L.A. Care Cal MediConnect Plan ( 聯邦醫療保險 -Medicaid 計劃 ) 05 年承保藥物清單 ( 處方集 ) 請詳閱 : 本文件包含本計劃承保藥物的資訊 本處方集更新日期為 05 年 9 月 9 日 如有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan 會員服務部, 電話 -888-5-98 (TTY: -888--60) 如需詳細資訊, 請上網瀏覽 www.calmediconnectla.org www.lacare.org H858_560_05Formulary_CH Accepted Formulary ID 00058, Version 5

這是會員可在 L.A. Care Cal MediConnect Plan 獲得的藥物清單 L.A. Care Health Plan 是一項與聯邦醫療保險和 Medi-Cal 簽約的保健計劃, 向投保人提供這兩項計劃的福利 福利 承保藥物清單 藥房和醫療服務提供者網絡及 ( 或 ) 共付額可能會在一年之中以及每年 月 日變更 您總是可以在線上 www.calmediconnectla.org 或致電 -888-5-98 (TTY: -888--60) 查詢 L.A. Care Cal MediConnect Plan 最新的承保藥物清單 您可以要求本資訊的其他格式版, 例如點字或大字版 請致電 -888-5-98 (TTY: -888--60) 這是免費電話 可能有侷限和限制 如需更多資訊, 請致電 L.A. Care Cal MediConnect Plan 會員服務部或閱讀 L.A. Care Cal MediConnect Plan 的會員手冊 處方藥的共付額可能因您獲得的 額外協助 額度而異 更多詳情, 請聯絡計劃 You can get this information for free in other languages. Call -888-5-98 (TTY: -888--60). The call is free. Puede obtener esta información gratis en otros idiomas. Llame al -888-5-98 (TTY: -888--60). La llamada es gratis. Այս տեղեկությունները անվճար կարող եք ստանալ այլ լեզուներով: Զանգահարեք -888-5-98 հեռախոսահամարով (TTY` -888--60): Զանգն անվճար է: អ នកអ ចទទ លព ត ម នន ជ ភ ស ផ ស ងៗដ យឥតគ តថ ល ស មហ ល ខ -888-5-98 (TTY: -888--60) ក រហ ន គ ឥតគ តថ ល ឡ យ 이정보는다른언어로도무료로구하실수있습니다. -888-5-98 (TTY: -888--60) 로전화하시면되며통화료는무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по номеру телефона -888-5-98 (TTY: -888--60). Звонок бесплатный. Makukuha ninyo ang impormasyong ito nang libre sa ibang mga wika. Tumawag sa -888-5-98 (TTY: -888--60). Ang tawag ay libre. 本資訊備有其他語言版本供您免費索取 請致電 -888-5-98 (TTY: -888--60) 這是免費電話 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org i

Quý vị có thể được cấp thông tin này miễn phí bằng nhiều ngôn ngữ. Vui lòng gọi số -888-5-98 (TTY: -888--60). Số điện thoại này miễn phí. یمكنك الحصول على ھذه المعلومات مجان ا بلغات أخرىاتصل على الرقم -888-5-98 (رقم الھاتف النصي: -888--60 ). ھذه المكالمة مجانیة. ii 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org

常見問題集 (FAQ) 在此處尋找您對於承保藥物清單的問題解答 您可以閱讀全部的常見問題集瞭解更多資訊, 或是尋找特定的問題和解答. 承保藥物清單上有哪些處方藥?( 我們將承保藥物清單簡稱為 藥物清單 ) 藥物清單上的藥物是 L.A. Care Cal MediConnect Plan 承保的藥物 這些藥物可在我們網絡內的藥房購買 如果我們與一家藥房簽訂協議一起合作並向您提供服務, 那家藥房就在我們的網絡內 我們將這些藥房稱為 網絡藥房 L.A. Care Cal MediConnect Plan 在以下情況承保藥物清單上所有醫療必要性的藥物 : 您的醫生或其他開立處方者表示您需要這些藥物以便好轉或保持健康, 而且 您會在 L.A. Care Cal MediConnect Plan 網絡藥房配領處方藥 在某些情況中, 您必須採取一些行動才能獲得藥物 ( 請看第 5 題 ) 您也可以在我們的網站 www.calmediconnectla.org 或致電會員服務部 -888-5-98 (TTY: -888--60) 查詢最新的承保藥物清單. 藥物清單會變更嗎? 會 L.A. Care Cal MediConnect Plan 可能會在一年之中增減藥物清單上的藥物 一般而言, 藥物清單只會在以下情況變更 : 市面上出現一種較便宜的藥物, 而且藥效與藥物清單上的藥物一樣好, 或是 我們得知一種藥物不安全 我們也可能會改變藥物的規定 例如, 我們可能 : 決定要求或不要求某種藥物的事先核准 ( 事先核准是您在取得藥物之前需要 L.A. Care Cal MediConnect Plan 的許可 ) 增加或改變您可以獲得的藥量 ( 稱為 數量限制 ) 增加或改變藥物的逐步治療限制 ( 逐步治療是指您必須先嘗試一種藥物, 我們才會承保另一種藥物 ) ( 如需這些藥物規定的更多資訊, 請看第 iv 頁 ) 當您服用的一種藥物從藥物清單撤出時, 我們會告訴您 當我們改變承保藥物的規定時, 我們也會告訴您 以下第 3 和 7 題會提供藥物清單變更時的更多資訊 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org iii

您總是可以在線上 www.calmediconnectla.org 查詢 L.A. Care Cal MediConnect Plan 最新的藥物清單 您也可以致電會員服務部 -888-5-98 (TTY: -888--60) 查詢最新的藥物清單 3. 如果市面上出現一種比較便宜的藥物, 而且藥效與藥物清單上的藥物一樣好怎麼辦? 如果您服用的一種藥物因為市面上出現一種比較便宜, 而且藥效與藥物清單上的藥物一樣好而被撤出藥物清單, 我們會告訴您 我們會在撤出藥物清單之前至少 60 天或是當您要求續配時告訴您 您會從一份稱為 福利說明書 的文件得知這項變化, 信上會顯示將在 60 天內從藥物清單撤出的藥物 撤出藥物的清單也會登在 L.A. Care Cal MediConnect Plan 網站 www.calmediconnectla.org. 當我們發現一種藥物不安全時會怎麼辦? 如果食品暨藥物管理局 (FDA) 表示您服用的一種藥物不安全, 我們會立刻撤出藥物清單 我們也會寄信告訴您 我們也會通知您的醫療服務提供者, 因此您可以與他 / 她商量改換成藥物清單上一種可以安全使用的藥物 5. 藥物承保有任何侷限或限制嗎? 還是需要採取任何行動以便獲得某些藥物? 是的, 某些藥物有承保規定或是對您可以獲得的藥量有限制 在某些情況中, 您必須採取一些行動才能獲得藥物 例如 : 事先核准 ( 或事先授權 ): 對於某些藥物, 您或您的醫生必須先取得 L.A. Care Cal MediConnect Plan 的核准, 您才能配領處方藥 如果您未取得核准,L.A. Care Cal MediConnect Plan 可能不會承保該藥物 數量限制 : 有時候 L.A. Care Cal MediConnect Plan 會限制您可以獲得的藥量 逐步治療 : 有時 L.A. Care Cal MediConnect Plan 要求您接受逐步治療 這是指您必須以某種順序使用藥物來治療您的醫學狀況 您必須先嘗試一種藥物, 我們才會承保另一種藥物 如果您的醫生認為第一種藥物對您無效, 我們才會承保第二種藥物 查閱第 -6 頁的表格, 即可找到您的藥物是否有額外規定或限制 您也可以造訪我們的網站 www.calmediconnectla.org 尋找詳細資訊 我們已在線上刊載一份文件, 解釋我們事先授權和逐步治療的限制 您也可以要求我們寄一份給您 您也可以對這些限制提出 例外處理 要求 請參閱第 題有關例外處理的詳細資訊 iv 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org

如果您住在療養院或其他長期護理設施, 而且需要一種不在藥物清單上的藥物, 或是您無法輕易取得需要的藥物, 我們可以幫助您 無論您是否是新的 L.A. Care Cal MediConnect Plan 會員, 我們都會為您需要的藥物承保 3 天的緊急份量 ( 除非處方箋開立的天數較少 ), 以便您有時間和醫生或其他開處方者討論, 他們可以幫助您決定您是否可以服用藥物清單上的另一種類似藥物, 或是否要求例外處理 請參閱第 題有關例外處理的詳細資訊 6. 您怎麼知道您想要的藥物是否有限制或需要採取什麼行動來獲得藥物? 承保藥物清單的第 頁有一欄稱為 必要的行動 限制或使用上限 7. 如果我們改變承保某些藥物的規定會如何? 例如, 如果我們增加藥物的事先授權 ( 核准 ) 數量限制, 及 ( 或 ) 逐步治療限制 我們會告訴您我們是否對某種藥物增加了事先核准 數量限制, 及 ( 或 ) 逐步治療侷限 我們會在增加限制之前至少 60 天或是在您下次要求藥房續配藥物時告訴您 然後, 您可以在承保規定變更之前獲得 60 天的藥量 這樣可以讓您有時間和醫生討論接下來該怎麼做 8. 如何查詢一種藥物是否列在藥物清單中? 有兩種方式可以尋找藥物 : 您可以按字母順序搜尋 ( 如果您知道如何拼出藥物名稱 ), 或是 您可以按照醫學狀況搜尋 要按照字母順序搜尋, 請翻到字母清單部分 您可以從清單末尾的索引來搜尋 藥物會按字母順序列出 要按照醫學狀況搜尋, 請翻到第 頁標示 按照醫學狀況排列的藥物清單 的部份, 然後找出您的醫學狀況 例如, 如果您有一種心臟狀況, 您應該查看該類別 您可以在此處找到治療心臟狀況的藥物 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org v

9. 如果您想服用的藥物不在藥物清單上怎麼辦? 如果您在藥物清單上沒有查到您的藥物, 請致電會員服務部, 電話號碼是 -888-5-98 (TTY: -888--60) 如果您得知 L.A. Care Cal MediConnect Plan 不會承保該藥物, 您可以採取以下一種行動 : 向會員服務部索取一份與您想服用的藥物類似的清單, 然後將該清單出示給您的醫生或其他開立處方者 他們可以開立藥物清單上與您想服用的藥物類似的藥物 或是 您可要求保健計劃進行例外處理以承保您的藥物 請參閱第 題有關例外處理的詳細資訊 0. 如果您是 L.A. Care Cal MediConnect Plan 的新會員, 而且在藥物清單上找不到您的藥物或是取得您的藥物遇到困難怎麼辦? 我們可以幫忙 我們會在您成為 L.A. Care Cal MediConnect Plan 會員後的最初 90 天承保一次暫時 30 天藥物用量, 以便您有時間和醫生或其他開立處方者討論, 他們可以幫助您決定您是否可以服用藥物清單上的另一種類似藥物, 或是否要求例外處理 我們在以下情況會承保 30 天的藥物用量 : 您服用一種不在藥物清單上的藥物, 或是 保健計劃規定不讓您取得開立處方者所囑咐的用量, 或是 藥物需要 L.A. Care Cal MediConnect Plan 的事先核准, 或是 您正在服用一種屬於逐步治療限制的藥物 如果您住在療養院或其他長期護理設施, 您最多可以續配 98 天的處方藥 您可以在這 90 天期間多次續配藥物 這會讓您的開立處方者有時間將您的藥物改成藥物清單上的藥物或是要求例外處理 護理層級的變更 您的護理層級變更時, 我們會為您的藥物提供過渡供應 護理層級的變更可能包括以下各項 :. 會員從醫院轉入長期護理設施. 會員從醫院出院返家 3. 會員搬離聯邦醫療保險 A 部分的專業護理設施, 需要回到 D 部分計劃處方集. 會員放棄安寧護理狀態, 回到標準聯邦醫療保險 A 部分和 B 部分福利 vi 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org

5. 會員搬離長期護理設施, 回到社區 6. 會員從精神病院出院, 需要高度個人化的藥物療法 藥房可能致電 -866-70-3877 聯絡 L.A. Care Cal MediConnect Plan 藥房服務部, 處理銷售點越權處置問題, 以確保會員可以獲得他們的藥物而無任何延誤. 您可以提出承保您藥物的例外處理要求嗎? 可以 您可以要求 L.A. Care Cal MediConnect Plan 破例承保一種沒有列在藥物清單中的藥物 您也可以要求我們更改對於您藥物的規定 例如,L.A. Care Cal MediConnect Plan 可能會限制對於某種藥物的承保份量 如果您的藥物有上限規定, 您可要求我們更改這項限制而承保更多藥量 其他例子 : 您可以要求我們撤銷逐步治療限制或是事先核准要求. 取得例外處理需要多少時間? 首先, 我們必須收到您的開立處方者聲明, 支持您對於例外處理的要求 我們收到聲明後, 會在 7 小時內對您的例外處理要求做出決定 如果您或您的開立處方者認為等候 7 小時做出決定會對您的健康造成危害, 您可以要求快速例外處理 這是更快速的決定 如果您的開立處方者支持您的要求, 我們會在收到您的開立處方者的支持聲明後 小時內做出決定 3. 如何提出例外處理要求? 要提出例外處理要求, 請致電會員服務部或我們的藥房部 您的護理團隊會與您和您的醫療服務提供者合作, 幫您提出例外處理要求. 何謂普通藥? 普通藥的成份與品牌藥相同 它們通常比品牌藥便宜, 而且它們的名稱較不為人所知 普通藥經過美國食品暨藥物管理局 (FDA) 的核准 L.A. Care Cal MediConnect Plan 承保品牌藥和普通藥 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org vii

5. 什麼是成藥? OTC 是指 成藥 您無須處方即可購買成藥 L.A. Care Cal MediConnect Plan 承保一些成藥 您可以在 L.A. Care Cal MediConnect Plan 藥物清單查看哪些成藥可獲得承保 6. L.A. Care Cal MediConnect Plan 是否承保非藥物成藥? L.A. Care Cal MediConnect Plan 承保某些非藥物成藥 您可以在 L.A. Care Cal MediConnect Plan 藥物清單查看哪些非藥物成藥可獲得承保 7. 您的共付額是多少? 您可以在 L.A. Care Cal MediConnect Plan 藥物清單查看每一種藥物的共付額 住在療養院或其他長期護理設施的 L.A. Care Cal MediConnect Plan 會員不必支付共付額 有些在社區內接受長期護理的會員也不必支付共付額 共付額按層級排列 層級是指共付額相同的藥物組 第 級藥物是普通藥 共付額從 $0 至 $.65, 根據您的 Medicaid 資格層級而定 第 級藥物是品牌藥 共付額從 $0 至 $6.60, 根據您的 Medicaid 資格層級而定 第 3 級藥物是非聯邦醫療保險處方普通藥 您不必支付第 3 級藥物的費用 第 級藥物是非聯邦醫療保險成藥 您不必支付第 級藥物的費用 承保藥物清單 以下或下一頁開始的承保藥物清單會說明 L.A. Care Cal MediConnect Plan 承保的藥物資訊 如果您在清單中尋找藥物時遇到困難, 請翻到第 頁開始的索引 表格的第一欄列出藥物名稱 品牌藥名稱用大寫字母表示 ( 例如 CYMBALTA), 普通藥則用小寫斜體字母列出 ( 例如 metformin) 必要行動 限制或使用上限 一欄的資訊會說明 L.A. Care Cal MediConnect Plan 承保您的藥物是否有任何規定 viii 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org

承保備註縮寫 縮寫說明解釋使用管理限制 事先授權限制 L.A. Care Cal MediConnect Plan 要求您 ( 或您的醫生 ) 在配領這種 處方藥之前取得事先授權 若未取得事先核准,L.A. Care Cal MediConnect Plan 可能不會承保該藥物 NSO B 部分與 D 部分決定的事先授權限制 只限新會員的事先授權限制 這種藥物也許可從聯邦醫療保險 B 部分或 D 部分獲得付款 L.A. Care Cal MediConnect Plan 要求您 ( 或您的醫生 ) 在配領這種處方藥之前取得事先授權, 以確定該藥物是否受到聯邦醫療保險 D 部分的承保 若未取得事先核准,L.A. Care Cal MediConnect Plan 可能不會承保該藥物 如果這是您的新處方藥, 也就是第一次向您開立這種藥物, 您 ( 或您的醫生 ) 在配領這種藥物之前需要向 L.A. Care Cal MediConnect Plan 取得事先授權 若未取得事先核准, L.A. Care Cal MediConnect Plan 可能不會承保該藥物 QL 數量限制 L.A. Care Cal MediConnect Plan 限制在一定時間範圍承保該藥物的 數量 ST 逐步治療限制 您必須先嘗試另一種藥物來治療您的醫學狀況,L.A. Care Cal MediConnect Plan 才會提供該藥物的承保 只有在其他藥物 對您無效時, 該藥物才會獲得承保 承保的其他特殊要求 LD 有限分發藥物 本處方藥僅在某些藥房出售 詳情請參閱您的醫療服務提供者 / 藥 房名錄或在一週 7 天, 每天 小時 ( 包括假日 ) 致電會員服務部, 電話號碼是 -888-5-98 (TTY: -888--60) 附註 : 藥物名稱旁邊的星號 (*) 代表藥物不是 D 部分藥物 您配領此藥處方所支付的費用不會計入您的整體藥物費用 ( 也就是您支付的金額不會使您有資格獲得重大傷病承保 ) 這些藥物也有不同的上訴規定 如果您認為我們做出錯誤的決定, 上訴是一種正式方式, 要求我們審核對您所做的承保決定並加以更改 例如, 我們也許決定您想要的某種藥是聯邦醫療保險或 Medi-Cal 不承保或不再承保的藥物 如果您或您的醫生不同意我們的決定, 您可以提出上訴 如果您有疑問, 請致電會員服務部, 電話號碼是 -8-5-98 (TTY: -888--60) 您亦可閱讀會員手冊, 以瞭解如何對一項決定提出上訴 如果您有問題, 請在一週 7 天, 每天 小時 ( 包括假日 ) 致電 L.A. Care Cal MediConnect Plan, 電話號碼 -888-5-98 (TTY: -888--60) 這是免費電話 如需詳細資訊, 請上網瀏覽? www.calmediconnectla.org ix

ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS AMPHETAMINES ADDERALL XR CAP amphetamine/ dextroamphetamine tab dexedrine tab dextroamphetamine ER cap dextroamphetamine tab methamphetamine tab VYVANSE CAP ANOREXIANTS NON-AMPHETAMINE phentermine cap 5mg, 30mg* 3 phentermine tab 37.5mg* 3 QSYMIA CAP* 3 ANTI-OBESITY AGENTS XENICAL CAP 0MG* 3 ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS guanfacine ER tab ST INTUNIV TAB MG, MG ST INTUNIV TAB 3MG, MG NSO ST STRATTERA CAP QL=60 Caps/30 Days STIMULANTS - MISC. dexmethylphenidate ER cap dexmethylphenidate tab metadate ER tab methylphenidate CD cap methylphenidate ER cap methylphenidate ER tab methylphenidate soln methylphenidate tab NUVIGIL TAB QL=30 Tabs/30 Days AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin inj gentamicin inj gentamicin/ nacl inj 0.8mg/ ml, mg/ ml gentamicin/ nacl inj 0.9mg/ ml,.mg/ ml,.6mg/ ml isotonic gentamicin inj neomycin tab paromomycin cap STREPTOMYCIN INJ TOBI NEB NM TOBI PODHALER NM tobramycin inj TOBRAMYCIN/ NACL INJ

ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ TAB QL=60 Tabs/30 Days ANTIRHEUMATIC ANTIMETABOLITES RHEUMATREX TAB DOSE CK ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ NM HUMIRA KIT NM SIMPONI INJ NM GOLD COMPOUNDS RIDAURA CAP INTERLEUKIN- BLOCKERS ARCALYST INJ NM INTERLEUKIN-BETA BLOCKERS ILARIS INJ NM NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELEBREX CAP QL=60 Caps/30 Days celecoxib cap QL=60 Caps/30 Days diclofenac EC tab diclofenac potassium tab diclofenac XR tab diclofenac/ misoprostol tab etodolac cap etodolac ER tab etodolac tab fenoprofen tab flurbiprofen tab ibuprofen cap 00mg* ibuprofen chew tab 00mg* ibuprofen susp ibuprofen tab ibuprofen tab 00mg* ibuprofen tab 00mg* QL=00 Tabs/00 Days INDOCIN SUSP indomethacin cap indomethacin ER cap ketoprofen cap ketorolac inj ketorolac tab QL=0 Tabs/5 Days MECLOFENAMATE SODIUM CAP mefenamic acid cap MELOXICAM SUSP meloxicam tab nabumetone tab

naproxen DR tab naproxen ER tab naproxen sodium tab NAPROXEN SUSP naproxen tab oxaprozin tab piroxicam cap sulindac tab tolmetin cap tolmetin tab TOLMETIN TAB 00MG PHOSPHODIESTERASE (PDE) INHIBITORS OTEZLA TAB OTEZLA TAB STARTER CK PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab SELECTIVE COSTIMULATION MODULATORS ORENCIA INJ ORENCIA SC INJ SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ ENBREL SURECLICK INJ ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS aspirin/ acetaminophen/ caffeine tab 50-50-65mg* tencon tab ANALGESICS OTHER acetaminophen cap 500mg* acetaminophen chew tab 60mg* acetaminophen CR tab 650mg* acetaminophen elixir 60mg/ 5ml* acetaminophen liquid 60mg/ 5ml* ACETAMINOPHEN LIQUID 500MG/ 5ML* acetaminophen soln 60mg/ 5ml* acetaminophen supp 80mg, 0mg, 35mg, 650mg* acetaminophen susp 80mg/ 0.8ml, 60mg/ 5ml* acetaminophen tab 35mg, 500mg* SALICYLATES ASCRIPTIN TAB 35MG* aspirin DR tab 8mg, 35mg* aspirin tab 35mg* aspirin tab 500mg* aspirin tab 8mg* diflunisal tab 3 NM QL=60 Tabs/30 Days NM QL=60 Tabs/30 Days NM NM QL=30 Tabs/30 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days

