AvMed Medicare Choice Formulary (List of Covered Drugs)

Transcription

1 AvMed Medicare Choice 2011 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, To get this material in other formats or ask for language translation services, call AvMed Member services at TTY users call HPMS Approved Formulary File 11206, Version 22 Page 1 of 128

2 What is the AvMed Medicare Choice Formulary? A formulary is a list of covered drugs selected by AvMed Medicare Choice 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. AvMed Medicare Choice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a AvMed Medicare Choice network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2011 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and 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 August 1, To get updated information about the drugs covered by AvMed Medicare Choice, please visit our Web site at or call Member Services at , 24 hours a day/7 days a week. TTY/TDD users should call The AvMed Medicare Choice monthly formulary updates include all changes approved by CMS and is posted monthly at You may request a printed formulary by calling , 24 hours a day/7 days a week. TTY/TDD users should call How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. 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 Page 2 of 128

3 to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 113. 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? AvMed Medicare Choice 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: AvMed Medicare Choice requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from AvMed Medicare Choice before you fill your prescriptions. If you don t get approval, AvMed Medicare Choice may not cover the drug. Quantity Limits: For certain drugs, AvMed Medicare Choice limits the amount of the drug that AvMed Medicare Choice will cover. For example, AvMed Medicare Choice provides 30 tablets per prescription for Zetia. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, AvMed Medicare Choice 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, AvMed Medicare Choice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AvMed Medicare Choice 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 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at Page 3 of 128

4 You can ask AvMed Medicare Choice to make an exception to these restrictions or limits. See the section, How do I request an exception to the AvMed Medicare Choice s formulary? on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that AvMed Medicare Choice does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by AvMed Medicare Choice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AvMed Medicare Choice. You can ask AvMed Medicare Choice to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the AvMed Medicare Choice s Formulary? You can ask AvMed Medicare Choice to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AvMed Medicare Choice limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand Name Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Name Drug tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier. Generally, AvMed Medicare Choice will only approve your request for an exception if the alternative drugs included on the plan s formulary, Preferred Brand Name Drug tier 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 are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s or Page 4 of 128

5 prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing physician s supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. You will be allowed to refill any appropriate and necessary drugs upon admission to or discharge from a long-term care facility. For more information For more detailed information about your AvMed Medicare Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AvMed Medicare Choice, please call Member Services at , 24 hours a day/7 days a week. TTY/TDD users should call Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY/TDD users should call Or, visit Page 5 of 128

6 AvMed Medicare Choice Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by AvMed Medicare Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 113. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The second column specifies the cost sharing tiers for your prescribed drugs. There are 4 tiers of cost sharing described as follows: Cost Sharing Tier 1 - Generic drugs Cost Sharing Tier 2 - Preferred brand drugs Cost Sharing Tier 3 Non-preferred brand drugs Cost Sharing Tier 4 Specialty drugs Please refer to your Evidence of Coverage for more information regarding how much you will pay for your prescription drugs. The information in the Notes column tells you if AvMed Medicare Choice has any special requirements for coverage of your drug. QL indicates that there is a quantity limit for the medication. PA indicates that a prior authorization is required before the medication will be covered. B/D indicates this drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. ST indicates that the medication has a step therapy and a preferred medication must first be tried. LA indicates limited availability. This prescription may be available only at certain pharmacies. E indicates this prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. MO indicates this is a medication that can be obtained through mail order. GAP indicates 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. Page 6 of 128

7 Analgesics Opioid Analgesics, Long-Acting AVINZA 24 HR CAP 120 mg, 30 mg, 60 mg, 90 mg AVINZA 24 HR CAP 45 mg, 75 mg 2 QL (30 EA per 30 DURAGESIC TRANSDERM PATCH 3 QL (10 EA per 30 EMBEDA CAP 3 QL (60 EA per 30 EXALGO ER 24 HR TAB 12 mg, 16 mg 3 QL (120 EA per 30 EXALGO ER 24 HR TAB 8 mg 3 QL (30 EA per 30 fentanyl transderm patch 1 GAP; QL (10 EA per 30 KADIAN CAP 2 morphine er tab 1 GAP MS CONTIN TAB 3 OPANA ER 12 HR TAB 3 OXYCONTIN 12 HR TAB 80 mg 2 QL (120 EA per 30 OXYCONTIN 12 HR TAB 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg 2 2 QL (60 EA per 30 tramadol er 24 hr tab 200 mg 1 GAP; QL (60 EA per 30 tramadol er 24 hr tab 100 mg 1 GAP; QL (90 EA per 30 ULTRAM ER 24 HR TAB 200 mg 3 QL (60 EA per 30 ULTRAM ER 24 HR TAB 100 mg 3 QL (90 EA per 30 Opioid Analgesics, Short-Acting ABSTRAL SUBLINGUAL TAB 3 QL (240 EA per 30 acetaminophen-codeine elixir 1 GAP acetaminophen-codeine tab 1 GAP; QL (360 EA per 30 ACTIQ LOZENGE ON A HANDLE 3 QL (120 EA per 30 ASCOMP W/CODEINE CAP 1 GAP; QL (240 EA per 30 buprenorphine sublingual tab 1 GAP codeine-butalbital-acetaminophen-caffeine cap 1 GAP; QL (240 EA per 30 codeine tab 1 GAP CO-GESIC TAB 1 GAP; QL (240 EA per 30 Page 7 of 128

8 COMBUNOX TAB 3 QL (150 EA per 30 DEMEROL TAB 3 DILAUDID TAB 3 DILAUDID-5 ORAL LIQUID 3 DILAUDID-HP INJECTION 3 B/D DOLOPHINE TAB 3 DURAMORPH INJECTION 1 B/D; GAP ENDOCET TAB mg 1 GAP; QL (180 EA per 30 ENDOCET TAB mg 1 GAP; QL (240 EA per 30 ENDOCET TAB mg, mg, mg 1 GAP; QL (360 EA per 30 ENDODAN TAB 1 GAP; QL (360 EA per 30 fentanyl lozenge on a handle 3 QL (120 EA per 30 FENTORA BUCCAL TAB, EFFERVESCENT 3 QL (120 EA per 30 FIORICET-CODEINE CAP 3 QL (240 EA per 30 FIORINAL-CODEINE #3 CAP 3 QL (240 EA per 30 hydrocodone-acetaminophen oral soln mg/15 ml hydrocodone-acetaminophen tab mg, mg hydrocodone-acetaminophen tab mg, mg, mg hydrocodone-acetaminophen tab mg, mg, mg, mg hydrocodone-acetaminophen tab mg, mg, mg 1 GAP 1 GAP; QL (150 EA per 30 1 GAP; QL (180 EA per 30 1 GAP; QL (240 EA per 30 1 GAP; QL (360 EA per 30 hydrocodone-ibuprofen tab 1 GAP; QL (240 EA per 30 hydromorphone tab 1 GAP hydromorphone (pf) injection 1 B/D; GAP ibuprofen-oxycodone tab 1 GAP; QL (150 EA per 30 LORCET 10/650 TAB 3 QL (180 EA per 30 LORCET PLUS TAB 3 QL (180 EA per 30 Page 8 of 128

9 LORTAB TAB 3 QL (240 EA per 30 LORTAB ELIXIR ORAL SOLN 3 MARGESIC-H CAP 1 GAP; QL (240 EA per 30 MAXIDONE TAB 3 QL (150 EA per 30 meperidine oral soln 1 GAP meperidine tab 1 GAP meperidine (pf) pca syringe 1 B/D; GAP methadone injection 1 B/D; GAP methadone oral concentrate 1 GAP methadone oral soln 1 GAP methadone tab 1 GAP METHADOSE TAB 1 GAP morphine injection 1 B/D; GAP morphine tab 1 GAP morphine (pf) injection 1 B/D; GAP morphine concentrate oral 1 GAP NORCO TAB 3 QL (360 EA per 30 ONSOLIS BUCCAL FILM 3 QL (120 EA per 30 OPANA TAB 3 oxycodone cap 1 oxycodone oral concentrate 1 oxycodone tab 1 GAP oxycodone hcl-oxycodone ter-aspirin tab 1 GAP; QL (360 EA per 30 oxycodone-acetaminophen cap 1 GAP; QL (240 EA per 30 oxycodone-acetaminophen tab mg 1 GAP; QL (180 EA per 30 oxycodone-acetaminophen tab mg 1 GAP; QL (240 EA per 30 oxycodone-acetaminophen tab mg, mg, mg, mg oxycodone-aspirin tab 1 oxymorphone tab 1 GAP 1 GAP; QL (360 EA per 30 Page 9 of 128

10 pentazocine-acetaminophen tab 1 GAP; QL (180 EA per 30 pentazocine-naloxone tab 1 GAP; QL (360 EA per 30 PERCOCET TAB mg 3 QL (240 EA per 30 PERCOCET TAB mg, mg, mg 3 QL (360 EA per 30 PERCODAN TAB 3 QL (360 EA per 30 ROXICET ORAL SOLN 3 QL (960 ML per 30 ROXICET TAB mg 1 GAP; QL (360 EA per 30 ROXICET TAB mg 3 QL (240 EA per 30 ROXICODONE TAB 3 SUBOXONE SUBLINGUAL FILM 3 SUBOXONE SUBLINGUAL TAB 3 SUBUTEX SUBLINGUAL TAB 3 TALACEN TAB 3 QL (180 EA per 30 TALWIN NX TAB 3 QL (360 EA per 30 tramadol tab 1 GAP; QL (240 EA per 30 tramadol-acetaminophen tab 1 GAP; QL (240 EA per 30 TYLENOL-CODEINE #3 TAB 3 QL (360 EA per 30 TYLENOL-CODEINE #4 TAB 3 QL (360 EA per 30 TYLOX CAP 3 QL (240 EA per 30 ULTRACET TAB 3 QL (240 EA per 30 ULTRAM TAB 3 QL (240 EA per 30 VICODIN TAB 3 QL (240 EA per 30 VICODIN ES TAB 3 QL (150 EA per 30 VICOPROFEN TAB 3 QL (240 EA per 30 Anesthetics Local Anesthetics EMLA TOPICAL CREAM 3 lidocaine mucosal gel 1 GAP lidocaine mucosal soln 1 GAP Page 10 of 128

11 lidocaine mucous membrane jelly in applicator 1 GAP lidocaine ointment 1 GAP lidocaine-prilocaine topical cream 1 GAP LIDODERM ADHESIVE PATCH 3 QL (90 EA per 30 SYNERA PATCH 2 XYLOCAINE JELLY MUCOSAL GEL 3 Antibacterials Amino Derivative Penicillins amoxicillin cap 1 GAP amoxicillin chewable tab 1 GAP amoxicillin oral susp 1 GAP amoxicillin tab 1 GAP amoxicillin-potassium clavulanate chewable tab 1 GAP amoxicillin-potassium clavulanate er 12 hr tab 1 GAP amoxicillin-potassium clavulanate oral susp 1 GAP amoxicillin-potassium clavulanate tab 1 GAP ampicillin cap 1 GAP ampicillin oral susp 1 GAP ampicillin solution for injection 1 B/D; GAP ampicillin-sulbactam solution for injection 1 B/D; GAP AUGMENTIN ES-600 ORAL SUSP 3 UNASYN SOLUTION FOR INJECTION 3 B/D Aminoglycosides amikacin injection 1 GAP gentamicin eye drops 1 GAP gentamicin injection 1 B/D; GAP gentamicin ointment 1 GAP gentamicin topical cream 1 GAP gentamicin in sodium chloride(iso-osmotic) iv piggy back 70 mg/50 ml 1 B/D Page 11 of 128

12 gentamicin in sodium chloride(iso-osmotic) iv piggy back 100 mg/100 ml, 60 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml gentamicin in sodium chloride(iso-osmotic) iv piggy back 80 mg/50 ml gentamicin in sodium chloride(iso-osmotic) iv piggy back 90 mg/100 ml gentamicin sulfate (pf) iv 3 1 B/D; GAP 1 GAP kanamycin injection 1 B/D; GAP neomycin tab 1 GAP paromomycin cap 1 GAP streptomycin im 3 B/D tobramycin in ns iv piggy back 3 B/D tobramycin eye drops 1 GAP tobramycin injection 1 B/D; GAP Antifolate Antibacterials PRIMSOL ORAL SOLN 2 trimethoprim tab 1 GAP Beta-Lactam, Other AZACTAM SOLUTION FOR INJECTION 3 AZACTAM IN ISO-OSMOTIC DEXTROSE IV PIGGY BACK aztreonam solution for injection 1 GAP INVANZ SOLUTION FOR INJECTION 3 PRIMAXIN IM SUSP 3 PRIMAXIN IV IV SOLUTION 3 Cephalosporin Antibacterials, 1St Generation cefadroxil cap 1 GAP cefadroxil oral susp 1 GAP cefadroxil tab 1 GAP cefazolin solution for injection 1 B/D; GAP cefazolin in dextrose (iso-osmotic) iv piggy back 1 B/D; GAP 3 3 Page 12 of 128

13 cephalexin cap 1 GAP cephalexin oral susp 1 GAP cephalexin tab 1 GAP KEFLEX CAP 250 mg, 500 mg 3 Cephalosporin Antibacterials, 2Nd Generation cefaclor cap 1 GAP cefaclor er 12 hr tab 1 GAP cefaclor oral susp 1 GAP cefoxitin iv solution 1 B/D; GAP cefoxitin in dextrose, iso-osmotic iv piggy back 1 gram/50 ml cefoxitin in dextrose, iso-osmotic iv piggy back 2 gram/50 ml 1 B/D; GAP 1 GAP cefprozil oral susp 1 GAP cefprozil tab 1 GAP CEFTIN ORAL SUSP 125 mg/5 ml 3 CEFTIN TAB 3 cefuroxime axetil oral susp 1 GAP cefuroxime axetil tab 1 GAP cefuroxime sodium iv solution 1 B/D; GAP cefuroxime sodium solution for injection 1 B/D; GAP cefuroxime-dextrose (iso-osmotic) iv piggy back 1 GAP Cephalosporin Antibacterials, 3Rd Generation CEDAX CAP 3 cefdinir cap 1 GAP cefdinir oral susp 1 GAP cefepime solution for injection 1 B/D; GAP cefotaxime solution for injection 500 mg 1 B/D; GAP cefotaxime solution for injection 1 gram, 10 gram, 2 gram 1 GAP cefpodoxime oral susp 1 GAP Page 13 of 128

14 cefpodoxime tab 1 GAP ceftazidime solution for injection 6 gram 1 B/D; GAP ceftazidime solution for injection 1 gram, 2 gram 1 GAP ceftriaxone iv solution 1 B/D; GAP CLAFORAN SOLUTION FOR INJECTION 10 gram, 2 gram CLAFORAN SOLUTION FOR INJECTION 500 mg FORTAZ SOLUTION FOR INJECTION 3 FORTAZ IN D5W IV PIGGY BACK 3 OMNICEF CAP 3 OMNICEF ORAL SUSP 3 SPECTRACEF TAB 3 SUPRAX ORAL SUSP 3 SUPRAX TAB B/D TAZICEF IV SOLUTION 1 GAP TAZICEF SOLUTION FOR INJECTION 1 GAP VANTIN TAB 3 Cephalosporin Antibacterials, 4Th Generation MAXIPIME SOLUTION FOR INJECTION 3 B/D Extended Spectrum Penicillins piperacillin iv solution 1 B/D; GAP piperacillin solution for injection 1 B/D; GAP piperacillin-tazobactam iv solution 4.5 gram 1 B/D piperacillin-tazobactam iv solution gram 1 B/D; GAP TIMENTIN IV SOLUTION 3 B/D ZOSYN IV SOLUTION 3 B/D ZOSYN IN DEXTROSE (ISO-OSMOTIC) IV PIGGY BACK Glycopeptide Antibacterials VANCOCIN CAP 2 3 B/D Page 14 of 128

15 vancomycin iv solution 10 gram 1 B/D; GAP vancomycin iv solution 1,000 mg, 500 mg 3 B/D VIBATIV IV SOLUTION 3 B/D Lincomycin Antibacterials CLEOCIN CAP 150 mg, 300 mg 3 CLEOCIN ORAL SOLUTION 3 CLEOCIN VAGINAL CREAM 3 CLEOCIN VAGINAL SUPPOSITORY 2 CLEOCIN IN D5W IV PIGGY BACK 3 B/D clindamycin cap 1 GAP clindamycin iv 1 B/D; GAP clindamycin vaginal cream 1 GAP CLINDESSE VAGINAL CREAM 3 LINCOCIN INJECTION 3 B/D Macrolides azithromycin iv solution 1 GAP azithromycin oral susp 1 GAP azithromycin tab 250 mg, 500 mg 1 GAP; QL (12 EA per 30 azithromycin tab 600 mg 1 GAP; QL (30 EA per 30 BIAXIN ORAL SUSP 3 BIAXIN TAB 3 BIAXIN XL 24 HR TAB 3 clarithromycin er 24 hr tab 1 GAP clarithromycin oral susp 1 GAP clarithromycin tab 1 GAP DIFICID TAB 3 PA; QL (20 EA per 30 ERY-TAB TAB 2 ERYTHROCIN IV SOLUTION 3 B/D ERYTHROCIN STEARATE TAB 1 GAP erythromycin eye ointment 1 GAP Page 15 of 128

16 erythromycin tab 2 erythromycin ethylsuccinate tab 1 erythromycin-sulfisoxazole oral susp 1 GAP KETEK TAB 3 ZITHROMAX IV SOLUTION 3 ZITHROMAX ORAL SUSP 3 ZITHROMAX TAB 250 mg, 500 mg 3 QL (12 EA per 30 ZITHROMAX TAB 600 mg 3 QL (30 EA per 30 ZITHROMAX TRI-PAK TAB 3 QL (12 EA per 30 ZITHROMAX Z-PAK TAB 3 QL (12 EA per 30 ZMAX ADULT-PEDIATRIC ORAL SUSP 2 Miscellaneous Antibacterials alcohol swabs 2 MO ALTABAX OINTMENT 3 QL (15 GM per 30 BACI-IM IM 1 B/D; GAP bacitracin im 1 B/D; GAP BACTROBAN OINTMENT 3 BACTROBAN TOPICAL CREAM 2 BACTROBAN NASAL OINTMENT 3 colistimethate sodium solution for injection 1 B/D; GAP COLY-MYCIN M PARENTERAL SOLUTION FOR INJECTION 3 B/D CUBICIN IV SOLUTION 3 B/D FLAGYL CAP 3 FLAGYL TAB 3 HIPREX TAB 3 meropenem iv solution 1 GAP MERREM IV SOLUTION 3 methenamine hippurate tab 1 GAP METROCREAM TOPICAL 3 Page 16 of 128

