SilverScript 2016 Formulary (List of Covered Drugs)

Transcription

1 SilverScript 2016 Formulary (List of Covered Drugs) Formulary File 16125, Version 7 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August 1, For more recent information or other questions, please contact SilverScript at or, for TTY users, 711, 2 hours a day, 7 days a week, or visit 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 SilverScript Insurance Company. When it refers to plan or our plan, it means SilverScript Plus (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 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 1, 2017, and from time to time during the year. Y0080_62001_FORM_COMP_2016 Accepted FRM-CM-PLS

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3 What is the SilverScript Formulary? A formulary is a list of covered drugs selected by SilverScript Plus (PDP) 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If the Food and Drug 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 January 1, To get updated information about the drugs covered by SilverScript Plus (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (i.e. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary may be obtained from our website or by calling us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. 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, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. If we remove drugs from our formulary, 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. 1

4 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 52. 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? SilverScript Plus (PDP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA) SilverScript Plus (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Step Therapy (ST) In some cases, SilverScript Plus (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. 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 us 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 SilverScript formulary? on page 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 Customer Care and ask if your drug is covered. If you learn that SilverScript Plus (PDP) does not cover your drug, you have two options: Quantity Limits (QL) For certain drugs, SilverScript Plus (PDP) limits the amount of the drug that we will cover. For example, our plan provides up to 0 tablets per prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply. l l You can ask Customer Care for a list of similar drugs that are covered by our plan. 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 us to make an exception and cover your drug. See below for information about how to request an exception. 2

5 How do I request an exception to the SilverScript Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. l l l 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, our plan 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, SilverScript Plus (PDP) 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 2 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 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 102-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception.

6 If you experience a change in your level of care, such as a move from a home to a Long-Term Care setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited), we may cover a one-time temporary supply from a network pharmacy for up to days unless you have a prescription for fewer days. You should use the plan's exception process if you wish to have continued coverage of the drug after the temporary supply is finished. For more information For more detailed information about your SilverScript Plus (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 ( ), 2 hours a day, 7 days a week. TTY users should call Or, visit SilverScript Plus (PDP) s Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 52. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. PA Prior authorization. QL Drug has quantity limit. ST Step therapy required. NM Not available at our mail-order pharmacies. LA Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at , 2 hours a day, 7 days a week. TTY users should call 711. HR - High Risk Drug. According to medical experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available. B/D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).

7 The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage period) for up to a one month supply of drugs in each tier. Initial Coverage Period Copayment / Coinsurance Levels Tier Cost-Sharing Tier 1 (Preferred Generic) (includes low cost preferred generic drugs) Cost-Sharing Tier 2 (Generic) (includes preferred generic and some preferred brand drugs) Cost-Sharing Tier (Preferred Brand) (includes preferred brand and non-preferred generic drugs) Standard retail costsharing (in-network) (up to a 0-day supply) Preferred retail costsharing (in-network) (up to a 0-day supply) Standard Mail-order costsharing (up to a 0-day supply) Preferred Mail-order costsharing (up to a 0-day supply) Long-term care (LTC) costsharing (up to a -day supply) Out-of-network cost-sharing (coverage is limited to certain situations; see your Evidence of Coverage for details) (up to a 0-day supply) $7.00 $0.00 $7.00 $0.00 $7.00 $7.00 $10.00 $.00 $10.00 $.00 $10.00 $10.00 $29.00 $22.00 $29.00 $22.00 $29.00 $

8 Tier Cost-Sharing Tier (Non-Preferred Brand) (includes non-preferred brand and non-preferred generic drugs) Cost-Sharing Tier 5 (Specialty Tier) (includes high cost generic and brand drugs) Standard retail costsharing (in-network) (up to a 0-day supply) Preferred retail costsharing (in-network) (up to a 0-day supply) Standard Mail-order costsharing (up to a 0-day supply) Preferred Mail-order costsharing (up to a 0-day supply) Long-term care (LTC) costsharing (up to a -day supply) Out-of-network cost-sharing (coverage is limited to certain situations; see your Evidence of Coverage for details) (up to a 0-day supply) 5% 5% 5% 5% 5% 5% % % % % % % You can find complete cost-sharing information, including costs for long-term supplies, in your Evidence of Coverage. 6

9 ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) 1 GC colchicine w/ probenecid COLCRYS QL (120 tabs / 0 probenecid ULORIC ST NSAIDS celecoxib (generic of CELEBREX) CAPS QL (60 caps / 0 diclofenac potassium 2 GC diclofenac sodium TB2 diclofenac sodium TBEC 2 GC diflunisal etodolac CAPS; TABS flurbiprofen TABS 2 GC ibuprofen SUSP ibuprofen TABS 00mg, 2 GC 600mg, 800mg ketoprofen CAPS 2 GC MELOXICAM SUSP meloxicam (generic of 1 GC MOBIC) TABS nabumetone TABS 2 GC naproxen SUSP naproxen (generic of 1 GC NAPROSYN) TABS naproxen (generic of 2 GC EC-NAPROSYN) TBEC naproxen sodium (generic of 2 GC ANAPROX) TABS 275mg naproxen sodium (generic of 2 GC ANAPROX DS) TABS 550mg sulindac TABS 2 GC OPIOID ANALGESICS acetaminophen w/ codeine 2 GC QL SOLN QL (5000 ml / 0 acetaminophen w/ codeine TABS QL (00 tabs / 0 2 GC QL acetaminophen w/ codeine (generic of TYLENOL/CODEINE #) TABS QL (00 tabs / 0 acetaminophen w/ codeine (generic of TYLENOL/CODEINE #) TABS QL (00 tabs / 0 butorphanol tartrate SOLN 1mg/ml, 2mg/ml BUTRANS 5mcg/hr QL (16 patches / 28 BUTRANS 10mcg/hr QL (8 patches / 28 BUTRANS 15mcg/hr, 20mcg/hr QL ( patches / 28 BUTRANS DIS 7.5MCG/HR QL (8 patches / 28 nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml nalbuphine hcl SOLN 20mg/ml tramadol hcl (generic of ULTRAM) TABS QL (20 tabs / 0 tramadol-acetaminophen (generic of ULTRACET) QL (20 tabs / 0 2 GC QL 2 GC QL 2 GC QL OPIOID ANALGESICS, CII DURAMORPH B/D endocet (generic of PERCOCET) QL (60 tabs / 0 fentanyl citrate (generic of ACTIQ) LPOP QL (120 lozenges / 0 fentanyl patch 12 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 5 QL NM PA 7

10 fentanyl patch 25 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 50 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 75 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 FENTORA QL (120 tabs / 0 hydroco/apap tab 5-25mg (generic of NORCO) QL (60 tabs / 0 hydroco/apap tab mg (generic of NORCO) QL (60 tabs / 0 hydroco/apap tab 10-25mg (generic of NORCO) QL (60 tabs / 0 hydrocodone-acetaminophen mg/15ml (generic of HYCET) QL (500 ml / 0 hydrocodone-ibuprofen mg (generic of VICOPROFEN) QL (150 tabs / 0 hydromorphon inj 10mg/ml (generic of DILAUDID-HP) hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl (generic of DILAUDID) TABS QL (270 tabs / 0 lorcet hd tab 10-25mg (generic of NORCO) QL (60 tabs / 0 5 QL NM PA 2 GC QL 2 GC QL 2 GC QL B/D 2 GC QL lorcet plus tab (generic of NORCO) QL (60 tabs / 0 lorcet tab 5-25mg (generic of NORCO) QL (60 tabs / 0 lortab tab 5-25mg (generic of NORCO) QL (60 tabs / 0 lortab tab (generic of NORCO) QL (60 tabs / 0 lortab tab 10-25mg (generic of NORCO) QL (60 tabs / 0 methadone hcl (generic of METHADOSE) CONC QL (120 ml / 0 methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (600 ml / 0 methadone hcl (generic of DOLOPHINE HCL) TABS 5mg QL (20 tabs / 0 methadone hcl (generic of DOLOPHINE) TABS 10mg QL (20 tabs / 0 morphine ext-rel tab (generic of MS CONTIN) 15mg, 0mg, 60mg, 100mg QL (90 tabs / 0 morphine ext-rel tab (generic of MS CONTIN) 200mg QL (60 tabs / 0 MORPHINE SUL INJ 1mg/ml, 10mg/ml, 15mg/ml morphine sul inj.5mg/ml, 1mg/ml MORPHINE SUL INJ 2MG/ML MORPHINE SUL INJ MG/ML MORPHINE SULFATE SOLN 8mg/ml 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL B/D B/D B/D B/D B/D 8

11 MORPHINE SULFATE TABS QL (180 tabs / 0 MORPHINE SULFATE ORAL SOL NUCYNTA ER 50mg, 100mg QL (120 tabs / 0 NUCYNTA ER 150mg, 200mg, 250mg QL (60 tabs / 0 OPANA ER (CRUSH RESISTANT QL (120 tabs / 0 oxycodone hcl CAPS QL (180 caps / 0 oxycodone hcl CONC OXYCODONE HCL SOLN oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 0mg QL (180 tabs / 0 oxycodone hcl TABS 10mg, 20mg QL (180 tabs / 0 oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen 5-25mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen 10-25mg (generic of PERCOCET) QL (60 tabs / 0 OXYCONTIN QL (120 tabs / 0 roxicet soln QL (1800 ml / 0 roxicet tab 5-25mg (generic of PERCOCET) QL (60 tabs / 0 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE-MPF) 1% lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE).5% lidocaine inj 0.5% (generic of B/D XYLOCAINE-MPF) lidocaine inj 1% (generic of B/D XYLOCAINE) lidocaine inj 1.5% (generic of B/D XYLOCAINE-MPF) lidocaine inj 2% (generic of B/D XYLOCAINE) ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS tobramycin (generic of TOBI) 5 B/D NM NEBU tobramycin inj 1.2/0ml tobramycin inj 1.2gm tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/2ml tobramycin sulfate in saline ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ALINIA atovaquone (generic of 5 NM MEPRON) SUSP AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM 5 NM 9

12 aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON 5 NM LA PA clindamycin cap 75mg 2 GC (generic of CLEOCIN) clindamycin cap 00mg 2 GC (generic of CLEOCIN) clindamycin hcl cap 150 mg 2 GC (generic of CLEOCIN) clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) clindamycin phosphate inj 150mg/ml clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) 150mg/ml, 00mg/2ml, 600mg/ml, 900mg/6ml, 9000mg/60ml clindamycin sol 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR CUBICIN 5 NM dapsone TABS DARAPRIM imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) 5 NM SOLN LINEZOLID TABS 5 NM meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of 2 GC FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal PA (generic of MACRODANTIN) 90 day limit per calendar year if 65 years and older; HR nitrofurantoin monohyd macro PA (generic of MACROBID) 90 day limit per calendar year if 65 years and older; HR PENTAM 00 SIVEXTRO 5 NM sulfamethoxazole-trimethopri m inj sulfamethoxazole-trimethopri m susp sulfamethoxazole-trimethopri 2 GC m tab (generic of BACTRIM) sulfamethoxazole-trimethopri 2 GC m tab (generic of BACTRIM DS) SYNERCID 5 NM trimethoprim TABS 2 GC TYGACIL 5 NM vancomycin hcl (generic of VANCOCIN HCL) CAPS 5 NM vancomycin hcl SOLR ZYVOX SUSR; TABS 5 NM ANTIFUNGALS ABELCET 5 B/D NM AMBISOME 5 B/D NM amphotericin b SOLR B/D CANCIDAS 5 NM fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose fluconazole inj nacl 200 fluconazole inj nacl 00 2 GC flucytosine (generic of 5 NM ANCOBON) CAPS griseofulvin microsize SUSP griseofulvin microsize (generic of GRIFULVIN V) TABS 10

13 Drug Tier Requirements/ Limits griseofulvin ultramicrosize (generic of GRIS-PEG) itraconazole (generic of PA SPORANOX) CAPS ketoconazole TABS PA MYCAMINE 5 NM NOXAFIL SUSP; TBEC 5 NM nystatin TABS terbinafine hcl (generic of 2 GC QL LAMISIL) TABS QL (90 tabs / 65 voriconazole (generic of VFEND IV) SOLR voriconazole (generic of 5 NM VFEND) SUSR; TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS 250mg chloroquine phosphate (generic of ARALEN) TABS 500mg COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate (generic of PA QUALAQUIN) CAPS ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) APTIVUS 5 NM CRIXIVAN didanosine (generic of VIDEX EC) EDURANT 5 NM EMTRIVA FUZEON 5 NM INTELENCE 25mg INTELENCE 100mg, 200mg 5 NM INVIRASE 5 NM ISENTRESS CHEW 25mg ISENTRESS CHEW 100mg 5 NM ISENTRESS PACK ISENTRESS TABS 5 NM lamivudine (generic of EPIVIR) LEXIVA NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200mg (generic of VIRAMUNE) nevirapine tb2 (generic of VIRAMUNE XR) NORVIR PREZISTA SUSP 5 NM PREZISTA TABS 75mg, 150mg PREZISTA TABS 600mg, 5 NM 800mg RESCRIPTOR RETROVIR IV INFUSION REYATAZ 5 NM SELZENTRY 5 NM stavudine (generic of ZERIT) SUSTIVA CAPS SUSTIVA TABS 5 NM TIVICAY 5 NM TYBOST VIDEX PEDIATRIC VIRACEPT 5 NM VIRAMUNE XR 100mg VIREAD 5 NM VITEKTA 5 NM ZIAGEN SOLN zidovudine (generic of RETROVIR) CAPS; SYRP zidovudine TABS ANTIRETROVIRAL COMBINATION AGENTS abacavir 5 NM sulfate-lamivudine-zidovudine (generic of TRIZIVIR) ATRIPLA 5 NM COMPLERA 5 NM EPZICOM 5 NM EVOTAZ 5 NM KALETRA SOL 5 NM KALETRA TAB MG 11

14 KALETRA TAB MG 5 NM lamivudine-zidovudine 5 NM (generic of COMBIVIR) PREZCOBIX 5 NM STRIBILD 5 NM TRIUMEQ 5 NM TRUVADA 5 QL NM ANTITUBERCULAR AGENTS CAPASTAT SULFATE cycloserine CAPS 5 NM ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS 2 GC isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml paser d/r PRIFTIN pyrazinamide rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO 5 NM LA PA TRECATOR ANTIVIRALS acyclovir (generic of 2 GC ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium SOLN B/D acyclovir sodium SOLR B/D 500mg adefovir dipivoxil (generic of 5 NM HEPSERA) BARACLUDE SOLN entecavir (generic of 5 NM BARACLUDE) EPIVIR HBV SOLN famciclovir (generic of FAMVIR) TABS foscarnet sodium ganciclovir inj 500mg (generic B/D of CYTOVENE) HARVONI 5 NM PA lamivudine (hbv) (generic of EPIVIR HBV) moderiba 800 dose pack 5 NM moderiba pak 600/day 5 NM moderiba pak 1000/day 5 NM MODERIBA PAK 1200/DAY 5 NM moderiba tab 200mg (generic NM of COPEGUS) PEG-INTRON 5 NM PA PEG-INTRON REDIPEN 5 NM PA PEGINTRON 80mcg/0.5ml, 5 NM PA 120mcg/0.5ml, 150mcg/0.5ml REBETOL SOL 0MG/ML 5 NM RELENZA DISKHALER ribapak mis 600/day 5 NM ribasphere (generic of NM REBETOL) CAPS ribasphere (generic of NM COPEGUS) TABS 200mg ribasphere TABS 00mg NM ribasphere TABS 600mg 5 NM ribasphere ribapak NM ribasphere ribapak NM ribasphere ribapak NM ribavirin cap 200mg (generic NM of REBETOL) ribavirin tab 200mg (generic NM of COPEGUS) rimantadine hydrochloride (generic of FLUMADINE) SOVALDI 5 NM PA TAMIFLU TYZEKA valacyclovir hcl (generic of VALTREX) TABS VALCYTE SOLR 5 NM valganciclovir hcl (generic of 5 NM VALCYTE) CEPHALOSPORINS cefaclor CAPS cefaclor SUSR 12

15 cefaclor er tab 500mg cefadroxil CAPS 2 GC cefadroxil SUSR cefadroxil TABS cefazolin in d5w cefazolin inj cefazolin sodium 1gm, 20gm cefdinir CAPS cefdinir SUSR cefepime hcl (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium (generic of CLAFORAN) 1gm, 2gm, 500mg cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime (generic of FORTAZ) 1gm, 2gm, 6gm CEFTAZIDIME/DEXTROSE ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm, 500mg cefuroxime axetil (generic of CEFTIN) cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg cefuroxime sodium 7.5gm cephalexin (generic of 2 GC KEFLEX) CAPS 250mg, 500mg cephalexin SUSR SUPRAX CAPS suprax CHEW SUPRAX SUSR 500mg/5ml tazicef (generic of FORTAZ) SOLR tazicef vial (generic of FORTAZ) TEFLARO Drug Tier Requirements/ Limits ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK azithromycin (generic of ZITHROMAX) SOLR 500mg azithromycin (generic of ZITHROMAX) SUSR azithromycin (generic of 2 GC ZITHROMAX) TABS clarithromycin (generic of BIAXIN) TABS clarithromycin er (generic of BIAXIN XL) clarithromycin for susp 125mg/5ml clarithromycin for susp (generic of BIAXIN) 250mg/5ml DIFICID 5 NM e.e.s. 00mg tab ery-tab erythrocin lactobionate 500mg erythrocin stearate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate FLUOROQUINOLONES ciprofloxacin (generic of CIPRO) SUSR ciprofloxacin er (generic of CIPRO XR) ciprofloxacin hcl tab 100mg, 2 GC 750mg ciprofloxacin hcl tab (generic 2 GC of CIPRO) 250mg, 500mg ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W) ciprofloxacin inj levofloxacin (generic of 2 GC LEVAQUIN) TABS levofloxacin in d5w levofloxacin in d5w (generic of LEVAQUIN) levofloxacin inj 25mg/ml 1

16 Drug Tier levofloxacin oral soln 25 mg/ml (generic of LEVAQUIN) Requirements/ Limits PENICILLINS amoxicillin 2 GC amoxicillin & pot clavulanate CHEW amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW amoxicillin & pot clavulanate SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR amoxicillin & pot clavulanate TABS amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) 2 GC 2 GC ampicillin cap 2 GC ampicillin inj ampicillin sodium ampicillin susp BICILLIN L-A dicloxacillin sodium nafcillin sodium 1gm nafcillin sodium 2gm, 10gm 5 NM oxacillin sodium 1gm, 2gm oxacillin sodium 10gm 5 NM PENICILLIN G POT IN DEXTROSE penicillin g procaine penicillin g sodium penicillin v potassium 2 GC penicilln gk inj 5mu penicilln gk inj 20mu piperacillin sodium-tazobactam sodium (generic of ZOSYN) TETRACYCLINES doxy doxycycline (monohydrate) 2 GC CAPS 50mg doxycycline (monohydrate) 2 GC (generic of MONODOX) CAPS 100mg doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg doxycycline (monohydrate) (generic of ADOXA PAK 1/150) TABS 150mg doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate TABS minocycline hcl (generic of 2 GC MINOCIN) CAPS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU B/D BUSULFEX 5 B/D NM CYCLOPHOSPHAMIDE B/D CAPS cyclophosphamide SOLR 5 B/D NM 1gm, 500mg cyclophosphamide SOLR B/D 2gm dacarbazine 200mg B/D EMCYT HEXALEN 5 NM IFEX gm B/D ifosfamide inj 1gm (generic of IFEX) B/D 1

17 ifosfamide inj 1gm/20ml B/D (generic of IFOSFAMIDE) IFOSFAMIDE INJ GM B/D ifosfamide inj gm/60ml B/D (generic of IFOSFAMIDE) LEUKERAN LOMUSTINE melphalan hcl (generic of 5 B/D NM ALKERAN) MUSTARGEN B/D TREANDA 5 B/D NM ANTHRACYCLINES adriamycin B/D daunorubicin hcl B/D doxorubicin hcl for inj 50 mg B/D doxorubicin hcl inj 2 mg/ml B/D doxorubicin hcl liposomal 5 B/D NM (generic of DOXIL) epirubicin hcl (generic of B/D ELLENCE) idarubicin hcl (generic of 5 B/D NM IDAMYCIN PFS) ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR B/D ANTIMETABOLITES adrucil B/D ALIMTA 5 B/D NM azacitidine (generic of 5 B/D NM VIDAZA) cladribine 5 B/D NM cytarabine 20mg/ml B/D fludarabine phosphate B/D SOLN fludarabine phosphate B/D (generic of FLUDARA) SOLR fluorouracil SOLN B/D GEMCITABINE HCL SOLN 5 B/D NM gemcitabine hcl (generic of 5 B/D NM GEMZAR) SOLR 1gm, 200mg gemcitabine hcl SOLR 2gm 5 B/D NM mercaptopurine TABS methotrexate sodium inj B/D Drug Tier Requirements/ Limits NIPENT 5 B/D NM PURIXAN 5 NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D NM DOCETAXEL CONC 5 B/D NM 20mg/ml, 80mg/ml docetaxel CONC 10mg/7ml 5 B/D NM DOCETAXEL SOLN 5 B/D NM 80mg/8ml, 200mg/20ml paclitaxel B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar B/D vincristine sulfate B/D vinorelbine tartrate (generic of B/D NAVELBINE) BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 B/D NM LA BELEODAQ 5 NM PA ERIVEDGE 5 NM LA PA FARYDAK 5 NM LA PA HERCEPTIN 5 B/D NM IBRANCE 5 NM LA PA ISTODAX 5 B/D NM KADCYLA 5 B/D NM KEYTRUDA 5 NM PA LYNPARZA 5 NM LA PA PROLEUKIN 5 B/D NM RITUXAN 5 NM LA PA VELCADE 5 B/D NM YERVOY 5 NM PA ZOLINZA 5 NM PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of 2 GC ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D exemestane (generic of AROMASIN) FARESTON 5 NM FASLODEX 5 B/D NM flutamide 15

