste 0.1 % (Triamcinolone Acetonide) (Peridex) (Salagen) (Sodium Fluoride) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% lotion 10 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acneclear gel 10 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * (Ammonium Lactate) ammonium lactate 12% cream (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate 12% lotion (otc) (Ammonium 12 % * Lactate) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) 118

135 ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (Benzoyl Peroxide) (otc) 10 % * benzoyl peroxide 5% gel aqueous (Benzoyl Peroxide) (otc) 5 % * BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % (Calcipotriene) calcipotriene topical cream % (Dovonex) calcipotriene topical ointment (Calcipotriene) % calcitrene topical ointment % (Calcipotriene) calcitriol topical ointment 3 (Vectical) mcg/gram CASTELLANI PAINT MODIFIED 1.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML cvs skin treatment body lotion 12 % (Ammonium * Lactate) fluorouracil topical cream 0.5 %, 5 (Carac) % fluorouracil topical solution 2 %, 5 (Fluorouracil) % (Ammonium geri-hydrolac 12% lotion 12 % * Lactate) (Ammonium geri-hydrolac 5% lotion 5 % * Lactate) PA PA PA PA 119

136 imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 10 mg (Oxsoralen-Ultra) PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 % * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podocon topical liquid 25 % (Podophyllum Resin) podofilox topical solution 0.5 % (Condylox) potassium hydroxide topical (Potassium solution 5 % Hydroxide) pv acne pimple 10% gel 10 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (15 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) 120

137 clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % (Cleocin T) (Cleocin T) (Cleocin T) (Cleocin T) (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel 2 % (Emgel) erythromycin with ethanol topical (Erythromycin solution 2 % Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab 2 % Base/Ethanol) gentamicin topical cream 0.1 % (Gentamicin Sulfate) gentamicin topical ointment 0.1 % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, 1 % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) 121

138 selenium sulfide topical shampoo (Selenium Sulfide) 2.25 % silver nitrate topical ointment 10 % (Silver Nitrate) silver nitrate topical solution 0.5 %, (Silver Nitrate) 10 %, 25 %, 50 % silver sulfadiazine topical cream 1 (Silvadene) % ssd topical cream 1 % (Silvadene) sulfacetamide sodium (acne) topical (Klaron) suspension 10 % (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 1 % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) (Alclometasone alclometasone topical cream 0.05 % Dipropionate) alclometasone topical ointment 0.05 (Alclometasone % Dipropionate) aquanil hc 1% lotion 1 % * (Cortizone-10) beta hc 1% lotion 1 % * (Cortizone-10) betamethasone valerate topical (Luxiq) foam 0.12 % betamethasone valerate topical (Betamethasone betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0.1 % Dipropionate) Dipropionate) Dipropionate) Valerate) lotion 0.1 % betamethasone valerate topical ointment 0.1 % Valerate) (Betamethasone Valerate) 122

139 betamethasone, augmented topical cream 0.05 % (Diprolene AF) betamethasone, augmented topical (Betamethasone gel 0.05 % Dipropionate) betamethasone, augmented topical lotion 0.05 % (Diprolene) betamethasone, augmented topical ointment 0.05 % (Diprolene) clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Clobetasol Propionate) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % (Clobetasol Propionate) clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0.1 % (Cloderm) colocort rectal enema 100 mg/60 ml (Cortenema) cormax scalp solution 0.05 % (Clobetasol Propionate) cortizone-10 1% creme maximum strength 1 % * (Hydrocortisone) CORTIZONE-10 1% LOTION 1 % * cortizone-10 1% ointment 1 % * (Hydrocortisone) dermarest eczema 1% lotion 1 % * (Cortizone-10) desonide topical cream 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % 123

140 fluocinonide 0.05% cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluocinonide-e topical cream 0.05 % (Vanos) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 % (Ultravate) halobetasol propionate topical ointment 0.05 % (Ultravate) hydro skin 1% lotion 1 % * (Cortizone-10) hydrocortisone 0.5% cream (otc) 0.5 % * (Hydrocortisone) hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone 1% cream maximum (Hydrocortisone) strength (otc) 1 % * hydrocortisone 1% cream maximum strength 1 % * hydrocortisone 1% lotion (otc) 1 % * hydrocortisone 1% ointment carton (otc) 1 % * hydrocortisone acet-aloe vera topical gel 2 % hydrocortisone acetate-aloe topical cream 0.5 % * hydrocortisone buty 0.1% cream 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone butyr-emollient topical cream 0.1 % (Hydrocortisone Acetate) (Cortizone-10) 3 $0 (Hydrocortisone) (Hydrocortisone Acetate/Aloe V) (Hydrocortisone Butyrate) (Locoid) (Locoid) (Hydrocortisone Butyrate) 124

141 hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream 0.2 % Valerate) hydrocortisone valerate topical ointment 0.2 % (Westcort) mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % (Elocon) neosporin 1% anti-itch cream 1 % * (Hydrocortisone) ONFI ORAL TABLET 10 MG, 20 MG prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * (Hydrocortisone) procto-med hc rectal cream 2.5 % (Hydrocortisone) procto-pak rectal cream 1 % (Anusol-HC) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctozone-hc rectal cream 2.5 % (Hydrocortisone) recort plus 1% cream 1 % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical (Triamcinolone cream %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex topical ointment 0.05 % u-cort topical cream 1-10 % Dermatological Retinoids Acetonide) (Triamcinolone Acetonide) (Triamcinolone Acetonide) (Hydrocortisone Acetate/Urea) PA NSO; QL (60 per 30 days) 125

142 adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel PA (Retin-A Micro) with pump 0.04 %, 0.1 % tretinoin topical cream %, PA (Retin-A) 0.05 %, 0.1 % tretinoin topical gel 0.01 %, (Retin-A) PA %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * (Piperonyl Butoxide/Pyrethrin s) cvs permethrin 1% lotion 1 % * (Nix) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * (Nix) sm lice treatment permethrin 2's 1 % * (Nix) v-r lice cream rinse 1 % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 31GX5/ ML 31 GAUGE X 5/16 BD INSULIN SYR 0.5 ML 31GX5/16" 0.5 ML 31 GAUGE X 5/

143 BD INSULIN SYR 1 ML 31GX5/16" 1 ML 31 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2 " VGO 40 DISPOSABLE DEVICE 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) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML 127

144 ELITEK INTRAVENOUS RECON SOLN 1.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000-27,000 unit PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG (Lipase/Protease/A mylase) PA PA; LA PA QL (90 per 30 days) 128

145 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetravisc) altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % (Iopidine) artificial tears 1.4 % drops 1.4 % * (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 % (Genteal Pm) * atropine ophthalmic drops 1 % (Isopto Atropine) atropine ophthalmic ointment 1 % (Atropine Sulfate) atropine-care ophthalmic drops 1 % (Isopto Atropine) ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 137 mcg (0.1 %) (Astepro) QL (30 per 25 days) 129

146 azelastine ophthalmic drops 0.05 % (Azelastine HCl) (Dextran bion tears eye drops % * 70/Hypromellose/P F) carteolol ophthalmic drops 1 % (Carteolol HCl) (Cromolyn cromolyn ophthalmic drops 4 % Sodium) cvs artificial tears drops sterile 1- (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile (Refresh Tears) 0.5 % * (Carboxymethylcel cvs lubricant dry eye rlf 1% 1 % * lulose Sodium) cvs lubricant eye ointment p/f (Genteal Pm) 42.5 % * cvs lubricant gel eye drops (Carboxymethylcel % * l/hypromellose) cvs lubricating eye drops dry eye (Refresh Optive) soln % * (Dextran cvs natural tears drops % * 70/Hypromellose/P F) cyclopentolate ophthalmic drops 0.5 (Cyclogyl) %, 1 %, 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) (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS % * 130