17 METROGEL VAGINAL 3 METROLOTION 3 metronidazole cap 1 GAP metronidazole lotion 1 GAP metronidazole tab 1 GAP metronidazole topical cream 1 GAP metronidazole topical gel 1 GAP metronidazole vaginal gel 1 GAP metronidazole in sodium chloride (iso-osm) iv piggy back MONUROL ORAL PACKET 2 1 GAP mupirocin ointment 1 GAP NEO-FRADIN ORAL SOLN 3 neomycin-polymyxin-hc ear drops, susp 1 GAP neomycin-polymyxin-hc ear soln 1 GAP polymyxin b sulfate solution for injection 1 GAP PREVPAC ORAL PACK 3 SILVADENE TOPICAL CREAM 3 silver sulfadiazine topical cream 1 GAP SSD TOPICAL CREAM 1 GAP SULFATRIM ORAL SUSP 1 GAP TEFLARO IV SOLUTION 4 B/D THERMAZENE TOPICAL CREAM 1 GAP TYGACIL IV SOLUTION 3 B/D VANDAZOLE VAGINAL GEL 1 GAP XIFAXAN TAB 550 mg 3 QL (60 EA per 30 XIFAXAN TAB 200 mg 3 QL (9 EA per 30 Natural Penicillins BICILLIN C-R IM SYRINGE 3 penicillin g pot in dextrose iv piggy back 1 B/D; GAP Page 17 of 128

18 penicillin g potassium solution for injection 1 B/D; GAP penicillin g procaine im syringe 1 B/D; GAP penicillin g sodium solution for injection 1 B/D; GAP penicillin v potassium oral susp 1 GAP penicillin v potassium tab 1 GAP PFIZERPEN-G SOLUTION FOR INJECTION 3 B/D Nitrofuran Antibacterials FURADANTIN ORAL SUSP 3 MACROBID CAP 3 MACRODANTIN CAP 100 mg, 50 mg 3 nitrofurantoin oral susp 1 nitrofurantoin macrocrystal cap 1 GAP nitrofurantoin monohydrate/macrocrystals cap 1 GAP Oxazolidinone Antibacterials ZYVOX IV 2 B/D ZYVOX ORAL SUSP 2 QL (180 ML per 3 ZYVOX TAB 2 QL (6 EA per 3 Penicillinase-Resistant Penicillins dicloxacillin cap 1 GAP nafcillin solution for injection 1 B/D; GAP oxacillin solution for injection 1 GAP oxacillin in dextrose, iso-osmotic iv piggy back 3 B/D Quinolones AVELOX TAB 2 AVELOX ABC PACK TAB 2 AVELOX IN SODIUM CHLORIDE (ISO- OSMOTIC) IV PIGGY BACK CIPRO ORAL SUSP 2 CIPRO TAB 3 CIPRO HC EAR DROPS, SUSP 3 2 B/D Page 18 of 128

19 CIPRODEX EAR DROPS, SUSP 3 QL (7.5 ML per 30 ciprofloxacin eye drops 1 GAP ciprofloxacin iv 1 B/D; GAP ciprofloxacin tab 1 GAP ciprofloxacin er multiphase 24 hr tab 1 GAP FACTIVE TAB 2 LEVAQUIN IV 3 B/D LEVAQUIN ORAL SOLN 3 LEVAQUIN TAB 3 LEVAQUIN IN D5W IV PIGGY BACK 3 B/D levofloxacin oral soln 1 levofloxacin tab 1 levofloxacin in d5w iv piggy back 1 B/D OCUFLOX EYE DROPS 3 ofloxacin ear drops 1 GAP ofloxacin eye drops 1 GAP ofloxacin tab 1 GAP Sulfonamides BACTRIM TAB 3 BACTRIM DS TAB 3 sulfacetamide-prednisolone eye drops 1 GAP sulfadiazine tab 2 sulfamethoxazole-trimethoprim iv 1 B/D; GAP sulfamethoxazole-trimethoprim oral susp 1 GAP sulfamethoxazole-trimethoprim tab 1 GAP Tetracyclines ADOXA TAB 50 mg 3 ADOXA PAK TAB 75 mg 3 demeclocycline tab 1 GAP doxycycline hyclate cap 1 GAP Page 19 of 128

20 doxycycline hyclate cap, delayed release 1 GAP doxycycline hyclate iv solution 100 mg 1 B/D; GAP doxycycline hyclate tab 1 GAP doxycycline hyclate tab, delayed release 1 doxycycline cap 1 doxycycline tab 1 GAP DYNACIN TAB 3 MINOCIN CAP 3 minocycline cap 1 GAP minocycline tab 1 GAP PERIOSTAT TAB 3 tetracycline cap 1 GAP VIBRAMYCIN CAP 3 VIBRA-TABS TAB 3 Anticonvulsants Anticonvulsants, Other BANZEL ORAL SUSP 3 QL (2400 ML per 30 BANZEL TAB 400 mg 3 MO; QL (240 EA per 30 BANZEL TAB 200 mg 3 MO; QL (480 EA per 30 clonazepam tab 2 mg 1 E; QL (120 EA per 30 clonazepam tab 0.5 mg, 1 mg 1 E; QL (90 EA per 30 DIASTAT ACUDIAL RECTAL KIT 3 E; QL (5 EA per 30 KEPPRA IV 3 KEPPRA ORAL SOLN 3 MO KEPPRA TAB 250 mg, 750 mg 3 MO; QL (120 EA per 30 KEPPRA TAB 500 mg 3 MO; QL (180 EA per 30 KEPPRA TAB 1,000 mg 3 MO; QL (90 EA per 30 KEPPRA XR 24 HR TAB 750 mg 2 MO; QL (120 EA per 30 KEPPRA XR 24 HR TAB 500 mg 2 MO; QL (180 EA per 30 levetiracetam iv 1 GAP Page 20 of 128

21 levetiracetam oral soln 1 MO; GAP levetiracetam tab 250 mg, 750 mg 1 MO; GAP; QL (120 EA per 30 levetiracetam tab 500 mg 1 MO; GAP; QL (180 EA per 30 levetiracetam tab 1,000 mg 1 MO; GAP; QL (90 EA per 30 Calcium Channel Modifying Agents CELONTIN CAP 2 MO ethosuximide cap 1 MO; GAP ethosuximide syrup 1 MO; GAP LYRICA CAP 150 mg 3 MO; QL (120 EA per 30 LYRICA CAP 100 mg, 25 mg, 50 mg, 75 mg 3 MO; QL (150 EA per 30 LYRICA CAP 225 mg, 300 mg 3 MO; QL (60 EA per 30 LYRICA CAP 200 mg 3 MO; QL (90 EA per 30 ZARONTIN CAP 3 MO ZARONTIN SYRUP 3 MO ZONEGRAN CAP 3 MO zonisamide cap 1 MO; GAP Gamma-Aminobutyric Acid (Gaba) Augmenting Agents DEPACON IV 3 DEPAKENE CAP 3 MO DEPAKENE SYRUP 3 MO DEPAKOTE TAB 3 MO DEPAKOTE ER 24 HR TAB 3 MO DEPAKOTE SPRINKLES SPRINKLE CAP 3 MO divalproex er 24 hr tab 1 MO; GAP divalproex sprinkle cap 1 MO; GAP divalproex tab, delayed release 1 MO; GAP gabapentin cap 1 MO; GAP gabapentin oral soln 1 QL (2160 ML per 30 Page 21 of 128

22 gabapentin tab 1 MO; GAP GABITRIL TAB 2 MO MYSOLINE TAB 50 mg 3 MYSOLINE TAB 250 mg 3 MO NEURONTIN CAP 3 MO NEURONTIN ORAL SOLN 3 MO; QL (2160 ML per 30 NEURONTIN TAB 3 MO primidone tab 1 MO; GAP SABRIL ORAL POWDER IN PACKET 4 LA; QL (180 EA per 30 SABRIL TAB 4 LA; QL (180 EA per 30 valproate sodium iv 1 GAP valproic acid cap 1 MO; GAP valproic acid (as sodium salt) syrup 1 MO; GAP Glutamate Reducing Agents FELBATOL ORAL SUSP 2 MO FELBATOL TAB 2 MO LAMICTAL TAB 3 MO lamotrigine dispersible tab 1 MO; GAP lamotrigine tab 1 MO; GAP TOPAMAX SPRINKLE CAP 3 MO TOPAMAX TAB 3 MO topiramate sprinkle cap 1 MO; GAP topiramate tab 1 MO; GAP Sodium Channel Inhibitors carbamazepine chewable tab 1 MO; GAP carbamazepine er 12 hr tab 1 MO; GAP carbamazepine er multiphase 12 hr cap 1 carbamazepine oral susp 1 MO; GAP carbamazepine tab 1 MO; GAP CEREBYX INJECTION 3 B/D Page 22 of 128

23 DILANTIN CAP 2 MO DILANTIN EXTENDED CAP 3 MO DILANTIN INFATABS CHEWABLE 2 MO DILANTIN-125 ORAL SUSP 3 MO EPITOL TAB 1 MO; GAP fosphenytoin injection 1 B/D; GAP oxcarbazepine oral susp 1 MO; GAP oxcarbazepine tab 1 MO; GAP PEGANONE TAB 2 MO PHENYTEK CAP 3 MO phenytoin oral susp 1 MO; GAP phenytoin sodium iv 1 B/D; GAP phenytoin sodium extended cap 200 mg, 300 mg 1 GAP phenytoin sodium extended cap 100 mg 1 MO; GAP TEGRETOL CHEWABLE TAB 3 MO TEGRETOL ORAL SUSP 3 MO TEGRETOL TAB 3 MO TEGRETOL XR 12 HR TAB 100 mg 2 MO TEGRETOL XR 12 HR TAB 200 mg, 400 mg 3 MO TRILEPTAL ORAL SUSP 3 MO TRILEPTAL TAB 3 MO VIMPAT IV 3 VIMPAT ORAL SOLN 3 MO; QL (1800 ML per 30 VIMPAT TAB 3 MO; QL (60 EA per 30 Antidementia Agents Antidementia Agents, Other ergoloid tab 1 GAP Cholinesterase Inhibitors ARICEPT TAB 23 mg 2 MO; QL (30 EA per 30 ARICEPT TAB 10 mg, 5 mg 3 MO; QL (30 EA per 30 Page 23 of 128

24 ARICEPT ODT TAB, RAPID DISSOLVE 3 MO; QL (30 EA per 30 COGNEX CAP 3 donepezil tab 1 MO; GAP; QL (30 EA per 30 donepezil tab, rapid dissolve 1 MO; GAP; QL (30 EA per 30 EXELON CAP 3 MO; QL (60 EA per 30 EXELON ORAL SOLN 2 MO; QL (600 ML per 30 EXELON TRANSDERM 24 HR PATCH 2 MO; QL (30 EA per 30 galantamine er 24 hr cap 1 MO; GAP; QL (30 EA per 30 galantamine oral soln 1 MO; GAP; QL (600 ML per 30 galantamine tab 1 MO; GAP; QL (60 EA per 30 RAZADYNE ORAL SOLN 3 MO; QL (600 ML per 30 RAZADYNE TAB 3 MO; QL (60 EA per 30 RAZADYNE ER 24 HR CAP 3 MO; QL (30 EA per 30 rivastigmine cap 1 MO; GAP; QL (60 EA per 30 Glutamate Pathway Modifiers NAMENDA ORAL SOLN 2 MO; QL (300 ML per 30 NAMENDA TAB 2 MO; QL (60 EA per 30 NAMENDA TITRATION PAK TABS IN A DOSE PACK Antidepressants Antidepressants, Other 2 MO BUDEPRION SR TAB 1 MO; GAP; QL (60 EA per 30 BUDEPRION XL 24 HR TAB 300 mg 1 MO; GAP; QL (30 EA per 30 BUDEPRION XL 24 HR TAB 150 mg 1 MO; GAP; QL (90 EA per 30 Page 24 of 128

25 bupropion hcl sr tab 150 mg 1 GAP; QL (60 EA per 30 bupropion hcl sr tab 100 mg, 200 mg 1 MO; GAP; QL (60 EA per 30 bupropion hcl tab 1 MO; GAP maprotiline tab 1 MO; GAP mirtazapine tab 1 MO; GAP mirtazapine tab, rapid dissolve 1 MO; GAP nefazodone tab 100 mg, 150 mg, 250 mg, 50 mg 1 MO; GAP; QL (60 EA per 30 nefazodone tab 200 mg 1 MO; GAP; QL (90 EA per 30 OLEPTRO ER 24 HR TAB 300 mg 3 QL (30 EA per 30 OLEPTRO ER 24 HR TAB 150 mg 3 QL (75 EA per 30 REMERON TAB 3 MO REMERON SOLTAB 3 MO trazodone tab 1 MO; GAP VIIBRYD TAB 3 QL (30 EA per 30 WELLBUTRIN TAB 3 MO WELLBUTRIN SR TAB 3 MO; QL (60 EA per 30 WELLBUTRIN XL 24 HR TAB 300 mg 3 MO; QL (30 EA per 30 WELLBUTRIN XL 24 HR TAB 150 mg 3 MO; QL (90 EA per 30 Monoamine Oxidase Inhibitors EMSAM TRANSDERM 24 HR PATCH 3 MO; QL (30 EA per 30 MARPLAN TAB 3 MO PARNATE TAB 3 MO tranylcypromine tab 1 MO; GAP Serotonin/ Norepinephrine Reuptake Inhibitors CYMBALTA CAP 60 mg 2 MO; QL (30 EA per 30 CYMBALTA CAP 20 mg, 30 mg 2 MO; QL (60 EA per 30 EFFEXOR TAB 3 MO; QL (90 EA per 30 EFFEXOR XR 24 HR CAP 150 mg, 37.5 mg 3 MO; QL (30 EA per 30 Page 25 of 128

26 EFFEXOR XR 24 HR CAP 75 mg 3 MO; QL (90 EA per 30 PRISTIQ 24 HR TAB 3 MO; QL (30 EA per 30 SAVELLA TAB 2 QL (60 EA per 30 SAVELLA TABS IN A DOSE PACK 2 QL (55 EA per 28 venlafaxine er 24 hr cap 150 mg, 37.5 mg 1 MO; GAP; QL (30 EA per 30 venlafaxine er 24 hr cap 75 mg 1 MO; GAP; QL (90 EA per 30 venlafaxine er 24 hr tab 150 mg, 225 mg 2 MO; QL (30 EA per 30 venlafaxine er 24 hr tab 37.5 mg, 75 mg 2 MO; QL (90 EA per 30 venlafaxine tab 75 mg 1 MO; GAP; QL (150 EA per 30 venlafaxine tab 100 mg, 25 mg, 37.5 mg, 50 mg 1 MO; GAP; QL (90 EA per 30 Tricyclics amitriptyline tab 1 MO; GAP amoxapine tab 1 MO; GAP ANAFRANIL CAP 3 MO clomipramine cap 1 MO; GAP desipramine tab 1 MO; GAP doxepin cap 1 MO; GAP doxepin oral concentrate 1 MO; GAP imipramine tab 1 MO; GAP imipramine pamoate cap 1 MO; GAP NORPRAMIN TAB 3 MO nortriptyline cap 1 MO; GAP nortriptyline oral soln 1 MO; GAP PAMELOR CAP 3 MO perphenazine-amitriptyline tab 1 MO; GAP protriptyline tab 1 MO; GAP SURMONTIL CAP 3 Page 26 of 128

27 TOFRANIL TAB 3 MO VIVACTIL TAB 3 MO Antidotes, Deterrents, And Toxicologic Agents Alcohol Deterrents ANTABUSE TAB 2 CAMPRAL TAB 2 disulfiram tab 1 Antidotes acetylcysteine soln 1 GAP amifostine crystalline iv solution 1 GAP ANTIZOL IV 3 B/D ETHYOL IV SOLUTION 3 EXJADE TAB 2 LA fomepizole iv 1 B/D; GAP leucovorin calcium solution for injection 1 B/D; GAP leucovorin calcium tab 1 MO; GAP mesna iv 1 B/D; GAP MESNEX TAB 2 MO sodium polystyrene sulfonate oral powder 1 GAP SYPRINE CAP 2 Opioid Antagonists DEPADE TAB 1 GAP naloxone syringe 1 B/D; GAP naltrexone tab 1 GAP REVIA TAB 3 Smoking Cessation Agents CHANTIX TAB 3 CHANTIX STARTING MONTH PAK TABS IN A DOSE PACK NICOTROL INHALATION CARTRIDGE 2 3 Page 27 of 128

28 NICOTROL NS NASAL SPRAY 2 Antiemetics 5-Hydroxytryptamine 3 (5-Ht3) Antagonists ANZEMET TAB 100 mg 3 B/D; QL (4 EA per 30 ANZEMET TAB 50 mg 3 B/D; QL (8 EA per 30 granisetron tab 1 B/D; GAP; QL (30 EA per 30 GRANISOL ORAL SOLN 1 B/D; GAP KYTRIL TAB 3 B/D; QL (30 EA per 30 ondansetron tab, rapid dissolve 1 B/D; GAP; QL (45 EA per 30 ondansetron hcl oral soln 1 B/D; GAP; QL (450 ML per 30 ondansetron hcl tab 24 mg 1 B/D; GAP; QL (15 EA per 30 ondansetron hcl tab 4 mg, 8 mg 1 B/D; GAP; QL (45 EA per 30 ondansetron hcl (pf) injection 1 GAP ZOFRAN IV 3 ZOFRAN ORAL SOLN 3 B/D; QL (450 ML per 30 ZOFRAN TAB 3 B/D; QL (45 EA per 30 ZOFRAN ODT TAB, RAPID DISSOLVE 3 B/D; QL (45 EA per 30 Antiemetics, Other CESAMET CAP 3 QL (60 EA per 30 COMPRO RECTAL SUPPOSITORY 1 MO; GAP dronabinol cap 1 GAP; QL (120 EA per 30 MARINOL CAP 3 QL (120 EA per 30 metoclopramide oral soln 1 GAP metoclopramide tab 1 GAP PHENADOZ RECTAL SUPPOSITORY 1 GAP PHENERGAN INJECTION 3 B/D prochlorperazine rectal suppository 1 MO; GAP Page 28 of 128

