2016 FORMULARY VADEMÉCUM 2016

Transcription

1 206 FORMULARY VADEMÉCUM 206 (LIST OF COVERED DRUGS) (LISTA DE MEDICAMENTOS CUBIERTOS) Amida Care True Life Plus (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN This formulary was updated on 08/0/206. This information is available for free in other languages. For more recent information or other questions, please contact Amida Care Member Services at or, for TTY users, 7, 8 am to 8 pm, Monday - Friday (every day October to February), or visit The Formulary may change at any time. You will receive notice when necessary. Este vademécum fue actualizado el 0/08/206. Esta información se encuentra disponible en forma gratuita en otros idiomas. Para acceder a información más reciente y si tiene otras preguntas, comuníquese con el Departamento de Servicios al Miembro de Amida Care al o, para usuarios de TTY, 7, De 8 a.m. a 8 p.m., de lunes a viernes (todos los días de octubre a febrero) o puede visitar El vademécum puede cambiar en cualquier momento. Usted recibirá una notificación de ser necesario. Amida Care (HMO) is a not-for-profit health plan with a Medicare Contract. Enrollment in Amida Care depends on contract renewal. Amida Care (HMO) es un plan de salud sin fines de lucro con contrato con Medicare. La inscripción en Amida Care depende de la renovación del contrato , Version 2 H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205

2 206 Part D Model Formulary (Abridged and Comprehensive) Amida Care True Life Plus (HMO) 206 Formulary (List of Covered s) 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. When this drug list (formulary) refers to we, us, or our, it means Amida Care Inc. When it refers to plan or our plan, it means Amida Care True Life Plus. This document includes list of the drugs (formulary) for our plan which is current as of 08/0/206. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 207, and from time to time during the year. What is the Amida Care True Life Plus Formulary? A formulary is a list of covered drugs selected by Amida Care True Life Plus 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. Amida Care True Life Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Amida Care True Life Plus 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 (drug list) change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 206 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. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 i

3 206 Part D Model Formulary (Abridged and Comprehensive) If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days 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 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 08/0/206. To get updated information about the drugs covered by Amida Care True Life Plus, please contact us. Our contact information appears on the front and back cover pages. We may update this formulary on a monthly basis throughout the year. Updates include additions, deletions and utilization management changes based on the most recent CMS approved formulary. You can access the most up to date formulary via our website at or by calling Member Services and requesting that a current printed version be sent to you. The printed version may contain an errata sheet reflecting the changes to the printed formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 2. 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, Antihypertensive Therapy. If you know what your drug is used for, look for the category name in the list that begins on page 2. 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 76. 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? Amida Care True Life Plus 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. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 ii

4 206 Part D Model Formulary (Abridged and Comprehensive) 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: Amida Care True Life Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Amida Care True Life Plus before you fill your prescriptions. If you don t get approval, Amida Care True Life Plus may not cover the drug. Quantity Limits: For certain drugs, Amida Care True Life Plus limits the amount of the drug that Amida Care True Life Plus will cover. For example, Amida Care True Life Plus provides up to 90 tablets per prescription for doxazosin mesylate. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Amida Care True Life Plus 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, Amida Care True Life Plus may not cover B unless you try A first. If A does not work for you, Amida Care True Life Plus 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 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Amida Care True Life Plus to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Amida Care True Life Plus formulary? on page iv 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 (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Amida Care True Life Plus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Amida Care True Life Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask Amida Care True Life Plus to make an exception and cover your drug. See below for information about how to request an exception. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 iii

5 206 Part D Model Formulary (Abridged and Comprehensive) How do I request an exception to the Amida Care True Life Plus Formulary? You can ask Amida Care True Life Plus 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 a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Amida Care True Life Plus 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 a greater amount. Generally, Amida Care True Life Plus will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug 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, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber 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 a supporting statement from your doctor or other prescriber. 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 days 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 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 iv

6 206 Part D Model Formulary (Abridged and Comprehensive) 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 9 to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days 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 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you experience a change in the level/location of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or a drug that is on our formulary but your ability to get it is limited, we will provide a one-time transition supply for up to 30 days (or 3 day if you are a long term care resident) when you go to a network pharmacy. The pharmacy will contact us to let us know there has been a level of care change so we can process the claim for a transition supply. For more information For more detailed information about your Amida Care True Life Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Amida Care True Life Plus, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Amida Care True Life Plus Formulary The formulary that begins on page 2 provides coverage information about the drugs covered by Amida Care True Life Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 76. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., DEMSER) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the column tells you if Amida Care True Life Plus has any special requirements for coverage of your drug. Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 v

7 206 Part D Model Formulary (Abridged and Comprehensive) List of Abbreviations o o o o o o B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs our plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, we require you first to try certain drugs to treat your medical condition before we will cover another drug for that condition. Column Headings o o Name: This column lists the drugs Amida Care covers on our formulary. The drug is designated as generic or brand depending on how it is presented. Brand name drugs are capitalized (e.g., DEMSER). Generic drugs are in lower case italics (e.g., lisinopril) : This column describes the tier of the drug and your cost share for a 30-day supply of the drug is: (Generic): $0 2 (Preferred Brand): $33 3 (Non-Preferred Brand Names): $45 4 (Specialty): 33% o column: As described above, if there is an abbreviation indicated in the column, please refer to the list above. These abbreviations indicate we have utilization management criteria or that the ability to obtain a medication may be limited to certain pharmacies. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 vi

8 206 Part D Model Formulary (Abridged and Comprehensive) Amida Care True Life Plus (HMO) Vademécum para el 206 (Lista de medicamentos cubiertos) Nota dirigida a los miembros activos: Este vademécum ha cambiado desde el año pasado. Por favor, revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma. Cuando en esta lista de medicamentos (vademécum) se dice nosotros o nuestro, se está haciendo referencia a Amida Care, Inc. Cuando se dice plan o nuestro plan, se está haciendo referencia a Amida Care True Life Plus. Este documento incluye una lista de medicamentos (vademécum) de nuestro plan actualizada para el 0/08/206. Para conocer un vademécum actualizado, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha más reciente de actualización del vademécum, aparece en las portadas delanteras y traseras. Por lo general, debe acudir a las farmacias de la red para utilizar su beneficio de los medicamentos de venta con receta. Los beneficios, vademécums, red de farmacias y/o copagos/coseguro pueden cambiar el o de enero de 207 y de vez en cuando durante el año. Qué es el vademécum de Amida Care True Life Plus? Un vademécum es una lista de medicamentos cubiertos seleccionados por Amida Care True Life Plus después de consultar a un equipo de proveedores de cuidados médicos, el cual representa las terapias a base de medicamentos de venta con receta que se creen necesarias para llevar a cabo un programa de tratamiento de calidad. Amida Care True Life Plus por lo general cubrirá los medicamentos listados en nuestro vademécum siempre y cuando el medicamento sea necesario en términos médicos, los medicamentos de venta con receta se despachen en una farmacia de la red del plan, y se sigan otras reglas del plan. Para más información sobre cómo obtener los medicamentos de venta con receta, por favor revise su material de Información sobre Cobertura. El vademécum (lista de medicamentos) puede cambiar? Por lo general, si usted está tomando un medicamento que está dentro de nuestro vademécum del 206 que estaba cubierto al comienzo del año, no suspenderemos o reduciremos la cobertura del medicamento durante el año de cobertura 206 excepto cuando esté disponible un medicamento genérico nuevo y menos costoso o cuando se publique información adversa sobre la seguridad y efectividad de un medicamento. Otro tipo de cambios en el vademécum, como la eliminación de un medicamento de nuestro vademécum, no afectará a los miembros que estén tomando el medicamento en la actualidad. Seguirá estando disponible al mismo costo compartido para aquellos miembros que lo estén tomando por el resto del año de la cobertura. Creemos que es importante que usted tenga acceso continuo por el resto del año de la cobertura a los medicamentos del vademécum que estaban disponibles cuando usted escogió nuestro plan, exceptuando los casos en los que usted pueda ahorrar dinero adicional o podamos garantizar su seguridad. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 vii

9 206 Part D Model Formulary (Abridged and Comprehensive) Si quitamos medicamentos de nuestro vademécum, o agregamos con autorización previa, límites de cantidades y/o restricciones en terapias escalonadas en cuanto a un medicamento o pasamos un medicamento a un nivel de costo compartido más elevado, debemos notificar a los miembros afectados sobre el cambio con al menos 60 días de antelación antes de que el cambio se haga efectivo, o cuando el miembro solicite los medicamentos de venta con receta, momento en el que el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Fármacos considera que un medicamento de nuestro vademécum no es seguro o si el fabricante del medicamento lo saca del mercado, quitaremos de inmediato el medicamento de nuestro vademécum y avisaremos a los miembros que tomen el medicamento. El vademécum adjunto está actualizado para el 0/08/206. Para obtener información actualizada sobre los medicamentos cubiertos por Amida Care True Life Plus, por favor póngase en contacto con nosotros. Nuestra información de contacto aparece en las portadas delanteras y traseras. Podemos actualizar este vademécum mensualmente a lo largo del año. Las actualizaciones incluyen adiciones, eliminaciones y cambios en cuanto al uso de acuerdo con el vademécum más reciente aprobado por los Centros para Servicios Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS). Puede acceder a los vademécums más actualizados a través de nuestra página web o llamando a Servicios al Miembro (Member Services) y solicitando que se le envíe una versión impresa actualizada. La versión impresa podría contener una hoja de errata con los cambios hechos al vademécum impreso. Cómo utilizo el vademécum? Hay dos maneras de encontrar sus medicamentos dentro del vademécum: Enfermedad: El vademécum comienza en la página 2. Los medicamentos en este vademécum están agrupados en categorías dependiendo del tipo de enfermedades para las que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca están listados bajo la categoría «Terapia Antihipertensora». Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 2. Luego busque su medicamento bajo el nombre de la categoría. Lista en orden alfabético Si no sabe en qué categoría buscar, debería buscar su medicamento en el Índice que comienza en la página 76. El Índice contiene una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos están listados en el Índice. Busque en el Índice y encuentre su medicamento. Al lado de su medicamento, verá el número de la página donde puede encontrar la información sobre la cobertura. Vaya a la página listada en el Índice y encontrará el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Amida Care True Life Plus cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico es aquel que contiene los mismos ingredientes activos que el medicamento de marca según la aprobación de la AAF (Administración de Alimentos y Fármacos). Por lo general, los medicamentos genéricos son más baratos que los de marca. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 viii

10 206 Part D Model Formulary (Abridged and Comprehensive) Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos podrían tener requerimientos adicionales o límites de cobertura. Estos requerimientos o límites podrían incluir: Autorización previa: Amida Care True Life Plus requiere que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que usted necesitará una aprobación por parte de Amida Care True Life Plus antes de obtener su medicamento de venta con receta. Si no obtiene esta aprobación, Amida Care True Life Plus podría no cubrir el medicamento. Límites de cantidad: Para ciertos medicamentos, Amida Care True Life Plus limita la cantidad del medicamento que Amida Care True Life Plus cubrirá. Por ejemplo, Amida Care True Life Plus proporciona 90 comprimidos por la receta de doxazosin mesylate. Esto podría ser en adición a un suministro estándar para uno o tres meses. Terapia escalonada: En algunos casos, Amida Care True Life Plus exige que usted primero pruebe algunos medicamentos para tratar su enfermedad antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el medicamento B sirven para el tratamiento de su enfermedad, Amida Care True Life Plus podría no cubrir el medicamento B a menos de que pruebe el medicamento A primero. Si el medicamento A no le sirve, entonces Amida Care True Life Plus cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites buscando en el vademécum que comienza en la página 2. También puede obtener más información sobre las restricciones que aplican a ciertos medicamentos cubiertos visitando nuestra página web. Hemos publicado documentos en línea que explican nuestras restricciones en cuanto a las autorizaciones previas y la terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha más reciente de actualización del vademécum, aparece en las portadas delanteras y traseras. Puede pedirle a Amida Care True Life Plus que haga una excepción en cuanto a estas restricciones o límites o pedirle una lista de otros medicamentos similares que puedan servir para tratar su enfermedad. Vea la sección «Cómo solicitarle una excepción para el vademécum de Amida Care True Life Plus? en la página xi para información sobre cómo solicitar una excepción. Qué ocurre si mi medicamento no se encuentra en el vademécum? Si su medicamento no está incluido en este vademécum (lista de los medicamentos cubiertos), primero debe ponerse en contacto con Servicios al Miembro y preguntar si su medicamento está cubierto. Si se entera de que Amida Care True Life Plus no cubre su medicamento, tiene dos opciones: H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 ix

11 206 Part D Model Formulary (Abridged and Comprehensive) Puede pedirle a Servicios al Miembro una lista de medicamentos similares que estén cubiertos por Amida Care True Life Plus. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan. Puede pedirle a Amida Care True Life Plus que haga una excepción y cubra su medicamento. Vea más abajo para obtener información sobre cómo solicitar una excepción. Cómo solicito una excepción para el vademécum de Amida Care True Life Plus? Puede solicitarle a Amida Care True Life Plus que haga una excepción en cuanto a nuestras reglas de cobertura. Existen varios tipos de excepciones que nos puede pedir que hagamos. Puede pedirnos que cubramos un medicamento, aún si este no está en nuestro vademécum. De aprobarse, este medicamento será cubierto a un nivel predeterminado de costo compartido y no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido más bajo. Puede pedirnos que cubramos un medicamento del vademécum a un costo compartido más bajo si este medicamento no se encuentra en el nivel de especialidades. De aprobarse, esto bajará el monto que debe pagar por su medicamento. Puede solicitarnos que no apliquemos las restricciones de cobertura o límites sobre su medicamento. Por ejemplo, para ciertos medicamentos, Amida Care True Life Plus limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor. Generalmente, Amida Care True Life Plus solo aprobará su solicitud de una excepción si los medicamentos alternativos incluidos en el vademécum del plan, el medicamento de costo compartido más bajo o las restricciones de uso adicionales no serán efectivos para tratar su enfermedad y/o le causarán un efecto médico adverso. Debe ponerse en contacto con nosotros con el fin de solicitarnos una decisión de cobertura inicial para una excepción en el vademécum, nivelación o restricciones de uso. Cuando solicita una excepción en el vademécum, nivelación o restricciones de uso, debe enviar una declaración por parte de su médico que apoye su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las primeras 72 horas de haber recibido la declaración de apoyo de su médico. Puede solicitar una excepción expedita (rápida) si usted o su médico creen que su salud puede verse gravemente afectada si debe esperar 72 horas por una decisión. Si se le concede esta solicitud expedita, debemos darle a conocer una decisión a no más tardar dentro de las 24 horas después de haber recibido la declaración de apoyo por parte de su médico u otra personas que haya emitido la receta. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 x

