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Transcription

1 L.A. Care Health Plan Medicare Advantage ( HMO SNP) 2013 Formula Formulario paraa 201 ary List of Covered s 3 Lista de medicamentos cubiertos Please read: This document contains information about the drugs we cover in this plan. Sírvase leer: Este documento contiene información sobre medicamentos que cubrimos en este plan. H2643_1085_Formulary File and Use H2643_1085_FormularySP File and Use Formulary ID Version Number 14 Last Updated 07/2013

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefits. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, L.A. Care Health Plan is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. This information is available in a different language or format, including large print, audio, and Braille. Please call L.A. Care Health Plan s Member Services Department at , 24 hours a day, 7 a week, including holi, if you need plan information in another language or format. TTY/TDD users should call Nota para los miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para verificar que todavía contiene los medicamentos que usted utiliza. Los beneficiarios deben usar las farmacias de la red para acceder a su beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias, la prima y/o los pagos compartidos/ seguro compartido pueden cambiar el 1. de enero de L.A. Care Health Plan es un plan de salud con servicios de atención médica coordinada que tiene contratos con Medicare y el programa California Medicaid. Esta información está disponible en un idioma o formato diferente, incluyendo letra grande, audio y Braille. Llame al Departamento de servicios para los miembros de L.A. Care Health Plan al , las 24 horas del día, los 7 días de la semana, incluso los días festivos, si necesita información del plan en otro idioma o formato. Los usuarios de TTY/TDD deben llamar al i

3 What is the L.A. Care Health Plan Medicare Advantage Formulary? A formulary is a list of covered drugs selected by L.A. Care Health Plan Medicare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. L.A. Care Health Plan Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an L.A. Care Health Plan Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, To get updated information about the drugs covered by L.A. Care Health Plan Medicare Advantage, please visit our website at or call Member Services at , 24 hours a day, 7 a week, including holi. TTY/TDD users should call In the event of mid-year non-maintenance formulary changes, we will provide you with an errata (correction) sheet for this formulary and update our website at ii

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiac s. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? L.A. Care Health Plan Medicare Advantage covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: L.A. Care Health Plan Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from L.A. Care Health Plan Medicare Advantage before you fill your prescriptions. If you don t get approval, L.A. Care Health Plan Medicare Advantage may not cover the drug. Quantity Limits: For certain drugs, L.A. Care Health Plan Medicare Advantage limits the amount of the drug that L.A. Care Health Plan Medicare Advantage will cover. For example, L.A. Care Health Plan Medicare Advantage provides 62 capsules per prescription for Geodon. This may be in addition to a standard one-month or three-month supply. iii

5 Step Therapy: In some cases, L.A. Care Health Plan Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, L.A. Care Health Plan Medicare Advantage may not cover B unless you try A first. If A does not work for you, L.A. Care Health Plan Medicare Advantage will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at You can ask L.A. Care Health Plan Medicare Advantage to make an exception to these restrictions or limits. See the section, How do I request an exception to the L.A. Care Health Plan Medicare Advantage Formulary? below for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that L.A. Care Health Plan Medicare Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by L.A. Care Health Plan Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by L.A. Care Health Plan Medicare Advantage. You can ask L.A. Care Health Plan Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception. iv

6 How do I request an exception to the L.A. Care Health Plan Medicare Advantage Formulary? You can ask L.A. Care Health Plan Medicare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, L.A. Care Health Plan Medicare Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. Generally, L.A. Care Health Plan Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s or prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing physician s supporting statement. v

7 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer ) when you go to a network pharmacy. After your first 90-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer ). We will cover more than one refill of these drugs for the first 90 you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer ) while you pursue a formulary exception. Note: You may experience a change in the level of care received and/or may be required to transition from one facility or treatment site to another. Exceptions are available to you if you experience a change in the level of care being received. If you experience a change in level of care, L.A. Care Health Plan Medicare Advantage will cover a temporary 31-day supply (unless you have a prescription written for a fewer ). For more information For more detailed information about your L.A. Care Health Plan Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about L.A. Care Health Plan Medicare Advantage, please call Member Services at , 24 hours a day, 7 a week, including holi. TTY/TDD users should call Or, visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day, 7 a week. TTY/TDD users should call Or, visit vi

8 L.A. Care Health Plan Medicare Advantage Formulary The formulary on page 1 provides coverage information about some of the drugs covered by L.A. Care Health Plan Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LEXAPRO), and generic drugs are listed in lowercase italics (e.g., flovent). The information in the column tells you if L.A. Care Health Plan Medicare Advantage has any special requirements for coverage of your drug. vii

9 COVERAGE NOTES ABBREVIATIONS The following abbreviations may be found within the body of this document: ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from L.A. Care Health Plan Medicare Advantage before you fill your prescription for this drug. Without prior approval, L.A. Care Health Plan Medicare Advantage may not cover this drug. QL Quantity Limit Restriction L.A. Care Health Plan Medicare Advantage limits the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before L.A. Care Health Plan Medicare Advantage will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage EX Excluded Part D This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 24 hours a day, 7 a week (including holi). TTY/TDD users should call GC Gap Coverage We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. NM Non-Mail-Order You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. s not available via your mail order benefit are noted with NM in the notes column of your formulary. HI Home Infusion This prescription drug may be covered under our medical benefit. For more information, call Member Services at , 24 hours a day, 7 a week, including holi, TTY/TDD users should call viii

10 Please see the chart below for a description of your prescription drug coverage: TIER 1 GENERIC DRUGS Your co-payment amount for generic drugs is: TIER 2 BRAND-NAME DRUGS Your co-payment amount for brand-name drugs is: STRENGTH AND DOSAGE FORM ABBREVIATIONS adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 12hr cpmp 24hr cpmp cpmp cream(g), cream(gm) cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln ix

11 STRENGTH AND DOSAGE FORM ABBREVIATIONS (cont d) iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring x

12 En qué consiste el formulario de L.A. Care Health Plan Medicare Advantage? Un formulario es una lista de medicamentos cubiertos seleccionados por L.A. Care Health Plan Medicare Advantage con el asesoramiento de un equipo de proveedores médicos, el cual representa las terapias recetadas que se consideran una parte necesaria de un programa de tratamiento de calidad. L.A. Care Health Plan Medicare Advantage generalmente cubrirá los medicamentos enumerados en nuestro formulario siempre y cuando el medicamento sea médicamente necesario, la receta se surta en una farmacia de la red de L.A. Care Health Plan Medicare Advantage y se cumplan otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de cobertura. Puede cambiar el formulario? Generalmente, si está tomando un medicamento que figura en nuestro formulario de 2013 que estaba cubierto a principios de año, no descontinuaremos ni reduciremos la cobertura de un medicamento durante el año de cobertura de 2013, excepto cuando haya disponible un nuevo medicamento genérico menos caro o cuando se divulgue nueva información adversa sobre la efectividad o seguridad del mismo. Otros tipos de cambios en el formulario, tales como remover un medicamento de nuestro formulario, no afectarán a los miembros que actualmente están tomando el medicamento. Continuará disponible al mismo costo compartido para aquellos miembros que están tomándolos por el resto del año cubierto. Creemos que es importante que tenga acceso continuo por el resto del año cubierto a los medicamentos del formulario que estaban disponibles cuando escogió nuestro plan, excepto para casos en los que puede ahorra dinero adicional o podemos asegurar su bienestar. Si retiramos medicamentos de nuestro formulario, o agregamos autorizaciones previas, límites a la cantidad y/o restricciones a la terapia escalonada en un medicamento, debemos notificar a los miembros afectados por dichos cambios por lo menos con 60 días de anticipación a que la modificación entre en vigor, o cuando el miembro solicite volver a surtir el medicamento, momento en el cual el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Drogas y Alimentos de los Estados Unidos (FDA, por sus siglas en inglés) considera que un medicamento en nuestro formulario no es seguro o el fabricante lo retira del mercado, nosotros retiraremos de inmediato el medicamento de nuestro formulario y le notificaremos a los miembros que utilizan el medicamento. El formulario anexo está actualizado al 1. de enero de Para obtener información actualizada sobre los medicamentos cubiertos por L.A. Care Health Plan Medicare Advantage, visite nuestro sitio web en o llame al Departamento de servicios para los miembros al , las 24 horas del día, los 7 días de la semana, incluso los días festivos. Los usuarios de TTY/TDD deben llamar al En caso que a mitad de año se realicen cambios al formulario que no sean de mantenimiento, le brindaremos una fe de erratas (corrección) para este formulario y actualizaremos nuestro sitio web en xi

13 Cómo utilizo el formulario? Hay dos maneras de encontrar sus medicamentos en el formulario: Condición médica El formulario inicia en la página 1. Los medicamentos en este formulario están agrupados en categorías, según el tipo de condiciones médicas a cuyo tratamiento se apliquen. Por ejemplo, los medicamentos que se utilizan para tratar una condición cardíaca están listados en la categoría Medicamentos para el corazón. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Luego busque dentro del nombre de categoría de su medicamento. Lista alfabética Si no está seguro en cuál categoría buscar, debe buscar su medicamento en el índice que empieza en la página I-1. El índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. En el índice se incluye tanto el nombre de marca como el nombre genérico. Busque en el índice y ubique su medicamento. Junto a su medicamento, verá el número de página donde hay información sobre su cobertura. Vaya a la página indicada en el índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? L.A. Care Health Plan Medicare Advantage cubre tanto medicamentos de marca como medicamentos genéricos. La FDA aprueba un medicamento genérico al contener el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca registrada. Existen restricciones en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir: Autorización previa: L.A. Care Health Plan Medicare Advantage requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación de L.A. Care Health Plan Medicare Advantage antes de surtir sus recetas. Si no recibe aprobación, L.A. Care Health Plan Medicare Advantage podría no cubrir el medicamento. Límites de cantidad: Para ciertos medicamentos, L.A. Care Health Plan Medicare Advantage limita la cantidad del medicamento que L.A. Care Health Plan Medicare Advantage cubrirá. Por ejemplo, L.A. Care Health Plan Medicare Advantage proporciona 62 cápsulas por receta para Geodon. Esto puede ser adicional al suministro estándar de uno o tres meses. xii

14 Terapia escalonada: En algunos casos, L.A. Care Health Plan Medicare Advantage requiere que primero use ciertos medicamentos para el tratamiento de su condición médica antes que cubramos otro medicamento para esa condición. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su condición médica, L.A. Care Health Plan Medicare Advantage quizás no cubra el medicamento B a menos que primero pruebe el A. Si el medicamento A no le funciona, entonces L.A. Care Health Plan Medicare Advantage cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos o límites adicionales al consultar el formulario que empieza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos al visitar nuestro sitio web en Puede pedirle a L.A. Care Health Plan Medicare Advantage que haga una excepción a esas restricciones o límites. Consulte la sección, Cómo solicito una excepción al formulario de L.A. Care Health Plan Medicare Advantage? de abajo para obtener información sobre cómo solicitar una excepción. Qué sucede si mi medicamento no está en el formulario? Si su medicamento no figura en este formulario, primero debe ponerse en contacto con Servicios para los miembros y confirmar que dicho medicamento no está cubierto. Si averigua que L.A. Care Health Plan Medicare Advantage no cubre su medicamento, tiene dos opciones: Puede pedirle a Servicios para los miembros una lista de medicamentos similares que son cubiertos por L.A. Care Health Plan Medicare Advantage. Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento similar que sí está cubierto por L.A. Care Health Plan Medicare Advantage. Puede pedirle a L.A. Care Health Plan Medicare Advantage que haga una excepción y cubra su medicamento. Consulte la información de abajo sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario de L.A. Care Health Plan Medicare Advantage? Puede pedirle a L.A. Care Health Plan Medicare Advantage que haga una excepción a las reglas de cobertura. Existen varios tipos de excepciones que nos puede pedir. Puede pedirnos que cubramos su medicamento aunque no esté incluido en el formulario. Nos puede pedir que renunciemos a las restricciones de cobertura o límites en su medicamento. Por ejemplo, para ciertos medicamentos L.A. Care Health Plan Medicare Advantage limita la cantidad del medicamento que cubrirá. Si su medicamento tiene un límite en la cantidad, nos puede pedir que renunciemos al límite y cubramos más. xiii

15 Por lo general, L.A. Care Health Plan Medicare Advantage solo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan o las restricciones adicionales de uso no son tan efectivas en el tratamiento de su condición y/o causarían que padezca efectos adversos. Debe contactarnos para obtener una decisión inicial de cobertura sobre una excepción al formulario, al nivel o a restricciones de uso. Cuando solicite una excepción a las restricciones del formulario o de uso, deberá presentar una declaración de su médico respaldando su solicitud. Por lo general, debemos tomar una decisión dentro de las primeras 72 horas después de recibir la declaración de respaldo del médico que receta. Puede solicitar una excepción acelerada (rápida) si su médico o usted creen que su salud estará en peligro si esperan la decisión hasta 72 horas. Si se concede su solicitud acelerada, debemos otorgarle una decisión dentro de las siguientes 24 horas después de obtener la declaración de respaldo del médico que receta. Qué debo hacer antes de hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como un miembro nuevo o continuo de nuestro plan puede estar tomando medicamentos que no están en nuestro formulario. O bien, usted puede estar tomando un medicamento que está en nuestro formulario pero su capacidad de obtenerlo es limitada. Por ejemplo, quizás necesite nuestra autorización previa antes de poder surtir su receta. Puede hablar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que utiliza. Mientras consulta con su médico para determinar el curso de acción correcto para usted, en ciertos casos podemos cubrir su medicamento durante los primeros 90 días de su membresía en nuestro plan. Para cada uno de sus medicamentos que no estén en nuestro formulario o si su capacidad de obtenerlos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 90 días, no pagaremos por esos medicamentos, aún si ha sido miembro del plan menos de 90 días. Si usted es residente de un centro de atención a largo plazo, le permitiremos resurtir su receta hasta que le hayamos proporcionado un suministro de transición de 93 días, consistente con el aumento del surtido (a menos que tenga una receta por menos días). Cubriremos más de un surtido de esos medicamentos por los primeros 90 días en que es miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o su capacidad de obtenerlos es limitada, pero han transcurrido los primeros 90 días de su membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días del medicamento (a menos que tenga una receta por menos días) mientras busca una excepción al formulario. Nota: Puede que experimente un cambio en el nivel de atención recibida y/o se le puede pedir que vaya de un centro de tratamiento a otro. Existen excepciones para usted si ha pasado por un cambio en el nivel de atención que ha estado recibiendo. Si sufre un cambio en el nivel de atención, L.A. Care Health Plan Medicare Advantage cubrirá un suministro temporal de 31 días (a menos que tenga una receta escrita por menos días). xiv

16 Para mayor información Para información más detallada sobre su cobertura de medicamentos recetados de L.A. Care Health Plan Medicare Advantage, revise su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre L.A. Care Health Plan Medicare Advantage, llame al Departamento de servicios para los miembros al , las 24 horas del día, los 7 días de la semana, incluso los días festivos. Los usuarios de TTY/TDD deben llamar al O visite Si tiene preguntas generales sobre la cobertura de medicamentos con receta de Medicare, llame a Medicare al MEDICARE ( ), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al O visite Formulario de L.A. Care Health Plan Medicare Advantage El formulario en la página 1 brinda información sobre la cobertura de algunos de los medicamentos cubiertos por L.A. Care Health Plan Medicare Advantage. Si tiene problemas para ubicar su medicamento en la lista, vaya al índice que empieza en la página I-1. La primera columna de la tabla detalla el nombre del medicamento. Los nombres de marca van en mayúsculas (p. ej., LEXAPRO), y los medicamentos genéricos en cursiva y minúsculas (p. ej., flovent). La información en la columna de Requisitos/Límites le dice si L.A. Care Health Plan Medicare Advantage tiene algún requisito especial de cobertura para su medicamento. xv

17 ABREVIATURAS DE NOTAS DE COBERTURA Las siguientes abreviaturas pueden encontrarse dentro del cuerpo de este documento: ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA QL ST EX LA Restricciones a la administración de uso Restricción de autorización previa Restricción por limitación de cantidad Restricción de terapia escalonada Usted (o su médico) deben obtener una autorización previa de L.A. Care Health Plan Medicare Advantage antes de surtir su receta para este medicamento. Sin una autorización previa, L.A. Care Health Plan Medicare Advantage no podrá cubrir este medicamento. L.A. Care Health Plan Medicare Advantage limita la cantidad de este medicamento que queda cubierta por cada prescripción, o dentro de tiempo específico. Antes que L.A. Care Health Plan Medicare Advantage brinde cobertura para este medicamento, usted primero debe utilizar otro medicamento para el tratamiento de su condición médica. Este medicamento sólo será cubierto si otros medicamentos no funcionan para usted. Otros requisitos especiales de cobertura Medicamento de la Parte D excluido Medicamento de acceso limitado Este medicamento recetado normalmente no está cubierto en un Plan para medicamentos recetados. La cantidad que usted paga cuando surte una receta para este medicamento no se incluye en los costos totales de medicamentos (es decir, la cantidad que usted paga no le ayuda a calificar para una cobertura catastrófica). Además, si está recibiendo ayuda adicional para pagar sus recetas, no recibirá ninguna ayuda adicional para pagar este medicamento. Esta receta puede estar disponible solo en ciertas farmacias. Para mayores informes consulte su Directorio de farmacias o llame al Departamento de servicios para los miembros de L.A. Care Health Plan al , las 24 horas del día, los 7 días de la semana (incluso los días festivos). Los usuarios de TTY/TDD deben llamar al GC Cobertura de brecha Proporcionamos cobertura de este medicamento recetado en la cobertura de brecha. Consulte nuestra Evidencia de cobertura para obtener más información sobre esta cobertura. NM HI Medicamento que no se puede enviar por postal Medicamento de infusión casera Usted puede recibir un suministro de más de 1 mes para la mayoría de medicamentos en su formulario por medio de un pedido por postal a costo compartido reducido. Los medicamentos que no están disponibles por correo tienen la anotación NM en la columna Requisitos/Límites de su formulario. médico. Para más información, llame al Departamento de servicios para los Miembros de L.A. Care Health Plan al , las 24 horas del día, los 7 días de la semana (incluso los días festivos). Los usuarios de TTY/TDD deben llamar al xvi

18 Vea el cuadro de abajo para una descripción de su cobertura de medicamentos recetados. NIVEL 2 MEDICAMENTOS NIVEL 1 MEDICAMENTOS GENÉRICOS CON NOMBRES DE MARCA El monto de su pago compartido por medicamentos genéricos es: El monto de su pago compartido por medicamentos de marca es: ABREVIATURAS DE POTENCIA Y DOSIS adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 12hr cpmp 24hr cpmp cpmp cream(g), cream(gm) cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln xvii

19 ABREVIATURAS DE POTENCIA Y DOSIS (cont.) iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring xviii

20

21 Name Adrenals Adrenals ADVAIR DISKUS 1 QL: 62 in 31 ADVAIR HFA 1 QL: 12 in 28 A-HYDROCORT 1 PA (PA for Part B vs A-METHAPRED 1 PA (PA for Part B vs betamet acet/betamet na ph (Celestone) 1 PA (PA for Part B vs budesonide (Entocort EC) 1 capdr & er cortisone acetate (Cortisone Acetate) 1 PA (PA for Part B vs dexamethasone acetate (Dexamethasone Acetate) 1 PA (PA for Part B vs dexamethasone sod phosphate dexamethasone sod phosphate (Dexamethasone Sod Phosphate) (Dexamethasone Sod Phosphate) 1 PA vial: 10mg/ml, (PA for Part B vs Part D 1 PA vial: 4mg/ml, (PA for Part B vs Part D dexamethasone (Dexamethasone) 1 PA elixir, tablet, (PA for Part B vs Part D dexamethasone (Dexamethasone) 1 PA tab ds pk, (PA for Part B vs Part D DULERA 1 QL: 13 in 28 FLOVENT DISKUS 1 QL: 120 FLOVENT DISKUS 1 QL: 60 in 30 FLOVENT HFA 1 QL: 12 in 28 FLOVENT HFA 1 QL: 21.2 in 28 disk w/dev: 250mcg disk w/dev: 50mcg, 100mcg aer w/adap: 110mcg aer w/adap: 44mcg 1

22 Name FLOVENT HFA 1 QL: 24 in aer w/adap: 220mcg 28 fludrocortisone acetate (Fludrocortisone Acetate) 1 hydrocortisone sod succinate (Hydrocortisone Sod Succinate) 1 PA (PA for Part B vs hydrocortisone (Cortef) 1 PA (PA for Part B vs methylprednisolone acetate (Depo-medrol) 1 PA (PA for Part B vs methylprednisolone sod succ (Solu-medrol) 1 PA (PA for Part B vs methylprednisolone (Medrol) 1 PA (PA for Part B vs prednisolone acetate (Prednisolone Acetate) 1 PA (PA for Part B vs prednisolone sod phosphate (Orapred) 1 PA (PA for Part B vs prednisolone (Prednisolone) 1 PA (PA for Part B vs PREDNISONE INTENSOL 1 PA (PA for Part B vs prednisone (Prednisone) 1 PA solution, tablet, (PA for Part B vs prednisone (Prednisone) 1 PA tab ds pk, (PA for Part B vs Part D QVAR 1 QL: 17.4 in 25 SOLU-CORTEF 1 PA (PA for Part B vs SOLU-MEDROL 1 PA vial: 40mg/ml, (PA for Part B vs Part D triamcinolone acetonide (Kenalog-40) 1 PA (PA for Part B vs VERIPRED 20 1 PA (PA for Part B vs Alpha-Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents doxazosin mesylate (Cardura) 1 2

23 Name prazosin hcl (Minipress) 1 terazosin hcl (Hytrin) 1 Ammonia Detoxicants Ammonia Detoxicants BUPHENYL 1 CARBAGLU 1 lactulose (Lactulose) 1 solution lactulose (Lactulose) 1 syrup LITHOSTAT 1 RAVICTI 1 PA sodium phenylbutyrate (Buphenyl) 1 Analgesics and Antipyretics Analgesics And Antipyretics, Miscellaneous acetaminophen/phenyltolx (Staflex) 1 cit DOLOGESIC 1 tablet mg sal/acetaminophn/ptlox/caf (Durabac Forte) 1 OFIRMEV 1 sal-amide/acetamin/p-tlox/ (Durabac) 1 caff sal-amide/acetaminophn/ (Asp) 1 p-tlox salicylamide/ (Salicylamide/ 1 acetaminophen acetaminophen) Nonsteroidal Anti-inflammatory Agents CALDOLOR 1 CELEBREX 1 ST, QL: 62 in 31 choline sal/mag salicylate (Choline Sal/mag Salicylate) 1 diclofenac potassium (Cataflam) 1 diclofenac sodium (Voltaren) 1 diclofenac sodium/ (Arthrotec 50) 1 misoprostol diflunisal (Diflunisal) 1 etodolac (Etodolac) 1 fenoprofen calcium (Fenoprofen Calcium) 1 flurbiprofen (Ansaid) 1 ibuprofen (Motrin) 1 3