ANALGESICS - OPIOID OPIOID AGONISTS codeine sulfate tab duramorph inj EMBEDA CAP EXALGO TAB fentanyl lollipop fentanyl patch HYDROMORPHONE ER SOLN hydromorphone ER tab hydromorphone inj hydromorphone oral liquid hydromorphone tab LAZANDA SPRAY LEVORPHANOL TAB meperitab tab methadone soln methadone tab morphine sulfate ER cap morphine sulfate ER tab MORPHINE SULFATE INJ MORPHINE SULFATE PF INJ morphine sulfate soln morphine sulfate tab NUCYNTA ER TAB oxycodone cap oxycodone soln oxycodone tab OXYCONTIN TAB OXYCONTIN TAB 80MG oxymorphone ER tab oxymorphone tab tramadol ER tab tramadol tab OPIOID COMBINATIONS acetaminophen/ codeine soln acetaminophen/ codeine tab endocet tab endodan tab hydrocodone/ acetaminophen soln 7.5-35mg/ 5ml hydrocodone/ acetaminophen tab.5-35mg, 5-35mg, 7.5-35mg, 0-35mg hydrocodone/ acetaminophen tab 5-300mg, 7.5-300mg, 0-300mg hydrocodone/ ibuprofen tab QL=0 Lozenges/30 Days QL=30 Bottles/30 Days QL=60 Caps/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days QL=60 Tabs/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days

oxycodone/ acetaminophen tab oxycodone/ aspirin tab oxycodone/ ibuprofen tab ROXICET SOLN tramadol/ acetaminophen tab OPIOID RTIAL AGONISTS buprenorphine inj buprenorphine SL tab butorphanol inj butorphanol soln BUTRANS TCH pentazocine/ naloxone tab SUBOXONE SL FILM ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 TAB oxandrolone tab ANDROGENS ANDRODERM TCH MG ANDRODERM TCH MG ANDROGEL 0.5 MG/.5GM (.6%) ANDROGEL 5MG ANDROGEL 0.5 MG/.5GM (.6%) ANDROGEL GEL %(50MG) ANDROGEL PUMP ANDROGEL PUMP % danazol cap testosterone cypionate inj testosterone enanthate inj ANORECTAL AGENTS INTRARECTAL STEROIDS colocort enema hydrocortisone enema UCERIS RECTAL FOAM RECTAL STEROIDS hydrocortisone rectal cream procto-pak cream proctozone-hc cream ANTACIDS ANTACID COMBINATIONS aluminum hydroxide/ magnesium carbonate chew tab* aluminum/ magnesium hydroxide/ simethicone susp 5-0-5mg/ 5ml* antacid susp* 5 QL= Bottles/30 Days QL= Patches/8 Days QL=60 Patches/30 Days QL=30 Patches/30 Days QL=30 Packets/30 Days QL=30 Packets/30 Days QL=60 Packets/30 Days QL=60 Packets/30 Days QL= Bottles/30 Days QL= Bottles/30 Days

GELUSIL CHEW TAB* MAALOX ADVANCED MAXIMUM STRENGTH CHEW TAB* maalox max susp* ANTACIDS - ALUMINUM SALTS ALUMINUM HYDROXIDE GEL SUSP 30MG/ 5ML* aluminum hydroxide gel susp 600mg/ 5ml* ANTACIDS - BICARBONATE sodium bicarbonate tab 650mg* ANTACIDS - CALCIUM SALTS calcium carbonate chew tab 0mg, 500mg, 750mg, 000mg* calcium carbonate tab 68mg* ANTHELMINTICS ANTHELMINTICS ALBENZA TAB ivermectin tab STROMECTOL TAB ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA TAB NITRATES isosorbide dinitrate ER tab isosorbide dinitrate tab isosorbide mononitrate ER tab isosorbide mononitrate tab minitran patch NITRO-DUR TCH 0.3MG, 0.8MG nitroglycerin inj nitroglycerin lingual spray nitroglycerin patch NITROSTAT SL TAB ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone tab 5mg, 7.5mg, 0mg, 5mg hydroxyzine pamoate cap hydroxyzine syrup hydroxyzine tab meprobamate tab BENZODIAZEPINES alprazolam ER tab alprazolam ODT alprazolam tab 6

chlordiazepoxide cap clorazepate tab diazepam intensol conc DIAZEM SOLN diazepam tab lorazepam intensol conc lorazepam tab oxazepam cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide cap NORCE CR CAP PROCAINAMIDE INJ quinidine gluconate CR tab QUINIDINE GLUCONATE INJ quinidine sulfate tab ANTIARRHYTHMICS TYPE I-B mexiletine cap ANTIARRHYTHMICS TYPE I-C flecainide tab propafenone ER cap propafenone tab ANTIARRHYTHMICS TYPE III amiodarone inj amiodarone tab MULTAQ TAB NEXTERONE INJ TIKOSYN CAP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR INJ NM ANTI-INFLAMMATORY AGENTS cromolyn neb BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALER INCRUSE ELLIPTA INHALER ipratropium neb SPIRIVA CAP HANDIHALER SPIRIVA RESPIMAT TUDORZA INHALER LEUKOTRIENE MODULATORS montelukast chew tab montelukast granules montelukast tab 7

zafirlukast tab SELECTIVE PHOSPHODIESTERASE (PDE) INHIBITORS DALIRESP TAB STEROID INHALANTS ARNUITY ELLIPTA INHALER ASMANEX HFA INHALER ASMANEX INHALER ASMANEX TWISTHALER budesonide neb FLOVENT DISKUS FLOVENT HFA INHALER 0MCG FLOVENT HFA INHALER MCG, 0MCG PULMICORT NEB MG/ ML QVAR INHALER SYMTHOMIMETICS ADVAIR DISKUS ADVAIR HFA INHALER albuterol neb albuterol sulfate ER tab albuterol syrup albuterol tab BREO ELLIPTA INHALER COMBIVENT RESPIMAT DULERA INHALER EPHEDRINE SULFATE CAP 5MG* FORADIL CAP ipratropium/ albuterol neb levalbuterol neb METAPROTERENOL SYRUP SEREVENT INHALER STRIVERDI INHALER SYMBICORT INHALER terbutaline inj terbutaline tab VENTOLIN HFA INHALER XANTHINES aminophylline inj ELIXOPHYLLIN SOLN theophylline ER tab theophylline soln ANTICOAGULANTS COUMARIN ANTICOAGULANTS jantoven tab warfarin tab QL= Inhalers/30 Days QL=60 Neb/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL=60 Neb/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days 8

DIRECT FACTOR XA INHIBITORS ELIQUIS TAB XARELTO TAB XARELTO TAB STARTER CK HERINS AND HERINOID-LIKE AGENTS enoxaparin inj fondaparinux inj FRAGMIN INJ heparin inj heparin/ d5w inj THROMBIN INHIBITORS argatroban inj 00mg/ ml ARGATROBAN INJ 5MG/ 5ML PRADAXA CAP ANTICONVULSANTS AM GLUTAMATE RECEPTOR ANTAGONISTS FYCOM TAB ANTICONVULSANTS - BENZODIAZEPINES clonazepam ODT clonazepam tab DIASTAT RECTAL GEL DIAZEM RECTAL GEL ONFI SUSP ONFI TAB ANTICONVULSANTS - MISC. APTIOM TAB BANZEL SUSP BANZEL TAB carbamazepine chew tab carbamazepine ER cap carbamazepine ER tab carbamazepine susp carbamazepine tab epitol tab gabapentin cap gabapentin soln gabapentin tab LAMICTAL ODT LAMICTAL TAB STARTER KIT LAMICTAL XR KIT lamotrigine chew tab lamotrigine ER tab lamotrigine ODT lamotrigine tab 9 QL=35 Syringes/7 Days NM NM NSO NSO NSO NSO

levetiracetam ER tab LEVETIRACETAM INJ levetiracetam inj levetiracetam soln levetiracetam tab LYRICA CAP LYRICA SOLN oxcarbazepine oral susp oxcarbazepine tab OXTELLAR XR TAB POTIGA TAB primidone tab TEGRETOL-XR TAB TOPIRAMATE ER CAP topiramate sprinkle cap topiramate tab TROKENDI XR CAP VIMT INJ VIMT SOLN VIMT TAB zonisamide cap CARBAMATES felbamate susp felbamate tab GABA MODULATORS GABITRIL TAB SABRIL POWDER SABRIL TAB tiagabine tab HYDANTOINS CEREBYX INJ DILANTIN CAP 30MG fosphenytoin inj PEGANONE TAB phenytoin cap phenytoin chew tab phenytoin inj phenytoin susp SUCCINIMIDES CELONTIN CAP ethosuximide cap ethosuximide soln VALPROIC ACID divalproex DR tab 0 NSO QL=90 Tabs/30 Days NSO NSO QL=60 Tabs/30 Days NM NM

divalproex ER tab divalproex sprinkle cap valproate sodium inj valproic acid cap valproic acid syrup ANTIDEPRESSANTS ALPHA- RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine ODT mirtazapine tab ANTIDEPRESSANTS - MISC. APLENZIN TAB bupropion SR tab bupropion tab bupropion XL tab maprotiline tab MODIFIED CYCLICS BRINTELLIX TAB NEFAZODONE TAB trazodone tab VIIBRYD TAB VIIBRYD TAB STARTER CK MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TCH MARPLAN TAB phenelzine tab tranylcypromine tab SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram soln citalopram tab escitalopram soln escitalopram tab fluoxetine cap fluoxetine soln fluoxetine tab fluvoxamine ER cap fluvoxamine tab paroxetine ER tab paroxetine tab XIL SUSP PEXEVA TAB sertraline conc sertraline tab SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER TAB ST ST ST NSO ST ST ST

duloxetine cap DULOXETINE DR CAP FETZIMA CAP FETZIMA CK IRENKA CAP KHEDEZYLA TAB PRISTIQ TAB venlafaxine ER cap venlafaxine ER tab VENLAFAXINE ER TAB 5MG venlafaxine tab TRICYCLIC AGENTS amitriptyline tab amoxapine tab clomipramine cap desipramine tab doxepin conc doxepine cap imipramine pamoate cap imipramine tab nortriptyline cap nortriptyline soln protriptyline tab SURMONTIL CAP ALPHA-GLUCOSIDASE INHIBITORS acarbose tab GLYSET TAB ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN INJ ANTIDIABETIC COMBINATIONS AVANDAMET TAB glipizide/ metformin tab glyburide/ metformin tab INVOKAMET TAB JANUMET TAB JANUMET XR TAB pioglitazone/ glimepiride tab pioglitazone/ metformin tab XIGDUO XR TAB BIGUANIDES metformin ER osmotic tab 000mg metformin ER tab metformin tab ANTIDIABETICS QL=60 Caps/30 Days ST QL=30 Caps/30 Days ST ST ST QL=30 Caps/30 Days ST ST NSO NSO NSO NSO NSO NSO NSO

DIABETIC OTHER GLUCAGEN HYPOKIT GLUCAGON KIT KORLYM TAB PROGLYCEM SUSP DIPEPTIDYL PEPTIDASE- (DPP-) INHIBITORS JANUVIA TAB ONGLYZA TAB TRADJENTA TAB INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON INJ BYDUREON PEN INJ MG TRULICITY INJ VICTOZA INJ INSULIN HUMALOG INJ HUMALOG KWIKPEN INJ HUMALOG VIAL HUMULIN 70/ 30 PEN HUMULIN N PEN HUMULIN R U-500 VIAL LANTUS SOLOSTAR LANTUS VIAL LEVEMIR FLEXPEN LEVEMIR INJ NOVOLIN 70/ 30 VIAL NOVOLIN N VIAL NOVOLIN R VIAL NOVOLOG FLEXPEN NOVOLOG MIX 70/ 30 PEN NOVOLOG MIX INJ NOVOLOG PENFILL NOVOLOG VIAL TOUJEO SOLOSTAR PEN INSULIN SENSITIZING AGENTS AVANDIA TAB pioglitazone tab MEGLITINIDE ANALOGUES nateglinide tab repaglinide tab SODIUM-GLUCOSE CO-TRANSPORTER (SGLT) INHIBITORS FARXIGA TAB INVOKANA TAB JARDIANCE TAB 3 NM QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days ST ST ST QL=30 Tabs/30 Days

SULFONYLUREAS chlorpropamide tab glimepiride tab glipizide ER tab glipizide tab glyburide micronized tab glyburide tab tolazamide tab TOLBUTAMIDE TAB ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC. bismuth subsalicylate chew tab 6mg* bismuth subsalicylate susp 6mg/ 5ml, 55mg/ 5ml* bismuth subsalicylate tab 6mg* ANTIPERISTALTIC AGENTS diphenoxylate/ atropine liquid diphenoxylate/ atropine tab loperamide cap loperamide tab mg* ANTIDOTES ANTIDOTES fomepizole inj ANTIDOTES - CHELATING AGENTS CHEMET CAP EXJADE ORAL SUSP FERRIPROX TAB JADENU TAB OPIOID ANTAGONISTS NALOXONE INJ naltrexone tab ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron inj granisetron tab ondansetron inj ondansetron ODT ondansetron soln ondansetron tab ANTIEMETICS - ANTICHOLINERGIC BONINE CHEW TAB 5MG* dimenhydrinate tab 50mg* meclizine tab TRANSDERM SCOP TCH NM LD NM QL=9 Tabs/ Days

trimethobenzamide cap ANTIEMETICS - MISCELLANEOUS AKYNZEO CAP QL= Caps/7 Days CESAMET CAP dronabinol cap SUBSTANCE P/ NEUROKININ (NK) RECEPTOR ANTAGONISTS EMEND CAP QL=3 Caps/ Days EMEND CAP CK QL=3 Caps/ Days ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS INJ NM ERAXIS INJ MYCAMINE INJ ANTIFUNGALS ABELCET INJ AMBISOME INJ AMPHOTERICIN B INJ flucytosine cap griseofulvin susp griseofulvin tab nystatin tab terbinafine tab IMIDAZOLE-RELATED ANTIFUNGALS fluconazole susp fluconazole tab fluconazole/ dextrose inj itraconazole cap ketoconazole tab NOXAFIL SUSP NOXAFIL TAB NM voriconazole inj voriconazole susp voriconazole tab NM ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES chlorpheniramine syrup mg/ 5ml* chlorpheniramine tab mg* ANTIHISTAMINES - ETHANOLAMINES BENADRYL CHEW TAB.5MG* carbinoxamine soln carbinoxamine tab CLEMASTINE SYRUP clemastine tab clemastine tab.3mg* 5

diphenhydramine cap 5mg, 50mg* diphenhydramine elixir.5mg/ 5ml* diphenhydramine inj diphenhydramine liquid.5mg/ 5ml* diphenhydramine oral soln (Rx only) diphenhydramine tab 5mg* ANTIHISTAMINES - NON-SEDATING ALLEGRA TAB 30MG* 3 cetirizine chew tab 5mg, 0mg* cetirizine oral soln (Rx only) cetirizine soln mg/ ml* cetirizine tab 5mg, 0mg* desloratadine ODT desloratatine tab fexofenadine tab 60mg, 80mg* 3 levocetirizine soln levocetirizine tab loratadine ODT 0mg* loratadine syrup 5mg/ 5ml* loratadine tab 0mg* ANTIHISTAMINES - PHENOTHIAZINES phenadoz supp promethazine inj promethazine supp promethazine syrup promethazine tab PROMETHAZINE VC SYRUP PLAIN promethegan supp PROMETHEGAN SUPP 50MG ANTIHISTAMINES - PIPERIDINES cyproheptadine syrup cyproheptadine tab ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS LIPTRUZET TAB ANTIHYPERLIPIDEMICS - MISC. LOVAZA CAP omega-3 acid ethyl esters cap VASCE CAP BILE ACID SEQUESTRANTS cholestyramine light powder cholestyramine light powder packet colestipol granules canister 5gm colestipol tab 6 QL=300 ml/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=300 ml/30 Days QL=30 Tabs/30 Days

WELCHOL TAB FIBRIC ACID DERIVATIVES fenofibrate micronized cap fenofibrate tab gemfibrozil tab LOFIBRA CAP LOFIBRA TAB TRIGLIDE TAB TRILIPIX CAP HMG COA REDUCTASE INHIBITORS atorvastatin tab CRESTOR TAB QL=30 Tabs/30 Days CRESTOR TAB 0MG QL=5 Tabs/30 Days fluvastatin cap LESCOL XL TAB lovastatin tab pravastatin tab SIMCOR TAB simvastatin tab INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB QL=30 Tabs/30 Days MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID CAP NM NICOTINIC ACID DERIVATIVES NIACOR TAB NIASN ER TAB ANTIHYPERTENSIVES ACE INHIBITORS benazepril tab captopril tab enalapril tab fosinopril tab lisinopril tab moexipril tab perindopril tab quinapril tab ramipril cap trandolapril tab AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP DIBENZYLINE CAP ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan tab DIOVAN TAB 7

eprosartan mesylate tab irbesartan tab losartan tab telmisartan tab valsartan tab ANTIADRENERGIC ANTIHYPERTENSIVES clonidine patch clonidine tab doxazosin tab guanfacine IR tab methyldopa tab prazosin cap terazosin cap ANTIHYPERTENSIVE COMBINATIONS amlodipine/ benazepril cap amlodipine/ valsartan tab atenolol/ chlorthalidone tab benazepril/ hydrochlorothiazide tab bisoprolol/ hydrochlorothiazide tab candesartan/ hydrochlorothiazide tab captopril/ hydrochlorothiazide tab DUTOPROL TAB enalapril/ hydrochlorothiazide tab EXFORGE HCT TAB EXFORGE TAB fosinopril/ hydrochlorothiazide tab irbesartan/ hydrochlorothiazide tab lisinopril/ hydrochlorothiazide tab losartan/ hydrochlorothiazide tab methyldopa/ hydrochlorothiazide tab metoprolol/ hydrochlorothiazide tab moexipril/ hydrochlorothiazide tab nadolol/ bendroflumethiazide tab propranolol/ hydrochlorothiazide tab quinapril/ hydrochlorothiazide tab telmisartan/ amlodipine tab telmisartan/ hydrochlorothiazide tab trandolapril/ verapamil ER tab valsartan/ hydrochlorothiazide tab SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab VASODILATORS hydralazine inj hydralazine tab minoxidil tab 8

ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AZACTAM/ DEXTROSE INJ aztreonam inj baciim inj colistimethate inj DALVANCE INJ metronidazole cap metronidazole tab metronidazole/ nacl inj NEBUPENT NEB PENTAM INJ tinidazole tab trimethoprim tab vancomycin cap vancomycin inj ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole/ trimethoprim DS tab SULFAMETHOXAZOLE/ TRIMETHOPRIM INJ sulfamethoxazole/ trimethoprim susp sulfamethoxazole/ trimethoprim tab ANTIPROTOZOAL AGENTS ALINIA SUSP ALINIA TAB atovaquone susp CARBAPENEMS DORIBAX INJ imipenem/ cilastatin inj INVANZ INJ meropenem inj CHLORAMPHENICOLS CHLORAMPHENICAL INJ CYCLIC LIPOPEPTIDES CUBICIN INJ GLYCYLCYCLINES TYGACIL INJ LEPROSTATICS dapsone tab LINCOSAMIDES clindamycin cap clindamycin inj clindamycin soln LINCOCIN INJ OXAZOLIDINONES 9 ST QL=56 Caps/0 Days NM

linezolid IV soln NM linezolid tab NM SIVEXTRO INJ NM QL=6 Injections/5 Days SIVEXTRO TAB NM QL=6 Tabs/5 Days ZYVOX INJ NM ZYVOX SUSP NM ZYVOX TAB NM POLYMYXINS polymyxin B inj STREPTOGRAMINS SYNERCID INJ ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone/ proguanil tab COARTEM TAB ANTIMALARIALS chloroquine tab DARAPRIM TAB hydroxychloroquine tab mefloquine tab PRIMAQUINE TAB quinine sulfate cap ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS GUANIDINE TAB MESTINON TIMESN TAB pyridostigmine tab ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS RIFAMATE CAP RIFATER TAB ANTIMYCOBACTERIAL AGENTS CASTAT INJ ethambutol tab isoniazid inj isoniazid syrup isoniazid tab SER GRANULE PRIFTIN TAB pyrazinamide tab rifabutin cap rifampin cap rifampin inj TRECATOR TAB 0

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS BICNU INJ BUSULFEX INJ carboplatin inj cisplatin inj CYCLOPHOSPHAMIDE CAP GLEOSTINE CAP HEXALEN CAP NM IFEX INJ ifosfamide inj LEUKERAN TAB LOMUSTINE CAP melphalan inj MYSTARGEN INJ oxaliplatin inj TREANDA INJ NM NSO ZANOSAR INJ ANTIMETABOLITES adrucil inj ALIMTA INJ ARRANON INJ azacitidine inj cladribine inj CLOLAR INJ cytarabine inj decitabine inj fludarabine inj fluorouracil inj FOLOTYN INJ NM NSO gemcitabine inj mercaptopurine tab methotrexate inj methotrexate PF inj methotrexate tab PURIXAN SUSP TABLOID TAB TREXALL TAB ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ NM ZALTRAP INJ NM NSO ANTINEOPLASTIC - ANTIBODIES ARZERRA INJ ERBITUX SOLN