29 prochlorperazine edisylate injection 1 GAP prochlorperazine maleate tab 1 MO; GAP promethazine injection 1 B/D; GAP promethazine rectal suppository 1 GAP promethazine syringe 1 B/D; GAP promethazine syrup 1 GAP promethazine tab 1 GAP PROMETHAZINE VC SYRUP 1 GAP PROMETHEGAN RECTAL SUPPOSITORY 1 GAP REGLAN TAB 3 SANCUSO TRANSDERM PATCH 3 QL (4 EA per 28 TIGAN CAP 3 TIGAN IM 3 B/D TRANSDERM-SCOP 72 HR TRANSDERM PATCH trimethobenzamide cap 1 GAP trimethobenzamide im syringe 1 B/D; GAP Neurokinin 1 (Nk1) Receptor Antagonists EMEND CAP 2 QL (6 EA per 30 EMEND CAPS IN DOSE PACK 2 QL (6 EA per 30 Antifungals Allylamine Antifungals LAMISIL TAB 3 QL (30 EA per 30 NAFTIN TOPICAL CREAM 2 NAFTIN TOPICAL GEL 2 terbinafine tab 1 GAP; QL (30 EA per 30 Antifungals (Other) ANCOBON CAP 3 ciclopirox shampoo 1 GAP ciclopirox topical cream 1 GAP 3 Page 29 of 128

30 ciclopirox topical gel 1 GAP ciclopirox topical soln 1 GAP ciclopirox topical susp 1 GAP GRIFULVIN V TAB 3 griseofulvin microsize oral susp 1 GAP LOPROX SHAMPOO 3 LOPROX TOPICAL GEL 3 PENLAC TOPICAL SOLN 3 Azole Antifungals clotrimazole topical cream 1 GAP clotrimazole troche 1 GAP clotrimazole-betamethasone lotion 1 GAP clotrimazole-betamethasone topical cream 1 GAP DIFLUCAN ORAL SUSP 3 DIFLUCAN TAB 100 mg, 200 mg, 50 mg 3 DIFLUCAN TAB 150 mg 3 QL (4 EA per 30 econazole topical cream 1 GAP EXELDERM TOPICAL CREAM 3 EXELDERM TOPICAL SOLN 3 fluconazole oral susp 1 GAP fluconazole tab 100 mg, 200 mg, 50 mg 1 GAP fluconazole tab 150 mg 1 GAP; QL (4 EA per 30 fluconazole in dextrose (iso-osmotic) iv piggy back 1 B/D; GAP itraconazole cap 1 PA; GAP ketoconazole shampoo 1 GAP ketoconazole tab 1 GAP ketoconazole topical cream 1 GAP KURIC TOPICAL CREAM 1 GAP LOTRISONE LOTION 3 Page 30 of 128

31 LOTRISONE TOPICAL CREAM 3 MICONAZOLE-3 VAGINAL SUPPOSITORY 1 GAP NIZORAL SHAMPOO 3 NOXAFIL ORAL SUSP 2 PA OXISTAT LOTION 3 OXISTAT TOPICAL CREAM 3 SPORANOX CAP 3 PA TERAZOL 3 VAGINAL CREAM 3 QL (40 GM per 30 TERAZOL 3 VAGINAL SUPPOSITORY 3 QL (12 EA per 30 TERAZOL 7 VAGINAL CREAM 3 QL (90 GM per 30 terconazole vaginal cream 0.8 % 1 GAP; QL (40 GM per 30 terconazole vaginal cream 0.4 % 1 GAP; QL (90 GM per 30 terconazole vaginal suppository 1 GAP; QL (12 EA per 30 VFEND ORAL SUSP 3 QL (300 ML per 30 VFEND TAB 50 mg 3 QL (120 EA per 30 VFEND TAB 200 mg 3 QL (60 EA per 30 VFEND IV SOLN 4 B/D voriconazole tab 50 mg 1 QL (120 EA per 30 voriconazole tab 200 mg 1 QL (60 EA per 30 ZAZOLE VAGINAL CREAM 0.8 % 1 GAP; QL (40 GM per 30 ZAZOLE VAGINAL CREAM 0.4 % 1 GAP; QL (90 GM per 30 ZAZOLE VAGINAL SUPPOSITORY 1 GAP Echinocandin Antifungals CANCIDAS IV SOLUTION 3 B/D ERAXIS(WATER DILUENT) IV SOLUTION 3 B/D Polyene Antifungals NATACYN EYE DROPS 3 nystatin ointment 1 GAP nystatin oral susp 1 GAP nystatin tab 1 GAP Page 31 of 128

32 nystatin topical cream 1 GAP nystatin topical powder 1 GAP nystatin-triamcinolone ointment 1 GAP nystatin-triamcinolone topical cream 1 GAP NYSTOP TOPICAL POWDER 1 GAP PEDI-DRI TOPICAL POWDER 1 GAP Antigout Agents Antigout Agents (Non-Renal Tubular Blocking Agents And Non-Xanthine Inhibitors) COLCRYS TAB 3 MO; QL (120 EA per 30 Renal Tubular Blocking Agents colchicine-probenecid tab 1 MO; GAP probenecid tab 1 MO; GAP Xanthine Oxidase Inhibitors allopurinol tab 1 MO; GAP allopurinol iv solution 1 B/D; GAP ALOPRIM IV SOLUTION 3 B/D; MO ULORIC TAB 2 MO; QL (30 EA per 30 ZYLOPRIM TAB 3 MO Anti-Inflammatory Agents Nonsteroidal Anti-Inflammatory Drugs ANAPROX TAB 3 ANAPROX DS TAB 3 ARTHROTEC 50 TAB 3 ARTHROTEC 75 TAB 3 CATAFLAM TAB 3 CELEBREX CAP 3 QL (60 EA per 30 CLINORIL TAB 3 DAYPRO TAB 3 diclofenac potassium tab 1 GAP diclofenac sodium er 24 hr tab 1 GAP Page 32 of 128

33 diclofenac sodium tab, delayed release 1 GAP diflunisal tab 1 GAP EC-NAPROSYN TAB 3 etodolac cap 1 GAP etodolac er 24 hr tab 1 GAP etodolac tab 1 GAP FELDENE CAP 3 fenoprofen tab 1 GAP FLECTOR ADHESIVE PATCH 3 QL (60 EA per 30 flurbiprofen tab 1 GAP ibuprofen tab 1 GAP indomethacin cap 1 GAP indomethacin er cap 1 GAP ketoprofen cap 1 GAP ketoprofen er 24 hr cap 1 GAP ketorolac injection 1 B/D; GAP ketorolac tab 1 GAP; QL (20 EA per 30 meclofenamate cap 3 meloxicam oral susp 1 GAP; QL (300 ML per 30 meloxicam tab 1 GAP; QL (30 EA per 30 MOBIC TAB 3 QL (30 EA per 30 nabumetone tab 1 GAP NALFON CAP 400 mg 3 NAPROSYN ORAL SUSP 3 NAPROSYN TAB 3 naproxen oral susp 1 GAP naproxen tab 500 mg 1 naproxen tab 250 mg, 375 mg 1 GAP naproxen tab, delayed release 1 GAP naproxen sodium tab 1 GAP Page 33 of 128

34 oxaprozin tab 1 GAP piroxicam cap 1 GAP sulindac tab 1 GAP tolmetin cap 1 GAP tolmetin tab 1 GAP VOLTAREN TAB 3 VOLTAREN TOPICAL GEL 3 VOLTAREN-XR 24 HR TAB 3 Antimigraine Agents Ergot Alkaloids CAFERGOT TAB 3 QL (40 EA per 30 D.H.E.45 INJECTION 3 B/D dihydroergotamine injection 1 B/D; GAP ergotamine-caffeine tab 1 GAP; QL (40 EA per 30 MIGERGOT RECTAL SUPPOSITORY 1 GAP; QL (20 EA per 28 MIGRANAL NASAL SPRAY 3 QL (16 ML per 30 Triptans AMERGE TAB 3 QL (9 EA per 30 FROVA TAB 3 QL (12 EA per 30 IMITREX SUB-Q 3 QL (6 ML per 30 IMITREX TAB 3 QL (9 EA per 30 MAXALT TAB 2 QL (12 EA per 30 MAXALT-MLT TAB, RAPID DISSOLVE 2 QL (12 EA per 30 naratriptan tab 1 GAP; QL (9 EA per 30 RELPAX TAB 2 QL (9 EA per 30 sumatriptan sub-q 6 mg/0.5 ml 1 GAP; QL (6 ML per 30 sumatriptan sub-q pen injector 1 QL (6 ML per 30 sumatriptan tab 1 GAP; QL (9 EA per 30 ZOMIG NASAL SPRAY 3 QL (6 EA per 30 ZOMIG TAB 3 QL (9 EA per 30 Page 34 of 128

35 ZOMIG ZMT TAB, RAPID DISSOLVE 3 QL (9 EA per 30 Antimyasthenic Agents Parasympathomimetics guanidine tab 1 GAP MESTINON SYRUP 3 MESTINON TAB 3 MYTELASE TAB 3 pyridostigmine bromide tab 1 GAP Antimycobacterials Antimycobacterials, Other ACZONE TOPICAL GEL 3 dapsone tab 2 MYCOBUTIN CAP 2 Antituberculars CAPASTAT SOLUTION FOR INJECTION 3 B/D ethambutol tab 1 GAP ISONARIF CAP 1 GAP isoniazid injection 1 GAP isoniazid syrup 1 GAP isoniazid tab 1 GAP MYAMBUTOL TAB 3 PASER ORAL PACKET 2 PRIFTIN TAB 2 pyrazinamide tab 1 GAP RIFADIN CAP 3 RIFADIN IV SOLUTION 3 B/D RIFAMATE CAP 3 rifampin cap 1 GAP rifampin iv solution 1 B/D; GAP RIFATER TAB 2 Page 35 of 128

36 SEROMYCIN CAP 2 TRECATOR TAB 2 Antineoplastics Alkylating Agents, Other BUSULFEX IV 3 B/D carboplatin iv 1 B/D; GAP cisplatin iv 1 B/D; GAP cyclophosphamide tab 1 MO; GAP dacarbazine iv solution 1 B/D; GAP ifosfamide iv solution 1 B/D; GAP ifosfamide-mesna iv kit 4 B/D MATULANE CAP 4 oxaliplatin soln 1 B/D; GAP thiotepa solution for injection 3 B/D TREANDA IV SOLUTION 4 B/D vinblastine iv powder for solution 2 B/D vincristine iv 1 B/D; GAP Antiangiogenic Agents REVLIMID CAP 4 LA; QL (30 EA per 30 THALOMID CAP 4 Anti-Cd20 Antibodies ARZERRA IV 4 B/D AVASTIN IV 3 B/D CAMPATH IV 2 B/D; LA ERBITUX IV 2 B/D RITUXAN CONCENTRATE, IV 4 B/D; LA SIMULECT IV SOLUTION 4 B/D VECTIBIX IV 3 B/D Antimetabolites, Other ALIMTA IV SOLUTION 4 B/D Page 36 of 128

37 DROXIA CAP 2 fluorouracil iv 1 B/D; GAP HYDREA CAP 3 MO hydroxyurea cap 1 MO; GAP idarubicin iv 1 B/D; GAP Antineoplastics, Other ABRAXANE IV SOLUTION 2 B/D ADRIAMYCIN PFS IV 1 B/D; GAP bleomycin solution for injection 2 B/D COSMEGEN IV SOLUTION 2 B/D daunorubicin iv solution 2 B/D DAUNOXOME IV 2 B/D DOCEFREZ IV SOLUTION 4 B/D docetaxel iv 4 B/D DOXIL IV 3 B/D doxorubicin iv 1 B/D; GAP ELSPAR SOLUTION FOR INJECTION 2 B/D epirubicin iv 1 B/D; GAP ETOPOPHOS IV SOLUTION 2 B/D etoposide iv 1 B/D; GAP HALAVEN IV 3 B/D HYCAMTIN IV SOLUTION 4 B/D irinotecan iv 1 B/D; GAP ISTODAX IV SOLUTION 4 B/D IXEMPRA IV SOLUTION 4 B/D JEVTANA IV 4 PA LYSODREN TAB 2 MO mitomycin iv solution 1 B/D; GAP mitoxantrone concentrate, iv 1 B/D; GAP NOVANTRONE CONCENTRATE, IV 3 B/D Page 37 of 128

38 ONCASPAR INJECTION 2 B/D ONTAK IV 2 B/D paclitaxel concentrate, iv 1 B/D; GAP PANRETIN TOPICAL GEL 2 PHOTOFRIN IV SOLUTION 4 B/D SYLATRON SUB-Q KIT 4 PA TAXOTERE IV 4 B/D topotecan iv solution 4 B/D TORISEL IV SOLUTION 4 B/D TRISENOX IV 2 B/D VELCADE IV SOLUTION 2 B/D vinorelbine iv 1 B/D; GAP ZANOSAR IV SOLUTION 2 B/D ZOLINZA CAP 4 QL (120 EA per 30 ZYTIGA TAB 4 PA Aromatase Inhibitors, 3Rd Generation anastrozole tab 1 MO; GAP ARIMIDEX TAB 3 MO AROMASIN TAB 3 MO exemestane tab 1 FEMARA TAB 3 MO letrozole tab 1 Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors IRESSA TAB 4 LA; QL (30 EA per 30 TARCEVA TAB 4 vandetanib tab 4 PA; LA Estrogen-Nitrosoureas EMCYT CAP 3 MO FASLODEX IM SYRINGE 4 B/D Ethylenimines/ Methylmelamines Page 38 of 128

39 HEXALEN CAP 4 Multitargeted Kinase Inhibitors, Bcr-Abl/C-Kit Receptor Tyrosine Kinase Inhibitors GLEEVEC TAB 4 SPRYCEL TAB 100 mg 4 MO; QL (30 EA per 30 SPRYCEL TAB 50 mg 4 QL (120 EA per 30 SPRYCEL TAB 140 mg, 80 mg 4 QL (30 EA per 30 SPRYCEL TAB 20 mg, 70 mg 4 QL (60 EA per 30 TASIGNA CAP 4 QL (112 EA per 28 Multitargeted Kinase Inhibitors, Her2 Receptor Tyrosine Kinase Inhibitors HERCEPTIN IV SOLUTION 4 B/D TYKERB TAB 4 QL (150 EA per 30 Multitargeted Kinase Inhibitors, Vascular Endothelial Growth Factor Receptor Tyrosine Kinase Inhib. AFINITOR TAB 4 QL (30 EA per 30 NEXAVAR TAB 4 LA; QL (120 EA per 30 SUTENT CAP 4 VOTRIENT TAB 4 MO; QL (120 EA per 30 ZORTRESS TAB 2 B/D; QL (60 EA per 30 Nitrogen Mustards LEUKERAN TAB 2 MO melphalan iv solution 1 B/D; GAP MUSTARGEN SOLUTION FOR INJECTION 2 B/D Nitrosoureas BICNU IV SOLUTION 3 B/D CEENU CAP 3 MO Purine Analogs And Related Inhibitors ARRANON IV 3 B/D cladribine iv 1 B/D; GAP CLOLAR IV 2 B/D cytarabine (pf) solution for injection 1 B/D; GAP DACOGEN IV SOLUTION 4 B/D Page 39 of 128

40 fludarabine iv powder for solution 1 B/D; GAP gemcitabine iv solution 1 B/D GEMZAR IV SOLUTION 3 B/D mercaptopurine tab 1 MO; GAP pentostatin iv solution 1 B/D; GAP PURINETHOL TAB 3 MO TABLOID TAB 3 MO VIDAZA SUB-Q SOLN 2 B/D Retinoids TARGRETIN CAP 4 TARGRETIN TOPICAL GEL 2 tretinoin (chemotherapy) cap 1 MO; GAP Selective Estrogen Receptor Modulators, 1St Generation FARESTON TAB 3 MO tamoxifen tab 1 MO; GAP Antiparasitics Anthelmintics ALBENZA TAB 3 BILTRICIDE TAB 3 mebendazole chewable tab 1 GAP Antimalarials ARALEN TAB 3 chloroquine tab 1 GAP COARTEM TAB 2 QL (24 EA per 31 DARAPRIM TAB 2 hydroxychloroquine tab 1 MO; GAP PLAQUENIL TAB 3 MO QUALAQUIN CAP 2 PA Antiprotozoals (Non-Antimalarials) ALINIA ORAL SUSP 3 QL (60 ML per 7 Page 40 of 128

41 ALINIA TAB 3 QL (60 EA per 30 MEPRON ORAL SUSP 2 NEBUPENT SOLUTION FOR INHALATION 3 PENTAM SOLUTION FOR INJECTION 3 B/D Pediculicides/ Scabicides EURAX LOTION 3 EURAX TOPICAL CREAM 3 OVIDE LOTION 3 permethrin topical cream 1 GAP Antiparkinson Agents Anticholinergics benztropine tab 1 MO; GAP trihexyphenidyl elixir 1 MO; GAP trihexyphenidyl tab 1 MO; GAP Antiparkinson Agents, Other amantadine cap 1 MO; GAP amantadine syrup 1 MO; GAP amantadine tab 1 MO; GAP APOKYN SUBQ CARTRIDGE 4 LA; QL (60 ML per 30 Catechol O-Methyltransferase (Comt) Inhibitors COMTAN TAB 2 MO TASMAR TAB 2 MO Dopamine Agonists, Ergot bromocriptine cap 1 MO; GAP bromocriptine tab 1 MO; GAP cabergoline tab 1 GAP PARLODEL CAP 3 MO PARLODEL TAB 3 MO Dopamine Agonists, Nonergot MIRAPEX TAB 3 MO Page 41 of 128