24 Name indomethacin sodium (Indocin I.v.) 1 (May be High Risk Med for Ages 65 and Older) indomethacin (Indomethacin) 1 (May be High Risk Med for Ages 65 and Older) ketoprofen (Ketoprofen) 1 ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 20 in 31 vial: 30mg/ml(1) ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 40 in vial: 15mg/ml 31 ketorolac tromethamine (Toradol) 1 QL: 20 in 31 ketorolac tromethamine (Toradol) 1 QL: 40 in 31 magnesium salicylate (Magnesium Salicylate) 1 meclofenamate sodium (Meclofenamate Sodium) 1 mefenamic acid (Ponstel) 1 meloxicam (Mobic) 1 nabumetone (Relafen) 1 naproxen sodium (Anaprox) 1 naproxen (Naprosyn) 1 oxaprozin (Oxaprozin) 1 piroxicam (Feldene) 1 salsalate (Salflex) 1 sulindac (Clinoril) 1 tolmetin sodium (Tolmetin Sodium) 1 VOLTAREN 1 ST gel (gram), (Topical Gel) Opiate Agonists acetaminophen with codeine acetaminophen with codeine acetaminophen with codeine codeine phos/ acetaminophen (Tylenol-codeine No.3) 1 QL: 180 (Tylenol-codeine No.3) 1 QL: 180 (Tylenol-codeine No.3) 1 QL: 360 (Codeine Phos/ acetaminophen) 1 QL: 2500 cartridge: 30mg/ml; disp syrin cartridge: 15mg/ml tablet: 300mg-60mg tablet: 650mg- 30mg, 650mg-60mg tablet: 300mg- 15mg, 300mg-30mg 4

25 Name codeine phosphate (Codeine Phosphate) 1 (Injection) codeine sulfate (Codeine Sulfate) 1 QL: 180 CODEINE SULFATE 1 QL: 1800 dhcodeine bt/ acetaminophn/caff dhcodeine bt/ acetaminophn/caff dihydrocodeine/aspirin/ caffein (Dhcodeine Bt/acetaminophn/ caff) 1 QL: 300 (Panlor SS) 1 QL: 150 (Synalgos-dc) 1 QL: 360 fentanyl citrate (Actiq) 1 PA, QL: 120 fentanyl (Duragesic) 1 PA, QL: 10 fentanyl (Duragesic) 1 PA, QL: 20 hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen (Hycet) 1 QL: 2025 (Hycet) 1 QL: 2700 (Hycet) 1 QL: 2700 (Norco) 1 QL: 150 (Norco) 1 QL: 180 capsule tablet patch td72: 12mcg/ hr, 25mcg/hr, 50mcg/hr, 75mcg/hr patch td72: 100mcg/ hr solution: /15 solution: / cup solution: / 15, /15 tablet: mg, mg tablet: mg, mg, 10mg- 650mg 5

26 hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen hydrocodone bit/ acetaminophen Name (Norco) 1 QL: 240 (Norco) 1 QL: 360 (Norco) 1 QL: 360 (Norco) 1 QL: 390 hydrocodone/ibuprofen (Vicoprofen) 1 QL: 150 hydromorphone hcl (Dilaudid) 1 QL: 1200 hydromorphone hcl (Dilaudid) 1 QL: 180 hydromorphone hcl (Dilaudid) 1 QL: 240 capsule, tablet: mg, 5mg- 500mg, mg, 10mg-500mg tablet: mg tablet: 5mg-325mg, mg, 10mg- 325mg tablet: 5mg-300mg, mg, 10mg- 300mg liquid tablet: 2mg, 4mg tablet: 8mg hydromorphone hcl (Hydromorphone HCl) 1 vial hydromorphone hcl/pf (Hydromorphone HCl/PF) 1 ampul, disp syrin hydromorphone hcl/pf (Hydromorphone HCl/PF) 1 vial ibuprofen/oxycodone hcl (Combunox) 1 QL: 28 in 30 KADIAN 1 ST, QL: 120 KADIAN 1 ST, QL: 60 KADIAN 1 ST, QL: 60 levorphanol tartrate (Levo-dromoran) 1 QL: 180 cap er pel: 200mg cap er pel: 10mg cap er pel: 40mg, 70mg, 130mg, 150mg 6

27 Name methadone hcl (Methadone HCl) 1 vial methadone hcl (Methadone HCl) 1 QL: 1800 oral conc, solution methadone hcl (Methadose) 1 QL: 360 methadone hcl (Methadose) 1 QL: 90 in 30 morphine sulfate in 0.9 % (Morphine Sulfate In 0.9 % 1 nacl NaCl) morphine sulfate (Kadian) 1 ST, QL: 60 tablet tablet sol cap er pel morphine sulfate (Morphine Sulfate) 1 ampul, cartridge, disp syrin, pen injctr, supp.rect, vial, vial port morphine sulfate (MS Contin) 1 QL: 120 morphine sulfate (MS Contin) 1 QL: 180 morphine sulfate (MSIR) 1 QL: 200 morphine sulfate (MSIR) 1 QL: 300 morphine sulfate (MSIR) 1 QL: 700 tablet er: 30mg, 60mg, 100mg tablet, tablet er: 15mg, 200mg morphine sulfate/d5w (Morphine Sulfate/D5W) 1 morphine sulfate/pf (Morphine Sulfate/PF) 1 pca vial morphine sulfate/pf (Morphine Sulfate/PF) 1 vial NUCYNTA ER 1 QL: 60 in 30 NUCYNTA 1 QL: 181 solution: 100mg/ 5ml solution: 20mg/5ml solution: 10mg/5ml 7

28 Name oxycodone hcl (Oxycodone HCl) 1 QL: 120 oxycodone hcl (Oxycodone HCl) 1 QL: 1300 oxycodone hcl (Oxycodone HCl) 1 QL: 60 in 30 oxycodone hcl (Roxicodone) 1 QL: 180 oxycodone hcl/ acetaminophen oxycodone hcl/ acetaminophen oxycodone hcl/ acetaminophen oxycodone hcl/ acetaminophen (Oxycodone HCl/ acetaminophen) 1 QL: 1800 (Percocet) 1 QL: 180 (Percocet) 1 QL: 240 (Percocet) 1 QL: 360 oxycodone hcl/aspirin (Percodan) 1 QL: 360 oxycodone hcl/oxycodon ter/asa (Oxycodone HCl/oxycodon Ter/asa) 1 QL: 360 OXYCONTIN 1 QL: 120 OXYCONTIN 1 QL: 60 in 30 oxymorphone hcl (Opana) 1 QL: 180 oxymorphone hcl (Oxymorphone HCl) 1 QL: 120 tab er 12h: 80mg solution tab er 12h: 10mg, 20mg, 40mg capsule, oral conc, tablet solution tablet: 10mg-650mg capsule, tablet: 5mg-500mg, mg tablet: mg, 5mg-325mg, mg, 10mg- 325mg tab er 12h: 80mg tab er 12h: 10mg, 15mg, 20mg, 30mg, 40mg, 60mg tablet tab er 12h: 30mg, 40mg 8

29 Name oxymorphone hcl (Oxymorphone HCl) 1 QL: 60 in 30 tramadol hcl (Ultram ER) 1 QL: 30 in 30 tramadol hcl (Ultram ER) 1 QL: 90 in 30 tramadol hcl (Ultram) 1 QL: 240 tramadol hcl/ acetaminophen tab er 12h: 5mg, 7.5mg, 10mg, 15mg, 20mg tab er 24h: 200mg, 300mg tab er 24h: 100mg tablet (Ultracet) 1 QL: 240 Opiate Partial Agonists buprenorphine hcl (Buprenorphine HCl) 1 disp syrin buprenorphine hcl (Subutex) 1 PA, QL: 90 tab subl buprenorphine hcl/ naloxone hcl (Suboxone) 1 PA, QL: 90 butorphanol tartrate (Butorphanol Tartrate) 1 disp syrin, vial butorphanol tartrate (Butorphanol Tartrate) 1 QL: 5 in 28 nalbuphine hcl (Nalbuphine HCl) 1 SUBOXONE 1 PA, QL: 60 SUBOXONE 1 PA, QL: 90 Androgens Androgens ANADROL-50 1 ANDRODERM 1 QL: 30 in 30 ANDROGEL 1 QL: 150 ANDROGEL 1 QL: 300 spray film: 12mg-3mg film: 2mg-0.5mg, 4mg-1mg, 8mg-2mg patch td24: 2mg/ 24hr, 4mg/24hr gel md pmp gel packet 9

30 Name AXIRON 1 QL: 180 in 28 danazol (Danocrine) 1 fluoxymesterone (Fluoxymesterone) 1 oxandrolone (Oxandrin) 1 testosterone cypionate (Depo-testosterone) 1 PA testosterone enanthate (Delatestryl) 1 PA, QL: 5 in 28 Anorexigenics, Respiratory, Cerebral Stimulants Amphetamines dextroamphetamine sulfate dextroamphetamine sulfate (Dexedrine) 1 QL: 120 (Zenzedi) 1 QL: 180 (Adderall XR) 1 QL: 30 in 30 (Adderall) 1 QL: 60 in dextroamphetamine/ amphetamine dextroamphetamine/ amphetamine 30 methamphetamine hcl (Desoxyn) 1 QL: 150 Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous caffeine citrated (Cafcit) 1 caffeine/sodium benzoate (Caffeine/sodium Benzoate) 1 dexmethylphenidate hcl (Focalin) 1 QL: 60 in 30 methylphenidate hcl (Concerta) 1 QL: 31 in 31 methylphenidate hcl (Concerta) 1 QL: 31 in 31 methylphenidate hcl (Metadate Cd) 1 QL: 30 in 30 methylphenidate hcl (Methylin) 1 QL: 900 methylphenidate hcl (Ritalin LA) 1 QL: 60 in 30 capsule er tablet cap er 24h tablet tab er 24: 18mg tab er 24: 27mg, 36mg, 54mg cpmp 30-70, cpmp 50-50: 20mg, 40mg solution cpmp 50-50: 30mg 10

31 Name methylphenidate hcl (Ritalin) 1 QL: 90 in 30 methylphenidate hcl (Ritalin) 1 QL: 90 in 30 modafinil (Provigil) 1 PA, QL: 60 Anthelmintics Anthelmintics ALBENZA 1 BILTRICIDE 1 mebendazole (Mebendazole) 1 STROMECTOL 1 Antiallergic Agents Antiallergic Agents ASTEPRO 1 QL: 30 in 25 azelastine hcl (Astelin) 1 QL: 30 in 25 tablet er: 10mg tablet, tablet er: 20mg spray/pump azelastine hcl (Optivar) 1 drops epinastine hcl (Elestat) 1 PATADAY 1 ST PATANOL 1 ST Antibacterials Aminoglycosides amikacin sulfate (Amikacin Sulfate) 1 gentamicin in nacl, isoosm gentamicin in nacl, isoosm (Gentamicin In Nacl, Isoosm) (Gentamicin In Nacl, Isoosm) 1 piggyback: 60mg/ 100ml, 100mg/50ml 1 piggyback: 60mg/ 50ml, 70mg/50ml, 80mg/100ml, 80mg/ 50ml, 90mg/100ml, 100mg/0.1l gentamicin sulfate (Garamycin) 1 gentamicin sulfate/pf (Gentamicin Sulfate/PF) 1 kanamycin sulfate (Kanamycin Sulfate) 1 vial: 1g/3ml kanamycin sulfate (Kanamycin Sulfate) 1 vial: 500mg/2ml neomycin sulfate (Neomycin Sulfate) 1 solution neomycin sulfate (Neomycin Sulfate) 1 tablet streptomycin sulfate (Streptomycin Sulfate) 1 11

32 Name TOBI PODHALER 1 QL: 224 in 28 TOBI 1 PA (PA for Part B vs tobramycin sulfate (Nebcin) 1 tobramycin/sodium (Tobramycin/sodium 1 chloride Chloride) Antibacterials, Miscellaneous bacitracin (Bacitracin) 1 chloramphenicol sod succ (Chloramphenicol Sod Succ) 1 clindamycin hcl (Cleocin HCl) 1 clindamycin palmitate hcl (Cleocin Palmitate) 1 clindamycin phosphate (Cleocin Phosphate) 1 clindamycin phosphate/ (Cleocin Phosphate In D5w) 1 d5w colistin (colistimethate na) (Coly-mycin M Parenteral) 1 CUBICIN 1 PA (PA for ESRD polymyxin b sulfate (Polymyxin B Sulfate) 1 SYNERCID 1 vancomycin hcl (Vancocin HCl) 1 capsule vancomycin hcl (Vancomycin HCl) 1 PA vial: 1g, 10g, (PA for ESRD vancomycin hcl (Vancomycin HCl) 1 PA vial: 750mg, (PA for ESRD vancomycin hcl/d5w (Vancomycin HCl/D5W) 1 VANCOMYCIN HCL 1 vancomycin/0.9% sod chloride (Vancomycin/0.9% Sod Chloride) XIFAXAN 1 PA, QL: 60 XIFAXAN 1 PA, QL: 9 1 PA (PA for ESRD tablet: 550mg tablet: 200mg ZYVOX 1 Cephalosporins cefaclor (Ceclor) 1 capsule, tab er 12h cefaclor (Ceclor) 1 susp recon cefadroxil hydrate (Cefadroxil Hydrate) 1 cefazolin sodium (Ancef) 1 12

33 Name cefazolin sodium/ (Cefazolin Sodium/dextrose, 1 froz.piggy dextrose,iso Iso) cefazolin sodium/ (Cefazolin Sodium/dextrose, 1 piggyback dextrose,iso Iso) cefdinir (Omnicef) 1 cefditoren pivoxil (Spectracef) 1 cefepime hcl (Maxipime) 1 CEFEPIME 1 CEFEPIME-DEXTROSE 1 cefotaxime sodium (Claforan) 1 vial: 1g, 2g, 10g cefotaxime sodium (Claforan) 1 vial: 500mg cefpodoxime proxetil (Vantin) 1 cefprozil (Cefzil) 1 ceftazidime pentahydrate (Fortaz) 1 vial: 1g; vial port ceftazidime pentahydrate (Fortaz) 1 vial: 2g, 6g, 500mg CEFTAZIDIME 1 ceftriaxone na/ (Ceftriaxone Na/dextrose, 1 dextrose,iso Iso) ceftriaxone sodium (Rocephin) 1 cefuroxime axetil (Ceftin) 1 tablet cefuroxime axetil (Cefuroxime Axetil) 1 susp recon cefuroxime sodium (Zinacef) 1 cefuroxime sodium/ (Cefuroxime Sodium/ 1 dextrose,iso dextrose, Iso) cephalexin (Keflex) 1 capsule: 250mg, 500mg; susp recon, tablet cephalexin (Keflex) 1 capsule: 750mg SUPRAX 1 tab chew, tablet TAZICEF IN DEXTROSE Macrolides azithromycin hydrogen citrate (Azithromycin Hydrogen 1 Citrate) azithromycin (Zithromax) 1 packet azithromycin (Zithromax) 1 susp recon, tablet, vial clarithromycin (Biaxin) 1 DIFICID 1 QL: 20 in 10 ery e-succ/sulfisoxazole (Pediazole) 1 ERY-TAB

34 Name ERYTHROCIN 1 vial port: 1g LACTOBIONATE ERYTHROCIN 1 vial port: 500mg LACTOBIONATE erythromycin base (Eryc) 1 capsule dr erythromycin base (Erythromycin Base) 1 tablet, tablet dr erythromycin (Erythromycin 1 oral susp ethylsuccinate Ethylsuccinate) erythromycin (Erythromycin 1 tablet ethylsuccinate Ethylsuccinate) erythromycin stearate (Erythromycin Stearate) 1 tablet: 250mg erythromycin stearate (Erythromycin Stearate) 1 tablet: 500mg KETEK 1 ST Miscellaneous B-lactam Antibiotics aztreonam (Azactam) 1 CAYSTON 1 LA cefotetan disod/ (Cefotetan Disod/dextrose, 1 dextrose,iso Iso) cefotetan disodium (Cefotetan Disodium) 1 cefoxitin sodium (Mefoxin) 1 cefoxitin sodium/ (Cefoxitin Sodium/dextrose, 1 dextrose,iso Iso) imipenem/cilastatin (Primaxin) 1 sodium INVANZ 1 vial INVANZ 1 vial port meropenem (Merrem) 1 Penicillins amoxicillin (Amoxil) 1 capsule, susp recon, tab chew: 125mg, 250mg; tablet amoxicillin (Amoxil) 1 tab chew: 200mg, 400mg amoxicillin/potassium clav (Augmentin) 1 ampicillin sodium (Totacillin-N) 1 vial ampicillin sodium (Totacillin-N) 1 vial port (Unasyn) 1 vial ampicillin sodium/ sulbactam na ampicillin sodium/ sulbactam na ampicillin trihydrate (Ampicillin Trihydrate) 1 BICILLIN C-R 1 (Unasyn) 1 vial port 14

35 Name BICILLIN L-A 1 dicloxacillin sodium (Dicloxacillin Sodium) 1 nafcillin in dextrose,isoososm) (Nafcillin In Dextrose,iso- 1 nafcillin sodium (Unipen) 1 vial nafcillin sodium (Unipen) 1 vial port oxacillin sodium (Oxacillin Sodium) 1 oxacillin sodium/ (Oxacillin Sodium/dextrose, 1 dextrose,iso Iso) pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 1mm/ 50ml pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 2mm/ 50ml, 3mm/50ml penicillin g potassium (Penicillin G Potassium) 1 penicillin g potassium/d5w (Penicillin G Potassium/ 1 D5W) penicillin g procaine (Penicillin G Procaine) 1 disp syrin: 1.2mm/ 2ml penicillin g procaine (Penicillin G Procaine) 1 disp syrin: / ml penicillin v potassium (Veetids 500) 1 piperacillin sodium (Piperacillin Sodium) 1 piperacillin sodium/ (Zosyn) 1 tazobactam ZOSYN 1 froz.piggy Quinolones AVELOX ABC PACK 1 AVELOX IV 1 AVELOX 1 ciprofloxacin hcl (Cipro) 1 ciprofloxacin lactate (Cipro I.V.) 1 ciprofloxacin lactate/d5w (Cipro I.V.) 1 ciprofloxacin/ciprofloxa (Cipro XR) 1 hcl levofloxacin (Levaquin) 1 levofloxacin/d5w (Levaquin) 1 nalidixic acid (Nalidixic Acid) 1 ofloxacin (Floxin) 1 Sulfonamides (Systemic) sulfadiazine (Sulfadiazine) 1 sulfamethoxazole/ trimethoprim (Bactrim DS) 1 15

36 Name sulfasalazine (Azulfidine) 1 Tetracyclines demeclocycline hcl (Declomycin) 1 doxycycline hyclate (Vibramycin) 1 capsule, tablet dr, vial doxycycline hyclate (Vibra-tabs) 1 capsule dr, tablet doxycycline monohydrate (Adoxa) 1 capsule: 75mg; tablet doxycycline monohydrate (Monodox) 1 capsule: 150mg MINOCIN 1 vial minocycline hcl (Dynacin) 1 tetracycline hcl (Ala-tet) 1 capsule tetracycline hcl (Tetracycline HCl) 1 oral susp TYGACIL 1 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine sulfate (Atropine Sulfate) 1 ampul, vial atropine sulfate (Atropine Sulfate) 1 disp syrin ATROVENT HFA 1 QL: 25.8 in 28 dicyclomine hcl (Bentyl) 1 capsule, syrup, tablet glycopyrrolate (Robinul) 1 isopropamide/ (Isopropamide/ 1 prochlorperazine prochlorperazine) methscopolamine bromide (Pamine) 1 propantheline bromide (Propantheline Bromide) 1 (May be High Risk Med for Ages 65 and Older) SPIRIVA 1 QL: 30 in 30 Anticonvulsants Anticonvulsants, Miscellaneous BANZEL 1 ST carbamazepine (Tegretol) 1 divalproex sodium (Depakote ER) 1 felbamate (Felbatol) 1 gabapentin (Neurontin) 1 GABITRIL 1 tablet: 12mg, 16mg lamotrigine (Lamictal (green)) 1 tab ds pk 16

37 Name lamotrigine (Lamictal) 1 tab er 24, tablet, tb chw dsp levetiracetam in nacl (isoosos)) (Levetiracetam In Nacl (iso- 1 levetiracetam (Keppra) 1 LYRICA 1 QL: 900 solution LYRICA 1 QL: 93 in capsule 31 magnesium chloride (Magnesium Chloride) 1 magnesium sulfate in (Magnesium Sulfate in 0.9% 1 0.9% nacl NaCl) MAGNESIUM SULFATE 1 IN DEXTROSE magnesium sulfate (Magnesium Sulfate) 1 disp syrin magnesium sulfate (Magnesium Sulfate) 1 infus. btl, piggyback, vial magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 oxcarbazepine (Trileptal) 1 OXTELLAR XR 1 ST POTIGA 1 ST, QL: 270 POTIGA 1 ST, QL: 90 tablet: 50mg tablet: 200mg, 300mg, 400mg SABRIL 1 TEGRETOL XR 1 tab er 12h: 100mg tiagabine hcl (Gabitril) 1 topiramate (Topamax) 1 valproate sodium (Depacon) 1 valproic acid (Depakene) 1 VIMPAT 1 ST, QL: 1200 in 30 VIMPAT 1 ST, QL: 200 in 5 VIMPAT 1 ST, QL: 60 solution vial tablet 17

38 Name zonisamide (Zonegran) 1 Hydantoins DILANTIN 1 capsule: 30mg fosphenytoin sodium (Cerebyx) 1 PEGANONE 1 PHENYTEK 1 phenytoin sodium (Dilantin) 1 extended phenytoin sodium (Phenytoin Sodium) 1 ampul phenytoin sodium (Phenytoin Sodium) 1 disp syrin phenytoin (Dilantin-125) 1 Succinimides CELONTIN 1 ethosuximide (Zarontin) 1 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) 1 QL: 90 in 30 BYDUREON 1 ST, QL: 4 in 28 BYETTA 1 ST, QL: 1.2 in 28 BYETTA 1 ST, QL: 2.4 in 28 GLYSET 1 QL: 90 in 30 INVOKANA 1 ST, QL: 30 INVOKANA 1 ST, QL: 60 JANUMET XR 1 QL: 30 in 30 JANUMET XR 1 QL: 60 in 30 JANUMET 1 QL: 60 in 30 pen injctr: 5mcg/ 0.02 pen injctr: 10mcg/ 0.04 tablet: 300mg tablet: 100mg tbmp 24hr: 50mg- 500mg, mg tbmp 24hr: mg 18

39 Name JANUVIA 1 QL: 30 in 30 JENTADUETO 1 QL: 60 in 30 JUVISYNC 1 QL: 30 in 30 KORLYM 1 PA, QL: 112 in 28 metformin hcl (Glucophage) 1 QL: 120 metformin hcl (Glucophage) 1 QL: 60 in 30 metformin hcl (Glucophage) 1 QL: 90 in 30 nateglinide (Starlix) 1 QL: 90 in 30 PRANDIMET 1 QL: 150 PRANDIN 1 QL: 240 SYMLIN 1 PA, QL: 20 in 28 SYMLINPEN PA, QL: 16.2 in 28 SYMLINPEN 60 1 PA, QL: 9 in 28 TRADJENTA 1 QL: 30 in 30 VICTOZA 3-PAK 1 PA, QL: 9 in 28 Insulins HUMALOG MIX QL: 30 in 28 tab er 24h: 500mg; tablet: 500mg tab er 24, tablet: 1000mg tab er 24h: 750mg; tablet: 850mg insuln pen 19