HERCEPTIN INJ KADCYLA INJ KEYTRUDA INJ OPDIVO INJ PERJETA INJ RITUXAN INJ VECTIBIX INJ YERVOY INJ ANTINEOPLASTIC - HEDGEHOG THWAY INHIBITORS ERIVEDGE CAP ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole tab bicalutamide tab ELIGARD INJ EMCYT CAP exemestane tab FARESTON TAB FASLODEX INJ FIRMAGON INJ flutamide cap letrozole tab leuprolide inj LUPRON DEPOT (3 MONTH) KIT.5MG,.5MG LUPRON DEPOT ( MONTH) KIT 30MG LUPRON DEPOT (6 MONTH) KIT 5MG LUPRON DEPOT INJ LYSODREN TAB megestrol acetate susp megestrol acetate tab NILANDRON TAB SOLTAMOX ORAL SOLN tamoxifen citrate tab TRELSTAR DEPOT MIXJECT INJ TRELSTAR LA MIXJECT INJ TRELSTAR MIXJECT INJ XTANDI CAP ZYTIGA TAB ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP ANTINEOPLASTIC ANTIBIOTICS bleomycin sulfate inj COSMEGEN INJ 0.5MG daunorubicin inj DAUNOXOME INJ doxorubicin inj NM NM NSO NM NSO NM NSO NM NSO NSO NM NSO NM NM NM NSO NM NM NM NSO NSO NSO NM NSO QL=0 Caps/30 Days NM NSO NM NSO

epirubicin inj idarubicin inj mitomycin inj mitoxantrone inj ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DISPERZ TAB AFINITOR TAB BELEODAQ INJ BOSULIF TAB CAPRELSA TAB COMETRIQ CK FARYDAK CAP GILOTRIF TAB GLEEVEC TAB IBRANCE CAP ICLUSIG TAB IMBRUVICA CAP INLYTA TAB ISTODAX INJ JAKAFI TAB LENVIMA CAP THERAPY CK LYNRZA CAP MEKINIST TAB NEXAVAR TAB SPRYCEL TAB STIVARGA TAB SUTENT CAP TAFINLAR CAP TARCEVA TAB TASIGNA CAP TORISEL SOLN TYKERB TAB VELCADE INJ VOTRIENT TAB XALKORI CAP ZELBORAF TAB ZOLINZA CAP ZYDELIG TAB ZYKADIA CAP ANTINEOPLASTIC ENZYMES ERWINAZE INJ ONCASR INJ ANTINEOPLASTICS MISC. ACTIMMUNE INJ dacarbazine inj 3 NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO NM NSO NM NSO NM NSO QL=60 Tabs/30 Days NM NSO NM NSO NM NSO LD NM NSO NM NSO NM NSO QL=0 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO LD NM NSO NM NM NSO NM NSO NM NSO NM NSO NSO NM NSO NM NSO

hydroxyurea cap INTRON-A INJ MATULANE CAP PROLEUKINE IV SOLN SYLATRON INJ SYNRIBO INJ TARGRETIN CAP tretinoin cap TRISENOX INJ UVADEX SOLN CHEMOTHERAPY ADJUNCTS ELITEK INJ KEPIVANCE INJ CHEMOTHERAPY RESCUE/ ANTIDOTE AGENTS amifostine inj dexrazoxane inj FUSILEV INJ leucovorin inj leucovorin tab LEVOLEUCOVORIN INJ mesna inj MESNEX TAB MITOTIC INHIBITORS ABRAXANE SUSP DOCEFREZ INJ DOCETAXEL INJ ETOPOPHOS INJ etoposide inj HALAVEN INJ IXEMPRA INJ JEVTANA INJ paclitaxel inj TAXOTERE INJ toposar inj vinblastine inj vincasar PFS inj vincristine inj vinorelbine inj TOPOISOMERASE I INHIBITORS irinotecan inj topotecan inj ANTIRKINSON AGENTS ANTIRKINSON ADJUVANTS carbidopa tab NM NM NSO NM NM NSO NM NM NM NM NM NM

ANTIRKINSON ANTICHOLINERGICS benztropine inj benztropine tab trihexyphenidyl soln trihexyphenidyl tab ANTIRKINSON COMT INHIBITORS entacapone tab TASMAR TAB tolcapone tab ANTIRKINSON DOMINERGICS amantadine cap amantadine syrup APOKYN INJ bromocriptine cap bromocriptine tab CARBIDO/ ENTACAPONE/ LEVODO TAB carbidopa/ levodopa ER tab carbidopa/ levodopa ODT carbidopa/ levodopa tab NEUPRO TCH pramipexole ER tab pramipexole tab ropinirole ER tab ropinirole tab STALEVO TAB ANTIRKINSON MONOAMINE OXIDASE INHIBITORS AZILECT TAB selegiline cap selegiline tab ANTIPSYCHOTICS/ ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate cap lithium carbonate ER tab lithium carbonate tab lithium citrate soln ANTIPSYCHOTICS - MISC. EQUETRO CAP GEODON INJ LATUDA TAB NSO QL=30 Tabs/30 Days ziprasidone cap BENZISOXAZOLES FANAPT TAB NSO FANAPT TAB TITRATION CK NSO INVEGA SUSTENNA INJ NSO 5

INVEGA TAB RISPERDAL CONSTA INJ risperidone ODT risperidone soln risperidone tab BUTYROPHENONES haloperidol decanoate inj haloperidol inj haloperidol oral conc haloperidol tab DIBENZAPINES CLOZAPINE ODT clozapine tab FAZACLO TAB loxapine cap olanzapine inj olanzapine ODT olanzapine tab quetiapine tab SAPHRIS SL TAB SEROQUEL XR TAB VERSACLOZ SUSP ZYPREZA INJ PHENOTHIAZINES chlorpromazine inj chlorpromazine tab compro supp FLUPHENAZINE DECANOATE INJ fluphenazine elixir FLUPHENAZINE INJ fluphenazine oral conc fluphenazine tab perphenazine tab prochlorperazine edisylate inj prochlorperazine supp prochlorperazine tab thioridazine tab trifluoperazine tab QUINOLINONE DERIVATIVES ABILIFY MAINTENA INJ ABILIFY TAB aripiprazole tab THIOXANTHENES thiothixene cap 6 NSO NSO QL=60 Tabs/30 Days NSO QL=60 Tabs/30 Days QL=60 Tabs/30 Days

ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID %* chlorhexidine gluconate liquid %* CHLORHEXIDINE GLUCONATE DS %* chlorhexidine gluconate soln 0%* 3 ANTIVIRALS ANTIRETROVIRALS abacavir tab abacavir/ lamivudine/ zidovudine tab APTIVUS CAP APTIVUS SOLN ATRIPLA TAB COMPLERA TAB CRIXIVAN CAP didanosine cap EDURANT TAB EMTRIVA CAP EMTRIVA SOLN EPIVIR HBV SOLN EPIVIR SOLN EPZICOM TAB EVOTAZ TAB FUZEON INJ INTELENCE TAB INVIRASE CAP INVIRASE TAB ISENTRESS CHEW TAB ISENTRESS POWDER CK ISENTRESS TAB KALETRA SOLN KALETRA TAB lamivudine oral soln lamivudine tab lamivudine/ zidovudine tab LEXIVA SUSP LEXIVA TAB nevirapine ER tab 00mg nevirapine tab NORVIR CAP NORVIR SOLN NORVIR TAB PREZCOBIX TAB PREZISTA SUSP QL=0 ml/365 Days QL=0 ml/30 Days QL=0 ml/30 Days NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM 7

PREZISTA TAB RESCRIPTOR TAB RETROVIR INJ REYATAZ CAP REYATAZ POWDER CKET SELZENTRY TAB stavudine cap stavudine soln STRIBILD TAB SUSTIVA CAP SUSTIVA TAB TIVICAY TAB TRIUMEQ TAB TRUVADA TAB TYBOST TAB VIDEX SOLN VIRACEPT TAB VIRAMUNE SUSP VIRAMUNE XR TAB 00MG VIREAD POWDER VIREAD TAB VITEKTA TAB ZIAGEN SOLN zidovudine cap zidovudine syrup zidovudine tab CMV AGENTS cidofovir inj FOSCARNET INJ ganciclovir inj VALCYTE SOLN VALCYTE TAB valganciclovir tab 50mg HETITIS AGENTS adefovir tab BARACLUDE SOLN BARACLUDE TAB entecavir tab HARVONI TAB moderiba tab 00mg MODERIBA TAB 00MG, 600MG OLYSIO TAB PEG-INTRON INJ PEGASYS INJ PEGASYS PROCLICK INJ 8 NM NM NM NM NM QL=30 Tabs/30 Days NM QL=60 Tabs/30 Days NM QL=30 Tabs/30 Days NM NM NM NM NM NM NM NM QL=30 Tabs/30 Days NM NM NM NM NM

ribasphere cap ribasphere tab ribavirin cap ribavirin tab SOVALDI TAB TYZEKA TAB HERPES AGENTS acyclovir cap acyclovir inj acyclovir susp acyclovir tab famciclovir tab valacyclovir tab INFLUENZA AGENTS RELENZA DISKHALER rimantadine tab TAMIFLU CAP 30MG TAMIFLU CAP 5MG, 75MG TAMIFLU SUSP RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE INHALATION SOLN ASSORTED CLASSES CHELATING AGENTS CUPRIMINE CAP DEPEN TITRATABS SYPRINE CAP IMMUNOMODULATORS REVLIMID CAP.5MG, 0MG REVLIMID CAP 5MG, 0MG, 5MG, 5MG THALOMID CAP IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL CAP ATGAM INJ AZASAN TAB azathioprine tab CELLCEPT IV INJ CELLCEPT SUSP cyclosporine cap cyclosporine inj cyclosporine modified cap CYCLOSPORINE MODIFIED CAP 50MG cyclosporine modified soln gengraf cap gengraf soln 9 NM QL=30 Tabs/30 Days QL=56 Blisters/80 Days QL=8 Caps/80 Days QL=8 Caps/80 Days QL=6 Bottles/80 Days NM NSO QL=30 Caps/30 Days LD NM NSO QL=30 Caps/30 Days NM NSO NM

mycophenolate cap mycophenolate sodium tab mycophenolate susp mycophenolate tab NULOJIX INJ PROGRAF INJ RAMUNE SOLN RAMUNE TAB SANDIMMUNE SOLN SIMULECT INJ sirolimus cap sirolimus tab tacrolimus cap THYMOGLOBULIN INJ ZORTRESS TAB IRRIGATION SOLUTIONS lactated ringers irrigation physiolyte irrigation soln physiosol irrigation soln ringers irrigation sterile water irrigation LYMPHATIC AGENTS SYLVANT INJ POTASSIUM REMOVING RESINS kionex powder sodium polystyrene sulfonate susp BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol tab labetalol inj labetalol tab BETA BLOCKERS CARDIO-SELECTIVE acebutolol cap atenolol tab betaxolol tab bisoprolol tab BYSTOLIC TAB metoprolol ER tab metoprolol inj metoprolol tab BETA BLOCKERS NON-SELECTIVE INNOPRAN XL CAP nadolol tab pindolol tab 30 NM NM NSO NM

propranolol ER cap propranolol inj propranolol oral soln propranolol tab sorine tab sotalol tab timolol maleate tab BIOLOGICALS MISC BIOLOGICALS MISC ADAGEN INJ CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS afeditab CR tab amlodipine tab CARDENE INJ cartia XT cap dilt-xr cap diltiazem CD cap diltiazem ER cap diltiazem inj diltiazem tab felodipine ER tab isradipine cap matzim LA tab nicardipine cap nicardipine inj nifedical XL tab nifedipine cap nifedipine ER tab nimodipine cap nisoldipine ER tab taztia-xt cap verapamil ER cap verapamil ER tab verapamil inj verapamil tab CARDIOTONICS CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tab 0.5mg digoxin tab 0.5mg CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS 3 NM QL=30 Tabs/30 Days

amlodipine/ atorvastatin tab BIDIL TAB PROSTAGLANDIN VASODILATORS REMODULIN INJ NM TYVASO INHALATION SOLN NM VENTAVIS INHALATION SOLN NM PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB NM OPSUMIT TAB NM QL=30 Tabs/30 Days TRACLEER TAB LD NM PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB NM sildenafil tab CEPHALOSPORINS CEPHALOSPORINS - ST GENERATION cefadroxil cap cefadroxil susp cefadroxil tab cefazolin inj CEFAZOLIN/ D5W INJ cephalexin cap cephalexin susp cephalexin tab CEPHALOSPORINS - ND GENERATION cefaclor cap CEFOTETAN INJ cefoxitin inj CEFOXITIN/ DEXTROSE INJ cefprozil susp cefprozil tab cefuroxime inj cefuroxime tab CEPHALOSPORINS - 3RD GENERATION CEDAX SUSP cefdinir cap cefdinir susp cefotaxime inj cefpodoxime susp cefpodoxime tab ceftazidime inj CEFTAZIDIME/ DEXTROSE INJ ceftriaxone inj SUPRAX CAP tazicef inj 3

CEPHALOSPORINS - TH GENERATION CEFEPIME INJ cefepime inj CEPHALOSPORINS - 5TH GENERATION TEFLARO INJ CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL amethia tab apri tab aranelle tab ashlyna 9 day tab aubra tab aviane tab balziva tab BEYAZ TAB briellyn tab cryselle-8 tab cyclafem tab delyla tab desogestrel/ ethinyl estradiol tab emoquette tab enpresse-8 tab falmina tab gildagia tab gildess.5/ 30 tab gildess FE tab introvale tab junel FE tab junel tab kariva tab kelnor tab larin FE tab larin tab leena tab lessina levonest tab levonorgestrel/ ethinyl estradiol tab levora-8 tab low-ogestrel tab lutera tab marlissa tab microgestin tab mononessa tab NATAZIA TAB 33

necon tab norethindrone/ ethinyl estradiol FE chew tab norethindrone/ ethinyl estradiol FE tab nortrel tab orsythia tab ORTHO TRI-CYCLEN LO TAB pimtrea tab pirmella tab portia-8 tab previfem tab QUARTETTE TAB quasense tab reclipsen tab sprintec-8 tab sronyx tab tarina FE tab tri-legest FE tab tri-previfem tab tri-sprintec tab trinessa tab trivora-8 tab velivet tab vyfemla tab wymzya FE chew tab YASMIN TAB zenchent FE tab zenchent tab zovia tab COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane patch COMBINATION CONTRACEPTIVES - VAGINAL NUVARING EMERGENCY CONTRACEPTIVES ELLA TAB PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone inj PROGESTIN CONTRACEPTIVES - ORAL camila tab deblitane tab errin tab jolivette tab lyza tab nora-be tab norethindrone tab 3

norlyroc tab sharobel tab CORTICOSTEROIDS GLUCOCORTICOSTEROIDS A-HYDROCORT INJ budesonide EC cap CORTEF TAB cortisone tab dexamethasone conc dexamethasone elixir dexamethasone inj dexamethasone tab hydrocortisone tab KENALOG INJ MEDROL TAB MG methylprednisolone acetate inj methylprednisolone dose pack methylprednisolone sodium succinate inj methylprednisolone tab ORAPRED ODT prednisolone ODT prednisolone sodium phosphate soln PREDNISONE INTENSOL CONC prednisone soln prednisone tab SOLU-CORTEF INJ triamcinolone acetonide inj UCERIS TAB MINERALOCORTICOIDS fludrocortisone tab COUGH/ COLD/ ALLERGY ANTITUSSIVES benzonatate cap 00mg, 00mg* dextromethorphan liquid 5mg/ 5ml* dextromethorphan syrup 7.5mg/ 5ml, 0mg/ 5ml, 5mg/ 5ml* hydrocodone/ homatropine syrup 5-.5mg/ 5ml* ZONATUSS CAP 50MG* COUGH/ COLD/ ALLERGY COMBINATIONS brompheniramine/ pseudoephedrine elixir -5mg/ 5ml* chlorpheniramine DM liquid -5mg/ 5ml* chlorpheniramine/ pseudoephedrine tab -60mg* dextromethorphan/ guaifenesin liquid 0-00mg/ 5ml* dextromethorphan/ guaifenesin liquid 0-00mg/ 5ml* 35 NM QL=30 Tabs/30 Days QL=90 Caps/30 Days QL=90 Caps/30 Days

dextromethorphan/ guaifenesin liquid 5-00mg/ 5ml* dextromethorphan/ guaifenesin liquid 30-00mg/ 5ml* dextromethorphan/ guaifenesin liquid 5-00mg/ 5ml* dextromethorphan/ guaifenesin syrup 0-00mg/ 5ml* ED A-HIST LIQUID -0MG/ 5ML* guaifenesin/ codeine soln 00-0mg/ 5ml* LOHIST-D LIQUID -30MG* loratadine-d tab 0-0mg* loratadine-d tab 5-0mg* phenylephrine chlorpheniramine soln 0--5mg/ 5ml, 0--5mg/ 5ml* phenylephrine DM/ guaifenesin liquid 5-0-00mg/ 5ml* phenylephrine/ guaifenesin liquid 5-00mg/ 5ml* promethazine DM syrup 6.5-5mg/ 5ml* promethazine/ codeine syrup 6.5-0mg/ 5ml* pseudoephedrine DM/ guaifenesin liquid 30-0-00mg/ 5ml* pseudoephedrine/ brompheniramine DM elixir 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM liquid 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM syrup 30--0mg/ 5ml* pseudoephedrine/ doxylamine/ DM/ acetaminophen liquid 60-.5-30-000mg/ 30ml* pseudoephedrine/ guaifenesin liquid 7.5-50mg/ ml* pseudoephedrine/ guaifenesin syrup 30-00mg/ 5ml* triprolidine/ pseudoephedrine syrup.5-30mg/ 5ml* triprolidine/ pseudoephedrine tab.5-60mg* EXPECTORANTS guaifenesin liquid 00mg/ 5ml, 00mg/ 5ml* guaifenesin tab 00mg* MUCOLYTICS acetylcysteine soln DERMATOLOGICALS ACNE PRODUCTS adapalene cream adapalene gel amnesteem cap avita cream avita gel benzoyl peroxide gel 0%* BENZOYL PEROXIDE GEL.5%* benzoyl peroxide liquid 5%, 0%* QL=60 Tabs/30 Days QL=60 Tabs/30 Days 36