12 206 Part D Model Formulary (Abridged and Comprehensive) Qué debo hacer antes de poder hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o regular de nuestro plan, podría estar tomando medicamentos que no estén dentro de nuestro vademécum. O, podría estar tomando un medicamento que está en nuestro vademécum pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte antes de que pueda obtener sus medicamentos de venta con receta. Es recomendable que hable con su médico para decidir si debería cambiar a un medicamento apropiado que cubramos o solicitar una excepción en el vademécum para que cubramos el medicamento que usted toma. Mientras habla con su médico para determinar qué debe hacer, podríamos cubrir su medicamento en algunos casos durante los primeros 90 días en los que usted es miembro de nuestro plan. Por cada uno de sus medicamentos que no estén en nuestro vademécum o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro de 30 días temporal (a menos de que tenga una receta escrita por menos días) cuando acuda a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días. Si es residente de un centro de cuidados a largo plazo, le permitiremos reponer sus medicamentos de venta con receta hasta que le hayamos proporcionado un suministro de transición de 9 a 98 días, consecuente con aumento en el despacho (a menos de que tenga una receta escrita por menos días). Cubriremos más de una reposición de estos medicamentos durante los primeros 90 días en que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro vademécum o su capacidad de obtener los medicamentos es limitada, pero hace más de 90 días es miembro del plan, cubriremos un suministro de emergencia por 3 días para este medicamento a menos de que tenga una receta escrita por menos días) mientras tramita una excepción al vademécum. Si experimenta un cambio en el nivel/ubicación de cuidado, como el traslado desde un hospital al hogar, y necesita un medicamento que no está en nuestro vademécum, o su capacidad para obtener sus medicamentos está limitada, cubriremos un suministro temporal único por hasta 30 días (o 3 días si reside en un centro de cuidado a largo plazo) cuando acuda a una farmacia de la red. La farmacia se pondrá en contacto con nosotros para hacernos saber que ha habido un cambio a nivel de cuidado para que podamos procesar la solicitud de un suministro temporal. Para más información Para más información sobre la cobertura de medicamentos de ventas con receta de Amida Care True Life Plus, por favor revise su Información sobre Cobertura y otros materiales sobre el plan. Si tiene preguntas sobre Amida Care True Life Plus, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha más reciente de actualización del vademécum, aparece en las portadas delanteras y traseras. Si tiene preguntas generales sobre la cobertura de medicamentos de venta con receta de Medicare, por favor llame a Medicare al -800-MEDICARE ( ) 24 horas al día/7 días a la semana. Los usuarios del servicio TTY deben llamar al O visite H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 xi

13 206 Part D Model Formulary (Abridged and Comprehensive) Vademécum de Amida Care True Life Plus El vademécum que comienza en la página 2 proporciona información sobre la cobertura de medicamentos por parte de Amida Care True Life Plus. Si tiene dificultades para encontrar su medicamento en la lista, pase al Índice que comienza en la página 76. La primera columna del cuadro lista el nombre del medicamento. Los medicamentos de marca están en mayúscula (por ejemplo, DEMSER) y los medicamentos genéricos están en minúscula y cursiva (por ejemplo, lisinopril). La información en la columna de Requerimientos/Límites le dice si Amida Care True Life Plus tiene algún requerimiento especial para la cobertura de su medicamento. Abajo está una lista de abreviaciones que podrían aparecer en las páginas siguientes en la columna de Requerimientos/Límites que le dice si hay algún requerimiento especial para la cobertura de su medicamento. Lista de abreviaciones o o o o o o B/D PA: El medicamento de venta con receta podría estar cubierto bajo la Parte B o D de Medicare según las circunstancias. Podría ser necesario enviar información donde se describa el uso y tipo de medicamento para llevar a cabo la determinación. LA: Disponibilidad limitada. Estos medicamentos de venta con receta pueden estar disponibles solo en algunas farmacias. Para más información, por favor llame a Servicios al Miembro. MO: Medicamento de orden por correo. Este medicamento de venta con receta está disponible a través de nuestro servicio de orden por correo, como también a través de nuestra red de farmacias. Considere utilizar las órdenes por correo para sus medicamentos de uso a largo plazo (de mantenimiento) (como medicamentos para la presión arterial elevada). Las farmacias de la red pueden ser más apropiadas para los medicamentos de venta con receta de uso a corto plazo (como los antibióticos). PA: Autorización previa. Nuestro plan requiere que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que usted necesitará una aprobación antes de obtener su medicamento de venta con receta. Si no obtiene esta aprobación, puede que no cubramos el medicamento. QL: Límites de cantidad. Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. ST: Terapia escalonada. En algunos casos, nuestro plan exige que usted primero pruebe algunos medicamentos para tratar su enfermedad antes de que cubramos otro medicamento para esa enfermedad. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 xii

14 206 Part D Model Formulary (Abridged and Comprehensive) Encabezados de columnas o o Nombre del medicamento: Esta columna lista los medicamentos que Amida Care cubre en nuestro vademécum. El medicamento es designado como genérico o de marca dependiendo de su presentación. Los medicamentos de marca están escritos en mayúscula sostenida (ejemplo, DEMSER). Los medicamentos genéricos están escritos en minúscula y cursiva (ejemplo, lisinopril). Nivel del medicamento: Esta columna describe el nivel del medicamento y la parte que usted debe pagar por un suministro de 30 días del medicamento es: Nivel (Genérico): $0 Nivel 2 (Marca de su preferencia): $33 Nivel 3 (Marcas que no son de su preferencia): $45 Nivel 4 (Especialidad): 33% o Columna de requerimientos/límites: Como se describió anteriormente, si hay una abreviación indicada en la columna, por favor revise la lista de arriba. Estas abreviaciones indican que tenemos criterios en cuanto al uso o que la capacidad para obtener un medicamento puede estar limitada a ciertas farmacias. H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 xiii

15 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan 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, we may not cover B unless you try A first. If A does not work for you, we will then cover B.

16 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 B/D PA; MO AMBISOME 4 B/D PA; MO amphotericin b B/D PA; MO CANCIDAS 4 B/D PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) piggyback 200 mg/00 ml fluconazole in nacl (iso-osm) piggyback 400 mg/200 ml 4 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral LAMISIL ORAL GRANULES IN PACKET MYCAMINE NOXAFIL ORAL Name nystatin oral suspension 2 nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole voriconazole oral ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium solution B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 4 cidofovir 4 B/D PA; MO COMPLERA

17 Name CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DAKLINZA ORAL TABLET 30 MG, 60 MG DAKLINZA ORAL TABLET 90 MG DESCOVY 4 (84 per 28 4 PA; QL (28 per 28 didanosine EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir foscarnet B/D PA FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI (28 per 28 INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET Name ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 00 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET moderiba moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine 3

18 Name NORVIR ODEFSEY 4 OLYSIO (28 per 28 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 200 mg (28)- 400 mg (28) Name ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg 4 rimantadine SELZENTRY SOVALDI (28 per 28 stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 00 MG/ML SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU 4

19 Name TECHNIVIE (56 per 28 TIVICAY ORAL TABLET 0 MG TIVICAY ORAL TABLET 25 MG TIVICAY ORAL TABLET 50 MG 2 4 TRIUMEQ TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG 4 TYZEKA valacyclovir ; QL (30 VALCYTE ORAL RECON SOLN valganciclovir VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK (2 per 28 VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIRAZOLE Name 5 VIREAD VITEKTA ZEPATIER (28 per 28 ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) piggyback gram/50 ml, 2 gram/50 ml cefazolin injection recon soln gram, 500 mg

20 Name cefazolin injection recon soln 0 gram, 00 gram, 20 gram, 300 g cefazolin cefdinir cefepime cefepime in dextrose,iso-osm piggyback gram/50 ml cefepime in dextrose,iso-osm piggyback 2 gram/00 ml cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotaxime injection recon soln 0 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin recon soln gram cefoxitin recon soln 0 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln gram, 2 gram Name ceftazidime injection recon soln 6 gram ceftibuten ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 0 gram ceftriaxone cefuroxime axetil oral tablet cefuroxime sodium injection recon soln.5 gram, 750 mg cefuroxime sodium cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 3 MO 3 3 MO TEFLARO 3 MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin recon soln 500 mg 6

21 Name azithromycin recon soln 500 mg (2 mg/ml) azithromycin oral clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES 2 ALBENZA ALINIA amikacin injection solution,000 mg/4 ml, 500 mg/2 ml Name atovaquone atovaquoneproguanil aztreonam baciim bacitracin intramuscular BETHKIS 4 B/D PA; MO; QL (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate solution 600 mg/4 ml 7

22 Name COARTEM colistin (colistimethate na) CUBICIN DAPSONE DARAPRIM EMVERM 4 ethambutol gentamicin in nacl (iso-osm) piggyback 00 mg/00 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) piggyback 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) solution 00 mg/0 ml gentamicin sulfate (pf) solution 60 mg/6 ml, 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid injection 3 MO Name 8 isoniazid oral ivermectin oral lincomycin injection linezolid 4 linezolid oral linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) 4 metronidazole oral NEBUPENT 2 B/D PA; MO; QL (6 per 28 neomycin paromomycin PASER PENTAM 3 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA STREPTOMYCIN INTRAMUSCULA R SYNERCID 4 tinidazole

23 Name tobramycin in % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 4 B/D PA; MO; QL (280 per 28 TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/00 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate 4 ampicillin ampicillin sodium injection Name ampicillin sodium ampicillin-sulbactam injection recon soln.5 gram, 3 gram ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam recon soln.5 gram ampicillin-sulbactam recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML 9 BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm piggyback gram/50 ml nafcillin in dextrose iso-osm piggyback 2 gram/00 ml nafcillin injection recon soln gram, 2 gram nafcillin injection recon soln 0 gram nafcillin

24 Name oxacillin in dextrose(iso-osm) piggyback gram/50 ml oxacillin in dextrose(iso-osm) piggyback 2 gram/50 ml oxacillin injection recon soln gram, 2 gram oxacillin injection recon soln 0 gram oxacillin penicillin g potassium penicillin g procaine intramuscular syringe.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium pfizerpen-g QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral Name ciprofloxacin in 5 % dextrose ciprofloxacin lactate solution 200 mg/20 ml ciprofloxacin lactate solution 400 mg/40 ml levofloxacin in d5w piggyback 250 mg/50 ml levofloxacin in d5w piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine oral piperacillintazobactam sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline doxy-00 doxycycline hyclate doxycycline hyclate oral capsule doxycycline hyclate oral tablet 0

25 Name doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg, 50 mg, 75 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 200 mg, 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral mondoxyne nl morgidox oral capsule 00 mg tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG methenamine hippurate methenamine mandelate nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin oral trimethoprim Name VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK vancomycin 2 vancomycin oral ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl recon soln 250 mg dexrazoxane hcl recon soln 500 mg 4 ELITEK FUSILEV KEPIVANCE 4 leucovorin calcium injection recon soln 00 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral levoleucovorin calcium mesna MESNEX ORAL 4

26 Name XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adrucil solution 2.5 gram/50 ml adrucil solution 5 gram/00 ml, 500 mg/0 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 4 PA; MO (60 per 30 4 PA; MO ALECENSA (240 per 30 ALIMTA ALKERAN ORAL 2 B/D PA; MO anastrozole ARRANON 4 ARZERRA 4 B/D PA; MO AVASTIN azacitidine azathioprine B/D PA; MO azathioprine sodium B/D PA BELEODAQ BENDEKA bexarotene bicalutamide BICNU 3 MO Name 2 bleomycin BLINCYTO 4 B/D PA; MO BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG BUSULFEX 4 4 PA; MO (30 per 30 CABOMETYX 4 PA; LA CAMPATH 4 CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG carboplatin solution CELLCEPT INTRAVENOUS CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N 4 PA; MO; LA; QL (90 per 30 4 PA; MO; LA; QL (30 per 30 2 B/D PA; MO 4 B/D PA; MO cisplatin cladribine CLOLAR COMETRIQ 4 PA; MO COSMEGEN COTELLIC 4 PA; MO; LA; QL (63 per 28 cyclophosphamide

27 Name CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine cyclosporine modified cyclosporine oral capsule 2 B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA 4 B/D PA; MO cytarabine cytarabine (pf) injection solution 00 mg/5 ml (20 mg/ml), 2 gram/20 ml (00 mg/ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DARZALEX ; LA daunorubicin solution decitabine DEPOCYT (PF) DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel solution 0 mg/ml, 60 mg/6 ml (0 mg/ml), 60 mg/8 ml (20 mg/ml), 20 mg/2 ml (0 mg/ml) 4 4 Name docetaxel solution 20 mg/ml ( ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) DOXIL doxorubicin recon soln doxorubicin solution doxorubicin, pegliposomal DROXIA EMCYT EMPLICITI 4 B/D PA; MO epirubicin solution 200 mg/00 ml epirubicin solution 50 mg/25 ml ERBITUX ERIVEDGE (30 per 30 ERWINAZE ETOPOPHOS 3 MO etoposide exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG (2 per 2 3