40 Name HUMALOG MIX QL: 40 in 28 HUMALOG MIX QL: 30 in 28 HUMALOG MIX QL: 40 in 28 HUMALOG 1 QL: 30 in 28 HUMALOG 1 QL: 40 in 28 HUMULIN QL: 30 in 28 HUMULIN QL: 40 in 28 HUMULIN N 1 QL: 30 in 28 HUMULIN N 1 QL: 40 in 28 HUMULIN R 1 QL: 40 in 28 LANTUS SOLOSTAR 1 QL: 30 in 28 LANTUS 1 QL: 40 in 28 LEVEMIR FLEXPEN 1 ST, QL: 30 in 28 LEVEMIR 1 ST, QL: 40 in 28 NOVOLIN INNOLET 1 QL: 30 in 28 NOVOLIN QL: 40 in 28 NOVOLIN N INNOLET 1 QL: 30 in 28 NOVOLIN N 1 QL: 40 in 28 NOVOLIN R 1 QL: 30 in 28 NOVOLIN R 1 QL: 40 in 28 vial insuln pen vial insuln pen vial insuln pen vial insuln pen vial insuln pen vial 20

41 Name NOVOLOG FLEXPEN 1 QL: 30 in 28 NOVOLOG MIX FLEXPEN 1 QL: 30 in 28 NOVOLOG MIX QL: 40 in 28 NOVOLOG 1 QL: 40 in 28 Sulfonylureas glimepiride (Amaryl) 1 QL: 30 in 30 glimepiride (Amaryl) 1 QL: 60 in 30 glipizide (Glucotrol XL) 1 QL: 30 in 30 glipizide (Glucotrol) 1 QL: 120 glipizide (Glucotrol) 1 QL: 60 in 30 glipizide/metformin hcl (Metaglip) 1 QL: 120 glipizide/metformin hcl (Metaglip) 1 QL: 60 in 30 glyburide (Micronase) 1 PA, QL: 120 glyburide (Micronase) 1 PA, QL: 30 glyburide,micronized (Glynase) 1 PA, QL: 30 glyburide,micronized (Glynase) 1 PA, QL: 60 tablet: 1mg, 2mg tablet: 4mg tab er 24: 2.5mg, 5mg tablet: 10mg tab er 24: 10mg; tablet: 5mg tablet: mg, 5mg-500mg tablet: mg tablet: 5mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: 1.25mg, 2.5mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: 1.5mg, 3mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: 6mg, (PA for Ages 65 and Older; May be High Risk Med) 21

42 Name glyburide/metformin hcl (Glucovance) 1 PA, QL: 120 glyburide/metformin hcl (Glucovance) 1 PA, QL: 60 tolazamide (Tolazamide) 1 QL: 120 tolazamide (Tolazamide) 1 QL: 60 in 30 tolbutamide (Tolbutamide) 1 QL: 180 Thiazolidinediones ACTOPLUS MET XR 1 QL: 60 in 30 AVANDAMET 1 PA, QL: 60 AVANDARYL 1 PA, QL: 30 AVANDIA 1 PA, QL: 30 pioglitazone hcl (Actos) 1 QL: 30 in 30 tablet: mg, 5mg-500mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: 250mg tablet: 500mg pioglitazone hcl/ glimepiride (Duetact) 1 QL: 30 in 30 pioglitazone hcl/metformin (Actoplus Met) 1 QL: 90 in hcl 30 Antidiarrhea Agents Antidiarrhea Agents diphenoxylate hcl/atropine (Lomotil) 1 (May be High Risk Med for Ages 65 and Older) FULYZAQ 1 QL: 60 in 30 22

43 Name loperamide hcl (Loperamide HCl) 1 paregoric (Paregoric) 1 Antiemetics 5-ht3 Receptor Antagonists granisetron hcl (Kytril) 1 vial granisetron hcl (Kytril) 1 PA solution, tablet, (PA for Part B vs granisetron hcl/pf (Kytril) 1 ondansetron hcl (Zofran) 1 vial ondansetron hcl (Zofran) 1 PA solution, tablet, (PA for Part B vs ondansetron (Zofran Odt) 1 PA (PA for Part B vs Antiemetics, Miscellaneous CESAMET 1 dronabinol (Marinol) 1 EMEND 1 PA, QL: 1 per fill EMEND 1 PA, QL: 2 per fill EMEND 1 PA, QL: 3 per fill capsule: 40mg, 125mg, (PA for Part B vs Part D capsule: 80mg, (PA for Part B vs Part D cap ds pk, (PA for Part B vs Part D vial EMEND 1 QL: 2 in 28 Antihistamines (GI s) dimenhydrinate (Dimenhydrinate) 1 meclizine hcl (Antivert) 1 prochlorperazine edisylate (Compazine) 1 prochlorperazine maleate (Compazine) 1 Antifungal (Systemic) Antifungals, Miscellaneous ABELCET 1 PA (PA for Part B vs amphotericin b (Amphotericin B) 1 PA (PA for Part B vs 23

44 Name flucytosine (Ancobon) 1 griseofulvin ultramicrosize (Gris-peg) 1 griseofulvin,microsize (Grifulvin V) 1 nystatin (Nystatin) 1 oral susp, tablet nystatin (Nystatin) 1 powder terbinafine hcl (Lamisil) 1 triacetin (Triacetin) 1 Azoles fluconazole in nacl,isoosm (Diflucan in Saline) 1 fluconazole (Diflucan) 1 itraconazole (Sporanox) 1 ketoconazole (Nizoral) 1 NOXAFIL 1 SPORANOX 1 solution VFEND 1 susp recon voriconazole (Vfend) 1 Echinocandins CANCIDAS 1 ERAXIS (WATER 1 DILUENT) Antiglaucoma Agents Antiglaucoma Agents acetazolamide sodium (Acetazolamide Sodium) 1 acetazolamide (Acetazolamide) 1 ALPHAGAN P 1 drops: 0.1% AZOPT 1 betaxolol hcl (Betaxolol HCl) 1 BETIMOL 1 ST brimonidine tartrate (Alphagan P) 1 drops: 0.15%, 0.20% COMBIGAN 1 dorzolamide hcl (Trusopt) 1 dorzolamide hcl/timolol (Cosopt) 1 maleat ISOPTO CARPINE 1 drops: 8% ISTALOL 1 latanoprost (Xalatan) 1 levobunolol hcl (Betagan) 1 drops: 0.25% levobunolol hcl (Betagan) 1 drops: 0.5% 24

45 Name LUMIGAN 1 QL: 2.5 in 25 methazolamide (Neptazane) 1 metipranolol (Optipranolol) 1 PHOSPHOLINE IODIDE 1 pilocarpine hcl (Isopto Carpine) 1 PILOPINE HS 1 timolol maleate (Timoptic) 1 TRAVATAN Z 1 QL: 2.5 in 25 travoprost (benzalkonium) (Travatan) 1 QL: 2.5 in 25 Antihistamines Antihistamines carbinoxamine maleate (Palgic) 1 PA (PA for Ages 65 and Older; May be High Risk Med) clemastine fumarate (Clemastine Fumarate) 1 PA syrup, tablet: 2.68mg, (PA for Ages 65 and Older; May be High Risk Med) clemastine fumarate (Clemastine Fumarate) 1 PA tablet: 1.34mg, (PA for Ages 65 and Older; May be High Risk Med) desloratadine (Clarinex) 1 diphenhydramine hcl (Benadryl) 1 vial diphenhydramine hcl (Diphenhydramine HCl) 1 disp syrin levocetirizine (Xyzal) 1 dihydrochloride NUHIST 1 p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1 phenyleph/acetaminop/ptlox/ctlox/cp) (Phenyleph/acetaminop/p- 1 phenylephrine/chlor-tan (Rynatan) 1 promethazine hcl (Phenergan) 1 PA (PA for Ages 65 and Older; May be High Risk Med) 25

46 Name tripelennamine hcl (Tripelennamine HCl) 1 Anti-infectives (EENT) Anti-infectives (EENT) acetic acid (Vosol) 1 acetic acid/aluminum (Domeboro) 1 acetate acetic acid/hydrocortisone (Vosol HC) 1 bacitracin (Bacitracin) 1 bacitracin/polymyxin b (Polycin-b) 1 sulfate BLEPHAMIDE S.O.P. 1 BLEPHAMIDE 1 chlorhexidine gluconate (Peridex) 1 CIPRO HC 1 CIPRODEX 1 ciprofloxacin hcl (Cetraxal) 1 droperette ciprofloxacin hcl (Ciloxan) 1 drops COLY-MYCIN S 1 CORTISPORIN-TC 1 cresyl ace/ben alc/ (Cresyl Ace/ben Alc/butanol/ 1 butanol/ipa ipa) doxycycline hyclate (Periostat) 1 erythromycin base (Ilotycin) 1 gentamicin sulfate (Garamycin) 1 levofloxacin (Quixin) 1 MOXEZA 1 NATACYN 1 neo/polymyx b sulf/ (Ak-trol) 1 dexameth neomy sulf/bacitra/ (Neo-polycin) 1 polymyxin b neomy sulf/bacitrac zn/ (Triple Antibiotic HC) 1 poly/hc neomycin sulfate/dex na (Neomycin Sulfate/dex Na 1 ph Ph) neomycin/polymyxin b (Oticin HC) 1 sulf/hc neomycin/polymyxn b/ (Neosporin) 1 gramicidin ofloxacin (Floxin) 1 26

47 Name polymyxin b sulf/ (Polytrim) 1 trimethoprim sulfacetamide sodium (Sulfac) 1 sulfacetamide/ (Sulfacetamide/prednisolone 1 prednisolone sp Sp) tobramycin (Tobrex) 1 tobramycin/ (Tobradex) 1 dexamethasone trifluridine (Viroptic) 1 TRIPLE ANTIBIOTIC 1 VIGAMOX 1 ZYLET 1 ZYMAR 1 ZYMAXID 1 Anti-infectives (Skin and Mucous Membrane) Antibacterials (Skin and Mucous Membrane) clindamycin phos/benzoyl (Benzaclin) 1 perox clindamycin phosphate (Cleocin T) 1 erythromycin base/ethanol (Emgel) 1 erythromycin/benzoyl (Benzamycin) 1 peroxide gentamicin sulfate (Gentamicin Sulfate) 1 metronidazole (Metrocream) 1 mupirocin calcium (Bactroban) 1 mupirocin (Bactroban) 1 neomy sulf/polymyxin b (Neosporin G.U. Irrigant) 1 sulfate Antifungals (Skin and Mucous Membrane) ciclopirox olamine (Loprox) 1 ciclopirox (Penlac) 1 clotrimazole (Mycelex) 1 clotrimazole/ (Lotrisone) 1 betamethasone dip econazole nitrate (Spectazole) 1 EXELDERM 1 GYNAZOLE-1 1 ketoconazole (Kuric) 1 LAMISIL 1 miconazole nitrate (Monistat 3) 1 27

48 Name nystatin (Mycostatin) 1 cream (g), oint. (g), powder nystatin (Nystatin) 1 tablet nystatin/triamcin (Mycogen II) 1 sod propion/inositol/aa14/ (Sod Propion/inositol/aa14/ 1 urea urea) sodium thiosulfate/sal acid (Sodium Thiosulfate/sal 1 Acid) terconazole (Terazol 7) 1 Antivirals (Skin and Mucous Membrane) acyclovir (Zovirax) 1 QL: 30 in 30 DENAVIR 1 ZOVIRAX 1 QL: 15 in 30 cream (g) ZOVIRAX 1 QL: 30 in oint. (g) 30 Local Anti-infectives, Miscellaneous acetic ac/ricinoleic/ (Acetic Ac/ricinoleic/ 1 oxyquinol oxyquinol) alcohol antiseptic pads (Alcohol Antiseptic Pads) 1 AVC 1 mafenide acetate (Sulfamylon) 1 selenium sulfide (Selenium Sulfide) 1 suspension selenium sulfide (Selseb) 1 shampoo silver nitrate (Silver Nitrate) 1 silver sulfadiazine (Silvadene) 1 sulfacetamide sodium (Klaron) 1 Scabicides and Pediculicides EURAX 1 lindane (Lindane) 1 malathion (Ovide) 1 permethrin (Elimite) 1 spinosad (Natroba) 1 Anti-infectives (systemic), Miscellaneous Anti-infectives (systemic), Miscellaneous FUROXONE 1 Anti-inflammatory Agents (EENT) Anti-inflammatory Agents (EENT) ALREX 1 BROMDAY 1 28

49 Name bromfenac sodium (Bromfenac Sodium) 1 dexamethasone sod (Ak-dex) 1 phosphate diclofenac sodium (Voltaren) 1 DUREZOL 1 flunisolide (Nasarel) 1 QL: 50 in 25 flunisolide (Nasarel) 1 QL: 50 in 25 fluocinolone acetonide oil (Dermotic) 1 fluorometholone (Fluorometholone) 1 flurbiprofen sodium (Ocufen) 1 fluticasone propionate (Flonase) 1 QL: 16 in 30 ILEVRO 1 ketorolac tromethamine (Acular LS) 1 LOTEMAX 1 NASONEX 1 QL: 34 in 28 NEVANAC 1 prednisolone acetate (Pred Forte) 1 prednisolone sod (Prednisol) 1 phosphate PROLENSA 1 QNASL 1 RESTASIS 1 PA, QL: 64 in 31 triamcinolone acetonide (Nasacort Aq) 1 QL: 16.5 Anti-inflammatory Agents (GI s) Anti-inflammatory Agents (GI s) APRISO 1 ASACOL HD 1 ASACOL 1 balsalazide disodium (Colazal) 1 DIPENTUM 1 mesalamine w/cleansing wipes (Rowasa) 1 spray: 25mcg spray: 29mcg 29

50 Name Anti-inflammatory Agents (Respiratory) Anti-inflammatory Agents (Respiratory) cromolyn sodium (Cromolyn Sodium) 1 drops, solution cromolyn sodium (Intal) 1 PA ampul-neb, (PA for Part B vs Part D montelukast sodium (Singulair) 1 zafirlukast (Accolate) 1 Anti-inflammatory Agents (Skin and Mucous) Anti-inflammatory Agents (Skin and Mucous) alclometasone (Aclovate) 1 dipropionate amcinonide (Amcinonide) 1 APEXICON E 1 betamethasone (Del-beta) 1 dipropionate betamethasone valerate (Betamethasone Valerate) 1 betamethasone/propylene (Diprolene AF) 1 glyc clobetasol propionate (Temovate) 1 CLODERM 1 CORDRAN SP 1 CORDRAN 1 lotion, med. tape CORDRAN 1 oint. (g) desonide (Desowen) 1 cream (g), lotion, oint. (g): 0.05% desoximetasone (Topicort) 1 diflorasone diacetate (Psorcon) 1 fluocinolone acetonide (Synalar) 1 fluocinolone/shower cap (Derma-smoothe-fs) 1 fluocinonide (Fluocinonide) 1 fluticasone propionate (Cutivate) 1 halobetasol propionate (Ultravate) 1 hydrocortisone acetate (Hydrocortisone Acetate) 1 hydrocortisone acetate/ (Nuzon) 1 aloe v hydrocortisone acetate/ (Carmol HC) 1 urea hydrocortisone butyrate (Hydrocortisone Butyrate) 1 hydrocortisone valerate (Hydrocortisone Valerate) 1 30

51 Name hydrocortisone (Anusol-HC) 1 cream (g): 1%, 2.5%; enema, lotion, oint. (g) hydrocortisone (Anusol-HC) 1 cream (g): 2.5%; cream(gm) LOCOID 1 cream (g) mometasone furoate (Elocon) 1 prednicarbate (Dermatop) 1 triamcinolone acetonide (Triamcinolone Acetonide) 1 cream (g), lotion, oint. (g): 0.025%, 0.1%, 0.5%; paste (g) triamcinolone acetonide (Triderm) 1 cream, oint. (g): 0.05% Antilipemic Agents Antilipemic Agents, Miscellaneous KYNAMRO 1 PA, QL: 4 in 28 LOVAZA 1 niacin (Niacin) 1 tablet: 500mg NIASPAN 1 ZETIA 1 Bile Acid Sequestrants cholestyramine (with (Questran) 1 sugar) cholestyramine/aspartame (Questran Light) 1 colestipol hcl (Colestid) 1 WELCHOL 1 Fibric Acid Derivatives fenofibrate (Triglide) 1 nanocrystallized fenofibrate (Lofibra) 1 fenofibrate,micronized (Antara) 1 fenofibric acid (Fibricor) 1 gemfibrozil (Lopid) 1 TRILIPIX 1 HMG-CoA Reductase Inhibitors amlodipine/atorvastatin (Caduet) 1 atorvastatin calcium (Lipitor) 1 CRESTOR 1 fluvastatin sodium (Lescol) 1 31

52 Name lovastatin (Mevacor) 1 pravastatin sodium (Pravachol) 1 simvastatin (Zocor) 1 QL: 30 in 30 Antimigraine Agents Selective Serotonin Agonists naratriptan hcl (Amerge) 1 QL: 18 in 28 rizatriptan benzoate (Maxalt) 1 QL: 18 in 28 sumatriptan succinate (Imitrex) 1 QL: 18 in tablet 28 sumatriptan succinate (Imitrex) 1 QL: 4 in 28 sumatriptan succinate (Imitrex) 1 QL: 4 in 28 sumatriptan (Imitrex) 1 QL: 12 in 28 sumatriptan (Imitrex) 1 QL: 18 in 28 zolmitriptan (Zomig Zmt) 1 QL: 12 in 28 Antimycobacterials Antimycobacterials CAPASTAT SULFATE 1 dapsone (Dapsone) 1 ethambutol hcl (Myambutol) 1 isoniazid (Isoniazid) 1 MYCOBUTIN 1 PASER 1 PRIFTIN 1 pyrazinamide (Pyrazinamide) 1 rifampin (Rifadin) 1 rifampin/isoniazid (Rifampin/isoniazid) 1 SEROMYCIN 1 TRECATOR 1 Antineoplastic Agents Antineoplastic Agents ABRAXANE 1 ADCETRIS 1 cartridge: 4mg/ 0.5ml cartridge: 6mg/ 0.5ml; vial spray: 20mg spray: 5mg 32

53 Name AFINITOR DISPERZ 1 PA, QL: 112 in 28 AFINITOR 1 PA, QL: 28 in 28 ALIMTA 1 anastrozole (Arimidex) 1 PA ARRANON 1 ARZERRA 1 PA, QL: 80 AVASTIN 1 BEXXAR 1 bicalutamide (Casodex) 1 BICNU 1 bleomycin sulfate (Bleomycin Sulfate) 1 PA BOSULIF 1 PA, QL: 120 BOSULIF 1 PA, QL: 30 BUSULFEX 1 CAMPATH 1 CAPRELSA 1 PA, QL: 30 CAPRELSA 1 PA, QL: 60 tablet: 100mg tablet: 500mg tablet: 300mg tablet: 100mg carboplatin (Carboplatin) 1 CEENU 1 cisplatin (Cisplatin) 1 cladribine (Leustatin) 1 PA (PA for Part B vs CLOLAR 1 COMETRIQ 1 PA, QL: 112 in 28 cyclophosphamide (Cyclophosphamide) 1 PA, ST tablet, (PA for Part B vs 33

54 Name cyclophosphamide (Cytoxan) 1 PA vial, (PA for Part B vs cytarabine/pf (Cytarabine/PF) 1 PA (PA for Part B vs dacarbazine (Dtic-Dome IV) 1 DACOGEN 1 dactinomycin (Cosmegen) 1 daunorubicin hcl (Cerubidine) 1 DAUNOXOME 1 DOCEFREZ 1 docetaxel (Taxotere) 1 vial: 20mg/2ml, 20mg/ml(1) docetaxel (Taxotere) 1 vial: fnl20mg/2 doxorubicin hcl pegliposomal (Doxil) 1 PA (PA for Part B vs doxorubicin hcl (Adriamycin RDF) 1 PA vial: 50mg DROXIA 1 ELIGARD 1 QL: 1 in 112 disp syrin: 30mg ELIGARD 1 QL: 1 in disp syrin: 45mg 168 ELIGARD 1 QL: 1 in disp syrin: 7.5mg 28 ELIGARD 1 QL: 1 in disp syrin: 22.5mg 84 ELSPAR 1 EMCYT 1 epirubicin hcl (Ellence) 1 ERBITUX 1 ERIVEDGE 1 PA, QL: 30 ERWINAZE 1 PA, QL: 60 ETOPOPHOS 1 etoposide (Etoposide) 1 exemestane (Aromasin) 1 PA FARESTON 1 FASLODEX 1 disp syrin: 125mg/

55 Name FASLODEX 1 disp syrin: 250mg/ 5ml FIRMAGON 1 floxuridine (FUDR) 1 PA (PA for Part B vs fludarabine phosphate (Fludara) 1 fluorouracil (Fluorouracil) 1 PA (vial; PA for Part B vs flutamide (Flutamide) 1 FOLOTYN 1 gemcitabine hcl (Gemzar) 1 vial: 1g gemcitabine hcl (Gemzar) 1 vial: 200mg GLEEVEC 1 QL: 60 in 30 HALAVEN 1 PA, QL: 24 in 28 HERCEPTIN 1 PA (PA for Part B vs HEXALEN 1 hydroxyurea (Hydrea) 1 ICLUSIG 1 PA, QL: 30 ICLUSIG 1 PA, QL: 60 tablet: 45mg tablet: 15mg idarubicin hcl (Idamycin Pfs) 1 ifosfamide (Ifex) 1 PA (PA for Part B vs ifosfamide/mesna (Ifex-mesnex) 1 PA kit: 1g-1g, 3g-1g, (PA for Part B vs INLYTA 1 PA, QL: 180 INLYTA 1 PA, QL: 60 IRESSA 1 PA, QL: 30 tablet: 1mg tablet: 5mg 35

56 Name irinotecan hcl (Camptosar) 1 ISTODAX 1 PA IXEMPRA 1 JAKAFI 1 PA, QL: 60 JEVTANA 1 KADCYLA 1 PA, QL: 2 in 21 KYPROLIS 1 letrozole (Femara) 1 PA LEUKERAN 1 leuprolide acetate (Lupron) 1 QL: 2 in 28 LUPRON DEPOT 1 ST, QL: 1 in 112 LUPRON DEPOT 1 ST, QL: 1 in 168 LUPRON DEPOT 1 ST, QL: 1 in 28 LUPRON DEPOT 1 ST, QL: 1 in 84 syringekit: 30mg syringekit: 45mg syringekit: 3.75mg syringekit: 11.25mg, 22.5mg LUPRON DEPOT-PED 1 ST, QL: 1 in 28 LYSODREN 1 MATULANE 1 MEGACE ES 1 (May be High Risk Med for Ages 65 and Older) megestrol acetate (Megace) 1 (May be High Risk Med for Ages 65 and Older) melphalan hcl (Alkeran) 1 mercaptopurine (Purinethol) 1 methotrexate sodium (Methotrexate Sodium) 1 PA, ST tablet, (PA for Part B vs 36