BENZOYL PEROXIDE LOTION 5%, 0%* claravis cap clindamycin foam clindamycin phosphate gel clindamycin phosphate lotion clindamycin phosphate soln clindamycin phosphate swab clindamycin/ benzoyl peroxide gel DIFFERIN LOTION EPIDUO GEL ery pad erythromycin topical gel erythromycin topical soln erythromycin/ benzoyl peroxide gel myorisan cap RETIN-A MICRO GEL sulfacetamide sodium lotion TRETIN-X CREAM tretinoin cream tretinoin gel ZENATANE CAP zenatane cap ANTIBIOTICS - TOPICAL bacitracin ointment 500unit/ gm* bacitracin zinc ointment 500unit/ gm* bacitracin/ polymyxin B ointment* gentamicin sulfate cream gentamicin sulfate ointment mupirocin cream mupirocin ointment ANTIFUNGALS - TOPICAL ciclopirox cream ciclopirox gel ciclopirox nail lacquer ciclopirox shampoo ciclopirox susp clotrimazole cream clotrimazole soln clotrimazole/ betamethasone cream clotrimazole/ betamethasone lotion econazole nitrate cream ERTACZO CREAM ketoconazole cream ketoconazole shampoo ketoconazole shampoo %* 37

miconazole cream %* miconazole powder %* naftifine cream NAFTIN CREAM NAFTIN GEL nyamyc powder nystatin cream nystatin ointment nystatin topical powder nystatin/ triamcinolone cream nystatin/ triamcinolone ointment nystop topical powder OXISTAT CREAM OXISTAT LOTION tolnaftate cream %* tolnaftate soln %* ANTIHISTAMINES-TOPICAL diphenhydramine cream %* diphenhydramine gel %* diphenhydramine soln %* diphenhydramine/ zinc acetate cream -0.%* ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium topical soln PENNSAID SOLN VOLTAREN GEL QL=5 Tubes/ Days ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL CARAC CREAM diclofenac gel FLUOROURACIL CREAM fluorouracil cream fluorouracil soln NRETIN GEL NM PICATO GEL 0.05% QL=3 Tubes/0 Days PICATO GEL 0.05% QL= Tubes/0 Days VALCHLOR GEL NM NSO QL= Tubes/30 Days ANTIPRURITICS - TOPICAL prudoxin cream ANTIPSORIATICS 8-MOP CAP acitretin cap calcipotriene cream calcipotriene ointment calcipotriene soln CALCITRIOL OINTMENT 38

methoxsalen cap STELARA INJ TAZORAC CREAM TAZORAC GEL VECTICAL OINTMENT ANTISEBORRHEIC PRODUCTS selenium sulfide shampoo ANTIVIRALS - TOPICAL DENAVIR CREAM ZOVIRAX OINTMENT BURN PRODUCTS silver sulfadiazine cream ssd cream SULFAMYLON CREAM CORTICOSTEROIDS - TOPICAL ala cort cream alclometasone cream alclometasone ointment amcinonide cream AMCINONIDE OINTMENT augmented betamethasone cream augmented betamethasone gel augmented betamethasone lotion augmented betamethasone ointment betamethasone dipropionate cream betamethasone dipropionate gel betamethasone dipropionate lotion betamethasone valerate cream betamethasone valerate foam betamethasone valerate lotion betamethasone valerate ointment calcipotriene/ betamethasone ointment clobetasol E cream clobetasol gel clobetasol lotion clobetasol ointment clobetasol shampoo clobetasol soln clobetasol topical foam clobetasol topical spray cormax topical soln DESONATE GEL desonide cream desonide lotion desonide ointment 39 NM

desoximetasone cream DESOXIMETASONE CREAM 0.05% desoximetasone gel desoximetasone ointment diflorasone cream diflorasone ointment fluocinolone acetonide cream fluocinolone acetonide oil fluocinolone acetonide ointment fluocinolone acetonide soln fluocinonide cream fluocinonide E cream fluocinonide gel fluocinonide ointment fluocinonide soln fluticasone propionate cream fluticasone propionate lotion fluticasone propionate ointment halobetasol cream halobetasol ointment hydrocortisone acetate ointment %* hydrocortisone butyrate lipo cream hydrocortisone butyrate ointment hydrocortisone butyrate soln hydrocortisone cream hydrocortisone cream 0.5%* hydrocortisone lotion hydrocortisone lotion %* hydrocortisone ointment hydrocortisone ointment 0.5%* hydrocortisone soln %* hydrocortisone valerate cream hydrocortisone valerate ointment hydrocortisone/ aloe cream %* LOCOID CREAM LOCOID LOTION LOCOID OINTMENT LOCOID SOLN lokara lotion mometasone furoate cream mometasone furoate lotion mometasone furoate ointment prednicarbate ointment prenicarbate cream TOPICORT CREAM 0 QL= Tubes/30 Days QL= Tubes/30 Days QL= Tubes/30 Days

triamcinolone cream triamcinolone lotion triamcinolone ointment TRIANEX OINTMENT triderm cream u-cort cream EMOLLIENTS ammonium lactate cream ammonium lactate lotion ENZYMES - TOPICAL SANTYL OINTMENT IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream ZYCLARA CREAM IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL CREAM PROTOPIC OINTMENT tacrolimus ointment KERATOLYTIC/ ANTIMITOTIC AGENTS podofilox soln salicylic acid soln 3%* LOCAL ANESTHETICS - TOPICAL lidocaine gel lidocaine ointment lidocaine patch lidocaine soln lidocaine/ prilocaine cream MISC. TOPICAL aluminum acetate soln* CALAMINE LOTION* zinc oxide ointment 0%* ROSACEA AGENTS FINACEA GEL metronidazole cream metronidazole gel metronidazole lotion SCABICIDES & PEDICULICIDES EURAX CREAM lice treatment creme rinse* lice treatment shampoo* lindane lotion lindane shampoo malathion lotion permethrin cream QL=90 Patches/30 Days

permethrin creme rinse %* SPINOSAD SUSP WOUND CARE PRODUCTS REGRANEX GEL WOUND CLEANSER LIQUID* DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS DIASTIX URINE TEST STRIP* KETOCARE URINE TEST STRIP* DIGESTIVE AIDS DIGESTIVE ENZYMES CREON CAP NCREAZE CAP ULTRESA CAP DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide inj acetazolamide SR cap acetazolamide tab methazolamide tab DIURETIC COMBINATIONS amiloride/ hydrochlorothiazide tab spironolactone/ hydrochlorothiazide tab triamterene/ hydrochlorothiazide cap triamterene/ hydrochlorothiazide tab LOOP DIURETICS bumetanide inj bumetanide tab EDECRIN TAB furosemide inj furosemide soln furosemide tab torsemide tab POTASSIUM SRING DIURETICS amiloride tab DYRENIUM CAP spironolactone tab THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide inj chlorothiazide tab chlorthalidone tab DIURIL SUSP hydrochlorothiazide cap QL= Tubes/5 Days QL= Bottles/30 Days ST ST

hydrochlorothiazide tab indapamide tab METHYCLOTHIAZIDE TAB metolazone tab ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS ACTONEL TAB alendronate soln alendronate tab ALENDRONATE TAB 0MG calcitonin nasal spray etidronate disodium tab FORTEO INJ NM FORTICAL NASAL SPRAY ibandronate inj ST ibandronate tab ST QL= Tabs/30 Days MIACALCIN INJ NATRA INJ NM pamidronate inj MIDRONATE INJ 6MG/ ML PROLIA INJ risedronate sodium tab XGEVA INJ zoledronic acid inj NM ZOMETA INJ MG/ 00ML NM GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT INJ NM GROWTH HORMONES NORDITROPIN INJ NM HORMONE RECEPTOR MODULATORS raloxifene tab INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ LD NM LHRH/ GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT-PED KIT NM SYNAREL NASAL SOLN NM METABOLIC MODIFIERS ALDURAZYME INJ NM calcitriol cap calcitriol inj calcitriol soln doxercalciferol cap doxercalciferol inj ELAPRASE INJ 3

FABRAZYME INJ KUVAN POWDER CKET KUVAN TAB levocarnitine inj levocarnitine soln levocarnitine tab LUMIZYME INJ MYOZYME INJ NAGLAZYME INJ ORFADIN CAP paricalcitol cap RICALCITOL INJ SENSIR TAB sodium phenylbutyrate powder ZEMPLAR INJ POSTERIOR PITUITARY HORMONES desmopressin acetate nasal soln desmopressin inj desmopressin nasal spray desmopressin tab STIMATE NASAL SOLN PROLACTIN INHIBITORS cabergoline tab SOMATOSTATIC AGENTS octreotide inj SIGNIFOR INJ SOMATULINE DEPOT INJ ESTROGEN COMBINATIONS ANGELIQ TAB COMBITCH estradiol/ norethindrone tab ethinyl estradiol/ norethindrone acetate tab jinteli tab lopreeza tab mimvey lo tab mimvey tab PREMPHASE TAB PREMPRO TAB ESTROGENS ELESTRIN GEL estradiol inj estradiol patch estradiol tab ESTROGENS NM NM NM NM NM NM NM NM NM QL=60 Vials/30 Days NM

estradiol valerate inj estropipate tab PREMARIN TAB VIVELLE-DOT TCH FLUOROQUINOLONES FLUOROQUINOLONES AVELOX INJ ciprofloxacin ER tab ciprofloxacin IV soln ciprofloxacin oral susp ciprofloxacin tab ciprofloxacin/ D5W inj levofloxacin inj levofloxacin soln levofloxacin tab moxifloxacin tab ofloxacin tab GASTROINTESTINAL AGENTS - MISC. ANTIFLATULENTS simethicone cap 5mg* simethicone susp 0mg/ 0.6ml* GALLSTONE SOLUBILIZING AGENTS CHENODAL TAB ursodiol cap ursodiol tab GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium oral soln GASTROINTESTINAL STIMULANTS metoclopramide inj metoclopramide soln metoclopramide tab INFLAMMATORY BOWEL AGENTS APRISO CAP ASACOL HD TAB balsalazide cap CANASA SUPP CIMZIA INJ DELZICOL CAP LIALDA TAB mesalamine kit PENTASA CAP REMICADE INJ sulfasalazine tab sulfazine EC tab 5 NM ST NM

INTESTINAL ACIDIFIERS enulose soln generlac soln IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron tab LINZESS CAP QL=30 Caps/30 Days LOTRONEX TAB PERIPHERAL OPIOID RECEPTOR ANTAGONISTS RELISTOR INJ PHOSPHATE BINDER AGENTS AURYXIA TAB calcium acetate cap FOSRENOL CHEW TAB FOSRENOL POWDER CK PHOSLYRA SOLN RENVELA CKET RENVELA/ SEVELAMER CARBONATE TAB GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS potassium citrate CR tab potassium citrate ER tab 5meq UROCIT-K 5 TAB CYSTINOSIS AGENTS CYSTAGON CAP GENITOURINARY IRRIGANTS neomycin/ polymyxin B GU irrigation soln sodium chloride irrigation soln INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP PROSTATIC HYPERTROPHY AGENTS alfuzosin ER tab AVODART CAP finasteride tab JALYN CAP RAFLO CAP tamsulosin cap URINARY STONE AGENTS LITHOSTAT TAB THIOLA TAB GOUT AGENTS GOUT AGENT COMBINATIONS colchicine/ probenecid tab GOUT AGENTS 6

allopurinol tab COLCHICINE TAB COLCRYS TAB ULORIC TAB URICOSURICS probenecid tab HEMATOLOGICAL AGENTS - MISC. BRADYKININ B RECEPTOR ANTAGONISTS FIRAZYR INJ COMPLEMENT INHIBITORS BERINERT INJ CINRYZE INJ RUCONEST INJ HEMATORHEOLOGIC AGENTS pentoxifylline ER tab PLATELET AGGREGATION INHIBITORS AGGRENOX CAP anagrelide cap BRILINTA TAB cilostazol tab clopidogrel tab 75mg dipyridamole tab EFFIENT TAB ticlopidine tab HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CEREZYME INJ ZAVESCA CAP AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP COBALAMINS cyanocobalamin inj 000mcg/ ml* FOLIC ACID/ FOLATES folic acid tab mg* HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 00MCG, 50MCG, 00MCG, 300MCG, 500MCG ARANESP INJ 0MCG, 5MCG, 0MCG, 60MCG LEUKINE INJ NEULASTA INJ NEUMEGA INJ NEUPOGEN INJ PROCRIT INJ ST NM NM NM NM NM NM NM ST ST NM NM NM NM NM 7

PROMACTA TAB IRON ferrous sulfate EC tab 35mg* ferrous sulfate elixir 0mg/ 5ml* ferrous sulfate soln 75mg/ ml* FERROUS SULFATE SYRUP 300MG/ 5ML* ferrous sulfate tab 35mg* STEM CELL MOBILIZERS MOZOBIL INJ HEMOSTATICS HEMOSTATICS - SYSTEMIC tranexamic acid inj tranexamic acid tab HYPNOTICS ANTIHISTAMINE HYPNOTICS diphenhydramine (sleep) cap 50mg* diphenhydramine (sleep) tab 50mg* BARBITURATE HYPNOTICS BUTISOL TAB phenobarbital elixir phenobarbital tab SECONAL CAP NON-BARBITURATE HYPNOTICS estazolam tab eszopiclone tab flurazepam cap temazepam cap triazolam tab zaleplon cap zolpidem tab LAXATIVES BULK LAXATIVES calcium polycarbophil tab 65mg* METAMUCIL SMOOTH POWDER CKET 8%* METAMUCIL WAFER* psyllium cap 0.5gm* psyllium powder 8.3%, 30.9%, 9%, 58.6%* PSYLLIUM POWDER CKET 00%* LAXATIVE COMBINATIONS gavilyte-c powder gavilyte-g soln gavilyte-n powder GOLYTELY CKET NM QL=00 Tabs/00 Days QL=00 ml/00 Days QL=50 ml/50 Days QL=00 ml/00 Days QL=00 Tabs/00 Days NM NSO NSO NSO NSO QL=30 Tabs/30 Days QL=90 Caps/365 Days QL=90 Tabs/365 Days 8

METAMUCIL PLUS CALCIUM CAP* peg 3350/ electrolyte soln SUCLEAR KIT SUPREP BOWEL PREP trilyte soln LAXATIVES - MISCELLANEOUS constulose soln glycerin supp.gm* lactulose soln polyethylene glycol powder 3350 sorbitol soln 70%* LUBRICANT LAXATIVES MINERAL OIL* SALINE LAXATIVES magnesium citrate soln* magnesium hydroxide susp 00mg/ 5ml* sodium phosphate enema* STIMULANT LAXATIVES bisacodyl DR tab 5mg* bisacodyl supp 0mg* senna syrup 8.8mg/ 5ml* senna tab 8.6mg* SURFACTANT LAXATIVES COLACE CAP 50MG* docusate cap 00mg, 50mg* docusate enema 83mg* docusate sodium liquid 50mg/ 5ml* docusate sodium syrup 60mg/ 5ml* docusate tab 00mg* LOCAL ANESTHETICS-RENTERAL LOCAL ANESTHETICS - AMIDES lidocaine inj MACROLIDES AZITHROMYCIN azithromycin inj azithromycin susp azithromycin tab CLARITHROMYCIN clarithromycin ER tab clarithromycin susp clarithromycin tab ERYTHROMYCINS E.E.S GRANULES 9

e.e.s. tab ERY-TAB ERYPED SUSP ERYTHROCIN LACTOBIONATE INJ ERYTHROCIN STEARATE TAB erythromycin tab MEDICAL DEVICES BANDAGES-DRESSINGS-TAPE GAUZE D CONTRACEPTIVES CONDOMS* MISC. DEVICES ALCOHOL SWAB RENTERAL THERAPY SUPPLIES B-D INSULIN SYRINGE INSULIN SYRINGE (ALL OTHERS) NOVOFINE PEN NEEDLES PRECISION INSULIN SYRINGE RESPIRATORY THERAPY SUPPLIES SCER HOLDING CHAMBER* MIGRAINE PRODUCTS MIGRAINE COMBINATIONS CAFERGOT TAB MIGERGOT SUPP TREXIMET TAB MIGRAINE PRODUCTS dihydroergotamine inj DIHYDROERGOTAMINE NASAL SPRAY ERGOMAR TAB SEROTONIN AGONISTS IMITREX NASAL SPRAY naratriptan tab rizatriptan ODT rizatriptan tab sumatriptan inj SUMATRIPTAN NASAL SPRAY sumatriptan tab zolmitriptan ODT zolmitriptan tab ZOMIG NASAL SPRAY MINERALS & ELECTROLYTES BICARBONATES sodium lactate inj QL= Fills/30 Days ST QL=8 Tabs/30 Days QL= Bottles/30 Days QL= Sprays/30 Days QL=8 Tabs/30 Days QL=36 Tabs/60 Days QL=36 Tabs/60 Days QL=0 Injections/30 Days QL= Sprays/30 Days QL=8 Tabs/30 Days QL=8 Tabs/30 Days QL=8 Tabs/30 Days QL= Sprays/30 Days 50

CALCIUM calcium carbonate susp 50mg/ 5ml* calcium carbonate tab 600mg, 50mg* calcium chew tab 500mg* calcium citrate+vit D tab 35mg-00unit* calcium citrate+vit D tab 35mg-50unit* CALCIUM GLUBIONATE SYRUP.8MG/ 5ML* CALCIUM GLUCONATE TAB 500MG* calcium+d tab 50mg-5unit* calcium+d tab 500mg-00unit* calcium+d tab 600mg-00unit* calcium+d tab 600mg-00unit* calcium/ cholecalciferol tab 50mg-5unit* calcium/ cholecalciferol tab 500mg-5unit* calcium/ cholecalciferol tab 500mg-00unit* CITRACAL/ VITAMIN D TAB 50MG-00UNIT* vitamin D with calcium tab* CHLORIDE AMMONIUM CHLORIDE INJ ELECTROLYTE MIXTURES dextrose/ sodium chloride inj electrolyte oral soln* IONOSOL-B/ D5W INJ IONOSOL-MB/ D5W INJ ISOLYTE-S INJ ISOLYTE/ D5W INJ lactated ringers soln lactated ringers/ d5w inj normosol-m/ d5w inj NORMOSOL-R INJ NORMOSOL/ D5W INJ PLASMA-LYTE INJ PLASMA-LYTE/ D5W INJ POTASSIUM CHLORIDE (0MEQ)/ D5W/ NACL INJ potassium chloride/ d5w inj POTASSIUM CHLORIDE/ D5W/ LACTATED RINGERS SOLN POTASSIUM CHLORIDE/ D5W/ NACL INJ potassium chloride/ d5w/ nacl inj potassium chloride/ nacl inj ringers inj tpn electrolytes soln FLUORIDE sodium fluoride tab 5

MAGNESIUM magnesium oxide tab 00mg* magnesium sulfate inj POTASSIUM K-TAB ER TAB KLOR-CON M5 TAB klor-con tab potassium chloride ER cap potassium chloride ER tab potassium chloride inj meq potassium chloride soln SODIUM sodium chloride inj MOUTH/ THROAT/ DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine viscous soln ANTI-INFECTIVES - THROAT clotrimazole troche nystatin susp ANTISEPTICS - MOUTH/ THROAT chlorhexidine gluconate soln periogard soln STEROIDS - MOUTH/ THROAT triamcinolone in orabase paste THROAT PRODUCTS - MISC. cevimeline cap pilocarpine tab MULTIVITAMINS B-COMPLEX W/ C vitamin B complex w/ C cap* MULTIPLE VITAMINS W/ MINERALS multivitamin w/ minerals tab* MULTIVITAMINS multivitamin liquid* multivitamin tab* PED MV W/ IRON pediatric multivitamin w/ iron drops 0mg/ ml* PEDIATRIC MULTIPLE VITAMINS pediatric multivitamin soln 35mg/ ml* PEDIATRIC VITAMINS tri-vitamin pediatric drops* PRENATAL VITAMINS PRENATAL VITAMIN TAB 5 QL=00 Tabs/00 Days QL=00 ml/00 Days QL=00 Tabs/00 Days QL=50 ml/50 Days QL=50 ml/50 Days

PRENATAL VITAMIN TAB (OTC)* MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen tab carisoprodol tab chlorzoxazone tab cyclobenzaprine tab metaxalone tab METAXALONE TAB methocarbamol tab orphenadrine citrate inj orphenadrine ER tab tizanidine cap tizanidine tab DIRECT MUSCLE RELAXANTS dantrolene cap MUSCLE RELAXANT COMBINATIONS carisoprodol/ aspirin tab carisoprodol/ aspirin/ codeine tab NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENTS - MISC. saline nasal spray 0.65%* NASAL ANTIALLERGY ASTEPRO NASAL SPRAY cromolyn nasal soln 5.mg* TANASE NASAL SOLN NASAL ANTICHOLINERGICS ipratropium nasal spray NASAL STEROIDS flunisolide nasal spray QL= Bottles/5 Days fluticasone nasal spray QL= Bottles/5 Days NASONEX NASAL SPRAY QL= Bottles/5 Days triamcinolone nasal spray QL= Bottles/5 Days VERAMYST NASAL SPRAY QL= Bottles/5 Days SYMTHOMIMETIC DECONGESTANTS pseudoephedrine hr tab 0mg* pseudoephedrine liquid 5mg/ 5ml* pseudoephedrine tab 30mg, 60mg* NEUROMUSCULAR AGENTS ALS AGENTS riluzole tab NUTRIENTS CARBOHYDRATES 53

dextrose inj LIPIDS intralipid inj nutrilipid inj MISC. NUTRITIONAL SUBSTANCES omega-3 fatty acid cap 000mg, 00mg* PROTEINS AMINO ACID ORAL LIQUID* 3 AMINO ACID POWDER* 3 AMINOSYN II INJ AMINOSYN INJ AMINOSYN-HBC INJ AMINOSYN-PF INJ AMINOSYN-RF INJ AMINOSYN/ ELECTROLYTES INJ CLINIMIX E INJ CLINIMIX E/ DEXTROSE INJ CLINIMIX INJ clinisol SF inj FREAMINE HBC INJ heptamine inj NEPHRAMINE INJ PREMASOL SOLN 0% premasol soln 6% PROCALAMINE INJ PROSOL INJ TRAVASOL INJ TROPHAMINE INJ OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS artificial tears* LACRISERT OPHTH INSERT BETA-BLOCKERS - OPHTHALMIC betaxolol ophth soln BETIMOL OPHTH SOLN BETOPTIC-S OPHTH SUSP carteolol ophth soln COMBIGAN OPHTH SOLN dorzolamide/ timolol ophth soln ISTALOL OPHTH SOLN levobunolol ophth soln metipranolol ophth soln timolol maleate ophth gel timolol maleate ophth soln QL=60 Caps/30 Days 5

CYCLOPLEGIC MYDRIATICS atropine sulfate ophth soln MIOTICS PHOSPHOLINE IODIDE OPHTH SOLN pilocarpine ophth soln OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P OPHTH SOLN 0.% apraclonidine ophth soln brimonidine ophth soln IOPIDINE OPHTH SOLN % OPHTHALMIC ANTI-INFECTIVES AZASITE OPHTH SOLN bacitracin ophth ointment bacitracin/ polymyxin B ophth ointment BESIVANCE OPHTH SUSP ciprofloxacin ophth soln erythromycin ophth ointment gatifloxacin ophth soln gentak ophth ointment gentamicin ophth ointment gentamicin ophth soln levofloxacin ophth soln MOXEZA OPHTH SOLN NATACYN OPHTH SUSP neomycin/ bacitracin/ polymyxin ophth ointment neomycin/ polymyxin/ gramicidin ophth soln ofloxacin ophth soln polymyxin B/ trimethoprim ophth soln sulfacetamide sodium ophth ointment sulfacetamide sodium ophth soln tobramycin ophth soln trifluridine ophth soln VIGAMOX OPHTH SOLN ZIRGAN OPHTH GEL OPHTHALMIC DECONGESTANTS CLEAR EYES OPHTH SOLN* NAPHAZOLINE OPHTH SOLN naphazoline/ glycerin ophth soln* naphazoline/ pheniramine ophth soln* OPHTHALMIC IMMUNOMODULATORS RESTASIS EMULSION OPHTHALMIC LOCAL ANESTHETICS proparacaine ophth soln OPHTHALMIC STEROIDS 55 ST ST