28 Name FARYDAK ORAL CAPSULE 5 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine fludarabine recon soln fludarabine solution fluorouracil (6 per 2 flutamide FOLOTYN GAZYVA gemcitabine recon soln gram, 200 mg gemcitabine recon soln 2 gram gemcitabine solution gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 00 mg, 25 mg gengraf oral capsule 50 mg 4 4 B/D PA; MO B/D PA Name gengraf oral solution GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEEVEC ORAL TABLET 00 MG GLEEVEC ORAL TABLET 400 MG B/D PA; MO (60 per 30 (40 per 30 (30 per 30 4 PA; MO (60 per 30 GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE (2 per 28 ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide recon soln ifosfamide solution (90 per 30 (30 per 30 4

29 Name ifosfamide-mesna kit - gram imatinib oral tablet 00 mg imatinib oral tablet 400 mg 4 4 PA; MO (60 per 30 IMBRUVICA (20 per 30 INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG 4 PA; MO (20 per 30 IRESSA (30 per 30 irinotecan solution 00 mg/5 ml irinotecan solution 40 mg/2 ml irinotecan solution 500 mg/25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG 4 4 PA; MO (60 per 30 JEVTANA KADCYLA Name KEYTRUDA LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ) LENVIMA ORAL CAPSULE 8 MG/DAY (0 MG X -4 MG X2), 8 MG/DAY (4 MG X 2) 4 PA; MO 4 PA letrozole LEUKERAN leuprolide subcutaneous kit lipodox lipodox 50 LONSURF 4 PA; MO LUPRON DEPOT 4 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED (3 MONTH) 4 PA; MO 4 PA; MO 4 PA; MO 4 PA; MO 4 PA; MO LYNPARZA 4 PA; MO LYSODREN MATULANE 5

30 Name megestrol oral suspension 400 mg/0 ml (0 ml) megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl 4 4 PA; QL (20 4 PA; QL (30 mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin recon soln 20 mg, 5 mg mitomycin recon soln 40 mg B/D PA B/D PA; MO mitoxantrone MUSTARGEN 3 MO mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet B/D PA; MO 4 B/D PA; MO B/D PA; MO Name mycophenolate sodium B/D PA; MO NEXAVAR 4 PA; MO; LA; QL (20 per 30 NILANDRON NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 28 (4 per 28 (3 per 28 NULOJIX 4 B/D PA; MO octreotide acetate injection solution,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml) octreotide acetate injection syringe 500 mcg/ml ( ml) ODOMZO 4 PA; MO; LA; QL (30 per 30 ONCASPAR OPDIVO oxaliplatin recon soln 00 mg 6

31 Name oxaliplatin recon soln 50 mg oxaliplatin solution 4 paclitaxel PERJETA POMALYST PORTRAZZA 4 B/D PA; MO PROGRAF INTRAVENOUS 2 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET MG RAPAMUNE ORAL TABLET 2 MG 2 B/D PA; MO 3 B/D PA; MO 4 B/D PA; MO REVLIMID 4 PA; MO; LA RITUXAN 4 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT 2 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus oral tablet 0.5 mg, mg 2 B/D PA 2 B/D PA; MO B/D PA; MO Name sirolimus oral tablet 2 mg 7 4 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 40 MG SPRYCEL ORAL TABLET 70 MG 4 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT ORAL CAPSULE 2.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG 4 PA; MO (60 per 30 (30 per 30 SYLVANT SYNRIBO TABLOID tacrolimus oral capsule 0.5 mg, mg tacrolimus oral capsule 5 mg TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG B/D PA; MO 4 B/D PA; MO (80 per 30 4 PA; QL (20

32 Name TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG 4 PA; MO (30 per 30 TARGRETIN TASIGNA ORAL CAPSULE 50 MG TASIGNA ORAL CAPSULE 200 MG 4 PA; MO (2 per 28 TECENTRIQ 4 LA TEMODAR INTRAVENOUS THALOMID 4 PA; MO thiotepa toposar topotecan recon soln topotecan solution 4 TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR tretinoin (chemotherapy) Name 8 TRISENOX TYKERB 4 PA; MO; LA; QL (80 per 30 UNITUXIN VALSTAR VANTAS 3 MO VECTIBIX 4 B/D PA; MO VELCADE VENCLEXTA ORAL TABLET 0 MG, 50 MG VENCLEXTA ORAL TABLET 00 MG VENCLEXTA STARTING PACK vinblastine solution vincasar pfs solution mg/ml vincasar pfs solution 2 mg/2 ml 2 PA; LA 4 PA; LA 4 PA; LA; QL (42 per 28 vincristine vinorelbine VOTRIENT (20 per 30 XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 4 PA; MO (60 per 30

33 Name XTANDI (20 per 30 YERVOY YONDELIS ZALTRAP ZANOSAR 3 MO ZELBORAF (240 per 30 ZOLADEX 3 MO ZOLINZA ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 2 B/D PA; MO 4 B/D PA; MO ZYDELIG (90 per 30 ZYKADIA (50 per 30 ZYTIGA (20 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION 3 MO Name BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL 4 carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr 00 mg carbamazepine oral tablet extended release 2 hr 200 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 3 clonazepam PA; MO diazepam rectal PA; MO DILANTIN 30 MG divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) 9

34 Name epitol ethosuximide felbamate fosphenytoin FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack 25 mg (35) Name LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK,000 MG/00 ML,,500 MG/00 ML LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 500 MG/00 ML levetiracetam levetiracetam oral solution 00 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 2 LYRICA 2 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG 2 PA; MO 2 PA; MO oxcarbazepine PEGANONE phenobarbital phenobarbital sodium injection solution 30 mg/ml phenobarbital sodium injection solution 65 mg/ml 20

35 Name phenytoin oral suspension 00 mg/4 ml phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium solution phenytoin sodium syringe POTIGA primidone roweepra SABRIL ; LA SPRITAM 3 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Name valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/0 ml (0 ml) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 2 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO 3 MO pramipexole ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 2.5 mg almotriptan malate oral tablet 6.25 mg dihydroergotamine injection ; QL (24 per 28 ; QL (8 per 28

36 Name dihydroergotamine nasal ; QL (8 per 28 frovatriptan QL (27 per 28 migergot naratriptan ; QL (8 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (8 per 28 ; QL (36 per 28 ; QL (8 per 28 ; QL (6 per 28 ; QL (6 per 28 ; QL (6 per 28 QL (6 per 28 zolmitriptan ; QL (8 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 4 PA; MO; LA Name donepezil oral tablet 0 mg, 5 mg donepezil oral tablet 23 mg donepezil oral tablet,disintegrating EXELON TRANSDERMAL 2 ST; MO galantamine GILENYA 4 PA; MO glatopa (30 per 30 LEMTRADA 4 PA; MO memantine oral solution memantine oral tablet NAMENDA ORAL SOLUTION PA; MO PA; MO 2 PA; MO NAMENDA XR 2 PA; MO NAMZARIC 2 PA; MO NUEDEXTA rivastigmine rivastigmine tartrate TECFIDERA 4 PA; MO tetrabenazine 4 PA; MO TYSABRI 4 PA; MO; LA XENAZINE 4 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen dantrolene enlon 22

37 Name LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON TIMESPAN neostigmine methylsulfate solution 0.5 mg/ml neostigmine methylsulfate solution mg/ml pyridostigmine bromide regonol revonto 2 B/D PA; MO 2 B/D PA tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution 20 mg-2 mg /5 ml (5 ml), 300 mg-30 mg /2.5 ml acetaminophencodeine oral solution 20-2 mg/5 ml acetaminophencodeine oral tablet mg, mg QL (4500 per 30 ; QL (4500 ; QL (360 Name acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg codeine sulfate oral tablet dihydrocodeacetaminophen-caff oral capsule dihydrocodeineaspirin-caff ; QL (80 ; QL (267 QL (267 per 30 ; QL (300 ; QL (75 ; QL (80 QL (300 per 30 QL (300 per 30 diskets QL (30 per 30 duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml endocet oral tablet mg, mg, mg, mg fentanyl citrate (pf) injection fentanyl citrate (pf) syringe 00 mcg/2 ml (50 mcg/ml) ; QL (4000 QL (2000 per 30 ; QL (360 ; QL (400 QL (400 per 30 23

38 Name Name fentanyl citrate buccal lozenge on a handle,200 mcg fentanyl citrate buccal lozenge on a handle,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr fentanyl transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution mg/5 ml(5 ml), 5-63 mg/7.5ml(7.5ml) (39 per 30 (29 per 30 (20 per 30 (6 per 30 (77 per 30 (58 per 30 ; QL (9 per 30 ; QL (0 QL (5550 per 30 hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution mg/ml hydromorphone (pf) injection solution 0 mg/ml hydromorphone (pf) injection solution 2 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution hydromorphone injection syringe mg/ml hydromorphone injection syringe 2 mg/ml ; QL (360 ; QL (50 QL (300 per 30 ; QL (20 QL (50 per 30 ; QL (75 ; QL (50 QL (300 per 30 QL (50 per 30 hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral solution mg/5 ml QL (3600 per 30 ; QL (5550 hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet ; QL (75 ; QL (500 ; QL (80 24

39 Name hydromorphone oral tablet extended release 24 hr 2 mg, 8 mg hydromorphone oral tablet extended release 24 hr 6 mg hydromorphone oral tablet extended release 24 hr 32 mg ; QL (60 ; QL (60 ; QL (47 ibuprofen-oxycodone ; QL (28 levorphanol tartrate ; QL (20 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg ; QL (360 lortab ; QL (360 lortab ; QL (360 lortab ; QL (360 methadone injection QL (60 per 30 methadone intensol ; QL (90 methadone oral concentrate methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg ; QL (90 ; QL (600 ; QL (200 ; QL (20 Name methadone oral tablet 5 mg methadone oral tablet,soluble methadose oral concentrate methadose oral tablet,soluble morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution mg/ml morphine (pf) patient control.analgesia soln 50 mg/30 ml morphine (pf) patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine cartridge 5 mg/ml morphine cartridge 2 mg/ml morphine cartridge 4 mg/ml morphine solution 0 mg/ml 25 ; QL (240 QL (30 per 30 ; QL (90 ; QL (30 QL (4000 per 30 ; QL (2000 B/D PA; MO; QL (400 per 30 B/D PA; QL (2000 per 30 ; QL (300 QL (34 per 30 QL (000 per 30 QL (500 per 30 ; QL (200

40 Name morphine solution 00 mg/4 ml, 25 mg/ml, 250 mg/0 ml morphine solution 50 mg/ml morphine syringe 2 mg/ml morphine syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 20 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 0 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 00 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution QL (80 per 30 ; QL (40 QL (000 per 30 QL (500 per 30 ; QL (50 ; QL (60 ; QL (90 ; QL (60 ; QL (75 ; QL (900 morphine oral tablet ; QL (80 morphine oral tablet extended release 00 mg ; QL (60 Name morphine oral tablet extended release 5 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg morphine rectal suppository 0 mg morphine rectal suppository 20 mg morphine rectal suppository 30 mg morphine rectal suppository 5 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg, mg, mg, mg ; QL (20 ; QL (30 ; QL (00 ; QL (600 ; QL (300 ; QL (200 ; QL (200 ; QL (360 ; QL (80 ; QL (200 ; QL (80 ; QL (34 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 26

41 Name oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 2 hr 30 mg oxymorphone oral tablet extended release 2 hr 40 mg ; QL (200 ; QL (80 ; QL (90 ; QL (67 ; QL (50 reprexain ; QL (50 vicodin ; QL (360 vicodin es ; QL (360 vicodin hp ; QL (360 xylon 0 QL (50 per 30 zamicet QL (5550 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution mg/ml PA; MO; QL (360 per 30 PA; MO; QL (90 per 30 ; QL (720 Name butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal ; QL (360 celecoxib clonidine (pf) diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel % diclofenacmisoprostol ; QL (5 per 28 diflunisal etodolac fenoprofen oral tablet flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg klofensaid ii meclofenamate oral mefenamic acid meloxicam oral suspension 27

42 Name meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg ; QL (30 nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml ; QL (200 ; QL (00 naloxone naltrexone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NARCAN ; QL (2 per 28 oxaprozin piroxicam salsalate sulindac oral tolmetin tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr ; QL (30 Name tramadol oral tablet, er multiphase 24 hr tramadolacetaminophen VOLTAREN GEL TOPICAL GEL % ZUBSOLV SUBLINGUAL TABLET MG, MG ZUBSOLV SUBLINGUAL TABLET MG ZUBSOLV SUBLINGUAL TABLET MG ZUBSOLV SUBLINGUAL TABLET MG 28 ; QL (30 ; QL (240 2 ST; MO 2 PA; MO; QL (90 per 30 2 PA 2 PA; MO 2 PA; MO; QL (60 per 30 PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE 2 amitriptyline PA; MO amoxapine aripiprazole oral solution aripiprazole oral tablet 0 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg ; QL (90 ; QL (60 ; QL (450 ; QL (60

43 Name aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 0 mg aripiprazole oral tablet,disintegrating 5 mg ; QL (30 ; QL (80 ; QL (90 ; QL (60 ARISTADA armodafinil bupropion hcl oral tablet bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 50 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (20 ; QL (90 ; QL (60 ; QL (90 ; QL (60 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 20 mg ; QL (20 ; QL (60 Name citalopram oral tablet 40 mg ; QL (30 clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg desipramine oral dexedrine dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine diazepam injection solution diazepam injection syringe PA PA; MO diazepam intensol PA; MO diazepam oral concentrate diazepam oral solution 5 mg/5 ml ( mg/ml) PA; MO PA; MO diazepam oral tablet PA; MO doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg ; QL (80 29

44 Name duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (20 ; QL (90 ; QL (60 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (20 eszopiclone ST; MO; QL (30 per 30 FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG 3 MO; QL (720 3 QL (90 per 30 3 MO; QL (60 3 MO; QL (360 3 MO; QL (80 3 MO; QL (20 3 MO; QL (90 Name FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG 3 MO; QL (8 per MO; QL (28 per 28 3 MO; QL (30 3 MO; QL (80 3 MO; QL (90 3 MO; QL (45 flumazenil fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution ; QL (240 ; QL (60 ; QL (4 per 28 30