57 Name methotrexate sodium (Methotrexate Sodium) 1 PA vial, (PA for Part B vs methotrexate sodium/pf (Methotrexate Sodium/PF) 1 PA (PA for Part B vs mitomycin (Mitomycin) 1 PA mitoxantrone hcl (Novantrone) 1 MUSTARGEN 1 NEXAVAR 1 PA, QL: 120 NILANDRON 1 ONCASPAR 1 ONTAK 1 oxaliplatin (Oxaliplatin) 1 paclitaxel (Taxol) 1 pentostatin (Nipent) 1 PERJETA 1 POMALYST 1 PA, QL: 21 in 28 PROLEUKIN 1 REVLIMID 1 LA, QL: 30 RITUXAN 1 PA SOLTAMOX 1 SPRYCEL 1 STIVARGA 1 PA, QL: 84 in 28 SUTENT 1 PA, QL: 30 SYNRIBO 1 PA, QL: 28 in 28 TABLOID 1 tamoxifen citrate (Nolvadex) 1 TARCEVA 1 PA, QL: 30 TARGRETIN 1 37

58 Name TASIGNA 1 TEMODAR 1 PA thiotepa (Thiotepa) 1 topotecan hcl (Hycamtin) 1 TORISEL 1 PA (PA for Part B vs TREANDA 1 TRELSTAR 1 ST, QL: 1 in 168 TRELSTAR 1 ST, QL: 1 in 28 TRELSTAR 1 ST, QL: 1 in 84 disp syrin: 22.5mg/ 2ml disp syrin: 3.75mg/ 2ml disp syrin: 11.25/ 2ml tretinoin (Tretinoin) 1 TREXALL 1 PA, ST (PA for Part B vs TRISENOX 1 TYKERB 1 VALSTAR 1 VANDETANIB 1 PA, QL: 30 VANDETANIB 1 PA, QL: 60 tablet: 300mg tablet: 100mg VECTIBIX 1 VELCADE 1 VIDAZA 1 vinblastine sulfate (Vinblastine Sulfate) 1 PA (PA for Part B vs vincristine sulfate (Vincristine Sulfate) 1 PA (PA for Part B vs vinorelbine tartrate (Navelbine) 1 VOTRIENT 1 PA, QL: 120 VUMON 1 38

59 Name XALKORI 1 PA, QL: 60 XTANDI 1 PA, QL: 120 YERVOY 1 PA, QL: 30 in 21 ZALTRAP 1 ZANOSAR 1 ZELBORAF 1 PA, QL: 240 ZOLADEX 1 QL: 1 in 28 implant: 3.6mg ZOLADEX 1 QL: 1 in implant: 10.8mg 84 ZOLINZA 1 ZYTIGA 1 PA, QL: 120 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) 1 APOKYN 1 AZILECT 1 benztropine mesylate (Benztropine Mesylate) 1 PA (PA for Ages 65 and Older; May be High Risk Med) bromocriptine mesylate (Parlodel) 1 cabergoline (Cabergoline) 1 carbidopa/levodopa (Sinemet ) 1 carbidopa/levodopa/ (Stalevo 50) 1 entacapone COMTAN 1 entacapone (Comtan) 1 NEUPRO 1 ST, QL: 30 pramipexole di-hcl (Mirapex) 1 ropinirole hcl (Requip) 1 39

60 Name selegiline hcl (Eldepryl) 1 STALEVO STALEVO STALEVO STALEVO STALEVO 50 1 STALEVO 75 1 TASMAR 1 trihexyphenidyl hcl (Trihexyphenidyl HCl) 1 PA (PA for Ages 65 and Older; May be High Risk Med) Antiprotozoal Agents Antiprotozoal Agents ALINIA 1 atovaquone/proguanil hcl (Malarone) 1 tablet: mg atovaquone/proguanil hcl (Malarone) 1 tablet: mg chloroquine phosphate (Aralen Phosphate) 1 COARTEM 1 DARAPRIM 1 HALFAN 1 hydroxychloroquine (Plaquenil) 1 sulfate mefloquine hcl (Lariam) 1 MEPRON 1 metronidazole (Flagyl) 1 metronidazole/sodium (Metro IV) 1 chloride paromomycin sulfate (Paromomycin Sulfate) 1 pentamidine isethionate (Pentam 300) 1 PRIMAQUINE 1 QL: 93 in 31 quinine sulfate (Qualaquin) 1 PA, QL: 42 tinidazole (Tindamax) 1 YODOXIN 1 Antipruritics and Local Anesthetics Antipruritics and Local Anesthetics AMERICAINE 1 ANACAINE 1 lidocaine hcl (Pre-attached Lta Kit) 1 40

61 Name lidocaine (Lidocaine) 1 PA (PA for ESRD lidocaine/prilocaine (EMLA) 1 PA (PA for ESRD LIDODERM 1 Antiulcer Agents Antiulcer Agents CARAFATE 1 oral susp cimetidine hcl (Cimetidine HCl) 1 (Rx Product cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 1 (Rx Product cimetidine (Tagamet) 1 (Rx Product famotidine in nacl,isoosm/pf (Famotidine In Nacl,iso-osm/ 1 PF) famotidine (Pepcid) 1 (Rx Product lansoprazole (Prevacid) 1 ST capsule dr, (Rx Product lansoprazole (Prevacid) 1 ST tab rap dr, (Rx Product misoprostol (Cytotec) 1 nizatidine (Axid) 1 omeprazole (Prilosec) 1 capsule dr: 10mg, 20mg, 40mg, (Rx Product omeprazole/sodium (Zegerid) 1 (Rx Product bicarbonate pantoprazole sodium (Protonix) 1 ranitidine hcl (Zantac) 1 (Rx Product sucralfate (Carafate) 1 tablet sucralfate (Sucralfate) 1 oral susp Antivirals (Systemic) Antiretrovirals abacavir sulfate (Ziagen) 1 APTIVUS 1 capsule APTIVUS 1 solution ATRIPLA 1 COMPLERA 1 CRIXIVAN 1 capsule: 100mg CRIXIVAN 1 capsule: 200mg, 400mg didanosine (Videx EC) 1 EDURANT 1 41

62 Name EMTRIVA 1 EPIVIR HBV 1 EPIVIR 1 solution EPZICOM 1 FUZEON 1 INTELENCE 1 tablet: 100mg, 200mg INTELENCE 1 tablet: 25mg INVIRASE 1 ISENTRESS 1 KALETRA 1 lamivudine (Epivir) 1 lamivudine/zidovudine (Combivir) 1 LEXIVA 1 nevirapine (Viramune) 1 oral susp nevirapine (Viramune) 1 tablet NORVIR 1 PREZISTA 1 RESCRIPTOR 1 RETROVIR 1 vial REYATAZ 1 SELZENTRY 1 stavudine (Zerit) 1 STRIBILD 1 SUSTIVA 1 capsule: 100mg SUSTIVA 1 capsule: 50mg, 200mg; tablet TRIZIVIR 1 TRUVADA 1 VIDEX 1 VIRACEPT 1 powder VIRACEPT 1 tablet VIRAMUNE XR 1 VIRAMUNE 1 oral susp VIREAD 1 ZIAGEN 1 solution zidovudine (Retrovir) 1 Antivirals, Miscellaneous foscarnet sodium (Foscavir) 1 PA (PA for Part B vs RELENZA 1 42

63 Name rimantadine hcl (Flumadine) 1 SYNAGIS 1 TAMIFLU 1 QL: 42 in 180 TAMIFLU 1 QL: 48 in 180 TAMIFLU 1 QL: 540 in 180 capsule: 75mg capsule: 45mg susp recon: 6mg/ml TAMIFLU 1 QL: 84 in capsule: 30mg 180 Hcv Protease Inhibitors INCIVEK 1 PA, QL: 168 in 28 VICTRELIS 1 PA, QL: 336 in 28 Interferons ALFERON N 1 INTRON A 1 PA pen ij kit, vial: 6mmunit/ml, 10mm/ ml INTRON A 1 PA vial: 18mmunit, 50mmunit PEGASYS PROCLICK 1 PA PEGASYS 1 PA PEGINTRON REDIPEN 1 PA PEGINTRON 1 PA kit: 50mcg/0.5 PEGINTRON 1 PA kit: 80mcg/0.5, 120mcg/0.5, 150mcg/0.5 SYLATRON 1 PA, QL: 1 in 28 Nucleosides and Nucleotides acyclovir sodium (Acyclovir Sodium) 1 PA (PA for Part B vs acyclovir (Zovirax) 1 BARACLUDE 1 cidofovir (Vistide) 1 famciclovir (Famvir) 1 43

64 Name ganciclovir sodium (Cytovene) 1 PA (PA for Part B vs ganciclovir (Cytovene) 1 HEPSERA 1 RIBATAB 1 tab ds pk: mg ribavirin (Copegus) 1 capsule, tab ds pk: mg, mg; tablet ribavirin (Ribatab) 1 tab ds pk: mg TYZEKA 1 valacyclovir hcl (Valtrex) 1 VALCYTE 1 tablet Anxiolytics, Sedatives and Hypnotics Anxiolytics, Sedatives and Hypnotics, Miscellaneous buspirone hcl (Buspar) 1 droperidol (Inapsine) 1 glutethimide (Glutethimide) 1 hydroxyzine hcl (Hydroxyzine HCl) 1 PA (PA for Ages 65 and Older; May be High Risk Med) hydroxyzine pamoate (Vistaril) 1 PA (PA for Ages 65 and Older; May be High Risk Med) ROZEREM 1 zaleplon (Sonata) 1 PA, QL: 90 in 365 (PA if age 65 and older and QL exceeds 90 supply per year for any zolipdem, zaleplon or eszopiclone product; May be High Risk Med) 44

65 Name zolpidem tartrate (Ambien) 1 PA, QL: 90 in 365 Astringents Astringents aluminum chloride (Drysol) 1 XERAC AC 1 Benzodiazepines Benzodiazepines alprazolam (Xanax XR) 1 QL: 30 in 30 alprazolam (Xanax XR) 1 QL: 60 in 30 alprazolam (Xanax) 1 QL: 90 in 30 chlordiazepoxide hcl (Librium) 1 QL: 120 clonazepam (Klonopin) 1 QL: 300 clonazepam (Klonopin) 1 QL: 90 in 30 clorazepate dipotassium (Tranxene T-tab) 1 QL: 120 clorazepate dipotassium (Tranxene T-tab) 1 QL: 60 in 30 DIASTAT ACUDIAL 1 (PA if age 65 and older and QL exceeds 90 supply per year for any zolipdem, zaleplon or eszopiclone product; May be High Risk Med) tab er 24h: 0.5mg, 1mg tab er 24h: 2mg, 3mg tab rapdis, tablet tab rapdis: 2mg; tablet: 2mg tab rapdis: 0.125mg, 0.25mg, 0.5mg, 1mg; tablet: 0.5mg, 1mg tablet: 15mg tablet: 3.75mg, 7.5mg diazepam (Diastat) 1 kit diazepam (Diazepam) 1 QL: 1200 oral conc, solution 45

66 Name diazepam (Valium) 1 QL: 120 diazepam (Valium) 1 QL: 2 in 28 estazolam (Prosom) 1 QL: 30 in 30 flurazepam hcl (Dalmane) 1 QL: 30 in 30 lorazepam (Ativan) 1 QL: 2 in 30 lorazepam (Ativan) 1 QL: 90 in 30 lorazepam (Lorazepam) 1 QL: 150 midazolam hcl (Midazolam HCl) 1 QL: 10 in 30 midazolam hcl (Midazolam HCl) 1 QL: 2 in 30 ONFI 1 PA, QL: 60 oxazepam (Oxazepam) 1 QL: 120 temazepam (Restoril) 1 QL: 30 in 30 triazolam (Halcion) 1 QL: 30 in 30 Beta-Adrenergic Blocking Agents Beta-Adrenergic Blocking Agents acebutolol hcl (Sectral) 1 atenolol (Tenormin) 1 atenolol/chlorthalidone (Tenoretic 100) 1 betaxolol hcl (Kerlone) 1 bisoprolol fumarate (Zebeta) 1 bisoprolol fumarate/hctz (Ziac) 1 BYSTOLIC 1 carvedilol (Coreg) 1 COREG CR 1 DUTOPROL 1 tablet disp syrin capsule: 15mg, 30mg disp syrin, vial tablet oral conc syrup disp syrin, vial 46

67 Name esmolol hcl (Esmolol HCl) 1 PA (PA for Part B vs labetalol hcl (Trandate) 1 disp syrin labetalol hcl (Trandate) 1 tablet, vial metoprolol succinate (Toprol XL) 1 metoprolol tartrate (Lopressor) 1 metoprolol/ (Lopressor HCT) 1 hydrochlorothiazide nadolol (Corgard) 1 nadolol/ (Corzide) 1 bendroflumethiazide pindolol (Pindolol) 1 propranolol hcl (Propranolol HCl) 1 propranolol/ (Propranolol/ 1 hydrochlorothiazid hydrochlorothiazid) sotalol hcl (Betapace) 1 SOTALOL HCL 1 timolol maleate (Timolol Maleate) 1 Blood Derivatives Blood Derivatives ALBUKED-25 1 ALBUKED-5 1 ALBUMIN (HUMAN) 1 ALBUMINAR-25 1 ALBUMINAR-5 1 ALBURX 1 ALBUTEIN 1 BUMINATE 1 FLEXBUMIN 1 KEDBUMIN 1 PLASBUMIN-25 1 PLASBUMIN-5 1 STERILE DILUENT 1 Calcium-Channel Blocking Agents Calcium-Channel Blocking Agents, Miscellaneous diltiazem hcl (Cardizem CD) 1 verapamil hcl (Calan) 1 ampul, cap24h pct, cap24h pel: 120mg, 180mg, 240mg; tablet, tablet er 47

68 Name verapamil hcl (Verelan) 1 cap24h pel: 360mg; disp syrin Dihydropyridines amlodipine besylate (Norvasc) 1 amlodipine besylate/ (Lotrel) 1 benazepril AZOR 1 ST CARDENE I.V. 1 piggyback: 20mg/ 200ml CARDENE I.V. 1 piggyback: 40mg/ 200ml CLEVIPREX 1 EXFORGE HCT 1 ST EXFORGE 1 ST felodipine (Plendil) 1 isradipine (Dynacirc) 1 nicardipine hcl (Nicardipine HCl) 1 nifedipine (Procardia XL) 1 tab er 24, tablet er nimodipine (Nimotop) 1 nisoldipine (Sular) 1 Caloric Agents Caloric Agents AMINO ACIDS 1 PA AMINOSYN II 3.5% M- DEXTROSE 5% AMINOSYN II 3.5%- DEXTROSE 25% AMINOSYN II 3.5%- DEXTROSE 5% AMINOSYN II 4.25% M- DEXT 10% AMINOSYN II 4.25%- DEXTROSE 25% AMINOSYN II 5% IN 25% DEXTROSE AMINOSYN II IN DEXTROSE AMINOSYN II with LYTES-CA-DW 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA (PA for Part B vs 1 PA iv soln: 3.5%, (PA for Part B vs Part D 48

69 AMINOSYN II with LYTES-CA-DW Name 1 PA iv soln: 4.25%, (PA for Part B vs Part D AMINOSYN II 1 PA iv soln: 10%, (PA for Part B vs Part D AMINOSYN II 1 PA iv soln: 15%, (PA for Part B vs Part D AMINOSYN II 1 PA iv soln: 7%, (PA for Part B vs Part D AMINOSYN II 1 PA iv soln: 8.5%, (PA for Part B vs Part D AMINOSYN M 1 PA (PA for Part B vs AMINOSYN with ELECTROLYTES 1 PA (PA for Part B vs AMINOSYN 1 PA iv soln: 10%, (PA for Part B vs Part D AMINOSYN 1 PA iv soln: 3.5%, (PA for Part B vs Part D AMINOSYN 1 PA iv soln: 5%, (PA for Part B vs Part D AMINOSYN 1 PA iv soln: 7%, (PA for Part B vs Part D AMINOSYN 1 PA iv soln: 8.5%, (PA for Part B vs Part D AMINOSYN-HBC 1 PA (PA for Part B vs AMINOSYN-HF 1 PA (PA for Part B vs AMINOSYN-PF 1 PA iv soln: 10%, (PA for Part B vs Part D 49

70 Name AMINOSYN-PF 1 PA iv soln: 7%, (PA for Part B vs Part D AMINOSYN-RF 1 PA (PA for Part B vs BRANCHAMIN 1 PA (PA for Part B vs CLINIMIX E 1 PA iv soln: 2.75%, (PA for Part B vs Part D CLINIMIX E 1 PA iv soln: 4.25%, (PA for Part B vs Part D CLINIMIX E 1 PA iv soln: 5%, (PA for Part B vs Part D CLINIMIX 1 PA iv soln: 2.75%, (PA for Part B vs Part D CLINIMIX 1 PA iv soln: 4.25%, (PA for Part B vs Part D CLINIMIX 1 PA iv soln: 5%, (PA for Part B vs Part D CLINISOL 1 PA (PA for Part B vs cysteine hcl (Cysteine HCl) 1 PA (PA for Part B vs dextrose 10 % and 0.2 % (Dextrose 10 % and 0.2 % 1 dehp fr bg nacl NaCl) dextrose 10 % and 0.2 % (Dextrose 10 % and 0.2 % 1 iv soln nacl NaCl) dextrose 10 % and 0.9 % (Dextrose 10 % and 0.9 % 1 nacl NaCl) dextrose 10%-0.5 normal (Dextrose 10%-0.5 Normal 1 saline Saline) dextrose 10%-water (Dextrose 10%-water) 1 PA (PA for Part B vs dextrose 2.5 % in water (Dextrose 2.5 % in Water) 1 PA (PA for Part B vs 50

71 Name dextrose 2.5%-0.5normal (Dextrose 2.5%-0.5 Normal 1 saline Saline) dextrose 20%-water (Dextrose 20%-water) 1 PA (PA for Part B vs dextrose 25 % in water (Dextrose 25 % in Water) 1 PA (PA for Part B vs dextrose 40%-water (Dextrose 40%-water) 1 PA (PA for Part B vs dextrose 5 % and 0.3 % (Dextrose 5 % and 0.3 % 1 nacl NaCl) dextrose 5 % and 0.9 % (Dextrose 5 % and 0.9 % 1 nacl NaCl) dextrose 5 % in water (Dextrose 5 % in Water) 1 dextrose 5 %-0.2 % nacl (Dextrose 5 %-0.2 % NaCl) 1 dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 1 dextrose 50 % in water (Dextrose 50 % in Water) 1 PA (PA for Part B vs dextrose 60 % in water (Dextrose 60 % in Water) 1 PA (PA for Part B vs dextrose 70%-water (Dextrose 70%-water) 1 PA (PA for Part B vs ethyl alcohol/d5w (Ethyl Alcohol/D5W) 1 FREAMINE HBC 1 PA (PA for Part B vs FREAMINE III with ELECTROLYTES 1 PA (PA for Part B vs FREAMINE III 1 PA iv soln: 10%, (PA for Part B vs Part D FREAMINE III 1 PA iv soln: 8.5%, (PA for Part B vs Part D fructose 10% (Fructose 10%) 1 PA (PA for Part B vs HEPATAMINE 1 PA (PA for Part B vs HEPATASOL 1 PA (PA for Part B vs INTRALIPID 1 PA emulsion: 10%, (PA for Part B vs 51

72 Name INTRALIPID 1 PA emulsion: 20%, 30%, (PA for Part B vs LIPOSYN II 1 PA (PA for Part B vs LIPOSYN III 1 PA emulsion: 10%, 20%, (PA for Part B vs LIPOSYN III 1 PA emulsion: 30%, (PA for Part B vs NEPHRAMINE 1 PA (PA for Part B vs NOVAMINE 1 PA (PA for Part B vs PREMASOL 1 PA iv soln: 10%, (PA for Part B vs Part D PREMASOL 1 PA iv soln: 6%, (PA for Part B vs Part D PROCALAMINE 1 PA (PA for Part B vs PROSOL 1 PA (PA for Part B vs QUICK MIX with LYTES 1 PA (PA for Part B vs RENAMIN 1 PA (PA for Part B vs TRAVAMULSION 1 PA (PA for Part B vs TRAVASOL W/ DEXTROSE TRAVASOL W/ ELECTROLYTES TRAVASOL W/ ELECTROLYTES TRAVASOL with DEXTROSE 1 PA (PA for Part B vs 1 PA iv soln.: 5.5%, (PA for Part B vs Part D 1 PA iv soln.: 8.5%, (PA for Part B vs Part D 1 PA iv soln: 8.5%, (PA for Part B vs Part D 52

73 Name TRAVASOL with ELECTROLYTES 1 PA (PA for Part B vs TRAVASOL 1 PA iv soln: 10%, (PA for Part B vs Part D TRAVASOL 1 PA iv soln: 5.5%, (PA for Part B vs Part D TRAVASOL 1 PA iv soln: 8.5%, (PA for Part B vs Part D TRAVERT IN NORMAL SALINE 1 PA (PA for Part B vs TRAVERT 1 PA iv soln: 10%, (PA for Part B vs Part D TRAVERT 1 PA iv soln: 5%, (PA for Part B vs Part D TROPHAMINE 1 PA iv soln: 10%, (PA for Part B vs Part D TROPHAMINE 1 PA iv soln: 6%, (PA for Part B vs Part D Cardiac s Antiarrhythmic Agents amiodarone hcl (Amiodarone HCl) 1 disp syrin amiodarone hcl (Cordarone) 1 ampul, tablet disopyramide phosphate (Norpace) 1 capsule disopyramide phosphate (Norpace) 1 capsule er flecainide acetate (Tambocor) 1 lidocaine hcl (Lidocaine HCl) 1 lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 1 iv soln: 2mg/ml, 8mg/ml lidocaine hcl/pf (Lidocaine HCl/PF) 1 mexiletine hcl (Mexitil) 1 MULTAQ 1 procainamide hcl (Procainamide HCl) 1 capsule, tablet sa procainamide hcl (Procainamide HCl) 1 vial PRONESTYL 1 propafenone hcl (Rythmol) 1 53

74 Name quinidine gluconate (Quinidine Gluconate) 1 quinidine sulfate (Quinidine Sulfate) 1 TIKOSYN 1 Cardiac s, Miscellaneous digoxin (Lanoxin) 1 PA, QL: 30 digoxin (Lanoxin) 1 PA, QL: 30 tablet, 125mcg (PA if age 65 and older and QL exceeds 1 tablet per day; May be High Risk Med) tablet, 250mcg (PA/QL for ages 65 and older; May be High Risk Med) digoxin (Lanoxin) 1 PA ampul, (PA for ages 65 and older; May be High Risk Med) DIGOXIN 1 PA, QL: 75 solution (PA if age 65 or older and QL exceeds 5ml per day; May be High Risk Med) inamrinone lactate (Inamrinone Lactate) 1 PA (PA for Part B vs milrinone lactate (Milrinone Lactate) 1 PA (PA for Part B vs milrinone lactate/d5w (Primacor in 5% Dextrose) 1 PA (PA for Part B vs RANEXA 1 QL: 120 RANEXA 1 QL: 60 in 30 Cathartics and Laxatives Cathartics and Laxatives AMITIZA 1 QL: 60 in 30 peg 3350/na sulf,bicarb,cl/ (Colyte with Flavor Packets) 1 kcl polyethylene glycol 3350 (Miralax) 1 sodium chloride/nahco3/ kcl/peg (Nulytely with Flavor Packs) 1 tab er 12h: 500mg tab er 12h: 1000mg 54