ALREX OPHTH SUSP BLEPHAMIDE OPHTH SUSP dexamethasone sodium phosphate ophth soln DUREZOL OPHTH EMULSION fluorometholone ophth susp LOTEMAX OPHTH GEL LOTEMAX OPHTH OINTMENT LOTEMAX OPHTH SUSP MAXIDEX OPHTH SUSP neomycin/ polymyxin/ bacitracin/ hydrocortisone ophth ointment neomycin/ polymyxin/ dexamethasone ophth ointment neomycin/ polymyxin/ dexamethasone ophth soln neomycin/ polymyxin/ hydrocortisone ophth susp PRED MILD OPHTH SUSP PRED-G OPHTH SUSP PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN prednisolone susp sulfacetamide sodium/ prednisolone ophth soln TOBRADEX OPHTH OINTMENT tobramycin/ dexamethasone ophth soln VEXOL OPHTH SUSP ZYLET OPHTH SOLN OPHTHALMICS - MISC. ALOCRIL OPHTH SOLN ALOMIDE OPHTH SOLN azelastine ophth soln AZOPT OPHTH SUSP bromfenac ophth soln cromolyn sodium ophth soln CYSTARAN OPHTH SOLN diclofenac ophth soln dorzolamide ophth soln ENUCLENE OPHTH SOLN 0.5%* epinastine ophth soln flurbiprofen ophth soln ILEVRO OPHTH SUSP ketorolac ophth soln NEVANAC OPHTH SUSP TADAY OPHTH SOLN sodium chloride hypertonic ophth ointment 5%* sodium chloride hypertonic ophth soln 5%* PROSTAGLANDINS - OPHTHALMIC BIMATOPROST OPHTH SOLN 56 QL=5 ml/30 Days

latanoprost ophth soln LUMIGAN OPHTH SOLN TRAVATAN Z OPHTH SOLN TRAVOPROST OPHTH SOLN OTIC AGENTS OTIC AGENTS - MISCELLANEOUS acetic acid otic soln OTIC ANTI-INFECTIVES ofloxacin otic soln OTIC COMBINATIONS CIPRODEX OTIC SUSP COLY-MYCIN S OTIC SUSP CORTISPORIN-TC OTIC SUSP neomycin/ polymyxin/ hydrocortisone otic soln neomycin/ polymyxin/ hydrocortisone otic susp OTIC STEROIDS fluocinolone acetonide otic oil hydrocortisone/ acetic acid otic soln OXYTOCICS OXYTOCICS methylergonovine tab SSIVE IMMUNIZING AGENTS IMMUNE SERUMS BIVIGAM INJ FLEBOGAMMA INJ GAMASTAN S/ D INJ GAMMAGARD INJ GAMMAKED INJ GAMMAPLEX INJ GAMUNEX-C INJ OCTAGAM INJ PRIVIGEN INJ MONOCLONAL ANTIBODIES SYNAGIS INJ PENICILLINS AMINOPENICILLINS amoxicillin cap amoxicillin chew tab AMOXICILLIN CHEW TAB 50MG amoxicillin susp amoxicillin tab ampicillin cap ampicillin inj 57 QL=5 ml/30 Days QL=5 ml/30 Days QL=5 ml/30 Days QL=5 ml/30 Days NM NM NM NM NM

AMPICILLIN INJ 5MG ampicillin susp NATURAL PENICILLINS BICILLIN L-A INJ penicillin g potassium inj PENICILLIN G PROCAINE INJ PENICILLIN G SODIUM INJ PENICILLIN G/ DEXTROSE INJ penicillin v potassium soln penicillin v potassium tab PENICILLIN COMBINATIONS amoxicillin/ clavulanate chew tab amoxicillin/ clavulanate ER tab amoxicillin/ clavulanate susp amoxicillin/ clavulanate tab ampicillin/ sulbactam inj AUGMENTIN SUSP 5MG BICILLIN C-R INJ piperacillin/ tazobactam inj ZOSYN INJ PENICILLINASE-RESISTANT PENICILLINS dicloxacillin cap nafcillin inj NAFCILLIN/ DEXTROSE INJ oxacillin inj OXACILLIN/ DEXTROSE INJ PROGESTINS PROGESTINS medroxyprogesterone tab norethindrone tab progesterone cap PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate tab disulfiram tab ANTI-CATAPLECTIC AGENTS XYREM ORAL SOLN NM ANTIDEMENTIA AGENTS donepezil ODT QL=30 Tabs/30 Days donepezil tab QL=60 Tabs/30 Days donepezil tab 3mg ST QL=30 Tabs/30 Days EXELON TCH galantamine ER cap galantamine soln 58

galantamine tab NAMENDA SOLN NAMENDA TAB NAMENDA TAB TITRATION K NAMENDA XR CAP QL=30 Caps/30 Days rivastigmine tab COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide/ amitriptyline tab NSO olanzapine/ fluoxetine cap perphenazine/ amitriptyline tab NSO FIBROMYALGIA AGENTS SAVELLA TAB QL=60 Tabs/30 Days SAVELLA TITRATION CK MOVEMENT DISORDER DRUG THERAPY XENAZINE TAB NM MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB NM QL=30 Tabs/30 Days AVONEX INJ NM QL= Injections/8 Days COXONE INJ NM QL=30 Injections/30 Days EXTAVIA INJ NM ST QL=5 Injections/30 Days GILENYA CAP NM QL=30 Caps/30 Days REBIF INJ NM QL= Injections/8 Days REBIF REBIDOSE INJ TITRATION CK NM QL= Kits/8 Days REBIF TITRATION CK NM QL= Injections/8 Days TECFIDERA CAP NM TECFIDERA CAP STARTER CK NM TYSABRI INJ NM PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP QL=60 Caps/30 Days PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ergoloid mesylates tab ORAP TAB SMOKING DETERRENTS buproban tab CHANTIX K CHANTIX TAB nicotine gum mg, mg* QL=360 Blisters/30 Days nicotine patch 7mg, mg, mg* QL=56 Patches/8 Days NICOTROL INHALER NICOTROL NASAL SPRAY RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST NP INJ NM GLASSIA INJ NM 59

ZEMAIRA INJ CYSTIC FIBROSIS AGENTS KALYDECO K KALYDECO TAB PULMOZYME SOLN SULFONAMIDES SULFONAMIDES SULFADIAZINE TAB TETRACYCLINES TETRACYCLINES demeclocycline tab doxycycline 0mg/ ml soln doxycycline cap 75mg doxycycline hyclate cap 50mg, 00mg doxycycline hyclate DR tab doxycycline hyclate inj doxycycline hyclate tab 0mg, 00mg doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate tab 50mg, 75mg, 00mg, 50mg doxycycline susp minocycline cap minocycline ER tab minocycline tab tetracycline cap THYROID AGENTS ANTITHYROID AGENTS methimazole tab propylthiouracil tab THYROID HORMONES levothyroxine tab levoxyl tab liothyronine inj liothyronine tab SYNTHROID TAB THYROLAR TAB unithroid tab TOXOIDS TOXOID COMBINATIONS ADACEL INJ BOOSTRIX INJ DAPTACEL INJ NM NM QL=60 Packets/30 Days NM NM 60

DIPHTHERIA/ TETANUS VACCINE INJ INFANRIX INJ QUADRACEL INJ TENIVAC INJ TETANUS/ DIPHTHERIA TOXOID INJ TOXOIDS TETANUS TOXOID ADSORBED INJ ANTISSMODICS atropine inj dicyclomine cap DICYCLOMINE SOLN dicyclomine tab glycopyrrolate inj glycopyrrolate tab methscopolamine tab PRONTHELINE TAB H- ANTAGONISTS cimetidine oral soln cimetidine tab famotidine inj famotidine susp famotidine tab famotidine tab 0mg* FAMOTIDINE/ NACL INJ nizatidine cap nizatidine soln ranitidine cap ranitidine inj ranitidine syrup ranitidine tab MISC. ANTI-ULCER sucralfate tab PROTON PUMP INHIBITORS esomeprazole inj lansoprazole cap omeprazole cap OMEPRAZOLE TAB 0MG* pantoprazole tab PREVACID SOLUTAB rabeprazole tab ULCER DRUGS - PROSTAGLANDINS misoprostol tab ULCER THERAPY COMBINATIONS ULCER DRUGS 6 ST

lansoprazole/ amoxicillin/ clarithromycin tab PYLERA CAP URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES MACRODANTIN CAP QL=80 Caps/365 Days methenamine hippurate tab nitrofurantoin macro cap 50mg, 00mg QL=80 Caps/365 Days nitrofurantoin mono cap QL=80 Caps/365 Days nitrofurantoin susp URINARY ANTISSMODICS URINARY ANTISSMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) oxybutynin ER tab tolterodine tartrate ER cap trospium chloride ER cap URINARY ANTISSMODICS bethanechol tab flavoxate tab oxybutynin ER tab oxybutynin syrup oxybutynin tab tolterodine tab TOVIAZ TAB trospium tab VESICARE TAB VACCINES BACTERIAL VACCINES ACTHIB INJ BCG VACCINE INJ BEXSERO INJ MENACTRA INJ MENOMUNE A-C-Y-W INJ MENVEO INJ PEDVAX HIB INJ TYPHIM VI INJ MIXED VACCINE COMBINATIONS COMVAX INJ VIRAL VACCINES CERVARIX INJ ENGERIX-B INJ GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ IMOVAX RABIES (H.D.C.V.) INJ IPOL INJ 6

IXIARO INJ M-M-R II WITH DILUENT INJ PROQUAD INJ RABAVERT INJ RECOMBIVAX-HB INJ ROTARIX SUSP ROTATEQ ORAL SUSP TWINRIX INJ VAQTA INJ VARIVAX INJ YF-VAX INJ ZOSTAVAX INJ VAGINAL PRODUCTS SPERMICIDES NONOXYNOL-9 FOAM.5%* nonoxynol-9 gel 3%* VAGINAL ANTI-INFECTIVES AVC SULFANILAMIDE VAGINAL CREAM clindamycin vaginal cream clotrimazole vaginal cream %, %* metronidazole vaginal gel miconazole cream kit* miconazole nitrate vaginal supp 00mg* miconazole vaginal cream %, %* miconazole vaginal kit* terconazole vaginal cream terconazole vaginal supp tioconazole vaginal ointment 6.5%* vandazole vaginal gel zazole vaginal cream VAGINAL ESTROGENS ESTRACE VAGINAL CREAM ESTRING VAGINAL RING PREMARIN VAGINAL CREAM VAGINAL PROGESTINS CRINONE VAGINAL GEL VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS EPIPEN INJ EPIPEN JR INJ VASOPRESSORS midodrine tab VITAMINS OIL SOLUBLE VITAMINS 63 QL= Injections/5 Days QL= Injections/5 Days

cholecalciferol cap 000unit, 5000unit* cholecalciferol tab 00unit, 000unit* ergocalciferol cap 50000unit* ergocalciferol soln 8000unit/ ml* phytonadione tab 00mcg* WATER SOLUBLE VITAMINS niacin CR cap 50mg, 500mg* NIACIN CR TAB 000MG* niacin CR tab 500mg, 750mg* niacin tab 50mg, 00mg, 50mg, 500mg* pyridoxine tab 5mg, 50mg, 00mg* thiamine tab 00mg* 3 6

ALPHABETICAL LISTING OF DRUGS Other 8-MOP CAP 38 A abacavir tab 7 abacavir/ lamivudine/ 7 zidovudine tab ABELCET INJ 5 ABILIFY MAINTENA 6 INJ ABILIFY TAB 6 ABRAXANE SUSP acamprosate tab 58 acarbose tab acebutolol cap 30 acetaminophen cap 3 500mg* acetaminophen chew tab 3 60mg* acetaminophen CR tab 3 650mg* acetaminophen elixir 3 60mg/ 5ml* acetaminophen liquid 3 60mg/ 5ml* ACETAMINOPHEN 3 LIQUID 500MG/ 5ML* acetaminophen soln 3 60mg/ 5ml* acetaminophen supp 80mg, 3 0mg, 35mg, 650mg* acetaminophen susp 80mg/ 3 0.8ml, 60mg/ 5ml* acetaminophen tab 35mg, 3 500mg* acetaminophen/ codeine soln acetaminophen/ codeine tab acetazolamide inj acetazolamide SR cap acetazolamide tab acetic acid otic soln 57 acetylcysteine soln 36 acitretin cap 38 ACTHIB INJ 6 ACTIMMUNE INJ 3 ACTONEL TAB 3 acyclovir cap 9 acyclovir inj 9 acyclovir susp 9 acyclovir tab 9 ADACEL INJ 60 ADAGEN INJ 3 adapalene cream 36 adapalene gel 36 ADCIRCA TAB 3 ADDERALL XR CAP adefovir tab 8 adrucil inj ADVAIR DISKUS 8 ADVAIR HFA INHALER 8 afeditab CR tab 3 AFINITOR DISPERZ 3 TAB AFINITOR TAB 3 AGGRENOX CAP 7 A-HYDROCORT INJ 35 AKYNZEO CAP 5 ala cort cream 39 ALBENZA TAB 6 albuterol neb 8 albuterol sulfate ER tab 8 albuterol syrup 8 albuterol tab 8 alclometasone cream 39 alclometasone ointment 39 ALCOHOL SWAB 50 ALDURAZYME INJ 3 alendronate soln 3 alendronate tab 3 ALENDRONATE TAB 3 0MG alfuzosin ER tab 6 ALIMTA INJ ALINIA SUSP 9 ALINIA TAB 9 ALLEGRA TAB 30MG* 6 allopurinol tab 7 ALOCRIL OPHTH SOLN 56 ALOMIDE OPHTH SOLN 56 alosetron tab 6 ALPHAGAN P OPHTH 55 SOLN 0.% 65 alprazolam ER tab 6 alprazolam ODT 6 alprazolam tab 6 ALREX OPHTH SUSP 56 aluminum acetate soln* ALUMINUM 6 HYDROXIDE GEL SUSP 30MG/ 5ML* aluminum hydroxide gel 6 susp 600mg/ 5ml* aluminum hydroxide/ 5 magnesium carbonate chew tab* aluminum/ magnesium 5 hydroxide/ simethicone susp 5-0-5mg/ 5ml* amantadine cap 5 amantadine syrup 5 AMBISOME INJ 5 amcinonide cream 39 AMCINONIDE 39 OINTMENT amethia tab 33 amifostine inj amikacin inj amiloride tab amiloride/ hydrochlorothiazide tab AMINO ACID ORAL 5 LIQUID* AMINO ACID POWDER* 5 aminophylline inj 8 AMINOSYN II INJ 5 AMINOSYN INJ 5 AMINOSYN/ 5 ELECTROLYTES INJ AMINOSYN-HBC INJ 5 AMINOSYN-PF INJ 5 AMINOSYN-RF INJ 5 amiodarone inj 7 amiodarone tab 7 amitriptyline tab amlodipine tab 3 amlodipine/ atorvastatin 3 tab amlodipine/ benazepril cap 8 amlodipine/ valsartan tab 8

ALPHABETICAL LISTING OF DRUGS AMMONIUM 5 CHLORIDE INJ ammonium lactate cream ammonium lactate lotion amnesteem cap 36 amoxapine tab amoxicillin cap 57 amoxicillin chew tab 57 AMOXICILLIN CHEW 57 TAB 50MG amoxicillin susp 57 amoxicillin tab 57 amoxicillin/ clavulanate 58 chew tab amoxicillin/ clavulanate 58 ER tab amoxicillin/ clavulanate 58 susp amoxicillin/ clavulanate 58 tab amphetamine/ dextroamphetamine tab AMPHOTERICIN B INJ 5 ampicillin cap 57 ampicillin inj 57 AMPICILLIN INJ 5MG 58 ampicillin susp 58 ampicillin/ sulbactam inj 58 ANADROL-50 TAB 5 anagrelide cap 7 anastrozole tab ANDRODERM TCH 5 MG ANDRODERM TCH 5 MG ANDROGEL 0.5 MG/ 5.5GM (.6%) ANDROGEL 5MG 5 ANDROGEL 0.5 MG/ 5.5GM (.6%) ANDROGEL GEL % 5 (50MG) ANDROGEL PUMP 5 ANDROGEL PUMP % 5 ANGELIQ TAB antacid susp* 5 APLENZIN TAB APOKYN INJ 5 apraclonidine ophth soln 55 apri tab 33 APRISO CAP 5 APTIOM TAB 9 APTIVUS CAP 7 APTIVUS SOLN 7 ARALAST NP INJ 59 aranelle tab 33 ARANESP INJ 00MCG, 7 50MCG, 00MCG, 300MCG, 500MCG ARANESP INJ 0MCG, 7 5MCG, 0MCG, 60MCG ARCALYST INJ argatroban inj 00mg/ ml 9 ARGATROBAN INJ 9 5MG/ 5ML aripiprazole tab 6 ARNUITY ELLIPTA 8 INHALER ARRANON INJ artificial tears* 5 ARZERRA INJ ASACOL HD TAB 5 ASCRIPTIN TAB 3 35MG* ashlyna 9 day tab 33 ASMANEX HFA 8 INHALER ASMANEX INHALER 8 ASMANEX 8 TWISTHALER aspirin DR tab 8mg, 3 35mg* aspirin tab 35mg* 3 aspirin tab 500mg* 3 aspirin tab 8mg* 3 aspirin/ acetaminophen/ 3 caffeine tab 50-50-65mg* ASTAGRAF XL CAP 9 ASTEPRO NASAL 53 SPRAY atenolol tab 30 atenolol/ chlorthalidone 8 tab ATGAM INJ 9 atorvastatin tab 7 66 atovaquone susp 9 atovaquone/ proguanil tab 0 ATRIPLA TAB 7 atropine inj 6 atropine sulfate ophth soln 55 ATROVENT HFA 7 INHALER AUBAGIO TAB 59 aubra tab 33 augmented betamethasone 39 cream augmented betamethasone 39 gel augmented betamethasone 39 lotion augmented betamethasone 39 ointment AUGMENTIN SUSP 58 5MG AURYXIA TAB 6 AVANDAMET TAB AVANDIA TAB 3 AVASTIN INJ AVC SULFANILAMIDE 63 VAGINAL CREAM AVELOX INJ 5 aviane tab 33 avita cream 36 avita gel 36 AVODART CAP 6 AVONEX INJ 59 azacitidine inj AZACTAM/ DEXTROSE 9 INJ AZASAN TAB 9 AZASITE OPHTH SOLN 55 azathioprine tab 9 azelastine ophth soln 56 AZILECT TAB 5 azithromycin inj 9 azithromycin susp 9 azithromycin tab 9 AZOPT OPHTH SUSP 56 aztreonam inj 9 B baciim inj 9

ALPHABETICAL LISTING OF DRUGS bacitracin ointment 37 500unit/ gm* bacitracin ophth ointment 55 bacitracin zinc ointment 37 500unit/ gm* bacitracin/ polymyxin B 37 ointment* bacitracin/ polymyxin B 55 ophth ointment baclofen tab 53 balsalazide cap 5 balziva tab 33 BANZEL SUSP 9 BANZEL TAB 9 BARACLUDE SOLN 8 BARACLUDE TAB 8 BCG VACCINE INJ 6 B-D INSULIN SYRINGE 50 BELEODAQ INJ 3 BENADRYL CHEW TAB 5.5MG* benazepril tab 7 benazepril/ 8 hydrochlorothiazide tab benzonatate cap 00mg, 35 00mg* benzoyl peroxide gel 0%* 36 BENZOYL PEROXIDE 36 GEL.5%* benzoyl peroxide liquid 36 5%, 0%* BENZOYL PEROXIDE 37 LOTION 5%, 0%* benztropine inj 5 benztropine tab 5 BERINERT INJ 7 BESIVANCE OPHTH 55 SUSP betamethasone 39 dipropionate cream betamethasone 39 dipropionate gel betamethasone 39 dipropionate lotion betamethasone valerate 39 cream betamethasone valerate 39 foam betamethasone valerate 39 lotion betamethasone valerate 39 ointment betaxolol ophth soln 5 betaxolol tab 30 bethanechol tab 6 BETIMOL OPHTH SOLN 5 BETOPTIC-S OPHTH 5 SUSP BEXSERO INJ 6 BEYAZ TAB 33 bicalutamide tab BICILLIN C-R INJ 58 BICILLIN L-A INJ 58 BICNU INJ BIDIL TAB 3 BIMATOPROST OPHTH 56 SOLN bisacodyl DR tab 5mg* 9 bisacodyl supp 0mg* 9 bismuth subsalicylate chew tab 6mg* bismuth subsalicylate susp 6mg/ 5ml, 55mg/ 5ml* bismuth subsalicylate tab 6mg* bisoprolol tab 30 bisoprolol/ 8 hydrochlorothiazide tab BIVIGAM INJ 57 bleomycin sulfate inj BLEPHAMIDE OPHTH 56 SUSP BONINE CHEW TAB 5MG* BOOSTRIX INJ 60 BOSULIF TAB 3 BREO ELLIPTA 8 INHALER briellyn tab 33 BRILINTA TAB 7 brimonidine ophth soln 55 BRINTELLIX TAB bromfenac ophth soln 56 bromocriptine cap 5 bromocriptine tab 5 67 brompheniramine/ 35 pseudoephedrine elixir -5mg/ 5ml* budesonide EC cap 35 budesonide neb 8 bumetanide inj bumetanide tab buprenorphine inj 5 buprenorphine SL tab 5 buproban tab 59 bupropion SR tab bupropion tab bupropion XL tab buspirone tab 5mg, 7.5mg, 6 0mg, 5mg BUSULFEX INJ BUTISOL TAB 8 butorphanol inj 5 butorphanol soln 5 BUTRANS TCH 5 BYDUREON INJ 3 BYDUREON PEN INJ 3 MG BYSTOLIC TAB 30 C cabergoline tab CAFERGOT TAB 50 CALAMINE LOTION* calcipotriene cream 38 calcipotriene ointment 38 calcipotriene soln 38 calcipotriene/ 39 betamethasone ointment calcitonin nasal spray 3 calcitriol cap 3 calcitriol inj 3 CALCITRIOL 38 OINTMENT calcitriol soln 3 calcium acetate cap 6 calcium carbonate chew 6 tab 0mg, 500mg, 750mg, 000mg* calcium carbonate susp 5 50mg/ 5ml* calcium carbonate tab 5 600mg, 50mg*