45 Name fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg fluphenazine decanoate ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R ; QL (90 ; QL (60 ; QL (90 ; QL (360 ; QL (80 3 MO guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ 4 PA; MO imipramine hcl PA; MO imipramine pamoate PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR.5 MG 3 MO; QL (240 Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML 3 MO; QL (20 3 MO; QL (60 3 MO; QL (4 3 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 00 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 20 MG 3 MO; QL (20 3 MO; QL (240 ; QL (30 3

46 Name LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG 3 MO; QL (240 3 MO; QL (20 3 MO; QL (60 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam injection solution lorazepam injection syringe PA; MO PA lorazepam intensol PA; MO lorazepam oral PA; MO loxapine succinate maprotiline MARPLAN metadate er methamphetamine methylphenidate oral mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil PA; MO molindone nefazodone nortriptyline NUPLAZID 4 olanzapine intramuscular Name olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (60 ; QL (30 ; QL (240 ; QL (20 ; QL (8 ; QL (60 ; QL (30 ; QL (20 ORAP oxazepam PA; MO paliperidone oral tablet extended release 24hr.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 0 mg ; QL (240 ; QL (20 ; QL (60 ; QL (4 ; QL (80 32

47 Name paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION ; QL (90 ; QL (60 ; QL (45 ; QL (80 ; QL (90 ; QL (60 3 MO perphenazine phenelzine pimozide procentra protriptyline quetiapine oral tablet 00 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg ; QL (240 ; QL (20 ; QL (902 ; QL (8 ; QL (60 ; QL (480 Name REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET MG REXULTI ORAL TABLET 2 MG REXULTI ORAL TABLET 3 MG REXULTI ORAL TABLET 4 MG RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 2.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QL (480 ; QL (240 ; QL (20 ; QL (60 ; QL (40 ; QL (30 ; QL (480 ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 33

48 Name risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ROZEREM ; QL (30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg 3 MO; QL (60 3 MO; QL (240 3 MO; QL (20 ; QL (60 ; QL (240 Name sertraline oral tablet 50 mg ; QL (20 STRATTERA SURMONTIL 3 PA; MO temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine PA; MO TRINTELLIX ORAL TABLET 0 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg 2 QL (60 per 30 2 QL (30 per 30 2 QL (20 per 30 ; QL (60 ; QL (80 ; QL (90 ; QL (90 ; QL (270 ; QL (80 34

49 Name venlafaxine oral tablet 50 mg venlafaxine oral tablet extended release 24hr VERSACLOZ 4 VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE.5 MG VRAYLAR ORAL CAPSULE 3 MG VRAYLAR ORAL CAPSULE 4.5 MG VRAYLAR ORAL CAPSULE 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK ; QL (50 ; QL (20 ; QL (60 ; QL (30 ; QL (30 4 QL (20 per 30 4 QL (60 per 30 4 QL (40 per 30 4 QL (30 per 30 3 QL (7 per 30 XYREM ; LA zaleplon oral capsule 0 mg zaleplon oral capsule 5 mg zenzedi oral tablet 0 mg, 5 mg ziprasidone hcl oral capsule 20 mg ST; MO; QL (60 per 30 ST; MO; QL (30 per 30 ; QL (240 Name ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg 35 ; QL (20 ; QL (80 ; QL (60 zolpidem oral ST; MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 20 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 300 MG 4 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS adenosine amiodarone solution amiodarone syringe B/D PA; MO B/D PA amiodarone oral dofetilide flecainide ibutilide fumarate lidocaine (pf) in d7.5w

50 Name lidocaine (pf) solution lidocaine (pf) syringe lidocaine in 5 % dextrose (pf) parenteral solution 4 mg/ml (0.4 %), 8 mg/ml (0.8 %) mexiletine pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet sorine oral tablet 20 mg, 60 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral SOTYLIZE TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr Name amiloride amlodipine atenolol benazepril betaxolol oral bisoprolol fumarate bumetanide injection bumetanide oral candesartan captopril amiloridehydrochlorothiazide amlodipinebenazepril amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol chlorothiazide chlorothiazide sodium 36

51 Name chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 clonidine hcl oral tablet clorpres oral tablet 0.-5 mg, mg DEMSER diltiazem hcl diltiazem hcl oral capsule, extended release diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr dilt-xr doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 ; QL (60 enalapril maleate enalaprilat solution Name eplerenone epoprostenol (glycine) B/D PA; MO eprosartan esmolol solution ethacrynate sodium 4 felodipine fosinopril furosemide injection furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide isradipine labetalol solution labetalol syringe 20 mg/4 ml (5 mg/ml) labetalol oral lisinopril 37

52 Name losartan lisinoprilhydrochlorothiazide losartanhydrochlorothiazide mannitol 0 % mannitol 20 % mannitol 25 % solution mannitol 5 % matzim la methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate solution metoprolol tartrate syringe metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg minoxidil oral moexipril nadolol Name nicardipine solution nicardipine oral nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr nimodipine nisoldipine osmitrol 5 % osmitrol 20 % perindopril erbumine phenoxybenzamine phentolamine injection recon soln pindolol prazosin oral propranolol propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet quinapril metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide ramipril 38

53 Name REMODULIN 4 PA; MO; LA spironolactone taztia xt telmisartan terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg ; QL (30 ; QL (60 timolol maleate oral torsemide oral trandolapril UPTRAVI 4 PA; MO; LA valsartan spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide veletri B/D PA; MO verapamil solution verapamil syringe verapamil oral CARDIAC GLYCOSIDES digitek Name digox digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX 3 MO aminocaproic acid aspirin-dipyridamole bivalirudin 4 BRILINTA CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cilostazol clopidogrel dipyridamole PA dipyridamole oral ELIQUIS enoxaparin eptifibatide B/D PA fondaparinux subcutaneous syringe 0 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 39

54 Name heparin (porcine) in 5 % dex parenteral solution 2,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex parenteral solution 25,000 unit/250 ml(00 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) parenteral solution,000 unit/500 ml, 2,000 unit/,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 2,500 UNIT/250 ML heparin(porcine) in 0.45% nacl parenteral solution 25,000 unit/250 ml heparin(porcine) in 0.45% nacl parenteral solution 25,000 unit/500 ml heparin, porcine (pf) injection 2 jantoven Name NPLATE pentoxifylline PRADAXA 3 MO PROMACTA 4 PA; MO; LA protamine tranexamic acid warfarin XARELTO LIPID/CHOLESTEROL LOWERING AGENTS amlodipineatorvastatin ; QL (30 atorvastatin ; QL (30 cholestyramine (with sugar) cholestyramine light colestipol fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet 20 mg, 40 mg fenofibrate oral tablet 60 mg, 54 mg fenofibric acid fenofibric acid (choline) fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg ; QL (30 ; QL (60 40

55 Name fluvastatin oral tablet extended release 24 hr ; QL (30 gemfibrozil oral JUXTAPID ; LA lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg niacin oral tablet extended release 24 hr PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 50 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 75 MG/ML ; QL (30 ; QL (60 (2 per 28 (4 per 28 (2 per 28 (4 per 28 pravastatin ; QL (30 prevalite REPATHA SURECLICK REPATHA SYRINGE rosuvastatin (3 (3 Name simvastatin ; QL (30 VASCEPA 3 MO ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS cardioplegic soln CORLANOR 2 PA; MO dobutamine B/D PA dobutamine in d5w parenteral solution,000 mg/250 ml (4,000 mcg/ml) dobutamine in d5w parenteral solution 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dopamine in 5 % dextrose solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/500 ml (,600 mcg/ml) dopamine in 5 % dextrose solution 800 mg/250 ml (3,200 mcg/ml) dopamine solution 200 mg/5 ml (40 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) B/D PA; MO B/D PA B/D PA B/D PA; MO B/D PA 4

56 Name dopamine solution 400 mg/0 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml) B/D PA; MO ENTRESTO 2 PA; MO; QL (60 per 30 milrinone B/D PA; MO milrinone in 5 % dextrose piggyback 20 mg/00 ml (200 mcg/ml) milrinone in 5 % dextrose piggyback 40 mg/200 ml (200 mcg/ml) norepinephrine bitartrate B/D PA B/D PA; MO RANEXA VECAMYL 4 NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin in 5 % dextrose solution 00 mg/250 ml (400 mcg/ml), 200 mg/500 ml (400 mcg/ml), 50 mg/250 ml (200 mcg/ml), 50 mg/500 ml (00 mcg/ml) B/D PA Name nitroglycerin in 5 % dextrose solution 25 mg/250 ml (00 mcg/ml) nitroglycerin B/D PA; MO B/D PA nitroglycerin oral nitroglycerin transdermal patch 24 hour nitroglycerin translingual NITROSTAT DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 0 mg acitretin oral capsule 7.5 mg, 25 mg calcipotriene calcipotrienebetamethasone calcitrene calcitriol topical selenium sulfide topical lotion BURN THERAPY silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS 8-MOP 42

57 Name ammonium lactate diclofenac sodium topical gel 3 % doxepin topical fluorouracil topical cream 5 % fluorouracil topical solution PA; MO imiquimod methoxsalen rapid PANRETIN podofilox prudoxin REGRANEX tacrolimus topical PA; MO UVADEX 3 VALCHLOR THERAPY FOR ACNE adapalene topical cream adapalene topical gel adapalene topical gel with pump PA; MO PA; MO PA; MO avita topical cream PA; MO claravis clindacin etz topical swab clindacin p clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel ery pads Name erygel erythromycin with ethanol erythromycinbenzoyl peroxide metronidazole topical myorisan oral capsule 0 mg, 20 mg, 40 mg myorisan oral capsule 30 mg neuac rosadan topical cream rosadan topical gel TAZORAC 2 PA; MO tretinoin microspheres PA; MO tretinoin topical PA; MO zenatane TOPICAL ANESTHETICS bupivacaine bupivacaine (pf) injection solution 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml) bupivacaine (pf) injection solution 0.75 % (7.5 mg/ml) bupivacaineepinephrine (pf) bupivacaineepinephrine injection solution 0.25 %-:200,000 43

58 Name bupivacaineepinephrine injection solution 0.5 %-:200,000 carbocaine (pf) injection solution 5 mg/ml (.5 %) glydo lidocaine (pf) injection solution 0 mg/ml ( %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 5 mg/ml (.5 %) lidocaine hcl injection solution lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment PA; MO lidocaine viscous lidocaineepinephrine (pf) lidocaineepinephrine injection solution 0.5 %-:200,000 Name lidocaineepinephrine injection solution %-:00,000, 2 %- :00,000 lidocaine-prilocaine topical cream marcaine (pf) injection solution 0.75 % (7.5 mg/ml) 44 relador pak relador pak plus sensorcaine injection solution 0.5 % (5 mg/ml) sensorcaine-mpf injection solution 0.5 % (5 mg/ml) TOPICAL ANTIBACTERIALS gentamicin topical mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS ciclodan ciclopirox clotrimazole topical clotrimazolebetamethasone econazole topical ketoconazole topical naftifine topical cream 2 %

59 Name nyamyc nystatin topical nystatintriamcinolone nystop oxiconazole TOPICAL ANTIVIRALS acyclovir topical DENAVIR ZOVIRAX TOPICAL CREAM 3 MO TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented clobetasol clobetasol-emollient clodan cormax scalp desonide desoximetasone diflorasone fluocinolone fluocinolone and shower cap Name fluocinonide fluocinonide-e flurandrenolide fluticasone topical halobetasol propionate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet mometasone topical prednicarbate triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0. %, 0.5 % 45

60 Name trianex triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo malathion permethrin topical cream DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate acetic acid irrigation ADAGEN alendronate oral tablet 40 mg ; QL (30 anagrelide ARALAST NP INTRAVENOUS RECON SOLN,000 MG Name ARALAST NP INTRAVENOUS RECON SOLN 500 MG BUPHENYL ORAL TABLET bupivacainedextrose-water(pf) caffeine citrated ; LA caffeine citrated oral CARBAGLU ; LA cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 2 B/D PA deferoxamine B/D PA; MO dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) 46

61 Name dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) parenteral solution dextrose 50 % in water (d50w) syringe dextrose 70 % in water (d70w) dextrose with sodium chloride disulfiram etidronate disodium EXJADE ; LA FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET 4 INCRELEX ; LA JADENU kionex levocarnitine (with sugar) levocarnitine Name levocarnitine oral tablet lmd 0 % in 0.9 % sodium chlor lmd 0 % in 5 % dextrose midodrine NORTHERA ORFADIN ORAL CAPSULE 4 LA pilocarpine hcl oral PROLASTIN-C 4 LA RAVICTI RENVELA riluzole risedronate oral tablet 30 mg sodium chloride 0.9 % sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 30 gram/20 ml ; QL (30 SOLIRIS 4 B/D PA; MO 47

62 Name sps oral sps rectal SYPRINE THIOLA VELTASSA water for irrigation, sterile XIAFLEX zoledronic acidmannitol-water piggyback 5 mg/00 ml zoledronic acidmannitol-water solution PA SMOKING DETERRENTS buproban bupropion hcl (smoking deter) PA; MO CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 3 MO NICOTROL NS 3 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 Name chlorhexidine gluconate mucous membrane 48 denta 5000 plus dentagel fluoridex daily defense ipratropium bromide nasal ; QL (30 olopatadine nasal ; QL (30.5 oralone paroex oral rinse perio med periogard sf sf 5000 plus triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic acetic acidaluminum acetate ciprofloxacin hcl otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC

63 Name CIPRODEX neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort betamethasone acet,sod phos cortisone deltasone oral tablet 20 mg dexamethasone intensol dexamethasone oral elixir dexamethasone oral solution dexamethasone oral tablet dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection B/D PA; MO fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack B/D PA; MO Name methylprednisolone sodium succ injection recon soln 25 mg, 40 mg methylprednisolone sodium succ millipred dp millipred oral tablet B/D PA; MO prednisolone oral solution 5 mg/5 ml prednisolone sodium phosphate oral solution 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating B/D PA; MO prednisone intensol B/D PA; MO prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack triamcinolone acetonide injection suspension 0 mg/ml triamcinolone acetonide injection suspension 40 mg/ml B/D PA; MO veripred 20 ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg 49