75 Name Cell Stimulants and Proliferants Cell Stimulants and Proliferants KEPIVANCE 1 tretinoin microspheres (Retin-a Micro) 1 gel (gram): 0.04% tretinoin microspheres (Retin-a Micro) 1 PA gel (gram): 0.1% tretinoin (Retin-A) 1 PA Central Nervous System Agents, Miscellaneous Central Nervous System Agents, Miscellaneous BUTISOL SODIUM 1 PA, QL: 120 BUTISOL SODIUM 1 PA, QL: 473 BUTISOL SODIUM 1 PA, QL: 60 CAMPRAL 1 flumazenil (Romazicon) 1 INTUNIV 1 QL: 30 in 30 lithium carbonate (Eskalith) 1 lithium citrate (Lithium Citrate) 1 LODOSYN 1 LUMINAL SODIUM 1 PA, QL: 2 NAMENDA XR 1 QL: 28 in 28 NAMENDA XR 1 QL: 30 in 30 NAMENDA 1 QL: 360 NAMENDA 1 QL: 49 in 28 NAMENDA 1 QL: 62 in 31 tablet: 30mg, (May be High Risk Med for Ages 65 and Older) elixir: 30mg/5ml, (May be High Risk Med for Ages 65 and Older) tablet: 50mg, (May be High Risk Med for Ages 65 and Older) disp syrin: 60mg/ ml, 130mg/ml cap24 dspk cap spr 24 solution tab ds pk tablet 55

76 Name NUEDEXTA 1 QL: 60 in 30 phenobarbital sodium (Phenobarbital Sodium) 1 PA, QL: 2 phenobarbital (Phenobarbital) 1 PA, QL: 1500 in 30 phenobarbital (Phenobarbital) 1 PA, QL: 200 phenobarbital (Phenobarbital) 1 PA, QL: 90 primidone (Mysoline) 1 RILUTEK 1 SAVELLA 1 QL: 60 in 30 STRATTERA 1 XENAZINE 1 PA, QL: 112 in 28 XYREM 1 LA Contraceptives Contraceptives AMETHYST 1 vial: 65mg/ml, 130mg/ml elixir: 20mg/5ml, (May be High Risk Med for Ages 65 and Older) tablet: 30mg, (May be High Risk Med for Ages 65 and Older) tablet: 15mg, 16.2mg, 32.4mg, 60mg, 64.8mg, 97.2mg, 100mg, (May be High Risk Med for Ages 65 and Older) desogestrel-ethinyl (Desogen) 1 estradiol desog-et estra/ethin estra (Mircette) 1 ethinyl estradiol/ (Yaz) 1 drospirenone ethynodiol d-ethinyl (Demulen 1/50-28) 1 estradiol levonorgestrel (Plan B) 1 tablet: 0.75mg levonorgestrel (Plan B) 1 tablet: 1.5mg 56

77 Name levonorgestrel-eth (Chateal) 1 tablet estradiol levonorgestrel-eth (Seasonale) 1 QL: 91 in tbdspk 3mo estradiol 84 l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 100- estra 84 20(84) l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 150- estra 84 30(84) noreth a-et estra/fe (Loestrin Fe) 1 fumarate noreth-ethinyl estradiol/ (Femcon Fe) 1 iron norethindrone a-e (Loestrin) 1 estradiol norethindrone (Nor-Q-D) 1 norethindrone-ethinyl (Ortho-novum) 1 estrad norethindrone-mestranol (Ortho-novum) 1 norgestimate-ethinyl estradiol (Ortho Tri-cyclen) 1 tablet: , 7x328 norgestimate-ethinyl (Ortho Tri-cyclen) 1 tablet: 7x328 estradiol norgestrel-ethinyl (Ovral-21) 1 estradiol NUVARING 1 ST, QL: 1 in 28 ORTHO EVRA 1 ST, QL: 3 in 28 Devices Devices needles, insulin disp., safety (Needles, Insulin Disp., 1 Safety) needles, insulin disposable (Needles, Insulin Disposable) 1 syring w- (Syring W- 1 ndl,disp,insul,0.3ml ndl,disp,insul,0.3ml) syring w- (Syring W- 1 ndl,disp,insul,0.5ml ndl,disp,insul,0.5ml) syringe & needle,insulin,1 ml (Syringe & Needle,insulin,1 Ml) 1 57

78 Name Diuretics Diuretics, Miscellaneous chlorothiazide sodium (Diuril Sodium) 1 chlorothiazide (Chlorothiazide) 1 chlorthalidone (Chlorthalidone) 1 hydrochlorothiazide (Hydrochlorothiazide) 1 indapamide (Lozol) 1 methyclothiazide (Methyclothiazide) 1 metolazone (Zaroxolyn) 1 SAMSCA 1 QL: 30 in 30 tablet: 15mg SAMSCA 1 QL: 60 in tablet: 30mg 30 Loop Diuretics bumetanide (Bumex) 1 furosemide (Furosemide) 1 disp syrin furosemide (Lasix) 1 solution, tablet, vial torsemide (Demadex) 1 Potassium-sparing Diuretics amiloride hcl (Midamor) 1 amiloride/ (Amiloride/ 1 hydrochlorothiazide hydrochlorothiazide) DYRENIUM 1 triamterene/ (Maxzide-25mg) 1 hydrochlorothiazid EENT s, Miscellaneous EENT s, Miscellaneous apraclonidine hcl (Iopidine) 1 atropine sulfate (Isopto Atropine) 1 carteolol hcl (Carteolol HCl) 1 CYCLOGYL 1 drops: 0.5% cyclopentolate hcl (Cyclogyl) 1 homatropine hbr (Isopto Homatropine) 1 ipratropium bromide (Atrovent) 1 QL: 15 in 10 spray: 42mcg ipratropium bromide (Atrovent) 1 QL: 30 in spray: 21mcg 28 ISOPTO 1 drops: 2% HOMATROPINE LACRISERT 1 naphazoline hcl (Albalon) 1 58

79 Name naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1 phenylephrine hcl (Mydfrin) 1 PROPINE 1 tropicamide (Mydral) 1 TYZINE 1 drops TYZINE 1 spray Enzymes Enzymes ADAGEN 1 ALDURAZYME 1 CEREDASE 1 CEREZYME 1 ELAPRASE 1 ELELYSO 1 ELITEK 1 FABRAZYME 1 KRYSTEXXA 1 LUMIZYME 1 MYOZYME 1 NAGLAZYME 1 PULMOZYME 1 PA (PA for Part B vs VPRIV 1 XIAFLEX 1 PA, QL: 1 in 28 Estrogens and Antiestrogens Estrogens and Antiestrogens COMBIPATCH 1 PA, QL: 8 in 28 (PA for Ages 65 and Older; May be High Risk Med) ESTRACE 1 cream/appl estradiol valerate (Delestrogen) 1 estradiol (Climara) 1 PA, QL: 4 in 28 patch tdwk, (PA for Ages 65 and Older; May be High Risk Med) estradiol (Estrace) 1 PA tablet, (PA for Ages 65 and Older; May be High Risk Med) 59

80 estradiol/norethindrone acet Name (Activella) 1 PA (PA for Ages 65 and Older; May be High Risk Med) ESTRASORB 1 PA, QL: in 28 (PA for Ages 65 and Older; May be High Risk Med) estropipate (Ogen) 1 PA (PA for Ages 65 and Older; May be High Risk Med) EVISTA 1 FEMRING 1 QL: 1 in 84 MENEST 1 PA (PA for Ages 65 and Older; May be High Risk Med) norethind ac/ethinyl (Femhrt) 1 estradiol PREMARIN 1 cream/appl, vial PREMARIN 1 PA tablet, (PA for Ages 65 and Older; May be High Risk Med) PREMPHASE 1 PA (PA for Ages 65 and Older; May be High Risk Med) PREMPRO 1 PA (PA for Ages 65 and Older; May be High Risk Med) VAGIFEM 1 QL: 18 in 28 VAGIFEM 1 QL: 8 in 28 VIVELLE-DOT 1 PA, QL: 8 in 28 Genitourinary Smooth Muscle Relaxants Genitourinary Smooth Muscle Relaxants DETROL LA 1 flavoxate hcl (Urispas) 1 oxybutynin chloride (Ditropan) 1 tolterodine tartrate (Detrol) 1 TOVIAZ 1 tablet: 10mcg tablet: 25mcg (PA for Ages 65 and Older; May be High Risk Med) 60

81 Name trospium chloride (Sanctura) 1 VESICARE 1 GI s, Miscellaneous GI s, Miscellaneous CHENODAL 1 PA, QL: 120 CIMZIA 1 PA, QL: 3 in 28 CREON 1 LINZESS 1 QL: 30 in 30 lipase/protease/amylase (Zenpep) 1 LOTRONEX 1 metoclopramide hcl (Metoclopramide HCl) 1 disp syrin metoclopramide hcl (Reglan) 1 solution, tablet, vial NUTRESTORE 1 RELISTOR 1 PA, QL: disp syrin 28 in 28 RELISTOR 1 PA, QL: vial 28 in 28 ursodiol (Actigall) 1 ZENPEP 1 Heavy Metal Antagonists Heavy Metal Antagonists BAL IN OIL 1 CALCIUM DISODIUM 1 VERSENATE deferoxamine mesylate (Desferal) 1 PA (PA for Part B vs edetate disodium (Edetate Disodium) 1 ENDRATE 1 EXJADE 1 FERRIPROX 1 GALZIN 1 na nitrite/na thiosul/amyl (Na Nitrite/na Thiosul/amyl 1 nit Nit) sodium thiosulfate (Sodium Thiosulfate) 1 61

82 Name SYPRINE 1 Hematologic Agents Anticoagulants CEPROTIN 1 citrate-phos-dex solution (Citrate-phos-dex Solution) 1 enoxaparin sodium (Lovenox) 1 QL: 13.6 disp syrin: 40mg/ 0.4ml enoxaparin sodium (Lovenox) 1 QL: 18 in 30 enoxaparin sodium (Lovenox) 1 QL: 20.4 enoxaparin sodium (Lovenox) 1 QL: 27.2 disp syrin: 30mg/ 0.3ml disp syrin: 60mg/ 0.6ml disp syrin: 80mg/ 0.8ml, 120mg/.8ml enoxaparin sodium (Lovenox) 1 QL: 34 in disp syrin: 150mg/ 30 ml enoxaparin sodium (Lovenox) 1 QL: 36 in disp syrin: 100mg/ 30 ml; vial fondaparinux sodium (Arixtra) 1 QL: 12 in disp syrin: 5mg/ ml fondaparinux sodium (Arixtra) 1 QL: 15 in disp syrin: 2.5mg/ fondaparinux sodium (Arixtra) 1 QL: 18 in disp syrin: 7.5mg/ fondaparinux sodium (Arixtra) 1 QL: 24 in disp syrin: 10mg/ ml heparin sod,pork in 0.45% (Heparin Sod,pork In 0.45% 1 PA (PA for ESRD nacl NaCl) heparin sodium,porcine (Hep-lock) 1 PA (PA for ESRD heparin sodium,porcine/ (Heparin Sodium, porcine/ 1 d5w D5W) heparin sodium,porcine/ (Heparin Sodium, porcine/ns/ 1 ns/pf PF) heparin sodium,porcine/pf (Hep-lock) 1 vial port heparin sodium,porcine/pf (Hep-lock) 1 PA vial, (PA for ESRD heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 PA disp syrin, (PA for ESRD 62

83 Name IPRIVASK 1 PA, QL: 24 in 28 PRADAXA 1 PA, QL: 60 warfarin sodium (Coumadin) 1 XARELTO 1 QL: 30 in 30 tablet: 10mg, 20mg XARELTO 1 QL: 42 in tablet: 15mg 21 Hematologic Agents, Miscellaneous aminocaproic acid (Amicar) 1 anagrelide hcl (Agrylin) 1 LYSTEDA 1 QL: 30 in 30 pentoxifylline (Trental) 1 protamine sulfate (Protamine Sulfate) 1 PA (PA for ESRD tranexamic acid (Lysteda) 1 QL: 30 in 30 tranexamic acid (Tranexamic Acid) 1 vial Platelet-aggregation Inhibitors BRILINTA 1 QL: 60 in 30 cilostazol (Pletal) 1 clopidogrel bisulfate (Plavix) 1 EFFIENT 1 QL: 30 in 30 Hematopoietic Agents Hematopoietic Agents ARANESP 1 PA, QL: 1.2 in 28 ARANESP 1 PA, QL: 1.6 in 28 ARANESP 1 PA, QL: 1.68 in 28 tablet disp syrin: 60mcg/ 0.3, 150mcg/0.3 disp syrin: 40mcg/ 0.4, 200mcg/0.4 disp syrin: 25mcg/

84 Name ARANESP 1 PA, QL: 2 in 28 ARANESP 1 PA, QL: 2.4 in 28 ARANESP 1 PA, QL: 4 in 28 EPOGEN 1 PA, QL: 12 in 28 EPOGEN 1 PA, QL: 6 in 28 LEUKINE 1 MOZOBIL 1 PA, QL: 9.6 per fill NEULASTA 1 NEUMEGA 1 NEUPOGEN 1 PROCRIT 1 PA, QL: 12 in 28 PROCRIT 1 PA, QL: 6 in 28 PROMACTA 1 PA, QL: 30 Hypotensive Agents Hypotensive Agents, Miscellaneous clonidine hcl (Catapres) 1 disp syrin: 100mcg/ 0.5 disp syrin: 300mcg/ 0.6 disp syrin: 500mcg/ ml; vial vial: 2000/ml, 3000/ ml, 4000/ml, 10000/ ml, 20000/ml vial: 40000/ml vial: 2000/ml, 3000/ ml, 4000/ml, 10000/ ml, 20000/ml vial: 40000/ml clonidine hcl/ (Clonidine HCl/ 1 chlorthalidone chlorthalidone) clonidine (Catapres-TTS 3) 1 QL: 4 in 28 patch tdwk: 0.1mg/ 24hr, 0.2mg/24hr clonidine (Catapres-TTS 3) 1 QL: 8 in 28 patch tdwk: 0.3mg/ 24hr fenoldopam mesylate (Fenoldopam Mesylate) 1 PA (PA for Part B vs 64

85 Name guanfacine hcl (Tenex) 1 PA (PA for Ages 65 and Older; May be High Risk Med) hydralazine hcl (Apresoline) 1 hydralazine/ (Hydralazine/ 1 hydrochlorothiazid hydrochlorothiazid) hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1 PA, QL: 30 minoxidil (Minoxidil) 1 PROGLYCEM 1 reserpine (Reserpine) 1 PA, QL: 30 reserpine (Reserpine) 1 PA, QL: 30 reserpine/ hydrochlorothiazide (Reserpine/ hydrochlorothiazide) VECAMYL 1 Ion-Removing Agents Ion-Removing Agents calcium acetate (Phoslo) 1 1 PA, QL: 30 (PA for Ages 65 and Older; May be High Risk Med) tablet: 0.1mg (PA if age 65 or older and QL exceeds 1 tablet per day; May be High Risk Med) tablet: 0.25mg (PA/ QL for ages 65 and older; May be High Risk Med) (PA/QL for Ages 65 and Older; May be High Risk Med) calcium carbonate/mag (Calcium Carbonate/mag 1 carb/fa Carb/fa) PHOSLYRA 1 RENAGEL 1 RENVELA 1 powd pack: 2.4g; tablet sodium polystyrene (Sodium Polystyrene 1 sulfonate Sulfonate) Irrigating Solutions Irrigating Solutions acetic acid (Acetic Acid) 1 GLYCINE 1 LACTATED RINGERS 1 mannitol/sorbitol solution (Mannitol/sorbitol Solution) 1 ringers solution (Tis-u-sol) 1 65

86 Name sod chloride 0.45% irrig. (Sod Chloride 0.45% Irrig. 1 soln Soln) sodium chloride irrig (Sodium Chloride Irrig 1 solution Solution) sorbitol solution (Sorbitol Solution) 1 urologic solution-g (Urologic Solution-g) 1 water for irrigation,sterile (Water for Irrigation, Sterile) 1 Keratolytic Agents Keratolytic Agents benzoyl peroxide microspheres (Neobenz Micro) 1 benzoyl peroxide (Delos) 1 cleanser, gel (gram): 2.5%, 4%, 8%, 10%; gel alcohl, lotion, med. pad benzoyl peroxide/aloe (Benzoyl Peroxide/aloe Vera) 1 vera benzoyl peroxide/ (Benzoyl Peroxide/ 1 hydrocortison hydrocortison) benzoyl peroxide/urea (Zoderm) 1 potassium hydroxide (Potassium Hydroxide) 1 salicylic acid (Salex) 1 salicylic acid/ammon lact/ (Salkera) 1 aloe salicylic acid/ceramide (Salex) 1 cmb #1 silver nitrate applicator (Silver Nitrate Applicator) 1 Keratoplastic Agents Keratoplastic Agents DRITHO-SCALP 1 sulfacetamide sodium/urea (Rosula Ns) 1 med. pad Local Anesthetics Local Anesthetics aa/antipyrn/bcaine/ polico#1/al (Auralgan) 1 aa/antpy/bcaine/polico/al (Aa/antpy/bcaine/polico/al 1 acet Acet) AKTEN 1 antipyrine/benzocaine/ (Otra Nr) 1 glycerin benzocaine (Omedia Otic) 1 66

87 Name chloroprocaine hcl/pf (Nesacaine-MPF) 1 vial: 20mg/ml, 30mg/ml chloroxylenol/pramoxine (Chloroxylenol/pramoxine 1 hcl HCl) cocaine hcl (Cocaine HCl) 1 lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app, solution lidocaine hcl (Xylocaine) 1 PA vial, (PA for ESRD lidocaine hcl/pf (Lidocaine HCl/PF) 1 disp syrin lidocaine hcl/pf (Xylocaine-MPF) 1 PA ampul, ampul luer, (PA for ESRD mepivacaine hcl/pf (Mepivacaine HCl/PF) 1 OTOGESIC 1 proparacaine hcl (Ophthetic) 1 proparacaine/fluorescein (Proparacaine/fluorescein 1 sod Sod) tetracaine hcl/pf (Pontocaine) 1 XYLOCAINE 1 vial: 20mg/ml Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents acetylcysteine (Acetadote) 1 PA ACTEMRA 1 PA, QL: 40 ACTIMMUNE 1 ACTONEL with CALCIUM 1 ST, QL: 28 in 28 ACTONEL 1 ST, QL: 1 in 28 ACTONEL 1 ST, QL: 31 in 31 ACTONEL 1 ST, QL: 4 in 28 tablet: 150mg tablet: 5mg, 30mg tablet: 35mg alendronate sodium (Fosamax) 1 tablet: 5mg, 10mg, 40mg 67

88 Name alendronate sodium (Fosamax) 1 QL: 300 in 28 alendronate sodium (Fosamax) 1 QL: 4 in 28 allopurinol sodium (Aloprim) 1 allopurinol (Zyloprim) 1 amifostine crystalline (Ethyol) 1 ammonium chloride (Ammonium Chloride) 1 AMPYRA 1 PA, QL: 60 ARCALYST 1 AUBAGIO 1 PA, QL: 28 in 28 AVODART 1 AVONEX ADMINISTRATION PACK 1 ST solution tablet: 35mg, 70mg AVONEX 1 ST azathioprine sodium (Azathioprine Sodium) 1 PA (PA for Part B vs azathioprine (Imuran) 1 PA (PA for Part B vs BENLYSTA 1 PA, QL: 2 in 28 BERINERT 1 PA, QL: 4 0 BETASERON 1 ST BONIVA 1 PA, ST, QL: 3 in 84 BONIVA 1 ST, QL: 31 in 31 BOTOX 1 PA, QL: 1 in 90 disp syrin, (PA for ESRD tablet: 2.5mg vial: 200unit 68

89 Name BOTOX 1 PA, QL: 4 in 90 vial: 100unit CELLCEPT 1 PA susp recon, (PA for Part B vs Part D CELLCEPT 1 PA vial, (PA for Part B vs CINRYZE 1 PA, QL: 20 in 28 citric acid/sodium citrate (Bicitra) 1 colchicine/probenecid (Colchicine/probenecid) 1 COLCRYS 1 COPAXONE 1 cyclosporine (Sandimmune) 1 PA capsule, vial, (PA for Part B vs Part D cyclosporine (Sandimmune) 1 PA solution, (PA for Part B vs Part D cyclosporine, modified (Neoral) 1 PA (PA for Part B vs CYSTADANE 1 dexrazoxane (Totect) 1 disulfiram (Antabuse) 1 DUODOTE 1 DYSPORT 1 PA, QL: 2 in 90 ELMIRON 1 ENBREL 1 PA, QL: 7.84 in 28 ENBREL 1 PA, QL: 8 in 28 ENBREL 1 PA, QL: 8.16 in 28 etidronate disodium (Didronel) 1 EXTAVIA 1 ST pen injctr vial disp syrin 69

90 Name finasteride (Proscar) 1 FIRAZYR 1 fomepizole (Antizol) 1 FUSILEV 1 gauze bandage (Gauze Bandage) 1 GILENYA 1 QL: 28 in 28 GLUCAGEN 1 GLUCAGON 1 EMERGENCY KIT gold sodium thiomalate (Myochrysine) 1 H.P. ACTHAR 1 PA, QL: 35 in 28 HUMIRA 1 PA, QL: 4 in 28 HUMIRA 1 PA, QL: 6 in 28 kit, pen ij kit: 40mg/ 0.8ml pen ij kit: 40mg/ 0.8ml, (Starter Kit) ibandronate sodium (Boniva) 1 QL: 1 in 28 ILARIS 1 JALYN 1 QL: 30 in 30 KALBITOR 1 KINERET 1 PA, QL: in 28 K-PHOS M.F. 1 K-PHOS NO.2 1 KUVAN 1 leflunomide (Arava) 1 leucovorin calcium (Leucovorin Calcium) 1 levocarnitine (with sugar) (Carnitor) 1 PA (PA for ESRD levocarnitine (Carnitor) 1 PA (PA for ESRD mesna (Mesnex) 1 MESNEX 1 tablet methylene blue (Methylene Blue) 1 methylergonovine maleate (Methergine) 1 tablet 70

91 Name methylergonovine maleate (Methylergonovine Maleate) 1 vial mycophenolate mofetil (Cellcept) 1 PA MYFORTIC 1 PA (PA for Part B vs MYOBLOC 1 PA, QL: 1 in 90 NPLATE 1 PA, QL: 8 in 28 NULOJIX 1 PA (PA for Part B vs octreotide acetate (Octreotide Acetate) 1 disp syrin octreotide acetate (Sandostatin) 1 vial ORENCIA 1 PA, QL: 4 in 28 ORENCIA 1 PA, QL: 4 in 28 disp syrin ORFADIN 1 pamidronate disodium (Aredia) 1 PA (PA for ESRD phosphorus #1 (K-phos Neutral) 1 potassium citrate (Urocit-K) 1 potassium citrate/citric (Polycitra-k) 1 acid PRALIDOXIME 1 CHLORIDE probenecid (Probenecid) 1 PROGRAF 1 PA ampul, (PA for Part B vs PROLIA 1 PA, QL: 1 in 180 PROTOPAM CHLORIDE 1 RAPAMUNE 1 PA (PA for Part B vs REBIF REBIDOSE 1 REBIF 1 vial 71