18 letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0.2 NM PA LUPRON DEP-PED INJ 5 NM PA 0MG (-MONTH) LUPRON DEPO INJ 11.25MG 5 NM PA (-MONTH) LUPRON DEPOT.75mg 5 NM PA LUPRON DEPOT-PED 5 NM PA LYSODREN MEGACE ES 5 NM PA HR megestrol acetate (generic of PA MEGACE ORAL) SUSP 0mg/ml PA if 65 years and older; HR megestrol acetate TABS PA PA if 65 years and older; HR NILANDRON 5 NM SOLTAMOX tamoxifen citrate TABS 1 GC TRELSTAR DEP INJ.75MG 5 NM PA TRELSTAR LA INJ 11.25MG 5 NM PA XTANDI 5 NM LA PA ZYTIGA 5 NM LA PA KINASE INHIBITORS AFINITOR 5 NM PA AFINITOR DISPERZ 5 NM PA BOSULIF 5 NM PA CAPRELSA 5 NM LA PA COMETRIQ 5 NM LA PA GILOTRIF TAB 20MG 5 NM LA PA GILOTRIF TAB 0MG 5 NM LA PA GILOTRIF TAB 0MG 5 NM LA PA GLEEVEC 5 NM PA ICLUSIG 5 NM LA PA IMBRUVICA CAP 10MG 5 NM LA PA INLYTA 5 NM LA PA JAKAFI 5 NM LA PA LENVIMA 10MG DAILY 5 NM LA PA DOSE LENVIMA 1MG DAILY DOSE 5 NM LA PA LENVIMA 20MG DAILY 5 NM LA PA DOSE LENVIMA 2MG DAILY 5 NM LA PA DOSE MEKINIST 5 NM LA PA NEXAVAR 5 NM LA PA SPRYCEL 5 NM PA STIVARGA 5 NM LA PA SUTENT 5 NM PA TAFINLAR 5 NM LA PA TARCEVA 5 NM LA PA TASIGNA 5 NM PA TYKERB 5 NM LA PA VOTRIENT 5 NM LA PA XALKORI 5 NM LA PA ZELBORAF 5 NM LA PA ZYDELIG 5 NM LA PA ZYKADIA 5 NM LA PA MISCELLANEOUS DROXIA hydroxyurea (generic of HYDREA) CAPS MATULANE 5 NM LA mitoxantrone hcl B/D NM POMALYST CAP 1MG 5 NM LA PA POMALYST CAP 2MG 5 NM LA PA POMALYST CAP MG 5 NM LA PA POMALYST CAP MG 5 NM LA PA SYLATRON KIT 200MCG 5 NM PA SYLATRON KIT 00MCG 5 NM PA SYLATRON KIT 600MCG 5 NM PA SYNRIBO 5 NM PA TARGRETIN CAPS 5 NM PA tretinoin (chemotherapy) 5 NM TRISENOX 5 B/D NM PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin 5 B/D NM PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL) 5 B/D NM dexrazoxane (generic of 5 B/D NM ZINECARD) 250mg ELITEK 5 B/D NM 16

19 FUSILEV 5 B/D NM leucovorin calcium SOLR B/D leucovorin calcium TABS leucovorin calcium for inj 500 B/D mg levoleucovorin calcium 5 B/D NM mesna (generic of MESNEX) B/D MESNEX TABS 5 NM TOPOISOMERASE INHIBITORS etoposide SOLN B/D 500mg/25ml irinotecan hcl (generic of B/D CAMPTOSAR) 0mg/2ml, 100mg/5ml irinotecan hcl 500mg/25ml B/D toposar 1gm/50ml B/D topotecan hcl (generic of 5 B/D NM HYCAMTIN) SOLR CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine 2 GC QL besylate-benazepril hcl cap mg (generic of LOTREL) QL (0 caps / 0 amlodipine 2 GC QL besylate-benazepril hcl cap 5-10 mg (generic of LOTREL) QL (0 caps / 0 amlodipine 2 GC QL besylate-benazepril hcl cap 5-20 mg (generic of LOTREL) QL (0 caps / 0 amlodipine 2 GC QL besylate-benazepril hcl cap 5-0 mg QL (0 caps / 0 amlodipine 2 GC QL besylate-benazepril hcl cap mg (generic of LOTREL) QL (0 caps / 0 amlodipine besylate-benazepril hcl cap 10-0 mg (generic of LOTREL) 2 GC benazepril & 2 GC hydrochlorothiazide benazepril & 2 GC hydrochlorothiazide (generic of LOTENSIN HCT) captopril & 2 GC hydrochlorothiazide enalapril maleate & 2 GC hydrochlorothiazide enalapril maleate & 2 GC hydrochlorothiazide (generic of VASERETIC) fosinopril sodium & 2 GC hydrochlorothiazide lisinopril & 1 GC hydrochlorothiazide (generic of ZESTORETIC) moexipril-hydrochlorothiazide 2 GC quinapril-hydrochlorothiazide 2 GC (generic of ACCURETIC) ACE INHIBITORS benazepril hcl TABS 5mg 1 GC benazepril hcl (generic of 1 GC LOTENSIN) TABS 10mg, 20mg, 0mg captopril TABS 2 GC enalapril maleate (generic of 2 GC VASOTEC) TABS fosinopril sodium 2 GC lisinopril (generic of ZESTRIL) 1 GC TABS 2.5mg, 0mg, 0mg lisinopril (generic of PRINIVIL) 1 GC TABS 5mg, 10mg, 20mg moexipril hcl 2 GC perindopril erbumine 2mg 2 GC perindopril erbumine (generic 2 GC of ACEON) mg, 8mg quinapril hcl (generic of 2 GC ACCUPRIL) ramipril (generic of ALTACE) 2 GC trandolapril (generic of 2 GC MAVIK) ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) 17

20 spironolactone (generic of 1 GC ALDACTONE) TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) 1mg, 2mg, mg doxazosin mesylate (generic of CARDURA) 8mg prazosin hcl (generic of 2 GC MINIPRESS) terazosin hcl 2 GC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan 2 GC QL tab mg (generic of EXFORGE) amlodipine besylate-valsartan 2 GC QL tab 5-20 mg (generic of EXFORGE) amlodipine besylate-valsartan 2 GC QL tab mg (generic of EXFORGE) amlodipine besylate-valsartan 2 GC tab mg (generic of EXFORGE) amlodipine-valsartan-hctz tab 2 GC QL mg (generic of EXFORGE HCT) amlodipine-valsartan-hctz tab 2 GC QL mg (generic of EXFORGE HCT) QL (60 tabs / 0 amlodipine-valsartan-hctz tab 2 GC QL mg (generic of EXFORGE HCT) amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) 2 GC QL amlodipine-valsartan-hctz tab 2 GC mg (generic of EXFORGE HCT) AZOR TAB 5-20MG AZOR TAB 5-0MG AZOR TAB 10-20MG AZOR TAB 10-0MG BENICAR HCT 0-25MG BENICAR HCT TAB MG BENICAR HCT TAB MG losartan potassium & hctz tab 2 GC mg (generic of HYZAAR) losartan potassium & hctz tab 2 GC mg (generic of HYZAAR) losartan potassium & hctz tab 2 GC mg (generic of HYZAAR) TRIBENZOR TAB MG TRIBENZOR TAB MG TRIBENZOR TAB MG TRIBENZOR TAB TRIBENZOR TAB MG valsartan & hctz tab 2 GC mg (generic of DIOVAN HCT) valsartan & hctz tab 2 GC mg (generic of DIOVAN HCT) valsartan & hctz tab mg (generic of DIOVAN HCT) 2 GC 18

21 valsartan & hctz tab mg (generic of DIOVAN HCT) valsartan & hctz tab 20-25mg (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2 GC 2 GC losartan potassium (generic of 1 GC COZAAR) valsartan (generic of 2 GC DIOVAN) ANTIARRHYTHMICS amiodarone hcl soln amiodarone tab 100mg amiodarone tab 200mg 2 GC (generic of CORDARONE) amiodarone tab 00mg disopyramide phosphate PA (generic of NORPACE) PA if 65 years and older; HR flecainide acetate mexiletine hcl MULTAQ NORPACE CR PA PA if 65 years and older; HR pacerone 100mg, 00mg pacerone (generic of 2 GC CORDARONE) 200mg propafenone hcl (generic of RYTHMOL SR) CP12 propafenone hcl (generic of RYTHMOL) TABS 150mg, 225mg propafenone hcl TABS 00mg quinidine gluconate TBCR quinidine sulfate TABS 2 GC sorine (generic of 2 GC BETAPACE) 80mg, 120mg, 160mg sorine 20mg 2 GC sotalol hcl (generic of 2 GC BETAPACE) 80mg, 120mg, 160mg sotalol hcl 20mg 2 GC sotalol hcl (afib/afl) (generic of BETAPACE AF) TIKOSYN CAP 125MCG NM TIKOSYN CAP 250MCG NM TIKOSYN CAP 500MCG NM ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) TABS CRESTOR lovastatin 10mg lovastatin 20mg QL (120 tabs / 0 lovastatin (generic of MEVACOR) 0mg QL (60 tabs / 0 pravastatin sodium 10mg pravastatin sodium (generic of PRAVACHOL) 20mg, 0mg, 80mg simvastatin (generic of ZOCOR) TABS 1 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 1 GC QL ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light choline fenofibrate cap dr 5 mg (generic of TRILIPIX) choline fenofibrate cap dr 15 mg (generic of TRILIPIX) colestipol hcl (generic of COLESTID) GRAN; PACK colestipol hcl (generic of COLESTID) TABS 19

22 fenofibrate (generic of TRICOR) TABS 8mg, 15mg fenofibrate (generic of LOFIBRA) TABS 5mg, 160mg fenofibrate micronized (generic of LOFIBRA) 67mg, 1mg, 200mg Drug Tier Requirements/ Limits gemfibrozil (generic of LOPID) 2 GC TABS JUXTAPID 5 NM LA PA KYNAMRO 5 NM PA niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg QL (90 tabs / 0 niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg niacor omega--acid ethyl esters (generic of LOVAZA) prevalite (generic of QUESTRAN LIGHT) VASCEPA WELCHOL ZETIA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50) atenolol & chlorthalidone (generic of TENORETIC 100) bisoprolol & hydrochlorothiazide (generic of ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS 2 GC 2 GC atenolol (generic of 1 GC TENORMIN) TABS bisoprolol fumarate (generic of ZEBETA) BYSTOLIC carvedilol (generic of 2 GC COREG) labetalol hcl (generic of TRANDATE) TABS metoprolol succinate (generic 2 GC QL of TOPROL XL) 25mg, 50mg QL (60 tabs / 0 metoprolol succinate (generic 2 GC QL of TOPROL XL) 100mg QL (5 tabs / 0 metoprolol succinate (generic 2 GC of TOPROL XL) 200mg metoprolol tartrate SOLN metoprolol tartrate TABS 1 GC 25mg metoprolol tartrate (generic of 1 GC LOPRESSOR) TABS 50mg, 100mg pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl SOLN 1mg/ml propranolol hcl SOLN 20mg/5ml, 0mg/5ml propranolol hcl TABS 2 GC timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC) 0mg QL (60 tabs / 0 afeditab cr (generic of ADALAT CC) 60mg amlodipine besylate (generic 1 GC of NORVASC) TABS cartia xt (generic of CARDIZEM CD) dilt-xr cap 20

23 Drug Tier diltiazem cap (generic of TIAZAC) diltiazem cap 120mg/2hr diltiazem cap er/12hr diltiazem hcl SOLN Requirements/ Limits diltiazem hcl (generic of 2 GC CARDIZEM) TABS 0mg, 60mg, 120mg diltiazem hcl TABS 90mg 2 GC diltiazem hcl coated beads (generic of CARDIZEM CD) CP2 diltzac cap 120mg/2 (generic of TIAZAC) diltzac cap 180mg/2 (generic of TIAZAC) diltzac cap 20mg/2 (generic of TIAZAC) diltzac cap 00mg/2 (generic of TIAZAC) felodipine 2.5mg felodipine 5mg QL (60 tabs / 0 felodipine 10mg isradipine nicardipine hcl CAPS nifedical (generic of PROCARDIA XL) 0mg nifedical (generic of PROCARDIA XL) 60mg nifedipine (generic of ADALAT CC) TB2 0mg QL (60 tabs / 0 nifedipine (generic of ADALAT CC) TB2 60mg, 90mg nifedipine er (generic of PROCARDIA XL) 0mg nifedipine er (generic of PROCARDIA XL) 60mg, 90mg nimodipine CAPS 5 NM NYMALIZE 5 NM taztia (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 100mg, 200mg, 00mg verapamil cap er (generic of VERELAN) 120mg, 180mg, 20mg VERAPAMIL CAP ER 60mg verapamil hcl SOLN verapamil hcl TABS 0mg 2 GC verapamil hcl (generic of 2 GC CALAN) TABS 80mg, 120mg verapamil tab er (generic of 2 GC CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) PA.25mg PA if 65 years and older; HR digitek (generic of LANOXIN).125mg HR (doses > mg/day) digoxin (generic of LANOXIN) 125mcg HR (doses > mg/day) digoxin (generic of LANOXIN) PA 250mcg PA if 65 years and older; HR digoxin inj (generic of LANOXIN) HR (doses > mg/day) DIGOXIN SOL 50MCG/ML PA PA if 65 years and older; HR DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 150mg TEKTURNA 00mg 21

24 TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG QL (60 tabs / 0 TEKTURNA HCT TAB MG TEKTURNA HCT TAB 00-25MG DIURETICS acetazolamide (generic of DIAMOX) CP12 acetazolamide TABS amiloride & 2 GC hydrochlorothiazide amiloride hcl bumetanide SOLN bumetanide TABS chlorothiazide tabs chlorthalidone 25mg, 50mg furosemide SOLN 2 GC furosemide (generic of LASIX) 1 GC TABS furosemide inj 10mg/ml FUROSEMIDE INJ 10mg/ml hydrochlorothiazide (generic 1 GC of MICROZIDE) CAPS hydrochlorothiazide TABS 1 GC indapamide 2 GC methazolamide (generic of NEPTAZANE) TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide inj torsemide tabs (generic of 2 GC DEMADEX) 5mg, 10mg, 20mg torsemide tabs 100mg 2 GC triamterene & 1 GC hydrochlorothiazide (generic of MAXZIDE) TABS triamterene & 1 GC hydrochlorothiazide (generic of MAXZIDE-25) TABS triamterene & 2 GC hydrochlorothiazide cap mg (generic of DYAZIDE) MISCELLANEOUS BIDIL clonidine hcl (generic of CATAPRES-TTS-1) PTWK.1mg/2hr clonidine hcl (generic of CATAPRES-TTS-2) PTWK.2mg/2hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/2hr clonidine hcl (generic of 2 GC CATAPRES) TABS DEMSER 5 NM hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS RANEXA NITRATES isosorb mononitrate tab 2 GC isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 20mg, 0mg isosorbide dinitrate er isosorbide mononitrate er 2 GC minitran (generic of NITRO-DUR) nitro-bid NITRO-DUR DIS 0.MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin td patch 2hr 0.1 mg/hr 22

25 Drug Tier nitroglycerin td patch 2hr 0.2 mg/hr nitroglycerin td patch 2hr 0. mg/hr nitroglycerin td patch 2hr 0.6 mg/hr NITROSTAT PULMONARY ARTERIAL HYPERTENSION ADEMPAS QL (90 tabs / 0 LETAIRIS OPSUMIT REMODULIN REVATIO SUSR QL (22 ml / 0 sildenafil citrate (pulmonary hypertension) (generic of REVATIO) TABS QL (90 tabs / 0 Requirements/ Limits 5 QL NM LA PA 5 QL NM LA PA 5 QL NM LA PA 5 B/D NM LA 5 QL NM PA NM PA TRACLEER 62.5mg 5 QL NM LA PA QL (120 tabs / 0 TRACLEER 125mg 5 QL NM LA PA QL (60 tabs / 0 CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX) 2 GC QL QL (20 tabs / 0 alprazolam tab 0.25mg 2 GC QL (generic of XANAX) QL (80 tabs / 0 alprazolam tab 1mg (generic 2 GC QL of XANAX) QL (120 tabs / 0 alprazolam tab 2 mg (generic 2 GC QL of XANAX) QL (150 tabs / 0 buspirone hcl TABS fluvoxamine maleate TABS 25mg, 50mg QL (5 tabs / 0 fluvoxamine maleate TABS 100mg lorazepam CONC QL (150 ml / 0 lorazepam (generic of ATIVAN) SOLN lorazepam (generic of 2 GC QL ATIVAN) TABS QL (150 tabs / 0 ANTICONVULSANTS APTIOM 200mg QL (180 tabs / 0 APTIOM 00mg QL (90 tabs / 0 APTIOM 600mg QL (60 tabs / 0 APTIOM 800mg BANZEL SUS 0MG/ML PA BANZEL TAB 200MG PA BANZEL TAB 00MG PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP12 carbamazepine (generic of TEGRETOL) SUSP carbamazepine (generic of TEGRETOL) TABS carbamazepine (generic of TEGRETOL-XR) TB12 CELONTIN clonazepam (generic of 2 GC QL KLONOPIN) TABS 1mg QL (120 tabs / 0 clonazepam (generic of 2 GC QL KLONOPIN) TABS 2mg QL (00 tabs / 0 clonazepam (generic of 2 GC QL KLONOPIN) TABS.5mg QL (20 tabs / 0 clonazepam TBDP 1mg QL (120 tabs / 0 clonazepam TBDP 2mg QL (00 tabs / 0 clonazepam TBDP.5mg QL (20 tabs / 0 clonazepam TBDP.25mg QL (80 tabs / 0 2

26 clonazepam TBDP.125mg QL (960 tabs / 0 clorazepate dipotassium 2 GC QL PA (generic of TRANXENE T).75mg, 7.5mg QL (120 tabs / 0 clorazepate dipotassium 2 GC QL PA (generic of TRANXENE T) 15mg QL (180 tabs / 0 diazepam CONC PA QL (20 ml / 0 diazepam SOLN PA QL (1200 ml / 0 diazepam (generic of 2 GC QL PA VALIUM) TABS QL (120 tabs / 0 DIAZEPAM GEL (ANTICONVULSANT) diazepam inj dilantin DILANTIN-125 SUS 125/5ML divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP divalproex sodium (generic of DEPAKOTE ER) TB2 divalproex sodium (generic of DEPAKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of 5 NM FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOMPA 2mg PA QL (180 tabs / 0 FYCOMPA mg PA QL (90 tabs / 0 FYCOMPA 6mg PA QL (60 tabs / 0 FYCOMPA 8mg, 10mg, 12mg PA gabapentin (generic of 2 GC QL NEURONTIN) CAPS 100mg QL (1080 caps / 0 gabapentin (generic of 2 GC QL NEURONTIN) CAPS 00mg QL (60 caps / 0 gabapentin (generic of 2 GC QL NEURONTIN) CAPS 00mg QL (270 caps / 0 gabapentin (generic of NEURONTIN) SOLN QL (2160 ml / 0 gabapentin (generic of 2 GC QL NEURONTIN) TABS 600mg QL (180 tabs / 0 gabapentin (generic of 2 GC QL NEURONTIN) TABS 800mg QL (120 tabs / 0 GABITRIL 12mg, 16mg lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of 2 GC LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB2 levetiracetam (generic of KEPPRA) TABS levetiracetam (generic of KEPPRA XR) TB2 levetiracetam inj (generic of KEPPRA) LEVETIRACETAM IV levetiracetam sol 100mg/ml (generic of KEPPRA) LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg QL (120 caps / 0 LYRICA CAPS 200mg QL (90 caps / 0 LYRICA CAPS 225mg, 00mg QL (60 caps / 0 LYRICA SOLN QL (96 ml / 0 2

27 ONFI SOLN PA ONFI TAB PA oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS PA PA if 65 years and older; HR PHENOBARBITAL SODIUM PA 65mg/ml PA if 65 years and older; HR phenobarbital sodium PA 10mg/ml PA if 65 years and older; HR phenytek phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-125) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 100mg phenytoin sodium extended 200mg, 00mg POTIGA 50mg POTIGA 200mg QL (180 tabs / 0 POTIGA 00mg, 00mg QL (90 tabs / 0 primidone (generic of MYSOLINE) TABS SABRIL PACK 5 QL NM LA PA QL (180 packets / 0 SABRIL TABS 5 QL NM LA PA QL (180 tabs / 0 TEGRETOL TEGRETOL-XR tiagabine hcl (generic of GABITRIL) topiramate (generic of TOPAMAX SPRINKLE) CPSP topiramate (generic of TOPAMAX) TABS Drug Tier Requirements/ Limits valproate sodium (generic of DEPACON) SOLN valproate sodium (generic of 2 GC DEPAKENE) SYRP valproic acid (generic of DEPAKENE) CAPS VIMPAT SOLN 10mg/ml QL (1200 ml / 0 VIMPAT SOLN 200mg/20ml VIMPAT TABS 50mg QL (180 tabs / 0 VIMPAT TABS 100mg, 150mg, 200mg QL (60 tabs / 0 zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg zonisamide CAPS 50mg ANTIDEMENTIA donepezil hydrochloride (generic of ARICEPT) TABS 5mg donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS 2mg donepezil hydrochloride TBDP 5mg donepezil hydrochloride TBDP 10mg EXELON PATCHES QL (0 patches / 0 galantamine hydrobromide (generic of RAZADYNE ER) CP2 8mg, 16mg QL (0 caps / 0 2 GC QL 2 GC 25