147 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 0.1%-0.3% drop % * (Tears Naturale) homatropaire ophthalmic drops 5 % (Isopto Homatropine) homatropine hbr ophthalmic drops (Isopto 5 % Homatropine) ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) isopto tears 0.5% eye drops 0.5 % * (Genteal Mild To Moderate) LACRISERT OPHTHALMIC INSERT 5 MG lubricant % eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant % eye drops % * (Refresh Optive) lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment % * (Genteal Pm) muro-128 2% eye drops 2 % * (Sodium Chloride) muro-128 5% eye drops 5 % * (Sodium Chloride) muro-128 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0.1 % (Naphazoline HCl) nasal decongestant 0.05% spray 0.05 % * (Afrin) natural balance tears drops 0.4 % * (Genteal Mild To Moderate) nature's tears drops 0.4 % * (Genteal Mild To Moderate) QL (30 per 28 days) QL (15 per 10 days) 131

148 neo-synephrine 12 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * (Little Remedies) olopatadine ophthalmic drops 0.1 % (Patanol) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops (Mydfrin) 10 %, 2.5 % proparacaine ophthalmic drops 0.5 (Proparacaine HCl) % pure & gentle eye drops lubricant (Genteal Mild To 0.3 % * Moderate) (Genteal Mild To pv artificial tears 0.4 % * Moderate) pv lubricant 1.4 % eye drops 1.4 % (Polyvinyl * Alcohol) REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * REFRESH OPTIVE EYE DROPS % * (Carboxymethylcel retaine cmc 0.5% eye drops 0.5 % * lulose Sodium) saline mist 0.65% nose spry 0.65 % (Little Remedies) * 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 % * pv pure-gentle eye drops sterile 0.3 (Genteal Mild To % * Moderate) ST 132

149 SYSTANE GEL EYE DROPS % * tears again 1.4 % drops 1.4 % * (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) ultra fresh pm ointment * (Lanolin/Min Oil/Petrolat, Wht) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 12 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment ,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) 133

150 gentamicin ophthalmic drops 0.3 % (Garamycin) gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic drops 0.5 % (Levofloxacin) 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-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension , mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% (Cortisporin) neo-polycin hc ophthalmic ointment (Neomycin Su/Baci ,000 mg-unit/g-1% Zn/Poly/HC) (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy ,000 mg-unit-unit/g xin) ofloxacin ophthalmic drops 0.3 % (Ocuflox) 134

151 ofloxacin otic drops 0.3 % (Ocuflox) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 (Polytrim) mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic (Sulfacetamide drops 10 % Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide ointment 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre ophthalmic drops 10 %-0.23 % dnisolone Sp) (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % (Diclofenac Sodium) ST 135

152 DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0.1 % 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 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * cvs gas relief 125 mg chew tab extra strength 125 mg * cvs gas relief 125 mg softgel softgel 125 mg * (Flunisolide) (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) (Simethicone) (Gas-X) (Phazyme) QL (50 per 25 days) QL (60 per 30 days) 136

153 cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 125 mg chew tablet max str,lactose-free 125 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 180 mg * (Phazyme) 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 125 mg tab 125 mg * (Gas-X) simethicone 180 mg softgel 180 mg * (Phazyme) simethicone 40 mg/0.6 ml drop 40 mg/0.6 ml * (Simethicone) v-r anti-gas 166 mg softgel 166 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 CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Cimetidine) cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) (Rx Product Only) 137

154 famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) gnp acid reducer 10 mg tablet 10 mg * (Pepcid Ac) lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 14-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg (Prilosec) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) oral capsule mg-gram pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ra omeprazole-bicarb 20-1,100 3x14 day course (otc) mggram (Zegerid Otc) * ranitidine 150 mg tablet maximum strength (otc) 150 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl 50 mg/2 ml vial sdv 50 (Rx Product Only) (Zantac) mg/2 ml (25 mg/ml) 138

155 ranitidine hcl injection solution 25 (Rx Product Only) (Zantac) mg/ml ranitidine hcl oral capsule 150 mg, (Rx Product Only) (Ranitidine HCl) 300 mg ranitidine hcl oral syrup 15 mg/ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg sucralfate oral suspension 100 mg/ml (Sucralfate) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 150 MG TABLET TWIN PACK(2X45TABS) (OTC) 150 MG * ZANTAC 150 MG TABLET TWIN PK, MAX STRGTH (OTC) 150 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid mg/15 ml * (Gaviscon) almacone liquid mg/5 (Maalox Maximum ml * Strength) almacone-2 liquid mg/5 (Maalox Maximum 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 (1,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * Strength) (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) QL (60 per 30 days) 139

156 antacid-antigas liquid mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-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 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml cvs antacid-antigas tab chew 1, mg * (Maalox Maximum Strength) (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) (Gastrocrom) (Calcium Carbonate/Simethi cone) 140

157 cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * (Pepto-Bismol) cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) digestive relief 262 mg chw tb 262 (Pepto-Bismol Tomg * Go) diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) flanax antacid liquid (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid mg/15 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 10 gram/15 ml (Lactulose) glycopyrrolate injection solution 0.2 mg/ml (Robinul) glycopyrrolate oral tablet 1 mg, 2 mg (Robinul) PA PA 141

158 imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/15 ml susp vanilla flavor 262 mg/15 ml * kionex 15 gm/60 ml suspension 15 gram/60 ml kionex oral powder (Loperamide HCl) (Pepto-Bismol) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) lactulose oral solution 10 gram/15 ml (Lactulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG loperamide 1 mg/5 ml liquid 1 mg/5 ml * (Loperamide HCl) loperamide oral capsule 2 mg (Loperamide HCl) LOTRONEX ORAL TABLET 0.5 MG, 1 MG maalox advanced suspension (Maalox Maximum regular strength mg/5 Strength) ml * MAGNEBIND 300 TABLET MG * magnesium 500 mg capsule s/f,na/f 500 mg * magnesium oxide 250 mg tablet 250 mg * magnesium oxide 400 mg tablet 400 mg * magnesium oxide 500 mg tablet p/f,s/f,lactose-free 500 mg * masanti liquid mg/5 ml * medi-first pep-t-med tab chew 262 mg * (Uromag) (Magox 400) (Magox 400) (Magox 400) (Maalox Maximum Strength) (Pepto-Bismol To- Go) QL (30 per 30 days) 142

159 methscopolamine oral tablet 2.5 mg, (Methscopolamine 5 mg Bromide) metoclopramide hcl injection (Metoclopramide solution 5 mg/ml HCl) metoclopramide hcl oral solution 5 (Metoclopramide mg/5 ml HCl) metoclopramide hcl oral tablet 10 mg, 5 mg (Reglan) mgo 400 mg tablet 400 mg * (Magox 400) 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 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide 1 mg/7.5 ml susp mint (Loperamide HCl) 1 mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML QL (30 per 30 days) PA PA; QL (28 per 28 days) PA; QL (28 per 28 days) 143

160 ri-gel ii suspension mg/5 ml * ri-mox suspension mg/5 ml * sm foaming antacid tablet chew mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 10 gr 650 mg * sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps 15 gm/60 ml suspension 15 gram/60 ml (Maalox Maximum Strength) (Maalox Maximum Strength) (Gaviscon) (Bismuth Subsalicylate) (Sodium Bicarbonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) (Pepto-Bismol) (Sodium Polystyrene Sulfonate) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 10 mg suppository 10 mg * (Dulcolax) bisacodyl 10 mg suppository 10 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 10 mg suppository 10 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * ST; QL (60 per 30 days) 144

161 COLACE 100 MG CAPSULE 100 MG * cvs enema disposable 19-7 gram/118 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 100 mg mini enema 100 mg/5 ml * (Docusate Sodium) cvs purelax powder 14 once-daily doses 17 gram/dose * (Gavilax) cvs purelax powder packet s/f, 10 daily doses 17 gram * cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 mg * (Surfak) doc-q-lace 100 mg softgel 100 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml * (Docusate Sodium) docusate sodium 100 mg tablet crushable 100 mg * (Docusate Sodium) docusate sodium-senna tablet (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 100 mg softgel softgel 100 mg * (Colace) dok 100 mg tablet 100 mg * (Docusate Sodium) dulcolax ss 100 mg softgel 100 mg * (Colace) enema disposable 19-7 gram/118 ml * (Enema) enema ready to use latex-free 19-7 gram/118 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)) 145