ALPHABETICAL LISTING OF DRUGS calcium carbonate tab 6 68mg* calcium chew tab 500mg* 5 calcium citrate+vit D tab 5 35mg-00unit* calcium citrate+vit D tab 5 35mg-50unit* CALCIUM 5 GLUBIONATE SYRUP.8MG/ 5ML* CALCIUM GLUCONATE 5 TAB 500MG* calcium polycarbophil tab 8 65mg* calcium/ cholecalciferol 5 tab 50mg-5unit* calcium/ cholecalciferol 5 tab 500mg-5unit* calcium/ cholecalciferol 5 tab 500mg-00unit* calcium+d tab 5 50mg-5unit* calcium+d tab 5 500mg-00unit* calcium+d tab 5 600mg-00unit* calcium+d tab 5 600mg-00unit* camila tab 3 CANASA SUPP 5 CANCIDAS INJ 5 candesartan tab 7 candesartan/ 8 hydrochlorothiazide tab CASTAT INJ 0 CAPRELSA TAB 3 captopril tab 7 captopril/ 8 hydrochlorothiazide tab CARAC CREAM 38 carbamazepine chew tab 9 carbamazepine ER cap 9 carbamazepine ER tab 9 carbamazepine susp 9 carbamazepine tab 9 carbidopa tab CARBIDO/ 5 ENTACAPONE/ LEVODO TAB carbidopa/ levodopa ER 5 tab carbidopa/ levodopa ODT 5 carbidopa/ levodopa tab 5 carbinoxamine soln 5 carbinoxamine tab 5 carboplatin inj CARDENE INJ 3 carisoprodol tab 53 carisoprodol/ aspirin tab 53 carisoprodol/ aspirin/ 53 codeine tab carteolol ophth soln 5 cartia XT cap 3 carvedilol tab 30 CEDAX SUSP 3 cefaclor cap 3 cefadroxil cap 3 cefadroxil susp 3 cefadroxil tab 3 cefazolin inj 3 CEFAZOLIN/ D5W INJ 3 cefdinir cap 3 cefdinir susp 3 CEFEPIME INJ 33 cefepime inj 33 cefotaxime inj 3 CEFOTETAN INJ 3 cefoxitin inj 3 CEFOXITIN/ DEXTROSE 3 INJ cefpodoxime susp 3 cefpodoxime tab 3 cefprozil susp 3 cefprozil tab 3 ceftazidime inj 3 CEFTAZIDIME/ 3 DEXTROSE INJ ceftriaxone inj 3 cefuroxime inj 3 cefuroxime tab 3 CELEBREX CAP celecoxib cap CELLCEPT IV INJ 9 CELLCEPT SUSP 9 68 CELONTIN CAP 0 cephalexin cap 3 cephalexin susp 3 cephalexin tab 3 CEREBYX INJ 0 CEREZYME INJ 7 CERVARIX INJ 6 CESAMET CAP 5 cetirizine chew tab 5mg, 6 0mg* cetirizine oral soln (Rx 6 only) cetirizine soln mg/ ml* 6 cetirizine tab 5mg, 0mg* 6 cevimeline cap 5 CHANTIX K 59 CHANTIX TAB 59 CHEMET CAP CHENODAL TAB 5 CHLORAMPHENICAL 9 INJ chlordiazepoxide cap 7 chlordiazepoxide/ 59 amitriptyline tab CHLORHEXIDINE 7 GLUCONATE LIQUID %* chlorhexidine gluconate 7 liquid %* CHLORHEXIDINE 7 GLUCONATE DS %* chlorhexidine gluconate 5 soln chlorhexidine gluconate 7 soln 0%* chloroquine tab 0 chlorothiazide inj chlorothiazide tab chlorpheniramine DM 35 liquid -5mg/ 5ml* chlorpheniramine syrup 5 mg/ 5ml* chlorpheniramine tab 5 mg* chlorpheniramine/ 35 pseudoephedrine tab -60mg* chlorpromazine inj 6

ALPHABETICAL LISTING OF DRUGS chlorpromazine tab 6 chlorpropamide tab chlorthalidone tab chlorzoxazone tab 53 cholecalciferol cap 6 000unit, 5000unit* cholecalciferol tab 00unit, 6 000unit* cholestyramine light 6 powder cholestyramine light 6 powder packet ciclopirox cream 37 ciclopirox gel 37 ciclopirox nail lacquer 37 ciclopirox shampoo 37 ciclopirox susp 37 cidofovir inj 8 cilostazol tab 7 cimetidine oral soln 6 cimetidine tab 6 CIMZIA INJ 5 CINRYZE INJ 7 CIPRODEX OTIC SUSP 57 ciprofloxacin ER tab 5 ciprofloxacin IV soln 5 ciprofloxacin ophth soln 55 ciprofloxacin oral susp 5 ciprofloxacin tab 5 ciprofloxacin/ D5W inj 5 cisplatin inj citalopram soln citalopram tab CITRACAL/ VITAMIN D 5 TAB 50MG-00UNIT* cladribine inj claravis cap 37 clarithromycin ER tab 9 clarithromycin susp 9 clarithromycin tab 9 CLEAR EYES OPHTH 55 SOLN* CLEMASTINE SYRUP 5 clemastine tab 5 clemastine tab.3mg* 5 clindamycin cap 9 clindamycin foam 37 clindamycin inj 9 clindamycin phosphate gel 37 clindamycin phosphate 37 lotion clindamycin phosphate 37 soln clindamycin phosphate 37 swab clindamycin soln 9 clindamycin vaginal cream 63 clindamycin/ benzoyl 37 peroxide gel CLINIMIX E INJ 5 CLINIMIX E/ 5 DEXTROSE INJ CLINIMIX INJ 5 clinisol SF inj 5 clobetasol E cream 39 clobetasol gel 39 clobetasol lotion 39 clobetasol ointment 39 clobetasol shampoo 39 clobetasol soln 39 clobetasol topical foam 39 clobetasol topical spray 39 CLOLAR INJ clomipramine cap clonazepam ODT 9 clonazepam tab 9 clonidine patch 8 clonidine tab 8 clopidogrel tab 75mg 7 clorazepate tab 7 clotrimazole cream 37 clotrimazole soln 37 clotrimazole troche 5 clotrimazole vaginal cream 63 %, %* clotrimazole/ 37 betamethasone cream clotrimazole/ 37 betamethasone lotion CLOZAPINE ODT 6 clozapine tab 6 COARTEM TAB 0 codeine sulfate tab COLACE CAP 50MG* 9 COLCHICINE TAB 7 colchicine/ probenecid tab 6 69 COLCRYS TAB 7 colestipol granules canister 6 5gm colestipol tab 6 colistimethate inj 9 colocort enema 5 COLY-MYCIN S OTIC 57 SUSP COMBIGAN OPHTH 5 SOLN COMBITCH COMBIVENT 8 RESPIMAT COMETRIQ CK 3 COMPLERA TAB 7 compro supp 6 COMVAX INJ 6 CONDOMS* 50 constulose soln 9 COXONE INJ 59 cormax topical soln 39 CORTEF TAB 35 cortisone tab 35 CORTISPORIN-TC OTIC 57 SUSP COSMEGEN INJ 0.5MG CREON CAP CRESTOR TAB 7 CRESTOR TAB 0MG 7 CRINONE VAGINAL 63 GEL CRIXIVAN CAP 7 cromolyn nasal soln 53 5.mg* cromolyn neb 7 cromolyn sodium ophth 56 soln cromolyn sodium oral soln 5 cryselle-8 tab 33 CUBICIN INJ 9 CUPRIMINE CAP 9 cyanocobalamin inj 7 000mcg/ ml* cyclafem tab 33 cyclobenzaprine tab 53 CYCLOPHOSPHAMIDE CAP cyclosporine cap 9

ALPHABETICAL LISTING OF DRUGS cyclosporine inj 9 cyclosporine modified cap 9 CYCLOSPORINE 9 MODIFIED CAP 50MG cyclosporine modified soln 9 cyproheptadine syrup 6 cyproheptadine tab 6 CYSTAGON CAP 6 CYSTARAN OPHTH 56 SOLN cytarabine inj D dacarbazine inj 3 DALIRESP TAB 8 DALVANCE INJ 9 danazol cap 5 dantrolene cap 53 dapsone tab 9 DAPTACEL INJ 60 DARAPRIM TAB 0 daunorubicin inj DAUNOXOME INJ deblitane tab 3 decitabine inj delyla tab 33 DELZICOL CAP 5 demeclocycline tab 60 DEMSER CAP 7 DENAVIR CREAM 39 DEPEN TITRATABS 9 desipramine tab desloratadine ODT 6 desloratatine tab 6 desmopressin acetate nasal soln desmopressin inj desmopressin nasal spray desmopressin tab desogestrel/ ethinyl 33 estradiol tab DESONATE GEL 39 desonide cream 39 desonide lotion 39 desonide ointment 39 desoximetasone cream 0 DESOXIMETASONE 0 CREAM 0.05% desoximetasone gel 0 desoximetasone ointment 0 DESVENLAFAXINE ER TAB dexamethasone conc 35 dexamethasone elixir 35 dexamethasone inj 35 dexamethasone sodium 56 phosphate ophth soln dexamethasone tab 35 dexedrine tab dexmethylphenidate ER cap dexmethylphenidate tab dexrazoxane inj dextroamphetamine ER cap dextroamphetamine tab dextromethorphan liquid 35 5mg/ 5ml* dextromethorphan syrup 35 7.5mg/ 5ml, 0mg/ 5ml, 5mg/ 5ml* dextromethorphan/ 35 guaifenesin liquid 0-00mg/ 5ml* dextromethorphan/ 35 guaifenesin liquid 0-00mg/ 5ml* dextromethorphan/ 36 guaifenesin liquid 5-00mg/ 5ml* dextromethorphan/ 36 guaifenesin liquid 30-00mg/ 5ml* dextromethorphan/ 36 guaifenesin liquid 5-00mg/ 5ml* dextromethorphan/ 36 guaifenesin syrup 0-00mg/ 5ml* dextrose inj 5 dextrose/ sodium chloride 5 inj DIASTAT RECTAL GEL 9 DIASTIX URINE TEST STRIP* diazepam intensol conc 7 70 DIAZEM RECTAL 9 GEL DIAZEM SOLN 7 diazepam tab 7 DIBENZYLINE CAP 7 diclofenac EC tab diclofenac gel 38 diclofenac ophth soln 56 diclofenac potassium tab diclofenac sodium topical 38 soln diclofenac XR tab diclofenac/ misoprostol tab dicloxacillin cap 58 dicyclomine cap 6 DICYCLOMINE SOLN 6 dicyclomine tab 6 didanosine cap 7 DIFFERIN LOTION 37 diflorasone cream 0 diflorasone ointment 0 diflunisal tab 3 digoxin inj 3 digoxin oral soln 3 digoxin tab 0.5mg 3 digoxin tab 0.5mg 3 dihydroergotamine inj 50 DIHYDROERGOTAMIN 50 E NASAL SPRAY DILANTIN CAP 30MG 0 diltiazem CD cap 3 diltiazem ER cap 3 diltiazem inj 3 diltiazem tab 3 dilt-xr cap 3 dimenhydrinate tab 50mg* DIOVAN TAB 7 diphenhydramine (sleep) 8 cap 50mg* diphenhydramine (sleep) 8 tab 50mg* diphenhydramine cap 6 5mg, 50mg* diphenhydramine cream 38 %* diphenhydramine elixir 6.5mg/ 5ml* diphenhydramine gel %* 38

ALPHABETICAL LISTING OF DRUGS diphenhydramine inj 6 diphenhydramine liquid 6.5mg/ 5ml* diphenhydramine oral soln 6 (Rx only) diphenhydramine soln %* 38 diphenhydramine tab 6 5mg* diphenhydramine/ zinc 38 acetate cream -0.%* diphenoxylate/ atropine liquid diphenoxylate/ atropine tab DIPHTHERIA/ TETANUS 6 VACCINE INJ dipyridamole tab 7 disopyramide cap 7 disulfiram tab 58 DIURIL SUSP divalproex DR tab 0 divalproex ER tab divalproex sprinkle cap DOCEFREZ INJ DOCETAXEL INJ docusate cap 00mg, 9 50mg* docusate enema 83mg* 9 docusate sodium liquid 9 50mg/ 5ml* docusate sodium syrup 9 60mg/ 5ml* docusate tab 00mg* 9 donepezil ODT 58 donepezil tab 58 donepezil tab 3mg 58 DORIBAX INJ 9 dorzolamide ophth soln 56 dorzolamide/ timolol ophth 5 soln doxazosin tab 8 doxepin conc doxepine cap doxercalciferol cap 3 doxercalciferol inj 3 doxorubicin inj doxycycline 0mg/ ml soln 60 doxycycline cap 75mg 60 doxycycline hyclate cap 60 50mg, 00mg doxycycline hyclate DR tab 60 doxycycline hyclate inj 60 doxycycline hyclate tab 60 0mg, 00mg doxycycline monohydrate 60 cap doxycycline monohydrate 60 cap doxycycline monohydrate 60 tab 50mg, 75mg, 00mg, 50mg doxycycline susp 60 dronabinol cap 5 DROXIA CAP 7 DULERA INHALER 8 duloxetine cap DULOXETINE DR CAP duramorph inj DUREZOL OPHTH 56 EMULSION DUTOPROL TAB 8 DYRENIUM CAP E E.E.S GRANULES 9 e.e.s. tab 50 econazole nitrate cream 37 ED A-HIST LIQUID 36-0MG/ 5ML* EDECRIN TAB EDURANT TAB 7 EFFIENT TAB 7 ELAPRASE INJ 3 electrolyte oral soln* 5 ELESTRIN GEL ELIDEL CREAM ELIGARD INJ ELIQUIS TAB 9 ELITEK INJ ELIXOPHYLLIN SOLN 8 ELLA TAB 3 ELMIRON CAP 6 EMBEDA CAP EMCYT CAP EMEND CAP 5 EMEND CAP CK 5 7 emoquette tab 33 EMSAM TCH EMTRIVA CAP 7 EMTRIVA SOLN 7 enalapril tab 7 enalapril/ 8 hydrochlorothiazide tab ENBREL INJ 3 ENBREL SURECLICK 3 INJ endocet tab endodan tab ENGERIX-B INJ 6 enoxaparin inj 9 enpresse-8 tab 33 entacapone tab 5 entecavir tab 8 ENUCLENE OPHTH 56 SOLN 0.5%* enulose soln 6 EPHEDRINE SULFATE 8 CAP 5MG* EPIDUO GEL 37 epinastine ophth soln 56 EPIPEN INJ 63 EPIPEN JR INJ 63 epirubicin inj 3 epitol tab 9 EPIVIR HBV SOLN 7 EPIVIR SOLN 7 eplerenone tab 8 eprosartan mesylate tab 8 EPZICOM TAB 7 EQUETRO CAP 5 ERAXIS INJ 5 ERBITUX SOLN ergocalciferol cap 6 50000unit* ergocalciferol soln 6 8000unit/ ml* ergoloid mesylates tab 59 ERGOMAR TAB 50 ERIVEDGE CAP errin tab 3 ERTACZO CREAM 37 ERWINAZE INJ 3 ery pad 37 ERYPED SUSP 50

ALPHABETICAL LISTING OF DRUGS ERY-TAB 50 ERYTHROCIN 50 LACTOBIONATE INJ ERYTHROCIN 50 STEARATE TAB erythromycin ophth 55 ointment erythromycin tab 50 erythromycin topical gel 37 erythromycin topical soln 37 erythromycin/ benzoyl 37 peroxide gel escitalopram soln escitalopram tab esomeprazole inj 6 estazolam tab 8 ESTRACE VAGINAL 63 CREAM estradiol inj estradiol patch estradiol tab estradiol valerate inj 5 estradiol/ norethindrone tab ESTRING VAGINAL 63 RING estropipate tab 5 eszopiclone tab 8 ethambutol tab 0 ethinyl estradiol/ norethindrone acetate tab ethosuximide cap 0 ethosuximide soln 0 etidronate disodium tab 3 etodolac cap etodolac ER tab etodolac tab ETOPOPHOS INJ etoposide inj EURAX CREAM EVOTAZ TAB 7 EXALGO TAB EXELON TCH 58 exemestane tab EXFORGE HCT TAB 8 EXFORGE TAB 8 EXJADE ORAL SUSP EXTAVIA INJ 59 F FABRAZYME INJ falmina tab 33 famciclovir tab 9 famotidine inj 6 famotidine susp 6 famotidine tab 6 famotidine tab 0mg* 6 FAMOTIDINE/ NACL 6 INJ FANAPT TAB 5 FANAPT TAB 5 TITRATION CK FARESTON TAB FARXIGA TAB 3 FARYDAK CAP 3 FASLODEX INJ FAZACLO TAB 6 felbamate susp 0 felbamate tab 0 felodipine ER tab 3 fenofibrate micronized cap 7 fenofibrate tab 7 fenoprofen tab fentanyl lollipop fentanyl patch FERRIPROX TAB ferrous sulfate EC tab 8 35mg* ferrous sulfate elixir 8 0mg/ 5ml* ferrous sulfate soln 75mg/ 8 ml* FERROUS SULFATE 8 SYRUP 300MG/ 5ML* ferrous sulfate tab 35mg* 8 FETZIMA CAP FETZIMA CK fexofenadine tab 60mg, 6 80mg* FINACEA GEL finasteride tab 6 FIRAZYR INJ 7 FIRMAGON INJ flavoxate tab 6 FLEBOGAMMA INJ 57 flecainide tab 7 FLOVENT DISKUS 8 7 FLOVENT HFA 8 INHALER 0MCG FLOVENT HFA 8 INHALER MCG, 0MCG fluconazole susp 5 fluconazole tab 5 fluconazole/ dextrose inj 5 flucytosine cap 5 fludarabine inj fludrocortisone tab 35 flunisolide nasal spray 53 fluocinolone acetonide 0 cream fluocinolone acetonide oil 0 fluocinolone acetonide 0 ointment fluocinolone acetonide otic 57 oil fluocinolone acetonide soln 0 fluocinonide cream 0 fluocinonide E cream 0 fluocinonide gel 0 fluocinonide ointment 0 fluocinonide soln 0 fluorometholone ophth 56 susp FLUOROURACIL 38 CREAM fluorouracil cream 38 fluorouracil inj fluorouracil soln 38 fluoxetine cap fluoxetine soln fluoxetine tab FLUPHENAZINE 6 DECANOATE INJ fluphenazine elixir 6 FLUPHENAZINE INJ 6 fluphenazine oral conc 6 fluphenazine tab 6 flurazepam cap 8 flurbiprofen ophth soln 56 flurbiprofen tab flutamide cap fluticasone nasal spray 53 fluticasone propionate 0 cream

ALPHABETICAL LISTING OF DRUGS fluticasone propionate 0 lotion fluticasone propionate 0 ointment fluvastatin cap 7 fluvoxamine ER cap fluvoxamine tab folic acid tab mg* 7 FOLOTYN INJ fomepizole inj fondaparinux inj 9 FORADIL CAP 8 FORTEO INJ 3 FORTICAL NASAL 3 SPRAY FOSCARNET INJ 8 fosinopril tab 7 fosinopril/ 8 hydrochlorothiazide tab fosphenytoin inj 0 FOSRENOL CHEW TAB 6 FOSRENOL POWDER 6 CK FRAGMIN INJ 9 FREAMINE HBC INJ 5 furosemide inj furosemide soln furosemide tab FUSILEV INJ FUZEON INJ 7 FYCOM TAB 9 G gabapentin cap 9 gabapentin soln 9 gabapentin tab 9 GABITRIL TAB 0 galantamine ER cap 58 galantamine soln 58 galantamine tab 59 GAMASTAN S/ D INJ 57 GAMMAGARD INJ 57 GAMMAKED INJ 57 GAMMAPLEX INJ 57 GAMUNEX-C INJ 57 ganciclovir inj 8 GARDASIL 9 INJ 6 GARDASIL INJ 6 gatifloxacin ophth soln 55 GAUZE D 50 gavilyte-c powder 8 gavilyte-g soln 8 gavilyte-n powder 8 GELUSIL CHEW TAB* 6 gemcitabine inj gemfibrozil tab 7 generlac soln 6 gengraf cap 9 gengraf soln 9 gentak ophth ointment 55 gentamicin inj gentamicin ophth ointment 55 gentamicin ophth soln 55 gentamicin sulfate cream 37 gentamicin sulfate ointment 37 gentamicin/ nacl inj 0.8mg/ ml, mg/ ml gentamicin/ nacl inj 0.9mg/ ml,.mg/ ml,.6mg/ ml GEODON INJ 5 gildagia tab 33 gildess.5/ 30 tab 33 gildess FE tab 33 GILENYA CAP 59 GILOTRIF TAB 3 GLASSIA INJ 59 GLEEVEC TAB 3 GLEOSTINE CAP glimepiride tab glipizide ER tab glipizide tab glipizide/ metformin tab GLUCAGEN HYPOKIT 3 GLUCAGON KIT 3 glyburide micronized tab glyburide tab glyburide/ metformin tab glycerin supp.gm* 9 glycopyrrolate inj 6 glycopyrrolate tab 6 GLYSET TAB GOLYTELY CKET 8 granisetron inj granisetron tab griseofulvin susp 5 griseofulvin tab 5 73 guaifenesin liquid 00mg/ 36 5ml, 00mg/ 5ml* guaifenesin tab 00mg* 36 guaifenesin/ codeine soln 36 00-0mg/ 5ml* guanfacine ER tab guanfacine IR tab 8 GUANIDINE TAB 0 H HALAVEN INJ halobetasol cream 0 halobetasol ointment 0 haloperidol decanoate inj 6 haloperidol inj 6 haloperidol oral conc 6 haloperidol tab 6 HARVONI TAB 8 HAVRIX INJ 6 heparin inj 9 heparin/ d5w inj 9 heptamine inj 5 HERCEPTIN INJ HEXALEN CAP HUMALOG INJ 3 HUMALOG KWIKPEN 3 INJ HUMALOG VIAL 3 HUMIRA INJ HUMIRA KIT HUMULIN 70/ 30 PEN 3 HUMULIN N PEN 3 HUMULIN R U-500 VIAL 3 hydralazine inj 8 hydralazine tab 8 hydrochlorothiazide cap hydrochlorothiazide tab 3 hydrocodone/ acetaminophen soln 7.5-35mg/ 5ml hydrocodone/ acetaminophen tab.5-35mg, 5-35mg, 7.5-35mg, 0-35mg hydrocodone/ acetaminophen tab 5-300mg, 7.5-300mg, 0-300mg