28 galantamine hydrobromide (generic of RAZADYNE ER) CP2 2mg galantamine hydrobromide SOLN galantamine hydrobromide (generic of RAZADYNE) TABS mg QL (180 tabs / 0 galantamine hydrobromide (generic of RAZADYNE) TABS 8mg QL (90 tabs / 0 galantamine hydrobromide (generic of RAZADYNE) TABS 12mg memantine hcl (generic of NAMENDA) PA if < 0 yrs NAMENDA SOL 10MG/5ML PA if < 0 yrs NAMENDA TAB PA if < 0 yrs NAMENDA XR PA if < 0 yrs NAMENDA XR TITRATION PACK PA if < 0 yrs rivastigmine tartrate (generic of EXELON) ANTIDEPRESSANTS amitriptyline hcl TABS PA if 65 years and older; HR Drug Tier Requirements/ Limits PA PA PA PA PA PA amoxapine BRINTELLIX 5mg QL (120 tabs / 0 BRINTELLIX 10mg QL (60 tabs / 0 BRINTELLIX 20mg bupropion hcl (generic of WELLBUTRIN) TABS bupropion hcl (generic of WELLBUTRIN SR) TB12 bupropion hcl (generic of WELLBUTRIN XL) TB2 150mg QL (90 tabs / 0 bupropion hcl (generic of WELLBUTRIN XL) TB2 00mg citalopram hydrobromide SOLN citalopram hydrobromide (generic of CELEXA) TABS 10mg, 20mg QL (5 tabs / 0 citalopram hydrobromide (generic of CELEXA) TABS 0mg clomipramine hcl (generic of ANAFRANIL) CAPS PA if 65 years and older; HR desipramine hcl (generic of NORPRAMIN) TABS doxepin hcl CAPS; CONC PA if 65 years and older; HR duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 0mg, 60mg QL (60 caps / 0 EMSAM QL (0 patches / 0 escitalopram oxalate (generic of LEXAPRO) SOLN QL (600 ml / 0 escitalopram oxalate (generic of LEXAPRO) TABS 5mg, 10mg QL (5 tabs / 0 escitalopram oxalate (generic of LEXAPRO) TABS 20mg QL (60 tabs / 0 FETZIMA 20mg QL (180 caps / 0 1 GC QL 1 GC QL PA PA 5 QL NM PA 26

29 FETZIMA 0mg QL (90 caps / 0 FETZIMA 80mg, 120mg QL (0 caps / 0 FETZIMA TITRATION PACK fluoxetine hcl (generic of 1 GC QL PROZAC) CAPS 10mg QL (0 caps / 0 fluoxetine hcl (generic of 1 GC QL PROZAC) CAPS 20mg QL (120 caps / 0 fluoxetine hcl (generic of 1 GC PROZAC) CAPS 0mg fluoxetine hcl SOLN fluoxetine hcl TABS 10mg QL (5 tabs / 0 fluoxetine hcl TABS 20mg imipramine hcl (generic of PA TOFRANIL) TABS PA if 65 years and older; HR maprotiline hcl MARPLAN TAB 10MG QL (180 tabs / 0 mirtazapine TABS 7.5mg 2 GC QL QL (5 tabs / 0 mirtazapine (generic of 2 GC QL REMERON) TABS 15mg QL (5 tabs / 0 mirtazapine (generic of 2 GC REMERON) TABS 0mg, 5mg mirtazapine (generic of REMERON SOLTAB) TBDP 15mg mirtazapine (generic of REMERON SOLTAB) TBDP 0mg, 5mg nefazodone hcl nortriptyline hcl (generic of 2 GC PAMELOR) CAPS nortriptyline hcl SOLN Tier Limits paroxetine hcl (generic of 1 GC QL PAXIL) TABS 10mg, 20mg, 0mg QL (5 tabs / 0 paroxetine hcl (generic of 1 GC QL PAXIL) TABS 0mg QL (60 tabs / 0 PAXIL SUSP QL (900 ml / 0 phenelzine sulfate (generic of NARDIL) TABS PRISTIQ protriptyline hcl sertraline hcl (generic of ZOLOFT) CONC sertraline hcl (generic of 1 GC QL ZOLOFT) TABS 25mg, 50mg QL (5 tabs / 0 sertraline hcl (generic of 1 GC ZOLOFT) TABS 100mg SURMONTIL CAP 25MG PA QL (20 caps / 0 PA if 65 years and older; HR SURMONTIL CAP 50MG PA QL (120 caps / 0 PA if 65 years and older; HR SURMONTIL CAP 100MG PA QL (60 caps / 0 PA if 65 years and older; HR tranylcypromine sulfate (generic of PARNATE) trazodone hcl TABS 50mg, 2 GC 100mg, 150mg venlafaxine hcl (generic of EFFEXOR XR) CP2 7.5mg, 75mg QL (0 caps / 0 venlafaxine hcl (generic of EFFEXOR XR) CP2 150mg QL (60 caps / 0 venlafaxine hcl TABS 27

30 VIIBRYD KIT VIIBRYD TABS ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; TABS amantadine hcl SYRP 2 GC APOKYN 5 NM LA PA AZILECT BENZTROPINE MESYLATE SOLN benztropine mesylate TABS PA PA if 65 years and older; HR bromocriptine mesylate (generic of PARLODEL) CAPS bromocriptine mesylate TABS carbidopa-levodopa (generic of SINEMET) TABS carbidopa-levodopa (generic of SINEMET CR) TBCR carbidopa-levodopa TBDP CARBIDOPA/LEVODOPA/EN TACAPONE CARBIDOPA/LEVODOPA/EN TACAPONE CARBIDOPA/LEVODOPA/EN TACAPONE CARBIDOPA/LEVODOPA/EN TACAPONE CARBIDOPA/LEVODOPA/EN TACAPONE CARBIDOPA/LEVODOPA/EN TACAPONE ENTACAPONE NEUPRO pramipexole dihydrochloride 2 GC (generic of MIRAPEX) TABS ropinirole hydrochloride (generic of REQUIP) TABS selegiline hcl (generic of ELDEPRYL) CAPS selegiline hcl TABS ANTIPSYCHOTICS ABILIFY DISC TAB 10MG QL (60 tabs / 0 ABILIFY MAINTENA QL (1 injection / 28 aripiprazole (generic of ABILIFY) chlorpromazine hcl SOLN; TABS clozapine (generic of CLOZARIL) TABS 100mg QL (270 tabs / 0 clozapine TABS 200mg QL (15 tabs / 0 CLOZAPINE TBDP 12.5mg, PA 25mg CLOZAPINE TBDP 100mg PA QL (270 tabs / 0 CLOZAPINE TBDP 150mg PA QL (180 tabs / 0 CLOZAPINE TBDP 200mg PA QL (15 tabs / 0 clozapine tab 25mg (generic of CLOZARIL) clozapine tab 50mg FANAPT ST QL (60 tabs / 0 FANAPT TITRATION PACK ST FAZACLO 150mg PA QL (180 tabs / 0 FAZACLO 200mg PA QL (15 tabs / 0 fluphenazine decanoate SOLN fluphenazine hcl CONC; ELIX; SOLN fluphenazine hcl TABS 2 GC GEODON SOLR QL (6 ml / haloperidol TABS haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml 28

31 haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml Drug Tier Requirements/ Limits haloperidol lactate conc haloperidol lactate inj 5mg/ml (generic of HALDOL) INVEGA 1.5mg, mg, 9mg INVEGA 6mg QL (60 tabs / 0 INVEGA SUST INJ 9MG/0.25ML QL (1 injection / 28 INVEGA SUST INJ 78MG/0.5ML QL (1 injection / 28 INVEGA SUST INJ 117MG/0.75ML QL (1 injection / 28 INVEGA SUST INJ 156MG/ML QL (1 injection / 28 INVEGA SUST INJ 2MG/1.5ML QL (1 injection / 28 LATUDA 20mg QL (20 tabs / 0 LATUDA 0mg, 120mg LATUDA 60mg, 80mg QL (60 tabs / 0 loxapine succinate olanzapine (generic of ZYPREXA) SOLR QL ( vials / 1 day) olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg QL (60 tabs / 0 olanzapine (generic of ZYPREXA ZYDIS) TBDP 5mg olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg, 15mg, 20mg QL (60 tabs / 0 ORAP perphenazine TABS quetiapine fumarate (generic of SEROQUEL) QL (90 tabs / 0 RISPERDAL INJ 12.5MG QL (2 injections / 28 RISPERDAL INJ 25MG QL (2 injections / 28 RISPERDAL INJ 7.5MG QL (2 injections / 28 RISPERDAL INJ 50MG QL (2 injections / 28 risperidone (generic of RISPERDAL) SOLN QL (20 ml / 0 risperidone (generic of RISPERDAL) TABS 1mg, 2mg, mg QL (60 tabs / 0 risperidone (generic of RISPERDAL) TABS mg QL (120 tabs / 0 risperidone (generic of RISPERDAL) TABS.25mg,.5mg QL (90 tabs / 0 29

32 risperidone (generic of RISPERDAL M-TAB) TBDP 1mg, 2mg, mg QL (60 tabs / 0 risperidone (generic of RISPERDAL M-TAB) TBDP mg QL (120 tabs / 0 risperidone (generic of RISPERDAL M-TAB) TBDP.5mg QL (90 tabs / 0 risperidone TBDP.25mg QL (90 tabs / 0 SAPHRIS 2.5mg QL (20 tabs / 0 SAPHRIS 5mg QL (120 tabs / 0 SAPHRIS 10mg QL (60 tabs / 0 SEROQUEL XR 50mg QL (120 tabs / 0 SEROQUEL XR 150mg, 200mg SEROQUEL XR 00mg, 00mg QL (60 tabs / 0 thioridazine hcl TABS PA PA if 65 years and older; HR thiothixene trifluoperazine hcl VERSACLOZ 5 QL NM PA QL (600 ml / 0 ziprasidone hcl (generic of GEODON) 20mg, 0mg QL (60 caps / 0 ziprasidone hcl (generic of GEODON) 60mg, 80mg QL (90 caps / 0 ZYPREXA RELPREVV 00mg QL (2 vials / 28 PA ZYPREXA RELPREVV 05mg QL (1 vial / 28 ZYPREXA RELPREVV 210MG QL (2 vials / 28 PA PA ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroampheta mine cap sr 2hr 5 mg (generic of ADDERALL XR) QL (90 caps / 0 amphetamine-dextroampheta mine cap sr 2hr 10 mg (generic of ADDERALL XR) QL (90 caps / 0 amphetamine-dextroampheta mine cap sr 2hr 15 mg (generic of ADDERALL XR) QL (0 caps / 0 amphetamine-dextroampheta mine cap sr 2hr 20 mg (generic of ADDERALL XR) QL (0 caps / 0 amphetamine-dextroampheta mine cap sr 2hr 25 mg (generic of ADDERALL XR) QL (0 caps / 0 amphetamine-dextroampheta mine cap sr 2hr 0 mg (generic of ADDERALL XR) QL (0 caps / 0 amphetamine-dextroampheta mine tab 5 mg (generic of ADDERALL) QL (60 tabs / 0 amphetamine-dextroampheta mine tab 7.5 mg (generic of ADDERALL) QL (20 tabs / 0 amphetamine-dextroampheta mine tab 10 mg (generic of ADDERALL) QL (180 tabs / 0 0

33 amphetamine-dextroampheta mine tab 12.5 mg (generic of ADDERALL) QL (1 tabs / 0 amphetamine-dextroampheta mine tab 15 mg (generic of ADDERALL) QL (120 tabs / 0 amphetamine-dextroampheta mine tab 20 mg (generic of ADDERALL) QL (90 tabs / 0 amphetamine-dextroampheta mine tab 0 mg (generic of ADDERALL) QL (60 tabs / 0 guanfacine hcl (adhd) PA (generic of INTUNIV) PA if 65 years and older; HR metadate tab 20mg er QL (90 tabs / 0 methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg QL (180 tabs / 0 methylphenidate hcl (generic of RITALIN) TABS 20mg QL (90 tabs / 0 methylphenidate hcl TBCR 10mg, 20mg QL (90 tabs / 0 methylphenidate hcl oral soln (generic of METHYLIN) 5mg/5ml QL (1800 ml / 0 methylphenidate hcl oral soln (generic of METHYLIN) 10mg/5ml QL (900 ml / 0 STRATTERA 10mg, 18mg, 25mg QL (120 caps / 0 STRATTERA 0mg QL (60 caps / 0 STRATTERA 60mg, 80mg, 100mg QL (0 caps / 0 HYPNOTICS HETLIOZ 5 NM LA PA ROZEREM SILENOR mg QL (60 tabs / 0 HR (doses > 6mg/day) SILENOR 6mg HR (doses > 6mg/day) temazepam (generic of 2 GC QL PA RESTORIL) 7.5mg QL (0 caps / 0 90 day limit per calendar year if 65 years and older temazepam (generic of 2 GC QL PA RESTORIL) 15mg QL (60 caps / 0 90 day limit per calendar year if 65 years and older zolpidem tartrate (generic of PA AMBIEN) TABS 90 day limit per calendar year if 65 years and older; HR MIGRAINE dihydroergotamine mesylate (generic of D.H.E. 5) 1mg/ml naratriptan hcl (generic of AMERGE) QL (9 tabs / 0 RELPAX QL (12 tabs / 0 rizatriptan benzoate (generic of MAXALT) TABS QL (18 tabs / 0 rizatriptan benzoate (generic of MAXALT-MLT) TBDP QL (18 tabs / 0 1

34 SUMATRIPTAN SOLN 5mg/act QL (2 inhalers / 0 SUMATRIPTAN SOLN 20mg/act QL (12 inhalers / 0 sumatriptan succinate (generic of IMITREX) TABS QL (9 tabs / 0 SUMATRIPTAN SUCCINATE INJ MG/0.5ML QL (12 injections / 0 sumatriptan succinate inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ QL (12 injections / 0 SUMATRIPTAN SUCCINATE INJ 6MG/0.5ML SOCT QL (12 injections / 0 sumatriptan succinate inj 6mg/0.5ml (generic of IMITREX) SOLN QL (6 ml / 0 sumatriptan succinate inj 6mg/0.5ml SOSY QL (12 injections / 0 zolmitriptan (generic of ZOMIG) TABS QL (12 tabs / 0 zolmitriptan odt (generic of ZOMIG ZMT) QL (12 tabs / 0 MISCELLANEOUS GRALISE 00mg QL (180 tabs / 0 GRALISE 600mg QL (90 tabs / 0 GRALISE STARTER lithium carbonate CAPS; 2 GC TABS lithium carbonate er (generic 2 GC of LITHOBID) 00mg lithium carbonate er 50mg 2 GC LITHIUM SOLN 8MEQ/5ML NUEDEXTA pyridostigmine bromide (generic of MESTINON) TABS riluzole (generic of RILUTEK) XENAZINE 12.5mg 5 QL NM LA PA QL (20 tabs / 0 XENAZINE 25mg 5 QL NM LA PA QL (120 tabs / 0 MULTIPLE SCLEROSIS AGENTS AMPYRA 5 NM LA PA BETASERON 5 QL NM PA QL (1 syringes / 28 COPAXONE INJ 0MG/ML 5 QL NM PA QL (12 syringes / 28 COPAXONE KIT 20MG/ML 5 QL NM PA QL (0 syringes per 0 GILENYA CAP 0.5MG 5 QL NM PA QL (28 caps / 28 TYSABRI 5 NM LA PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 2 GC cyclobenzaprine hcl TABS PA 5mg, 10mg PA if 65 years and older; HR dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg dantrolene sodium CAPS 100mg tizanidine hcl TABS 2mg tizanidine hcl (generic of ZANAFLEX) TABS mg NARCOLEPSY/CATAPLEXY 2

35 NUVIGIL 50mg PA QL (150 tabs / 0 NUVIGIL 150mg PA QL (60 tabs / 0 NUVIGIL 200mg, 250mg PA XYREM 5 QL NM LA PA QL (50 ml / 0 PSYCHOTHERAPEUTIC-MISC acamprosate calcium buprenorphine hcl SUBL PA buprenorphine hcl-naloxone PA hcl sl QL (120 tabs / 0 buproban (generic of ZYBAN) CHANTIX CONTINUING PA MONTH CHANTIX PAK 0.5& 1MG PA CHANTIX TAB 0.5MG PA CHANTIX TAB 1MG PA disulfiram (generic of ANTABUSE) TABS naloxone inj 0.mg/ml naloxone inj 1mg/ml naltrexone hcl (generic of REVIA) TABS NICOTROL INHALER NICOTROL NS SUBOXONE MIS 2-0.5MG PA QL (120 SL films / 0 SUBOXONE MIS -1MG PA QL (120 SL films / 0 SUBOXONE MIS 8-2MG PA QL (120 SL films / 0 SUBOXONE MIS 12-MG PA QL (60 SL films / 0 ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM QL (0 patches / 0 PA AXIRON PA QL (0 ml / 0 oxandrolone tab 2.5mg PA (generic of OXANDRIN) oxandrolone tab 10mg 5 NM PA (generic of OXANDRIN) testosterone cypionate PA SOLN 100mg/ml testosterone cypionate PA (generic of DEPO-TESTOSTERONE) SOLN 200mg/ml testosterone enanthate PA SOLN ANTIDIABETICS, INJECTABLE ALCOHOL SWABS BYDUREON PEN QL ( pens / 28 BYDUREON SUSR QL ( vials / 28 BYETTA QL (1 pen / 0 GAUZE PADS 2" X 2" HUMULIN R INJ U B/D NM INSULIN PEN NEEDLE INSULIN SYRINGE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH NOVOLIN 70/0 RELION not covered NOVOLIN N RELION not covered NOVOLIN R RELION not covered NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/0 NOVOLOG MIX 70/0 PREFILL NOVOLOG PENFILL SYMLINPEN 60 QL (8 pens / 0 PA

36 SYMLINPEN 120 PA QL ( pens / 0 TANZEUM QL ( pens / 28 TOUJEO SOLOSTAR TRULICITY QL ( pens / 28 VICTOZA QL ( pens / 0 ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) FARXIGA 5mg QL (60 tabs / 0 FARXIGA 10mg glimepiride (generic of 1 GC QL AMARYL) 1mg QL (20 tabs / 0 glimepiride (generic of 1 GC QL AMARYL) 2mg QL (120 tabs / 0 glimepiride (generic of 1 GC QL AMARYL) mg QL (60 tabs / 0 glip/metform tab mg 2 GC QL QL (20 tabs / 0 glip/metform tab mg 2 GC QL QL (120 tabs / 0 glip/metform tab 5-500mg 2 GC QL QL (120 tabs / 0 glipizide (generic of 1 GC QL GLUCOTROL) TABS 5mg QL (20 tabs / 0 glipizide (generic of 1 GC QL GLUCOTROL) TABS 10mg QL (120 tabs / 0 glipizide (generic of 2 GC QL GLUCOTROL XL) TB2 2.5mg QL (20 tabs / 0 glipizide (generic of GLUCOTROL XL) TB2 5mg QL (120 tabs / 0 2 GC QL glipizide (generic of GLUCOTROL XL) TB2 10mg QL (60 tabs / 0 INVOKAMET TAB MG QL (120 tabs / 0 INVOKAMET TAB QL (60 tabs / 0 INVOKAMET TAB QL (60 tabs / 0 INVOKAMET TAB QL (60 tabs / 0 INVOKANA 100mg QL (90 tabs / 0 INVOKANA 00mg JANUMET QL (60 tabs / 0 JANUMET XR TAB MG QL (60 tabs / 0 JANUMET XR TAB QL (60 tabs / 0 JANUMET XR TAB JANUVIA JENTADUETO QL (60 tabs / 0 metformin hcl (generic of GLUCOPHAGE) TABS 500mg QL (150 tabs / 0 metformin hcl (generic of GLUCOPHAGE) TABS 850mg QL (90 tabs / 0 metformin hcl (generic of GLUCOPHAGE) TABS 1000mg QL (75 tabs / 0 metformin hcl (generic of GLUCOPHAGE XR) TB2 500mg QL (120 tabs / 0 2 GC QL 1 GC QL 1 GC QL 1 GC QL 1 GC QL

37 metformin hcl (generic of GLUCOPHAGE XR) TB2 750mg QL (60 tabs / 0 nateglinide (generic of STARLIX) QL (90 tabs / 0 pioglitazone hcl (generic of ACTOS) repaglinide (generic of PRANDIN) 2mg QL (20 tabs / 0 1 GC QL 2 GC QL 2 GC QL 2 GC QL repaglinide (generic of 2 GC QL PRANDIN).5mg, 1mg QL (120 tabs / 0 TRADJENTA BISPHOSPHONATES alendronate sodium TABS 1 GC 5mg, 10mg, 0mg alendronate sodium TABS 1 GC QL 5mg QL ( tabs / 28 alendronate sodium (generic 1 GC QL of FOSAMAX) TABS 70mg QL ( tabs / 28 BINOSTO QL ( tabs / 28 ibandronate tab 150mg B/D QL (generic of BONIVA) QL (1 tab / 0 pamidronate disodium SOLN B/D zoledronic acid (generic of B/D NM RECLAST) SOLN 5mg/100ml zoledronic inj mg/5ml B/D NM (generic of ZOMETA) CALCIUM RECEPTOR AGONISTS SENSIPAR 0mg NM QL (120 tabs / 0 SENSIPAR 60mg 5 QL NM QL (60 tabs / 0 SENSIPAR 90mg 5 QL NM QL (120 tabs / 0 CHELATING AGENTS CHEMET DEPEN TITRATABS 5 NM EXJADE 5 NM LA PA FERRIPROX 5 NM LA PA kionex powder (generic of KAYEXALATE) kionex susp 15gm/60ml sodium polystyrene sulfonate sps susp 15gm/60ml SYPRINE 5 NM CONTRACEPTIVES altavera apri 28 day (generic of DESOGEN) aranelle 28 (generic of TRI-NORINYL 28) aubra 28 day aviane 28 balziva 28 day (generic of OVCON-5) briellyn 28 day (generic of OVCON-5) camila 28 day (generic of NOR-QD) cryselle 28 cyclafem 1/5 28 day (generic of NORINYL 1+5) cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7) deblitane 28 day (generic of NOR-QD) delyla 28 day desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE) drospirenone-ethinyl estradiol (generic of YASMIN 28) ELLA emoquette (generic of DESOGEN) enpresse 28 day errin 28 day (generic of ORTHO MICRONOR) 5