42 MIRAPEX ER 24 HR TAB mg, 0.75 mg, 1.5 mg, 3 mg 3 MO MIRAPEX ER 24 HR TAB 4.5 mg 3 MO; QL (30 EA per 30 pramipexole tab 1 MO; GAP REQUIP TAB 3 MO REQUIP XL 24 HR TAB 12 mg, 6 mg, 8 mg 2 MO; QL (60 EA per 30 REQUIP XL 24 HR TAB 2 mg, 4 mg 2 MO; QL (90 EA per 30 ropinirole tab 1 MO; GAP Dopamine Precursors carbidopa-levodopa er tab 1 MO; GAP carbidopa-levodopa tab 1 MO; GAP PARCOPA TAB, RAPID DISSOLVE mg, mg 3 MO SINEMET TAB 3 MO SINEMET CR TAB 3 MO STALEVO 100 TAB 2 MO STALEVO 125 TAB 2 MO STALEVO 150 TAB 2 MO STALEVO 200 TAB 2 MO STALEVO 50 TAB 2 MO STALEVO 75 TAB 2 MO Monoamine Oxidase B (Mao-B) Inhibitors AZILECT TAB 2 MO; QL (30 EA per 30 ELDEPRYL CAP 3 MO selegiline cap 1 MO; GAP selegiline tab 1 MO; GAP Antipsychotics Atypicals ABILIFY IM 2 ABILIFY ORAL SOLN 2 MO ABILIFY TAB 2 MO Page 42 of 128

43 ABILIFY DISCMELT 2 MO clozapine tab 1 MO; GAP CLOZARIL TAB 3 MO FANAPT TAB 3 MO FANAPT TABS IN A DOSE PACK 3 MO FAZACLO TAB, RAPID DISSOLVE 2 MO GEODON CAP 2 MO; QL (60 EA per 30 GEODON IM 2 INVEGA 24 HR TAB 3 mg, 9 mg 3 MO; QL (30 EA per 30 INVEGA 24 HR TAB 1.5 mg, 6 mg 3 MO; QL (60 EA per 30 INVEGA SUSTENNA IM SYRINGE 39 mg/0.25 ml INVEGA SUSTENNA IM SYRINGE 156 mg/ml (1 ml), 78 mg/0.5 ml INVEGA SUSTENNA IM SYRINGE 117 mg/0.75 ml, 234 mg/1.5 ml 3 MO; QL (0.5 ML per 30 3 MO; QL (1 ML per 30 3 MO; QL (1.5 ML per 30 LATUDA TAB 3 MO; QL (30 EA per 30 RISPERDAL ORAL SOLN 3 MO RISPERDAL TAB 3 MO RISPERDAL CONSTA IM SYRINGE 2 RISPERDAL M-TAB 3 MO risperidone oral soln 1 MO; GAP risperidone tab 1 MO; GAP risperidone tab, rapid dissolve 1 MO; GAP SAPHRIS SUBLINGUAL TAB 3 MO; QL (60 EA per 30 SEROQUEL TAB 50 mg 2 MO SEROQUEL TAB 100 mg, 200 mg, 25 mg, 300 mg, 400 mg 2 MO; QL (60 EA per 30 SEROQUEL XR 24 HR TAB 300 mg, 400 mg 2 MO; QL (60 EA per 30 SEROQUEL XR 24 HR TAB 150 mg, 200 mg, 50 mg ZYPREXA IM 2 2 MO; QL (90 EA per 30 Page 43 of 128

44 ZYPREXA TAB 2 MO; QL (30 EA per 30 ZYPREXA ZYDIS TAB, RAPID DISSOLVE 2 MO; QL (30 EA per 30 Conventional chlorpromazine injection 1 GAP chlorpromazine tab 1 MO; GAP fluphenazine decanoate injection 1 GAP fluphenazine elixir 1 MO; GAP fluphenazine injection 1 GAP fluphenazine oral concentrate 1 MO; GAP fluphenazine tab 1 MO; GAP HALDOL INJECTION 3 HALDOL DECANOATE IM 3 haloperidol tab 1 MO; GAP haloperidol decanoate im 1 GAP haloperidol injection 1 GAP haloperidol oral concentrate 1 MO; GAP loxapine cap 1 MO; GAP LOXITANE CAP 3 MO NAVANE CAP 10 mg, 2 mg, 5 mg 3 MO ORAP TAB 2 perphenazine tab 1 MO; GAP thioridazine tab 1 MO; GAP thiothixene cap 1 MO; GAP trifluoperazine tab 1 MO; GAP Antispasticity Agents Antispasticity Agents baclofen tab 1 GAP DANTRIUM CAP 3 dantrolene cap 1 GAP tizanidine tab 1 GAP Page 44 of 128

45 ZANAFLEX TAB 3 Antivirals Anti-Cytomegalovirus (Cmv) Agents foscarnet iv 1 B/D; GAP ganciclovir cap 1 MO; GAP VISTIDE IV 3 B/D Antihepatitis Agents BARACLUDE ORAL SOLN 2 QL (600 ML per 30 BARACLUDE TAB 2 QL (30 EA per 30 COPEGUS TAB 3 PA HEPSERA TAB 2 QL (30 EA per 30 INCIVEK TAB 4 PA REBETOL CAP 3 PA REBETOL ORAL SOLN 2 PA RIBASPHERE CAP 1 PA; GAP RIBASPHERE TAB 1 PA; GAP ribavirin cap 1 PA; GAP ribavirin tab 1 PA; GAP TYZEKA TAB 2 QL (30 EA per 30 VICTRELIS CAP 4 PA Antiherpetic Agents acyclovir cap 1 GAP acyclovir oral susp 1 GAP acyclovir tab 1 GAP acyclovir sodium iv powder for solution 1 B/D; GAP CYTOVENE IV SOLUTION 3 B/D DENAVIR TOPICAL CREAM 3 famciclovir tab 500 mg 1 GAP; QL (60 EA per 30 famciclovir tab 125 mg, 250 mg 1 GAP; QL (90 EA per 30 FAMVIR TAB 500 mg 3 QL (60 EA per 30 Page 45 of 128

46 FAMVIR TAB 125 mg, 250 mg 3 QL (90 EA per 30 ganciclovir iv solution 1 B/D; GAP valacyclovir tab 1 GAP; QL (60 EA per 30 VALCYTE ORAL SOLUTION 3 VALCYTE TAB 3 MO VALTREX TAB 3 QL (60 EA per 30 ZOVIRAX CAP 3 ZOVIRAX OINTMENT 2 QL (30 GM per 30 ZOVIRAX ORAL SUSP 3 ZOVIRAX TAB 3 ZOVIRAX TOPICAL CREAM 2 QL (15 GM per 30 Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors ATRIPLA TAB 4 QL (30 EA per 30 EDURANT TAB 3 QL (30 EA per 30 INTELENCE TAB 100 mg 4 QL (120 EA per 30 INTELENCE TAB 200 mg 4 QL (60 EA per 30 RESCRIPTOR DISPERSIBLE TAB 3 MO RESCRIPTOR TAB 3 MO SUSTIVA CAP 2 MO SUSTIVA TAB 2 MO VIRAMUNE ORAL SUSP 2 MO VIRAMUNE TAB 2 MO VIRAMUNE XR 24 HR TAB 2 Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors COMBIVIR TAB 2 MO didanosine cap, delayed release 1 MO; GAP EMTRIVA CAP 3 MO EMTRIVA ORAL SOLN 3 MO EPIVIR ORAL SOLN 2 MO EPIVIR TAB 2 MO Page 46 of 128

47 EPIVIR HBV ORAL SOLN 2 MO EPIVIR HBV TAB 2 MO EPZICOM TAB 2 MO RETROVIR CAP 3 MO RETROVIR IV 3 RETROVIR SYRUP 3 MO RETROVIR TAB 3 MO stavudine cap 1 MO; GAP stavudine oral solution 1 MO; GAP TRIZIVIR TAB 4 TRUVADA TAB 4 VIDEX 2 GRAM PEDIATRIC ORAL SOLUTION 3 MO VIDEX EC CAP 3 MO VIREAD TAB 3 MO ZERIT CAP 3 MO ZERIT ORAL SOLUTION 3 MO ZIAGEN ORAL SOLN 2 MO ZIAGEN TAB 2 MO zidovudine cap 1 MO; GAP zidovudine syrup 1 MO; GAP zidovudine tab 1 MO; GAP Anti-Hiv Agents, Other FUZEON SUB-Q KIT 4 QL (1 EA per 30 ISENTRESS TAB 4 QL (60 EA per 30 SELZENTRY TAB 300 mg 4 QL (120 EA per 30 SELZENTRY TAB 150 mg 4 QL (60 EA per 30 Anti-Hiv Agents, Protease Inhibitors APTIVUS CAP 3 MO APTIVUS ORAL SOLN 3 MO; QL (300 ML per 30 Page 47 of 128

48 CRIXIVAN CAP 3 MO INVIRASE CAP 3 MO INVIRASE TAB 3 MO KALETRA ORAL SOLN 4 KALETRA TAB mg 3 MO KALETRA TAB mg 4 LEXIVA ORAL SUSP 3 MO LEXIVA TAB 3 MO NORVIR CAP 3 MO NORVIR ORAL SOLN 3 MO NORVIR TAB 3 MO PREZISTA TAB 3 MO REYATAZ CAP 2 MO VIRACEPT ORAL POWDER 3 MO VIRACEPT TAB 3 MO Anti-Influenza Agents FLUMADINE TAB 3 RELENZA DISKHALER FOR INHALATION 3 QL (56 EA per 180 rimantadine tab 1 GAP TAMIFLU CAP 75 mg 2 QL (28 EA per 180 TAMIFLU CAP 45 mg 2 QL (42 EA per 180 TAMIFLU CAP 30 mg 2 QL (84 EA per 180 TAMIFLU ORAL SUSP 12 mg/ml 2 QL (275 ML per 180 TAMIFLU ORAL SUSP 6 mg/ml 2 QL (550 ML per 180 Anxiolytics Antidepressants CELEXA TAB 3 MO citalopram oral soln 1 MO; GAP citalopram tab 1 MO; GAP fluoxetine cap 1 MO; GAP Page 48 of 128

49 fluoxetine cap, delayed release 1 MO; GAP; QL (4 EA per 28 fluoxetine oral soln 1 MO; GAP fluoxetine tab 1 MO; GAP fluvoxamine tab 1 MO; GAP LEXAPRO ORAL SOLN 2 MO; QL (600 ML per 30 LEXAPRO TAB 20 mg, 5 mg 2 MO; QL (30 EA per 30 LEXAPRO TAB 10 mg 2 MO; QL (45 EA per 30 NARDIL TAB 3 MO paroxetine er 24 hr tab 12.5 mg 1 MO; GAP; QL (60 EA per 30 paroxetine er 24 hr tab 25 mg 1 MO; GAP; QL (90 EA per 30 paroxetine er 24 hr tab 37.5 mg 1 QL (60 EA per 30 paroxetine oral susp 1 MO; GAP paroxetine tab 1 MO; GAP PAXIL ORAL SUSP 3 MO PAXIL TAB 3 MO PAXIL CR 24 HR TAB 12.5 mg 3 MO; QL (60 EA per 30 PAXIL CR 24 HR TAB 25 mg 3 MO; QL (90 EA per 30 phenelzine tab 1 PROZAC CAP 3 MO PROZAC WEEKLY CAP 3 MO; QL (4 EA per 28 sertraline oral concentrate 1 MO; GAP; QL (300 ML per 30 sertraline tab 1 MO; GAP ZOLOFT ORAL CONCENTRATE 3 MO; QL (300 ML per 30 ZOLOFT TAB 3 MO Anxiolytics, Other alprazolam tab 1 E; QL (90 EA per 30 amitriptyline-chlordiazepoxide tab 1 MO; GAP Page 49 of 128

50 BUSPAR TAB 3 MO buspirone tab 1 MO; GAP chlordiazepoxide cap 1 E; QL (120 EA per 30 clorazepate dipotassium tab 15 mg 1 E; QL (120 EA per 30 clorazepate dipotassium tab 3.75 mg, 7.5 mg 1 E; QL (90 EA per 30 diazepam tab 1 E; QL (120 EA per 30 lorazepam tab 1 E; QL (90 EA per 30 meprobamate tab 1 GAP oxazepam cap 1 E; QL (120 EA per 30 Bipolar Agents Bipolar Agents lithium carbonate cap 1 MO; GAP lithium carbonate er tab 1 MO; GAP lithium carbonate tab 1 MO; GAP lithium citrate oral soln 1 MO; GAP LITHOBID TAB 3 MO SYMBYAX CAP 2 MO; QL (30 EA per 30 Blood Glucose Regulators Alpha Glucosidase Inhibitors acarbose tab 1 MO; GAP; QL (90 EA per 30 GLYSET TAB 2 MO; QL (90 EA per 30 PRECOSE TAB 3 MO; QL (90 EA per 30 Amylinomimetics SYMLIN SUB-Q 2 MO; QL (20 ML per 30 SYMLINPEN 120 SUB-Q PEN INJECTOR 2 MO; QL (5.4 ML per 30 SYMLINPEN 60 SUB-Q PEN INJECTOR 2 MO; QL (6 ML per 30 Biguanides GLUCOPHAGE TAB 500 mg 3 MO; QL (120 EA per 30 GLUCOPHAGE TAB 1,000 mg 3 MO; QL (60 EA per 30 Page 50 of 128

51 GLUCOPHAGE TAB 850 mg 3 MO; QL (90 EA per 30 GLUCOPHAGE XR 24 HR TAB 500 mg 3 MO; QL (120 EA per 30 GLUCOPHAGE XR 24 HR TAB 750 mg 3 MO; QL (90 EA per 30 GLUMETZA 24 HR TAB 3 MO; QL (120 EA per 30 metformin er 24 hr tab 500 mg 1 MO; GAP; QL (120 EA per 30 metformin er 24 hr tab 750 mg 1 MO; GAP; QL (90 EA per 30 metformin tab 500 mg 1 MO; GAP; QL (120 EA per 30 metformin tab 1,000 mg 1 MO; GAP; QL (60 EA per 30 metformin tab 850 mg 1 MO; GAP; QL (90 EA per 30 Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors JANUMET TAB 2 MO; QL (60 EA per 30 JANUVIA TAB 2 MO; QL (30 EA per 30 KOMBIGLYZE XR 24 HR TAB 5-1,000 mg, mg 2 MO; QL (30 EA per 30 KOMBIGLYZE XR 24 HR TAB 2.5-1,000 mg 2 MO; QL (60 EA per 30 ONGLYZA TAB 2 MO; QL (30 EA per 30 Glycemic Agents GLUCAGEN HYPOKIT INJECTION 2 GLUCAGON EMERGENCY INJECTION KIT 2 QL (2 EA per 30 Incretin Mimetics BYETTA SUB-Q PEN INJECTOR 10 mcg/0.04 ml BYETTA SUB-Q PEN INJECTOR 5 mcg/0.02 ml 2 MO; QL (2.4 ML per 30 2 MO; QL (4.8 ML per 30 VICTOZA SUB-Q PEN INJECTOR 3 ST; MO; QL (9 ML per 30 Insulin Mixtures, Analogs CURITY GAUZE BANDAGE 2 HUMALOG MIX SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 Page 51 of 128

52 HUMALOG MIX KWIKPEN SUB-Q PEN 2 MO; QL (35 ML per 30 HUMALOG MIX SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 HUMALOG MIX KWIKPEN SUB-Q PEN 2 MO; QL (35 ML per 30 INSULIN PEN NEEDLE 2 MO; QL (100 EA per 30 insulin syringe-needle u MO; QL (100 EA per 30 NOVOLOG MIX SUB-Q 2 MO; QL (35 ML per 30 NOVOLOG MIX FLEXPEN SUB-Q 2 MO; QL (35 ML per 30 safety needles 2 MO; QL (100 EA per 30 Insulin Mixtures, Short-Acting And Intermediate-Acting HUMULIN 70/30 SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 HUMULIN 70/30 PEN SUBQ 2 MO; QL (35 ML per 30 NOVOLIN 70/30 SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 Insulin, Intermediate-Acting HUMULIN N SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 HUMULIN N PEN SUBQ 2 MO; QL (35 ML per 30 NOVOLIN N SUSP, SUB-Q INJ 2 MO; QL (35 ML per 30 Insulin, Long-Acting LANTUS SUB-Q 2 MO; QL (35 ML per 30 LANTUS SOLOSTAR SUB-Q INSULIN PEN 2 MO; QL (35 ML per 30 LEVEMIR SUB-Q 2 MO; QL (35 ML per 30 LEVEMIR FLEXPEN SUB-Q INSULIN PEN 2 MO; QL (35 ML per 30 Insulin, Rapid-Acting APIDRA SUB-Q 3 MO; QL (35 ML per 30 APIDRA SOLOSTAR SUB-Q INSULIN PEN 3 MO; QL (35 ML per 30 HUMALOG SUB-Q 2 MO; QL (35 ML per 30 HUMALOG KWIKPEN SUB-Q PEN 2 MO; QL (35 ML per 30 NOVOLOG SUB-Q 2 MO; QL (35 ML per 30 NOVOLOG FLEXPEN SUB-Q 2 MO; QL (35 ML per 30 Insulin, Short-Acting HUMULIN R INJECTION 2 MO; QL (35 ML per 30 Page 52 of 128

53 NOVOLIN R INJECTION 2 MO; QL (35 ML per 30 Meglitinides nateglinide tab 1 MO; GAP; QL (90 EA per 30 PRANDIN TAB 2 MO STARLIX TAB 3 MO; QL (90 EA per 30 Sulfonylureas AMARYL TAB 3 MO chlorpropamide tab 1 MO; GAP glimepiride tab 1 MO; GAP glipizide er 24 hour tab 1 MO; GAP glipizide tab 1 MO; GAP glipizide-metformin tab 1 MO; GAP GLUCOTROL TAB 3 MO GLUCOTROL XL 24 HR TAB 3 MO GLUCOVANCE TAB 3 MO glyburide tab 1 MO; GAP glyburide micronized tab 1 MO; GAP glyburide-metformin tab 1 MO; GAP GLYCRON TAB 1 MO; GAP GLYNASE TAB 3 MO METAGLIP TAB 3 MO tolazamide tab 1 MO; GAP Thiazolidinediones ACTOPLUS MET TAB 2 MO; QL (90 EA per 30 ACTOPLUS MET XR 24 HR TAB 30-1,000 mg 2 MO; QL (30 EA per 30 ACTOPLUS MET XR 24 HR TAB 15-1,000 mg 2 MO; QL (60 EA per 30 ACTOS TAB 2 MO; QL (30 EA per 30 AVANDAMET TAB 2 MO; QL (60 EA per 30 AVANDARYL TAB 4-4 mg, 8-2 mg, 8-4 mg 2 MO; QL (30 EA per 30 Page 53 of 128