64 Name propylthiouracil DIABETES THERAPY acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QL (90 ; QL (360 ; QL (80 ALCOHOL PADS BYDUREON 2 PA; MO; QL (4 per 28 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 PA; MO; QL (2.4 per 30 2 PA; MO; QL (.2 per 30 CYCLOSET 3 MO; QL (80 GAUZE PADS 2 X 2 glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 0 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 0 mg ; QL (240 ; QL (20 ; QL (60 ; QL (20 ; QL (240 ; QL (60 Name glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) 50 ; QL (240 ; QL (20 ; QL (240 ; QL (20 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONC) KWIKPEN 2

65 Name HUMULIN R U-500 (CONCENTRATED ) INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, ML, /2 ML INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG INVOKAMET ORAL TABLET MG INVOKANA ORAL TABLET 00 MG INVOKANA ORAL TABLET 300 MG ; QL (60 ; QL (20 ; QL (90 ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 MG ; QL (30 ; QL (60 JANUVIA ; QL (30 JARDIANCE ; QL (30 JENTADUETO ; QL (60 LANTUS Name LANTUS SOLOSTAR 5 LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr,000 mg metformin oral tablet extended release (osm) 24hr 500 mg metformin oral tablet,er gast.retention 24 hr,000 mg metformin oral tablet,er gast.retention 24 hr 500 mg miglitol oral tablet 00 mg miglitol oral tablet 25 mg miglitol oral tablet 50 mg ; QL (75 ; QL (50 ; QL (90 ; QL (20 ; QL (75 ; QL (75 ; QL (50 ; QL (60 ; QL (20 QL (90 per 30 QL (360 per 30 QL (80 per 30

66 Name nateglinide oral tablet 20 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY ; QL (90 ; QL (80 NOVOFINE 32 pioglitazone ; QL (30 ; QL (30 ; QL (90 PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet mg repaglinide oral tablet 2 mg pioglitazoneglimepiride pioglitazonemetformin repaglinidemetformin ; QL (960 ; QL (480 ; QL (240 ; QL (50 RIOMET ; QL (765 SYMLINPEN 20 2 PA; MO; QL (8.9 per 30 SYMLINPEN 60 2 PA; MO; QL (0.5 per 30 SYNJARDY ORAL TABLET 2.5-,000 MG, MG, 5-,000 MG SYNJARDY ORAL TABLET MG ; QL (60 ; QL (20 Name tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (20 ; QL (60 tolbutamide ; QL (80 TOUJEO SOLOSTAR TRADJENTA ; QL (30 VGO 20 VGO 30 VGO 40 MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 4 PA; MO ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 2 PA; MO 2 PA; MO androxy cabergoline calcitonin (salmon) calcitriol solution mcg/ml calcitriol oral CERDELGA 52

67 Name CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chorionic gonadotropin, human PA; MO danazol oral desmopressin injection desmopressin nasal desmopressin oral doxercalciferol doxercalciferol oral ELAPRASE FABRAZYME fortical KANUMA KORLYM KUVAN LUMIZYME methyltestosterone oral capsule MIACALCIN INJECTION 3 MO MYALEPT 4 PA; MO; LA MYOZYME NAGLAZYME ; LA NATPARA 4 PA; MO; LA novarel PA; MO oxandrolone oral tablet 0 mg 4 PA; MO Name oxandrolone oral tablet 2.5 mg PA; MO pamidronate paricalcitol oral SAMSCA 4 PA; MO SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SOMAVERT STIMATE STRENSIQ ; LA SYNAREL testosterone cypionate testosterone enanthate testosterone transdermal gel in metered-dose pump.25 gram/ actuation ( %) testosterone transdermal gel in packet PA; MO PA; MO vasopressin VIMIZIM ZAVESCA ; LA ZEMPLAR INTRAVENOUS zoledronic acid recon soln zoledronic acid solution 53

68 Name THYROID HORMONES levothyroxine recon soln 200 mcg, 500 mcg levothyroxine oral levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine unithroid GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0. mg/ml diphenoxylateatropine glycopyrrolate injection glycopyrrolate oral loperamide oral capsule opium tincture paregoric MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO 2 B/D PA; MO alosetron ALOXI balsalazide Name budesonide oral CHENODAL 4 PA; MO; LA CHOLBAM ORAL CAPSULE 250 MG CHOLBAM ORAL CAPSULE 50 MG 4 PA; MO (20 per 30 colocort compro constulose CORTIFOAM CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 6,000-9,000-30,000 UNIT CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 36,000-4,000-80,000 UNIT cromolyn oral CYSTADANE dimenhydrinate injection solution DIPENTUM dronabinol oral capsule 0 mg dronabinol oral capsule 2.5 mg, 5 mg 4 B/D PA; MO B/D PA; MO 54

69 Name droperidol injection solution EMEND INTRAVENOUS EMEND ORAL 2 B/D PA; MO ENTYVIO 4 PA; MO enulose GATTEX 30-VIAL GATTEX ONE- VIAL gavilyte-c gavilyte-g gavilyte-h and bisacodyl gavilyte-n generlac granisetron (pf) granisetron hcl granisetron hcl oral B/D PA; MO hydrocortisone rectal cream hydrocortisone rectal enema lactulose LIALDA LINZESS meclizine oral tablet 2.5 mg, 25 mg mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution Name metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet metoclopramide hcl oral tablet,disintegrating 0 mg metoclopramide hcl oral tablet,disintegrating 5 mg ondansetron B/D PA; MO ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg peg electrolytes oral recon soln gram peg electrolytes oral recon soln gram peg-electrolyte soln B/D PA; MO B/D PA B/D PA; MO 55

70 Name peg-prep PENTASA polyethylene glycol 3350 oral prochlorperazine prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-med hc procto-pak proctosol hc proctozone-hc RECTIV RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 4 PA; MO SUCRAID sulfasalazine TRANSDERM- SCOP trilyte with flavor packets 3 MO UCERIS ORAL ursodiol VIOKACE ULCER THERAPY Name amoxicilclarithromylansopraz carafate oral suspension 56 ; QL (2 cimetidine cimetidine hcl oral esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg esomeprazole sodium ; QL (30 famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine famotidine oral suspension famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 5 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg ; QL (30 misoprostol nizatidine omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg ; QL (30

71 Name omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule 20-. mggram omeprazole-sodium bicarbonate oral capsule 40-. mggram pantoprazole pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ; QL (30 ; QL (30 rabeprazole ranitidine hcl injection ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 50 mg, 300 mg sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARCALYST 4 PA; MO Name AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT 57 (4 per 28 (4 per 28 (4 per 28 (4 per 28 (5 per 28 ILARIS (PF) 4 PA; MO; LA INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION RECON SOLN 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION LEUKINE INJECTION RECON SOLN MOZOBIL NEULASTA 4 PA; MO NEUPOGEN 4 PA; MO OMNITROPE 4 PA; MO PEGASYS ; QL (4 per 28

72 Name PEGASYS PROCLICK ; QL (4 per 28 PEGINTRON ; QL (4 per 28 PEGINTRON REDIPEN PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML ; QL (4 per 28 ( per 28 ( per 80 ( per 28 ( per 80 2 PA; MO 4 PA; MO PROLEUKIN REBIF (WITH ALBUMIN) (6 per 28 Name REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK (6 per 28 (4.2 per 80 (2 per 28 SYLATRON ZARXIO 4 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP BOTOX 2 PA; MO CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) 2 B/D PA; MO ENGERIX-B PEDIATRIC (PF) 2 B/D PA; MO fomepizole GAMASTAN S/D GARDASIL (PF) 58

73 Name GARDASIL 9 (PF) GRASTEK 2 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION HAVRIX (PF) INTRAMUSCULA R SYRINGE,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) 2 HIZENTRA 4 B/D PA; MO HYPERHEP B S/D INTRAMUSCULA R SOLUTION 220 UNIT/ML HYPERHEP B S/D INTRAMUSCULA R SOLUTION 220 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULA R SYRINGE HYPERHEP B S-D NEONATAL HYPERRHO S/D INTRAMUSCULA R SYRINGE,500 UNIT (300 MCG) HYPERRHO S/D INTRAMUSCULA R SYRINGE 250 UNIT (50 MCG) HYQVIA 4 B/D PA; MO 2 Name IMOGAM RABIES- HT (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) IPOL INJECTION SUSPENSION 2 IXIARO (PF) KINRIX (PF) INTRAMUSCULA R SUSPENSION KINRIX (PF) INTRAMUSCULA R SYRINGE MENACTRA (PF) INTRAMUSCULA R SOLUTION MENHIBRIX (PF) 2 MENOMUNE - A/C/Y/W-35 MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y- W-35-DIP (PF) 2 2 M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PRIVIGEN 4 PA; MO PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) RAGWITEK 59

74 Name RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 0 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 2 ROTATEQ VACCINE 2 B/D PA; MO 2 B/D PA; MO 2 B/D PA TENIVAC (PF) TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD TICE BCG TRUMENBA 2 TWINRIX (PF) TYPHIM VI INTRAMUSCULA R SOLUTION TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) INTRAMUSCULA R SUSPENSION VAQTA (PF) INTRAMUSCULA R SYRINGE 2 2 Name 60 VARIVAX (PF) VARIZIG YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol aloprim colchicineprobenecid COLCRYS KRYSTEXXA MITIGARE probenecid ULORIC 2 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 0 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (286 ; QL (30 ; QL (4 per 28 FORTEO (2.4 per 28 ibandronate PA; MO ibandronate oral ; QL ( per 30 PROLIA 2 PA; MO raloxifene risedronate oral tablet 50 mg ; QL ( per 30

75 Name risedronate oral tablet 35 mg, 35 mg (2 pack), 35 mg (4 pack) risedronate oral tablet 5 mg risedronate oral tablet,delayed release (dr/ec) ; QL (4 per 28 ; QL (30 ; QL (4 per 28 OTHER RHEUMATOLOGICALS ACTEMRA 4 PA; MO BENLYSTA CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 3 MO (8 per 28 (8 per 28 (4 per 28 (4 per 28 (2.4 per 80 Name HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) (4.8 per 80 HUMIRA PEN (3.2 per 28 HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS STARTER HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (4.8 per 80 (3.2 per 80 (0.4 per 28 (2 per 28 (3.2 per 28 leflunomide ; QL (30 ORENCIA 4 PA; MO ORENCIA (WITH MALTOSE) 4 PA; MO OTEZLA 4 PA; MO OTEZLA STARTER 4 PA; MO RIDAURA OBSTETRICS / GYNECOLOGY 6

76 Name ESTROGENS / PROGESTINS camila deblitane DEPO-PROVERA INTRAMUSCULA R SOLUTION errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiolnorethindrone acet ; QL (8 per 28 ; QL (4 per 28 estropipate fyavolv heather hydroxyprogesterone caproate jencycla jevantique lo jolivette lyza MAKENA INTRAMUSCULA R OIL 250 MG/ML 4 Name MAKENA INTRAMUSCULA R OIL 250 MG/ML ( ML) medroxyprogesteron e 4 MENEST mimvey mimvey lo nora-be norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, -5 mg-mcg norlyroc progesterone progesterone in oil progesterone micronized sharobel MISCELLANEOUS OB/GYN clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository MIRENA NEXPLANON terconazole tranexamic acid oral 62

77 Name vandazole xulane ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) alyacen /35 (28) alyacen 7/7/7 (28) amethia amethia lo amethyst apri aranelle (28) ashlyna aubra aviane azurette (28) balziva (28) bekyree (28) blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) briellyn camrese camrese lo caziant (28) chateal cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) cyred dasetta /35 (28) Name dasetta 7/7/7 (28) daysee delyla (28) desoge.estradiol/e.estradio l desogestrel-ethinyl estradiol drospirenone-ethinyl estradiol elinest ELLA emoquette enpresse enskyce estarylla falmina (28) gianvi (28) gildagia gildess.5/30 (2) gildess /20 (2) gildess 24 fe gildess fe.5/30 (28) gildess fe /20 (28) introvale jolessa juleber junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe 24 63

78 Name kaitlib fe kariva (28) kelnor /35 (28) kimidess (28) kurvelo l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (7) l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) layolis fe leena 28 lessina levonest (28) levonorgestrelethinyl estrad oral tablet mgmcg, mg levonorgestrelethinyl estrad oral tablet mcg levonorgestrelethinyl estrad oral tablets,dose pack,3 month Name levonorg-eth estrad triphasic levora-28 lomedia 24 fe loryna (28) low-ogestrel (28) lutera (28) marlissa microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) mono-linyah mononessa (28) myzilra necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nikki (28) noreth-ethinyl estradiol-iron norethindrone ac-eth estradiol oral tablet -20 mg-mcg norethindronee.estradiol-iron norgestimate-ethinyl estradiol 64

79 Name nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia philith pimtrea (28) pirmella portia previfem quasense reclipsen (28) setlakin sprintec (28) sronyx syeda tarina fe /20 (28) tilia fe tri-estarylla tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trinessa (28) trinessa lo tri-previfem (28) tri-sprintec (28) trivora (28) Name velivet triphasic regimen (28) 65 vestura (28) vienva viorele (28) vyfemla (28) wera (28) wymzya fe zarah zenchent (28) zenchent fe zovia /35e (28) zovia /50e (28) OXYTOCICS methergine methylergonovine oxytocin injection solution OPHTHALMOLOGY ANTIBIOTICS bacitracin ophthalmic bacitracinpolymyxin b ophthalmic ciprofloxacin hcl ophthalmic erythromycin ophthalmic gatifloxacin gentak ophthalmic ointment gentamicin ophthalmic