38 Drug Tier falmina 28 day GIANVI TAB -0.02MG gildagia (generic of OVCON-5) gildess 1.5/0 21 day (generic of LOESTRIN 1.5/0-21) heather (generic of NOR-QD) introvale 91 day JOLESSA TAB MG JOLIVETTE junel 1.5/0 21 day (generic of LOESTRIN 1.5/0-21) junel 1/20 21 day (generic of LOESTRIN 1/20-21) junel fe 1.5/0 28 day (generic of LOESTRIN FE 1.5/0) junel fe 1/20 28 day (generic of LOESTRIN FE 1/20) kariva 28 day (generic of MIRCETTE) kelnor 1/5 28 day kimidess (generic of MIRCETTE) larin 1.5/0 (generic of LOESTRIN 1.5/0-21) larin 1/20 (generic of LOESTRIN 1/20-21) larin fe 1.5/0 (generic of LOESTRIN FE 1.5/0) larin fe 1/20 (generic of LOESTRIN FE 1/20) LEENA TAB lessina 28 day levonest 28 day levonorgestrel & eth estradiol levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg levonorgestrel (emergency oc).75mg levonorgestrel-ethinyl estradiol (91-day) levora 0.15/0 28 day loryna 28 day (generic of YAZ) Requirements/ Limits Drug Tier low-ogestrel lutera 28 day lyza (generic of ORTHO MICRONOR) marlissa 28 day medroxyprogesterone acetate 150 mg/ml (generic of DEPO-PROVERA CONTRACEPTIV) MICROGESTIN 1.5/0 MICROGESTIN 1/20 MICROGESTIN FE 1.5/0 MICROGESTIN FE 1/20 MONONESSA my way (generic of PLAN B ONE-STEP) myzilra necon 0.5/5 28 day (generic of BREVICON-28) necon 1/5 28 day (generic of NORINYL 1+5) NECON 1/50-28 NECON 7/7/7 necon 10/11 28 day next choice one dose (generic of PLAN B ONE-STEP) nikki 28 day (generic of YAZ) NORA-BE TAB 0.5MG norethindrone (contraceptive) (generic of NOR-QD) norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN) norlyroc 28 day (generic of NOR-QD) nortrel 0.5/5 28 day (generic of BREVICON-28) nortrel 1/5 21 day (generic of NORINYL 1+5) nortrel 1/5 28 day (generic of NORINYL 1+5) nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7) NUVARING Requirements/ Limits 6

39 Drug Tier OCELLA TAB -0.0MG orsythia 28 day philith (generic of OVCON-5) pimtrea pack (generic of MIRCETTE) pirmella 1/5 28 day (generic of NORINYL 1+5) portia 28 day previfem 28 day (generic of ORTHO-CYCLEN) quasense 91 day reclipsen 28 day (generic of DESOGEN) sharobel 28 day (generic of ORTHO MICRONOR) SOLIA sprintec 28 day (generic of ORTHO-CYCLEN) sronyx 28 day syeda (generic of YASMIN 28) tarina fe 1/20 28 day (generic of LOESTRIN FE 1/20) tri-legest 28 day (generic of ESTROSTEP FE) tri-previfem 28 day (generic of ORTHO TRI-CYCLEN) tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN) TRINESSA trivora 28 day velivet 28 day (generic of CYCLESSA) vestura (generic of YAZ) viorele (generic of MIRCETTE) vyfemla 28 day (generic of OVCON-5) xulane (generic of ORTHO EVRA) zarah (generic of YASMIN 28) zenchent 28 day (generic of OVCON-5) zovia 1/5e 28 day zovia 1/50e 28 day Requirements/ Limits ENDOMETRIOSIS danazol CAPS SYNAREL 5 NM ENZYME REPLACEMENTS ADAGEN 5 NM LA PA ALDURAZYME 5 NM LA PA CARBAGLU 5 NM LA PA CERDELGA 5 NM PA CEREZYME 5 NM LA PA CYSTADANE POW 5 NM LA CYSTAGON NM LA PA FABRAZYME 5 NM LA PA KUVAN 5 NM LA PA levocarnitine (metabolic B/D modifiers) (generic of CARNITOR) SOLN 1gm/10ml levocarnitine (metabolic B/D modifiers) (generic of CARNITOR) SOLN 200mg/ml levocarnitine (metabolic B/D modifiers) (generic of CARNITOR) TABS LUMIZYME 5 NM LA PA MYOZYME 5 NM LA PA NAGLAZYME 5 NM LA PA ORFADIN 5 NM LA PA RAVICTI 5 NM PA sodium phenylbutyrate 5 NM (generic of BUPHENYL) ZAVESCA 5 NM LA PA ESTROGENS DELESTROGEN 10mg/ml estrace CREA estrad val inj 20mg/ml (generic of DELESTROGEN) estrad val inj 0mg/ml (generic of DELESTROGEN) estradiol (generic of CLIMARA) PTWK PA if 65 years and older; HR PA 7

40 estradiol (generic of ESTRACE) TABS PA if 65 years and older; HR jinteli PA if 65 years and older; HR norethindrone acetate-ethinyl estradiol PA if 65 years and older; HR VAGIFEM GLUCOCORTICOIDS a-hydrocort cortisone acetate TABS PA PA PA dexamethasone CONC; ELIX; SOLN dexamethasone TABS 2 GC dexamethasone sodium phosphate fludrocortisone acetate 2 GC TABS hydrocortisone (generic of CORTEF) TABS methylpr ace inj 0mg/ml B/D (generic of DEPO-MEDROL) methylpr ace inj 80mg/ml B/D (generic of DEPO-MEDROL) methylpr ss inj 1gm (generic B/D of SOLU-MEDROL) methylpr ss inj 0mg (generic B/D of SOLU-MEDROL) methylpr ss inj 125mg B/D (generic of SOLU-MEDROL) methylpred pak mg (generic B/D of MEDROL DOSEPAK) methylpred tab mg (generic B/D of MEDROL) methylpred tab 8mg (generic B/D of MEDROL) methylpred tab 16mg (generic B/D of MEDROL) methylpred tab 2mg (generic B/D of MEDROL) pred sod pho sol 5mg/5ml (generic of PEDIAPRED) 2 GC B/D prednisolone sol 15mg/5ml 2 GC B/D prednisolone sol 25mg/5ml 2 GC B/D prednisolone syrup 15 mg/5ml 2 GC B/D prednisone con 5mg/ml B/D prednisone pak 5mg 2 GC B/D prednisone pak 10mg 2 GC B/D prednisone sol 5mg/5ml B/D prednisone tab 1mg 2 GC B/D prednisone tab 2.5mg 2 GC B/D prednisone tab 5mg 2 GC B/D prednisone tab 10mg 2 GC B/D prednisone tab 20mg 2 GC B/D prednisone tab 50mg 2 GC B/D SOLU-CORTEF 250mg GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT KORLYM 5 NM LA PA PROGLYCEM SUS 50MG/ML HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO 5 NM PA NORDITROPIN NORDIFLEX 5 NM PA PEN MISCELLANEOUS cabergoline calcitonin (salmon) (generic of MIACALCIN) FORTICAL INCRELEX 5 NM LA PA methylergonovine maleate (generic of METHERGINE) TABS MIACALCIN 200unit/ml B/D octreotide acetate (generic of NM PA SANDOSTATIN) 50mcg/ml, 100mcg/ml octreotide acetate (generic of 5 NM PA SANDOSTATIN) 200mcg/ml, 500mcg/ml, 1000mcg/ml PROLIA QL (1 syringe / 180 NM 8

41 raloxifene tab 60mg (generic of EVISTA) SANDOSTATIN LAR DEPOT 5 NM PA SIGNIFOR 5 NM LA PA SOMATULINE DEPOT 5 NM PA SOMAVERT 5 NM LA PA XGEVA 5 NM PA PARATHYROID HORMONES FORTEO 5 QL NM PA QL (1 pen / 28 NATPARA 5 NM PA PHOSPHATE BINDER AGENTS AURYXIA 5 NM calcium acetate (phosphate binder) (generic of PHOSLO) CAPS calcium acetate (phosphate binder) (generic of ELIPHOS) TABS RENVELA PAK 0.8GM RENVELA PAK 2.GM RENVELA TAB 800MG PROGESTINS medroxyprogesterone acetate 2 GC tab (generic of PROVERA) norethindrone acetate (generic of AYGESTIN) TABS THYROID AGENTS levothyroxine sodium (generic 2 GC of SYNTHROID) TABS liothyronine sodium (generic of CYTOMEL) TABS methimazole (generic of 2 GC TAPAZOLE) TABS propylthiouracil TABS SYNTHROID VASOPRESSINS desmopressin acetate spray (generic of DDAVP) desmopressin acetate spray refrigerated desmopressin acetate tabs (generic of DDAVP) Drug Tier desmopressin inj mcg/ml (generic of DDAVP) DESMOPRESSIN SOL 0.01% GASTROINTESTINAL ANTIEMETICS compro Requirements/ Limits dronabinol (generic of B/D QL MARINOL) 2.5mg, 5mg QL (60 caps / 0 dronabinol (generic of 5 B/D QL NM MARINOL) 10mg QL (60 caps / 0 EMEND CAP 0MG B/D EMEND CAP 80MG B/D EMEND CAP 125MG B/D EMEND PAK 80 & 125 B/D granisetron hcl SOLN granisetron hcl TABS B/D meclizine hcl TABS 2 GC metoclopramide hcl SOLN 2 GC metoclopramide hcl (generic 2 GC of REGLAN) TABS metoclopramide hcl inj ondansetron hcl (generic of B/D ZOFRAN) TABS mg, 8mg ondansetron hcl TABS 2mg B/D ondansetron hcl inj mg/2ml ondansetron hcl inj (generic of ZOFRAN) 0mg/20ml ondansetron hcl oral soln B/D (generic of ZOFRAN) ondansetron odt (generic of B/D ZOFRAN ODT) phenadoz PA PA if 65 years and older; HR phenergan SUPP PA PA if 65 years and older; HR prochlorperazine inj prochlorperazine maleate 2 GC (generic of COMPAZINE) TABS prochlorperazine supp 9

42 promethazine hcl (generic of PHENERGAN) SOLN PA if 65 years and older; HR promethazine hcl SUPP; SYRP; TABS PA if 65 years and older; HR promethegan PA if 65 years and older; HR TRANSDERM-SCOP QL (10 patches / 0 PA if 65 years and older; HR PA PA PA PA ANTISPASMODICS CUVPOSA dicyclomine hcl (generic of 2 GC BENTYL) CAPS; TABS dicyclomine hcl SOLN glycopyrrolate (generic of ROBINUL) SOLN mg/20ml glycopyrrolate (generic of ROBINUL) TABS 1mg glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg H2-RECEPTOR ANTAGONISTS famotidine inj famotidine tab (generic of 2 GC PEPCID) ranitidine hcl (generic of ZANTAC) SOLN ranitidine hcl (generic of ZANTAC) TABS 150mg, 00mg 2 GC ranitidine hcl inj (generic of ZANTAC) ranitidine syrup INFLAMMATORY BOWEL DISEASE APRISO ASACOL HD balsalazide disodium (generic of COLAZAL) budesonide ec (generic of 5 NM ENTOCORT EC) CANASA colocort (generic of CORTENEMA) DELZICOL DIPENTUM 5 NM HYDROCORTISONE (INTRARECTAL) mesalamine enema mesalamine w/ cleanser (generic of ROWASA) sulfasalazine (generic of AZULFIDINE) TABS sulfasalazine ec (generic of AZULFIDINE EN-TABS) UCERIS TB2 LAXATIVES constulose 2 GC enulose 2 GC gaviltye-g (generic of 2 GC GOLYTELY) gavilyte-c (generic of 2 GC COLYTE-FLAVOR PACKS) gavilyte-h 2 GC gavilyte-n (generic of 2 GC NULYTELY/FLAVOR PACKS) generlac 2 GC GOLYTELY lactulose 2 GC lactulose (encephalopathy) 2 GC MOVIPREP NULYTELY/FLAVOR PACKS PEG 50-KCL-SOD 2 GC BICARB-SOD CHLORIDE-SOD SULFATE peg 50-potassium 2 GC chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS) PEG 50/ELECTROLYTES 2 GC polyethylene glycol 50 2 GC PACK; POWD RELISTOR PA SUPREP BOWEL PREP 0

43 trilyte (generic of 2 GC NULYTELY/FLAVOR PACKS) MISCELLANEOUS alosetron hcl (generic of PA LOTRONEX) AMITIZA QL (60 caps / 0 cromolyn sodium 5 NM (mastocytosis) (generic of GASTROCROM) diphenoxylate w/ atropine LIQD diphenoxylate w/ atropine (generic of LOMOTIL) TABS GATTEX 5 NM LA PA LINZESS 15mcg QL (60 caps / 0 LINZESS 290mcg QL (0 caps / 0 loperamide hcl CAPS 2 GC misoprostol (generic of CYTOTEC) TABS MOVANTIK 12.5mg QL (60 tabs / 0 MOVANTIK 25mg SUCRAID 5 NM LA sucralfate (generic of CARAFATE) TABS ursodiol (generic of ACTIGALL) CAPS ursodiol (generic of URSO 250) TABS 250mg ursodiol (generic of URSO FORTE) TABS 500mg XIFAXAN 550mg 5 NM PA PANCREATIC ENZYMES CREON ZENPEP PROTON PUMP INHIBITORS DEXILANT CAP 0MG DR DEXILANT CAP 60MG DR esomeprazole sodium inj 20mg esomeprazole sodium inj (generic of NEXIUM I.V.) 0mg Drug Tier NEXIUM CAP 20MG NEXIUM CAP 0MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR NEXIUM GRA 20MG DR NEXIUM GRA 0MG DR Requirements/ Limits omeprazole (generic of 2 GC QL PRILOSEC) CPDR 10mg QL (0 caps / 0 omeprazole cap 20mg 2 GC (generic of PRILOSEC) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of 2 GC QL UROXATRAL) AVODART QL (0 caps / 0 finasteride (generic of 2 GC PROSCAR) TABS 5mg JALYN QL (0 caps / 0 tamsulosin hcl (generic of 2 GC FLOMAX) MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS ELMIRON POTASSIUM CITRATE (ALKALINIZER) 50mg POTASSIUM CITRATE (ALKALINIZER) 1080mg URINARY ANTISPASMODICS MYRBETRIQ TAB 25MG QL (60 tabs / 0 MYRBETRIQ TAB 50MG oxybutynin chloride SYRP 2 GC oxybutynin chloride TABS 1

44 oxybutynin chloride (generic of DITROPAN XL) TB2 5mg oxybutynin chloride (generic of DITROPAN XL) TB2 10mg, 15mg QL (60 tabs / 0 tolterodine tartrate cap er (generic of DETROL LA) QL (0 caps / 0 tolterodine tartrate tabs (generic of DETROL) TOVIAZ trospium chloride TABS QL (60 tabs / 0 VESICARE VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal (generic of CLEOCIN) metronidazole vaginal (generic of METROGEL-VAGINAL) terconazole vaginal (generic of TERAZOL 7) CREA.% terconazole vaginal (generic of TERAZOL ) CREA.8% terconazole vaginal SUPP VANDAZOLE zazole (generic of TERAZOL 7).% ZAZOLE.8% HEMATOLOGIC ANTICOAGULANTS COUMADIN ELIQUIS enoxaparin sodium (generic of LOVENOX) 0mg/0.ml, 0mg/0.ml, 60mg/0.6ml, 80mg/0.8ml, 00mg/ml enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml 5 NM fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml fondaparinux sodium (generic 5 NM of ARIXTRA) 5mg/0.ml, 7.5mg/0.6ml, 10mg/0.8ml HEPARIN SOD (PORCINE) IN D5W heparin sod inj 1000/ml B/D HEPARIN SOD INJ 2000/ML B/D HEPARIN SOD INJ 2500/ML B/D heparin sod inj 5000/ml B/D heparin sod inj 10000/ml B/D heparin sod inj 20000/ml B/D HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.5% jantoven (generic of 1 GC COUMADIN) PRADAXA warfarin sodium (generic of COUMADIN) 1 GC XARELTO XARELTO STARTER PACK HEMATOPOIETIC GROWTH FACTORS GRANIX 5 NM PA LEUKINE 5 NM PA MOZOBIL 5 NM PA NEUMEGA 5 NM NEUPOGEN 5 NM PA PROCRIT 2000unit/ml, 000unit/ml, 000unit/ml, 10000unit/ml NM PA PROCRIT 20000unit/ml, 5 NM PA 0000unit/ml MISCELLANEOUS anagrelide hcl 1mg anagrelide hcl (generic of AGRYLIN).5mg cilostazol (generic of PLETAL) CINRYZE 5 NM LA PA FIRAZYR 5 NM PA pentoxifylline TBCR PROMACTA 12.5mg QL (60 tabs / 0 5 QL NM LA PA 2

45 PROMACTA 25mg 5 QL NM LA PA QL (180 tabs / 0 PROMACTA 50mg 5 QL NM LA PA QL (90 tabs / 0 PROMACTA 75mg 5 QL NM LA PA QL (60 tabs / 0 tranexamic acid (generic of CYKLOKAPRON) SOLN tranexamic acid (generic of LYSTEDA) TABS PLATELET AGGREGATION INHIBITORS AGGRENOX BRILINTA clopidogrel bisulfate (generic of PLAVIX) 75mg 1 GC EFFIENT ZONTIVITY IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA KIT 5 NM PA CIMZIA KIT STARTER 5 NM PA CIMZIA PREFL KIT 5 NM PA 200MG/ML HUMIRA 5 NM PA HUMIRA KIT 0MG/0.8 5 NM PA HUMIRA PEN 5 NM PA HUMIRA PEN-CROHNS 5 NM PA DISEASE HUMIRA PEN-PSORIASIS 5 NM PA STAR hydroxychloroquine sulfate leflunomide (generic of ARAVA) TABS methotrexate sodium tabs REMICADE INJ 100MG 5 NM PA IMMUNOGLOBULINS BIVIGAM 5 NM PA CARIMUNE NANOFILTERED 5 NM PA 12gm FLEBOGAMMA 5 NM PA FLEBOGAMMA DIF 5 NM PA GAMASTAN S/D B/D NM GAMMAGARD LIQUID 5 NM PA GAMMAGARD S/D 5 NM PA GAMMAKED 5 NM PA GAMMAPLEX 2.5gm/50ml, 5 NM PA 5gm/100ml, 10gm/200ml GAMUNEX-C 5 NM PA OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml 5 NM PA PRIVIGEN 5 NM PA IMMUNOMODULATORS ACTIMMUNE 5 NM LA PA ARCALYST 5 NM PA INTRON-A INJ 10MU 5 B/D NM INTRON-A INJ 18MU 5 B/D NM INTRON-A INJ 25MU 5 B/D NM INTRON-A INJ 50MU 5 B/D NM REVLIMID 5 NM LA PA THALOMID 5 NM PA IMMUNOSUPPRESSANTS azathioprine (generic of IMURAN) TABS B/D BENLYSTA 5 NM PA cyclosporine (generic of SANDIMMUNE) CAPS; SOLN B/D cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg cyclosporine modified (for microemulsion) CAPS 50mg cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN B/D B/D B/D gengraf (generic of NEORAL) B/D mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS B/D mycophenolate mofetil SUSR mycophenolate sodium (generic of MYFORTIC) 180mg mycophenolate sodium (generic of MYFORTIC) 60mg 5 B/D NM B/D 5 B/D NM

46 NEORAL B/D NULOJIX 5 B/D NM PROGRAF CAPS 5mg 5 B/D NM PROGRAF CAPS.5mg, B/D 1mg RAPAMUNE SOLN 5 B/D NM SANDIMMUNE SOLN B/D 100mg/ml SIROLIMUS TABS 2mg 5 B/D NM sirolimus (generic of B/D RAPAMUNE) TABS.5mg, 1mg tacrolimus (generic of 5 B/D NM PROGRAF) CAPS 5mg tacrolimus (generic of B/D PROGRAF) CAPS.5mg, 1mg ZORTRESS TAB 0.5MG 5 B/D NM ZORTRESS TAB 0.25MG B/D ZORTRESS TAB 0.75MG 5 B/D NM VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX CERVARIX COMVAX DAPTACEL DIPHTHERIA/TETANUS B/D TOXOID ENGERIX-B SUSP B/D GARDASIL GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX M-M-R II MENACTRA MENOMUNE-A/C/Y/W-15 MENVEO PEDVAX HIB PROQUAD QUADRACEL RABAVERT RECOMBIVAX HB B/D ROTARIX ROTATEQ SYNAGIS 5 NM TENIVAC B/D TETANUS/DIPHTHERIA B/D TOXOID TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON 8 KLOR-CON 10 klor-con m15 2 GC klor-con m20 2 GC klor-con pow 20meq MAGNESIUM SULFATE SOLN 0mg/ml, 50%, 80mg/ml magnesium sulfate SOLN 50% MAGNESIUM SULFATE IN D5W potassium chloride (generic of 2 GC MICRO-K) CPCR POTASSIUM CHLORIDE LIQD potassium chloride TBCR 8meq POTASSIUM CHLORIDE TBCR 10meq, 20meq

47 potassium chloride 2 GC microencapsulated crystals cr SODIUM CHLORIDE SOLN 2.5meq/ml SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN 2 GC TPN ELECTROLYTES B/D IV NUTRITION AMINOSYN B/D AMINOSYN B/D 7%/ELECTROLYTES AMINOSYN B/D 8.5%/ELECTROLYTE AMINOSYN II B/D AMINOSYN II B/D 8.5%/ELECTROL AMINOSYN M B/D AMINOSYN-HBC B/D AMINOSYN-PF 7% B/D AMINOSYN-PF 10% B/D AMINOSYN-RF B/D CLINIMIX 2.75%/DEXTROSE B/D 5% CLINIMIX.25%/DEXTROSE B/D 5% CLINIMIX.25%/DEXTROSE B/D 25% CLINIMIX 5%/DEXTROSE B/D 15% CLINIMIX 5%/DEXTROSE B/D 20% CLINIMIX 5%/DEXTROSE B/D 25% CLINIMIX INJ.25/D10 B/D CLINIMIX INJ.25/D20 B/D FREAMINE HBC 6.9% B/D FREAMINE III B/D HEPATAMINE B/D INTRALIPID INJ 20% B/D INTRALIPID INJ 0% B/D NEPHRAMINE B/D NUTRILIPID INJ 20% B/D premasol 6% B/D premasol 10% B/D PROCALAMINE B/D PROSOL B/D TRAVASOL B/D TROPHAMINE INJ 10% B/D IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.5% DEXTROSE 5% DEXTROSE 5% /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/NACL 0.% DEXTROSE 5%/NACL 0.5% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 10% FLEX CONTAIN DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.5% DEXTROSE 50% DEXTROSE INJ 70% IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% ISOLYTE P ISOLYTE S KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225 % KCL 0.%/D5W/NACL 0.9% KCL 0.%/D5W/NACL 0.5% KCL 0.15%/D5W/NACL 0.9% KCL 0.075%/D5W/NACL 0.5% KCL IN NACL INJ KCL/D5W INJ 0.% 5