54 AVANDARYL TAB 4-1 mg, 4-2 mg 2 MO; QL (60 EA per 30 AVANDIA TAB 8 mg 2 MO; QL (30 EA per 30 AVANDIA TAB 2 mg, 4 mg 2 MO; QL (60 EA per 30 DUETACT TAB 2 MO; QL (30 EA per 30 Blood Products/Modifiers/ Volume Expanders Adenosine Diphosphate P2y12 Inhibitors EFFIENT TAB 2 MO; QL (35 EA per 30 PLAVIX TAB 300 mg 2 PLAVIX TAB 75 mg 2 MO; QL (33 EA per 30 ticlopidine tab 1 MO; GAP Anticoagulants, Oral COUMADIN TAB 2 MO JANTOVEN TAB 1 MO; GAP PRADAXA CAP 2 MO; QL (60 EA per 30 warfarin tab 1 MO; GAP Colony Stimulating Factors LEUKINE INJECTION 2 PA LEUKINE SOLUTION FOR INJECTION 2 PA MOZOBIL SUB-Q 4 PA NEULASTA SUB-Q SYRINGE 4 PA NEUPOGEN INJECTION 4 PA NEUPOGEN SYRINGE 4 PA Cyclic Adenosine Monophosphate Reuptake Inhibitors AGGRENOX 12 HR CAP 2 MO; QL (60 EA per 30 AGRYLIN CAP 3 MO anagrelide cap 1 MO; GAP dipyridamole tab 1 MO; GAP PERSANTINE TAB 3 MO Erythropoietins Page 54 of 128

55 ARANESP (POLYSORBATE) INJECTION 25 mcg/ml ARANESP (POLYSORBATE) INJECTION 40 mcg/ml ARANESP (POLYSORBATE) INJECTION 200 mcg/ml, 300 mcg/ml ARANESP (POLYSORBATE) INJECTION 100 mcg/ml, 60 mcg/ml ARANESP (POLYSORBATE) SYRINGE 40 mcg/0.4 ml ARANESP (POLYSORBATE) SYRINGE 25 mcg/0.42 ml ARANESP (POLYSORBATE) SYRINGE 150 mcg/0.3 ml ARANESP (POLYSORBATE) SYRINGE 60 mcg/0.3 ml ARANESP (POLYSORBATE) SYRINGE 200 mcg/0.4 ml ARANESP (POLYSORBATE) SYRINGE 100 mcg/0.5 ml, 500 mcg/ml ARANESP (POLYSORBATE) SYRINGE 300 mcg/0.6 ml EPOGEN INJECTION 2,000 unit/ml, 3,000 unit/ml, 4,000 unit/ml EPOGEN INJECTION 20,000 unit/2 ml, 20,000 unit/ml, 40,000 unit/ml 3 PA; QL (4 ML per 28 3 PA; QL (4 ML per 30 4 PA; QL (2 ML per 30 4 PA; QL (4 ML per 30 3 PA; QL (1.6 ML per 30 3 PA; QL (1.68 ML per 28 4 PA; QL (1 ML per 30 4 PA; QL (1.2 ML per 30 4 PA; QL (1.6 ML per 28 4 PA; QL (2 ML per 28 4 PA; QL (2.4 ML per 28 3 PA 4 PA NEUMEGA SUB-Q SOLN 4 PA PROCRIT INJECTION 10,000 unit/ml, 2,000 unit/ml, 3,000 unit/ml, 4,000 unit/ml PROCRIT INJECTION 20,000 unit/ml, 40,000 unit/ml 3 PA 4 PA PROMACTA TAB 4 PA; QL (30 EA per 30 Factor Xa Inhibitors, Indirect ARIXTRA SUB-Q SYRINGE 2 QL (21 ML per 60 fondaparinux sub-q syringe 1 QL (21 ML per 60 Page 55 of 128

56 XARELTO TAB 2 QL (70 EA per 35 Low Molecular Weight Heparins enoxaparin sub-q syringe 1 GAP; QL (42 ML per 60 FRAGMIN SUB-Q 3 QL (21 ML per 60 FRAGMIN SUB-Q SYRINGE 3 QL (21 ML per 60 heparin (porcine) injection 1,000 unit/ml, 10,000 unit/ml, 5,000 unit/ml heparin (porcine) injection 20,000 unit/ml 2 1 GAP heparin (porcine) in d5w iv 1 B/D; GAP heparin (porcine) in ns (pf) iv 1 B/D; GAP heparin (porcine)-0.45% nacl iv 25,000 unit/250 ml heparin (porcine)-0.45% nacl iv 25,000 unit/500 ml 1 B/D; GAP 2 B/D heparin, porcine (pf) iv 1 GAP LOVENOX SUB-Q 2 QL (21 ML per 60 LOVENOX SUB-Q SYRINGE 3 QL (42 ML per 60 Phosphodiesterase Iii/Adenosine Uptake Inhibitors cilostazol tab 1 MO; GAP PLETAL TAB 3 MO Protease Inhibitors LYSTEDA TAB 3 QL (30 EA per 30 Cardiovascular Agents 3-Hydroxy-3-Methylglutaryl Coenzyme A (Hmg Coa) Reductase Inhibitors ADVICOR 24 HR TAB 1, mg, mg 2 MO; QL (30 EA per 30 ADVICOR 24 HR TAB 1, mg, mg 2 MO; QL (60 EA per 30 CRESTOR TAB 2 MO; QL (30 EA per 30 LESCOL CAP 20 mg 3 MO; QL (30 EA per 30 LESCOL CAP 40 mg 3 MO; QL (60 EA per 30 LESCOL XL 24 HR TAB 3 MO; QL (30 EA per 30 LIPITOR TAB 10 mg, 40 mg, 80 mg 2 MO; QL (30 EA per 30 Page 56 of 128

57 LIPITOR TAB 20 mg 2 MO; QL (45 EA per 30 lovastatin tab 10 mg, 20 mg 1 MO; GAP; QL (30 EA per 30 lovastatin tab 40 mg 1 MO; GAP; QL (60 EA per 30 MEVACOR TAB 20 mg 3 MO; QL (30 EA per 30 MEVACOR TAB 40 mg 3 MO; QL (60 EA per 30 PRAVACHOL TAB 10 mg, 20 mg, 80 mg 3 MO; QL (30 EA per 30 PRAVACHOL TAB 40 mg 3 MO; QL (60 EA per 30 pravastatin tab 10 mg, 20 mg, 80 mg 1 MO; GAP; QL (30 EA per 30 pravastatin tab 40 mg 1 MO; GAP; QL (60 EA per 30 SIMCOR 24 HR TAB 1, mg, mg, mg, mg 2 MO; QL (30 EA per 30 SIMCOR 24 HR TAB 1, mg 2 MO; QL (60 EA per 30 simvastatin tab 1 MO; GAP; QL (30 EA per 30 VYTORIN TAB 2 MO; QL (30 EA per 30 VYTORIN TAB 2 MO; QL (30 EA per 30 VYTORIN TAB 2 MO; QL (30 EA per 30 VYTORIN TAB 2 MO; QL (30 EA per 30 ZOCOR TAB 3 MO; QL (30 EA per 30 Alpha-Adrenergic Agonists CATAPRES TAB 3 MO CATAPRES-TTS-1 TRANSDERM PATCH 3 MO; QL (4 EA per 28 CATAPRES-TTS-2 TRANSDERM PATCH 3 MO; QL (4 EA per 28 CATAPRES-TTS-3 TRANSDERM PATCH 3 MO; QL (8 EA per 28 clonidine tab 1 MO; GAP clonidine weekly transderm patch 0.1 mg/24 hr, 0.2 mg/24 hr 1 MO; GAP; QL (4 EA per 28 clonidine weekly transderm patch 0.3 mg/24 hr 1 MO; GAP; QL (8 EA per 28 Page 57 of 128

58 guanabenz tab 1 MO; GAP guanfacine tab 1 MO; GAP INTUNIV ER 24 HR TAB 3 QL (30 EA per 30 methyldopa tab 1 MO; GAP methyldopa-hydrochlorothiazide tab 1 MO; GAP midodrine tab 1 GAP PROAMATINE TAB 3 TENEX TAB 3 MO Alpha-Adrenergic Blocking Agents CARDURA TAB 3 MO doxazosin tab 1 MO; GAP MINIPRESS CAP 3 MO prazosin cap 1 MO; GAP terazosin cap 1 mg, 10 mg, 2 mg 1 MO; GAP terazosin cap 5 mg 1 MO; GAP; QL (30 EA per 30 Angiotensin Ii Receptor Antagonists ATACAND TAB 3 MO; QL (30 EA per 30 ATACAND HCT TAB 3 MO; QL (30 EA per 30 AVALIDE TAB 3 MO; QL (30 EA per 30 AVAPRO TAB 3 MO; QL (30 EA per 30 BENICAR TAB 20 mg, 40 mg 3 MO; QL (30 EA per 30 BENICAR TAB 5 mg 3 MO; QL (60 EA per 30 BENICAR HCT TAB 3 MO; QL (30 EA per 30 COZAAR TAB 3 MO; QL (30 EA per 30 DIOVAN TAB 2 MO; QL (30 EA per 30 DIOVAN HCT TAB 2 MO; QL (30 EA per 30 EDARBI TAB 3 HYZAAR TAB 3 MO; QL (30 EA per 30 losartan tab 1 MO; GAP; QL (30 EA per 30 Page 58 of 128

59 losartan-hydrochlorothiazide tab 1 MO; GAP; QL (30 EA per 30 MICARDIS TAB 2 MO; QL (30 EA per 30 MICARDIS HCT TAB 2 MO; QL (30 EA per 30 TEVETEN TAB 3 MO; QL (30 EA per 30 TEVETEN HCT TAB 3 MO; QL (30 EA per 30 Angiotensin-Converting Enzyme (Ace) Inhibitors ACCUPRIL TAB 3 MO ACCURETIC TAB 3 MO ACEON TAB 2 mg, 4 mg 3 MO; QL (30 EA per 30 ACEON TAB 8 mg 3 MO; QL (60 EA per 30 ALTACE CAP 1.25 mg, 2.5 mg, 5 mg 3 MO; QL (30 EA per 30 ALTACE CAP 10 mg 3 MO; QL (60 EA per 30 AZOR TAB 3 MO; QL (30 EA per 30 benazepril tab 1 MO; GAP benazepril-hydrochlorothiazide tab 1 MO; GAP captopril tab 1 MO; GAP captopril-hydrochlorothiazide tab 1 MO; GAP enalapril maleate tab 1 MO; GAP enalapril-hydrochlorothiazide tab 1 MO; GAP EXFORGE TAB 2 MO; QL (30 EA per 30 fosinopril tab 1 MO; GAP fosinopril-hydrochlorothiazide tab 1 MO; GAP lisinopril tab 1 MO; GAP lisinopril-hydrochlorothiazide tab 1 MO; GAP LOTENSIN TAB 3 MO LOTENSIN HCT TAB 3 MO MAVIK TAB 3 MO moexipril tab 1 MO; GAP moexipril-hydrochlorothiazide tab 1 MO; GAP Page 59 of 128

60 MONOPRIL TAB 3 MO perindopril erbumine tab 2 mg, 4 mg 1 MO; GAP; QL (30 EA per 30 perindopril erbumine tab 8 mg 1 MO; GAP; QL (60 EA per 30 PRINIVIL TAB 3 MO PRINZIDE TAB 3 MO quinapril tab 1 MO; GAP quinapril-hydrochlorothiazide tab 1 MO; GAP ramipril cap 1.25 mg, 2.5 mg, 5 mg 1 MO; GAP; QL (30 EA per 30 ramipril cap 10 mg 1 MO; GAP; QL (60 EA per 30 TARKA 24 HR TAB 3 MO; QL (30 EA per 30 trandolapril tab 1 MO; GAP UNIRETIC TAB 3 MO UNIVASC TAB 3 MO VASERETIC TAB 3 MO VASOTEC TAB 3 MO ZESTORETIC TAB 3 MO ZESTRIL TAB 3 MO Antiarrhythmics - Class Ia/Ii/Iii/Iv amiodarone tab 1 MO; GAP CORDARONE TAB 3 MO PACERONE TAB 400 mg 3 MO Antiarrhythmics - Class Ii LOPRESSOR IV 3 B/D metoprolol iv 1 B/D; GAP propranolol iv 1 B/D; GAP Antiarrhythmics - Class Ii/Iii BETAPACE TAB 3 MO Page 60 of 128

61 sotalol iv 1 GAP sotalol tab 1 MO; GAP Antiarrhythmics - Class Iii TIKOSYN CAP 2 MO Antiarrhythmics - Class Iv diltiazem iv 1 B/D; GAP diltiazem iv powder for solution 1 GAP verapamil iv 1 B/D; GAP Antiarrhythmics - Classes Ia, B, And C disopyramide cap 1 MO; GAP flecainide tab 1 MO; GAP mexiletine cap 1 MO; GAP MULTAQ TAB 3 MO; QL (60 EA per 30 NORPACE CAP 3 MO propafenone er 12 hr cap 1 GAP propafenone tab 1 MO; GAP quinidine er tab 1 MO; GAP quinidine sulfate er tab 1 MO; GAP quinidine tab 1 MO; GAP RYTHMOL TAB 3 MO RYTHMOL SR 12 HR CAP 3 MO TAMBOCOR TAB 3 MO Beta-Adrenergic Blocking Agents With Vasodilating Properties BYSTOLIC TAB 2.5 mg, 5 mg 2 MO BYSTOLIC TAB 10 mg 2 MO; QL (120 EA per 30 BYSTOLIC TAB 20 mg 2 MO; QL (60 EA per 30 carvedilol tab 1 MO; GAP; QL (60 EA per 30 COREG TAB 3 MO; QL (60 EA per 30 COREG CR 24 HR CAP 2 MO; QL (30 EA per 30 Page 61 of 128

62 labetalol iv 1 B/D; GAP labetalol tab 1 MO; GAP TRANDATE TAB 3 MO Bile Acid Sequestrants CHOLESTYRAMINE LIGHT PACKET 1 MO; GAP COLESTID ORAL GRANULES 3 MO COLESTID TAB 3 MO colestipol oral granules 1 MO; GAP colestipol tab 1 MO; GAP WELCHOL ORAL POWDER PACK 2 WELCHOL TAB 2 MO; QL (210 EA per 30 Calcium Channel Blocking Agents (Non-Dihydropyridines) CALAN TAB 3 MO CALAN SR TAB 3 MO CARDIZEM TAB 3 MO CARDIZEM CD 24 HR CAP 120 mg, 180 mg, 240 mg, 300 mg 3 MO CARDIZEM LA 24 HR TAB 3 MO; QL (30 EA per 30 CARTIA XT 24 HR CAP 1 MO; GAP DILACOR XR CAP 180 mg, 240 mg 3 MO DILT-CD 24 HR CAP 1 MO; GAP diltiazem cd 24 hr cap 1 MO; GAP diltiazem er 12 hr cap 1 MO; GAP diltiazem er cap 1 MO; GAP diltiazem tab 1 MO; GAP DILT-XR CAP 1 MO; GAP MATZIM LA 24 HR TAB 1 QL (30 EA per 30 TAZTIA XT CAP 1 MO; GAP TIAZAC CAP 3 MO verapamil er (pm) cap 24hr pellet ct 1 MO; GAP Page 62 of 128

63 verapamil er 24 hr cap 1 MO; GAP verapamil er tab 1 MO; GAP verapamil tab 1 MO; GAP VERELAN 24 HR CAP 120 mg, 180 mg, 240 mg 3 MO VERELAN PM CAP 3 MO Carbonic Anhydrase Inhibitors acetazolamide er cap 1 MO; GAP acetazolamide tab 1 MO; GAP methazolamide tab 1 MO; GAP Cardioselective Beta-Adrenergic Blocking Agents acebutolol cap 1 MO; GAP atenolol tab 1 MO; GAP atenolol-chlorthalidone tab 1 MO; GAP betaxolol tab 1 MO; GAP bisoprolol fumarate tab 1 MO; GAP bisoprolol-hydrochlorothiazide tab 1 MO; GAP KERLONE TAB 3 MO LOPRESSOR TAB 3 MO LOPRESSOR HCT TAB 3 MO metoprolol succinate er 24 hr tab 1 MO; GAP metoprolol tartrate tab 1 MO; GAP metoprolol-hydrochlorothiazide tab 1 MO; GAP SECTRAL CAP 3 MO TENORETIC 100 TAB 3 MO TENORETIC 50 TAB 3 MO TENORMIN TAB 3 MO TOPROL XL 24 HR TAB 3 MO ZEBETA TAB 3 MO ZIAC TAB 3 MO Cardiovascular Agents, Other Page 63 of 128

64 CINRYZE IV SOLUTION 4 PA dexrazoxane iv solution 1 B/D; GAP digoxin oral soln 1 MO; GAP digoxin tab 1 MO; GAP LANOXIN TAB 2 MO RANEXA 12 HR TAB 500 mg 2 MO; QL (120 EA per 30 RANEXA 12 HR TAB 1,000 mg 2 MO; QL (60 EA per 30 reserpine tab 0.25 mg 3 MO SAMSCA TAB 15 mg 4 QL (30 EA per 30 SAMSCA TAB 30 mg 4 QL (60 EA per 30 Cholesterol Absorption Inhibitors ZETIA TAB 3 MO; QL (30 EA per 30 Dihydropyridines ADALAT CC TAB 90 mg 3 MO; QL (60 EA per 30 ADALAT CC TAB 30 mg, 60 mg 3 MO; QL (90 EA per 30 AFEDITAB CR 1 MO; GAP; QL (90 EA per 30 amlodipine tab 10 mg, 2.5 mg 1 MO; GAP; QL (30 EA per 30 amlodipine tab 5 mg 1 MO; GAP; QL (45 EA per 30 amlodipine-benazepril cap 1 MO; GAP; QL (30 EA per 30 CADUET TAB 2 MO; QL (30 EA per 30 DYNACIRC CR 24 HR TAB 5 mg 3 MO DYNACIRC CR 24 HR TAB 10 mg 3 MO; QL (60 EA per 30 EXFORGE HCT TAB 2 MO; QL (30 EA per 30 felodipine er 24 hr tab 1 MO; GAP isradipine cap 1 MO; GAP LOTREL CAP 3 MO; QL (30 EA per 30 nicardipine cap 1 MO; GAP Page 64 of 128