80 Name levofloxacin ophthalmic NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin neo-polycin ofloxacin ophthalmic polycin polymyxin b sulftrimethoprim tobramycin ANTIVIRALS trifluridine ZIRGAN 3 MO BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 3 MO CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops Name DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops %, 2 %, 4 % MISCELLANEOUS OPHTHALMOLOGICS azelastine ophthalmic balanced salt bss cromolyn ophthalmic CYSTARAN epinastine EYLEA JETREA (PF) LUCENTIS olopatadine ophthalmic RESTASIS ; QL (60 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ketorolac ophthalmic ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral 66

81 Name OTHER GLAUCOMA DRUGS bimatoprost dorzolamide dorzolamide-timolol latanoprost miostat travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic neo-polycin hc STEROIDS dexamethasone sodium phosphate ophthalmic fluorometholone FML S.O.P. OZURDEX prednisolone acetate prednisolone sodium phosphate ophthalmic STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE 3 MO Name BLEPHAMIDE S.O.P. tobramycindexamethasone sulfacetamideprednisolone SULFONAMIDES sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment 67 SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0. % 3 MO apraclonidine brimonidine VASOCONSTRICTOR DECONGESTANTS naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection cetirizine oral solution mg/ml desloratadine ; QL (30 diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral elixir PA

82 Name epinephrine injection autoinjector epinephrine injection syringe 0. mg/ml ; QL (4 per 30 EPIPEN 2-PAK ; QL (4 per 30 EPIPEN JR 2-PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PA; MO ; QL (30 promethazine oral PA; MO PULMONARY AGENTS acetylcysteine B/D PA; MO ADEMPAS 4 PA; MO; LA albuterol sulfate inhalation solution for nebulization B/D PA; MO albuterol sulfate oral aminophylline ARCAPTA NEOHALER ; QL (30 ASMANEX HFA ; QL (3 Name ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (30 DOSES), 220 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (7 DOSES), 220 MCG (4 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (20 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (30 2 QL (28 per 30 ; QL (240 ; QL (60 ATROVENT HFA ; QL (25.8 budesonide inhalation B/D PA; MO budesonide nasal ; QL (7.2 CINRYZE 4 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 68

83 Name cromolyn inhalation B/D PA; MO DALIRESP 3 PA; MO DULERA 2 PA; MO; QL (3 per 30 elixophyllin oral elixir 80 mg/5 ml ESBRIET 4 PA; QL (270 FIRAZYR 4 PA; MO flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (50 fluticasone nasal ; QL (6 INCRUSE ELLIPTA ipratropium bromide inhalation ipratropiumalbuterol KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET ; QL (30 B/D PA; MO B/D PA; MO (56 per 28 (60 per 30 LETAIRIS 4 PA; MO; LA levalbuterol hcl B/D PA; MO metaproterenol mometasone nasal QL (34 per 30 montelukast NUCALA 4 PA; MO; LA; QL ( per 28 Name OFEV (60 per 30 OPSUMIT 4 PA; MO; LA ORKAMBI (2 per 28 PERFOROMIST 2 B/D PA; MO PROAIR HFA ; QL (7 PROAIR RESPICLICK PULMICORT INHALATION SUSPENSION FOR NEBULIZATION MG/2 ML ; QL (7 2 B/D PA; MO PULMOZYME 4 B/D PA; MO QVAR ; QL (7.4 SEREVENT DISKUS sildenafil ; QL (60 4 PA sildenafil oral PA; MO; QL (90 per 30 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER ; QL (60 ; QL (90 per 90 SYMBICORT 2 PA; MO; QL (0.2 per 30 terbutaline oral terbutaline subcutaneous 69

84 Name theophylline in dextrose 5 % parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral elixir theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 2 hr TRACLEER 4 PA; MO; LA TYVASO 4 B/D PA; MO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT 4 B/D PA 4 B/D PA; MO 4 B/D PA; MO XOLAIR 4 PA; MO; LA; QL (6 per 28 zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS darifenacin flavoxate Name oxybutynin chloride oral tolterodine trospium BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin dutasteride dutasteridetamsulosin finasteride oral tablet 5 mg tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS alprostadil CYSTAGON ; LA cytra k crystals ELMIRON glycine irrigation glycine urologic K-PHOS NO 2 K-PHOS ORIGINAL potassium citrate potassium citratecitric acid RENACIDIN IRRIGATION SOLUTION GRAM/00 ML 2 70

85 Name sodium citrate-citric acid VITAMINS, HEMATINICS / ELECTROLYTES BLOOD DERIVATIVES albumin, human 25 % albumin, human 5 % albuminar 25 % albuminar 5 % alburx (human) 25 % alburx (human) 5 % albutein 25 % albutein 5 % buminate 25 % buminate 5 % plasbumin 25 % plasbumin 5 % ELECTROLYTES calcium acetate oral capsule calcium acetate oral tablet 667 mg calcium chloride calcium gluconate dextrose-kcl-nacl effer-k oral tablet, effervescent 25 meq eliphos k-effervescent Name klor-con klor-con 0 klor-con 8 klor-con m0 klor-con m5 klor-con m20 klor-con sprinkle klor-con/ef k-phos-neutral k-tab oral tablet extended release 8 meq lactated ringers magnesium chloride injection MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK GRAM/00 ML magnesium sulfate in water parenteral solution magnesium sulfate in water piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water piggyback 4 gram/00 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe 2 7

86 Name NORMOSOL-R 2 NORMOSOL-R IN 5 % DEXTROSE phospha 250 neutral potassium acetate solution 2 meq/ml potassium bicarb and chloride potassium bicarbcitric acid potassium chloridd5-0.45%nacl parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl parenteral solution 20 meq/l potassium chloride in 0.9%nacl parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 parenteral solution 20 meq/l 2 Name potassium chloride in lr-d5 parenteral solution 40 meq/l potassium chloride piggyback 0 meq/00 ml, 20 meq/00 ml, 20 meq/50 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride piggyback 0 meq/50 ml potassium chloride solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.2%nacl parenteral solution 20 meq/l 72

87 Name potassium chlorided5-0.2%nacl parenteral solution 30 meq/l, 40 meq/l potassium chlorided5-0.3%nacl parenteral solution 20 meq/l potassium chlorided5-0.9%nacl parenteral solution 20 meq/l potassium chlorided5-0.9%nacl parenteral solution 40 meq/l potassium phosphate m-/d-basic ringers sodium acetate sodium bicarbonate solution sodium bicarbonate syringe 0 meq/0 ml (8.4 %) sodium bicarbonate syringe 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % ( meq/ml) sodium chloride 0.45 % parenteral solution Name sodium chloride 0.45 % piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride sodium lactate sodium phosphate virt-phos 250 neutral MISCELLANEOUS NUTRITION PRODUCTS amino acids 5 % B/D PA AMINOSYN 0 % 2 B/D PA AMINOSYN 7 % WITH ELECTROLYTES 2 B/D PA AMINOSYN 8.5 % 2 B/D PA AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % 2 B/D PA 2 B/D PA 2 B/D PA AMINOSYN II 7 % 2 B/D PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 73

88 Name AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE- FREE) cysteine (l-cysteine) solution electrolyte-48 in d5w 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA 2 B/D PA B/D PA freamine iii 0 % B/D PA HEPATAMINE 8% 2 B/D PA hetastarch 6 % in 0.9 % nacl intralipid emulsion 20 % IONOSOL-B IN D5W B/D PA; MO 2 Name IONOSOL-MB IN D5W 74 ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 NEPHRAMINE 5.4 % NORMOSOL-R PH 7.4 PLASMA-LYTE 48 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE plasmanate B/D PA premasol 0 % B/D PA; MO PREMASOL 6 % 2 B/D PA travasol 0 % B/D PA; MO TROPHAMINE 0 % B/D PA; MO TROPHAMINE 6% 2 B/D PA VITAMINS / HEMATINICS fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg) mg, 0.5 mg f (. mg) mg fluoritab oral tablet,chewable 0.5 mg fluoride (. mg) ludent fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (. mg)

89 Name multi-vit with fluoride-iron multivitamin with fluoride multi-vitamin with fluoride oral drops multi-vitamin with fluoride oral tablet,chewable 0.5 mg multivitamins with fluoride mvc-fluoride prenatal vitamin oral tablet sodium fluoride oral drops sodium fluoride oral tablet sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (. mg) tri-vit with fluoride and iron tri-vitamin with fluoride vitamins a,c,d and fluoride 75

90 Index 8 8-MOP A abacavir... 2 abacavir-lamivudinezidovudine... 2 ABELCET... 2 ABILIFY MAINTENA ABRAXANE... 2 acamprosate acarbose acebutolol acetaminophen-codeine acetasol hc acetazolamide acetazolamide sodium acetic acid... 46, 48 acetic acid-aluminum acetate 48 acetylcysteine... 46, 68 acitretin ACTEMRA... 6 ACTHIB (PF) ACTIMMUNE acyclovir... 2, 45 acyclovir sodium... 2 ADACEL(TDAP ADOLESN/ADULT)(PF) 58 ADAGEN adapalene ADASUVE adefovir... 2 ADEMPAS adenosine adrenalin adrucil... 2 afeditab cr AFINITOR... 2 AFINITOR DISPERZ... 2 AGGRENOX a-hydrocort AKYNZEO ala-cort ALBENZA... 7 albumin, human 25 %... 7 albumin, human 5 %... 7 albuminar 25 %... 7 albuminar 5 %... 7 alburx (human) 25 %... 7 alburx (human) 5 %... 7 albutein 25 %... 7 albutein 5 %... 7 albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME ALECENSA... 2 alendronate... 46, 60 alfuzosin ALIMTA... 2 ALINIA... 7 ALKERAN... 2 allopurinol almotriptan malate... 2 aloprim alosetron ALOXI ALPHAGAN P alprostadil altavera (28) alyacen /35 (28) alyacen 7/7/7 (28) amantadine hcl... 2 AMBISOME... 2 amcinonide amethia amethia lo amethyst amifostine crystalline... amikacin... 7 amiloride amiloride-hydrochlorothiazide amino acids 5 % aminocaproic acid aminophylline AMINOSYN 0 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 9 amoxicillin-pot clavulanate... 9 amphotericin b... 2 ampicillin... 9 ampicillin sodium... 9 ampicillin-sulbactam... 9 AMPYRA ANADROL anagrelide anastrozole... 2 ANDROGEL androxy apexicon e APOKYN... 2 apraclonidine apri APTIOM... 9 APTIVUS... 2 ARALAST NP aranelle (28) ARCALYST ARCAPTA NEOHALER aripiprazole... 28, 29 76

91 ARISTADA armodafinil ARRANON... 2 ARZERRA... 2 ashlyna ASMANEX HFA ASMANEX TWISTHALER 68 aspirin-dipyridamole atenolol atenolol-chlorthalidone atorvastatin atovaquone... 7 atovaquone-proguanil... 7 ATRIPLA... 2 atropine... 54, 66 ATROVENT HFA aubra AUGMENTIN... 9 AVASTIN... 2 aviane avita AVONEX AVONEX (WITH ALBUMIN) azacitidine... 2 azathioprine... 2 azathioprine sodium... 2 azelastine... 48, 66 AZILECT... 2 azithromycin... 6, 7 aztreonam... 7 azurette (28) B baciim... 7 bacitracin... 7, 65 bacitracin-polymyxin b baclofen balanced salt balsalazide balziva (28) BANZEL... 9 BARACLUDE... 2 BCG VACCINE, LIVE (PF) 58 bekyree (28) BELEODAQ... 2 benazepril benazepril-hydrochlorothiazide BENDEKA... 2 BENLYSTA... 6 benztropine... 2 betamethasone acet,sod phos 49 betamethasone dipropionate. 45 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 36, 66 bethanechol chloride BETHKIS... 7 bexarotene... 2 BEXSERO (PF) bicalutamide... 2 BICILLIN C-R... 9 BICILLIN L-A... 9 BICNU... 2 BILTRICIDE... 7 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bivalirudin bleomycin... 2 BLEPHAMIDE BLEPHAMIDE S.O.P BLINCYTO... 2 blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP BOSULIF... 2 BOTOX briellyn BRILINTA brimonidine BRIVIACT... 9 bromfenac bromocriptine... 2 bss budesonide... 54, 68 bumetanide buminate 25 %... 7 buminate 5 %... 7 BUPHENYL bupivacaine bupivacaine (pf) bupivacaine-dextrose-water(pf) bupivacaine-epinephrine. 43, 44 bupivacaine-epinephrine (pf) 43 buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl bupropion hcl (smoking deter) buspirone BUSULFEX... 2 butorphanol tartrate BYDUREON BYETTA C cabergoline CABOMETYX... 2 caffeine citrated calcipotriene calcipotriene-betamethasone 42 calcitonin (salmon) calcitrene calcitriol... 42, 52 calcium acetate... 7 calcium chloride... 7 calcium gluconate... 7 camila CAMPATH... 2 camrese camrese lo CANCIDAS... 2 candesartan candesartan-hydrochlorothiazid CAPASTAT... 7 CAPRELSA... 2 captopril captopril-hydrochlorothiazide carafate CARBAGLU carbamazepine... 9 carbidopa... 2 carbidopa-levodopa... 2 carbidopa-levodopaentacapone... 2 carbocaine (pf)