92 Name RECLAST 1 QL: REMICADE 1 PA REVLIMID 1 LA, QL: 30 RIDAURA 1 SANDOSTATIN LAR 1 SENSIPAR 1 SIGNIFOR 1 QL: 60 in 30 SIMPONI 1 PA, QL: 0.5 in 28 SIMPONI 1 PA, QL: 3 in 28 pen injctr disp syrin SIMULECT 1 PA (PA for Part B vs sod/pot/k cit/sod cit/cit (Polycitra-lc) 1 acid sodium bicarbonate (Sodium Bicarbonate) 1 sodium lactate (Sodium Lactate) 1 SOLIRIS 1 SOMATULINE DEPOT 1 QL: 1 in 28 STELARA 1 PA, QL: 10 in 360 vial STELARA 1 PA, QL: 5 in 360 disp syrin SUPPRELIN LA 1 QL: 1 in 360 SUPPRELIN 1 SYNAREL 1 tacrolimus (Prograf) 1 PA (PA for Part B vs TECFIDERA 1 PA, QL: 14 capsule dr: 120mg 72

93 Name TECFIDERA 1 PA, QL: 60 THALOMID 1 QL: 60 in 30 TYSABRI 1 LA, PA, QL: 15 in 28 ULORIC 1 ST, QL: 31 in 31 VANTAS 1 QL: 1 in 360 VORAXAZE 1 XELJANZ 1 PA, QL: 60 XGEVA 1 PA, QL: 1.7 in 28 ZAVESCA 1 zoledronic acid (Zometa) 1 capsule dr: mg, 240mg zoledronic acid/ mannitol&water (Reclast) 1 QL: ZOMETA 1 infus. btl ZORTRESS 1 PA, QL: 120 (PA for Part B vs Opiate Antagonists Opiate Antagonists naloxone hcl (Naloxone HCl) 1 ampul, disp syrin: 0.4mg/ml; vial naloxone hcl (Naloxone HCl) 1 disp syrin: 1mg/ml naltrexone hcl (Revia) 1 Parasympathomimetics (Cholinergic Agents) Parasympathomimetics (Cholinergic Agents) ARICEPT 1 PA, QL: 31 in 31 bethanechol chloride (Urecholine) 1 cevimeline hcl (Evoxac) 1 tablet: 23mg 73

94 Name CHANTIX 1 QL: 168 in 84 CHANTIX 1 QL: 53 in 28 donepezil hcl (Aricept) 1 QL: 31 in 31 EXELON 1 QL: 240 in 31 EXELON 1 QL: 30 in 30 galantamine hbr (Razadyne ER) 1 QL: 30 in 30 galantamine hbr (Razadyne) 1 QL: 200 tablet tab ds pk solution patch td24 cap24h pel solution galantamine hbr (Razadyne) 1 QL: 60 in tablet 30 guanidine hcl (Guanidine HCl) 1 MESTINON 1 syrup, tablet er MYTELASE 1 neostigmine methylsulfate (Neostigmine Methylsulfate) 1 NICOTROL 1 QL: 2016 in 365 physostigmine salicylate (Physostigmine Salicylate) 1 pilocarpine hcl (Salagen) 1 PROSTIGMIN 1 pyridostigmine bromide (Mestinon) 1 REGONOL 1 rivastigmine tartrate (Exelon) 1 QL: 62 in 31 Parathyroid Parathyroid calcitonin,salmon,syntheti c (Miacalcin) 1 QL: 3.7 in 28 FORTEO 1 PA, QL: 3 in 28 74

95 Name FORTICAL 1 QL: 3.7 in 28 MIACALCIN 1 PA vial, (PA for ESRD Pituitary Pituitary DDAVP 1 ampul: 15mcg/ml desmopressin acetate (DDAVP) 1 ampul, tablet desmopressin acetate (Desmopressin Acetate) 1 QL: 15 in solution 30 desmopressin acetate (Desmopressin Acetate) 1 QL: 15 in spray/pump 30 GENOTROPIN 1 PA HUMATROPE 1 PA NORDITROPIN 1 PA FLEXPRO NORDITROPIN 1 PA NORDIFLEX NORDITROPIN 1 PA NOVAREL 1 NUTROPIN AQ NUSPIN 1 PA cartridge: 10mg/2ml NUTROPIN AQ NUSPIN 1 PA cartridge: 5mg/2ml NUTROPIN AQ 1 PA NUTROPIN 1 PA OMNITROPE 1 PA SAIZEN 1 PA cartridge, vial: 5mg SAIZEN 1 PA vial: 8.8mg SEROSTIM 1 PA TEV-TROPIN 1 PA vasopressin (Pitressin) 1 ZORBTIVE 1 PA Progestins Progestins DEPO-PROVERA 1 QL: 10 in 28 medroxyprogesterone acetate medroxyprogesterone acetate (Depo-provera) 1 QL: 1 in 84 (Depo-provera) 1 QL: 1 in 84 vial: 400mg/ml disp syrin vial 75

96 Name medroxyprogesterone (Provera) 1 tablet acetate norethindrone acetate (Aygestin) 1 progesterone (Progesterone) 1 progesterone,micronized (Prometrium) 1 Psychotherapeutic Agents Antidepressants amitriptyline hcl (Amitriptyline HCl) 1 PA (PA for Ages 65 and Older; May be High Risk Med) amoxapine (Amoxapine) 1 bupropion hcl (Wellbutrin SR) 1 citalopram hydrobromide (Celexa) 1 solution citalopram hydrobromide (Celexa) 1 QL: 30 in tablet 30 clomipramine hcl (Anafranil) 1 PA (PA for Ages 65 and Older; May be High Risk Med) CYMBALTA 1 QL: 30 in capsule dr: 30mg 30 CYMBALTA 1 QL: 60 in capsule dr: 20mg, 30 60mg desipramine hcl (Norpramin) 1 DESVENLAFAXINE ER 1 ST, QL: 31 in 31 doxepin hcl (Doxepin HCl) 1 PA (PA for Ages 65 and Older; May be High Risk Med) EMSAM 1 QL: 30 in 30 escitalopram oxalate (Lexapro) 1 QL: 31 in 31 escitalopram oxalate (Lexapro) 1 QL: 720 in 31 tablet solution fluoxetine hcl (Prozac) 1 fluvoxamine maleate (Fluvoxamine Maleate) 1 tablet fluvoxamine maleate (Luvox CR) 1 cap er 24h imipramine hcl (Tofranil) 1 PA (PA for Ages 65 and Older; May be High Risk Med) 76

97 Name imipramine pamoate (Tofranil-PM) 1 PA (PA for Ages 65 and Older; May be High Risk Med) LEXAPRO 1 ST, QL: 720 in 31 LUVOX CR 1 ST, QL: 62 in 31 LUVOX CR 1 ST, QL: 93 in 31 solution cap er 24h: 150mg cap er 24h: 100mg maprotiline hcl (Maprotiline HCl) 1 MARPLAN 1 mirtazapine (Remeron) 1 nefazodone hcl (Nefazodone HCl) 1 nortriptyline hcl (Pamelor) 1 capsule nortriptyline hcl (Pamelor) 1 solution olanzapine/fluoxetine hcl (Symbyax) 1 paroxetine hcl (Paroxetine HCl) 1 oral susp paroxetine hcl (Paxil) 1 tab er 24h, tablet PAXIL 1 oral susp perphenazine/ amitriptyline hcl (Perphenazine/amitriptyline HCl) 1 PA (PA for Ages 65 and Older; May be High Risk Med) phenelzine sulfate (Nardil) 1 PRISTIQ ER 1 ST, QL: 31 in 31 protriptyline hcl (Vivactil) 1 sertraline hcl (Zoloft) 1 SILENOR 1 QL: 30 in 30 SURMONTIL 1 PA (PA for Ages 65 and Older; May be High Risk Med) tranylcypromine sulfate (Parnate) 1 trazodone hcl (Trazodone HCl) 1 trimipramine maleate (Surmontil) 1 PA (PA for Ages 65 and Older; May be High Risk Med) 77

98 Name VENLAFAXINE HCL 1 ER venlafaxine hcl (Effexor XR) 1 VIIBRYD 1 PA, QL: 30 Antipsychotic Agents ABILIFY DISCMELT 1 ST, QL: 62 in 31 ABILIFY DISCMELT 1 ST, QL: 93 in 31 ABILIFY MAINTENA 1 QL: 1 in 28 ABILIFY 1 ST, QL: in 28 ABILIFY 1 ST, QL: 31 in 31 ABILIFY 1 ST, QL: 62 in 31 ABILIFY 1 ST, QL: 930 in 31 tab rapdis: 15mg tab rapdis: 10mg vial tablet: 5mg, 10mg, 15mg, 20mg, 30mg tablet: 2mg solution chlorpromazine hcl (Chlorpromazine HCl) 1 ampul, tablet chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc. clozapine (Clozaril) 1 QL: 140 in 31 tablet: 200mg clozapine (Clozaril) 1 QL: 279 in 31 clozapine (Clozaril) 1 QL: 93 in 31 clozapine (Fazaclo) 1 ST, QL: 93 in 31 tablet: 100mg tablet: 25mg, 50mg tab rapdis 78

99 Name FANAPT 1 ST, QL: 60 FANAPT 1 ST, QL: 8 in 28 FAZACLO 1 ST, QL: 124 in 31 FAZACLO 1 ST, QL: 186 in 31 FAZACLO 1 ST, QL: 93 in 31 fluphenazine decanoate (Fluphenazine Decanoate) 1 fluphenazine hcl (Fluphenazine HCl) 1 GEODON 1 QL: 6 in 28 haloperidol decanoate (Haloperidol Decanoate) 1 haloperidol lactate (Haloperidol Lactate) 1 haloperidol (Haloperidol) 1 INVEGA SUSTENNA 1 QL: 0.25 in 28 INVEGA SUSTENNA 1 QL: 0.5 in 28 INVEGA SUSTENNA 1 QL: 0.75 in 28 INVEGA SUSTENNA 1 QL: 1 in 28 INVEGA SUSTENNA 1 QL: 1.5 in 28 INVEGA 1 ST, QL: 31 in 31 INVEGA 1 ST, QL: 62 in 31 tablet tab ds pk tab rapdis: 200mg tab rapdis: 150mg tab rapdis: 12.5mg, 25mg, 100mg vial disp syrin: 39mg/ 0.25 disp syrin: 78mg/ 0.5ml disp syrin: 117mg/ 0.75 disp syrin: 156mg/ ml disp syrin: 234mg/ 1.5 tab er 24: 1.5mg, 3mg, 9mg tab er 24: 6mg 79

100 Name LATUDA 1 ST, QL: 30 loxapine succinate (Loxitane) 1 MOBAN 1 NAVANE 1 capsule: 20mg olanzapine (Zyprexa) 1 QL: 31 in 31 ORAP 1 perphenazine (Perphenazine) 1 quetiapine fumarate (Seroquel) 1 QL: 93 in 31 RISPERDAL CONSTA 1 QL: 4 in 28 risperidone (Risperdal M-tab) 1 QL: 124 in 31 risperidone (Risperdal) 1 QL: 496 in 31 risperidone (Risperdal) 1 QL: 62 in 31 SAPHRIS 1 ST, QL: 60 SEROQUEL XR 1 ST, QL: 31 in 31 SEROQUEL XR 1 ST, QL: 62 in 31 tab rapdis: 3mg, 4mg solution tab rapdis: 0.25mg, 0.5mg, 1mg, 2mg; tablet tab er 24h: 200mg tab er 24h: 50mg, 150mg, 300mg, 400mg thioridazine hcl (Thioridazine HCl) 1 PA oral conc., (PA for Ages 65 and Older; May be High Risk Med) thioridazine hcl (Thioridazine HCl) 1 PA tablet, (PA for Ages 65 and Older; May be High Risk Med) thiothixene (Navane) 1 trifluoperazine hcl (Trifluoperazine HCl) 1 80

101 Name ziprasidone hcl (Geodon) 1 QL: 62 in 31 ZYPREXA RELPREVV 1 QL: 2 in 28 ZYPREXA 1 QL: 31 in 31 Renin-Angiotensin-Aldosterone System Inhibitors Angiotensin II Receptor Antagonists BENICAR HCT 1 ST BENICAR 1 ST candesartan cilexetil (Atacand) 1 candesartan/ (Atacand HCT) 1 hydrochlorothiazid DIOVAN 1 ST eprosartan mesylate (Teveten) 1 irbesartan (Avapro) 1 irbesartan/ (Avalide) 1 hydrochlorothiazide losartan potassium (Cozaar) 1 losartan/ (Hyzaar) 1 hydrochlorothiazide TRIBENZOR 1 ST valsartan/ (Diovan HCT) 1 hydrochlorothiazide Angiotensin-Converting Enzyme Inhibitors benazepril hcl (Lotensin) 1 benazepril/ (Lotensin HCT) 1 hydrochlorothiazide captopril (Capoten) 1 captopril/ (Capozide) 1 hydrochlorothiazide enalapril maleate (Vasotec) 1 enalapril/ (Vaseretic) 1 hydrochlorothiazide enalaprilat dihydrate (Enalaprilat Dihydrate) 1 fosinopril sodium (Monopril) 1 fosinopril/ (Monopril HCT) 1 hydrochlorothiazide lisinopril (Zestril) 1 lisinopril/ (Prinzide) 1 hydrochlorothiazide moexipril hcl (Univasc) 1 81 vial

102 Name moexipril/ (Uniretic) 1 hydrochlorothiazide perindopril erbumine (Aceon) 1 quinapril hcl (Accupril) 1 quinapril/ (Accuretic) 1 hydrochlorothiazide ramipril (Altace) 1 trandolapril (Mavik) 1 trandolapril/verapamil hcl (Trandolapril/verapamil HCl) 1 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) 1 spironolact/ (Aldactazide) 1 hydrochlorothiazid spironolactone (Aldactone) 1 Replacement Preparations Replacement Preparations 0.9 % sodium chloride (0.9 % Sodium Chloride) 1 calcium chloride (Calcium Chloride) 1 calcium gluconate (Calcium Gluconate) 1 PA (PA for ESRD dex 2.5%-half str (Dex 2.5%-half Str 1 lact.ringers Lact.ringers) dextrose 2.5% in half (Dextrose 2.5% In Half 1 ringers Ringers) dextrose 5% in ringers (Dextrose 5% In Ringers) 1 dextrose 5%-lactated (Dextrose 5%-Lactated 1 ringers Ringers) DEXTROSE W/ 1 ELECTROLYTE A DEXTROSE W/ 1 ELECTROLYTE B electrolyte-48 solution/ (Electrolyte-48 Solution/ 1 d10w d10w) electrolyte-48 solution/ (Electrolyte-48 Solution/ 1 d5w D5W) electrolyte-48/fructose (Electrolyte-48/fructose 10%) 1 10% electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 1 electrolyte-75 solution/ (Electrolyte-75 Solution/ 1 d5w D5W) electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 1 electrolyte-r solution/d5w (Normosol-r and Dextrose) 1 82

103 Name HYPERLYTE CR 1 HYPERLYTE R 1 IONOSOL B with 1 DEXTROSE 5% IONOSOL MB- 1 DEXTROSE 5% IONOSOL T-DEXTROSE 1 5% ISOLYTE E 1 ISOLYTE H W/ 1 DEXTROSE ISOLYTE M W/ 1 DEXTROSE ISOLYTE P with 1 DEXTROSE ISOLYTE S with 1 DEXTROSE ISOLYTE S 1 LACTATED RINGERS 1 NORMOSOL-M and 1 DEXTROSE NORMOSOL-R PH NUTRILYTE II 1 NUTRILYTE 1 PLASMA-LYTE PLASMA-LYTE 56 IN 1 DEXTROSE PLASMA-LYTE A PH PLASMA-LYTE M IN 1 DEXTROSE pot chloride/pot bicarb/cit (Pot Chloride/pot Bicarb/cit 1 ac Ac) potassium acetate (Potassium Acetate) 1 potassium bicarbonate/cit (Potassium Bicarbonate/cit 1 ac Ac) potassium chlorid/d10- (Potassium Chlorid/d %nacl 0.2%NaCl) potassium chloride in (Potassium Chloride In 1 0.9%nacl 0.9%NaCl) potassium chloride in d5w (Potassium Chloride In D5w) 1 iv soln: 10meq/l 83

104 Name potassium chloride in d5w (Potassium Chloride In D5w) 1 iv soln: 20meq/l, 30meq/l, 40meq/l potassium chloride in lrdd5) (Potassium Chloride In Lr- 1 potassium chloride (Kaochlor) 1 iv soln, liquid, packet, tablet sa potassium chloride (K-dur) 1 capsule er, disp syrin, piggyback, tab er prt, tablet er potassium chloride/d5-0.2%nacl (Potassium Chloride/d5-0.2%NaCl) 1 iv soln: 10meq/l, 30meq/l, 40meq/l potassium chloride/d5- (Potassium Chloride/d5-1 iv soln: 20meq/l 0.2%nacl 0.2%NaCl) potassium chloride/d5- (Potassium Chloride/D ns NS) potassium chloride/d5- (Potassium Chloride/d %nacl 0.3%NaCl) potassium chloride/d5- (Potassium Chloride/d nacl 0.45NaCl) potassium chloride/d5- (Potassium Chloride/d %nacl 0.9%NaCl) potassium chloride-0.45% (Potassium Chloride-0.45% 1 nacl NaCl) potassium gluconate (Potassium Gluconate) 1 potassium phos,m-basic-dbasibasic) (Potassium Phos,m-basic-d- 1 ringers solution (Ringers Solution) 1 sodium acetate (Sodium Acetate) 1 sodium chloride 0.45 % (Sodium Chloride 0.45 %) 1 sodium chloride 3% (Sodium Chloride 3%) 1 sodium chloride 5% (Sodium Chloride 5%) 1 sodium chloride (Sodium Chloride) 1 iv soln sodium chloride (Sodium Chloride) 1 vial sodium phos,m-basic-dbasibasic) (Sodium Phos,m-basic-d- 1 TPN ELECTROLYTES 1 TRAVERT- 1 ELECTROLYTE NO.1 TRAVERT- 1 iv soln: 10% ELECTROLYTE NO.2 TRAVERT- ELECTROLYTE NO.2 1 iv soln: 5% 84

105 Name TRAVERT- 1 ELECTROLYTE NO.3 TRAVERT- 1 ELECTROLYTE NO.4 Respiratory Tract Agents, Miscellaneous Respiratory Tract Agents, Miscellaneous acetylcysteine (Acetylcysteine) 1 PA (PA for Part B vs aminophylline (Aminophylline) 1 liquid, tablet aminophylline (Aminophylline) 1 vial ARALAST 1 DALIRESP 1 ST, QL: 30 guaifen/theop anhyd/pepheephed) (Guaifen/theop Anhyd/p- 1 KALYDECO 1 PA, QL: 60 PROLASTIN C 1 PROLASTIN 1 theophylline anhydrous (Theochron) 1 elixir, tab er 12h: 100mg, 200mg, 300mg, 450mg; tablet er theophylline anhydrous (Theochron) 1 solution, tab er 12h: 200mg theophylline/d5w (Theophylline/D5W) 1 XOLAIR 1 PA, QL: 6 in 28 ZEMAIRA 1 Sclerosing Agents Sclerosing Agents ethanolamine oleate (Ethanolamine Oleate) 1 sodium morrhuate (Sodium Morrhuate) 1 sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 1 Serums Serums ANASCORP 1 85

106 ANTIVENIN LATRODECTUS MACTANS ANTIVENIN MICRURUS FULVIUS CARIMUNE NF Name PA (PA for Part B vs NANOFILTERED CROFAB 1 CYTOGAM 1 DIGIBIND 1 DIGIFAB 1 FLEBOGAMMA DIF 1 PA (PA for Part B vs FLEBOGAMMA 1 PA (PA for Part B vs GAMASTAN S-D 1 PA (PA for Part B vs GAMMAGARD LIQUID 1 PA (PA for Part B vs GAMMAPLEX 1 PA (PA for Part B vs GAMUNEX-C 1 PA (PA for Part B vs HIZENTRA 1 PA (PA for Part B vs HYPERRAB S-D 1 HYPERRHO S-D 1 IMOGAM RABIES-HT 1 MICRHOGAM PLUS 1 OCTAGAM 1 PA (PA for Part B vs PRIVIGEN 1 PA (PA for Part B vs RHOGAM PLUS 1 RHOPHYLAC 1 VIVAGLOBIN 1 PA (PA for Part B vs WINRHO SDF 1 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) 1 86

107 Name carisoprodol (Soma) 1 PA, QL: 120 carisoprodol (Soma) 1 PA, QL: 120 tablet: 250mg, (PA for Ages 65 and Older; May be High Risk Med) tablet: 350mg, (PA for Ages 65 and Older; May be High Risk Med) chlorzoxazone (Parafon Forte DSC) 1 PA (PA for Ages 65 and Older; May be High Risk Med) chlorzoxazone/ acetaminophen (Chlorzoxazone/ acetaminophen) 1 PA (PA for Ages 65 and Older; May be High Risk Med) cyclobenzaprine hcl (Amrix) 1 PA (May be High Risk Med for Ages 65 and Older) cyclobenzaprine hcl (Flexeril) 1 PA (PA for Ages 65 and Older; May be High Risk Med) dantrolene sodium (Dantrium) 1 capsule dantrolene sodium (Dantrium) 1 vial metaxalone (Skelaxin) 1 PA (PA for Ages 65 and Older; May be High Risk Med) methocarbamol (Robaxin) 1 PA (PA for Ages 65 and Older; May be High Risk Med) tizanidine hcl (Zanaflex) 1 Skin and Mucous Membrane Agents, Miscellaneous Skin and Mucous Membrane Agents, Miscellaneous 8-MOP 1 adapalene (Differin) 1 AMEVIVE 1 PA, QL: 4 in 28 ammonium lactate (Lac-hydrin) 1 calcipotriene (Calcipotriene) 1 calcitriol (Vectical) 1 CARAC 1 CONDYLOX 1 gel (gram) ELIDEL 1 PA 87

108 Name FLUOROPLEX 1 fluorouracil (Efudex) 1 imiquimod (Aldara) 1 PA, QL: 24 isotretinoin (Accutane) 1 LEVULAN 1 METVIXIA 1 OXSORALEN-ULTRA 1 PANRETIN 1 PICATO 1 QL: 2 in 56 gel (ea): 0.05% PICATO 1 QL: 3 in gel (ea): 0.015% 56 podofilox (Condylox) 1 podophyllum resin (Pododerm) 1 PROTOPIC 1 PA SANTYL 1 SORIATANE 1 capsule: 10mg, 17.5mg, 25mg SORIATANE 1 capsule: 22.5mg STELARA 1 PA, QL: 10 in 360 TACLONEX 1 TARGRETIN 1 TAZORAC 1 UVADEX 1 ZYCLARA 1 PA, QL: 15 in 28 ZYCLARA 1 PA, QL: 28 in 28 Somatotropin Agonists and Antagonists Somatotropin Agonists and Antagonists INCRELEX 1 SOMAVERT 1 Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents alfuzosin hcl (Uroxatral) 1 crm md pmp cream pack 88