48 Drug Tier KCL/D5W/NACL INJ 0.22%/0.5% KCL/D5W/NACL INJ.15/.% KCL/D5W/NACL INJ.15/.5% KCL/NACL INJ KCL/NACL INJ 0.15%-0.9% LACTATED RINGER'S INJ NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W PLASMA-LYTE A PLASMA-LYTE-56/D5W PLASMA-LYTE-18 pot chloride inj 2meq/ml Requirements/ Limits POTASSIUM CHLORIDE SOLN potassium chloride in nacl RINGER'S SOD CHLORIDE INJ 0.9% SODIUM CHLORIDE SOLN %, 5% SODIUM CHLORIDE 0.5% VIA VITAMINS calcitriol (generic of B/D ROCALTROL) CAPS calcitriol inj B/D calcitriol oral soln 1 mcg/ml B/D (generic of ROCALTROL) paricalcitol (generic of B/D ZEMPLAR) CAPS 1mcg, 2mcg paricalcitol CAPS mcg B/D PRENATAL VITAMIN/FOLIC 2 GC ACID > 0.8 MG (GENERIC) OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc blephamide OINT neomycin-polymy-dexameth 2 GC (generic of MAXITROL) neomycin-polymyxin-hc (ophth) sulfacetamide 2 GC sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone (generic of TOBRADEX) ZYLET ANTI-INFECTIVES bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) 2 GC BESIVANCE CILOXAN OINT ciprofloxacin hcl (ophth) 2 GC (generic of CILOXAN) erythromycin (ophth) 2 GC gatifloxacin (ophth) (generic of ZYMAXID) gentak 2 GC gentamicin sulfate (ophth) 2 GC OINT gentamicin sulfate (ophth) 2 GC (generic of GARAMYCIN) SOLN ilotycin 2 GC MOXEZA NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidi n (generic of NEOSPORIN) ofloxacin (ophth) (generic of 2 GC OCUFLOX) polymyxin b-trimethoprim 2 GC (generic of POLYTRIM) sulfacet sod oin 10% op sulfacetamide sodium (ophth) (generic of BLEPH-10) tobramycin (ophth) (generic of 2 GC TOBREX) TOBREX OINT trifluridine (generic of VIROPTIC) SOLN VIGAMOX ZIRGAN 6

49 Drug Tier ANTI-INFLAMMATORIES dorzolamide hcl-timolol ALREX maleate (generic of COSOPT) bromfenac sodium (ophth) ISTALOL BROMFENAC SODIUM latanoprost (generic of (OPHTH)(ONCE-DAILY) XALATAN) SOLN dexamethasone sodium 2 GC levobunolol hcl (generic of phosphate (ophth) diclofenac sodium (ophth) 2 GC DUREZOL FLUOROMETHOLONE flurbiprofen sodium (generic 2 GC of OCUFEN) ILEVRO ketorolac tromethamine (ophth) (generic of ACULAR LS).% ketorolac tromethamine (ophth) (generic of ACULAR).5% LOTEMAX MAXIDEX PREDNISOLONE ACETATE (OPHTH) prednisolone sodium phosphate (ophth) ANTIALLERGICS azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) 2 GC LASTACAFT PATADAY PAZEO ANTIGLAUCOMA ALPHAGAN P SOL 0.1% ALPHAGAN P SOL 0.15% AZOPT betaxolol hcl (ophth) BETOPTIC-S brimonidine sol 0.2% 2 GC carteolol hcl (ophth) 2 GC COMBIGAN dorzolamide hcl (generic of TRUSOPT) BETAGAN).5% LEVOBUNOLOL HCL.25% LUMIGAN metipranolol PHOSPHOLINE IODIDE PILOCARPINE HCL SOLN SIMBRINZA Requirements/ Limits 2 GC timolol maleate (ophth) 2 GC (generic of TIMOPTIC) TIMOLOL MALEATE GEL TRAVATAN Z MISCELLANEOUS naphazoline 0.1% 2 GC PROLENSA proparacaine hcl (generic of 2 GC ALCAINE) SOLN RESTASIS QL (6 vials / 0 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA QL (60 inhalations / 0 COMBIVENT RESPIMAT QL (2 inhalers / 0 ipratropium-albuterol nebu B/D ANTICHOLINERGICS ATROVENT HFA QL (2 inhalers / 0 INCRUSE ELLIPTA QL (1 inhaler / 0 ipratropium bromide SOLN 2 GC B/D ipratropium bromide (nasal) (generic of ATROVENT) ANTIHISTAMINES ASTEPRO azelastine spr 0.1% 7

50 azelastine spr 0.15% (generic of ASTEPRO) cetirizine syrup diphenhydramine hcl inj hydroxyz hcl inj PA PA if 65 years and older; HR levocetirizine dihydrochloride (generic of XYZAL) SOLN levocetirizine dihydrochloride (generic of XYZAL) TABS olopatadine hcl (nasal) (generic of PATANASE) BETA AGONISTS albuterol sulfate NEBU 2 GC B/D albuterol sulfate SYRP 2 GC albuterol sulfate TABS PERFOROMIST B/D SEREVENT DISKUS QL (60 inhalations / 0 terbutaline sulfate SOLN 5 NM terbutaline sulfate TABS VENTOLIN HFA QL (2 inhalers / 0 XOPENEX HFA QL (2 inhalers / 0 LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic of SINGULAIR) CHEW montelukast sodium (generic of SINGULAIR) PACK montelukast sodium (generic 2 GC of SINGULAIR) TABS zafirlukast (generic of ACCOLATE) MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml B/D MISCELLANEOUS acetylcysteine SOLN 10%, B/D 20% ARALAST NP 5 NM LA PA AUVI-Q DALIRESP EPIPEN 2-PAK EPIPEN-JR 2-PAK ESBRIET 5 NM PA KALYDECO 5 NM PA OFEV 5 NM PA ORKAMBI 5 NM PA PROLASTIN-C 5 NM LA PA PULMOZYME 5 B/D NM XOLAIR 5 NM LA PA ZEMAIRA 5 NM LA PA NASAL STEROIDS flunisolide (nasal) QL (2 bottles / 0 fluticasone propionate (nasal) 2 GC QL QL (1 bottle / 0 STEROID INHALANTS ARNUITY ELLIPTA QL (0 inhalations / 0 budesonide (inhalation) B/D (generic of PULMICORT) FLOVENT DISKUS 50mcg/blist, 100mcg/blist QL (120 inhalations / 0 FLOVENT DISKUS 250mcg/blist QL (20 inhalations / 0 FLOVENT HFA QL (2 inhalers / 0 PULMICORT FLEXHALER QL (2 inhalers / 0 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS QL (60 inhalations / 0 ADVAIR HFA QL (1 inhaler / 0 BREO ELLIPTA QL (60 inhalations / 0 SYMBICORT QL (1 inhaler / 0 8

51 XANTHINES aminophylline inj elixophyllin theophylline SOLN theophylline TB12; TB2 TOPICAL DERMATOLOGY, ACNE amnesteem AVITA CREA AVITA GEL benzoyl peroxide-erythromycin (generic of BENZAMYCIN) claravis clindamax (generic of CLEOCIN-T) clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN clindamycin phosphate (topical) (generic of CLEOCIN-T) SOLN; SWAB ery pad 2% erythromycin (acne aid) (generic of ERYGEL) GEL erythromycin (acne aid) SOLN myorisan sulfacetamide sodium (acne) (generic of KLARON) tretinoin (generic of RETIN-A) CREA TRETINOIN GEL.01% tretinoin (generic of RETIN-A) GEL.025% zenatane DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) mupirocin (generic of 2 GC BACTROBAN) OINT SILVER SULFADIAZINE 2 GC CREA SSD 2 GC SULFAMYLON CREA Drug Tier Requirements/ Limits SULFAMYLON PACK 5 NM DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; SUSP ciclopirox GEL ciclopirox shampoo 1% (generic of LOPROX SHAMPOO) clotrimazole (topical) ketoconazole cream nyamyc nystatin (topical) nystop DERMATOLOGY, ANTIPRURITIC procto-pak 2 GC proctosol hc cre 2.5% 2 GC (generic of ANUSOL-HC) proctozone hc (generic of 2 GC ANUSOL-HC) PRUDOXIN CRE 5% DERMATOLOGY, ANTIPSORIATICS acitretin (generic of 5 NM PA SORIATANE) calcipotriene (generic of DOVONEX) CREA calcipotriene OINT; SOLN calcitrene oin 0.005% 8-MOP TAZORAC CREA PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2 GC (generic of NIZORAL) selenium sulfide LOTN 2 GC DERMATOLOGY, CORTICOSTEROIDS ala-cort 2 GC alclometasone dipropionate (generic of ACLOVATE) CREA alclometasone dipropionate OINT betamethasone dipropionate (topical) CREA; LOTN betamethasone dipropionate (topical) OINT 9

52 betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA betamethasone dipropionate augmented GEL betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT betamethasone valerate CREA; LOTN; OINT clobetasol propionate (generic of TEMOVATE) CREA clobetasol propionate (generic of TEMOVATE) GEL clobetasol propionate (generic of TEMOVATE) OINT clobetasol propionate (generic of TEMOVATE) SOLN clobetasol propionate e (generic of TEMOVATE E) cormax (generic of TEMOVATE) fluocinolone acetonide (generic of SYNALAR) SOLN Drug Tier fluocinonide CREA.05% fluocinonide GEL fluocinonide OINT fluocinonide SOLN fluocinonide emulsified base Requirements/ Limits fluticasone propionate 2 GC (generic of CUTIVATE) CREA fluticasone propionate OINT 2 GC hydrocortisone (topical) 2 GC CREA; OINT hydrocortisone (topical) LOTN hydrocortisone butyrate (generic of LOCOID) mometasone furoate (generic of ELOCON) CREA; OINT; SOLN triamcinolone acetonide (topical) CREA; OINT 2 GC triamcinolone acetonide (topical) LOTN triderm 2 GC DERMATOLOGY, LOCAL ANESTHETICS lidocaine (generic of PA LIDODERM) PTCH QL ( patches / 1 day) lidocaine hcl GEL 2 GC lidocaine hcl (generic of 2 GC XYLOCAINE) SOLN % lidocaine oint 5% lidocaine-prilocaine (generic B/D of EMLA) DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of ZOVIRAX) ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN ELIDEL CRE 1% PA fluorouracil (topical) (generic of EFUDEX) CREA 5% fluorouracil (topical) SOLN imiquimod (generic of ALDARA) CREA laclotion 12% (generic of LAC-HYDRIN) metronidazole (topical) (generic of METROCREAM) CREA metronidazole (topical) (generic of METROLOTION) LOTN metronidazole gel 0.75% PANRETIN 5 NM podofilox (generic of CONDYLOX) SOLN rosadan cre 0.75% (generic of METROCREAM) tacrolimus (topical) (generic of PA PROTOPIC) TARGRETIN GEL 5 NM PA VALCHLOR 5 NM LA PA VOLTAREN 50

53 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX malathion (generic of OVIDE) permethrin (generic of ELIMITE) CREA DERMATOLOGY, WOUND CARE AGENTS acetic acid.25% 2 GC REGRANEX 5 NM PA SANTYL SODIUM CHLORIDE 0.9% 2 GC STERILE WATER IRRIGATION MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate 2 GC (mouth-throat) (generic of PERIDEX) clotrimazole TROC lidocaine hcl (mouth-throat) 2 GC nystatin (mouth-throat) periogard (generic of 2 GC PERIDEX) PILOCARPINE HCL (ORAL) 5mg pilocarpine hcl (oral) (generic of SALAGEN) 7.5mg triamcinolone acetonide (mouth) OTIC acetic acid (otic) acetic acid-aluminum acetate CIPRODEX fluocinolone acetonide (otic) (generic of DERMOTIC) neomycin-polymyxin-hc (otic) 2 GC (generic of CORTISPORIN) SOLN neomycin-polymyxin-hc (otic) 2 GC SUSP ofloxacin (otic) 2 GC 51

54 Index 8 8-MOP... 9 A abacavir sulfate abacavir sulfate-lamivudine-zidovudin e ABELCET ABILIFY see aripiprazole ABILIFY DISC TAB 10MG 28 ABILIFY MAINTENA ABRAXANE acamprosate calcium... acarbose... ACCOLATE see zafirlukast... 8 ACCUPRIL see quinapril hcl ACCURETIC see quinapril-hydrochlorothiazi de acebutolol hcl ACEON see perindopril erbumine acetaminophen w/ codeine.7 acetazolamide acetic acid acetic acid (otic) acetic acid-aluminum acetate acetylcysteine... 8 acitretin... 9 ACLOVATE see alclometasone dipropionate... 9 ACTHIB... ACTIGALL see ursodiol... 1 ACTIMMUNE... ACTIQ see fentanyl citrate...7 ACTOS see pioglitazone hcl... 5 ACULAR see ketorolac tromethamine (ophth)... 7 ACULAR LS see ketorolac tromethamine (ophth)... 7 acyclovir acyclovir sodium acyclovir topical ADACEL... ADAGEN... 7 ADALAT CC see afeditab cr see nifedipine ADDERALL see amphetamine-dextroamph etamine tab 10 mg... 0 see amphetamine-dextroamph etamine tab 12.5 mg... 1 see amphetamine-dextroamph etamine tab 15 mg... 1 see amphetamine-dextroamph etamine tab 20 mg... 1 see amphetamine-dextroamph etamine tab 0 mg... 1 see amphetamine-dextroamph etamine tab 5 mg... 0 see amphetamine-dextroamph etamine tab 7.5 mg... 0 ADDERALL XR see amphetamine-dextroamph etamine cap sr 2hr 10 mg... 0 see amphetamine-dextroamph etamine cap sr 2hr 15 mg... 0 see amphetamine-dextroamph etamine cap sr 2hr 20 mg... 0 see amphetamine-dextroamph etamine cap sr 2hr 25 mg... 0 see amphetamine-dextroamph etamine cap sr 2hr 0 mg... 0 see amphetamine-dextroamph etamine cap sr 2hr 5 mg... 0 adefovir dipivoxil ADEMPAS... 2 ADOXA see doxycycline (monohydrate)... 1 ADOXA PAK 1/150 see doxycycline (monohydrate)... 1 adriamycin adrucil ADVAIR DISKUS... 8 ADVAIR HFA... 8 afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX... AGRYLIN see anagrelide hcl... 2 a-hydrocort... 8 ala-cort... 9 ALBENZA... 9 albuterol sulfate... 8 ALCAINE see proparacaine hcl... 7 alclometasone dipropionate... 9 ALCOHOL SWABS... ALDACTAZIDE see spironolactone & hydrochlorothiazide ALDACTONE see spironolactone ALDARA see imiquimod

55 ALDURAZYME... 7 alendronate sodium... 5 alfuzosin hcl... 1 ALIMTA ALINIA...9 ALKERAN see melphalan hcl allopurinol tab...7 alosetron hcl... 1 ALPHAGAN P SOL 0.1%.. 7 ALPHAGAN P SOL 0.15% 7 alprazolam tab 0.25mg... 2 alprazolam tab 0.5mg... 2 alprazolam tab 1mg... 2 alprazolam tab 2 mg... 2 ALREX... 7 ALTACE see ramipril altavera... 5 amantadine hcl AMARYL see glimepiride... AMBIEN see zolpidem tartrate... 1 AMBISOME AMERGE see naratriptan hcl... 1 amifostine crystalline amikacin sulfate...9 amiloride & hydrochlorothiazide amiloride hcl aminophylline inj... 9 AMINOSYN... 5 AMINOSYN 7%/ELECTROLYTES... 5 AMINOSYN 8.5%/ELECTROLYTE... 5 AMINOSYN II... 5 AMINOSYN II 8.5%/ELECTROL... 5 AMINOSYN M... 5 AMINOSYN-HBC... 5 AMINOSYN-PF 10%... 5 AMINOSYN-PF 7%... 5 AMINOSYN-RF... 5 amiodarone hcl soln amiodarone tab 100mg amiodarone tab 200mg amiodarone tab 00mg AMITIZA... 1 amitriptyline hcl amlodipine besylate amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 10-0 mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-0 mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab 5-20 mg amlodipine-valsartan-hctz tab mg amlodipine-valsartan-hctz tab mg amlodipine-valsartan-hctz tab mg amlodipine-valsartan-hctz tab mg amlodipine-valsartan-hctz tab mg ammonium lactate amnesteem... 9 amoxapine amoxicillin... 1 amoxicillin & pot clavulanate... 1 amphetamine-dextroamphet amine cap sr 2hr 10 mg.. 0 amphetamine-dextroamphet amine cap sr 2hr 15 mg.. 0 amphetamine-dextroamphet amine cap sr 2hr 20 mg.. 0 amphetamine-dextroamphet amine cap sr 2hr 25 mg.. 0 amphetamine-dextroamphet amine cap sr 2hr 0 mg.. 0 amphetamine-dextroamphet amine cap sr 2hr 5 mg... 0 amphetamine-dextroamphet amine tab 10 mg... 0 amphetamine-dextroamphet amine tab 12.5 mg... 1 amphetamine-dextroamphet amine tab 15 mg... 1 amphetamine-dextroamphet amine tab 20 mg... 1 amphetamine-dextroamphet amine tab 0 mg... 1 amphetamine-dextroamphet amine tab 5 mg... 0 amphetamine-dextroamphet amine tab 7.5 mg... 0 amphotericin b ampicillin & sulbactam sodium... 1 ampicillin cap... 1 ampicillin inj... 1 ampicillin sodium... 1 ampicillin susp... 1 AMPYRA... 2 ANAFRANIL see clomipramine hcl anagrelide hcl... 2 ANAPROX see naproxen sodium... 7 ANAPROX DS see naproxen sodium... 7 anastrozole ANCOBON see flucytosine ANDRODERM... 5

56 ANORO ELLIPTA... 7 ANTABUSE see disulfiram... ANUSOL-HC see proctosol hc cre 2.5%... 9 see proctozone hc... 9 APOKYN apri 28 day... 5 APRISO... 0 APTIOM... 2 APTIVUS ARALAST NP... 8 ARALEN see chloroquine phosphate aranelle ARAVA see leflunomide... ARCALYST... ARICEPT see donepezil hydrochloride ARIMIDEX see anastrozole aripiprazole ARIXTRA see fondaparinux sodium... 2 ARNUITY ELLIPTA... 8 AROMASIN see exemestane ASACOL HD... 0 ASTEPRO... 7 see azelastine spr 0.15%... 8 atenolol atenolol & chlorthalidone ATIVAN see lorazepam... 2 atorvastatin calcium atovaquone...9 atovaquone-proguanil hcl.. 11 ATRIPLA ATROVENT see ipratropium bromide (nasal)... 7 ATROVENT HFA... 7 aubra 28 day... 5 AUGMENTIN see amoxicillin & pot clavulanate... 1 AUGMENTIN ES-600 see amoxicillin & pot clavulanate... 1 AUGMENTIN XR see amoxicillin & pot clavulanate... 1 AURYXIA... 9 AUVI-Q... 8 AVASTIN aviane AVITA... 9 AVODART... 1 AXIRON... AYGESTIN see norethindrone acetate... 9 azacitidine AZACTAM see aztreonam AZACTAM/DEX INJ 1GM... 9 AZACTAM/DEX INJ 2GM... 9 azathioprine... azelastine drop 0.05%... 7 azelastine spr 0.1%... 7 azelastine spr 0.15%... 8 AZILECT azithromycin... 1 AZITHROMYCIN... 1 AZOPT... 7 AZOR TAB 10-20MG AZOR TAB 10-0MG AZOR TAB 5-20MG AZOR TAB 5-0MG aztreonam AZULFIDINE see sulfasalazine... 0 AZULFIDINE EN-TABS see sulfasalazine ec... 0 B bacitracin (ophthalmic)... 6 bacitracin-polymyxin b (ophth)... 6 bacitracin-poly-neomycin-hc... 6 baclofen... 2 BACTRIM see sulfamethoxazole-trimetho prim tab BACTRIM DS see sulfamethoxazole-trimetho prim tab BACTROBAN see mupirocin... 9 balsalazide disodium... 0 balziva 28 day... 5 BANZEL SUS 0MG/ML... 2 BANZEL TAB 200MG... 2 BANZEL TAB 00MG... 2 BARACLUDE see entecavir BCG VACCINE... BELEODAQ benazepril & hydrochlorothiazide benazepril hcl BENICAR BENICAR HCT 0-25MG. 18 BENICAR HCT TAB MG BENICAR HCT TAB MG BENLYSTA... BENTYL see dicyclomine hcl... 0 BENZAMYCIN see benzoyl peroxide-erythromycin... 9 benzoyl peroxide-erythromycin... 9 benztropine mesylate BENZTROPINE MESYLATE BEPREVE... 7 BESIVANCE... 6 BETAGAN see levobunolol hcl... 7 betamethasone dipropionate (topical)... 9 betamethasone dipropionate augmented