162 equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy powder 2 gram/19 (Citrucel) gram * fiber-lax captabs 500mg (Fibercon) polycarbophil 625 mg * fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 10 MG ENEMA 10 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 Flavor Packs) gentlelax powder 30 once-daily (Gavilax) doses 17 gram/dose * glycolax powder 7 doses (otc) 17 (Gavilax) 3 $0 gram/dose * healthylax powder packet 14x17gm, (Miralax) outer 17 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 10 mg suppos 10 mg * (Dulcolax) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET GRAM (Psyllium Seed natural fiber lax powder * (With Sugar)) 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) 146

163 oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon gram/15 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln gram, gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 100 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon gram/15 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 17 gram/dose Glycol 3350) polyethylene glycol 3350 oral (Polyethylene powder in packet 17 gram Glycol 3350) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (Gavilax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 17 gram * (Miralax) promolaxin 100 mg tablet 100 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * (Enema) ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) 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) 147

164 senokot-s tablet mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/15 ml syrup 60 mg/15 ml * (Docusate Sodium) sm clearlax powder 14 once-daily doses 17 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 10 oncedaily doses 17 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) (Calcium magnebind 400 oral tablet Carbonate/Mag 1 mg Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG 148

165 oxybutynin chloride oral syrup 5 (Oxybutynin mg/5 ml Chloride) oxybutynin chloride oral tablet 5 mg (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 (Ditropan XL) mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended (Trospium release 24hr 60 mg Chloride) trospium oral tablet 20 mg (Trospium Chloride) Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg (Uroxatral) tamsulosin oral capsule,extended release 24hr 0.4 mg (Flomax) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG (Desferal) 149

166 sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 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/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) (Sodium Thiosulfate) androxy oral tablet 10 mg (Fluoxymesterone) danazol oral capsule 100 mg, 200 mg, 50 mg (Danazol) oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) testosterone cypionate (Depointramuscular oil 100 mg/ml, 200 Testosterone) mg/ml testosterone enanthate (Testosterone intramuscular oil 200 mg/ml Enanthate) testosterone transdermal gel 50 mg/5 gram (1 %) (Testim) testosterone transdermal gel in metered-dose pump 1.25 gram/ (Vogelxo) actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) (Androgel) testosterone transdermal gel in packet 1 % (50 mg/5 gram) (Testim) PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) PA 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) 150

167 Estrogens And Antiestrogens COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 10 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, (Estrace) (Vivelle-Dot) (Climara) (Delestrogen) (Activella) (Estropipate) PA-HRM; QL (8 per 28 days) PA-HRM PA-HRM PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days) PA-HRM PA-HRM QL (1 per 84 days) PA-HRM MG, 1.25 MG, 2.5 MG mimvey lo oral tablet mg (Activella) PA-HRM mimvey oral tablet mg (Activella) PA-HRM PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PA-HRM 151

168 PREMPHASE ORAL TABLET PA-HRM MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3- PA-HRM 1.5 MG, MG, MG, MG raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 10 QL (18 per 28 days) MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 100 (Hydrocortisone mg Sod Succinate) betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) cortisone oral tablet 25 mg (Cortisone Acetate) dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone injection solution 10 mg/ml, 4 mg/ml Sod Phosphate) fludrocortisone oral tablet 0.1 mg (Fludrocortisone Acetate) hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone 125 mg vial 2ml sdv, 25's,l/f 125 mg (Solu-Medrol) methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (Solu-Medrol) 152

169 methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml (Prednisone) prednisone oral tablet 1 mg, 2.5 mg, (Prednisone) 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg (Prednisone) prednisone oral tablets,dose pack 10 (Prednisone) mg, 5 mg SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone suspension 10 mg/ml, 40 mg/ml Acetonide) Pituitary desmopressin injection solution 4 (Desmopressin mcg/ml Acetate) desmopressin nasal solution 0.1 QL (15 per 30 days) (DDAVP) mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) Acetate) (Desmopressin QL (15 per 30 days) desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) GENOTROPIN MINIQUICK PA SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS PA CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 153

170 LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 10 MG KIT 10 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) QL (1 per 84 days) PA PA PA PA 154

171 SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/10 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 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Depo-Provera) (Depo-Provera) (Provera) (Megace Es) (Aygestin) (Progesterone) (Prometrium) (Levothyroxine Sodium) (Levoxyl) (Cytomel) QL (1 per 28 days) QL (1 per 360 days) QL (10 per 28 days) QL (1 per 84 days) QL (1 per 84 days) 155

172 methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG AUBAGIO ORAL TABLET 14 PA; QL (28 per 28 MG, 7 MG days) azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon (Azathioprine soln 100 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) 250 mg/5 ml cyclosporine modified oral capsule (Neoral) 100 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) 100 mg/ml cyclosporine oral capsule 100 mg, (Sandimmune) 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG (1 ML) 156

173 ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 100 mg, 25 mg (Neoral) gengraf oral solution 100 mg/ml (Neoral) HUMIRA PEN CROHN'S-UC-HS PA START 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 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) 157

174 HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML (Arava) (Cellcept) (Cellcept) (Cellcept) (Myfortic) PA PA; QL (18.76 per 28 days) PA PA 158

175 RAPAMUNE ORAL SOLUTION 1 MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML (Rapamune) (Hecoria) PA; LA; QL (15 per 28 days) ; QL (120 per 30 days) 159

176 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 10'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 160

177 HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML 161

178 MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL) MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT QL (2 per 365 days) QL (2 per 365 days) 162

179 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 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 120 MCG/0.5 ML 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 (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) ; QL (3 per 365 days) 163

180 VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Alosetron HCl) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG DIPENTUM ORAL CAPSULE 250 MG QL (2 per 365 days) QL (1 per 365 days) ST 164

181 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % (Acetic Acid) LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Tis-U-Sol) sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution (Mannitol/Sorbitol g/100 ml Solution) water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation (Alendronate Sodium) (Fosamax) (Fosamax) (Miacalcin) calcitriol intravenous solution 1 mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) QL (300 per 28 days) QL (4 per 28 days) QL (3.7 per 28 days) 165

182 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION ibandronate intravenous solution 3 mg/3 ml ibandronate intravenous syringe 3 mg/3 ml (Ibandronate Sodium) (Boniva) PA; QL (2.4 per 28 days) QL (3.7 per 28 days) QL (3 per 84 days) QL (3 per 84 days) ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg (Zemplar) PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) 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/100 ml zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents (Zometa) (Zoledronic Acid/Mannitol and Water) (Reclast) QL (100 per 300 days) 166

183 Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML allopurinol oral tablet 100 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg anticoag citrate phos dextrose solution gram-mg/100ml 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 120 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG (Zyloprim) (Amifostine Crystalline) (Citrate Phosphate Dextros Soln) (Urecholine) (Buspirone HCl) colchicine oral tablet 0.6 mg (Colcrys) colchicine-probenecid oral tablet (Colchicine/Proben mg ecid) PA PA ST ST ST PA ST PA 167

184 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) fomepizole intravenous solution 1 gram/ml (Fomepizole) FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg (Guanidine HCl) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg (Hydroxyzine HCl) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg (Vistaril) QL (30 per 30 days) ST QL (28 per 28 days) PA-HRM PA-HRM PA-HRM PA-HRM 168

185 KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML leucovorin calcium 200 mg vial sdv, (Leucovorin p/f, latex-free 200 mg Calcium) leucovorin calcium injection recon (Leucovorin soln 100 mg, 350 mg Calcium) leucovorin calcium oral tablet 10 (Leucovorin mg, 15 mg, 25 mg, 5 mg Calcium) levocarnitine (with sugar) oral (Levocarnitine solution 100 mg/ml (With Sugar)) levocarnitine oral tablet 330 mg (Carnitor) mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PANTILINERS PAD * PA NSO; QL (120 per 30 days) PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 169