92 carboplatin... 2 cardioplegic soln... 4 carteolol cartia xt carvedilol CAYSTON... 7 caziant (28) cefaclor... 5 cefadroxil... 5 cefazolin... 5, 6 cefazolin in dextrose (iso-os). 5 cefdinir... 6 cefepime... 6 cefepime in dextrose,iso-osm. 6 cefixime... 6 cefotaxime... 6 cefotetan... 6 cefoxitin... 6 cefoxitin in dextrose, iso-osm 6 cefpodoxime... 6 cefprozil... 6 ceftazidime... 6 ceftibuten... 6 ceftriaxone... 6 ceftriaxone in dextrose,iso-os. 6 cefuroxime axetil... 6 cefuroxime sodium... 6 celecoxib CELLCEPT... 2 CELLCEPT INTRAVENOUS... 2 CELONTIN... 9 cephalexin... 6 CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) 39 CERDELGA CEREZYME CERVARIX VACCINE (PF) cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chateal CHEMET CHENODAL chloramphenicol sod succinate... 7 chlorhexidine gluconate chloroquine phosphate... 7 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone CHOLBAM cholestyramine (with sugar). 40 cholestyramine light chorionic gonadotropin, human ciclodan ciclopirox cidofovir... 2 cilostazol cimetidine cimetidine hcl CINRYZE CIPRODEX ciprofloxacin... 0 ciprofloxacin (mixture)... 0 ciprofloxacin hcl... 0, 48, 65 ciprofloxacin in 5 % dextrose... 0 ciprofloxacin lactate... 0 cisplatin... 2 citalopram cladribine... 2 claravis clarithromycin... 7 clindacin etz clindacin p clindamycin hcl... 7 clindamycin in 5 % dextrose.. 7 clindamycin palmitate hcl... 7 clindamycin pediatric... 7 clindamycin phosphate... 7, 43, 62 clindamycin-benzoyl peroxide CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE).. 74 clobetasol clobetasol-emollient clodan CLOLAR... 2 clomipramine clonazepam... 9 clonidine clonidine (pf) clonidine hcl... 29, 37 clopidogrel clorazepate dipotassium clorpres clotrimazole... 2, 44 clotrimazole-betamethasone. 44 clozapine COARTEM... 8 codeine sulfate colchicine-probenecid COLCRYS colestipol colistin (colistimethate na)... 8 colocort COMBIVENT RESPIMAT.. 68 COMETRIQ... 2 COMPLERA... 2 compro constulose CORLANOR... 4 cormax CORTIFOAM cortisone COSMEGEN... 2 COTELLIC... 2 CREON CRESEMBA... 2 CRIXIVAN

93 cromolyn... 54, 66, 69 cryselle (28) CUBICIN... 8 CUPRIMINE... 6 cyclafem /35 (28) cyclafem 7/7/7 (28) cyclophosphamide... 2 CYCLOPHOSPHAMIDE... 3 CYCLOSET cyclosporine... 3 cyclosporine modified... 3 CYRAMZA... 3 cyred CYSTADANE CYSTAGON CYSTARAN cysteine (l-cysteine) cytarabine... 3 cytarabine (pf)... 3 cytra k crystals D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine... 3 DAKLINZA... 3 DALIRESP danazol dantrolene DAPSONE... 8 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 8 darifenacin DARZALEX... 3 dasetta /35 (28) dasetta 7/7/7 (28) daunorubicin... 3 daysee deblitane decitabine... 3 deferoxamine deltasone delyla (28) demeclocycline... 0 DEMSER DENAVIR denta 5000 plus dentagel DEPEN TITRATABS... 6 DEPOCYT (PF)... 3 DEPO-PROVERA DESCOVY... 3 desipramine desloratadine desmopressin desog-e.estradiol/e.estradiol. 63 desogestrel-ethinyl estradiol. 63 desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 49, 67 dexedrine dexmethylphenidate dexrazoxane hcl... dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w). 47 dextrose 5 %-lactated ringers47 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl... 7 diazepam... 9, 29 diazepam intensol diclofenac potassium diclofenac sodium... 27, 43, 66 diclofenac-misoprostol dicloxacillin... 9 didanosine... 3 diflorasone diflunisal digitek digox digoxin dihydrocode-acetaminophencaff dihydrocodeine-aspirin-caff. 23 dihydroergotamine... 2, 22 DILANTIN 30 MG... 9 diltiazem hcl dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole diskets disulfiram divalproex... 9 dobutamine... 4 dobutamine in d5w... 4 DOCEFREZ... 3 docetaxel... 3 dofetilide donepezil dopamine... 4, 42 dopamine in 5 % dextrose... 4 dorzolamide dorzolamide-timolol doxazosin doxepin... 29, 43 doxercalciferol DOXIL

94 doxorubicin... 3 doxorubicin, peg-liposomal.. 3 doxy doxycycline hyclate... 0, doxycycline monohydrate... dronabinol droperidol drospirenone-ethinyl estradiol DROXIA... 3 DULERA duloxetine... 29, 30 duramorph (pf) dutasteride dutasteride-tamsulosin E e.e.s E.E.S. GRANULES... 7 econazole EDURANT... 3 effer-k... 7 ELAPRASE electrolyte-48 in d5w elinest eliphos... 7 ELIQUIS ELITEK... elixophyllin ELLA ELMIRON EMCYT... 3 EMEND emoquette EMPLICITI... 3 EMSAM EMTRIVA... 3 EMVERM... 8 enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL... 6 ENBREL SURECLICK... 6 endocet ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enlon enoxaparin enpresse enskyce entacapone... 2 entecavir... 3 ENTRESTO ENTYVIO enulose epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin... 3 epitol EPIVIR HBV... 3 eplerenone epoprostenol (glycine) eprosartan eptifibatide EPZICOM... 3 ERBITUX... 3 ergoloid ERIVEDGE... 3 errin ERWINAZE... 3 ery pads erygel ery-tab... 7 ERY-TAB... 7 ERYTHROCIN... 7 erythrocin (as stearate)... 7 erythromycin... 7, 65 erythromycin ethylsuccinate... 7 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esmolol esomeprazole magnesium esomeprazole sodium estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 62 estropipate eszopiclone ethacrynate sodium ethambutol... 8 ethosuximide etidronate disodium etodolac ETOPOPHOS... 3 etoposide... 3 EVOTAZ... 3 EXELON exemestane... 3 EXJADE EYLEA F FABRAZYME falmina (28) famciclovir... 3 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 56 FANAPT FARESTON... 3 FARYDAK... 3, 4 FASLODEX... 4 FAZACLO felbamate felodipine fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 40 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate fentanyl citrate (pf) FERRIPROX FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 4 flavoxate flecainide floxuridine... 4 fluconazole... 2 fluconazole in dextrose(iso-o) 2 fluconazole in nacl (iso-osm). 2 flucytosine

95 fludarabine... 4 fludrocortisone flumazenil flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap 45 fluocinonide fluocinonide-e fluor-a-day (with xylitol) fluoridex daily defense fluoritab fluorometholone fluorouracil... 4, 43 fluoxetine... 30, 3 fluphenazine decanoate... 3 fluphenazine hcl... 3 flurandrenolide flurbiprofen flurbiprofen sodium flutamide... 4 fluticasone... 45, 69 fluvastatin... 40, 4 fluvoxamine... 3 FML S.O.P FOLOTYN... 4 fomepizole fondaparinux FORTEO fortical foscarnet... 3 fosinopril fosinopril-hydrochlorothiazide fosphenytoin freamine iii 0 % frovatriptan furosemide FUSILEV... FUZEON... 3 fyavolv FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D ganciclovir sodium... 3 GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-h and bisacodyl gavilyte-n GAZYVA... 4 gemcitabine... 4 gemfibrozil... 4 generlac gengraf... 4 gentak gentamicin... 8, 44, 65 gentamicin in nacl (iso-osm).. 8 gentamicin sulfate (ped) (pf).. 8 gentamicin sulfate (pf)... 8 GENVOYA... 3 GEODON... 3 gianvi (28) gildagia gildess.5/30 (2) gildess /20 (2) gildess 24 fe gildess fe.5/30 (28) gildess fe /20 (28) GILENYA GILOTRIF... 4 glatopa GLEEVEC... 4 GLEOSTINE... 4 glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycine glycine urologic glycopyrrolate glydo granisetron (pf) granisetron hcl GRASTEK griseofulvin microsize... 2 griseofulvin ultramicrosize... 2 guanidine... 3 H HALAVEN... 4 halobetasol propionate haloperidol... 3 haloperidol decanoate... 3 haloperidol lactate... 3 HARVONI... 3 HAVRIX (PF) heather heparin (porcine) heparin (porcine) in 5 % dex 40 heparin (porcine) in nacl (pf) 40 heparin(porcine) in 0.45% nacl HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN... 4 hetastarch 6 % in 0.9 % nacl 74 HETLIOZ... 3 HEXALEN... 4 HIBERIX (PF) HIZENTRA HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMIRA... 6 HUMIRA PEDIATRIC CROHN'S START... 6 HUMIRA PEN... 6 HUMIRA PEN CROHN'S- UC-HS START... 6 HUMIRA PEN PSORIASIS STARTER... 6 HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R

96 HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED)... 5 hydralazine hydrochlorothiazide hydrocodone-acetaminophen 24 hydrocodone-ibuprofen hydrocortisone... 45, 49, 55 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet hydromorphone... 24, 25 hydromorphone (pf) hydroxychloroquine... 8 hydroxyprogesterone caproate hydroxyurea... 4 hydroxyzine hcl HYPERHEP B S/D HYPERHEP B S-D NEONATAL HYPERRHO S/D HYQVIA I ibandronate IBRANCE... 4 ibuprofen ibuprofen-oxycodone ibutilide fumarate ICLUSIG... 4 idarubicin... 4 ifosfamide... 4 ifosfamide-mesna... 5 ILARIS (PF) imatinib... 5 IMBRUVICA... 5 imipenem-cilastatin... 8 imipramine hcl... 3 imipramine pamoate... 3 imiquimod IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide INFANRIX (DTAP) (PF) INLYTA... 5 INSULIN PEN NEEDLE... 5 INSULIN SYRINGE (DISP) U INTELENCE... 3 intralipid INTRON A introvale INVANZ... 8 INVEGA... 3 INVEGA SUSTENNA... 3 INVEGA TRINZA... 3 INVIRASE... 3 INVOKAMET... 5 INVOKANA... 5 IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 48, 69 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... 5 irinotecan... 5 ISENTRESS... 3 ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 8 isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX... 5 itraconazole... 2 ivermectin... 8 IXEMPRA... 5 IXIARO (PF) J JADENU JAKAFI... 5 jantoven JANUMET... 5 JANUMET XR... 5 JANUVIA... 5 JARDIANCE... 5 jencycla JENTADUETO... 5 JETREA (PF) jevantique lo JEVTANA... 5 jolessa jolivette juleber junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID... 4 K KADCYLA... 5 kaitlib fe KALETRA... 3 KALYDECO KANUMA kariva (28) k-effervescent... 7 kelnor /35 (28) KEPIVANCE... ketoconazole... 2, 44 ketoprofen ketorolac KEYTRUDA... 5 KHEDEZLA... 3 kimidess (28) KINRIX (PF) kionex klofensaid ii klor-con... 7 klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle... 7 klor-con/ef... 7 KORLYM K-PHOS NO

97 K-PHOS ORIGINAL k-phos-neutral... 7 KRYSTEXXA k-tab... 7 kurvelo KUVAN L l norgest/e.estradiol-e.estrad. 64 labetalol lactated ringers... 46, 7 lactulose LAMISIL... 2 lamivudine... 3 lamivudine-zidovudine... 3 lamotrigine LANOXIN lansoprazole LANTUS... 5 LANTUS SOLOSTAR... 5 larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) latanoprost LATUDA... 3, 32 layolis fe leena leflunomide... 6 LEMTRADA LENVIMA... 5 lessina LETAIRIS letrozole... 5 leucovorin calcium... LEUKERAN... 5 LEUKINE leuprolide... 5 levalbuterol hcl LEVEMIR... 5 LEVEMIR FLEXTOUCH... 5 levetiracetam LEVETIRACETAM IN NACL (ISO-OS) levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 0, 66 levofloxacin in d5w... 0 levoleucovorin calcium... levonest (28) levonorgestrel-ethinyl estrad 64 levonorg-eth estrad triphasic 64 levora levorphanol tartrate levothyroxine levoxyl LEXIVA... 3 LIALDA lidocaine lidocaine (pf) in d7.5w lidocaine (pf)... 36, 44 lidocaine hcl lidocaine in 5 % dextrose (pf) lidocaine viscous lidocaine-epinephrine lidocaine-epinephrine (pf) lidocaine-prilocaine lincomycin... 8 lindane linezolid... 8 linezolid-0.9% sodium chloride... 8 LINZESS LIORESAL liothyronine lipodox... 5 lipodox lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate lmd 0 % in 0.9 % sodium chlor lmd 0 % in 5 % dextrose lomedia 24 fe LONSURF... 5 loperamide lorazepam lorazepam intensol lorcet (hydrocodone) lorcet hd lorcet plus lortab lortab lortab loryna (28) losartan losartan-hydrochlorothiazide 38 lovastatin... 4 low-ogestrel (28) loxapine succinate LUCENTIS ludent fluoride LUMIZYME LUPRON DEPOT... 5 LUPRON DEPOT (3 MONTH)... 5 LUPRON DEPOT (4 MONTH)... 5 LUPRON DEPOT (6 MONTH)... 5 LUPRON DEPOT-PED... 5 LUPRON DEPOT-PED (3 MONTH)... 5 lutera (28) LYNPARZA... 5 LYRICA LYSODREN... 5 lyza M MACRODANTIN... magnesium chloride... 7 magnesium sulfate... 7 MAGNESIUM SULFATE IN D5W... 7 magnesium sulfate in water.. 7 MAKENA malathion mannitol 0 % mannitol 20 % mannitol 25 % mannitol 5 % maprotiline marcaine (pf) marlissa MARPLAN MATULANE... 5 matzim la meclizine meclofenamate