65 NIFEDIAC CC TAB 90 mg 1 MO; GAP; QL (60 EA per 30 NIFEDIAC CC TAB 30 mg, 60 mg 1 MO; GAP; QL (90 EA per 30 NIFEDICAL XL 24 HR TAB 60 mg 1 MO; GAP; QL (30 EA per 30 NIFEDICAL XL 24 HR TAB 30 mg 1 MO; GAP; QL (90 EA per 30 nifedipine cap 1 MO; GAP nifedipine er 24 hr tab 1 MO; GAP nimodipine cap 1 MO; GAP nisoldipine er 24 hr tab 20 mg, 30 mg, 40 mg 1 MO; GAP; QL (30 EA per 30 nisoldipine er 24 hr tab 8.5 mg 1 QL (120 EA per 30 nisoldipine er 24 hr tab 25.5 mg, 34 mg 1 QL (30 EA per 30 nisoldipine er 24 hr tab 17 mg 1 QL (60 EA per 30 NORVASC TAB 10 mg, 2.5 mg 3 MO; QL (30 EA per 30 NORVASC TAB 5 mg 3 MO; QL (45 EA per 30 PROCARDIA CAP 3 MO PROCARDIA XL 24 HR TAB 3 MO SULAR 24 HR TAB 8.5 mg 3 MO; QL (120 EA per 30 SULAR 24 HR TAB 25.5 mg, 34 mg 3 MO; QL (30 EA per 30 SULAR 24 HR TAB 17 mg 3 MO; QL (60 EA per 30 TRIBENZOR TAB 3 MO; QL (30 EA per 30 Direct Renin Inhibitors AMTURNIDE TAB 2 MO; QL (30 EA per 30 TEKAMLO TAB 2 MO; QL (30 EA per 30 TEKTURNA TAB 2 MO; QL (30 EA per 30 TEKTURNA HCT TAB 2 MO; QL (30 EA per 30 VALTURNA TAB 2 MO; QL (30 EA per 30 Fibrates ANTARA CAP 3 MO; QL (30 EA per 30 Page 65 of 128

66 fenofibrate tab 1 MO; GAP; QL (30 EA per 30 fenofibrate micronized cap 1 MO; GAP; QL (30 EA per 30 FIBRICOR TAB 105 mg 3 QL (30 EA per 30 FIBRICOR TAB 35 mg 3 QL (60 EA per 30 gemfibrozil tab 1 MO; GAP; QL (60 EA per 30 LOFIBRA CAP 3 MO; QL (30 EA per 30 LOFIBRA TAB 3 MO; QL (30 EA per 30 LOPID TAB 3 MO; QL (60 EA per 30 TRICOR TAB 2 MO; QL (30 EA per 30 TRILIPIX CAP 2 MO; QL (30 EA per 30 Loop Diuretics bumetanide tab 1 MO; GAP DEMADEX TAB 3 MO furosemide injection 1 B/D; GAP furosemide oral soln 1 MO; GAP furosemide tab 1 MO; GAP LASIX TAB 3 MO torsemide tab 1 MO; GAP Nicotinic Acid NIASPAN EXTENDED-RELEASE 24 HR TAB 2 MO; QL (60 EA per 30 Nonselective Beta-Adrenergic Blocking Agents CORGARD TAB 3 MO CORZIDE TAB 3 MO INDERAL LA 24 HR CAP 3 MO nadolol tab 1 MO; GAP nadolol-bendroflumethiazide tab 1 MO; GAP pindolol tab 1 MO; GAP propranolol er 24 hr cap extended release 1 MO; GAP Page 66 of 128

67 propranolol oral soln 1 MO; GAP propranolol tab 1 MO; GAP propranolol-hydrochlorothiazide tab 1 MO; GAP SORINE TAB 1 MO; GAP timolol tab 1 MO; GAP Omega-3 Fatty Acids LOVAZA CAP 2 MO; QL (120 EA per 30 Potassium-Sparing Diuretics ALDACTAZIDE TAB mg 3 MO ALDACTONE TAB 3 MO amiloride tab 1 MO; GAP amiloride-hydrochlorothiazide tab 1 MO; GAP DYAZIDE CAP 3 MO DYRENIUM CAP 2 MO eplerenone tab 50 mg 1 MO; GAP eplerenone tab 25 mg 1 MO; GAP; QL (60 EA per 30 INSPRA TAB 50 mg 3 MO INSPRA TAB 25 mg 3 MO; QL (60 EA per 30 MAXZIDE TAB 3 MO MAXZIDE-25MG TAB 3 MO spironolactone tab 1 MO; GAP spironolactone-hydrochlorothiazide tab 1 MO; GAP triamterene-hydrochlorothiazide cap 1 MO; GAP triamterene-hydrochlorothiazide tab 1 MO; GAP Thiazide Diuretics chlorothiazide tab 1 MO; GAP chlorothiazide sodium iv solution 1 GAP chlorthalidone tab 1 MO; GAP DIURIL IV SOLUTION 3 Page 67 of 128

68 hydrochlorothiazide cap 1 MO; GAP hydrochlorothiazide tab 1 MO; GAP indapamide tab 1 MO; GAP methyclothiazide tab 1 MO; GAP metolazone tab 1 MO; GAP MICROZIDE CAP 3 MO ZAROXOLYN TAB 3 MO Vasodilators, Direct-Acting Arterial hydralazine injection 1 B/D; GAP hydralazine tab 1 MO; GAP minoxidil tab 1 MO; GAP Vasodilators, Direct-Acting Arterial/Venous BIDIL TAB 3 MO; QL (180 EA per 30 IMDUR 24 HR TAB 3 MO ISMO TAB 3 MO ISORDIL TITRADOSE TAB 3 MO isosorbide dinitrate er tab 1 MO; GAP isosorbide dinitrate sublingual tab 1 MO; GAP isosorbide dinitrate tab 1 MO; GAP isosorbide mononitrate er 24 hr tab 1 MO; GAP isosorbide mononitrate tab 1 MO; GAP MONOKET TAB 10 mg 3 MO NITRO-BID TRANSDERMAL OINTMENT 3 MO NITRO-DUR TRANSDERM 24 HR PATCH 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr 3 MO nitroglycerin transderm 24 hr patch 1 MO; GAP NITROLINGUAL SPRAY 2 MO NITROMIST SPRAY, AEROSOL 2 MO NITROSTAT SUBLINGUAL TAB 2 MO pentoxifylline er tab 1 MO; GAP Page 68 of 128

69 PROGLYCEM ORAL SUSP 2 MO TRENTAL TAB 3 MO Central Nervous System Agents Amphetamines, Adhd ADDERALL TAB 3 QL (60 EA per 30 ADDERALL XR 24 HR CAP 3 QL (60 EA per 30 AMPHETAMINE SALT COMBO TAB 1 GAP; QL (60 EA per 30 DEXEDRINE SPANSULE CAP 10 mg, 15 mg 3 QL (120 EA per 30 DEXEDRINE SPANSULE CAP 5 mg 3 QL (90 EA per 30 dextroamphetamine er cap 10 mg, 15 mg 1 GAP; QL (120 EA per 30 dextroamphetamine er cap 5 mg 1 GAP; QL (90 EA per 30 dextroamphetamine tab 1 GAP; QL (180 EA per 30 Non-Amphetamines, Adhd CONCERTA 24 HR TAB 18 mg, 27 mg, 54 mg 3 QL (30 EA per 30 CONCERTA 24 HR TAB 36 mg 3 QL (60 EA per 30 dexmethylphenidate tab 1 GAP; QL (60 EA per 30 FOCALIN TAB 3 QL (60 EA per 30 FOCALIN XR CAP 3 QL (30 EA per 30 KAPVAY 12 HR TAB 3 QL (120 EA per 30 METADATE ER TAB 1 GAP; QL (90 EA per 30 METHYLIN TAB 1 GAP; QL (90 EA per 30 METHYLIN ER TAB 1 GAP; QL (90 EA per 30 methylphenidate er tab 1 GAP; QL (90 EA per 30 methylphenidate oral soln 1 methylphenidate tab 1 GAP; QL (90 EA per 30 RITALIN TAB 3 QL (90 EA per 30 RITALIN LA CAP 40 mg 3 QL (30 EA per 30 RITALIN LA CAP 10 mg, 20 mg, 30 mg 3 QL (60 EA per 30 RITALIN SR TAB 3 QL (90 EA per 30 Page 69 of 128

70 STRATTERA CAP 10 mg, 100 mg, 18 mg, 25 mg, 60 mg, 80 mg 2 QL (30 EA per 30 STRATTERA CAP 40 mg 2 QL (60 EA per 30 Non-Amphetamines, Other AMPYRA 12 HR TAB 3 PA; QL (60 EA per 30 GILENYA CAP 4 PA; QL (30 EA per 30 NUVIGIL TAB 3 QL (30 EA per 30 PROVIGIL TAB 100 mg 3 QL (150 EA per 30 PROVIGIL TAB 200 mg 3 QL (60 EA per 30 RILUTEK TAB 2 MO XENAZINE TAB 4 XYREM ORAL SOLN 3 Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mouthwash 1 GAP CUVPOSA ORAL SOLN 3 CYKLOKAPRON IV 2 B/D EVOXAC CAP 3 KEPIVANCE SOLUTION 4 B/D PERIOGARD MOUTHWASH 1 GAP pilocarpine tab 1 GAP SALAGEN TAB 3 triamcinolone acetonide dental paste 1 GAP Dermatological Agents Dermatological Acne Agents AMNESTEEM CAP 1 GAP AZELEX TOPICAL CREAM 3 CLARAVIS CAP 1 GAP CLEOCIN T LOTION 3 CLEOCIN T SOLN 3 Page 70 of 128

71 CLEOCIN T TOPICAL GEL 3 CLEOCIN T TOPICAL SWAB 3 clindamycin lotion 1 GAP clindamycin phosphate topical swab 1 GAP clindamycin topical gel 1 GAP clindamycin topical soln 1 GAP ERY PADS TOPICAL SWAB 1 GAP erythromycin with ethanol topical gel 1 GAP erythromycin with ethanol topical soln 1 GAP FINACEA TOPICAL GEL 3 SOTRET CAP 1 GAP TAZORAC TOPICAL CREAM 3 TAZORAC TOPICAL GEL 3 tretinoin topical cream 1 GAP tretinoin topical gel 1 GAP Dermatological Anti-Inflammatory Agents PENNSAID TOPICAL DROPS 3 QL (300 ML per 30 SOLARAZE TOPICAL GEL 2 Dermatological Antipruritic Agents ZONALON TOPICAL CREAM 3 QL (45 GM per 30 Dermatological Calcineurin Inhibitors ELIDEL TOPICAL CREAM 2 PROTOPIC OINTMENT 3 Dermatological Caustic Agents CONDYLOX TOPICAL GEL 2 CONDYLOX TOPICAL SOLN 3 podofilox topical soln 1 GAP Dermatological Emollients ammonium lactate lotion 1 GAP LAC-HYDRIN LOTION 3 Page 71 of 128

72 Dermatological Genital Wart Agents ALDARA TOPICAL CREAM PACKET 3 QL (12 EA per 30 imiquimod topical cream packet 1 GAP; QL (12 EA per 30 VEREGEN OINTMENT 3 QL (15 GM per 30 Dermatological Mitotic Inhibitors selenium sulfide topical susp 1 GAP SELSUN TOPICAL SUSP 3 Dermatological Non-Melanoma Skin Cancer Agents CARAC TOPICAL CREAM 2 EFUDEX TOPICAL CREAM 3 EFUDEX TOPICAL SOLN 3 FLUOROPLEX TOPICAL CREAM 2 fluorouracil topical cream 1 GAP fluorouracil topical soln 1 GAP Dermatological Photochemotherapy Agents OXSORALEN ULTRA CAP 2 UVADEX INJECTION 2 B/D Dermatological Psoriasis Agents calcipotriene ointment 1 GAP; QL (120 GM per 30 calcipotriene topical soln 1 GAP; QL (60 ML per 30 DOVONEX TOPICAL CREAM 2 QL (120 GM per 30 DOVONEX TOPICAL SOLN 3 QL (60 ML per 30 SORIATANE CAP 3 TACLONEX OINTMENT 3 TACLONEX SCALP TOPICAL SUSP 3 QL (240 GM per 30 VECTICAL OINTMENT 2 Dermatological Wound Care Agents REGRANEX TOPICAL GEL 3 SANTYL OINTMENT 2 Enzyme Replacements/ Modifiers Page 72 of 128

73 Anti-Cystine Agents CYSTAGON CAP 2 Fabry Disease Treatment FABRAZYME IV SOLUTION 4 B/D; LA Gaucher's Disease Treatment CEREDASE IV 2 B/D; LA CEREZYME IV SOLUTION 4 B/D; LA VPRIV SOLUTION 4 B/D Glucosylceramide Synthase Inhibitors ZAVESCA CAP 2 MO Hereditary Tyrosinemia Type 1 (Ht-1) Treatment ORFADIN CAP 2 Mucopolysaccharidosis Disease Treatment ALDURAZYME IV 2 B/D; LA NAGLAZYME IV 4 B/D; LA Pancrelipase Replacement CREON CAP 2 MO PANCREAZE CAP 2 MO ZENPEP CAP 3 MO Phenylketonuria Treatment KUVAN SOLUBLE TAB 4 PA Severe Combined Immunodeficiency Disease (Scid) Treatment ADAGEN IM 2 B/D; LA Urea Cycle Disorder Treatment BUPHENYL ORAL POWDER 2 BUPHENYL TAB 2 ELITEK IV SOLUTION 2 B/D Gastrointestinal Agents Antispasmodics, Gastrointestinal atropine syringe 0.05 mg/ml 2 Page 73 of 128

74 BENTYL CAP 3 BENTYL IM 3 B/D BENTYL SYRUP 3 BENTYL TAB 3 dicyclomine cap 1 GAP dicyclomine im 1 B/D; GAP dicyclomine syrup 1 GAP dicyclomine tab 1 GAP glycopyrrolate tab 1 GAP methscopolamine tab 1 GAP PAMINE TAB 3 PAMINE FORTE TAB 3 propantheline tab 1 ROBINUL TAB 3 ROBINUL FORTE TAB 3 Gastrointestinal Agents, Other ACTIGALL CAP 3 MO AMITIZA CAP 2 QL (60 EA per 30 COLYTE WITH FLAVOR PACKS ORAL SOLUTION DIPENTUM CAP 3 MO diphenoxylate-atropine oral liquid 1 GAP diphenoxylate-atropine tab 1 GAP ENULOSE ORAL SOLN 1 GAP GAVILYTE-C ORAL SOLUTION 1 GAP GAVILYTE-G ORAL SOLUTION 1 GAP GAVILYTE-N ORAL SOLUTION 1 GAP GENERLAC ORAL SOLN 1 GAP GOLYTELY ORAL SOLUTION 3 HALFLYTELY-BISACODYL BOWEL KIT ORAL 3 3 Page 74 of 128

75 HALFLYTELY-BISACODYL W-FLAVOR PACK ORAL KIT HELIDAC ORAL PACK 3 KAYEXALATE ORAL POWDER 3 KRISTALOSE ORAL PACKET 3 lactulose oral soln 1 GAP LOMOTIL TAB 3 MOVIPREP ORAL POWDER PACKET 3 NULYTELY WITH FLAVOR PACKS ORAL SOLUTION OSMOPREP TAB 3 polyethylene glycol 3350 oral powder 1 GAP PYLERA CAP 3 QL (120 EA per 30 RELISTOR SUB-Q 3 QL (18 ML per 30 TRILYTE WITH FLAVOR PACKETS ORAL SOLUTION GAP URSO 250 TAB 3 MO URSO FORTE TAB 3 MO ursodiol cap 1 MO; GAP ursodiol tab 1 MO; GAP Histamine2 (H2) Blocking Agents AXID CAP 3 AXID ORAL SOLN 3 famotidine oral susp 1 GAP famotidine tab 1 GAP famotidine (pf) iv 1 B/D; GAP famotidine (pf) in saline (iso-osmotic) iv piggy back 1 B/D; GAP nizatidine cap 1 GAP nizatidine oral soln 1 GAP PEPCID IV 3 B/D Page 75 of 128

76 PEPCID TAB 3 PEPCID IN SODIUM CHLORIDE (ISO- OSMOTIC) IV PIGGY BACK 3 B/D ranitidine cap 1 GAP ranitidine injection 1 B/D; GAP ranitidine syrup 1 GAP ranitidine tab 1 GAP ZANTAC INJECTION 3 B/D ZANTAC SYRUP 3 ZANTAC TAB 3 Irritable Bowel Syndrome Agents budesonide dr & er cap,delayed & extended release CIMZIA SUBQ SYRINGE KIT 4 PA CIMZIA POWDER FOR RECONSTITUTION SUB-Q KIT 1 4 PA LOTRONEX TAB 2 QL (60 EA per 30 Protectants CARAFATE ORAL SUSP 2 CARAFATE TAB 3 CYTOTEC TAB 3 misoprostol tab 1 GAP sucralfate tab 1 GAP Proton Pump Inhibitors ACIPHEX TAB 3 ST; QL (30 EA per 30 DEXILANT CAPSULE 3 ST; QL (30 EA per 30 lansoprazole cap, delayed release 1 GAP; QL (30 EA per 30 lansoprazole rapid dissolve tab, delayed release 1 GAP; QL (30 EA per 30 NEXIUM CAP 3 ST; QL (30 EA per 30 NEXIUM IV SOLUTION 3 B/D NEXIUM PACKET ORAL SUSP 3 ST; QL (30 EA per 30 Page 76 of 128