186 PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 180 mg (Mestinon) qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 100 MG sb disp douche extra clns v&w * (Acetic Acid) ST ST PA 170

187 SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS QL (60 per 30 days) SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMPONI ARIA INTRAVENOUS PA SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN PA INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS PA SYRINGE 100 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS PA SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " summer's eve dche-xtra clns 12's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 12's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML TECFIDERA ORAL QL (14 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL QL (60 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 100 PA NSO; QL (60 per MG, 150 MG, 200 MG, 50 MG 30 days) topical light mineral oil * (Mineral Oil) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG 171

188 XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 125 mg, 250 mg (Acetazolamide) acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.15 %, 0.2 % (Alphagan P) COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % (Metipranolol) PA; QL (60 per 30 days) PA; QL (30 per 30 days) (drops: 0.15%, 0.20%) QL (2.5 per 25 days) 172

189 PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * calcium d tablet p/f,na/f,no lactose 500 mg(1,250mg) -400 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium vit d tablet mg-unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg (1,500 mg) * (Isopto Carpine) (Timoptic) (Timoptic-Xe) (Travoprost (Benzalkonium)) (Citracal-Vitamin D) (Calcium Citrate) (Caltrate D) (Caltrate D) (Calcium Vit D) (Calcium Carbonate/Vitamin D3) (Caltrate D) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) QL (2.5 per 25 days) QL (2.5 per 25 days) 173

190 calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(1,500mg) -400 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated mg-unit * calcium citrate-vit d3 caplet s/f, p/f mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 100 mg/ml (10%) calcium with vit d tablet mg-unit * CALTRATE D SOFT CHEW TAB VANILLA CREME 600 MG (1,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(1,500MG) -800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * (Calcium Carbonate/Vitamin D3) (Caltrate D) (Caltrate D) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) (Calcium Chloride) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) 174

191 cvs calcium + vitamin d3 sftgl absorbable 600 mg(1,500mg) -500 unit * cvs calcium vit d tablet oyster shell 500 mg(1,250mg) -125 unit * cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(1,500mg) unit * cvs magnesium 250 mg tablet 250 mg * (Calcium Carbonate/Vitamin D3) (Caltrate D) (Caltrate D) (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d10 %-0.45 % sodium chloride (Dextrose 10 % intravenous parenteral solution and 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % intravenous parenteral solution and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and intravenous parenteral solution 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 intravenous parenteral solution % NaCl) dextrose 10 % and 0.2 % nacl (Dextrose 10 % intravenous parenteral solution and 0.2 % NaCl) dextrose 5 %-lactated ringers (Dextrose 5%- intravenous parenteral solution Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 intravenous parenteral solution % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and intravenous parenteral solution 0.3 % NaCl) dextrose with sodium chloride (Dextrose 5 %-0.2 intravenous parenteral solution 5- % NaCl) 0.2 % effer-k oral tablet, effervescent 25 meq (Klor-Con-Ef) electrolyte-48 in d5w intravenous parenteral solution (Electrolyte-48 Solution/D5W) 175

192 eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium vit d3 tab 500mg (1,250mg) -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 * 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 150 MCG TABLET 150 MCG * klor-con 10 oral tablet extended release 10 meq (Calcium Carbonate/Vitamin D3) (Caltrate D) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Citracal-Vitamin D) (Klor-Con-Ef) (Potassium Chloride) 176

193 klor-con m10 tablet 10 meq (Potassium Chloride) klor-con m15 oral tablet,er (Potassium particles/crystals 15 meq Chloride) klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) klor-con sprinkle oral capsule, (Potassium extended release 10 meq, 8 meq Chloride) (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(1,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (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) magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium sulf in 0.45% nacl intravenous solution 20 gram/500 ml (40 mg/ml) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) 177

194 magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION (Magnesium Sulfate in Water) (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Calcium Carbonate) NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 71.5 mg tablet 71.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION MEQ/20 ML oysco 500+d tablet 500 mg(1,250mg) -200 unit * (Caltrate D) oysco d tablet mg-unit * (Caltrate D) oysco-500 tablet 500 mg calcium (Calcium (1,250 mg) * Carbonate) oyster shell 250 mg + vit d tb mg-unit * (Caltrate D) oyster shell calcium 500 mg tb 500mg elemental ca 500 mg calcium (1,250 mg) * oyster shell calcium tablet 500 mg(1,250mg) -400 unit * (Calcium Carbonate) (Caltrate D) 178

195 oyster shell calcium-vit d tab 500 mg(1,250mg) -200 unit * (Caltrate D) oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(1,250mg) (Caltrate D) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(1,250mg) -400 unit * (Caltrate D) pediatric electrolyte solution * (Pedialyte) PHOS-NAK PACKET MG * phospha 250 neutral oral tablet 250 mg (K-Phos Neutral) PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous (Potassium solution 2 meq/ml, 4 meq/ml Acetate) potassium bicarb and chloride oral (Pot Chloride/Pot tablet, effervescent 25 meq Bicarb/Cit Ac) potassium bicarb-citric acid oral tablet, effervescent 25 meq (Klor-Con-Ef) potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride/D5-0.45nacl) 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 0.9%NaCl) (Potassium Chloride In D5w) 179

196 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 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 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con) (K-Tab ER) (K-Tab ER) (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) (Urocit-K) (Potassium Citrate/Citric Acid) 180

197 potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 10 meq tablet f/c 10 meq potassium phosphate m-/d-basic intravenous solution 3 mmol/ml ra hi-cal plus vitamin d tab 500 mg(1,250mg) -200 unit * ra oyster shell-vitamin d tab s/f, p/f 250 (625)-125 mg-unit * (Potassium Chloride) (Potassium Chloride) (K-Tab ER) (Potassium Phos,M-Basic-D- Basic) (Caltrate D) (Calcium Carbonate/Vitamin D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution (Ringers Solution) sm calcium 600-vit d3 800 tab 600 mg(1,500mg) -800 unit * sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) sodium bicarbonate intravenous solution 1 meq/ml (8.4 %) sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % (Sodium Bicarbonate) (Sodium Bicarbonate) (Sodium Chloride 0.45 %) (0.9 % Sodium Chloride) (Sodium Chloride 3 %) (Sodium Chloride 5 %) 181

198 sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 167 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 133 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 MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION (Sodium Chloride) (Sodium Lactate) (Sodium Lactate) (Sodium Phos,M- Basic-D-Basic) (K-Phos Neutral) (Caltrate D) QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) 182

199 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION 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) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg (Albuterol Sulfate) (Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) QL (21.2 per 28 days) QL (17.4 per 25 days) 183

200 ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 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 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) (Metaproterenol Sulfate) (Metaproterenol Sulfate) (Terbutaline Sulfate) QL (25.8 per 28 days) QL (8 per 30 days) 184

201 terbutaline subcutaneous solution 1 mg/ml theochron oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 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 100 mg/ml (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) (Acetadote) (Cromolyn Sodium) (Nasalcrom) QL (2 per 28 days) PA QL (30 per 30 days) 185

202 ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg (Soma) (Parafon Forte DSC) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA PA; QL (120 per 30 days) cyclobenzaprine oral tablet 10 mg, 5 PA-HRM (Fexmid) mg dantrolene oral capsule 100 mg, 25 mg, 50 mg (Dantrium) metaxall oral tablet 800 mg (Skelaxin) PA-HRM metaxalone oral tablet 400 mg, 800 PA-HRM (Skelaxin) mg methocarbamol oral tablet 500 mg, PA-HRM (Robaxin) 750 mg revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) PA PA-HRM; QL (120 per 30 days) PA-HRM

203 tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) HETLIOZ ORAL CAPSULE 20 MG NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) zolpidem oral tablet 10 mg, 5 mg (Ambien) QL (30 per 30 days) PA-HRM; QL (30 per 30 days) PA PA LA PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) 187

204 zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) 188

205 TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z 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) PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (200 per 365 days) 189