57 betamethasone valerate BETAPACE see sorine see sotalol hcl BETAPACE AF see sotalol hcl (afib/afl).. 19 BETASERON... 2 betaxolol hcl (ophth)... 7 bethanechol chloride... 1 BETOPTIC-S... 7 BEXSERO... BIAXIN see clarithromycin... 1 see clarithromycin for susp... 1 BIAXIN XL see clarithromycin er... 1 bicalutamide BICILLIN L-A... 1 BICNU... 1 BIDIL BILTRICIDE BINOSTO... 5 bisoprolol & hydrochlorothiazide bisoprolol fumarate BIVIGAM... bleomycin sulfate BLEPH-10 see sulfacetamide sodium (ophth)... 6 blephamide... 6 BONIVA see ibandronate tab 150mg... 5 BOOSTRIX... BOSULIF BREO ELLIPTA... 8 BREVICON-28 see necon 0.5/5 28 day... 6 see nortrel 0.5/5 28 day... 6 briellyn 28 day... 5 BRILINTA... brimonidine sol 0.2%... 7 BRINTELLIX bromfenac sodium (ophth) 7 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)... 7 bromocriptine mesylate budesonide (inhalation)... 8 budesonide ec... 0 bumetanide BUPHENYL see sodium phenylbutyrate... 7 buprenorphine hcl... buprenorphine hcl-naloxone hcl sl... buproban... bupropion hcl buspirone hcl... 2 BUSULFEX... 1 butorphanol tartrate... 7 BUTRANS... 7 BUTRANS DIS 7.5MCG/HR... 7 BYDUREON... BYETTA... BYSTOLIC C cabergoline... 8 CALAN see verapamil hcl CALAN SR see verapamil tab er calcipotriene... 9 calcitonin (salmon)... 8 calcitrene oin 0.005%... 9 calcitriol... 6 calcitriol inj... 6 calcitriol oral soln 1 mcg/ml... 6 calcium acetate (phosphate binder)... 9 camila 28 day... 5 CAMPTOSAR see irinotecan hcl CANASA... 0 CANCIDAS CAPASTAT SULFATE CAPRELSA captopril captopril & hydrochlorothiazide CARAFATE see sucralfate... 1 CARBAGLU... 7 carbamazepine... 2 CARBATROL see carbamazepine... 2 CARBIDOPA/LEVODOPA/E NTACAPONE carbidopa-levodopa carboplatin CARDIZEM see diltiazem hcl CARDIZEM CD see cartia xt see diltiazem hcl coated beads CARDURA see doxazosin mesylate 18 CARIMUNE NANOFILTERED... CARNITOR see levocarnitine (metabolic modifiers)... 7 carteolol hcl (ophth)... 7 cartia xt carvedilol CASODEX see bicalutamide CATAPRES see clonidine hcl CATAPRES-TTS-1 see clonidine hcl CATAPRES-TTS-2 see clonidine hcl CATAPRES-TTS- see clonidine hcl CAYSTON cefaclor cefaclor er tab 500mg... 1 cefadroxil... 1 cefazolin in d5w... 1 cefazolin inj... 1 cefazolin sodium... 1 cefdinir... 1 cefepime hcl... 1 cefixime... 1 cefotaxime sodium... 1 cefoxitin sodium

58 cefpodoxime proxetil... 1 cefprozil... 1 ceftazidime... 1 CEFTAZIDIME/DEXTROSE... 1 CEFTIN see cefuroxime axetil... 1 ceftriaxone sodium... 1 cefuroxime axetil... 1 cefuroxime sodium... 1 CELEBREX see celecoxib...7 celecoxib...7 CELEXA see citalopram hydrobromide CELLCEPT see mycophenolate mofetil... CELONTIN... 2 cephalexin... 1 CERDELGA... 7 CEREZYME... 7 CERVARIX... cetirizine syrup... 8 CHANTIX CONTINUING MONTH... CHANTIX PAK 0.5& 1MG. CHANTIX TAB 0.5MG... CHANTIX TAB 1MG... CHEMET... 5 chlorhexidine gluconate (mouth-throat) chloroquine phosphate chlorothiazide tabs chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light choline fenofibrate cap dr 15 mg choline fenofibrate cap dr 5 mg ciclopirox... 9 ciclopirox shampoo 1%... 9 cilostazol... 2 CILOXAN... 6 see ciprofloxacin hcl (ophth)... 6 CIMZIA KIT... CIMZIA KIT STARTER... CIMZIA PREFL KIT 200MG/ML... CINRYZE... 2 CIPRO see ciprofloxacin... 1 see ciprofloxacin hcl tab 1 CIPRO I.V.-IN D5W see ciprofloxacin in d5w 1 CIPRO XR see ciprofloxacin er... 1 CIPRODEX ciprofloxacin... 1 ciprofloxacin er... 1 ciprofloxacin hcl (ophth)... 6 ciprofloxacin hcl tab... 1 ciprofloxacin in d5w... 1 ciprofloxacin inj... 1 cisplatin citalopram hydrobromide.. 26 cladribine CLAFORAN see cefotaxime sodium.. 1 claravis... 9 clarithromycin... 1 clarithromycin er... 1 clarithromycin for susp... 1 CLEOCIN see clindamycin cap 00mg see clindamycin cap 75mg see clindamycin hcl cap 150 mg see clindamycin phosphate vaginal... 2 CLEOCIN IN D5W see clindamycin phosphate in d5w CLEOCIN PEDIATRIC GRANULE see clindamycin sol 75mg/5ml CLEOCIN PHOSPHATE see clindamycin phosphate inj CLEOCIN-T see clindamax... 9 see clindamycin phosphate (topical)... 9 CLIMARA see estradiol... 7 clindamax... 9 clindamycin cap 00mg clindamycin cap 75mg clindamycin hcl cap 150 mg clindamycin phosphate (topical)... 9 clindamycin phosphate in d5w clindamycin phosphate inj. 10 clindamycin phosphate vaginal... 2 clindamycin sol 75mg/5ml. 10 CLINIMIX 2.75%/DEXTROSE 5%... 5 CLINIMIX.25%/DEXTROSE 25%... 5 CLINIMIX.25%/DEXTROSE 5%... 5 CLINIMIX 5%/DEXTROSE 15%... 5 CLINIMIX 5%/DEXTROSE 20%... 5 CLINIMIX 5%/DEXTROSE 25%... 5 CLINIMIX INJ.25/D CLINIMIX INJ.25/D clobetasol propionate clobetasol propionate e clomipramine hcl clonazepam... 2, 2 clonidine hcl clopidogrel bisulfate... clorazepate dipotassium... 2 clotrimazole clotrimazole (topical)... 9 clozapine CLOZAPINE clozapine tab 25mg clozapine tab 50mg CLOZARIL see clozapine

59 see clozapine tab 25mg 28 COARTEM COLAZAL see balsalazide disodium... 0 colchicine w/ probenecid...7 COLCRYS...7 COLESTID see colestipol hcl colestipol hcl colistimethate sodium colocort... 0 COLY-MYCIN M see colistimethate sodium COLYTE-FLAVOR PACKS see gavilyte-c... 0 COMBIGAN... 7 COMBIVENT RESPIMAT. 7 COMBIVIR see lamivudine-zidovudine COMETRIQ COMPAZINE see prochlorperazine maleate... 9 COMPLERA compro... 9 COMVAX... CONDYLOX see podofilox constulose... 0 COPAXONE INJ 0MG/ML... 2 COPAXONE KIT 20MG/ML... 2 COPEGUS see moderiba tab 200mg see ribasphere see ribavirin tab 200mg. 12 CORDARONE see amiodarone tab 200mg see pacerone COREG see carvedilol cormax CORTEF see hydrocortisone... 8 CORTENEMA see colocort... 0 cortisone acetate... 8 CORTISPORIN see neomycin-polymyxin-hc (otic) COSOPT see dorzolamide hcl-timolol maleate... 7 COUMADIN... 2 see jantoven... 2 see warfarin sodium... 2 COZAAR see losartan potassium. 19 CREON... 1 CRESTOR CRIXIVAN cromolyn sod neb 20mg/2ml... 8 cromolyn sodium (mastocytosis)... 1 cromolyn sodium (ophth).. 7 cryselle CUBICIN CUTIVATE see fluticasone propionate CUVPOSA... 0 cyclafem 1/5 28 day... 5 cyclafem 7/7/7 28 day... 5 CYCLESSA see velivet 28 day... 7 cyclobenzaprine hcl... 2 cyclophosphamide... 1 CYCLOPHOSPHAMIDE... 1 cycloserine cyclosporine... cyclosporine modified (for microemulsion)... CYKLOKAPRON see tranexamic acid... CYMBALTA see duloxetine hcl CYSTADANE POW... 7 CYSTAGON... 7 cytarabine CYTOMEL see liothyronine sodium 9 CYTOTEC see misoprostol... 1 CYTOVENE see ganciclovir inj 500mg D D.H.E. 5 see dihydroergotamine mesylate... 1 dacarbazine... 1 DALIRESP... 8 danazol... 7 DANTRIUM see dantrolene sodium.. 2 dantrolene sodium... 2 dapsone DAPTACEL... DARAPRIM daunorubicin hcl DDAVP see desmopressin acetate spray... 9 see desmopressin acetate tabs... 9 see desmopressin inj mcg/ml... 9 deblitane 28 day... 5 DELESTROGEN... 7 see estrad val inj 20mg/ml... 7 see estrad val inj 0mg/ml... 7 delyla 28 day... 5 DELZICOL... 0 DEMADEX see torsemide tabs DEMSER DEPACON see valproate sodium DEPAKENE see valproate sodium see valproic acid DEPAKOTE see divalproex sodium.. 2 DEPAKOTE ER 57

60 see divalproex sodium... 2 DEPAKOTE SPRINKLES see divalproex sodium... 2 DEPEN TITRATABS... 5 DEPO-MEDROL see methylpr ace inj 0mg/ml... 8 see methylpr ace inj 80mg/ml... 8 DEPO-PROVERA CONTRACEPTIV see medroxyprogesterone acetate 150 mg/ml... 6 DEPO-PROVERA INJ 00/ML DEPO-TESTOSTERONE see testosterone cypionate... DERMOTIC see fluocinolone acetonide (otic) desipramine hcl desmopressin acetate spray... 9 desmopressin acetate spray refrigerated... 9 desmopressin acetate tabs... 9 desmopressin inj mcg/ml. 9 DESMOPRESSIN SOL 0.01%... 9 DESOGEN see apri 28 day... 5 see emoquette... 5 see reclipsen 28 day... 7 desogestrel-ethinyl estradiol (biphasic)... 5 DETROL see tolterodine tartrate tabs... 2 DETROL LA see tolterodine tartrate cap er... 2 dexamethasone... 8 dexamethasone sodium phosphate... 8 dexamethasone sodium phosphate (ophth)... 7 DEXILANT CAP 0MG DR... 1 DEXILANT CAP 60MG DR... 1 dexrazoxane DEXTROSE 10% FLEX CONTAIN... 5 DEXTROSE 10%/NACL 0.2%... 5 DEXTROSE 10%/NACL 0.5%... 5 DEXTROSE 2.5%/NACL 0.5%... 5 DEXTROSE 5%... 5 DEXTROSE 5% /ELECTROLYTE... 5 DEXTROSE 5%/LACTATED RING... 5 DEXTROSE 5%/NACL 0.2%... 5 DEXTROSE 5%/NACL 0.225%... 5 DEXTROSE 5%/NACL 0.%... 5 DEXTROSE 5%/NACL 0.%... 5 DEXTROSE 5%/NACL 0.5%... 5 DEXTROSE 5%/NACL 0.9%... 5 DEXTROSE 5%/POTASSIUM CHL... 5 DEXTROSE 50%... 5 DEXTROSE INJ 70%... 5 DIAMOX see acetazolamide diazepam... 2 DIAZEPAM GEL (ANTICONVULSANT)... 2 diazepam inj... 2 diclofenac potassium... 7 diclofenac sodium... 7 diclofenac sodium (ophth). 7 dicloxacillin sodium... 1 dicyclomine hcl... 0 didanosine DIFICID... 1 DIFLUCAN see fluconazole diflunisal... 7 digitek digoxin digoxin inj DIGOXIN SOL 50MCG/ML dihydroergotamine mesylate... 1 dilantin... 2 DILANTIN see phenytoin sodium extended DILANTIN INFATABS see phenytoin DILANTIN-125 see phenytoin DILANTIN-125 SUS 125/5ML... 2 DILAUDID see hydromorphone hcl... 8 DILAUDID-HP see hydromorphon inj 10mg/ml... 8 diltiazem cap diltiazem cap 120mg/2hr. 21 diltiazem cap er/12hr diltiazem hcl diltiazem hcl coated beads 21 dilt-xr cap diltzac cap 120mg/ diltzac cap 180mg/ diltzac cap 20mg/ diltzac cap 00mg/ DIOVAN see valsartan DIOVAN HCT see valsartan & hctz tab mg see valsartan & hctz tab mg see valsartan & hctz tab mg see valsartan & hctz tab 20-25mg see valsartan & hctz tab mg DIPENTUM

61 diphenhydramine hcl inj... 8 diphenoxylate w/ atropine. 1 DIPHTHERIA/TETANUS TOXOID... DIPROLENE see betamethasone dipropionate augmented 50 DIPROLENE AF see betamethasone dipropionate augmented 50 disopyramide phosphate disulfiram... DITROPAN XL see oxybutynin chloride. 2 divalproex sodium... 2 docetaxel DOCETAXEL DOLOPHINE see methadone hcl...8 DOLOPHINE HCL see methadone hcl...8 donepezil hydrochloride dorzolamide hcl... 7 dorzolamide hcl-timolol maleate... 7 DOVONEX see calcipotriene... 9 doxazosin mesylate doxepin hcl DOXIL see doxorubicin hcl liposomal doxorubicin hcl for inj 50 mg doxorubicin hcl inj 2 mg/ml 15 doxorubicin hcl liposomal.. 15 doxy... 1 doxycycline (monohydrate)... 1 doxycycline hyclate... 1 dronabinol... 9 drospirenone-ethinyl estradiol... 5 DROXIA duloxetine hcl DURAGESIC see fentanyl patch 100 mcg/hr...8 see fentanyl patch 12 mcg/hr... 7 see fentanyl patch 25 mcg/hr... 8 see fentanyl patch 50 mcg/hr... 8 see fentanyl patch 75 mcg/hr... 8 DURAMORPH... 7 DUREZOL... 7 DYAZIDE see triamterene & hydrochlorothiazide cap mg E e.e.s. 00mg tab... 1 EC-NAPROSYN see naproxen... 7 EDURANT EFFEXOR XR see venlafaxine hcl EFFIENT... EFUDEX see fluorouracil (topical) 50 ELDEPRYL see selegiline hcl ELIDEL CRE 1% ELIMITE see permethrin ELIPHOS see calcium acetate (phosphate binder)... 9 ELIQUIS... 2 ELITEK elixophyllin... 9 ELLA... 5 ELLENCE see epirubicin hcl ELMIRON... 1 ELOCON see mometasone furoate EMCYT... 1 EMEND CAP 125MG... 9 EMEND CAP 0MG... 9 EMEND CAP 80MG... 9 EMEND PAK 80 & EMLA see lidocaine-prilocaine. 50 emoquette... 5 EMSAM EMTRIVA enalapril maleate enalapril maleate & hydrochlorothiazide endocet... 7 ENGERIX-B... enoxaparin sodium... 2 enpresse 28 day... 5 ENTACAPONE entecavir ENTOCORT EC see budesonide ec... 0 enulose... 0 EPIPEN 2-PAK... 8 EPIPEN-JR 2-PAK... 8 epirubicin hcl epitol... 2 EPIVIR see lamivudine EPIVIR HBV see lamivudine (hbv) eplerenone EPZICOM ERIVEDGE errin 28 day... 5 ery pad 2%... 9 ERYGEL see erythromycin (acne aid)... 9 ery-tab... 1 erythrocin lactobionate... 1 erythrocin stearate... 1 erythromycin (acne aid)... 9 erythromycin (ophth)... 6 erythromycin base... 1 erythromycin cap 250mg ec... 1 erythromycin ethylsuccinate... 1 ESBRIET... 8 escitalopram oxalate esomeprazole sodium inj.. 1 estrace... 7 ESTRACE see estradiol

62 estrad val inj 20mg/ml... 7 estrad val inj 0mg/ml... 7 estradiol... 7, 8 ESTROSTEP FE see tri-legest 28 day... 7 ethambutol hcl ethosuximide... 2 ETHYOL see amifostine crystalline etodolac...7 etoposide EURAX EVISTA see raloxifene tab 60mg 9 EVOTAZ EXELON see rivastigmine tartrate 26 EXELON PATCHES exemestane EXFORGE see amlodipine besylate-valsartan tab mg see amlodipine besylate-valsartan tab mg see amlodipine besylate-valsartan tab mg see amlodipine besylate-valsartan tab 5-20 mg EXFORGE HCT see amlodipine-valsartan-hctz tab mg see amlodipine-valsartan-hctz tab mg see amlodipine-valsartan-hctz tab mg see amlodipine-valsartan-hctz tab mg see amlodipine-valsartan-hctz tab mg EXJADE... 5 F FABRAZYME... 7 falmina 28 day... 6 famciclovir famotidine inj... 0 famotidine tab... 0 FAMVIR see famciclovir FANAPT FANAPT TITRATION PACK FARESTON FARXIGA... FARYDAK FASLODEX FAZACLO felbamate... 2 FELBATOL see felbamate... 2 felodipine FEMARA see letrozole fenofibrate fenofibrate micronized fentanyl citrate... 7 fentanyl patch 100 mcg/hr... 8 fentanyl patch 12 mcg/hr... 7 fentanyl patch 25 mcg/hr... 8 fentanyl patch 50 mcg/hr... 8 fentanyl patch 75 mcg/hr... 8 FENTORA... 8 FERRIPROX... 5 FETZIMA... 26, 27 FETZIMA TITRATION PACK finasteride... 1 FIRAZYR... 2 FLAGYL see metronidazole FLEBOGAMMA... FLEBOGAMMA DIF... flecainide acetate FLOMAX see tamsulosin hcl... 1 FLOVENT DISKUS... 8 FLOVENT HFA... 8 fluconazole fluconazole in dextrose fluconazole inj nacl fluconazole inj nacl flucytosine FLUDARA see fludarabine phosphate fludarabine phosphate fludrocortisone acetate... 8 FLUMADINE see rimantadine hydrochloride flunisolide (nasal)... 8 fluocinolone acetonide fluocinolone acetonide (otic) fluocinonide fluocinonide emulsified base FLUOROMETHOLONE... 7 fluorouracil fluorouracil (topical) fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurbiprofen... 7 flurbiprofen sodium... 7 flutamide fluticasone propionate fluticasone propionate (nasal)... 8 fluvoxamine maleate... 2 fondaparinux sodium... 2 FORTAZ see ceftazidime... 1 see tazicef... 1 see tazicef vial... 1 FORTEO... 9 FORTICAL... 8 FOSAMAX see alendronate sodium 5 foscarnet sodium fosinopril sodium fosinopril sodium & hydrochlorothiazide FREAMINE HBC 6.9%... 5 FREAMINE III

63 furosemide furosemide inj FUROSEMIDE INJ FUSILEV FUZEON FYCOMPA... 2 G gabapentin... 2 GABITRIL... 2 see tiagabine hcl galantamine hydrobromide... 25, 26 GAMASTAN S/D... GAMMAGARD LIQUID... GAMMAGARD S/D... GAMMAKED... GAMMAPLEX... GAMUNEX-C... ganciclovir inj 500mg GARAMYCIN see gentamicin sulfate (ophth)... 6 GARDASIL... GARDASIL 9... GASTROCROM see cromolyn sodium (mastocytosis)... 1 gatifloxacin (ophth)... 6 GATTEX... 1 GAUZE PADS 2" X 2"... gaviltye-g... 0 gavilyte-c... 0 gavilyte-h... 0 gavilyte-n... 0 gemcitabine hcl GEMCITABINE HCL gemfibrozil GEMZAR see gemcitabine hcl generlac... 0 gengraf... gentak... 6 gentamicin in saline...9 gentamicin sulfate...9 gentamicin sulfate (ophth). 6 gentamicin sulfate (topical)... 9 GEODON see ziprasidone hcl... 0 GIANVI TAB -0.02MG... 6 gildagia... 6 gildess 1.5/0 21 day... 6 GILENYA CAP 0.5MG... 2 GILOTRIF TAB 20MG GILOTRIF TAB 0MG GILOTRIF TAB 0MG GLEEVEC glimepiride... glip/metform tab mg... glip/metform tab mg... glip/metform tab 5-500mg. glipizide... GLUCAGEN HYPOKIT... 8 GLUCAGON EMERGENCY KIT... 8 GLUCOPHAGE see metformin hcl... GLUCOPHAGE XR see metformin hcl..., 5 GLUCOTROL see glipizide... GLUCOTROL XL see glipizide... glycopyrrolate... 0 GOLYTELY... 0 see gaviltye-g... 0 GRALISE... 2 GRALISE STARTER... 2 granisetron hcl... 9 GRANIX... 2 GRIFULVIN V see griseofulvin microsize griseofulvin microsize griseofulvin ultramicrosize. 11 GRIS-PEG see griseofulvin ultramicrosize guanfacine hcl (adhd)... 1 H HALDOL see haloperidol lactate inj 5mg/ml HALDOL DECANOATE 100 see haloperidol decanoate HALDOL DECANOATE 50 see haloperidol decanoate haloperidol haloperidol decanoate 28, 29 haloperidol lactate conc haloperidol lactate inj 5mg/ml HARVONI HAVRIX... heather... 6 HEPARIN SOD (PORCINE) IN D5W... 2 heparin sod inj 1000/ml... 2 heparin sod inj 10000/ml... 2 HEPARIN SOD INJ 2000/ML... 2 heparin sod inj 20000/ml... 2 HEPARIN SOD INJ 2500/ML... 2 heparin sod inj 5000/ml... 2 HEPARIN SODIUM/D5W. 2 HEPARIN SODIUM/NACL 0.5%... 2 HEPATAMINE... 5 HEPSERA see adefovir dipivoxil HERCEPTIN HETLIOZ... 1 HEXALEN... 1 HIBERIX... HIPREX see methenamine hippurate HUMIRA... HUMIRA KIT 0MG/ HUMIRA PEN... HUMIRA PEN-CROHNS DISEASE... HUMIRA PEN-PSORIASIS STAR... HUMULIN R INJ U HYCAMTIN see topotecan hcl HYCET see 61