109 Name dihydroergotamine (D.H.E. 45) 1 ampul mesylate dihydroergotamine (Migranal) 1 QL: 8 in spray/pump mesylate 28 ergotamine tartrate/ (Cafergot) 1 tablet caffeine ergotamine tartrate/ (Ergotamine Tartrate/ 1 supp.rect caffeine caffeine) phentolamine mesylate (Phentolamine Mesylate) 1 PA tamsulosin hcl (Flomax) 1 Sympathomimetic (Adrenergic) Agents Sympathomimetic (Adrenergic) Agents albuterol sulfate (Accuneb) 1 PA solution, vial-neb: 0.63mg/3ml, 1.25mg/3ml, 2.5mg/ 3ml, (PA for Part B vs albuterol sulfate (Proventil) 1 syrup, tab er 12h, tablet COMBIVENT RESPIMAT 1 QL: 8 in 30 COMBIVENT 1 QL: 29.4 dobutamine hcl (Dobutamine HCl) 1 PA (PA for Part B vs dobutamine hcl/d5w (Dobutamine HCl/D5W) 1 PA (PA for Part B vs dopamine hcl (Dopamine HCl) 1 PA (PA for Part B vs dopamine hcl/d5w (Dopamine HCl/D5W) 1 PA (PA for Part B vs dopamine hcl/dextrose 5%-water (Dopamine HCl/dextrose 5%- water) ephedrine sulfate (Ephedrine Sulfate) 1 epinephrine (Adrenaclick) 1 QL: 2 in 30 1 PA (PA for Part B vs disp syrin: 0.3mg/ 0.3; pen injctr epinephrine (Epinephrine) 1 ampul epinephrine (Epinephrine) 1 disp syrin: 0.1mg/ ml EPIPEN 2-PAK 1 QL: 2 in 30 89

110 Name EPIPEN JR 2-PAK 1 QL: 2 in 30 FORADIL 1 QL: 62 in 31 isoproterenol hcl (Isoproterenol HCl) 1 metaproterenol sulfate (Metaproterenol Sulfate) 1 midodrine hcl (Proamatine) 1 norepinephrine bit/0.9 % nacl (Norepinephrine Bit/0.9 % NaCl) 1 PA (PA for Part B vs norepinephrine bitartrate (Levophed Bitartrate) 1 PA (PA for Part B vs norepinephrine bitartrate/ d5w (Norepinephrine Bitartrate/ D5W) 1 PA (PA for Part B vs phenylephrine hcl (Phenylephrine HCl) 1 phenylephrine tannate (Phenylephrine Tannate) 1 PROAIR HFA 1 QL: 17 in 25 SEREVENT DISKUS 1 QL: 62 in 31 terbutaline sulfate (Brethine) 1 Thyroid and Antithyroid Agents Thyroid and Antithyroid Agents levothyroxine sodium (Levothyroxine Sodium) 1 vial levothyroxine sodium (Synthroid) 1 tablet liothyronine sodium (Cytomel) 1 methimazole (Tapazole) 1 tablet: 20mg methimazole (Tapazole) 1 tablet: 5mg, 10mg propylthiouracil (Propylthiouracil) 1 Toxoids Toxoids ADACEL 1 disp syrin ADACEL 1 vial BOOSTRIX 1 DAPTACEL 1 DIPHTHERIA- TETANUS TOXOID DIPHTHERIA- TETANUS TOXOIDS- PED INFANRIX PF 1 INFANRIX

111 Name TE ANATOXAL BERNA 1 PA (PA for Part B vs TENIVAC 1 TETANUS DIPHTHERIA 1 TOXOIDS TETANUS TOXOID ADSORBED 1 PA (PA for Part B vs TETANUS-DIPHTERIA- 1 DECAVAC TRIHIBIT 1 TRIPEDIA 1 Urinary Anti-infectives Urinary Anti-infectives methenamine mandelate (Mandelamine) 1 tablet: 1g methenamine mandelate (Mandelamine) 1 tablet: 500mg nitrofurantoin macrocrystal (Macrobid) 1 PA, QL: 90 in 365 nitrofurantoin (Furadantin) 1 PA, QL: 600 in 365 trimethoprim (Trimethoprim) 1 Vaccines Vaccines ACTHIB 1 ATTENUVAX VACCINE with DILUENT (PA if age 65 and older and QL exceeds 90 supply per year for any nitrofurantoin product; May be High Risk Med) (PA if age 65 and older and QL exceeds 90 supply per year for any nitrofurantoin product; May be High Risk Med) 1 PA (PA for Part B vs BCG VACCINE (TICE STRAIN) 1 PA (PA for Part B vs BIOTHRAX 1 CERVARIX 1 disp syrin CERVARIX 1 vial COMVAX 1 91

112 Name ENGERIX-B 1 PA (PA for Part B vs GARDASIL 1 disp syrin GARDASIL 1 vial HAVRIX 1 PA (PA for Part B vs IMOVAX RABIES VACCINE 1 PA (PA for Part B vs IPOL 1 IXIARO 1 JE-VAX 1 KINRIX 1 MENACTRA 1 disp syrin MENACTRA 1 vial MENOMUNE-A-C-Y-W MENVEO A-C-Y-W DIP MERUVAX II VACCINE 1 W-DILUENT M-M-R II VACCINE 1 MUMPSVAX VACCINE 1 W-DILUENT PEDIARIX 1 PEDVAXHIB 1 PENTACEL 1 PROQUAD 1 RABAVERT 1 PA (PA for Part B vs RECOMBIVAX HB 1 PA disp syrin: 10mcg/ ml; vial, (PA for Part B vs Part D RECOMBIVAX HB 1 PA disp syrin: 5mcg/ 0.5ml, 10mcg/ml, (PA for Part B vs ROTARIX 1 ROTATEQ 1 THERACYS 1 PA (PA for Part B vs TWINRIX 1 disp syrin 92

113 Name TWINRIX 1 vial TYPHIM VI 1 VAQTA 1 PA disp syrin, (PA for Part B vs Part D VAQTA 1 PA vial, (PA for Part B vs VARIVAX VACCINE 1 YF-VAX 1 ZOSTAVAX 1 Vasodilating Agents Vasodilating Agents ADCIRCA 1 PA, QL: 60 AGGRENOX 1 QL: 60 in 30 alprostadil (Alprostadil) 1 PA amyl nitrite (Amyl Nitrite) 1 epoprostenol sodium (glycine) isosorbide dinitrate (Isordil) 1 isosorbide mononitrate (Imdur) 1 ISOVEX 1 LETAIRIS 1 PA, QL: 30 NITRO-BID 1 nitroglycerin (Nitro-dur) 1 QL: 30 in 30 (Flolan) 1 PA (PA for Part B vs patch td24: 0.1mg/ hr, 0.2mg/hr, 0.6mg/ hr nitroglycerin (Nitro-dur) 1 QL: 60 in patch td24: 0.4mg/ 30 hr nitroglycerin (Nitroglycerin) 1 vial: 50mg/10ml nitroglycerin (Nitrolingual) 1 spray, vial: 5mg/ml nitroglycerin/d5w (Nitroglycerin/D5W) 1 NITROSTAT 1 nylidrin hcl (Nylidrin HCl) 1 tablet: 12mg papaverine hcl (Papaverine HCl) 1 PA REMODULIN 1 PA (PA for Part B vs 93

114 Name REVATIO 1 PA, QL: 37.5 in 1 day sildenafil citrate (Revatio) 1 PA, QL: 90 TRACLEER 1 LA, PA, QL: 60 in 30 TYVASO 1 PA VENTAVIS 1 PA (PA for Part B vs Vitamins and Minerals Vitamins and Minerals calcitriol (Rocaltrol) 1 PA (PA for ESRD fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 1 HECTOROL 1 PA (PA for ESRD multivitamins with (Multivitamins with Fluoride) 1 fluoride pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 1 (All Pre-Natal Vitamins are Covered) sodium fluoride (Luride) 1 ZEMPLAR 1 PA (PA for ESRD vial 94

115 INDEX 0.9 % sodium chloride A-HYDROCORT... 1 AMINOSYN II MOP AKTEN AMINOSYN II 3.5% M- aa/antipyrn/bcaine/polico#1/al ALBENZA DEXTROSE 5% ALBUKED AMINOSYN II 3.5%- aa/antpy/bcaine/polico/al acet ALBUKED DEXTROSE 25% ALBUMIN HUMAN AMINOSYN II 3.5%- abacavir sulfate ALBUMINAR DEXTROSE 5% ABELCET ALBUMINAR AMINOSYN II 4.25% M- ABILIFY ALBURX DEXT 10% ABILIFY DISCMELT ALBUTEIN AMINOSYN II 4.25%- ABILIFY MAINTENA albuterol sulfate DEXTROSE 25% ABRAXANE alclometasone dipropionate.. 30 AMINOSYN II 5% IN 25% acarbose alcohol antiseptic pads DEXTROSE acebutolol hcl ALDURAZYME AMINOSYN II IN acetaminophen with codeine... 4 alendronate sodium... 67, 68 DEXTROSE acetaminophen/phenyltolx cit. 3 ALFERON N AMINOSYN II with LYTESacetazolamide alfuzosin hcl CA-DW... 48, 49 acetazolamide sodium ALIMTA AMINOSYN M acetic ac/ricinoleic/oxyquinol28 ALINIA AMINOSYN with acetic acid... 26, 65 allopurinol ELECTROLYTES acetic acid/aluminum acetate 26 allopurinol sodium AMINOSYN-HBC acetic acid/hydrocortisone ALPHAGAN P AMINOSYN-HF acetylcysteine... 67, 85 alprazolam AMINOSYN-PF... 49, 50 ACTEMRA alprostadil AMINOSYN-RF ACTHIB ALREX amiodarone hcl ACTIMMUNE aluminum chloride AMITIZA ACTONEL amantadine hcl amitriptyline hcl ACTONEL with CALCIUM 67 amcinonide amlodipine besylate ACTOPLUS MET XR AMERICAINE amlodipine besylate/benazepril acyclovir... 28, 43 A-METHAPRED acyclovir sodium AMETHYST amlodipine/atorvastatin ADACEL AMEVIVE ammonium chloride ADAGEN amifostine crystalline ammonium lactate adapalene amikacin sulfate amoxapine ADCETRIS amiloride hcl amoxicillin ADCIRCA amiloride/hydrochlorothiazide amoxicillin/potassium clav ADVAIR DISKUS amphotericin b ADVAIR HFA... 1 AMINO ACIDS ampicillin sodium AFINITOR aminocaproic acid ampicillin sodium/sulbactam na AFINITOR DISPERZ aminophylline AGGRENOX AMINOSYN ampicillin trihydrate I-1

116 AMPYRA AVELOX BERINERT amyl nitrite AVELOX ABC PACK betamet acet/betamet na ph... 1 ANACAINE AVELOX IV betamethasone dipropionate. 30 ANADROL AVODART betamethasone valerate anagrelide hcl AVONEX betamethasone/propylene glyc ANASCORP AVONEX anastrozole ADMINISTRATION PACK BETASERON ANDRODERM betaxolol hcl... 24, 46 ANDROGEL... 9 AXIRON bethanechol chloride antipyrine/benzocaine/glycerin azathioprine BETIMOL azathioprine sodium BEXXAR ANTIVENIN LATRODECTUS azelastine hcl bicalutamide MACTANS AZILECT BICILLIN C-R ANTIVENIN MICRURUS azithromycin BICILLIN L-A FULVIUS azithromycin hydrogen citrate BICNU APEXICON E BILTRICIDE APOKYN AZOPT BIOTHRAX apraclonidine hcl AZOR bisoprolol fumarate APRISO aztreonam bisoprolol fumarate/hctz APTIVUS bacitracin... 12, 26 bleomycin sulfate ARALAST bacitracin/polymyxin b sulfate BLEPHAMIDE ARANESP... 63, BLEPHAMIDE S.O.P ARCALYST baclofen BONIVA ARICEPT BAL IN OIL BOOSTRIX ARRANON balsalazide disodium BOSULIF ARZERRA BANZEL BOTOX... 68, 69 ASACOL BARACLUDE BRANCHAMIN ASACOL HD BCG VACCINE TICE BRILINTA ASTEPRO STRAIN brimonidine tartrate atenolol benazepril hcl BROMDAY atenolol/chlorthalidone benazepril/hydrochlorothiazide bromfenac sodium atorvastatin calcium bromocriptine mesylate atovaquone/proguanil hcl BENICAR budesonide... 1 ATRIPLA BENICAR HCT bumetanide atropine sulfate... 16, 58 BENLYSTA BUMINATE ATROVENT HFA benzocaine BUPHENYL... 3 ATTENUVAX VACCINE with benzoyl peroxide buprenorphine hcl... 9 DILUENT benzoyl peroxide microspheres buprenorphine hcl/naloxone hcl AUBAGIO AVANDAMET benzoyl peroxide/aloe vera bupropion hcl AVANDARYL benzoyl peroxide/hydrocortison buspirone hcl AVANDIA BUSULFEX AVASTIN benzoyl peroxide/urea BUTISOL SODIUM AVC benztropine mesylate butorphanol tartrate... 9 I-2

117 BYDUREON CEENU chloroxylenol/pramoxine hcl 67 BYETTA cefaclor chlorpromazine hcl BYSTOLIC cefadroxil hydrate chlorthalidone cabergoline cefazolin sodium chlorzoxazone caffeine citrated cefazolin sodium/dextrose,iso13 chlorzoxazone/acetaminophen caffeine/sodium benzoate cefdinir calcipotriene cefditoren pivoxil cholestyramine (with sugar).31 calcitonin,salmon,synthetic CEFEPIME cholestyramine/aspartame calcitriol... 87, 94 cefepime hcl choline sal/mag salicylate... 3 calcium acetate CEFEPIME-DEXTROSE ciclopirox calcium carbonate/mag carb/fa cefotaxime sodium ciclopirox olamine cefotetan disod/dextrose,iso.. 14 cidofovir calcium chloride cefotetan disodium cilostazol CALCIUM DISODIUM cefoxitin sodium cimetidine VERSENATE cefoxitin sodium/dextrose,iso 14 cimetidine hcl calcium gluconate cefpodoxime proxetil cimetidine in 0.9 % nacl CALDOLOR... 3 cefprozil CIMZIA CAMPATH CEFTAZIDIME CINRYZE CAMPRAL ceftazidime pentahydrate CIPRO HC CANCIDAS ceftriaxone na/dextrose,iso CIPRODEX candesartan cilexetil ceftriaxone sodium ciprofloxacin hcl... 15, 26 candesartan/hydrochlorothiazid cefuroxime axetil ciprofloxacin lactate cefuroxime sodium ciprofloxacin lactate/d5w CAPASTAT SULFATE cefuroxime sodium/dextrose,iso ciprofloxacin/ciprofloxa hcl.. 15 CAPRELSA cisplatin captopril CELEBREX... 3 citalopram hydrobromide captopril/hydrochlorothiazide CELLCEPT citrate-phos-dex solution CELONTIN citric acid/sodium citrate CARAC cephalexin cladribine CARAFATE CEPROTIN clarithromycin CARBAGLU... 3 CEREDASE clemastine fumarate carbamazepine CEREZYME CLEVIPREX carbidopa/levodopa CERVARIX clindamycin hcl carbidopa/levodopa/entacapone CESAMET clindamycin palmitate hcl cevimeline hcl clindamycin phos/benzoyl perox carbinoxamine maleate CHANTIX carboplatin CHENODAL clindamycin phosphate... 12, 27 CARDENE I.V chloramphenicol sod succ clindamycin phosphate/d5w.. 12 CARIMUNE NF chlordiazepoxide hcl CLINIMIX NANOFILTERED chlorhexidine gluconate CLINIMIX E carisoprodol chloroprocaine hcl/pf CLINISOL carteolol hcl chloroquine phosphate clobetasol propionate carvedilol chlorothiazide CLODERM CAYSTON chlorothiazide sodium CLOLAR I-3

118 clomipramine hcl CUBICIN dextroamphetamine sulfate clonazepam cyclobenzaprine hcl dextroamphetamine/ clonidine CYCLOGYL amphetamine clonidine hcl cyclopentolate hcl dextrose 10 % and 0.2 % nacl clonidine hcl/chlorthalidone.64 cyclophosphamide... 33, clopidogrel bisulfate cyclosporine dextrose 10 % and 0.9 % nacl clorazepate dipotassium cyclosporine, modified clotrimazole CYMBALTA dextrose 10%-0.5 normal saline clotrimazole/betamethasone dip CYSTADANE cysteine hcl dextrose 10%-water clozapine cytarabine/pf dextrose 2.5 % in water COARTEM CYTOGAM dextrose 2.5% in half ringers 82 cocaine hcl dacarbazine dextrose 2.5%-0.5normal saline codeine phos/acetaminophen.. 4 DACOGEN codeine phosphate... 5 dactinomycin dextrose 20%-water codeine sulfate... 5 DALIRESP dextrose 25 % in water CODEINE SULFATE... 5 danazol dextrose 40%-water colchicine/probenecid dantrolene sodium dextrose 5 % and 0.3 % nacl 51 COLCRYS dapsone dextrose 5 % and 0.9 % nacl 51 colestipol hcl DAPTACEL dextrose 5 % in water colistin (colistimethate na) DARAPRIM dextrose 5 %-0.2 % nacl COLY-MYCIN S daunorubicin hcl dextrose 5 %-0.45 % nacl COMBIGAN DAUNOXOME dextrose 5% in ringers COMBIPATCH DDAVP dextrose 5%-lactated ringers 82 COMBIVENT deferoxamine mesylate dextrose 50 % in water COMBIVENT RESPIMAT.. 89 demeclocycline hcl dextrose 60 % in water COMETRIQ DENAVIR dextrose 70%-water COMPLERA DEPO-PROVERA DEXTROSE W/ COMTAN desipramine hcl ELECTROLYTE A COMVAX desloratadine DEXTROSE W/ CONDYLOX desmopressin acetate ELECTROLYTE B COPAXONE desogestrel-ethinyl estradiol. 56 dhcodeine bt/acetaminophn/caff CORDRAN desog-et estra/ethin estra CORDRAN SP desonide DIASTAT ACUDIAL COREG CR desoximetasone diazepam... 45, 46 cortisone acetate... 1 DESVENLAFAXINE ER diclofenac potassium... 3 CORTISPORIN-TC DETROL LA diclofenac sodium... 3, 29 CREON dex 2.5%-half str lact.ringers 82 diclofenac sodium/misoprostol 3 CRESTOR dexamethasone... 1 dicloxacillin sodium cresyl ace/ben alc/butanol/ipa dexamethasone acetate... 1 dicyclomine hcl dexamethasone sod phosphate1, didanosine CRIXIVAN DIFICID CROFAB dexmethylphenidate hcl diflorasone diacetate cromolyn sodium dexrazoxane diflunisal... 3 I-4

119 DIGIBIND DULERA... 1 EPIVIR HBV DIGIFAB DUODOTE eplerenone digoxin DUREZOL EPOGEN DIGOXIN DUTOPROL epoprostenol sodium (glycine) dihydrocodeine/aspirin/caffein5 DYRENIUM dihydroergotamine mesylate. 89 DYSPORT eprosartan mesylate DILANTIN econazole nitrate EPZICOM diltiazem hcl edetate disodium ERAXIS WATER DILUENT24 dimenhydrinate EDURANT ERBITUX DIOVAN EFFIENT ergotamine tartrate/caffeine. 89 DIPENTUM ELAPRASE ERIVEDGE diphenhydramine hcl electrolyte-48 solution/d10w. 82 ERWINAZE diphenoxylate hcl/atropine electrolyte-48 solution/d5w ery e-succ/sulfisoxazole DIPHTHERIA-TETANUS electrolyte-48/fructose 10%.. 82 ERY-TAB TOXOID electrolyte-48/fructose 5% ERYTHROCIN DIPHTHERIA-TETANUS electrolyte-75 solution/d5w LACTOBIONATE TOXOIDS-PED electrolyte-75/fructose 5% erythromycin base... 14, 26 disopyramide phosphate electrolyte-r solution/d5w erythromycin base/ethanol disulfiram ELELYSO erythromycin ethylsuccinate.14 divalproex sodium ELIDEL erythromycin stearate dobutamine hcl ELIGARD erythromycin/benzoyl peroxide dobutamine hcl/d5w ELITEK DOCEFREZ ELMIRON escitalopram oxalate docetaxel ELSPAR esmolol hcl DOLOGESIC... 3 EMCYT estazolam donepezil hcl EMEND ESTRACE dopamine hcl EMSAM estradiol dopamine hcl/d5w EMTRIVA estradiol valerate dopamine hcl/dextrose 5%- enalapril maleate estradiol/norethindrone acet.60 water enalapril/hydrochlorothiazide ESTRASORB dorzolamide hcl estropipate dorzolamide hcl/timolol maleat enalaprilat dihydrate ethambutol hcl ENBREL ethanolamine oleate doxazosin mesylate... 2 ENDRATE ethinyl estradiol/drospirenone doxepin hcl ENGERIX-B doxorubicin hcl enoxaparin sodium ethosuximide doxorubicin hcl peg-liposomal entacapone ethyl alcohol/d5w ephedrine sulfate ethynodiol d-ethinyl estradiol56 doxycycline hyclate... 16, 26 epinastine hcl etidronate disodium doxycycline monohydrate epinephrine etodolac... 3 DRITHO-SCALP EPIPEN 2-PAK ETOPOPHOS dronabinol EPIPEN JR 2-PAK etoposide droperidol epirubicin hcl EURAX DROXIA EPIVIR EVISTA I-5