206 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) antioxidant softgel softgel * (Beta-Carotene(A) W-C and E/Min) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula #1 tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 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-100 tablet * (Vitamin B Complex) balanced b-100 tablet 100 mg * (Vit B Complex 100 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) 190

207 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 b12 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) 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 1,000 mg tablet sa 1,000 mg * (Ascorbic Acid) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) centram-care multivit-min liq 9 mg iron/15 ml * centravites 50 plus tablet * centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults mg-mcg-mcg * (Multivit- Minerals/Ferrous Gluc) (Multivit with Iron- Minerals) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) 191

208 century adults 50+ tablet gluten free mg-mcg-mcg * century mature tablet * cerovite liquid 9 mg iron/15 ml * certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet mg-mcg * child chew + iron tab chew * (Biocel) century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 15 mg/ml 15 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-100 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-150 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) 192

209 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) 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 hair, skin & nails tablet (Multivitamin with w/antioxidants * Minerals) 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 mg-mcg * (Multivitamin/Iron/ Folic Acid) 193

210 cvs super b complx & c cplt caplet, (Vita-Bee with C) p/f * cvs vision formula tablet 1,000 unit- (Vit A,C and 200 mg-60 unit-2 mg * E/Lutein/Minerals) (Vitamin B cvs vitamin b-100 complx tb * Complex) cvs vitamin c 1,000 mg tb chw 1,000 (Ascorbic Acid) mg * cvs vitamin d3 1,000 unit sfgl softgel (D3-50) 1,000 unit * cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin 3 $0 1,000 mcg/ml * (Vitamin B-12)) 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) daily multivitamin-iron tablet 18- daily vit formula + iron tab (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 194

211 dino-life iron-zinc tb chew * (Multivit with Iron- Minerals) dino-life tablet chewable * (Multivitamin) eldertonic elixir mg * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 18 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) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet mg * (Tab A Vite) eql one daily men's tablet * (Multivitamin with Minerals) eql vision formula tablet * (Beta-Carotene(A) W-C and E/Min) ergocalciferol 8,000 units/ml 8,000 unit/ml * (Drisdol) essentia tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) essential balance tablet * (Mv,Fe,Min/Lutein ) 195

212 essential daily tablet w/iron & calcium mg * ferocon capsule mg * ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule mg * (Tab A Vite) (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 (Ferrous Fumarate) (Iron Polysaccharide Complex) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (106 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (106 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 (38 mg (Fergon) iron) * ferrous gluconate 325 mg tab p/f,s/f,gluten-free 325 mg (36 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) * (Ferrous Sulfate) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) 196

213 flintstones with iron tab chew 18 mg iron * (Pedi Mv No.79/Ferrous Fumarate) folic acid 1 mg tablet (rx) 1 mg * (Folic Acid) 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 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 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet (Pnv133/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew (Multivitamin) multivit & minerals * hair vitamins * (Multivitamin with Iron) (Vit A,C and E/Lutein/Minerals) healthy eyes caplet caplet 1,000 unit-200 mg-60 unit-2 mg * hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * (Ferrous Fumarate) hi-b complex tablet * (Vitamin B Complex) hm complete 50+ tablet (Biocel) mg-mcg-mcg * hm one daily with iron tablet glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) 197

214 honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 150 capsule 150 mg iron * (Iron Polysaccharide Complex) 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/15 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 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 Minerals/Lut) multi complete-iron tablet (Multivitamin/Iron/ mg-mcg * multi-day plus iron tablet mg-mcg * Folic Acid) (Multivitamin/Iron/ Folic Acid) 198

215 multi-delyn with iron liquid 10 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/15 ml * multivit-fluor 0.5 mg tab chew chewable, d/f, s/f 0.5 mg multivit-iron child tab chew children's * multivit-mineral hp cap * multivit-minerals tablet s/f,p/f * (Multivit- Minerals/Ferrous Gluc) (Pedi M.Vit No.17 with Fluoride) (Multivitamin with Iron) (Multivitamin,Ther and Minerals) (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * nephplex rx tablet mg-mg-mcg-mg * nephron fa tablet mg * nephro-vite rx tablet mgmg-mcg * niacinamide er 500 mg tablet 500 mg * nu-iron 150 capsule 150 mg iron * (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Fe Fumarate/Doss/Fa/ Bcomp,C) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 3 $0 3 $0 3 $0 (Niacinamide) (Iron Polysaccharide Complex) 199

216 ocutabs tablet s/f, w/lutein * (Beta-Carotene(A) W-C and E/Min) 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 18- (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 18- (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- 1 mg Ca,No.72/Iron/Fa) (Iron poly-iron 150 mg capsule 150 mg Polysaccharide iron * Complex) poly-vita drops 1, unitmg-unit/ml * (Pediatric Multivitamin No.20) (All Rx Prenatal Vitamins Covered) 200

217 poly-vita with iron drops 1,500 unit- (Ped Multivit 400 unit-10 mg/ml * #46/Iron Sulfate) (Pediatric poly-vitamin drops 1, Multivitamin unit-mg-unit/ml * No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops 1,500 (Ped Multivit unit-400 unit-10 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) mg * No.130/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-100 complex * Complex) (Vitamin B pv b-50 complex * Complex) pv kid's gummy bear tab chew (Multivitamin) chewable * pv kid's vit + extra c chew tb * (Multivitamin) (Multivitamin with pv kid's vit + iron tab chew * Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) 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- 1 mg 800 mcg * Ca,No.72/Iron/Fa) Fumarate/Fa) Selenate/Copper) pv kids vitamins+iron tab chew 15 mg iron * (Ped Multivit #17/Iron Fumarate) (All Rx Prenatal Vitamins Covered) 201

218 pv multivital platinum tablet * pv multivital platinum tablet w/lutein & lycopene mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pyridoxine 100 mg/ml vial 100 mg/ml * qc child complete vit chew tab 18 mg iron * (Multivitamin with Minerals/Lut) (Biocel) (Prenatal Vit No.131/Iron/Fa) (Multivitamin,Stres s Formula/Zn) (Pyridoxine HCl) 3 $0 (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 18- (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-100 tablet 0.4 mg * Complex/Folic Acid) (Vitamin B ra b-complex tablet p/f * Complex) (Vitamin B ra b-complex tablet p/f * Complex) (Multivitamin with ra central vite select tab p/f * Minerals/Lut) (Multivit with Ironra central-vite select tab p/f * Minerals) ra central-vite senior tablet (Biocel) 250 mg-mcg-mcg * ra central-vite tablet (Biocel) mg-mcg-mcg * 202

219 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-12 1,000 mcg/ml liq 1,000 (Cyanocobalamin mcg/ml * (Vitamin B-12)) ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 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 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) (Vit A,C, and sm airshield effervescent tab 5,000- E/Dietary Supp unit-mg-unit * No.12) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) 203

220 sm animal shapes w-iron tab children's * sm antioxidant vitamins tablet 1,000 unit-200 mg-60 unit-2 mg * sm b complex with vit c tablet gluten-free * sm complete multi-vit-mineral advanced formula mg-mcg * sm complete senior formula tab * sm complete senior formula tab mg-mcg-mcg * sm multivitamin w-iron tab * sm natural balanced b-100 tab 100 mg * sm opti-vitamin tablet 1,000 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-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride 1 mg (2.2 mg) 1 mg fluoride (2.2 mg) sodium fluoride oral tablet 1 mg fluoride (2.2 mg) (Multivitamin with Iron) (Vit A,C and E/Lutein/Minerals) (Vita-Bee with C) (Multivitamin/Iron/ Folic Acid) (Multivit with Iron- Minerals) (Biocel) (Multivitamin with Iron) (Vit B Complex 100 Cmb #2/Herbs) (Vit A,C and E/Lutein/Minerals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Sodium Fluoride) (Pedi M.Vit No.17 with Fluoride) 204