98 medroxyprogesterone mefenamic acid mefloquine... 8 megestrol... 6 MEKINIST... 6 meloxicam... 27, 28 melphalan hcl... 6 memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y-W-35-DIP (PF) mercaptopurine... 6 meropenem... 8 mesalamine mesalamine with cleansing wipe mesna... MESNEX... MESTINON MESTINON TIMESPAN metadate er metaproterenol metformin... 5 methadone methadone intensol methadose methamphetamine methazolamide methenamine hippurate... methenamine mandelate... methergine methimazole methotrexate sodium... 6 methotrexate sodium (pf)... 6 methoxsalen rapid methyclothiazide methyldopa methylergonovine methylphenidate methylprednisolone methylprednisolone acetate.. 49 methylprednisolone sodium succ methyltestosterone metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metro i.v... 8 metronidazole... 8, 43, 62 metronidazole in nacl (iso-os) 8 mexiletine MIACALCIN miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) midodrine migergot miglitol... 5 millipred millipred dp milrinone milrinone in 5 % dextrose mimvey mimvey lo minocycline... minoxidil miostat MIRENA mirtazapine misoprostol MITIGARE mitomycin... 6 mitoxantrone... 6 M-M-R II (PF) modafinil moderiba... 3 moderiba dose pack... 3 moexipril moexipril-hydrochlorothiazide molindone mometasone... 45, 69 mondoxyne nl... mono-linyah mononessa (28) montelukast morgidox... morphine... 25, 26 morphine (pf) morphine concentrate moxifloxacin... 0 MOZOBIL multi-vit with fluoride-iron multivitamin with fluoride multi-vitamin with fluoride.. 75 multi-vitamin with fluoride.. 75 multivitamins with fluoride.. 75 mupirocin mupirocin calcium MUSTARGEN... 6 mvc-fluoride MYALEPT MYCAMINE... 2 mycophenolate mofetil... 6 mycophenolate sodium... 6 myorisan MYOZYME myzilra N nabumetone nadolol nadolol-bendroflumethiazide 38 nafcillin... 9 nafcillin in dextrose iso-osm.. 9 naftifine NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN NATACYN nateglinide NATPARA NEBUPENT

99 necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin... 8 neomycin-bacitracin-poly-hc 67 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc 49, 67 neo-polycin neo-polycin hc neostigmine methylsulfate NEPHRAMINE 5.4 % neuac NEULASTA NEUPOGEN NEUPRO... 2 nevirapine... 3 NEXAVAR... 6 NEXPLANON niacin... 4 nicardipine NICOTROL NICOTROL NS nifedical xl nifedipine nikki (28) NILANDRON... 6 nimodipine NINLARO... 6 nisoldipine nitro-bid nitrofurantoin... nitrofurantoin macrocrystal.. nitrofurantoin monohyd/mcryst... nitroglycerin nitroglycerin in 5 % dextrose 42 NITROSTAT nizatidine nora-be norepinephrine bitartrate noreth-ethinyl estradiol-iron. 64 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 62, 64 norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR... 4 novarel NOVOFINE NOXAFIL... 2 NPLATE NUCALA NUEDEXTA NULOJIX... 6 NUPLAZID nyamyc nystatin... 2, 45 nystatin-triamcinolone nystop O ocella octreotide acetate... 6 ODEFSEY... 4 ODOMZO... 6 OFEV ofloxacin... 0, 48, 66 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine... 48, 66 OLYSIO... 4 omeprazole... 56, 57 omeprazole-sodium bicarbonate OMNITROPE ONCASPAR... 6 ondansetron ondansetron hcl ondansetron hcl (pf) ONFI OPDIVO... 6 opium tincture OPSUMIT oralone ORAP ORENCIA... 6 ORENCIA (WITH MALTOSE)... 6 ORFADIN ORKAMBI orsythia osmitrol 5 % osmitrol 20 % OTEZLA... 6 OTEZLA STARTER... 6 oxacillin... 0 oxacillin in dextrose(iso-osm)... 0 oxaliplatin... 6, 7 oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oxymorphone oxytocin OZURDEX P pacerone paclitaxel... 7 paliperidone pamidronate PANRETIN pantoprazole

100 paregoric paricalcitol paroex oral rinse paromomycin... 8 paroxetine hcl... 32, 33 PASER... 8 PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN peg-prep penicillin g potassium... 0 penicillin g procaine... 0 penicillin g sodium... 0 penicillin v potassium... 0 PENTACEL (PF) PENTAM... 8 PENTASA pentoxifylline PERFOROMIST perindopril erbumine perio med periogard PERJETA... 7 permethrin perphenazine pfizerpen-g... 0 phenelzine phenobarbital phenobarbital sodium phenoxybenzamine phentolamine phenytoin... 2 phenytoin sodium... 2 phenytoin sodium extended.. 2 philith phospha 250 neutral PHOSPHOLINE IODIDE pilocarpine hcl... 47, 66 pimozide pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 0 pirmella piroxicam plasbumin 25 %... 7 plasbumin 5 %... 7 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE plasmanate PLEGRIDY podofilox polycin polyethylene glycol polymyxin b sulfate... 8 polymyxin b sulf-trimethoprim POMALYST... 7 portia PORTRAZZA... 7 potassium acetate potassium bicarb and chloride potassium bicarb-citric acid.. 72 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl... 72, 73 potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid.. 70 potassium phosphate m-/dbasic POTIGA... 2 PRADAXA PRALUENT PEN... 4 PRALUENT SYRINGE... 4 pramipexole... 2 pravastatin... 4 prazosin prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 49, 67 prednisone prednisone intensol premasol 0 % PREMASOL 6 % prenatal vitamin oral tablet prevalite... 4 previfem PREZCOBIX... 4 PREZISTA... 4 PRIFTIN... 8 PRIMAQUINE... 8 primidone... 2 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide procentra prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc progesterone progesterone in oil progesterone micronized PROGLYCEM PROGRAF... 7 PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine propafenone

101 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) protamine protriptyline prudoxin PULMICORT PULMOZYME PURIXAN... 7 pyrazinamide... 8 pyridostigmine bromide Q QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... 8 QVAR R RABAVERT (PF) rabeprazole RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE... 7 RAVICTI REBIF (WITH ALBUMIN). 58 REBIF REBIDOSE REBIF TITRATION PACK 58 reclipsen (28) RECOMBIVAX HB (PF) RECTIV regonol REGRANEX relador pak relador pak plus RELENZA DISKHALER... 4 RELISTOR REMICADE REMODULIN RENACIDIN RENVELA repaglinide repaglinide-metformin REPATHA SURECLICK... 4 REPATHA SYRINGE... 4 reprexain RESCRIPTOR... 4 RESTASIS RETROVIR... 4 REVLIMID... 7 revonto REXULTI REYATAZ... 4 ribasphere... 4 ribasphere ribapak... 4 ribavirin... 4 RIDAURA... 6 rifabutin... 8 rifampin... 8 riluzole rimantadine... 4 ringers... 46, 73 RIOMET risedronate... 47, 60, 6 RISPERDAL CONSTA risperidone... 33, 34 RITUXAN... 7 rivastigmine rivastigmine tartrate rizatriptan ropinirole... 2 rosadan rosuvastatin... 4 ROTARIX ROTATEQ VACCINE roweepra... 2 ROZEREM S SABRIL... 2 salsalate SAMSCA SANDIMMUNE... 7 SANDOSTATIN LAR DEPOT... 7 SANTYL SAPHRIS (BLACK CHERRY) selegiline hcl... 2 selenium sulfide SELZENTRY... 4 SENSIPAR sensorcaine sensorcaine-mpf SEREVENT DISKUS sertraline setlakin sf 48 sf 5000 plus sharobel SIGNIFOR... 7 sildenafil silver sulfadiazine SIMULECT... 7 simvastatin... 4 sirolimus... 7 SIRTURO... 8 sodium acetate sodium bicarbonate sodium chloride... 47, 73 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium citrate-citric acid... 7 sodium fluoride sodium lactate sodium phenylbutyrate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLIRIS SOLTAMOX... 7 SOMATULINE DEPOT... 7 SOMAVERT sorine sotalol sotalol af SOTYLIZE SOVALDI... 4 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone

102 spironolacton-hydrochlorothiaz SPORANOX... 2 sprintec (28) SPRITAM... 2 SPRYCEL... 7 sps sronyx ssd stavudine... 4 STIMATE STIVARGA... 7 STRATTERA STRENSIQ STREPTOMYCIN... 8 STRIBILD... 4 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 44 sulfacetamide-prednisolone.. 67 sulfadiazine... 0 sulfamethoxazole-trimethoprim... 0 SULFAMYLON sulfasalazine sulindac sumatriptan sumatriptan succinate SUPRAX... 6 SURMONTIL SUSTIVA... 4 SUTENT... 7 syeda SYLATRON SYLVANT... 7 SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS... 4 SYNAREL SYNERCID... 8 SYNJARDY SYNRIBO... 7 SYPRINE T TABLOID... 7 tacrolimus... 7, 43 TAFINLAR... 7 TAGRISSO... 8 TAMIFLU... 4 tamoxifen... 8 tamsulosin TARCEVA... 8 TARGRETIN... 8 tarina fe /20 (28) TASIGNA... 8 TAZORAC taztia xt TECENTRIQ... 8 TECFIDERA TECHNIVIE... 5 TEFLARO... 6 TEGRETOL XR... 2 telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TEMODAR... 8 TENIVAC (PF) terazosin terbinafine hcl... 2 terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline... THALOMID... 8 theophylline theophylline in dextrose 5 % 70 THIOLA thioridazine thiotepa... 8 thiothixene tiagabine... 2 TICE BCG TIKOSYN tilia fe timolol maleate... 39, 66 tinidazole... 8 TIVICAY... 5 tizanidine tobramycin tobramycin in % nacl... 9 tobramycin sulfate... 9 tobramycin-dexamethasone.. 67 tolazamide tolbutamide tolcapone... 2 tolmetin tolterodine topiramate... 2 toposar... 8 topotecan... 8 TORISEL... 8 torsemide TOUJEO SOLOSTAR TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid... 40, 62 TRANSDERM-SCOP tranylcypromine travasol 0 % travoprost (benzalkonium) trazodone TREANDA... 8 TRECATOR... 9 TRELSTAR... 8 tretinoin tretinoin (chemotherapy)... 8 tretinoin microspheres triamcinolone acetonide. 45, 48, 49 triamterene-hydrochlorothiazid trianex triderm tri-estarylla trifluoperazine trifluridine tri-legest fe tri-linyah tri-lo-estarylla

103 tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim... trimipramine trinessa (28) trinessa lo TRINTELLIX tri-previfem (28) TRISENOX... 8 tri-sprintec (28) TRIUMEQ... 5 tri-vit with fluoride and iron. 75 tri-vitamin with fluoride trivora (28) TROPHAMINE 0 % TROPHAMINE 6% trospium TRUMENBA TRUVADA... 5 TWINRIX (PF) TYGACIL... 9 TYKERB... 8 TYPHIM VI TYSABRI TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA... 5 TYZINE U UCERIS ULORIC unithroid UNITUXIN... 8 UPTRAVI ursodiol UVADEX V valacyclovir... 5 VALCHLOR VALCYTE... 5 valganciclovir... 5 valproate sodium... 2 valproic acid... 2 valproic acid (as sodium salt)... 2 valsartan valsartan-hydrochlorothiazide VALSTAR... 8 vancomycin... VANCOMYCIN IN 0.9% SODIUM CL... vandazole VANTAS... 8 VAQTA (PF) VARIVAX (PF) VARIZIG VASCEPA... 4 vasopressin VECAMYL VECTIBIX... 8 VELCADE... 8 veletri velivet triphasic regimen (28) VELTASSA VENCLEXTA... 8 VENCLEXTA STARTING PACK... 8 venlafaxine... 34, 35 verapamil veripred VERSACLOZ vestura (28) VGO VGO VGO vicodin vicodin es vicodin hp VIDEX 2 GRAM PEDIATRIC... 5 VIDEX 4 GRAM PEDIATRIC... 5 VIEKIRA PAK... 5 vienva VIIBRYD VIMIZIM VIMPAT... 2 vinblastine... 8 vincasar pfs... 8 vincristine... 8 vinorelbine... 8 VIOKACE viorele (28) VIRACEPT... 5 VIRAMUNE XR... 5 VIRAZOLE... 5 VIREAD... 5 virt-phos 250 neutral vitamins a,c,d and fluoride VITEKTA... 5 VOLTAREN GEL voriconazole... 2 VOTRIENT... 8 VRAYLAR vyfemla (28) W warfarin water for irrigation, sterile wera (28) wymzya fe X XALKORI... 8 XARELTO XENAZINE XGEVA... 2 XIAFLEX XIFAXAN... 9 XOLAIR XTANDI... 9 xulane xylon XYREM Y YERVOY... 9 YF-VAX (PF) YONDELIS... 9 Z zafirlukast zaleplon ZALTRAP... 9 zamicet ZANOSAR... 9 zarah ZARXIO ZAVESCA ZELBORAF... 9 ZEMPLAR

104 zenatane zenchent (28) zenchent fe zenzedi ZEPATIER... 5 ZETIA... 4 ZIAGEN... 5 zidovudine... 5 ziprasidone hcl ZIRGAN ZOLADEX... 9 zoledronic acid zoledronic acid-mannitol-water ZOLINZA... 9 zolmitriptan zolpidem zonisamide... 2 ZORTRESS... 9 ZOSTAVAX (PF) zovia /35e (28) zovia /50e (28) ZOVIRAX ZUBSOLV ZYDELIG... 9 ZYKADIA... 9 ZYPREXA RELPREVV ZYTIGA... 9 ZYVOX

105 H6745_085_206MAPDEngSpaFormulary Accepted 0/03/5 Aceptado 03/0/205 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN This formulary was updated on 08/0/206. This information is available for free in other languages. For more recent information or other questions, please contact Amida Care Member Services at or, for TTY users, 7, 8 am to 8 pm, Monday - Friday (every day October to February), or visit The Formulary may change at any time. You will receive notice when necessary. Este vademécum fue actualizado el 0/08/206. Esta información se encuentra disponible en forma gratuita en otros idiomas. Para acceder a información más reciente y si tiene otras preguntas, comuníquese con el Departamento de Servicios al Miembro de Amida Care al o, para usuarios de TTY, 7, De 8 a.m. a 8 p.m., de lunes a viernes (todos los días de octubre a febrero) o puede visitar El vademécum puede cambiar en cualquier momento. Usted recibirá una notificación de ser necesario. Amida Care (HMO) is a not-for-profit health plan with a Medicare Contract. Enrollment in Amida Care depends on contract renewal. Amida Care (HMO) es un plan de salud sin fines de lucro con contrato con Medicare. La inscripción en Amida Care depende de la renovación del contrato.