120 EXELDERM flunisolide GALZIN EXELON fluocinolone acetonide GAMASTAN S-D exemestane fluocinolone acetonide oil GAMMAGARD LIQUID EXFORGE fluocinolone/shower cap GAMMAPLEX EXFORGE HCT fluocinonide GAMUNEX-C EXJADE fluoride/iron/vit a,c&d ganciclovir EXTAVIA fluorometholone ganciclovir sodium FABRAZYME FLUOROPLEX GARDASIL famciclovir fluorouracil... 35, 88 gauze bandage famotidine fluoxetine hcl gemcitabine hcl famotidine in nacl,iso-osm/pf 41 fluoxymesterone gemfibrozil FANAPT fluphenazine decanoate GENOTROPIN FARESTON fluphenazine hcl gentamicin in nacl, iso-osm.. 11 FASLODEX... 34, 35 flurazepam hcl gentamicin sulfate... 11, 26, 27 FAZACLO flurbiprofen... 3 gentamicin sulfate/pf felbamate flurbiprofen sodium GEODON felodipine flutamide GILENYA FEMRING fluticasone propionate... 29, 30 GLEEVEC fenofibrate fluvastatin sodium glimepiride fenofibrate nanocrystallized.. 31 fluvoxamine maleate glipizide fenofibrate,micronized FOLOTYN glipizide/metformin hcl fenofibric acid fomepizole GLUCAGEN fenoldopam mesylate fondaparinux sodium GLUCAGON EMERGENCY fenoprofen calcium... 3 FORADIL KIT fentanyl... 5 FORTEO glutethimide fentanyl citrate... 5 FORTICAL glyburide FERRIPROX foscarnet sodium glyburide,micronized finasteride fosinopril sodium glyburide/metformin hcl FIRAZYR fosinopril/hydrochlorothiazide GLYCINE FIRMAGON glycopyrrolate flavoxate hcl fosphenytoin sodium GLYSET FLEBOGAMMA FREAMINE HBC gold sodium thiomalate FLEBOGAMMA DIF FREAMINE III granisetron hcl flecainide acetate FREAMINE III with granisetron hcl/pf FLEXBUMIN ELECTROLYTES griseofulvin ultramicrosize FLOVENT DISKUS... 1 fructose 10% griseofulvin,microsize FLOVENT HFA... 1, 2 FULYZAQ guaifen/theop anhyd/p-ephed 85 floxuridine furosemide guanfacine hcl fluconazole FUROXONE guanidine hcl fluconazole in nacl,iso-osm FUSILEV GYNAZOLE flucytosine FUZEON H.P. ACTHAR fludarabine phosphate gabapentin HALAVEN fludrocortisone acetate... 2 GABITRIL HALFAN flumazenil galantamine hbr halobetasol propionate I-6

121 haloperidol hydroxyurea IONOSOL MB-DEXTROSE haloperidol decanoate hydroxyzine hcl % haloperidol lactate hydroxyzine pamoate IONOSOL T-DEXTROSE 5% HAVRIX HYPERLYTE CR HECTOROL HYPERLYTE R IPOL heparin sod,pork in 0.45% nacl HYPERRAB S-D ipratropium bromide HYPERRHO S-D IPRIVASK heparin sodium,porcine ibandronate sodium irbesartan heparin sodium,porcine/d5w.62 ibuprofen... 3 irbesartan/hydrochlorothiazide heparin sodium,porcine/ns/pf 62 ibuprofen/oxycodone hcl heparin sodium,porcine/pf ICLUSIG IRESSA HEPATAMINE idarubicin hcl irinotecan hcl HEPATASOL ifosfamide ISENTRESS HEPSERA ifosfamide/mesna ISOLYTE E HERCEPTIN ILARIS ISOLYTE H W/DEXTROSE 83 HEXALEN ILEVRO ISOLYTE M W/DEXTROSE83 HIZENTRA imipenem/cilastatin sodium.. 14 ISOLYTE P with DEXTROSE homatropine hbr imipramine hcl HUMALOG imipramine pamoate ISOLYTE S HUMALOG MIX , 20 imiquimod ISOLYTE S with DEXTROSE HUMALOG MIX IMOGAM RABIES-HT HUMATROPE IMOVAX RABIES VACCINE isoniazid HUMIRA isopropamide/prochlorperazine HUMULIN inamrinone lactate HUMULIN N INCIVEK isoproterenol hcl HUMULIN R INCRELEX ISOPTO CARPINE hydralazine hcl indapamide ISOPTO HOMATROPINE.. 58 hydralazine/hydrochlorothiazid indomethacin... 4 isosorbide dinitrate indomethacin sodium... 4 isosorbide mononitrate hydralazine/reserpin/hctz INFANRIX isotretinoin hydrochlorothiazide INFANRIX PF ISOVEX hydrocodone bit/acetaminophen INLYTA isradipine , 6 INTELENCE ISTALOL hydrocodone/ibuprofen... 6 INTRALIPID... 51, 52 ISTODAX hydrocortisone... 2, 31 INTRON A itraconazole hydrocortisone acetate INTUNIV IXEMPRA hydrocortisone acetate/aloe v30 INVANZ IXIARO hydrocortisone acetate/urea. 30 INVEGA JAKAFI hydrocortisone butyrate INVEGA SUSTENNA JALYN hydrocortisone sod succinate.. 2 INVIRASE JANUMET hydrocortisone valerate INVOKANA JANUMET XR hydromorphone hcl... 6 IONOSOL B with DEXTROSE JANUVIA hydromorphone hcl/pf % JENTADUETO hydroxychloroquine sulfate JE-VAX I-7

122 JEVTANA LEVEMIR FLEXPEN lovastatin JUVISYNC levetiracetam LOVAZA KADCYLA levetiracetam in nacl (iso-os) 17 loxapine succinate KADIAN... 6 levobunolol hcl LUMIGAN KALBITOR levocarnitine LUMINAL SODIUM KALETRA levocarnitine (with sugar) LUMIZYME KALYDECO levocetirizine dihydrochloride LUPRON DEPOT kanamycin sulfate LUPRON DEPOT-PED KEDBUMIN levofloxacin... 15, 26 LUVOX CR KEPIVANCE levofloxacin/d5w LYRICA KETEK levonorgestrel LYSODREN ketoconazole... 24, 27 levonorgestrel-eth estradiol.. 57 LYSTEDA ketoprofen... 4 levorphanol tartrate... 6 mafenide acetate ketorolac tromethamine... 4, 29 levothyroxine sodium magnesium chloride KINERET LEVULAN magnesium salicylate... 4 KINRIX LEXAPRO magnesium sulfate KORLYM LEXIVA magnesium sulfate in 0.9% nacl K-PHOS M.F lidocaine K-PHOS NO lidocaine hcl... 40, 53, 67 MAGNESIUM SULFATE IN KRYSTEXXA lidocaine hcl/d5w/pf DEXTROSE KUVAN lidocaine hcl/pf... 53, 67 magnesium sulfate/d5w KYNAMRO lidocaine/prilocaine malathion KYPROLIS LIDODERM mannitol/sorbitol solution labetalol hcl lindane maprotiline hcl LACRISERT LINZESS MARPLAN LACTATED RINGERS. 65, 83 liothyronine sodium MATULANE lactulose... 3 lipase/protease/amylase mebendazole LAMISIL LIPOSYN II meclizine hcl lamivudine LIPOSYN III meclofenamate sodium... 4 lamivudine/zidovudine lisinopril medroxyprogesterone acetate lamotrigine... 16, 17 lisinopril/hydrochlorothiazide... 75, 76 lansoprazole mefenamic acid... 4 LANTUS lithium carbonate mefloquine hcl LANTUS SOLOSTAR lithium citrate MEGACE ES latanoprost LITHOSTAT... 3 megestrol acetate LATUDA l-norgest-eth estr/ethin estra. 57 meloxicam... 4 leflunomide LOCOID melphalan hcl LETAIRIS LODOSYN MENACTRA letrozole loperamide hcl MENEST leucovorin calcium lorazepam MENOMUNE-A-C-Y-W-135 LEUKERAN losartan potassium LEUKINE losartan/hydrochlorothiazide 81 MENVEO A-C-Y-W-135-DIP leuprolide acetate LOTEMAX LEVEMIR LOTRONEX mepivacaine hcl/pf I-8

123 MEPRON MIACALCIN nadolol/bendroflumethiazide 47 mercaptopurine miconazole nitrate nafcillin in dextrose,iso-osm. 15 meropenem MICRHOGAM PLUS nafcillin sodium MERUVAX II VACCINE W- midazolam hcl NAGLAZYME DILUENT midodrine hcl nalbuphine hcl... 9 mesalamine w/cleansing wipes milrinone lactate nalidixic acid milrinone lactate/d5w naloxone hcl mesna MINOCIN naltrexone hcl MESNEX minocycline hcl NAMENDA MESTINON minoxidil NAMENDA XR metaproterenol sulfate mirtazapine naphazoline hcl metaxalone misoprostol naphazoline hcl/antazoline metformin hcl mitomycin naproxen... 4 methadone hcl... 7 mitoxantrone hcl naproxen sodium... 4 methamphetamine hcl M-M-R II VACCINE naratriptan hcl methazolamide MOBAN NASONEX methenamine mandelate modafinil NATACYN methimazole moexipril hcl nateglinide methocarbamol moexipril/hydrochlorothiazide NAVANE methotrexate sodium... 36, needles, insulin disp., safety.. 57 methotrexate sodium/pf mometasone furoate needles, insulin disposable methscopolamine bromide montelukast sodium nefazodone hcl methyclothiazide morphine sulfate... 7 neo/polymyx b sulf/dexameth 26 methylene blue morphine sulfate in 0.9 % nacl7 neomy sulf/bacitra/polymyxin b methylergonovine maleate... 70, morphine sulfate/d5w morphine sulfate/pf... 7 neomy sulf/bacitrac zn/poly/hc methylphenidate hcl... 10, 11 MOXEZA methylprednisolone... 2 MOZOBIL neomy sulf/polymyxin b sulfate methylprednisolone acetate... 2 MULTAQ methylprednisolone sod succ.. 2 multivitamins with fluoride neomycin sulfate metipranolol MUMPSVAX VACCINE W- neomycin sulfate/dex na ph metoclopramide hcl DILUENT neomycin/polymyxin b sulf/hc26 metolazone mupirocin neomycin/polymyxn b/ metoprolol succinate mupirocin calcium gramicidin metoprolol tartrate MUSTARGEN neostigmine methylsulfate metoprolol/hydrochlorothiazide MYCOBUTIN NEPHRAMINE mycophenolate mofetil NEULASTA metronidazole... 27, 40 MYFORTIC NEUMEGA metronidazole/sodium chloride MYOBLOC NEUPOGEN MYOZYME NEUPRO METVIXIA MYTELASE NEVANAC mexiletine hcl na nitrite/na thiosul/amyl nit.61 nevirapine mg sal/acetaminophn/p-tlox/caf nabumetone... 4 NEXAVAR nadolol niacin I-9

124 NIASPAN NOVOLIN N INNOLET oxacillin sodium nicardipine hcl NOVOLIN R oxacillin sodium/dextrose,iso 15 NICOTROL NOVOLOG oxaliplatin nifedipine NOVOLOG FLEXPEN oxandrolone NILANDRON NOVOLOG MIX oxaprozin... 4 nimodipine NOVOLOG MIX oxazepam nisoldipine FLEXPEN oxcarbazepine NITRO-BID NOXAFIL OXSORALEN-ULTRA nitrofurantoin NPLATE OXTELLAR XR nitrofurantoin macrocrystal.. 91 NUCYNTA... 7 oxybutynin chloride nitroglycerin NUCYNTA ER... 7 oxycodone hcl... 8 nitroglycerin/d5w NUEDEXTA oxycodone hcl/acetaminophen 8 NITROSTAT NUHIST oxycodone hcl/aspirin... 8 nizatidine NULOJIX oxycodone hcl/oxycodon ter/asa NORDITROPIN NUTRESTORE NORDITROPIN FLEXPRO. 75 NUTRILYTE OXYCONTIN... 8 NORDITROPIN NORDIFLEX NUTRILYTE II oxymorphone hcl... 8, NUTROPIN paclitaxel norepinephrine bit/0.9 % nacl NUTROPIN AQ pamidronate disodium NUTROPIN AQ NUSPIN PANRETIN norepinephrine bitartrate NUVARING pantoprazole sodium norepinephrine bitartrate/d5w nylidrin hcl papaverine hcl nystatin... 24, 28 paregoric noreth a-et estra/fe fumarate 57 nystatin/triamcin paromomycin sulfate noreth-ethinyl estradiol/iron.57 OCTAGAM paroxetine hcl norethind ac/ethinyl estradiol60 octreotide acetate PASER norethindrone OFIRMEV... 3 PATADAY norethindrone acetate ofloxacin... 15, 26 PATANOL norethindrone a-e estradiol.. 57 olanzapine PAXIL norethindrone-ethinyl estrad 57 olanzapine/fluoxetine hcl PEDIARIX norethindrone-mestranol omeprazole PEDVAXHIB norgestimate-ethinyl estradiol omeprazole/sodium bicarbonate peg 3350/na sulf,bicarb,cl/kcl PEGANONE norgestrel-ethinyl estradiol OMNITROPE PEGASYS NORMOSOL-M and ONCASPAR PEGASYS PROCLICK DEXTROSE ondansetron PEGINTRON NORMOSOL-R PH ondansetron hcl PEGINTRON REDIPEN nortriptyline hcl ONFI pen g pot/dextrose-water NORVIR ONTAK penicillin g potassium NOVAMINE ORAP penicillin g potassium/d5w NOVAREL ORENCIA penicillin g procaine NOVOLIN ORFADIN penicillin v potassium NOVOLIN INNOLET 20 ORTHO EVRA PENTACEL NOVOLIN N OTOGESIC pentamidine isethionate I-10

125 pentostatin PLASMA-LYTE M IN PRANDIN pentoxifylline DEXTROSE pravastatin sodium p-epd tan/chlor-tan pnv with ca,no.72/iron/fa prazosin hcl... 3 perindopril erbumine podofilox prednicarbate PERJETA podophyllum resin prednisolone... 2 permethrin polyethylene glycol prednisolone acetate... 2, 29 perphenazine polymyxin b sulf/trimethoprim prednisolone sod phosphate... 2, perphenazine/amitriptyline hcl polymyxin b sulfate prednisone... 2 phenelzine sulfate POMALYST PREDNISONE INTENSOL... 2 phenobarbital pot chloride/pot bicarb/cit ac 83 PREMARIN phenobarbital sodium potassium acetate PREMASOL phentolamine mesylate potassium bicarbonate/cit ac 83 PREMPHASE phenyleph/acetaminop/p-tlox/cp potassium chlorid/d10-0.2%nacl PREMPRO PREZISTA phenylephrine hcl... 59, 90 potassium chloride PRIFTIN phenylephrine tannate potassium chloride in 0.9%nacl PRIMAQUINE phenylephrine/chlor-tan primidone PHENYTEK potassium chloride in d5w... 83, PRISTIQ ER phenytoin PRIVIGEN phenytoin sodium potassium chloride in lr-d PROAIR HFA phenytoin sodium extended potassium chloride/d5- probenecid PHOSLYRA %nacl procainamide hcl PHOSPHOLINE IODIDE potassium chloride/d5-0.25ns84 PROCALAMINE phosphorus # potassium chloride/d5- prochlorperazine edisylate physostigmine salicylate %nacl prochlorperazine maleate PICATO potassium chloride/d5-0.45nacl PROCRIT pilocarpine hcl... 25, progesterone PILOPINE HS potassium chloride/d5- progesterone,micronized pindolol %nacl PROGLYCEM pioglitazone hcl potassium chloride-0.45% nacl PROGRAF pioglitazone hcl/glimepiride PROLASTIN pioglitazone hcl/metformin hcl potassium citrate PROLASTIN C potassium citrate/citric acid. 71 PROLENSA piperacillin sodium potassium gluconate PROLEUKIN piperacillin sodium/tazobactam potassium hydroxide PROLIA potassium phos,m-basic-d-basic PROMACTA piroxicam promethazine hcl PLASBUMIN POTIGA PRONESTYL PLASBUMIN PRADAXA propafenone hcl PLASMA-LYTE PRALIDOXIME CHLORIDE propantheline bromide PLASMA-LYTE 56 IN proparacaine hcl DEXTROSE pramipexole di-hcl proparacaine/fluorescein sod 67 PLASMA-LYTE A PH PRANDIMET PROPINE I-11

126 propranolol hcl reserpine/hydrochlorothiazide SELZENTRY propranolol/hydrochlorothiazid SENSIPAR RESTASIS SEREVENT DISKUS propylthiouracil RETROVIR SEROMYCIN PROQUAD REVATIO SEROQUEL XR PROSOL REVLIMID... 37, 72 SEROSTIM PROSTIGMIN REYATAZ sertraline hcl protamine sulfate RHOGAM PLUS SIGNIFOR PROTOPAM CHLORIDE RHOPHYLAC sildenafil citrate PROTOPIC RIBATAB SILENOR protriptyline hcl ribavirin silver nitrate PULMOZYME RIDAURA silver nitrate applicator pyrazinamide rifampin silver sulfadiazine pyridostigmine bromide rifampin/isoniazid SIMPONI QNASL RILUTEK SIMULECT quetiapine fumarate rimantadine hcl simvastatin QUICK MIX with LYTES ringers solution... 65, 84 sod chloride 0.45% irrig. soln quinapril hcl RISPERDAL CONSTA quinapril/hydrochlorothiazide risperidone sod propion/inositol/aa14/urea RITUXAN quinidine gluconate rivastigmine tartrate sod/pot/k cit/sod cit/cit acid.. 72 quinidine sulfate rizatriptan benzoate sodium acetate quinine sulfate ropinirole hcl sodium bicarbonate QVAR... 2 ROTARIX sodium chloride RABAVERT ROTATEQ sodium chloride 0.45 % ramipril ROZEREM sodium chloride 3% RANEXA SABRIL sodium chloride 5% ranitidine hcl SAIZEN sodium chloride irrig solution RAPAMUNE sal-amide/acetamin/p-tlox/caff RAVICTI... 3 sal-amide/acetaminophn/p-tlox3 sodium chloride/nahco3/kcl/peg REBIF salicylamide/acetaminophen REBIF REBIDOSE salicylic acid sodium fluoride RECLAST salicylic acid/ammon lact/aloe sodium lactate RECOMBIVAX HB sodium morrhuate REGONOL salicylic acid/ceramide cmb #1 sodium phenylbutyrate... 3 RELENZA sodium phos,m-basic-d-basic 84 RELISTOR salsalate... 4 sodium polystyrene sulfonate 65 REMICADE SAMSCA sodium tetradecyl sulfate REMODULIN SANDOSTATIN LAR sodium thiosulfate RENAGEL SANTYL sodium thiosulfate/sal acid RENAMIN SAPHRIS SOLIRIS RENVELA SAVELLA SOLTAMOX RESCRIPTOR selegiline hcl SOLU-CORTEF... 2 reserpine selenium sulfide SOLU-MEDROL... 2 I-12

127 SOMATULINE DEPOT SUSTIVA tetracaine hcl/pf SOMAVERT SUTENT tetracycline hcl sorbitol solution SYLATRON TEV-TROPIN SORIATANE SYMLIN THALOMID sotalol hcl SYMLINPEN theophylline anhydrous SOTALOL HCL SYMLINPEN theophylline/d5w spinosad SYNAGIS THERACYS SPIRIVA SYNAREL thioridazine hcl spironolact/hydrochlorothiazid SYNERCID thiotepa SYNRIBO thiothixene spironolactone SYPRINE tiagabine hcl SPORANOX syring w-ndl,disp,insul,0.3ml 57 TIKOSYN SPRYCEL syring w-ndl,disp,insul,0.5ml 57 timolol maleate... 25, 47 STALEVO syringe & needle,insulin,1 ml 57 tinidazole STALEVO TABLOID tizanidine hcl STALEVO TACLONEX TOBI STALEVO tacrolimus TOBI PODHALER STALEVO TAMIFLU tobramycin STALEVO tamoxifen citrate tobramycin sulfate stavudine tamsulosin hcl tobramycin/dexamethasone STELARA... 72, 88 TARCEVA tobramycin/sodium chloride. 12 STERILE DILUENT TARGRETIN... 37, 88 tolazamide STIVARGA TASIGNA tolbutamide STRATTERA TASMAR tolmetin sodium... 4 streptomycin sulfate TAZICEF IN DEXTROSE tolterodine tartrate STRIBILD TAZORAC topiramate STROMECTOL TE ANATOXAL BERNA topotecan hcl SUBOXONE... 9 TECFIDERA... 72, 73 TORISEL sucralfate TEGRETOL XR torsemide sulfacetamide sodium... 27, 28 temazepam TOVIAZ sulfacetamide sodium/urea TEMODAR TPN ELECTROLYTES sulfacetamide/prednisolone sp TENIVAC TRACLEER terazosin hcl... 3 TRADJENTA sulfadiazine terbinafine hcl tramadol hcl... 9 sulfamethoxazole/trimethoprim terbutaline sulfate tramadol hcl/acetaminophen terconazole trandolapril sulfasalazine testosterone cypionate trandolapril/verapamil hcl sulindac... 4 testosterone enanthate tranexamic acid sumatriptan TETANUS DIPHTHERIA tranylcypromine sulfate sumatriptan succinate TOXOIDS TRAVAMULSION SUPPRELIN TETANUS TOXOID TRAVASOL SUPPRELIN LA ADSORBED TRAVASOL W/DEXTROSE SUPRAX TETANUS-DIPHTERIA SURMONTIL DECAVAC I-13

128 TRAVASOL W/ TRIZIVIR VFEND ELECTROLYTES TROPHAMINE VICTOZA 3-PAK TRAVASOL with DEXTROSE tropicamide VICTRELIS trospium chloride VIDAZA TRAVASOL with TRUVADA VIDEX ELECTROLYTES TWINRIX... 92, 93 VIGAMOX TRAVATAN Z TYGACIL VIIBRYD TRAVERT TYKERB VIMPAT TRAVERT IN NORMAL TYPHIM VI vinblastine sulfate SALINE TYSABRI vincristine sulfate TRAVERT-ELECTROLYTE TYVASO vinorelbine tartrate NO TYZEKA VIRACEPT TRAVERT-ELECTROLYTE TYZINE VIRAMUNE NO ULORIC VIRAMUNE XR TRAVERT-ELECTROLYTE urologic solution-g VIREAD NO ursodiol VIVAGLOBIN TRAVERT-ELECTROLYTE UVADEX VIVELLE-DOT NO VAGIFEM VOLTAREN... 4 travoprost (benzalkonium) valacyclovir hcl VORAXAZE trazodone hcl VALCYTE voriconazole TREANDA valproate sodium VOTRIENT TRECATOR valproic acid VPRIV TRELSTAR valsartan/hydrochlorothiazide VUMON tretinoin... 38, warfarin sodium tretinoin microspheres VALSTAR water for irrigation,sterile TREXALL vancomycin hcl WELCHOL triacetin VANCOMYCIN HCL WINRHO SDF triamcinolone acetonide... 2, 29, vancomycin hcl/d5w XALKORI vancomycin/0.9% sod chloride XARELTO triamterene/hydrochlorothiazid XELJANZ VANDETANIB XENAZINE triazolam VANTAS XERAC AC TRIBENZOR VAQTA XGEVA trifluoperazine hcl VARIVAX VACCINE XIAFLEX trifluridine vasopressin XIFAXAN trihexyphenidyl hcl VECAMYL XOLAIR TRIHIBIT VECTIBIX XTANDI TRILIPIX VELCADE XYLOCAINE trimethoprim venlafaxine hcl XYREM trimipramine maleate VENLAFAXINE HCL ER YERVOY TRIPEDIA VENTAVIS YF-VAX tripelennamine hcl verapamil hcl... 47, 48 YODOXIN TRIPLE ANTIBIOTIC VERIPRED zafirlukast TRISENOX VESICARE zaleplon I-14

129 ZALTRAP ZANOSAR ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid/ mannitol&water ZOLINZA zolmitriptan zolpidem tartrate ZOMETA zonisamide ZORBTIVE ZORTRESS ZOSTAVAX ZOSYN ZOVIRAX ZYCLARA ZYLET ZYMAR ZYMAXID ZYPREXA ZYPREXA RELPREVV ZYTIGA ZYVOX I-15

130 LA / /2013