221 stress b tablet * (Vitamin B Complex) stress b with zinc tablet * (Multivitamin,Stres s Formula/Zn) stress formula tablet * (Multivitamin,Stres s Formula) stress formula with iron tab * (Iron/Mv,Stress Form) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) stress formula with zinc tab * (Multivitamin,Stres s Formula/Zn) (Vit B stress-c with iron tablet 500 mg-400 Comp/C/Fa/Iron/Vi mcg- 18 mg iron * t E) (Mv-Min/Iron sunvite tablet 18 mg iron-400 mcg- Fum/Fa/K/Lyco/Lu 25 mcg * 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 * (B Complex with Vitamin C) super b-50 complex capsule * (Vitamin B Complex) super b-50 complex plus tab * super b-complex folic-vit c tb p/f 400 mcg * (Vitamin B Complex) (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) 205

222 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 & nails caplet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) 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) 206

223 thiamine 200 mg/2 ml vial 25's,mdv,outer 100 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 1, unit-mgunit/ml * tri-vitamin drops 1, unitmg-unit/ml * ultra b-100 complex tablet * v-c forte capsule 1 mg * vic-forte capsule 1 mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f 1,000 unit-200 mg-60 unit-2 mg * vit d mg (50,000 unit) 50,000 unit * vitalets tablet chewable child, orange,s/f * vitamin a 10,000 units capsule soluble 10,000 unit * vitamin a 25,000 units capsule softgel 25,000 unit * vitamin and minerals tablet * (Pedi Multivits A,C, and D3 No.21) (Pedi Multivits A,C, and D3 No.21) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A) W-C and E/Min) (Vit A,C and E/Lutein/Minerals) 3 $0 3 $0 (Drisdol) 3 $0 (Multivitamin with Iron) (Vitamin A) (Vitamin A) (Multivitamin,Ther and Minerals) 207

224 vitamin b complex tablet 500 mg- 400 mcg- 18 mg iron * vitamin b complex-vit c cap * (Vit B Comp/C/Fa/Iron/Vi t E) (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b-12 1,000 mcg tablet 1,000 mcg * (B-12) vitamin b mcg tablet 100 mcg * (B-12) vitamin b mcg tablet 250 mcg * (B-12) vitamin b mcg tablet 500 mcg * (B-12) vitamin b12-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) vitamin b-complex & c caplet p/f,no (Fa/Vit B Complex lactose,cplt mcg-mg * and C/Rice Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 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/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d 1,000 unit tablet 1,000 unit * (Vitamin D3) vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * (Vitamin D3) vitamin d3 1,000 units softgel softgel, p/f, s/f 1,000 unit * (D3-50) vitamin d3 10,000 unit softgel softgel 10,000 unit * (D3-50) 208

225 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 100 mcg tablet p/f, glutenfree 100 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-100 tablet * (Vitamin B Complex) yelets tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 209

226 INDEX 3 3 day vaginal pse-150gfn-15dm day vaginal 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... 68, 69 abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose... 45, 46 acebutolol acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 165 acetylcysteine acid gone antacid acid reducer (famotidine) , 138 acid relief (cimetidine) acitretin acne medication , 120 ACNE MEDICATION acne-clear ACTEMRA , 167 ACTHIB (PF) ACTIMMUNE actinel pediatric acyclovir... 74, 118 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 159 ADAGEN adapalene , 126 ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max adult multivitamin gummies 190 adult nasal decongestant adult one daily gummies adult robitussin lingering cld 107 adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVIL af 50 afeditab cr AFINITOR AFINITOR DISPERZ AFTERA a-hydrocort airshield AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-12 allergy-sinus ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges ALLEGRA ALLERGY aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy (diphenhydramine) allergy relief (cetirizine) allerhist aller-tec d allopurinol ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 49 I-1

227 alophen alosetron ALPHAGAN P alprazolam ALREX altacaine altamist altavera (28) aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide92 AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin... 93, 94 amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium 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).. 140, 141 antifungal antifungal (tolnaftate)... 50, 53 anti-gas maximum strength antioxidant antioxidant vitamins apatate forte APOKYN apraclonidine apri APRISO aprodine APTIOM APTIVUS aquanil hc aranelle (28) ARCALYST aripiprazole ARISTADA arthritis pain relief (acetam)... 9 artificial tears artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc) artificial tears(glycerin-peg). 130 artificial tears(hypromellose) 132 ASACOL HD ascomp with codeine... 3 ascorbic acid (vitamin c) , 208 ashlyna aspirin... 10, 11 aspirin, buffered aspirin-dipyridamole aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin I-2

228 atovaquone atovaquone-proguanil ATRIPLA atropine... 37, 129 atropine-care ATROVENT HFA AUBAGIO aubra AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine , 130 AZILECT azithromycin AZOPT AZOR aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 197, 205 b-100 complex b-12 dots b-50 complex bacitracin... 17, 120, 133 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 202 balanced b balanced b balanced b-50 complex balsalazide balziva (28) banophen banophen allergy BANZEL... 37, 38 baza antifungal BCG VACCINE, LIVE (PF) 159 b-complex b-complex with vitamin c , 192, 204, 208 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE , 127 bekyree (28) BELBUCA... 3 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 152 betamethasone dipropionate. 122 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 87, 172 bethanechol chloride BETHKIS... 16, 17 bexarotene BEXSERO (PF) bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF bp 8 cough BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm bromfenac I-3

229 bromocriptine bromphenex dm brompheniramine-pseudoephdm , 108 budesonide bufferin bumetanide BUPHENYL buprenorphine hcl... 3, 14 buprenorphine-naloxone buproban bupropion hcl... 14, 42, 43 buspirone butalbital compound w/codeine 3 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC C c complex cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol , 165 calcium d calcium d (d3) calcium calcium d(3) , 174 calcium 600 with vitamin d3 177 calcium acetate calcium antacid calcium carbonate , 174 calcium carbonate-vitamin d calcium carbonate-vitamin d , 174, 175, 176, 181 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d , 176 calcium gluconate calcium+d CALDOLOR cal-gest antacid calphron CALTRATE D CALTRATE WITH VITAMIN D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 85 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT MODIFIED CAYSTON caziant (28) cefaclor... 19, 20 cefadroxil cefazolin cefazolin in dextrose (iso-os). 20 CEFAZOLIN IN DEXTROSE (ISO-OS) cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 20 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 21 cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT INTRAVENOUS CELONTIN centamin centergy dm central vite with lutein central-vite central-vite for seniors central-vite select , 202 central-vite senior centram-care I-4

230 centravites 50 plus centrum centrum complete centrum silver century century adults century mature , 195, 197 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula certavite senior-antioxidant certavite-antioxid (iron gluc) 192 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX cheracol d cheratussin dac chest congestion relief + dm 109 chest congestion relief pe chewable multi vitamin child allergy relf(cetirizine) child complete multivitamin 195 child cough and sore throat child mucinex chest congestion child plus cough and runnynose child triaminic cold-allergy child triaminic cough-congest child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 108 CHILDREN'S ADVIL children's allegra allergy.. 54, 55 children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 192 children's chewable w/minerals CHILDREN'S CLARITIN54, 55 children's cold-cough daytime children's complete vitamin. 202 children's mapap... 4 children's mucinex cough children's multivit w/extra c. 195 children's non-aspirin... 4 children's pain reliever... 9 children's pain-fever relief... 4 children's pepto childrens plus multi-symp cold children's silapap... 4 children's silfedrine children's soothe children's sudafed children's sudafed pe cough. 108 children's tactinal... 4 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 chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 194, 208, 209 cholestyramine (with sugar) cholestyramine light choline,magnesium salicylate 11 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 26, 133 ciprofloxacin in 5 % dextrose 26 ciprofloxacin lactate citalopram citracal + d maximum citrus calcium clarithromycin CLARITIN CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax clemastine I-5