77 omeprazole cap, delayed release 40 mg 1 GAP; QL (30 EA per 30 omeprazole cap, delayed release 10 mg, 20 mg 1 GAP; QL (60 EA per 30 omeprazole-sodium bicarbonate cap 1 GAP; QL (30 EA per 30 pantoprazole tab, delayed release 1 GAP; QL (60 EA per 30 PREVACID CAP 3 QL (30 EA per 30 PREVACID SOLUTAB RAPID DISSOLVE 3 QL (30 EA per 30 PRILOSEC CAP 40 mg 3 ST; QL (30 EA per 30 PRILOSEC CAP 10 mg, 20 mg 3 ST; QL (60 EA per 30 PROTONIX IV SOLUTION 3 PROTONIX ORAL SUSP 3 ST; QL (30 EA per 30 PROTONIX TAB 3 ST; QL (60 EA per 30 ZEGERID CAP 3 ST; QL (30 EA per 30 ZEGERID ORAL PACKET 3 ST; QL (30 EA per 30 Genitourinary Agents 5 Alpha-Reductase Inhibitors AVODART CAP 2 MO; QL (30 EA per 30 finasteride tab 1 MO; GAP; QL (30 EA per 30 JALYN 24 HR CAP 2 MO; QL (30 EA per 30 PROSCAR TAB 3 MO; QL (30 EA per 30 Alpha 1-Adrenergic Blocking Agents alfuzosin er 24 hr tab 1 QL (30 EA per 30 FLOMAX 24 HR CAP 3 MO; QL (60 EA per 30 tamsulosin er 24 hr cap 1 MO; GAP; QL (60 EA per 30 UROXATRAL 24 HR TAB 2 MO; QL (30 EA per 30 Antispasmodics, Urinary DETROL TAB 2 MO; QL (60 EA per 30 DETROL LA 24 HR CAP 2 MO; QL (30 EA per 30 DITROPAN XL 24 HR TAB 5 mg 3 MO; QL (30 EA per 30 DITROPAN XL 24 HR TAB 10 mg, 15 mg 3 MO; QL (60 EA per 30 Page 77 of 128

78 ENABLEX 24 HR TAB 3 MO; QL (30 EA per 30 flavoxate tab 1 MO; GAP GELNIQUE TRANSDERMAL GEL PACKET 3 MO; QL (30 GM per 30 oxybutynin chloride er 24 hr tab 5 mg 1 MO; GAP; QL (30 EA per 30 oxybutynin chloride er 24 hr tab 10 mg, 15 mg 1 MO; GAP; QL (60 EA per 30 oxybutynin chloride syrup 1 MO; GAP oxybutynin chloride tab 1 MO; GAP OXYTROL TRANSDERM PATCH 3 MO; QL (8 EA per 28 SANCTURA TAB 3 MO; QL (60 EA per 30 SANCTURA XR 24 HR CAP 3 MO; QL (30 EA per 30 TOVIAZ 24 HR TAB 3 MO; QL (30 EA per 30 trospium tab 1 MO; GAP; QL (60 EA per 30 VESICARE TAB 2 MO; QL (30 EA per 30 Genitourinary Agents, Other bethanechol chloride tab 1 MO; GAP CIALIS TAB 3 E; QL (3 EA per 30 ELMIRON CAP 3 MO URECHOLINE TAB 3 MO VIAGRA TAB 3 E; QL (3 EA per 30 Phosphate Binders calcium acetate cap 1 MO; GAP FOSRENOL CHEWABLE TAB 500 mg, 750 mg 2 MO FOSRENOL CHEWABLE TAB 1,000 mg 2 MO; QL (90 EA per 30 PHOSLO CAP 3 MO PHOSLYRA ORAL SOLN 3 RENAGEL TAB 2 MO RENVELA ORAL PWPK 2.4 gram 2 MO; QL (175 EA per 30 RENVELA ORAL PWPK 0.8 gram 2 MO; QL (525 EA per 30 Page 78 of 128

79 RENVELA TAB 2 MO; QL (525 EA per 30 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids-Systemic A-HYDROCORT SOLUTION FOR INJECTION 1 B/D; GAP A-METHAPRED SOLUTION FOR INJECTION 1 B/D; GAP CELESTONE ORAL SOLN 3 CORTEF TAB 3 cortisone tab 1 GAP DEPO-MEDROL SUSP FOR INJECTION 3 B/D dexamethasone elixir 1 GAP dexamethasone tab 1 GAP DEXPAK DOSE PACK, TAB 3 FLO-PRED ORAL SUSP 3 hydrocortisone tab 1 GAP MEDROL TAB 3 MEDROL (PAK) TABS IN A DOSE PACK 3 methylprednisolone tab 1 GAP methylprednisolone tabs in a dose pack 1 GAP methylprednisolone acetate susp for injection 1 B/D; GAP methylprednisolone sodium succ iv solution 1 B/D; GAP methylprednisolone sodium succ solution for injection ORAPRED ORAL SOLN 3 PEDIAPRED ORAL SOLN 3 1 B/D; GAP prednisolone sodium phosphate oral soln 1 GAP prednisone oral soln 2 prednisone tab 1 GAP PREDNISONE INTENSOL ORAL CONCENTRATE SOLU-MEDROL IV SOLUTION 3 B/D 2 Page 79 of 128

80 SOLU-MEDROL (PF) SOLUTION FOR INJECTION Glucocorticoids-Topical-High Potency 3 B/D amcinonide lotion 1 GAP amcinonide ointment 1 GAP amcinonide topical cream 1 GAP betamethasone valerate ointment 1 GAP desoximetasone topical cream 1 GAP desoximetasone topical gel 1 GAP fluocinolone ointment 1 GAP fluocinolone topical cream 1 GAP fluocinonide ointment 1 GAP fluocinonide topical gel 1 GAP fluocinonide topical soln 1 GAP HALOG OINTMENT 2 HALOG TOPICAL CREAM 2 LUXIQ TOPICAL FOAM 3 triamcinolone acetonide ointment 1 GAP triamcinolone acetonide topical cream 1 GAP TRIDERM OINTMENT 1 GAP TRIDERM TOPICAL CREAM 1 GAP Glucocorticoids-Topical-Low Potency ACLOVATE OINTMENT 3 ACLOVATE TOPICAL CREAM 3 alclometasone ointment 1 GAP alclometasone topical cream 1 GAP ANUSOL-HC RECTAL CREAM 3 CORTENEMA 3 CORTIFOAM RECTAL 3 desonide lotion 1 GAP Page 80 of 128

81 desonide ointment 1 GAP desonide topical cream 1 GAP hydrocortisone enema 1 GAP hydrocortisone lotion 2.5 % 1 GAP hydrocortisone ointment 1 GAP hydrocortisone topical cream 2.5 % 1 GAP LOKARA LOTION 1 GAP PROCTOSOL HC RECTAL CREAM 1 GAP PROCTOZONE-HC RECTAL CREAM 1 GAP SOLU-CORTEF (PF) SOLUTION FOR INJECTION 250 mg/2 ml Glucocorticoids-Topical-Medium Potency 3 B/D betamethasone dipropionate lotion 1 GAP betamethasone valerate lotion 1 GAP betamethasone valerate topical cream 1 GAP BETA-VAL TOPICAL CREAM 1 GAP CAPEX SHAMPOO 2 CORDRAN TAPE 3 CUTIVATE OINTMENT 3 CUTIVATE TOPICAL CREAM 3 DERMA-SMOOTH/FS BODY OIL TOPICAL 2 DERMATOP OINTMENT 3 DERMATOP TOPICAL CREAM 3 desoximetasone ointment 1 GAP desoximetasone topical cream 1 GAP ELOCON LOTION 3 ELOCON OINTMENT 3 ELOCON TOPICAL CREAM 3 fluocinolone topical cream 1 GAP fluocinolone topical soln 1 GAP Page 81 of 128

82 fluticasone ointment 1 GAP fluticasone topical cream 1 GAP hydrocortisone butyrate ointment 1 GAP hydrocortisone butyrate topical cream 1 GAP hydrocortisone butyrate topical soln 1 GAP hydrocortisone valerate ointment 1 GAP hydrocortisone valerate topical cream 1 GAP LOCOID OINTMENT 3 LOCOID TOPICAL SOLN 3 mometasone lotion 1 GAP mometasone ointment 1 GAP mometasone topical cream 1 GAP prednicarbate ointment 1 GAP prednicarbate topical cream 1 GAP TOPICORT OINTMENT 3 TOPICORT TOPICAL CREAM 3 TOPICORT TOPICAL GEL 3 TOPICORT LP TOPICAL CREAM 3 triamcinolone acetonide lotion 1 GAP triamcinolone acetonide ointment %, 0.1 % 1 GAP triamcinolone acetonide ointment 0.05 % 2 triamcinolone acetonide topical cream 1 GAP WESTCORT OINTMENT 3 Glucocorticoids-Topical-Very High Potency betamethasone dipropionate ointment 1 GAP betamethasone dipropionate topical cream 1 GAP betamethasone, augmented lotion 1 GAP betamethasone, augmented ointment 1 GAP betamethasone, augmented topical cream 1 GAP betamethasone, augmented topical gel 1 GAP Page 82 of 128

83 clobetasol ointment 1 GAP clobetasol topical gel 1 GAP clobetasol topical soln 1 GAP clobetasol-emollient topical cream 1 GAP CLOBEX LOTION 3 CLOBEX SHAMPOO 3 diflorasone ointment 1 GAP diflorasone topical cream 1 GAP DIPROLENE LOTION 3 DIPROLENE AF TOPICAL CREAM 3 fluocinonide-emollient topical cream 1 GAP halobetasol propionate ointment 1 GAP halobetasol propionate topical cream 1 GAP TEMOVATE OINTMENT 3 TEMOVATE TOPICAL GEL 3 TEMOVATE TOPICAL SOLN 3 ULTRAVATE OINTMENT 3 ULTRAVATE TOPICAL CREAM 3 Mineralocorticoids fludrocortisone tab 1 MO; GAP Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Growth Hormone Analogs OMNITROPE SUB-Q SOLN 4 PA; LA Insulin-Like Growth Factor Analogs INCRELEX SUB-Q 4 PA Vasopressin Analogs DDAVP INJECTION 3 B/D DDAVP NASAL SOLN 3 MO DDAVP NASAL SPRAY AEROSOL 3 DDAVP TAB 3 MO Page 83 of 128

84 desmopressin injection 3 B/D desmopressin nasal soln 1 MO; GAP desmopressin nasal spray 1 GAP desmopressin tab 1 MO; GAP Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 TAB 3 MO OXANDRIN TAB 3 MO; QL (60 EA per 30 oxandrolone tab 1 MO; GAP; QL (60 EA per 30 Androgens ANDRODERM TRANSDERM 24 HR PATCH 2 MO; QL (30 EA per 30 ANDROGEL TRANSDERMAL GEL PUMP 2 QL (300 GM per 30 ANDROGEL TRANSDERMAL PACKET 2 MO; QL (300 GM per 30 ANDROXY TAB 2 MO AXIRON TRANSDERM SOLUTION IN METERED PUMP danazol cap 1 MO; GAP DEPO-TESTOSTERONE IM OIL 100 mg/ml 3 FORTESTA TRANSDERMAL GEL PUMP 3 testosterone cypionate im oil 1 GAP Estrogens ACTIVELLA TAB mg 2 MO ACTIVELLA TAB mg 3 ALORA TRANSDERM PATCH 2 MO; QL (8 EA per 28 AMETHIA TABS,3 MONTH DOSE PACK 1 QL (91 EA per 91 AMETHYST TAB 1 QL (28 EA per 28 ANGELIQ TAB 2 MO; QL (28 EA per 28 APRI TAB 1 MO; GAP; QL (28 EA per 28 BEYAZ TAB 2 MO; QL (28 EA per 28 3 Page 84 of 128

85 BRIELLYN TAB 1 QL (28 EA per 28 CENESTIN TAB 2 MO CESIA TAB 1 MO; GAP; QL (28 EA per 28 CLIMARA TRANSDERM PATCH mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.1 mg/24 hr CLIMARA TRANSDERM PATCH mg/24 hr, mg/24 hr 3 MO; QL (4 EA per 28 3 MO; QL (8 EA per 28 COMBIPATCH TRANSDERMAL 2 MO; QL (8 EA per 28 CRYSELLE (28) TAB 1 MO; GAP; QL (28 EA per 28 CYCLESSA TAB 3 MO; QL (28 EA per 28 DESOGEN TAB 3 MO; QL (28 EA per 28 DIVIGEL TRANSDERMAL GEL PACKET 3 MO ELESTRIN TRANSDERMAL GEL PUMP 3 MO EMOQUETTE TAB 1 QL (28 EA per 28 ENJUVIA TAB 3 MO ESTRACE TAB 3 MO ESTRACE VAGINAL CREAM 2 MO estradiol tab 1 MO; GAP estradiol weekly transderm patch mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.1 mg/24 hr estradiol weekly transderm patch mg/24 hr, mg/24 hr 1 MO; GAP; QL (4 EA per 28 1 MO; GAP; QL (8 EA per 28 estradiol-norethindrone acet tab 1 MO; GAP ESTRING VAGINAL 3 MO; QL (1 EA per 84 estropipate tab 1 MO; GAP ESTROSTEP FE-28 TAB 3 MO EVAMIST TRANSDERMAL SPRAY 3 MO FEMCON FE CHEWABLE TAB 3 QL (28 EA per 28 FEMHRT 1/5 TAB 3 MO Page 85 of 128

86 FEMHRT LOW DOSE TAB 2 MO FEMRING VAGINAL 3 MO; QL (1 EA per 84 FEMTRACE TAB 2 MO GIANVI TAB 1 MO; GAP; QL (28 EA per 28 INTROVALE TABS,3 MONTH DOSE PACK 1 QL (91 EA per 91 JINTELI TAB 1 KARIVA TAB 1 MO; GAP; QL (28 EA per 28 KELNOR 1/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 LO LOESTRIN FE TAB 3 QL (28 EA per 28 MENEST TAB 2 MO MONONESSA (28) TAB 1 MO; GAP; QL (28 EA per 28 NUVARING VAGINAL 2 MO; QL (1 EA per 28 OCELLA TAB 1 MO; GAP; QL (28 EA per 28 OGEN TAB 3 MO OGESTREL (28) TAB 1 MO; GAP; QL (28 EA per 28 ORSYTHIA TAB 1 QL (28 EA per 28 PREFEST TAB 2 MO PREMARIN SOLUTION FOR INJECTION 2 B/D PREMARIN TAB 2 MO PREMARIN VAGINAL CREAM 2 MO PREMPHASE TAB 2 MO; QL (28 EA per 28 PREMPRO TAB 2 MO; QL (28 EA per 28 PREVIFEM TAB 1 MO; GAP; QL (28 EA per 28 RECLIPSEN (28) TAB 1 MO; GAP; QL (28 EA per 28 SAFYRAL TAB 3 QL (28 EA per 28 Page 86 of 128

87 SOLIA TAB 1 MO; GAP; QL (28 EA per 28 SPRINTEC (28) TAB 1 MO; GAP; QL (28 EA per 28 TRINESSA (28) TAB 1 MO; GAP; QL (28 EA per 28 TRI-PREVIFEM (28) TAB 1 MO; GAP; QL (28 EA per 28 TRI-SPRINTEC (28) TAB 1 MO; GAP; QL (28 EA per 28 VAGIFEM VAGINAL TAB 2 VELIVET TAB 1 MO; GAP; QL (28 EA per 28 VIVELLE-DOT TRANSDERM PATCH 2 MO; QL (8 EA per 28 YAZ 28 TAB 3 MO; QL (28 EA per 28 ZOVIA 1/35E (28) TAB 1 MO; GAP; QL (28 EA per 28 ZOVIA 1/50E (28) TAB 1 MO; GAP; QL (28 EA per 28 Progestins AVIANE TAB 1 MO; GAP; QL (28 EA per 28 AYGESTIN TAB 3 MO BREVICON (28) TAB 3 MO; QL (28 EA per 28 CAMILA TAB 1 MO; GAP; QL (28 EA per 28 CLIMARA PRO TRANSDERM PATCH 3 CRINONE VAGINAL GEL 3 CYCLAFEM 1/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 CYCLAFEM 7/7/7 (28) TAB 1 MO; GAP; QL (28 EA per 28 DEPO-PROVERA IM 2 B/D DEPO-PROVERA IM SUSP 3 Page 87 of 128

88 ELLA TAB 3 QL (1 EA per 30 ENPRESSE TAB 1 MO; GAP; QL (28 EA per 28 ERRIN TAB 1 MO; GAP; QL (28 EA per 28 JOLIVETTE TAB 1 MO; GAP; QL (28 EA per 28 JUNEL 1.5/30 (21) TAB 1 MO; GAP; QL (28 EA per 28 JUNEL 1/20 (21) TAB 1 MO; GAP; QL (28 EA per 28 JUNEL FE 1.5/30 (28) TAB 1 MO; GAP; QL (28 EA per 28 JUNEL FE 1/20 (28) TAB 1 MO; GAP; QL (28 EA per 28 LEENA 28 TAB 1 MO; GAP; QL (28 EA per 28 LESSINA TAB 1 MO; GAP; QL (28 EA per 28 LEVORA-28 TAB 1 MO; GAP; QL (28 EA per 28 LOESTRIN 1.5/30 (21) TAB 3 MO; QL (28 EA per 28 LOESTRIN 1/20 (21) TAB 3 MO; QL (28 EA per 28 LOESTRIN FE 1.5/30 (28) TAB 3 MO; QL (28 EA per 28 LOESTRIN FE 1/20 (28) TAB 3 MO; QL (28 EA per 28 LO-OVRAL (28) TAB 3 MO; QL (28 EA per 28 LOSEASONIQUE TABS,3 MONTH DOSE PACK 3 MO; QL (91 EA per 91 LOW-OGESTREL (28) TAB 1 MO; GAP; QL (28 EA per 28 LUTERA (28) TAB 1 MO; GAP; QL (28 EA per 28 medroxyprogesterone im susp 1 GAP medroxyprogesterone tab 1 MO; GAP Page 88 of 128