64 hydrocodone-acetaminoph en mg/15ml...8 hydralazine hcl HYDREA see hydroxyurea hydrochlorothiazide hydroco/apap tab 10-25mg...8 hydroco/apap tab 5-25mg.8 hydroco/apap tab mg...8 hydrocodone-acetaminophen mg/15ml...8 hydrocodone-ibuprofen mg...8 hydrocortisone... 8 HYDROCORTISONE (INTRARECTAL)... 0 hydrocortisone (topical) hydrocortisone butyrate hydromorphon inj 10mg/ml..8 hydromorphone hcl...8 hydroxychloroquine sulfate... hydroxyurea hydroxyz hcl inj... 8 HYZAAR see losartan potassium & hctz tab mg see losartan potassium & hctz tab mg see losartan potassium & hctz tab mg I ibandronate tab 150mg... 5 IBRANCE ibuprofen...7 ICLUSIG IDAMYCIN PFS see idarubicin hcl idarubicin hcl IFEX... 1 see ifosfamide inj 1gm... 1 IFOSFAMIDE see ifosfamide inj 1gm/20ml see ifosfamide inj gm/60ml ifosfamide inj 1gm... 1 ifosfamide inj 1gm/20ml IFOSFAMIDE INJ GM ifosfamide inj gm/60ml ILEVRO... 7 ilotycin... 6 IMBRUVICA CAP 10MG. 16 imipenem-cilastatin imipramine hcl imiquimod IMITREX see sumatriptan succinate... 2 see sumatriptan succinate inj 6mg/0.5ml... 2 IMITREX STATDOSE SYSTEM see sumatriptan succinate inj 6mg/0.5ml... 2 IMOVAX RABIES (H.D.C.V.)... IMURAN see azathioprine... INCRELEX... 8 INCRUSE ELLIPTA... 7 indapamide INDERAL LA see propranolol cap er INFANRIX... INLYTA INSPRA see eplerenone INSULIN PEN NEEDLE... INSULIN SYRINGE... INTELENCE INTRALIPID INJ 20%... 5 INTRALIPID INJ 0%... 5 INTRON-A INJ 10MU... INTRON-A INJ 18MU... INTRON-A INJ 25MU... INTRON-A INJ 50MU... introvale 91 day... 6 INTUNIV see guanfacine hcl (adhd)... 1 INVANZ INVEGA INVEGA SUST INJ 117MG/0.75ML INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 2MG/1.5ML INVEGA SUST INJ 9MG/0.25ML INVEGA SUST INJ 78MG/0.5ML INVIRASE INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG... INVOKANA... IONOSOL-B/DEXTROSE 5%... 5 IONOSOL-MB/DEXTROSE 5%... 5 IPOL INACTIVATED IPV.. ipratropium bromide... 7 ipratropium bromide (nasal)... 7 ipratropium-albuterol nebu 7 irinotecan hcl ISENTRESS ISOLYTE P... 5 ISOLYTE S... 5 isoniazid isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml ISORDIL TITRADOSE see isosorbide dinitrate. 22 isosorb mononitrate tab isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate er. 22 isradipine ISTALOL... 7 ISTODAX itraconazole ivermectin IXIARO... 62

65 J JAKAFI JALYN... 1 jantoven... 2 JANUMET... JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG... JANUVIA... JENTADUETO... jinteli... 8 JOLESSA TAB MG... 6 JOLIVETTE... 6 junel 1.5/0 21 day... 6 junel 1/20 21 day... 6 junel fe 1.5/0 28 day... 6 junel fe 1/20 28 day... 6 JUXTAPID K KADCYLA KALETRA SOL KALETRA TAB MG 11 KALETRA TAB MG 12 KALYDECO... 8 kariva 28 day... 6 KAYEXALATE see kionex powder... 5 KCL 0.075%/D5W/NACL 0.5%... 5 KCL 0.15%/D5W/NACL 0.9%... 5 KCL 0.%/D5W/NACL 0.5%... 5 KCL 0.%/D5W/NACL 0.9%... 5 KCL IN NACL INJ KCL/D5W INJ 0.%... 5 KCL/D5W/NACL INJ.15/.%... 6 KCL/D5W/NACL INJ.15/.5%... 6 KCL/D5W/NACL INJ 0.22%/0.5%... 6 KCL/NACL INJ 0.15%-0.9%... 6 KCL/NACL INJ KCL0.15%/D5W/NACL0.2%... 5 KCL0.15%/D5W/NACL0.225 %... 5 KEFLEX see cephalexin... 1 kelnor 1/5 28 day... 6 KEPPRA see levetiracetam... 2 see levetiracetam inj... 2 see levetiracetam sol 100mg/ml... 2 KEPPRA XR see levetiracetam... 2 ketoconazole ketoconazole cream... 9 ketoconazole shampoo... 9 ketoprofen... 7 ketorolac tromethamine (ophth)... 7 KEYTRUDA kimidess... 6 KINRIX... kionex powder... 5 kionex susp 15gm/60ml... 5 KLARON see sulfacetamide sodium (acne)... 9 KLONOPIN see clonazepam... 2 KLOR-CON KLOR-CON 8... klor-con m15... klor-con m20... klor-con pow 20meq... KORLYM... 8 KUVAN... 7 KYNAMRO L labetalol hcl LAC-HYDRIN see ammonium lactate.. 50 see laclotion 12% laclotion 12% LACTATED RINGER'S INJ... 6 lactulose... 0 lactulose (encephalopathy)... 0 LAMICTAL see lamotrigine... 2 LAMICTAL CHEWABLE DISPERS see lamotrigine... 2 LAMICTAL XR see lamotrigine... 2 LAMISIL see terbinafine hcl lamivudine lamivudine (hbv) lamivudine-zidovudine lamotrigine... 2 LANOXIN see digitek see digoxin see digoxin inj LANTUS... LANTUS SOLOSTAR... larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ LASIX see furosemide LASTACAFT... 7 latanoprost... 7 LATUDA LEENA TAB... 6 leflunomide... LENVIMA 10MG DAILY DOSE LENVIMA 1MG DAILY DOSE LENVIMA 20MG DAILY DOSE LENVIMA 2MG DAILY DOSE lessina 28 day... 6 LETAIRIS... 2 letrozole leucovorin calcium leucovorin calcium for inj 500 mg

66 LEUKERAN LEUKINE... 2 leuprolide inj 1mg/ LEVAQUIN see levofloxacin... 1 see levofloxacin in d5w.. 1 see levofloxacin oral soln 25 mg/ml... 1 LEVEMIR... LEVEMIR FLEXTOUCH... levetiracetam... 2 levetiracetam inj... 2 LEVETIRACETAM IV... 2 levetiracetam sol 100mg/ml... 2 levobunolol hcl... 7 LEVOBUNOLOL HCL... 7 levocarnitine (metabolic modifiers)... 7 levocetirizine dihydrochloride... 8 levofloxacin... 1 levofloxacin in d5w... 1 levofloxacin inj 25mg/ml... 1 levofloxacin oral soln 25 mg/ml... 1 levoleucovorin calcium levonest 28 day... 6 levonorgestrel & eth estradiol... 6 levonorgestrel (emergency oc)... 6 levonorgestrel-ethinyl estradiol (91-day)... 6 levora 0.15/0 28 day... 6 levothyroxine sodium... 9 LEXAPRO see escitalopram oxalate LEXIVA lidocaine lidocaine hcl lidocaine hcl (local anesth.).9 lidocaine hcl (mouth-throat) lidocaine inj 0.5%...9 lidocaine inj 1%...9 lidocaine inj 1.5%...9 lidocaine inj 2%... 9 lidocaine oint 5% lidocaine-prilocaine LIDODERM see lidocaine linezolid LINEZOLID LINZESS... 1 liothyronine sodium... 9 LIPITOR see atorvastatin calcium 19 lisinopril lisinopril & hydrochlorothiazide lithium carbonate... 2 lithium carbonate er... 2 LITHIUM SOLN 8MEQ/5ML... 2 LITHOBID see lithium carbonate er 2 LOCOID see hydrocortisone butyrate LOESTRIN 1.5/0-21 see gildess 1.5/0 21 day... 6 see junel 1.5/0 21 day. 6 see larin 1.5/ LOESTRIN 1/20-21 see junel 1/20 21 day... 6 see larin 1/ LOESTRIN FE 1.5/0 see junel fe 1.5/0 28 day... 6 see larin fe 1.5/ LOESTRIN FE 1/20 see junel fe 1/20 28 day 6 see larin fe 1/ see tarina fe 1/20 28 day... 7 LOFIBRA see fenofibrate see fenofibrate micronized LOMOTIL see diphenoxylate w/ atropine... 1 LOMUSTINE loperamide hcl... 1 LOPID see gemfibrozil LOPRESSOR see metoprolol tartrate.. 20 LOPRESSOR HCT see metoprolol & hydrochlorothiazide LOPROX SHAMPOO see ciclopirox shampoo 1%... 9 lorazepam... 2 lorcet hd tab 10-25mg... 8 lorcet plus tab lorcet tab 5-25mg... 8 lortab tab 10-25mg... 8 lortab tab 5-25mg... 8 lortab tab loryna 28 day... 6 losartan potassium losartan potassium & hctz tab mg losartan potassium & hctz tab mg losartan potassium & hctz tab mg LOTEMAX... 7 LOTENSIN see benazepril hcl LOTENSIN HCT see benazepril & hydrochlorothiazide LOTREL see amlodipine besylate-benazepril hcl cap mg see amlodipine besylate-benazepril hcl cap 10-0 mg see amlodipine besylate-benazepril hcl cap mg see amlodipine besylate-benazepril hcl cap 5-10 mg see amlodipine besylate-benazepril hcl cap 5-20 mg

67 LOTRONEX see alosetron hcl... 1 lovastatin LOVAZA see omega--acid ethyl esters LOVENOX see enoxaparin sodium. 2 low-ogestrel... 6 loxapine succinate LUMIGAN... 7 LUMIZYME... 7 LUPRON DEPO INJ 11.25MG (-MONTH) LUPRON DEPOT LUPRON DEPOT-PED LUPRON DEP-PED INJ 0MG (-MONTH) lutera 28 day... 6 LYNPARZA LYRICA... 2 LYSODREN LYSTEDA see tranexamic acid... lyza... 6 M MACROBID see nitrofurantoin monohyd macro MACRODANTIN see nitrofurantoin macrocrystal magnesium sulfate... MAGNESIUM SULFATE... MAGNESIUM SULFATE IN D5W... MALARONE see atovaquone-proguanil hcl malathion maprotiline hcl MARINOL see dronabinol... 9 marlissa 28 day... 6 MARPLAN TAB 10MG MATULANE MAVIK see trandolapril MAXALT see rizatriptan benzoate 1 MAXALT-MLT see rizatriptan benzoate 1 MAXIDEX... 7 MAXIPIME see cefepime hcl... 1 MAXITROL see neomycin-polymy-dexamet h... 6 MAXZIDE see triamterene & hydrochlorothiazide MAXZIDE-25 see triamterene & hydrochlorothiazide meclizine hcl... 9 MEDROL see methylpred tab 16mg... 8 see methylpred tab 2mg... 8 see methylpred tab mg 8 see methylpred tab 8mg 8 MEDROL DOSEPAK see methylpred pak mg... 8 medroxyprogesterone acetate 150 mg/ml... 6 medroxyprogesterone acetate tab... 9 mefloquine hcl MEGACE ES MEGACE ORAL see megestrol acetate megestrol acetate MEKINIST meloxicam... 7 MELOXICAM... 7 melphalan hcl memantine hcl MENACTRA... MENOMUNE-A/C/Y/W MENVEO... MEPRON see atovaquone... 9 mercaptopurine meropenem MERREM see meropenem mesalamine enema... 0 mesalamine w/ cleanser... 0 mesna MESNEX see mesna MESTINON see pyridostigmine bromide... 2 metadate tab 20mg er... 1 metformin hcl..., 5 methadone hcl... 8 METHADOSE see methadone hcl... 8 methazolamide methenamine hippurate METHERGINE see methylergonovine maleate... 8 methimazole... 9 methotrexate sodium inj methotrexate sodium tabs methyclothiazide methylergonovine maleate 8 METHYLIN see methylphenidate hcl oral soln... 1 methylphenidate hcl... 1 methylphenidate hcl oral soln... 1 methylpr ace inj 0mg/ml.. 8 methylpr ace inj 80mg/ml.. 8 methylpr ss inj 125mg... 8 methylpr ss inj 1gm... 8 methylpr ss inj 0mg... 8 methylpred pak mg... 8 methylpred tab 16mg... 8 methylpred tab 2mg... 8 methylpred tab mg... 8 methylpred tab 8mg... 8 metipranolol... 7 metoclopramide hcl... 9 metoclopramide hcl inj... 9 metolazone metoprolol & 65

68 hydrochlorothiazide metoprolol succinate metoprolol tartrate METROCREAM see metronidazole (topical) see rosadan cre 0.75%. 50 METROGEL-VAGINAL see metronidazole vaginal... 2 METROLOTION see metronidazole (topical) metronidazole metronidazole (topical) metronidazole gel 0.75%.. 50 metronidazole in nacl metronidazole vaginal... 2 MEVACOR see lovastatin mexiletine hcl MIACALCIN... 8 see calcitonin (salmon).. 8 MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN FE 1.5/0 6 MICROGESTIN FE 1/ MICRO-K see potassium chloride.. MICROZIDE see hydrochlorothiazide 22 midodrine hcl MINIPRESS see prazosin hcl minitran MINOCIN see minocycline hcl... 1 minocycline hcl... 1 minoxidil MIRAPEX see pramipexole dihydrochloride MIRCETTE see desogestrel-ethinyl estradiol (biphasic)... 5 see kariva 28 day... 6 see kimidess... 6 see pimtrea pack... 7 see viorele... 7 mirtazapine misoprostol... 1 mitomycin mitoxantrone hcl M-M-R II... MOBIC see meloxicam... 7 moderiba 800 dose pack moderiba pak 1000/day MODERIBA PAK 1200/DAY moderiba pak 600/day moderiba tab 200mg moexipril hcl moexipril-hydrochlorothiazid e mometasone furoate MONODOX see doxycycline (monohydrate)... 1 MONONESSA... 6 montelukast sodium... 8 morphine ext-rel tab... 8 morphine sul inj... 8 MORPHINE SUL INJ... 8 MORPHINE SUL INJ 2MG/ML... 8 MORPHINE SUL INJ MG/ML... 8 MORPHINE SULFATE... 8, 9 MORPHINE SULFATE ORAL SOL... 9 MOVANTIK... 1 MOVIPREP... 0 MOXEZA... 6 MOZOBIL... 2 MS CONTIN see morphine ext-rel tab.. 8 MULTAQ mupirocin... 9 MUSTARGEN my way... 6 MYAMBUTOL see ethambutol hcl MYCAMINE MYCOBUTIN see rifabutin mycophenolate mofetil... mycophenolate sodium... MYFORTIC see mycophenolate sodium... myorisan... 9 MYOZYME... 7 MYRBETRIQ TAB 25MG.. 1 MYRBETRIQ TAB 50MG.. 1 MYSOLINE see primidone myzilra... 6 N nabumetone... 7 nafcillin sodium... 1 NAGLAZYME... 7 nalbuphine hcl... 7 naloxone inj 0.mg/ml... naloxone inj 1mg/ml... naltrexone hcl... NAMENDA see memantine hcl NAMENDA SOL 10MG/5ML NAMENDA TAB NAMENDA XR NAMENDA XR TITRATION PACK naphazoline 0.1%... 7 NAPROSYN see naproxen... 7 naproxen... 7 naproxen sodium... 7 naratriptan hcl... 1 NARDIL see phenelzine sulfate.. 27 NATACYN... 6 nateglinide... 5 NATPARA... 9 NAVELBINE see vinorelbine tartrate.. 15 NEBUPENT necon 0.5/5 28 day... 6 necon 1/5 28 day... 6 NECON 1/ necon 10/11 28 day... 6 NECON 7/7/ nefazodone hcl

69 neomycin sulfate...9 neomycin-bacitracin zn-polymyxin... 6 neomycin-polymy-dexameth... 6 neomycin-polymyxin-gramici din... 6 neomycin-polymyxin-hc (ophth)... 6 neomycin-polymyxin-hc (otic) NEORAL... see cyclosporine modified (for microemulsion)... see gengraf... NEOSPORIN see neomycin-polymyxin-grami cidin... 6 NEPHRAMINE... 5 NEPTAZANE see methazolamide NEUMEGA... 2 NEUPOGEN... 2 NEUPRO NEURONTIN see gabapentin... 2 NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200mg nevirapine tb NEXAVAR NEXIUM CAP 20MG... 1 NEXIUM CAP 0MG... 1 NEXIUM GRA 10MG DR.. 1 NEXIUM GRA 2.5MG DR. 1 NEXIUM GRA 20MG DR.. 1 NEXIUM GRA 0MG DR.. 1 NEXIUM GRA 5MG DR... 1 NEXIUM I.V. see esomeprazole sodium inj... 1 next choice one dose... 6 niacin er (antihyperlipidemic) niacor NIASPAN see niacin er (antihyperlipidemic) nicardipine hcl NICOTROL INHALER... NICOTROL NS... nifedical nifedipine nifedipine er nikki 28 day... 6 NILANDRON nimodipine NIPENT nitro-bid NITRO-DUR see minitran NITRO-DUR DIS 0.MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystal 10 nitrofurantoin monohyd macro nitroglycerin td patch 2hr 0.1 mg/hr nitroglycerin td patch 2hr 0.2 mg/hr... 2 nitroglycerin td patch 2hr 0. mg/hr... 2 nitroglycerin td patch 2hr 0.6 mg/hr... 2 NITROSTAT... 2 NIZORAL see ketoconazole shampoo... 9 NORA-BE TAB 0.5MG... 6 NORCO see hydroco/apap tab 10-25mg... 8 see hydroco/apap tab 5-25mg... 8 see hydroco/apap tab mg... 8 see lorcet hd tab 10-25mg... 8 see lorcet plus tab see lorcet tab 5-25mg... 8 see lortab tab 10-25mg. 8 see lortab tab 5-25mg... 8 see lortab tab NORDITROPIN FLEXPRO... 8 NORDITROPIN NORDIFLEX PEN... 8 norethindrone (contraceptive)... 6 norethindrone acetate... 9 norethindrone acetate-ethinyl estradiol... 8 norgestimate-ethinyl estradiol (triphasic)... 6 NORINYL 1+5 see cyclafem 1/5 28 day... 5 see necon 1/5 28 day.. 6 see nortrel 1/5 21 day. 6 see nortrel 1/5 28 day. 6 see pirmella 1/5 28 day... 7 norlyroc 28 day... 6 NORMOSOL-M IN D5W... 6 NORMOSOL-R... 6 NORMOSOL-R IN D5W... 6 NORPACE see disopyramide phosphate NORPACE CR NORPRAMIN see desipramine hcl NOR-QD see camila 28 day... 5 see deblitane 28 day... 5 see heather... 6 see norethindrone (contraceptive)... 6 see norlyroc 28 day... 6 nortrel 0.5/5 28 day... 6 nortrel 1/5 21 day... 6 nortrel 1/5 28 day... 6 nortrel 7/7/7 28 day... 6 nortriptyline hcl NORVASC see amlodipine besylate 20 NORVIR NOVOLIN 70/0... NOVOLIN N... NOVOLIN R... 67

70 NOVOLOG... NOVOLOG FLEXPEN... NOVOLOG MIX 70/0... NOVOLOG MIX 70/0 PREFILL... NOVOLOG PENFILL... NOXAFIL NUBAIN see nalbuphine hcl...7 NUCYNTA ER...9 NUEDEXTA... 2 NULOJIX... NULYTELY/FLAVOR PACKS... 0 see gavilyte-n... 0 see peg 50-potassium chloride-sod bicarbonate-sod chloride... 0 see trilyte... 1 NUTRILIPID INJ 20%... 5 NUVARING... 6 NUVIGIL... nyamyc... 9 NYMALIZE nystatin nystatin (mouth-throat) nystatin (topical)... 9 nystop... 9 O OCELLA TAB -0.0MG... 7 OCTAGAM... octreotide acetate... 8 OCUFEN see flurbiprofen sodium. 7 OCUFLOX see ofloxacin (ophth)... 6 OFEV... 8 ofloxacin (ophth)... 6 ofloxacin (otic) olanzapine olopatadine hcl (nasal)... 8 omega--acid ethyl esters. 20 omeprazole... 1 omeprazole cap 20mg... 1 ondansetron hcl... 9 ondansetron hcl inj... 9 ondansetron hcl oral soln.. 9 ondansetron odt... 9 ONFI SOLN ONFI TAB OPANA ER (CRUSH RESISTANT... 9 OPSUMIT... 2 ORAP ORFADIN... 7 ORKAMBI... 8 orsythia 28 day... 7 ORTHO EVRA see xulane... 7 ORTHO MICRONOR see errin 28 day... 5 see lyza... 6 see sharobel 28 day... 7 ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic)... 6 see tri-previfem 28 day.. 7 see tri-sprintec 28 day... 7 ORTHO-CYCLEN see previfem 28 day... 7 see sprintec 28 day... 7 ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day... 5 see nortrel 7/7/7 28 day. 6 OVCON-5 see balziva 28 day... 5 see briellyn 28 day... 5 see gildagia... 6 see philith... 7 see vyfemla 28 day... 7 see zenchent 28 day... 7 OVIDE see malathion oxacillin sodium... 1 oxaliplatin OXANDRIN see oxandrolone tab 10mg... see oxandrolone tab 2.5mg... oxandrolone tab 10mg... oxandrolone tab 2.5mg... oxcarbazepine oxybutynin chloride... 1, 2 oxycodone hcl... 9 OXYCODONE HCL... 9 oxycodone w/ acetaminophen 10-25mg.. 9 oxycodone w/ acetaminophen mg. 9 oxycodone w/ acetaminophen 5-25mg... 9 oxycodone w/ acetaminophen mg. 9 OXYCONTIN... 9 P pacerone paclitaxel PAMELOR see nortriptyline hcl pamidronate disodium... 5 PANRETIN paricalcitol... 6 PARLODEL see bromocriptine mesylate PARNATE see tranylcypromine sulfate paromomycin sulfate... 9 paroxetine hcl paser d/r PATADAY... 7 PATANASE see olopatadine hcl (nasal)... 8 PAXIL see paroxetine hcl PAZEO... 7 PEDIAPRED see pred sod pho sol 5mg/5ml... 8 PEDVAX HIB... PEG 50/ELECTROLYTES... 0 PEG 50-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE... 0 peg 50-potassium chloride-sod bicarbonate-sod chloride