231 CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 18 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate... 18, 59, 121 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 83, 97 clopidogrel clorazepate dipotassium clorpres clotrimazole clotrimazole clotrimazole-betamethasone clozapine... 65, 66 COARTEM codeine sulfate... 4 codituss dm COLACE colchicine colchicine-probenecid cold and cough (diphenhydr-pe) cold multi-symptom day/night cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 184 COMETRIQ comfort gel comfort gel extra strength COMPLERA complete complete multi complete multivitamin. 192, 195 complete multivitamin-mineral , 204 complete senior , 204 compoz compro COMVAX (PF) CONDYLOX congestac congest-eze constulose COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR... 89, 90 cormax cortisone cortizone CORTIZONE COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 119 COTELLIC cough and cold cough and runny nose cough relief CREON CRESTOR critic-aid clear af CRIXIVAN cromolyn , 140, 185 cryselle (28) CUBICIN cyanocobalamin (vitamin b-12) , 194, 203, 208 cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET I-6

232 cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin daily gummies daily multiple , 194 daily multi-vitamin daily multivitamin with iron 194 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 194 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA... 72, 73 DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough daytime cold-flu day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol. 101 desogestrel-ethinyl estradiol 101 desonide desoximetasone despec-dm (pseudoeph-dmguaif) dex4 glucose dexamethasone dexamethasone sodium phosphate , 152 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine... 97, 98 dextromethorphan polistirex 110 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 81 dextrose 5 %-lactated ringers175 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 diabetic tussin dm diamode diazepam diazepam intensol diclofenac potassium diclofenac sodium... 11, 135 diclofenac-misoprostol dicloxacillin dicyclomine didanosine DIFICID diflunisal digestive relief digitek digox digoxin I-7

233 DIGOXIN dihydroergotamine DILANTIN diltiazem hcl... 88, 89 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 dipyridamole disopyramide phosphate disulfiram divalproex dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dok donepezil... 41, 42 dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) 145 DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM E e.c. prin e.e.s e.e.s. granules econazole econtra ez ed a-hist ed bron gp ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide 85 ENBREL , 157 ENBREL SURECLICK endocet... 4 endodan... 5 endur-acin enema , 147 enema disposable enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 74, 75 enpresse enskyce entacapone entecavir entre-cough ENTRESTO enulose ENVARSUS XR ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epitol EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle I-8

234 equalactin ergocalciferol (vitamin d2). 195, 207 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 23, 133 erythromycin ethylsuccinate.. 23 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 195 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 151 estropipate eszopiclone ethambutol ethamolin ethosuximide etodolac... 11, 12 ETOPOPHOS etoposide EVOTAZ exemestane EXJADE expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche F FABRAZYME falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 138 FANAPT FARESTON FARYDAK FASLODEX felbamate... 38, 39 felodipine feminine care douche FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 5 fentanyl citrate... 5 ferocon ferretts ferrex ferrex 150 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 198 ferrous sulfate , 196 FETZIMA feverall... 5 fexofenadine... 56, 57 fiber (calcium polycarbophil) fiber laxative (methylcellulo)148 fiber smooth fiber therapy (m-cell/sugar). 146 fiber therapy (m-cellulose) fiber therapy (psyllium/sugar) fiber-lax fibertab finasteride FIRAZYR flanax antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA floxuridine flu formula daytime-nighttime flu relief therapy daytime flu severe cold-congestion flucaine fluconazole fluconazole in dextrose(iso-o) 51 fluconazole in nacl (iso-osm). 51 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluocinonide-e fluorometholone fluorouracil... 31, 119 fluoxetine... 43, 44 fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 136 fluvoxamine I-9

235 foaming antacid , 144 folic acid FOLIC ACID fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief , 137 gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 17, 121, 134 gentamicin in nacl (iso-osm).. 17 gentamicin sulfate (ped) (pf).. 17 gentamicin sulfate (pf) GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-tussin dm gianvi (28) gildagia gildess 1.5/30 (21) gildess 1/20 (21) gildess 24 fe gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLEEVEC GLEOSTINE glimepiride glipizide... 48, 49 glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate glydo GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin guaifenesin dac guanfacine... 83, 98 guanidine gummi bear multivitamin , 201 gummy swirls H hair vitamins hair,skin and nails , 206 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthy eyes healthylax heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex.. 75 heparin (porcine) in nacl (pf). 75 I-10

236 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN hi-b complex hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen... 5 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen... 5 hydrocortisone , 125, 152 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone acetate-aloe. 124 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet hydromorphone... 5, 6 hydromorphone (pf)... 5 hydroskin hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA HYSINGLA ER... 6 I ibandronate IBRANCE ibuprofen... 11, 12, 13 ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant's ibuprofen INFANT'S MOTRIN infants' non-aspirin cold INLYTA insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide , 184 ipratropium-albuterol IPRIVASK irbesartan 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 I-11

237 IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO jolessa jolivette jr. acetaminophen... 9 juleber junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe junior mapap... 6 JUXTAPID K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) k-effervescent kelnor 1/35 (28) KELP (IODINE) ketoconazole ketoprofen ketorolac... 12, 136 KEVEYIS KEYTRUDA kids mini enema kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28) KINERET KINRIX (PF) kionex klor-con klor-con m klor-con m klor-con m klor-con sprinkle konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad 102 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) latanoprost LATUDA laxative peg LAZANDA... 6 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 26, 134 levofloxacin in d5w levonest (28) levonorgestrel levonorgestrel-ethinyl estrad 103 levonorg-eth estrad triphasic 103 levora levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 13, 86 lidocaine hcl lidocaine in 5 % dextrose (pf) 86 lidocaine viscous lidocaine-prilocaine life-pack women's linezolid LINZESS liothyronine I-12

238 lipodox LIPOSYN II LIPOSYN III liquibid d-r liquid calcium with vitamin d LIQUI-E lisinopril lisinopril-hydrochlorothiazide 85 lithium carbonate lithium citrate little animals little animals-iron lobana bath lohist-dm lomedia 24 fe lomustine LONSURF loperamide , 142, 143 loratadine loratadine-d lorazepam lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex loryna (28) losartan losartan-hydrochlorothiazide. 84 LOTEMAX LOTRONEX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 131 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 132 lubricant eye (propyl glycol) 131 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 , 177 magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide , 143 magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen)... 6 mapap arthritis pain... 6 mapap extra strength... 6 maprotiline mar-cof bp mar-cof cg margesic... 6 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu meclizine... 61, 62 medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol... 33, 155 MEKINIST meloxicam memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's one daily MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) I-13

239 MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesehist dm mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxall metaxalone metformin... 46, 47 methadone... 6 methadose... 6 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium... 33, 34 methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 98, 99 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ , 153 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 18, 59, 121 metronidazole in nacl (iso-os) 18 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 51, 52 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil , 171 MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 7 MORPHINE... 7 morphine (pf) in 0.9 % nacl... 6 morphine concentrate... 7 morphine in dextrose 5 %... 7 morrhuate sodium motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL mucus dm mucus dm max mucus relief , 113 mucus relief cough MULTAQ multi complete with iron multi-day with iron multi-delyn with iron multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multivital platinum multivitamin 50 plus multi-vitamin hp/minerals multivitamin with fluoride multivitamin with iron.. 199, 204 multivitamin with minerals multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way myco nail a mycophenolate mofetil mycophenolate sodium I-14

240 MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN nasal and sinus decongestant 112 nasal decongestant (oxymetazl) NASCOBAL nasohist dm NATACYN nateglinide NATPARA natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy 146 natural tears (pf) nature's tears (hypromellose) 131 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone neomycin neomycin-bacitracin-poly-hc 134 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA... 76, 77 NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR next choice one dose niacin niacinamide... 95, 199 niacor nicardipine NICODERM CQ nicorelief nicorette nicotine nicotine (polacrilex) NICOTROL nifedical xl nifedipine night time night time cold-flu night time cold-flu relief night time cough-sore throat 112 nighttime cough nikki (28) NILANDRON NINLARO NITE TIME COLD-FLU RELIEF nite time-d cold-flu relief NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose. 96 NITROSTAT NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength... 8, 9 non-aspirin flu non-aspirin jr strength... 4 nora-be NORDITROPIN FLEXPRO 154 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH nortemp... 8 I-15