ALPHABETICAL LISTING OF DRUGS hydrocodone/ homatropine 35 syrup 5-.5mg/ 5ml* hydrocodone/ ibuprofen tab hydrocortisone acetate 0 ointment %* hydrocortisone butyrate 0 lipo cream hydrocortisone butyrate 0 ointment hydrocortisone butyrate 0 soln hydrocortisone cream 0 hydrocortisone cream 0.5% 0 * hydrocortisone enema 5 hydrocortisone lotion 0 hydrocortisone lotion %* 0 hydrocortisone ointment 0 hydrocortisone ointment 0 0.5%* hydrocortisone rectal 5 cream hydrocortisone soln %* 0 hydrocortisone tab 35 hydrocortisone valerate 0 cream hydrocortisone valerate 0 ointment hydrocortisone/ acetic acid 57 otic soln hydrocortisone/ aloe cream 0 %* HYDROMORPHONE ER SOLN hydromorphone ER tab hydromorphone inj hydromorphone oral liquid hydromorphone tab hydroxychloroquine tab 0 hydroxyurea cap hydroxyzine pamoate cap 6 hydroxyzine syrup 6 hydroxyzine tab 6 I ibandronate inj 3 ibandronate tab 3 IBRANCE CAP 3 ibuprofen cap 00mg* ibuprofen chew tab 00mg* ibuprofen susp ibuprofen tab ibuprofen tab 00mg* ibuprofen tab 00mg* ICLUSIG TAB 3 idarubicin inj 3 IFEX INJ ifosfamide inj ILARIS INJ ILEVRO OPHTH SUSP 56 IMBRUVICA CAP 3 imipenem/ cilastatin inj 9 imipramine pamoate cap imipramine tab imiquimod cream IMITREX NASAL 50 SPRAY IMOVAX RABIES 6 (H.D.C.V.) INJ INCRELEX INJ 3 INCRUSE ELLIPTA 7 INHALER indapamide tab 3 INDOCIN SUSP indomethacin cap indomethacin ER cap INFANRIX INJ 6 INLYTA TAB 3 INNOPRAN XL CAP 30 INSULIN SYRINGE 50 (ALL OTHERS) INTELENCE TAB 7 intralipid inj 5 INTRON-A INJ introvale tab 33 INTUNIV TAB MG, MG INTUNIV TAB 3MG, MG INVANZ INJ 9 INVEGA SUSTENNA INJ 5 INVEGA TAB 6 INVIRASE CAP 7 INVIRASE TAB 7 7 INVOKAMET TAB INVOKANA TAB 3 IONOSOL-B/ D5W INJ 5 IONOSOL-MB/ D5W INJ 5 IOPIDINE OPHTH SOLN 55 % IPOL INJ 6 ipratropium nasal spray 53 ipratropium neb 7 ipratropium/ albuterol neb 8 irbesartan tab 8 irbesartan/ 8 hydrochlorothiazide tab IRENKA CAP irinotecan inj ISENTRESS CHEW TAB 7 ISENTRESS POWDER 7 CK ISENTRESS TAB 7 ISOLYTE/ D5W INJ 5 ISOLYTE-S INJ 5 isoniazid inj 0 isoniazid syrup 0 isoniazid tab 0 isosorbide dinitrate ER tab 6 isosorbide dinitrate tab 6 isosorbide mononitrate ER 6 tab isosorbide mononitrate tab 6 isotonic gentamicin inj isradipine cap 3 ISTALOL OPHTH SOLN 5 ISTODAX INJ 3 itraconazole cap 5 ivermectin tab 6 IXEMPRA INJ IXIARO INJ 63 J JADENU TAB JAKAFI TAB 3 JALYN CAP 6 jantoven tab 8 JANUMET TAB JANUMET XR TAB JANUVIA TAB 3 JARDIANCE TAB 3 JEVTANA INJ

ALPHABETICAL LISTING OF DRUGS jinteli tab jolivette tab 3 junel FE tab 33 junel tab 33 JUXTAPID CAP 7 K KADCYLA INJ KALETRA SOLN 7 KALETRA TAB 7 KALYDECO K 60 KALYDECO TAB 60 kariva tab 33 kelnor tab 33 KENALOG INJ 35 KEPIVANCE INJ KETOCARE URINE TEST STRIP* ketoconazole cream 37 ketoconazole shampoo 37 ketoconazole shampoo %* 37 ketoconazole tab 5 ketoprofen cap ketorolac inj ketorolac ophth soln 56 ketorolac tab KEYTRUDA INJ KHEDEZYLA TAB kionex powder 30 KLOR-CON M5 TAB 5 klor-con tab 5 KORLYM TAB 3 K-TAB ER TAB 5 KUVAN POWDER CKET KUVAN TAB L labetalol inj 30 labetalol tab 30 LACRISERT OPHTH 5 INSERT lactated ringers irrigation 30 lactated ringers soln 5 lactated ringers/ d5w inj 5 lactulose soln 9 LAMICTAL ODT 9 LAMICTAL TAB 9 STARTER KIT LAMICTAL XR KIT 9 lamivudine oral soln 7 lamivudine tab 7 lamivudine/ zidovudine tab 7 lamotrigine chew tab 9 lamotrigine ER tab 9 lamotrigine ODT 9 lamotrigine tab 9 lansoprazole cap 6 lansoprazole/ amoxicillin/ 6 clarithromycin tab LANTUS SOLOSTAR 3 LANTUS VIAL 3 larin FE tab 33 larin tab 33 latanoprost ophth soln 57 LATUDA TAB 5 LAZANDA SPRAY leena tab 33 leflunomide tab 3 LENVIMA CAP 3 THERAPY CK LESCOL XL TAB 7 lessina 33 LETAIRIS TAB 3 letrozole tab leucovorin inj leucovorin tab LEUKERAN TAB LEUKINE INJ 7 leuprolide inj levalbuterol neb 8 LEVEMIR FLEXPEN 3 LEVEMIR INJ 3 levetiracetam ER tab 0 LEVETIRACETAM INJ 0 levetiracetam inj 0 levetiracetam soln 0 levetiracetam tab 0 levobunolol ophth soln 5 levocarnitine inj levocarnitine soln levocarnitine tab levocetirizine soln 6 levocetirizine tab 6 levofloxacin inj 5 levofloxacin ophth soln 55 levofloxacin soln 5 75 levofloxacin tab 5 LEVOLEUCOVORIN INJ levonest tab 33 levonorgestrel/ ethinyl 33 estradiol tab levora-8 tab 33 LEVORPHANOL TAB levothyroxine tab 60 levoxyl tab 60 LEXIVA SUSP 7 LEXIVA TAB 7 LIALDA TAB 5 lice treatment creme rinse* lice treatment shampoo* lidocaine gel lidocaine inj 9 lidocaine ointment lidocaine patch lidocaine soln lidocaine viscous soln 5 lidocaine/ prilocaine cream LINCOCIN INJ 9 lindane lotion lindane shampoo linezolid IV soln 0 linezolid tab 0 LINZESS CAP 6 liothyronine inj 60 liothyronine tab 60 LIPTRUZET TAB 6 lisinopril tab 7 lisinopril/ 8 hydrochlorothiazide tab lithium carbonate cap 5 lithium carbonate ER tab 5 lithium carbonate tab 5 lithium citrate soln 5 LITHOSTAT TAB 6 LOCOID CREAM 0 LOCOID LOTION 0 LOCOID OINTMENT 0 LOCOID SOLN 0 LOFIBRA CAP 7 LOFIBRA TAB 7 LOHIST-D LIQUID 36-30MG* lokara lotion 0 LOMUSTINE CAP

ALPHABETICAL LISTING OF DRUGS loperamide cap loperamide tab mg* lopreeza tab loratadine ODT 0mg* 6 loratadine syrup 5mg/ 5ml* 6 loratadine tab 0mg* 6 loratadine-d tab 36 0-0mg* loratadine-d tab 5-0mg* 36 lorazepam intensol conc 7 lorazepam tab 7 losartan tab 8 losartan/ 8 hydrochlorothiazide tab LOTEMAX OPHTH GEL 56 LOTEMAX OPHTH 56 OINTMENT LOTEMAX OPHTH SUSP 56 LOTRONEX TAB 6 lovastatin tab 7 LOVAZA CAP 6 low-ogestrel tab 33 loxapine cap 6 LUMIGAN OPHTH 57 SOLN LUMIZYME INJ LUPRON DEPOT (3 MONTH) KIT.5MG,.5MG LUPRON DEPOT ( MONTH) KIT 30MG LUPRON DEPOT (6 MONTH) KIT 5MG LUPRON DEPOT INJ LUPRON DEPOT-PED 3 KIT lutera tab 33 LYNRZA CAP 3 LYRICA CAP 0 LYRICA SOLN 0 LYSODREN TAB lyza tab 3 M MAALOX ADVANCED 6 MAXIMUM STRENGTH CHEW TAB* maalox max susp* 6 MACRODANTIN CAP 6 magnesium citrate soln* 9 magnesium hydroxide susp 9 00mg/ 5ml* magnesium oxide tab 5 00mg* magnesium sulfate inj 5 malathion lotion maprotiline tab marlissa tab 33 MARPLAN TAB MATULANE CAP matzim LA tab 3 MAXIDEX OPHTH SUSP 56 meclizine tab MECLOFENAMATE SODIUM CAP MEDROL TAB MG 35 medroxyprogesterone inj 3 medroxyprogesterone tab 58 mefenamic acid cap mefloquine tab 0 megestrol acetate susp megestrol acetate tab MEKINIST TAB 3 MELOXICAM SUSP meloxicam tab melphalan inj MENACTRA INJ 6 MENOMUNE A-C-Y-W 6 INJ MENVEO INJ 6 meperitab tab meprobamate tab 6 mercaptopurine tab meropenem inj 9 mesalamine kit 5 mesna inj MESNEX TAB MESTINON TIMESN 0 TAB metadate ER tab METAMUCIL PLUS 9 CALCIUM CAP* METAMUCIL SMOOTH 8 POWDER CKET 8%* METAMUCIL WAFER* 8 76 METAPROTERENOL 8 SYRUP metaxalone tab 53 METAXALONE TAB 53 metformin ER osmotic tab 000mg metformin ER tab metformin tab methadone soln methadone tab methamphetamine tab methazolamide tab methenamine hippurate tab 6 methimazole tab 60 methocarbamol tab 53 methotrexate inj methotrexate PF inj methotrexate tab methoxsalen cap 39 methscopolamine tab 6 METHYCLOTHIAZIDE 3 TAB methyldopa tab 8 methyldopa/ 8 hydrochlorothiazide tab methylergonovine tab 57 methylphenidate CD cap methylphenidate ER cap methylphenidate ER tab methylphenidate soln methylphenidate tab methylprednisolone acetate 35 inj methylprednisolone dose 35 pack methylprednisolone sodium 35 succinate inj methylprednisolone tab 35 metipranolol ophth soln 5 metoclopramide inj 5 metoclopramide soln 5 metoclopramide tab 5 metolazone tab 3 metoprolol ER tab 30 metoprolol inj 30 metoprolol tab 30 metoprolol/ 8 hydrochlorothiazide tab

ALPHABETICAL LISTING OF DRUGS metronidazole cap 9 metronidazole cream metronidazole gel metronidazole lotion metronidazole tab 9 metronidazole vaginal gel 63 metronidazole/ nacl inj 9 mexiletine cap 7 MIACALCIN INJ 3 miconazole cream %* 38 miconazole cream kit* 63 miconazole nitrate vaginal 63 supp 00mg* miconazole powder %* 38 miconazole vaginal cream 63 %, %* miconazole vaginal kit* 63 microgestin tab 33 midodrine tab 63 MIGERGOT SUPP 50 mimvey lo tab mimvey tab MINERAL OIL* 9 minitran patch 6 minocycline cap 60 minocycline ER tab 60 minocycline tab 60 minoxidil tab 8 mirtazapine ODT mirtazapine tab misoprostol tab 6 mitomycin inj 3 mitoxantrone inj 3 M-M-R II WITH 63 DILUENT INJ moderiba tab 00mg 8 MODERIBA TAB 8 00MG, 600MG moexipril tab 7 moexipril/ 8 hydrochlorothiazide tab mometasone furoate cream 0 mometasone furoate lotion 0 mometasone furoate 0 ointment mononessa tab 33 montelukast chew tab 7 montelukast granules 7 montelukast tab 7 morphine sulfate ER cap morphine sulfate ER tab MORPHINE SULFATE INJ MORPHINE SULFATE PF INJ morphine sulfate soln morphine sulfate tab MOXEZA OPHTH SOLN 55 moxifloxacin tab 5 MOZOBIL INJ 8 MULTAQ TAB 7 multivitamin liquid* 5 multivitamin tab* 5 multivitamin w/ minerals 5 tab* mupirocin cream 37 mupirocin ointment 37 MYCAMINE INJ 5 mycophenolate cap 30 mycophenolate sodium tab 30 mycophenolate susp 30 mycophenolate tab 30 myorisan cap 37 MYOZYME INJ MYSTARGEN INJ N nabumetone tab nadolol tab 30 nadolol/ 8 bendroflumethiazide tab nafcillin inj 58 NAFCILLIN/ DEXTROSE 58 INJ naftifine cream 38 NAFTIN CREAM 38 NAFTIN GEL 38 NAGLAZYME INJ NALOXONE INJ naltrexone tab NAMENDA SOLN 59 NAMENDA TAB 59 NAMENDA TAB 59 TITRATION K NAMENDA XR CAP 59 77 NAPHAZOLINE OPHTH 55 SOLN naphazoline/ glycerin 55 ophth soln* naphazoline/ pheniramine 55 ophth soln* naproxen DR tab 3 naproxen ER tab 3 naproxen sodium tab 3 NAPROXEN SUSP 3 naproxen tab 3 naratriptan tab 50 NASONEX NASAL 53 SPRAY NATACYN OPHTH SUSP 55 NATAZIA TAB 33 nateglinide tab 3 NATRA INJ 3 NEBUPENT NEB 9 necon tab 3 NEFAZODONE TAB neomycin tab neomycin/ bacitracin/ 55 polymyxin ophth ointment neomycin/ polymyxin B GU 6 irrigation soln neomycin/ polymyxin/ 56 bacitracin/ hydrocortisone ophth ointment neomycin/ polymyxin/ 56 dexamethasone ophth ointment neomycin/ polymyxin/ 56 dexamethasone ophth soln neomycin/ polymyxin/ 55 gramicidin ophth soln neomycin/ polymyxin/ 56 hydrocortisone ophth susp neomycin/ polymyxin/ 57 hydrocortisone otic soln neomycin/ polymyxin/ 57 hydrocortisone otic susp NEPHRAMINE INJ 5 NEULASTA INJ 7 NEUMEGA INJ 7 NEUPOGEN INJ 7 NEUPRO TCH 5 NEVANAC OPHTH SUSP 56

ALPHABETICAL LISTING OF DRUGS nevirapine ER tab 00mg 7 nevirapine tab 7 NEXAVAR TAB 3 NEXTERONE INJ 7 niacin CR cap 50mg, 6 500mg* NIACIN CR TAB 6 000MG* niacin CR tab 500mg, 6 750mg* niacin tab 50mg, 00mg, 6 50mg, 500mg* NIACOR TAB 7 NIASN ER TAB 7 nicardipine cap 3 nicardipine inj 3 nicotine gum mg, mg* 59 nicotine patch 7mg, mg, 59 mg* NICOTROL INHALER 59 NICOTROL NASAL 59 SPRAY nifedical XL tab 3 nifedipine cap 3 nifedipine ER tab 3 NILANDRON TAB nimodipine cap 3 nisoldipine ER tab 3 NITRO-DUR TCH 6 0.3MG, 0.8MG nitrofurantoin macro cap 6 50mg, 00mg nitrofurantoin mono cap 6 nitrofurantoin susp 6 nitroglycerin inj 6 nitroglycerin lingual spray 6 nitroglycerin patch 6 NITROSTAT SL TAB 6 nizatidine cap 6 nizatidine soln 6 NONOXYNOL-9 FOAM 63.5%* nonoxynol-9 gel 3%* 63 nora-be tab 3 NORDITROPIN INJ 3 norethindrone tab 3 norethindrone tab 3 norethindrone/ ethinyl 3 estradiol FE chew tab norethindrone/ ethinyl 3 estradiol FE tab norlyroc tab 35 NORMOSOL/ D5W INJ 5 normosol-m/ d5w inj 5 NORMOSOL-R INJ 5 NORCE CR CAP 7 nortrel tab 3 nortriptyline cap nortriptyline soln NORVIR CAP 7 NORVIR SOLN 7 NORVIR TAB 7 NOVOFINE PEN 50 NEEDLES NOVOLIN 70/ 30 VIAL 3 NOVOLIN N VIAL 3 NOVOLIN R VIAL 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/ 30 3 PEN NOVOLOG MIX INJ 3 NOVOLOG PENFILL 3 NOVOLOG VIAL 3 NOXAFIL SUSP 5 NOXAFIL TAB 5 NUCYNTA ER TAB NUEDEXTA CAP 59 NULOJIX INJ 30 nutrilipid inj 5 NUVARING 3 NUVIGIL TAB nyamyc powder 38 nystatin cream 38 nystatin ointment 38 nystatin susp 5 nystatin tab 5 nystatin topical powder 38 nystatin/ triamcinolone 38 cream nystatin/ triamcinolone 38 ointment nystop topical powder 38 O OCTAGAM INJ 57 78 octreotide inj ofloxacin ophth soln 55 ofloxacin otic soln 57 ofloxacin tab 5 olanzapine inj 6 olanzapine ODT 6 olanzapine tab 6 olanzapine/ fluoxetine cap 59 OLYSIO TAB 8 omega-3 acid ethyl esters 6 cap omega-3 fatty acid cap 5 000mg, 00mg* omeprazole cap 6 OMEPRAZOLE TAB 6 0MG* ONCASR INJ 3 ondansetron inj ondansetron ODT ondansetron soln ondansetron tab ONFI SUSP 9 ONFI TAB 9 ONGLYZA TAB 3 OPDIVO INJ OPSUMIT TAB 3 ORAP TAB 59 ORAPRED ODT 35 ORENCIA INJ 3 ORENCIA SC INJ 3 ORFADIN CAP orphenadrine citrate inj 53 orphenadrine ER tab 53 orsythia tab 3 ORTHO TRI-CYCLEN 3 LO TAB OTEZLA TAB 3 OTEZLA TAB STARTER 3 CK oxacillin inj 58 OXACILLIN/ 58 DEXTROSE INJ oxaliplatin inj oxandrolone tab 5 oxaprozin tab 3 oxazepam cap 7 oxcarbazepine oral susp 0 oxcarbazepine tab 0