71 PEGANONE PEGINTRON PEG-INTRON PEG-INTRON REDIPEN PENICILLIN G POT IN DEXTROSE... 1 penicillin g procaine... 1 penicillin g sodium... 1 penicillin v potassium... 1 penicilln gk inj 20mu... 1 penicilln gk inj 5mu... 1 PENTAM pentoxifylline... 2 PEPCID see famotidine tab... 0 PERCOCET see endocet...7 see oxycodone w/ acetaminophen 10-25mg...9 see oxycodone w/ acetaminophen mg...9 see oxycodone w/ acetaminophen 5-25mg.9 see oxycodone w/ acetaminophen mg...9 see roxicet tab 5-25mg..9 PERFOROMIST... 8 PERIDEX see chlorhexidine gluconate (mouth-throat) see periogard perindopril erbumine periogard permethrin perphenazine phenadoz... 9 phenelzine sulfate phenergan... 9 PHENERGAN see promethazine hcl... 0 phenobarbital phenobarbital sodium PHENOBARBITAL SODIUM phenytek phenytoin phenytoin sodium phenytoin sodium extended philith... 7 PHOSLO see calcium acetate (phosphate binder)... 9 PHOSPHOLINE IODIDE... 7 PILOCARPINE HCL... 7 pilocarpine hcl (oral) PILOCARPINE HCL (ORAL) pimtrea pack... 7 pindolol pioglitazone hcl... 5 piperacillin sodium-tazobactam sodium... 1 pirmella 1/5 28 day... 7 PLAN B ONE-STEP see levonorgestrel (emergency oc)... 6 see my way... 6 see next choice one dose... 6 PLASMA-LYTE A... 6 PLASMA-LYTE PLASMA-LYTE-56/D5W... 6 PLAVIX see clopidogrel bisulfate PLETAL see cilostazol... 2 podofilox polyethylene glycol polymyxin b-trimethoprim.. 6 POLYTRIM see polymyxin b-trimethoprim... 6 POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP MG POMALYST CAP MG portia 28 day... 7 pot chloride inj 2meq/ml... 6 potassium chloride... POTASSIUM CHLORIDE, 6 potassium chloride in nacl 6 potassium chloride microencapsulated crystals cr... 5 POTASSIUM CITRATE (ALKALINIZER)... 1 POTIGA PRADAXA... 2 pramipexole dihydrochloride PRANDIN see repaglinide... 5 PRAVACHOL see pravastatin sodium. 19 pravastatin sodium prazosin hcl PRECOSE see acarbose... pred sod pho sol 5mg/5ml 8 PREDNISOLONE ACETATE (OPHTH)... 7 prednisolone sodium phosphate (ophth)... 7 prednisolone sol 15mg/5ml... 8 prednisolone sol 25mg/5ml... 8 prednisolone syrup 15 mg/5ml... 8 prednisone con 5mg/ml... 8 prednisone pak 10mg... 8 prednisone pak 5mg... 8 prednisone sol 5mg/5ml... 8 prednisone tab 10mg... 8 prednisone tab 1mg... 8 prednisone tab 2.5mg... 8 prednisone tab 20mg... 8 prednisone tab 50mg... 8 prednisone tab 5mg... 8 premasol 10%... 5 premasol 6%... 5 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)... 6 prevalite previfem 28 day... 7 PREZCOBIX

72 PREZISTA PRIFTIN PRILOSEC see omeprazole... 1 see omeprazole cap 20mg... 1 PRIMAQUINE PHOSPHATE PRIMAXIN IV see imipenem-cilastatin. 10 primidone PRINIVIL see lisinopril PRISTIQ PRIVIGEN... probenecid...7 PROCALAMINE... 5 PROCARDIA XL see nifedical see nifedipine er prochlorperazine inj... 9 prochlorperazine maleate.. 9 prochlorperazine supp... 9 PROCRIT... 2 procto-pak... 9 proctosol hc cre 2.5%... 9 proctozone hc... 9 PROGLYCEM SUS 50MG/ML... 8 PROGRAF... see tacrolimus... PROLASTIN-C... 8 PROLENSA... 7 PROLEUKIN PROLIA... 8 PROMACTA... 2, promethazine hcl... 0 promethegan... 0 propafenone hcl proparacaine hcl... 7 propranolol cap er propranolol hcl propylthiouracil... 9 PROQUAD... PROSCAR see finasteride... 1 PROSOL... 5 PROTOPIC see tacrolimus (topical). 50 protriptyline hcl PROVERA see medroxyprogesterone acetate tab... 9 PROZAC see fluoxetine hcl PRUDOXIN CRE 5%... 9 PULMICORT see budesonide (inhalation)... 8 PULMICORT FLEXHALER... 8 PULMOZYME... 8 PURIXAN pyrazinamide pyridostigmine bromide... 2 Q QUADRACEL... QUALAQUIN see quinine sulfate quasense 91 day... 7 QUESTRAN see cholestyramine QUESTRAN LIGHT see prevalite quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate R RABAVERT... raloxifene tab 60mg... 9 ramipril RANEXA ranitidine hcl... 0 ranitidine hcl inj... 0 ranitidine syrup... 0 RAPAMUNE... see sirolimus... RAVICTI... 7 RAZADYNE see galantamine hydrobromide RAZADYNE ER see galantamine hydrobromide... 25, 26 REBETOL see ribasphere see ribavirin cap 200mg 12 REBETOL SOL 0MG/ML 12 RECLAST see zoledronic acid... 5 reclipsen 28 day... 7 RECOMBIVAX HB... REGLAN see metoclopramide hcl 9 REGRANEX RELENZA DISKHALER RELISTOR... 0 RELPAX... 1 REMERON see mirtazapine REMERON SOLTAB see mirtazapine REMICADE INJ 100MG... REMODULIN... 2 RENVELA PAK 0.8GM... 9 RENVELA PAK 2.GM... 9 RENVELA TAB 800MG... 9 repaglinide... 5 REQUIP see ropinirole hydrochloride RESCRIPTOR RESTASIS... 7 RESTORIL see temazepam... 1 RETIN-A see tretinoin... 9 RETROVIR see zidovudine RETROVIR IV INFUSION. 11 REVATIO... 2 see sildenafil citrate (pulmonary hypertension)... 2 REVIA see naltrexone hcl... REVLIMID... REYATAZ ribapak mis 600/day ribasphere

73 ribasphere ribapak ribasphere ribapak ribasphere ribapak ribavirin cap 200mg ribavirin tab 200mg rifabutin RIFADIN see rifampin rifampin RIFATER RILUTEK see riluzole... 2 riluzole... 2 rimantadine hydrochloride. 12 RINGER'S... 6 RISPERDAL see risperidone RISPERDAL INJ 12.5MG.. 29 RISPERDAL INJ 25MG RISPERDAL INJ 7.5MG.. 29 RISPERDAL INJ 50MG RISPERDAL M-TAB see risperidone... 0 risperidone... 29, 0 RITALIN see methylphenidate hcl 1 RITUXAN rivastigmine tartrate rizatriptan benzoate... 1 ROBINUL see glycopyrrolate... 0 ROBINUL FORTE see glycopyrrolate... 0 ROCALTROL see calcitriol... 6 see calcitriol oral soln 1 mcg/ml... 6 ROCEPHIN see ceftriaxone sodium.. 1 ropinirole hydrochloride rosadan cre 0.75% ROTARIX... ROTATEQ... ROWASA see mesalamine w/ cleanser... 0 roxicet soln...9 roxicet tab 5-25mg...9 ROXICODONE see oxycodone hcl... 9 ROZEREM... 1 RYTHMOL see propafenone hcl RYTHMOL SR see propafenone hcl S SABRIL SALAGEN see pilocarpine hcl (oral) SANDIMMUNE... see cyclosporine... SANDOSTATIN see octreotide acetate... 8 SANDOSTATIN LAR DEPOT... 9 SANTYL SAPHRIS... 0 SECTRAL see acebutolol hcl selegiline hcl selenium sulfide... 9 SELZENTRY SENSIPAR... 5 SEREVENT DISKUS... 8 SEROQUEL see quetiapine fumarate 29 SEROQUEL XR... 0 sertraline hcl sharobel 28 day... 7 SIGNIFOR... 9 sildenafil citrate (pulmonary hypertension)... 2 SILENOR... 1 SILVER SULFADIAZINE.. 9 SIMBRINZA... 7 simvastatin SINEMET see carbidopa-levodopa 28 SINEMET CR see carbidopa-levodopa 28 SINGULAIR see montelukast sodium 8 sirolimus... SIROLIMUS... SIRTURO SIVEXTRO SOD CHLORIDE INJ 0.9%... 6 SODIUM CHLORIDE.. 5, 6 SODIUM CHLORIDE 0.5% VIA... 6 SODIUM CHLORIDE 0.9% SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN... 5 sodium phenylbutyrate... 7 sodium polystyrene sulfonate... 5 SOLIA... 7 SOLTAMOX SOLU-CORTEF... 8 SOLU-MEDROL see methylpr ss inj 125mg... 8 see methylpr ss inj 1gm 8 see methylpr ss inj 0mg... 8 SOMATULINE DEPOT... 9 SOMAVERT... 9 SORIATANE see acitretin... 9 sorine sotalol hcl sotalol hcl (afib/afl) SOVALDI spironolactone spironolactone & hydrochlorothiazide SPORANOX see itraconazole sprintec 28 day... 7 SPRYCEL sps susp 15gm/60ml... 5 sronyx 28 day... 7 SSD... 9 STARLIX see nateglinide... 5 stavudine STERILE WATER IRRIGATION STIVARGA STRATTERA

74 streptomycin sulfate...9 STRIBILD STROMECTOL see ivermectin SUBOXONE MIS 12-MG SUBOXONE MIS 2-0.5MG... SUBOXONE MIS -1MG.. SUBOXONE MIS 8-2MG.. SUCRAID... 1 sucralfate... 1 sulfacet sod oin 10% op... 6 sulfacetamide sodium (acne)... 9 sulfacetamide sodium (ophth)... 6 sulfacetamide sod-prednisolone... 6 sulfadiazine...9 sulfamethoxazole-trimethopri m inj sulfamethoxazole-trimethopri m susp sulfamethoxazole-trimethopri m tab SULFAMYLON... 9 sulfasalazine... 0 sulfasalazine ec... 0 sulindac...7 SUMATRIPTAN... 2 sumatriptan succinate... 2 SUMATRIPTAN SUCCINATE INJ MG/0.5ML... 2 sumatriptan succinate inj 6mg/0.5ml... 2 SUMATRIPTAN SUCCINATE INJ 6MG/0.5ML... 2 suprax... 1 SUPRAX... 1 see cefixime... 1 SUPREP BOWEL PREP... 0 SURMONTIL CAP 100MG 27 SURMONTIL CAP 25MG.. 27 SURMONTIL CAP 50MG.. 27 SUSTIVA SUTENT syeda... 7 SYLATRON KIT 200MCG. 16 SYLATRON KIT 00MCG. 16 SYLATRON KIT 600MCG. 16 SYMBICORT... 8 SYMLINPEN SYMLINPEN SYNAGIS... SYNALAR see fluocinolone acetonide SYNAREL... 7 SYNERCID SYNRIBO SYNTHROID... 9 see levothyroxine sodium... 9 SYPRINE... 5 T TABLOID tacrolimus... tacrolimus (topical) TAFINLAR TAMIFLU tamoxifen citrate tamsulosin hcl... 1 TANZEUM... TAPAZOLE see methimazole... 9 TARCEVA TARGRETIN... 16, 50 tarina fe 1/20 28 day... 7 TASIGNA tazicef... 1 tazicef vial... 1 TAZORAC... 9 taztia TEFLARO... 1 TEGRETOL see carbamazepine... 2 see epitol... 2 TEGRETOL-XR see carbamazepine... 2 TEKTURNA TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB 00-25MG temazepam... 1 TEMOVATE see clobetasol propionate see cormax TEMOVATE E see clobetasol propionate e TENIVAC... TENORETIC 100 see atenolol & chlorthalidone TENORETIC 50 see atenolol & chlorthalidone TENORMIN see atenolol TERAZOL see terconazole vaginal 2 TERAZOL 7 see terconazole vaginal 2 see zazole... 2 terazosin hcl terbinafine hcl terbutaline sulfate... 8 terconazole vaginal... 2 testosterone cypionate... testosterone enanthate... TETANUS/DIPHTHERIA TOXOID... THALOMID... theophylline... 9 thioridazine hcl... 0 thiothixene... 0 tiagabine hcl TIAZAC see diltiazem cap see diltzac cap 120mg/ see diltzac cap 180mg/ see diltzac cap 20mg/ see diltzac cap 00mg/2 72

75 see taztia TIKOSYN CAP 125MCG.. 19 TIKOSYN CAP 250MCG.. 19 TIKOSYN CAP 500MCG.. 19 timolol maleate timolol maleate (ophth)... 7 TIMOLOL MALEATE GEL 7 TIMOPTIC see timolol maleate (ophth)... 7 TIVICAY tizanidine hcl... 2 TOBI see tobramycin...9 TOBRADEX... 6 see tobramycin-dexamethason e... 6 TOBRADEX ST... 6 tobramycin...9 tobramycin (ophth)... 6 tobramycin inj 1.2/0ml...9 tobramycin inj 1.2gm...9 tobramycin inj 10mg/ml...9 tobramycin inj 0mg/ml...9 tobramycin inj 80mg/2ml...9 tobramycin sulfate in saline.9 tobramycin-dexamethasone... 6 TOBREX... 6 see tobramycin (ophth).. 6 TOFRANIL see imipramine hcl tolterodine tartrate cap er.. 2 tolterodine tartrate tabs... 2 TOPAMAX see topiramate TOPAMAX SPRINKLE see topiramate topiramate toposar topotecan hcl TOPROL XL see metoprolol succinate torsemide inj torsemide tabs TOUJEO SOLOSTAR... TOVIAZ... 2 TPN ELECTROLYTES... 5 TRACLEER... 2 TRADJENTA... 5 tramadol hcl... 7 tramadol-acetaminophen... 7 TRANDATE see labetalol hcl trandolapril tranexamic acid... TRANSDERM-SCOP... 0 TRANXENE T see clorazepate dipotassium... 2 tranylcypromine sulfate TRAVASOL... 5 TRAVATAN Z... 7 trazodone hcl TREANDA TRECATOR TRELSTAR DEP INJ.75MG TRELSTAR LA INJ 11.25MG tretinoin... 9 TRETINOIN... 9 tretinoin (chemotherapy) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide triamterene & hydrochlorothiazide cap mg TRIBENZOR TAB MG TRIBENZOR TAB TRIBENZOR TAB MG TRIBENZOR TAB MG TRIBENZOR TAB MG TRICOR see fenofibrate triderm trifluoperazine hcl... 0 trifluridine... 6 tri-legest 28 day... 7 TRILEPTAL see oxcarbazepine TRILIPIX see choline fenofibrate cap dr 15 mg see choline fenofibrate cap dr 5 mg trilyte... 1 trimethoprim TRINESSA... 7 TRI-NORINYL 28 see aranelle tri-previfem 28 day... 7 TRISENOX tri-sprintec 28 day... 7 TRIUMEQ trivora 28 day... 7 TRIZIVIR see abacavir sulfate-lamivudine-zidovud ine TROPHAMINE INJ 10%... 5 trospium chloride... 2 TRULICITY... TRUMENBA... TRUSOPT see dorzolamide hcl... 7 TRUVADA TWINRIX INJ... TYBOST TYGACIL TYKERB TYLENOL/CODEINE # see acetaminophen w/ codeine... 7 TYLENOL/CODEINE # see acetaminophen w/ codeine... 7 TYPHIM VI... TYSABRI... 2 TYZEKA U UCERIS

76 ULORIC...7 ULTRACET see tramadol-acetaminophen.7 ULTRAM see tramadol hcl...7 UNASYN see ampicillin & sulbactam sodium... 1 UNASYN BULK PACK see ampicillin & sulbactam sodium... 1 URECHOLINE see bethanechol chloride... 1 UROXATRAL see alfuzosin hcl... 1 URSO 250 see ursodiol... 1 URSO FORTE see ursodiol... 1 ursodiol... 1 V VAGIFEM... 8 valacyclovir hcl VALCHLOR VALCYTE see valganciclovir hcl valganciclovir hcl VALIUM see diazepam... 2 valproate sodium valproic acid valsartan valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab 20-25mg valsartan & hctz tab mg VALTREX see valacyclovir hcl VANCOCIN HCL see vancomycin hcl vancomycin hcl VANDAZOLE... 2 VAQTA... VARIVAX... VASCEPA VASERETIC see enalapril maleate & hydrochlorothiazide VASOTEC see enalapril maleate VELCADE velivet 28 day... 7 venlafaxine hcl VENTOLIN HFA... 8 verapamil cap er VERAPAMIL CAP ER verapamil hcl verapamil tab er VERELAN see verapamil cap er VERELAN PM see verapamil cap er VERSACLOZ... 0 VESICARE... 2 vestura... 7 VFEND see voriconazole VFEND IV see voriconazole VIBRAMYCIN see doxycycline hyclate. 1 VICOPROFEN see hydrocodone-ibuprofen mg... 8 VICTOZA... VIDAZA see azacitidine VIDEX EC see didanosine VIDEX PEDIATRIC VIGAMOX... 6 VIIBRYD VIMPAT vinblastine sulfate vincasar vincristine sulfate vinorelbine tartrate viorele... 7 VIRACEPT VIRAMUNE see nevirapine tab 200mg VIRAMUNE XR see nevirapine tb VIREAD VIROPTIC see trifluridine... 6 VITEKTA VOLTAREN voriconazole VOTRIENT vyfemla 28 day... 7 W warfarin sodium... 2 WELCHOL WELLBUTRIN see bupropion hcl WELLBUTRIN SR see bupropion hcl WELLBUTRIN XL see bupropion hcl X XALATAN see latanoprost... 7 XALKORI XANAX see alprazolam tab 0.25mg... 2 see alprazolam tab 0.5mg... 2 see alprazolam tab 1mg 2 see alprazolam tab 2 mg... 2 XARELTO... 2 XARELTO STARTER PACK... 2 XENAZINE... 2 XGEVA... 9 XIFAXAN... 1 XOLAIR... 8 XOPENEX HFA... 8 XTANDI xulane... 7 XYLOCAINE see lidocaine hcl

77 see lidocaine hcl (local anesth.)...9 see lidocaine inj 1%...9 see lidocaine inj 2%...9 XYLOCAINE-MPF see lidocaine hcl (local anesth.)...9 see lidocaine inj 0.5%...9 see lidocaine inj 1.5%...9 XYREM... XYZAL see levocetirizine dihydrochloride... 8 Y YASMIN 28 see drospirenone-ethinyl estradiol... 5 see syeda... 7 see zarah... 7 YAZ see loryna 28 day... 6 see nikki 28 day... 6 see vestura... 7 YERVOY YF-VAX... Z zafirlukast... 8 ZANAFLEX see tizanidine hcl... 2 ZANTAC see ranitidine hcl... 0 see ranitidine hcl inj... 0 zarah... 7 ZARONTIN see ethosuximide... 2 ZAVESCA... 7 zazole... 2 ZAZOLE... 2 ZEBETA see bisoprolol fumarate. 20 ZELBORAF ZEMAIRA... 8 ZEMPLAR see paricalcitol... 6 zenatane... 9 zenchent 28 day... 7 ZENPEP... 1 ZERIT see stavudine ZESTORETIC see lisinopril & hydrochlorothiazide ZESTRIL see lisinopril ZETIA ZIAC see bisoprolol & hydrochlorothiazide ZIAGEN see abacavir sulfate zidovudine ZINACEF see cefuroxime sodium. 1 ZINECARD see dexrazoxane ziprasidone hcl... 0 ZIRGAN... 6 ZITHROMAX see azithromycin... 1 ZOCOR see simvastatin ZOFRAN see ondansetron hcl... 9 see ondansetron hcl inj. 9 see ondansetron hcl oral soln... 9 ZOFRAN ODT see ondansetron odt... 9 zoledronic acid... 5 zoledronic inj mg/5ml... 5 ZOLINZA zolmitriptan... 2 zolmitriptan odt... 2 ZOLOFT see sertraline hcl zolpidem tartrate... 1 ZOMETA see zoledronic inj mg/5ml... 5 ZOMIG see zolmitriptan... 2 ZOMIG ZMT see zolmitriptan odt... 2 ZONEGRAN see zonisamide zonisamide ZONTIVITY... ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG.. ZORTRESS TAB 0.75MG ZOSTAVAX... ZOSYN see piperacillin sodium-tazobactam sodium... 1 zovia 1/5e 28 day... 7 zovia 1/50e 28 day... 7 ZOVIRAX see acyclovir see acyclovir topical ZYBAN see buproban... ZYDELIG ZYKADIA ZYLET... 6 ZYLOPRIM see allopurinol tab... 7 ZYMAXID see gatifloxacin (ophth). 6 ZYPREXA see olanzapine ZYPREXA RELPREVV... 0 ZYPREXA RELPREVV 210MG... 0 ZYPREXA ZYDIS see olanzapine ZYTIGA ZYVOX see linezolid

78 P.O. Box 522, Phoenix, AZ This formulary was updated on August 1, For more recent information or other questions, please contact SilverScript at or, for TTY users, 711, 2 hours a day, 7 days a week, or visit The Formulary may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. This information is available for free in other languages. Please call our Customer Care number at (TTY: 711), 2 hours a day, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Cuidado al Cliente, al (teléfono de texto (TTY): 711), las 2 horas del día, los 7 días de la semana. SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript Insurance Company. Enrollment in SilverScript depends on contract renewal.