241 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 8 NUCYNTA ER... 8 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING NUVIGIL nyamyc nystatin nystatin-triamcinolone nystop nyt-time sleep O ocean nasal ocella OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV ofloxacin... 26, 134, 135 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate ONCASPAR oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily , 203 one daily 50 plus one daily complete one daily energy one daily essential 195, 197, 200 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 200 one daily plus iron 197, 200, 203 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula200 one-a-day teen advantage ONFI... 16, 125 opcicon one-step OPDIVO OPSUMIT opti-vitamins oral saline laxative oralone ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORKAMBI orsythia OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 25 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 8 oxycodone-acetaminophen... 8 oxycodone-aspirin... 8 OXYCONTIN... 8 oxymorphone... 9 oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium with d oyster shell calcium-vit d , 179 oystercal-d P pacerone pain relief... 9 pain relief adult... 4 pain reliever jr strength... 9 paliperidone pancrelipase PANRETIN PANTILINERS pantoprazole papaverine paricalcitol I-16

242 paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx pedia relief pedia relief cough-cold pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte , 179, 181 pediatric freezer pops pediatric multivitamin.. 199, 203 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 127 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline persa-gel pfizerpen-g pharbetol... 9 pharmacist favorite multi-vit 200 phenadoz phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 84, 132 phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended philith phillips phillips liqui-gels PHOSLYRA PHOS-NAK phospha 250 neutral phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k1) PICATO pilocarpine hcl , 173 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 25, 26 pirmella piroxicam PLAN B ONE-STEP 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 poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 179 potassium chlorid-d5-0.45%nacl potassium chloride , 181 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. 180 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE I-17

243 pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 153 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 201, 204 prenatal formula prenatal plus (calcium carb). 200 prenatal tablet prenatal vit#96-ferrous fum-fa prenatal vitamin , 201 prenatal vitamin plus low iron prenatal vitamin with minerals prenatal vit-iron fumarate-fa 201 preparation h hydrocortisone 125 PREVAIL BLADDER CONTROL PAD prevalite PREVIDENT 5000 SENSITIVE previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 57, 62 promethazine vc-codeine promethazine-codeine promethazine-dm promethegan promolaxin propafenone... 86, 87 propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure and gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q q-dryl q-pap... 9 q-pap extra strength... 9 q-tapp dm q-tussin q-tussin dm QUADRACEL (PF) quasense quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 86 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl , 139 RAPAMUNE RASUVO (PF) RAVICTI react REBIF (WITH ALBUMIN). 170 REBIF REBIDOSE REBIF TITRATION PACK 170 reclipsen (28) RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) I-18

244 REFRESH LACRI-LUBE REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 53 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA repaglinide repaglinide-metformin REPATHA SURECLICK REPATHA SYRINGE reprexain... 9 RESCRIPTOR RESTASIS retaine cmc RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA ribasphere RIDAURA rifabutin rifampin... 60, 61 RIFATER ri-gel ii riluzole rimantadine ri-mox ringers , 181 risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan ROTARIX ROTATEQ VACCINE roxicet... 9 ROZEREM rydex rynex dm S SABRIL... 40, 41 safe tussin dm SAIZEN SAIZEN CLICK.EASY saline mist 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 , 122 SELZENTRY senexon senior tabs senna senna lax senna laxative senna with docusate sodium. 145 senokot-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROSTIM sertraline setlakin sharobel SIGNIFOR silace siladryl sa silapap... 9 sildenafil SILENOR siltussin sa siltussin-dm silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 57 sleep aid (doxylamine) smoothlax sodium acetate sodium bicarbonate , 181 sodium chloride , 165, 182, 186 sodium chloride 0.45 % sodium chloride 0.9 % I-19

245 sodium chloride 3 % sodium chloride 5 % sodium fluoride , 204 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) SPRITAM SPRYCEL sps sronyx ssd st joseph aspirin st. joseph aspirin stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin 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 sulfacetamide sodium sulfacetamide sodium (acne) 122 sulfacetamide-prednisolone. 135 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine... 26, 27 sulfatrim sulindac sumatriptan sumatriptan succinate... 59, 60 summer's eve disposable douche summers eve extra cleansing 171 sunvite super b complex-vitamin c.. 194, 204, 205 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURMONTIL SUSTIVA SUTENT syeda 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 I-20

246 TABLOID tacrolimus , 159 tactinal... 9 tactinal extra strength TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) 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 , 185 terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td 163 tetrabenazine tetracaine hcl (pf) tetracycline THALOMID the magic bullet theochron theophylline theophylline in dextrose 5 % 185 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 theratrum complete 50 plus/lut thiamine hcl (vitamin b1) thioridazine thiotepa thiothixene tiagabine TICE BCG TIKOSYN tilia fe timolol maleate... 88, 173 TIVICAY tizanidine , 187 TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone TOLAK tolazamide tolbutamide tolmetin tolnaftate tolterodine topiragen topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA... 35, 36 TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) I-21

247 tretinoin microspheres TREXALL triacting m-sym cold/cough. 117 triamcinolone acetonide , 125, 153 triaminic cold and cough (pe) TRIAMINIC COLD AND COUGHNT(PE) TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid trianex TRIBENZOR tri-buffered aspirin tri-dex pe tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRINTELLIX triple antibiotic , 122 triple paste af tri-previfem (28) tri-sprintec (28) TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28) TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL NEW FORMULA 116 TUSNEL PEDIATRIC TUSSI PRES-B tussin cf , 117 tussin cf cough-cold tussin cold-congestion tussin cough (dm only) tussin dm , 116 tussin dm cough and chest tussin maximum strength tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U u-cort ULORIC ultra b-100 complex ultra fresh pm ultra strength antacid unisom sleepgels UNITUXIN UPTRAVI ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 41 valsartan valsartan-hydrochlorothiazide 85 VALSTAR valu-tapp dm VANACOF vancomycin vancomycin in dextrose 5 %.. 19 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28) VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil VERSACLOZ vestura (28) VGO VIBERZI vic-forte vicks dayquil cold-flu relief. 116 vicks dayquil cough vicks nature fusion cough vicks nyquil severe cold-flu. 117 vicks qlearquil(oxymetazoline) vicks sinex 12-hour vicodin vicodin es vicodin hp VICTOZA 3-PAK I-22

248 VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK vienva VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine viorele (28) VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD virt-phos 250 neutral virtussin ac vision vision formula vision formula (with lutein) 194, 207 vision plus lutein vit b complex-folic acid vitalets vitamin a vitamin b complex , 202 vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 208 vitamin d , 208, 209 vitamins and minerals vitamins b complex , 208 vitamins for hair VITEKTA vitrum senior VOLTAREN voriconazole VOTRIENT VPRIV VRAYLAR vyfemla (28) W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 12 hour wal-phed... 58, 117 wal-phed pe day-night wal-phed pe sinus and allergy 58 wal-profen wal-sleep z wal-som (diphenhydramine).. 58 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin cough and cold cf 117 wal-tussin dm wal-zan wal-zyr (cetirizine)... 58, 59 wal-zyr d warfarin water for irrigation, sterile WELCHOL... 95, 96 wera (28) womens daily gummies women's daily multivitamin. 202 X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN XOLAIR XTANDI xulane xylon XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon ZANTAC ZANTAC zarah ZARXIO ZAVESCA zebutal ZELBORAF ZEMPLAR zenatane zenchent (28) ZENPEP ZEPATIER zephrex-d ZETIA ZIAGEN zidovudine zinc oxide ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem , 188 ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) I-23

249 zovia 1/50e (28) ZOVIRAX z-sleep ZUBSOLV ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA ZYVOX I-24

250

251 FOR HEALTHY LIVING CENTERS PLAN 中央計劃管理式長期護理護士服務 Centers Plan for FIDA Care Complete 電話 : ( 免費電話 ) TTY: 工作時間 : 每週七天, 早 8 點至晚 8 點電子郵件地址 :[email protected] 網址 :