ALPHABETICAL LISTING OF DRUGS OXISTAT CREAM 38 OXISTAT LOTION 38 OXTELLAR XR TAB 0 oxybutynin ER tab 6 oxybutynin ER tab 6 oxybutynin syrup 6 oxybutynin tab 6 oxycodone cap oxycodone soln oxycodone tab oxycodone/ acetaminophen 5 tab oxycodone/ aspirin tab 5 oxycodone/ ibuprofen tab 5 OXYCONTIN TAB OXYCONTIN TAB 80MG oxymorphone ER tab oxymorphone tab P paclitaxel inj pamidronate inj 3 MIDRONATE INJ 3 6MG/ ML NCREAZE CAP NRETIN GEL 38 pantoprazole tab 6 paricalcitol cap RICALCITOL INJ paromomycin cap paroxetine ER tab paroxetine tab SER GRANULE 0 TADAY OPHTH 56 SOLN TANASE NASAL 53 SOLN XIL SUSP pediatric multivitamin soln 5 35mg/ ml* pediatric multivitamin w/ 5 iron drops 0mg/ ml* PEDVAX HIB INJ 6 peg 3350/ electrolyte soln 9 PEGANONE TAB 0 PEGASYS INJ 8 PEGASYS PROCLICK 8 INJ PEG-INTRON INJ 8 penicillin g potassium inj 58 PENICILLIN G 58 PROCAINE INJ PENICILLIN G SODIUM 58 INJ PENICILLIN G/ 58 DEXTROSE INJ penicillin v potassium soln 58 penicillin v potassium tab 58 PENNSAID SOLN 38 PENTAM INJ 9 PENTASA CAP 5 pentazocine/ naloxone tab 5 pentoxifylline ER tab 7 perindopril tab 7 periogard soln 5 PERJETA INJ permethrin cream permethrin creme rinse % * perphenazine tab 6 perphenazine/ amitriptyline 59 tab PEXEVA TAB phenadoz supp 6 phenelzine tab phenobarbital elixir 8 phenobarbital tab 8 phentermine cap 5mg, 30mg* phentermine tab 37.5mg* phenylephrine 36 chlorpheniramine soln 0--5mg/ 5ml, 0--5mg/ 5ml* phenylephrine DM/ 36 guaifenesin liquid 5-0-00mg/ 5ml* phenylephrine/ guaifenesin 36 liquid 5-00mg/ 5ml* phenytoin cap 0 phenytoin chew tab 0 phenytoin inj 0 phenytoin susp 0 PHOSLYRA SOLN 6 PHOSPHOLINE IODIDE 55 OPHTH SOLN 79 physiolyte irrigation soln 30 physiosol irrigation soln 30 phytonadione tab 00mcg* 6 PICATO GEL 0.05% 38 PICATO GEL 0.05% 38 pilocarpine ophth soln 55 pilocarpine tab 5 pimtrea tab 3 pindolol tab 30 pioglitazone tab 3 pioglitazone/ glimepiride tab pioglitazone/ metformin tab piperacillin/ tazobactam inj 58 pirmella tab 3 piroxicam cap 3 PLASMA-LYTE INJ 5 PLASMA-LYTE/ D5W 5 INJ podofilox soln polyethylene glycol powder 9 3350 polymyxin B inj 0 polymyxin B/ trimethoprim 55 ophth soln POMALYST CAP portia-8 tab 3 POTASSIUM CHLORIDE 5 (0MEQ)/ D5W/ NACL INJ potassium chloride ER cap 5 potassium chloride ER tab 5 potassium chloride inj 5 meq potassium chloride soln 5 potassium chloride/ d5w inj 5 POTASSIUM 5 CHLORIDE/ D5W/ LACTATED RINGERS SOLN POTASSIUM 5 CHLORIDE/ D5W/ NACL INJ potassium chloride/ d5w/ 5 nacl inj potassium chloride/ nacl 5 inj potassium citrate CR tab 6

ALPHABETICAL LISTING OF DRUGS potassium citrate ER tab 6 5meq POTIGA TAB 0 PRADAXA CAP 9 pramipexole ER tab 5 pramipexole tab 5 pravastatin tab 7 prazosin cap 8 PRECISION INSULIN 50 SYRINGE PRED MILD OPHTH 56 SUSP PRED-G OPHTH SUSP 56 prednicarbate ointment 0 prednisolone ODT 35 PREDNISOLONE 56 SODIUM PHOSPHATE OPHTH SOLN prednisolone sodium 35 phosphate soln prednisolone susp 56 PREDNISONE 35 INTENSOL CONC prednisone soln 35 prednisone tab 35 PREMARIN TAB 5 PREMARIN VAGINAL 63 CREAM PREMASOL SOLN 0% 5 premasol soln 6% 5 PREMPHASE TAB PREMPRO TAB PRENATAL VITAMIN 5 TAB PRENATAL VITAMIN 53 TAB (OTC)* prenicarbate cream 0 PREVACID SOLUTAB 6 previfem tab 3 PREZCOBIX TAB 7 PREZISTA SUSP 7 PREZISTA TAB 8 PRIFTIN TAB 0 PRIMAQUINE TAB 0 primidone tab 0 PRISTIQ TAB PRIVIGEN INJ 57 probenecid tab 7 PROCAINAMIDE INJ 7 PROCALAMINE INJ 5 prochlorperazine edisylate 6 inj prochlorperazine supp 6 prochlorperazine tab 6 PROCRIT INJ 7 procto-pak cream 5 proctozone-hc cream 5 progesterone cap 58 PROGLYCEM SUSP 3 PROGRAF INJ 30 PROLEUKINE IV SOLN PROLIA INJ 3 PROMACTA TAB 8 promethazine DM syrup 36 6.5-5mg/ 5ml* promethazine inj 6 promethazine supp 6 promethazine syrup 6 promethazine tab 6 PROMETHAZINE VC 6 SYRUP PLAIN promethazine/ codeine 36 syrup 6.5-0mg/ 5ml* promethegan supp 6 PROMETHEGAN SUPP 6 50MG propafenone ER cap 7 propafenone tab 7 PRONTHELINE TAB 6 proparacaine ophth soln 55 propranolol ER cap 3 propranolol inj 3 propranolol oral soln 3 propranolol tab 3 propranolol/ 8 hydrochlorothiazide tab propylthiouracil tab 60 PROQUAD INJ 63 PROSOL INJ 5 PROTOPIC OINTMENT protriptyline tab prudoxin cream 38 pseudoephedrine hr tab 53 0mg* 80 pseudoephedrine DM/ 36 guaifenesin liquid 30-0-00mg/ 5ml* pseudoephedrine liquid 53 5mg/ 5ml* pseudoephedrine tab 30mg, 53 60mg* pseudoephedrine/ 36 brompheniramine DM elixir 5--5mg/ 5ml* pseudoephedrine/ 36 chlorpheniramine DM liquid 5--5mg/ 5ml* pseudoephedrine/ 36 chlorpheniramine DM syrup 30--0mg/ 5ml* pseudoephedrine/ 36 doxylamine/ DM/ acetaminophen liquid 60-.5-30-000mg/ 30ml* pseudoephedrine/ 36 guaifenesin liquid 7.5-50mg/ ml* pseudoephedrine/ 36 guaifenesin syrup 30-00mg/ 5ml* psyllium cap 0.5gm* 8 psyllium powder 8.3%, 8 30.9%, 9%, 58.6%* PSYLLIUM POWDER 8 CKET 00%* PULMICORT NEB MG/ 8 ML PULMOZYME SOLN 60 PURIXAN SUSP PYLERA CAP 6 pyrazinamide tab 0 pyridostigmine tab 0 pyridoxine tab 5mg, 6 50mg, 00mg* Q QSYMIA CAP* QUADRACEL INJ 6 QUARTETTE TAB 3 quasense tab 3 quetiapine tab 6 quinapril tab 7

ALPHABETICAL LISTING OF DRUGS quinapril/ 8 hydrochlorothiazide tab quinidine gluconate CR tab 7 QUINIDINE 7 GLUCONATE INJ quinidine sulfate tab 7 quinine sulfate cap 0 QVAR INHALER 8 R RABAVERT INJ 63 rabeprazole tab 6 raloxifene tab 3 ramipril cap 7 RANEXA TAB 6 ranitidine cap 6 ranitidine inj 6 ranitidine syrup 6 ranitidine tab 6 RAFLO CAP 6 RAMUNE SOLN 30 RAMUNE TAB 30 REBIF INJ 59 REBIF REBIDOSE INJ 59 TITRATION CK REBIF TITRATION 59 CK reclipsen tab 3 RECOMBIVAX-HB INJ 63 REGRANEX GEL RELENZA DISKHALER 9 RELISTOR INJ 6 REMICADE INJ 5 REMODULIN INJ 3 RENVELA CKET 6 RENVELA/ 6 SEVELAMER CARBONATE TAB repaglinide tab 3 RESCRIPTOR TAB 8 RESTASIS EMULSION 55 RETIN-A MICRO GEL 37 RETROVIR INJ 8 REVLIMID CAP.5MG, 9 0MG REVLIMID CAP 5MG, 9 0MG, 5MG, 5MG REYATAZ CAP 8 REYATAZ POWDER 8 CKET RHEUMATREX TAB DOSE CK ribasphere cap 9 ribasphere tab 9 ribavirin cap 9 ribavirin tab 9 RIDAURA CAP rifabutin cap 0 RIFAMATE CAP 0 rifampin cap 0 rifampin inj 0 RIFATER TAB 0 riluzole tab 53 rimantadine tab 9 ringers inj 5 ringers irrigation 30 risedronate sodium tab 3 RISPERDAL CONSTA 6 INJ risperidone ODT 6 risperidone soln 6 risperidone tab 6 RITUXAN INJ rivastigmine tab 59 rizatriptan ODT 50 rizatriptan tab 50 ropinirole ER tab 5 ropinirole tab 5 ROTARIX SUSP 63 ROTATEQ ORAL SUSP 63 ROXICET SOLN 5 RUCONEST INJ 7 S SABRIL POWDER 0 SABRIL TAB 0 salicylic acid soln 3%* saline nasal spray 0.65%* 53 SANDIMMUNE SOLN 30 SANTYL OINTMENT SAPHRIS SL TAB 6 SAVELLA TAB 59 SAVELLA TITRATION 59 CK SECONAL CAP 8 selegiline cap 5 8 selegiline tab 5 selenium sulfide shampoo 39 SELZENTRY TAB 8 senna syrup 8.8mg/ 5ml* 9 senna tab 8.6mg* 9 SENSIR TAB SEREVENT INHALER 8 SEROQUEL XR TAB 6 sertraline conc sertraline tab sharobel tab 35 SIGNIFOR INJ sildenafil tab 3 silver sulfadiazine cream 39 SIMCOR TAB 7 simethicone cap 5mg* 5 simethicone susp 0mg/ 5 0.6ml* SIMPONI INJ SIMULECT INJ 30 simvastatin tab 7 sirolimus cap 30 sirolimus tab 30 SIVEXTRO INJ 0 SIVEXTRO TAB 0 sodium bicarbonate tab 6 650mg* sodium chloride hypertonic 56 ophth ointment 5%* sodium chloride hypertonic 56 ophth soln 5%* sodium chloride inj 5 sodium chloride irrigation 6 soln sodium fluoride tab 5 sodium lactate inj 50 sodium phenylbutyrate powder sodium phosphate enema* 9 sodium polystyrene 30 sulfonate susp SOLTAMOX ORAL SOLN SOLU-CORTEF INJ 35 SOMATULINE DEPOT INJ SOMAVERT INJ 3 sorbitol soln 70%* 9

ALPHABETICAL LISTING OF DRUGS sorine tab 3 sotalol tab 3 SOVALDI TAB 9 SCER HOLDING 50 CHAMBER* SPINOSAD SUSP SPIRIVA CAP 7 HANDIHALER SPIRIVA RESPIMAT 7 spironolactone tab spironolactone/ hydrochlorothiazide tab sprintec-8 tab 3 SPRYCEL TAB 3 sronyx tab 3 ssd cream 39 STALEVO TAB 5 stavudine cap 8 stavudine soln 8 STELARA INJ 39 sterile water irrigation 30 STIMATE NASAL SOLN STIVARGA TAB 3 STRATTERA CAP STREPTOMYCIN INJ STRIBILD TAB 8 STRIVERDI INHALER 8 STROMECTOL TAB 6 SUBOXONE SL FILM 5 SUCLEAR KIT 9 sucralfate tab 6 sulfacetamide sodium 37 lotion sulfacetamide sodium 55 ophth ointment sulfacetamide sodium 55 ophth soln sulfacetamide sodium/ 56 prednisolone ophth soln SULFADIAZINE TAB 60 sulfamethoxazole/ 9 trimethoprim DS tab SULFAMETHOXAZOLE/ 9 TRIMETHOPRIM INJ sulfamethoxazole/ 9 trimethoprim susp sulfamethoxazole/ 9 trimethoprim tab SULFAMYLON CREAM 39 sulfasalazine tab 5 sulfazine EC tab 5 sulindac tab 3 sumatriptan inj 50 SUMATRIPTAN NASAL 50 SPRAY sumatriptan tab 50 SUPRAX CAP 3 SUPREP BOWEL PREP 9 SURMONTIL CAP SUSTIVA CAP 8 SUSTIVA TAB 8 SUTENT CAP 3 SYLATRON INJ SYLVANT INJ 30 SYMBICORT INHALER 8 SYMLINPEN INJ SYNAGIS INJ 57 SYNAREL NASAL SOLN 3 SYNERCID INJ 0 SYNRIBO INJ SYNTHROID TAB 60 SYPRINE CAP 9 T TABLOID TAB tacrolimus cap 30 tacrolimus ointment TAFINLAR CAP 3 TAMIFLU CAP 30MG 9 TAMIFLU CAP 5MG, 9 75MG TAMIFLU SUSP 9 tamoxifen citrate tab tamsulosin cap 6 TARCEVA TAB 3 TARGRETIN CAP tarina FE tab 3 TASIGNA CAP 3 TASMAR TAB 5 TAXOTERE INJ tazicef inj 3 TAZORAC CREAM 39 TAZORAC GEL 39 taztia-xt cap 3 TECFIDERA CAP 59 8 TECFIDERA CAP 59 STARTER CK TEFLARO INJ 33 TEGRETOL-XR TAB 0 telmisartan tab 8 telmisartan/ amlodipine tab 8 telmisartan/ 8 hydrochlorothiazide tab temazepam cap 8 tencon tab 3 TENIVAC INJ 6 terazosin cap 8 terbinafine tab 5 terbutaline inj 8 terbutaline tab 8 terconazole vaginal cream 63 terconazole vaginal supp 63 testosterone cypionate inj 5 testosterone enanthate inj 5 TETANUS TOXOID 6 ADSORBED INJ TETANUS/ DIPHTHERIA 6 TOXOID INJ tetracycline cap 60 THALOMID CAP 9 theophylline ER tab 8 theophylline soln 8 thiamine tab 00mg* 6 THIOLA TAB 6 thioridazine tab 6 thiothixene cap 6 THYMOGLOBULIN INJ 30 THYROLAR TAB 60 tiagabine tab 0 ticlopidine tab 7 TIKOSYN CAP 7 timolol maleate ophth gel 5 timolol maleate ophth soln 5 timolol maleate tab 3 tinidazole tab 9 tioconazole vaginal 63 ointment 6.5%* TIVICAY TAB 8 tizanidine cap 53 tizanidine tab 53 TOBI NEB TOBI PODHALER

ALPHABETICAL LISTING OF DRUGS TOBRADEX OPHTH 56 OINTMENT tobramycin inj tobramycin ophth soln 55 tobramycin/ 56 dexamethasone ophth soln TOBRAMYCIN/ NACL INJ tolazamide tab TOLBUTAMIDE TAB tolcapone tab 5 tolmetin cap 3 tolmetin tab 3 TOLMETIN TAB 00MG 3 tolnaftate cream %* 38 tolnaftate soln %* 38 tolterodine tab 6 tolterodine tartrate ER cap 6 TOPICORT CREAM 0 TOPIRAMATE ER CAP 0 topiramate sprinkle cap 0 topiramate tab 0 toposar inj topotecan inj TORISEL SOLN 3 torsemide tab TOUJEO SOLOSTAR 3 PEN TOVIAZ TAB 6 tpn electrolytes soln 5 TRACLEER TAB 3 TRADJENTA TAB 3 tramadol ER tab tramadol tab tramadol/ acetaminophen 5 tab trandolapril tab 7 trandolapril/ verapamil ER 8 tab tranexamic acid inj 8 tranexamic acid tab 8 TRANSDERM SCOP TCH tranylcypromine tab TRAVASOL INJ 5 TRAVATAN Z OPHTH 57 SOLN TRAVOPROST OPHTH 57 SOLN trazodone tab TREANDA INJ TRECATOR TAB 0 TRELSTAR DEPOT MIXJECT INJ TRELSTAR LA MIXJECT INJ TRELSTAR MIXJECT INJ tretinoin cap tretinoin cream 37 tretinoin gel 37 TRETIN-X CREAM 37 TREXALL TAB TREXIMET TAB 50 triamcinolone acetonide inj 35 triamcinolone cream triamcinolone in orabase 5 paste triamcinolone lotion triamcinolone nasal spray 53 triamcinolone ointment triamterene/ hydrochlorothiazide cap triamterene/ hydrochlorothiazide tab TRIANEX OINTMENT triazolam tab 8 triderm cream trifluoperazine tab 6 trifluridine ophth soln 55 TRIGLIDE TAB 7 trihexyphenidyl soln 5 trihexyphenidyl tab 5 tri-legest FE tab 3 TRILIPIX CAP 7 trilyte soln 9 trimethobenzamide cap 5 trimethoprim tab 9 trinessa tab 3 tri-previfem tab 3 triprolidine/ 36 pseudoephedrine syrup.5-30mg/ 5ml* triprolidine/ 36 pseudoephedrine tab.5-60mg* TRISENOX INJ tri-sprintec tab 3 TRIUMEQ TAB 8 tri-vitamin pediatric 5 drops* trivora-8 tab 3 TROKENDI XR CAP 0 TROPHAMINE INJ 5 trospium chloride ER cap 6 trospium tab 6 TRULICITY INJ 3 TRUVADA TAB 8 TUDORZA INHALER 7 TWINRIX INJ 63 TYBOST TAB 8 TYGACIL INJ 9 TYKERB TAB 3 TYPHIM VI INJ 6 TYSABRI INJ 59 TYVASO INHALATION 3 SOLN TYZEKA TAB 9 U UCERIS RECTAL FOAM 5 UCERIS TAB 35 u-cort cream ULORIC TAB 7 ULTRESA CAP unithroid tab 60 UROCIT-K 5 TAB 6 ursodiol cap 5 ursodiol tab 5 UVADEX SOLN V valacyclovir tab 9 VALCHLOR GEL 38 VALCYTE SOLN 8 VALCYTE TAB 8 valganciclovir tab 50mg 8 valproate sodium inj valproic acid cap valproic acid syrup valsartan tab 8 83

ALPHABETICAL LISTING OF DRUGS valsartan/ 8 hydrochlorothiazide tab vancomycin cap 9 vancomycin inj 9 vandazole vaginal gel 63 VAQTA INJ 63 VARIVAX INJ 63 VASCE CAP 6 VECTIBIX INJ VECTICAL OINTMENT 39 VELCADE INJ 3 velivet tab 3 venlafaxine ER cap venlafaxine ER tab VENLAFAXINE ER TAB 5MG venlafaxine tab VENTAVIS 3 INHALATION SOLN VENTOLIN HFA 8 INHALER VERAMYST NASAL 53 SPRAY verapamil ER cap 3 verapamil ER tab 3 verapamil inj 3 verapamil tab 3 VERSACLOZ SUSP 6 VESICARE TAB 6 VEXOL OPHTH SUSP 56 VICTOZA INJ 3 VIDEX SOLN 8 VIGAMOX OPHTH 55 SOLN VIIBRYD TAB VIIBRYD TAB STARTER CK VIMT INJ 0 VIMT SOLN 0 VIMT TAB 0 vinblastine inj vincasar PFS inj vincristine inj vinorelbine inj VIRACEPT TAB 8 VIRAMUNE SUSP 8 VIRAMUNE XR TAB 8 00MG VIRAZOLE 9 INHALATION SOLN VIREAD POWDER 8 VIREAD TAB 8 vitamin B complex w/ C 5 cap* vitamin D with calcium 5 tab* VITEKTA TAB 8 VIVELLE-DOT TCH 5 VOLTAREN GEL 38 voriconazole inj 5 voriconazole susp 5 voriconazole tab 5 VOTRIENT TAB 3 vyfemla tab 3 VYVANSE CAP W warfarin tab 8 WELCHOL TAB 7 WOUND CLEANSER LIQUID* wymzya FE chew tab 3 X XALKORI CAP 3 XARELTO TAB 9 XARELTO TAB 9 STARTER CK XELJANZ TAB XENAZINE TAB 59 XENICAL CAP 0MG* XGEVA INJ 3 XIGDUO XR TAB XOLAIR INJ 7 XTANDI CAP xulane patch 3 XYREM ORAL SOLN 58 Y YASMIN TAB 3 YERVOY INJ YF-VAX INJ 63 Z zafirlukast tab 8 zaleplon cap 8 ZALTRAP INJ ZANOSAR INJ 8 ZAVESCA CAP 7 zazole vaginal cream 63 ZELBORAF TAB 3 ZEMAIRA INJ 60 ZEMPLAR INJ ZENATANE CAP 37 zenatane cap 37 zenchent FE tab 3 zenchent tab 3 ZETIA TAB 7 ZIAGEN SOLN 8 zidovudine cap 8 zidovudine syrup 8 zidovudine tab 8 zinc oxide ointment 0%* ziprasidone cap 5 ZIRGAN OPHTH GEL 55 zoledronic acid inj 3 ZOLINZA CAP 3 zolmitriptan ODT 50 zolmitriptan tab 50 zolpidem tab 8 ZOMETA INJ MG/ 3 00ML ZOMIG NASAL SPRAY 50 ZONATUSS CAP 35 50MG* zonisamide cap 0 ZORTRESS TAB 30 ZOSTAVAX INJ 63 ZOSYN INJ 58 zovia tab 3 ZOVIRAX OINTMENT 39 ZYCLARA CREAM ZYDELIG TAB 3 ZYKADIA CAP 3 ZYLET OPHTH SOLN 56 ZYPREZA INJ 6 ZYTIGA TAB ZYVOX INJ 0 ZYVOX SUSP 0 ZYVOX TAB 0

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