89 MEGACE ES ORAL SUSP 3 MO MEGACE ORAL ORAL SUSP 3 MO megestrol oral susp 1 MO; GAP megestrol tab 1 MO; GAP MICROGESTIN 1.5/30 (21) TAB 1 MO; GAP; QL (28 EA per 28 MICROGESTIN 1/20 (21) TAB 1 MO; GAP; QL (28 EA per 28 MICROGESTIN FE 1.5/30 (28) TAB 1 MO; GAP; QL (28 EA per 28 MICROGESTIN FE 1/20 (28) TAB 1 MO; GAP; QL (28 EA per 28 NECON 0.5/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 NECON 1/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 NECON 10/11 (28) TAB 1 MO; GAP; QL (28 EA per 28 NECON 7/7/7 (28) TAB 1 MO; GAP; QL (28 EA per 28 NEXT CHOICE TAB 1 GAP NORA-BE TAB 1 MO; GAP; QL (28 EA per 28 NORDETTE-28 TAB 3 MO; QL (28 EA per 28 norethindrone acetate tab 1 MO; GAP NORINYL 1+35 (28) TAB 3 MO; QL (28 EA per 28 NOR-QD TAB 3 MO; QL (28 EA per 28 NORTREL 0.5/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 NORTREL 1/35 (21) TAB 1 MO; GAP; QL (28 EA per 28 NORTREL 1/35 (28) TAB 1 MO; GAP; QL (28 EA per 28 Page 89 of 128

90 NORTREL 7/7/7 (28) TAB 1 MO; GAP; QL (28 EA per 28 ORTHO EVRA TRANSDERM PATCH 2 MO; QL (3 EA per 28 ORTHO-CYCLEN (28) TAB 3 MO; QL (28 EA per 28 ORTHO-NOVUM 7/7/7 (28) TAB 3 MO; QL (28 EA per 28 PORTIA TAB 1 MO; GAP; QL (28 EA per 28 PROMETRIUM CAP 3 MO PROVERA TAB 3 MO QUASENSE TABS,3 MONTH DOSE PACK 1 MO; GAP; QL (91 EA per 91 SEASONALE TABS,3 MONTH DOSE PACK 3 MO; QL (91 EA per 91 SEASONIQUE TABS,3 MONTH DOSE PACK 3 MO; QL (91 EA per 91 TRI-LEGEST FE TAB 1 MO; GAP TRI-NORINYL (28) TAB 3 MO; QL (28 EA per 28 TRIVORA (28) TAB 1 MO; GAP; QL (28 EA per 28 Selective Estrogen Receptor Modifying Agents EVISTA TAB 2 MO; QL (30 EA per 30 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) CYTOMEL TAB 3 MO LEVOTHROID TAB 1 MO; GAP levothyroxine tab 1 MO; GAP LEVOXYL TAB 1 MO; GAP liothyronine tab 1 MO; GAP SYNTHROID TAB 1 MO; GAP THYROLAR-1 TAB 2 MO THYROLAR-1/4 TAB 2 MO THYROLAR-2 TAB 2 MO THYROLAR-3 TAB 2 MO Page 90 of 128

91 TIROSINT CAP 2 UNITHROID TAB 1 MO; GAP ZEOSA CHEWABLE TAB 1 QL (28 EA per 28 Hormonal Agents, Suppressant (Parathyroid) Calcimimetics SENSIPAR TAB 30 mg, 90 mg 2 MO; QL (120 EA per 30 SENSIPAR TAB 60 mg 2 MO; QL (150 EA per 30 Hormonal Agents, Suppressant (Pituitary) Gonadotropin-Releasing Hormone Analogs FIRMAGON SUB-Q SOLN 80 mg 2 B/D FIRMAGON SUB-Q SOLN 120 mg 4 B/D leuprolide sub-q kit 3 B/D LUPRON DEPOT IM KIT 4 B/D LUPRON DEPOT IM SYRINGE KIT 4 B/D LUPRON DEPOT (3 MONTH) IM KIT 4 B/D LUPRON DEPOT (3 MONTH) IM SYRINGE KIT LUPRON DEPOT (4 MONTH) IM SYRINGE KIT LUPRON DEPOT (6 MONTH) IM SYRINGE KIT 4 B/D 4 B/D 4 B/D LUPRON DEPOT-PED IM KIT 4 B/D SYNAREL NASAL SPRAY 3 PA TRELSTAR IM SUSP 2 B/D TRELSTAR IM SYRINGE 2 B/D Growth Hormone Antagonists SOMAVERT SUB-Q SOLN 4 B/D Somatostatin Analogs octreotide acetate injection 3 B/D SANDOSTATIN INJECTION 1,000 mcg/ml, 200 mcg/ml, 50 mcg/ml 3 B/D Page 91 of 128

92 SOMATULINE DEPOT SUB-Q SYRINGE 4 B/D Hormonal Agents, Suppressant (Sex Hormones/ Modifiers) Antiandrogens bicalutamide tab 1 MO; GAP CASODEX TAB 3 MO flutamide cap 1 MO; GAP NILANDRON TAB 2 MO Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole tab 1 MO; GAP propylthiouracil tab 1 MO; GAP TAPAZOLE TAB 3 MO Immunological Agents Immune Suppressants (Non-Tnf Inhibitors) ARCALYST SUB-Q SOLN 4 B/D azathioprine tab 1 B/D; MO; GAP azathioprine solution for injection 2 B/D CELLCEPT CAP 3 B/D; MO CELLCEPT ORAL SUSP 2 B/D; MO CELLCEPT TAB 3 B/D; MO CELLCEPT INTRAVENOUS IV SOLUTION 2 B/D CUPRIMINE CAP 3 cyclosporine cap 1 B/D; MO; GAP cyclosporine iv 1 B/D; GAP cyclosporine modified cap 1 B/D; MO; GAP cyclosporine modified oral soln 1 B/D; MO; GAP DEPEN TITRATABS TAB 3 GENGRAF CAP 25 mg 1 B/D; MO; GAP IMURAN TAB 3 B/D; MO methotrexate sodium injection 1 B/D; GAP Page 92 of 128

93 methotrexate sodium tab 1 MO; GAP methotrexate sodium (pf) solution for injection 1 B/D; GAP mycophenolate mofetil cap 1 B/D; MO; GAP mycophenolate mofetil tab 1 B/D; MO; GAP MYFORTIC TAB 3 B/D; MO NEORAL CAP 100 mg 3 B/D; MO NEORAL ORAL SOLN 3 B/D; MO NULOJIX IV SOLUTION 4 PA ORENCIA IV SOLUTION 4 B/D ORTHOCLONE OKT3 IV 3 B/D PROGRAF CAP 3 B/D; MO PROGRAF IV 2 B/D RAPAMUNE ORAL SOLN 2 B/D; MO RAPAMUNE TAB 2 B/D; MO SANDIMMUNE CAP 3 B/D; MO tacrolimus cap 1 B/D; MO; GAP Immunoglobulins ATGAM IV 2 B/D GAMMAGARD LIQUID IV 2 B/D GAMMAPLEX IV 2 B/D HIZENTRA SUB-Q 4 B/D PRIVIGEN IV 2 B/D THYMOGLOBULIN IV SOLUTION 4 B/D VIVAGLOBIN SUB-Q 4 B/D Immunomodulators, Other ARAVA TAB 3 MO COPAXONE SUB-Q KIT 4 ILARIS (PF) SUB-Q SOLN 4 KINERET SUB-Q SYRINGE 4 PA leflunomide tab 1 MO; GAP Page 93 of 128

94 PROLEUKIN IV SOLUTION 2 B/D RIDAURA CAP 2 MO Interferons, Alfa INTRON A INJECTION 4 PA INTRON A SOLUTION FOR INJECTION 3 PA INTRON A SUBQ PEN KIT 3 million unit /0.2 ml-6 doses INTRON A SUBQ PEN KIT 10 million unit/0.2 ml, 5 million unit/0.2 ml 3 PA 4 PA PEGASYS SUB-Q 4 PA PEGASYS CONVENIENCE PACK SUB-Q KIT 4 PA PEGINTRON SUB-Q KIT 4 PA PEGINTRON REDIPEN SUBQ KIT 4 PA Interferons, Beta AVONEX IM KIT 4 ST; QL (4 EA per 28 AVONEX ADMINISTRATION PACK IM KIT 4 ST; QL (4 EA per 28 BETASERON SUB-Q KIT 4 ST; QL (15 EA per 30 REBIF SUB-Q SYRINGE 4 QL (12 ML per 28 REBIF TITRATION PACK SUB-Q SYRINGE 4 QL (4.2 ML per 28 Interferons, Gamma ACTIMMUNE SUB-Q 4 LA Tumor Necrosis Factor (Tnf) Inhibitors ENBREL SUB-Q KIT 4 PA ENBREL SUB-Q SYRINGE 4 PA HUMIRA SUB-Q KIT 4 PA HUMIRA CROHN'S DISEASE STARTER PACK SUBQ PEN KIT 4 PA REMICADE IV SOLUTION 4 B/D SIMPONI SUB-Q SYRINGE 4 PA Vaccines To Prevent Diphtheria ADACEL (ADOLESCENT & ADULT) IM SUSP 2 Page 94 of 128

95 DECAVAC IM SYRINGE 2 tetanus,diphtheria toxoids ped (pf) im susp 2 Vaccines To Prevent Haemophilus Type B ACTHIB IM 2 COMVAX IM 2 B/D PEDVAX HIB (PF) IM 2 TRIHIBIT PRESERVATIVE FREE IM KIT 2 Vaccines To Prevent Hepatitis A HAVRIX (PF) IM SUSP 2 HAVRIX (PF) IM SYRINGE 2 TWINRIX (PF) IM SUSP 2 B/D VAQTA (PF) IM SUSP 2 Vaccines To Prevent Hepatitis B ENGERIX-B (PF) IM SUSP 2 B/D ENGERIX-B (PF) IM SYRINGE 2 B/D PEDIARIX (PF) IM SUSP 2 B/D RECOMBIVAX HB (PF) IM SUSP 2 B/D Vaccines To Prevent Japanese Encephalitis IXIARO (PF) IM SYRINGE 2 JE-VAX SUB-Q SOLN 2 Vaccines To Prevent Measles ATTENUVAX (PF) SUB-Q SUSP 2 M-M-R II (PF) SUB-Q SUSP 2 Vaccines To Prevent Meningococcal Disease MENACTRA (PF) IM SYRINGE 2 MENOMUNE - A/C/Y/W-135 (PF) SUB-Q SOLN MENVEO A-C-Y-W-135-DIP (PF) IM KIT 2 Vaccines To Prevent Mumps PROQUAD SUB-Q 2 2 Page 95 of 128

96 Vaccines To Prevent Papillomavirus Disease CERVARIX VACCINE IM SUSP 2 CERVARIX VACCINE IM SYRINGE 2 GARDASIL IM SUSP 2 Vaccines To Prevent Pertussis TRIPEDIA (PF) IM SUSP 2 Vaccines To Prevent Poliovirus IPOL SUSP FOR INJECTION 2 Vaccines To Prevent Rabies IMOVAX RABIES VACCINE IM SOLUTION 2 RABAVERT (PF) IM KIT 2 Vaccines To Prevent Rotavirus Disease ROTATEQ VACCINE ORAL SUSP 2 Vaccines To Prevent Rubella MERUVAX II (PF) SUB-Q SUSP 2 Vaccines To Prevent Tetanus BOOSTRIX IM SUSP 2 BOOSTRIX IM SYRINGE 2 DAPTACEL (PEDIATRIC) (PF) IM SUSP 2 INFANRIX (PF) IM SUSP 2 tetanus toxoid,adsorbed (pf) im 3 tetanus-diphtheria toxoids-td im susp 2 Vaccines To Prevent Typhoid TYPHIM VI IM 2 Vaccines To Prevent Varicella VARIVAX (PF) SUB-Q SOLN 2 Vaccines To Prevent Yellow Fever YF-VAX SUB-Q SUSP 2 Vaccines To Prevent Zoster ZOSTAVAX SUB-Q SOLN 2 Page 96 of 128

97 Inflammatory Bowel Disease Agents Glucocorticoids ENTOCORT EC CAP 3 Salicylates APRISO 24 HR CAP 3 MO; QL (120 EA per 30 ASACOL TAB 2 MO; QL (360 EA per 30 ASACOL HD TAB 2 MO; QL (180 EA per 30 balsalazide cap 1 MO; GAP CANASA RECTAL SUPPOSITORY 2 MO; QL (60 EA per 30 COLAZAL CAP 3 MO LIALDA TAB 2 MO; QL (120 EA per 30 mesalamine enema 1 MO; GAP PENTASA CAP 2 MO; QL (240 EA per 30 Sulfonamides AZULFIDINE TAB 3 MO AZULFIDINE EN-TABS TAB 3 MO sulfasalazine tab 1 MO; GAP SULFAZINE EC TAB 1 MO; GAP Metabolic Bone Disease Agents Bisphosphonates, Oral ACTONEL TAB 150 mg 3 ST; MO; QL (1 EA per 30 ACTONEL TAB 30 mg, 5 mg 3 ST; MO; QL (30 EA per 30 ACTONEL TAB 35 mg 3 ST; MO; QL (4 EA per 28 alendronate tab 10 mg, 40 mg, 5 mg 1 MO; GAP; QL (30 EA per 30 alendronate tab 35 mg, 70 mg 1 MO; GAP; QL (4 EA per 28 ATELVIA TAB 3 ST; MO; QL (4 EA per 28 BONIVA TAB 3 ST; MO DIDRONEL TAB 3 MO etidronate disodium tab 1 MO; GAP Page 97 of 128

98 FOSAMAX ORAL SOLN 3 MO; QL (300 ML per 28 FOSAMAX TAB 10 mg, 40 mg, 5 mg 3 ST; MO; QL (30 EA per 30 FOSAMAX TAB 35 mg, 70 mg 3 ST; MO; QL (4 EA per 28 Bisphosphonates, Parenteral BONIVA IV SYRINGE 3 B/D pamidronate iv 1 B/D; GAP RECLAST IV 3 B/D ZOMETA IV 3 B/D Calcium Regulating Hormones calcitonin (salmon) nasal spray 1 MO; GAP; QL (3.7 ML per 28 FORTICAL NASAL SPRAY 1 MO; GAP; QL (3.7 ML per 28 MIACALCIN NASAL SPRAY 3 MO; QL (3.7 ML per 28 Parathyroid Hormone Analogs FORTEO SUB-Q PEN INJECTOR 4 PA Vitamin D Related Agents/Metabolic Bone Disease Agents calcitriol cap 1 GAP calcitriol iv 1 B/D; GAP calcitriol oral soln 1 GAP HECTOROL CAP 3 HECTOROL IV 3 B/D PROLIA SUB-Q SYRINGE 3 B/D XGEVA SUB-Q 4 B/D ZEMPLAR CAP 2 Ophthalmic Agents Alpha-Adrenergic Agonists, Ophthalmic ALPHAGAN P EYE DROPS 3 MO; QL (15 ML per 30 apraclonidine eye drops 1 MO; GAP; QL (20 ML per 30 brimonidine eye drops 1 MO; GAP Page 98 of 128

99 IOPIDINE EYE DROPPERETTE 3 MO IOPIDINE EYE DROPS 3 MO; QL (20 ML per 30 Beta-Adrenergic Blocking Agents, Ophthalmic BETAGAN EYE DROPS 3 MO; QL (10 ML per 30 betaxolol eye drops 1 MO; GAP; QL (20 ML per 30 BETIMOL EYE DROPS 2 MO; QL (10 ML per 30 BETOPTIC S EYE DROPS 3 MO; QL (20 ML per 30 carteolol eye drops 1 MO; GAP COMBIGAN EYE DROPS 3 MO; QL (10 ML per 30 COSOPT EYE DROPS 3 MO; QL (10 ML per 30 dorzolamide-timolol eye drops 1 MO; GAP; QL (10 ML per 30 ISTALOL EYE DROPS 2 MO; QL (10 ML per 30 levobunolol eye drops 1 MO; GAP; QL (10 ML per 30 metipranolol eye drops 1 MO; GAP OPTIPRANOLOL EYE DROPS 3 MO timolol eye gel forming soln 1 MO; GAP timolol maleate eye drops 1 MO; GAP; QL (10 ML per 30 TIMOPTIC-XE EYE GEL 3 MO Carbonic Anhydrase Inhibitors, Ophthalmic AZOPT EYE DROPS 2 MO; QL (10 ML per 30 dorzolamide eye drops 1 MO; GAP; QL (10 ML per 30 TRUSOPT EYE DROPS 3 MO; QL (10 ML per 30 Cholinergic Agonists, Ophthalmic ISOPTO CARPINE EYE DROPS 3 PHOSPHOLINE IODIDE EYE DROPS 3 MO PILOPINE HS EYE GEL 2 MO Glucocorticoids, Ophthalmic Page 99 of 128

100 dexamethasone eye drops 1 GAP FLAREX EYE DROPS 3 QL (20 ML per 30 fluorometholone eye drops, susp 1 GAP FML FORTE EYE DROPS 2 FML LIQUIFILM EYE DROPS 3 FML S.O.P. EYE OINTMENT 2 LOTEMAX EYE DROPS 3 QL (20 ML per 30 OMNIPRED EYE DROPS 3 PRED MILD EYE DROPS 2 PRED-G EYE DROPS 3 QL (20 ML per 30 PRED-G S.O.P. EYE OINTMENT 3 prednisolone acetate eye drops, susp 1 GAP prednisolone sodium phosphate eye drops 1 GAP VEXOL EYE DROPS 3 Nonsteroidal Anti-Inflammatory Drugs, Ophthalmic ACULAR EYE DROPS 3 QL (10 ML per 30 ACULAR LS EYE DROPS 3 QL (10 ML per 30 BROMDAY EYE DROPS 3 QL (5 ML per 30 bromfenac eye drops 1 QL (5 ML per 30 diclofenac eye drops 1 GAP; QL (5 ML per 30 flurbiprofen eye drops 1 GAP; QL (2.5 ML per 30 ketorolac eye drops 1 GAP; QL (10 ML per 30 NEVANAC EYE DROPS 3 OCUFEN EYE DROPS 3 QL (2.5 ML per 30 VOLTAREN EYE DROPS 3 QL (5 ML per 30 Ophthalmic Agents, Other AK-TOB EYE DROPS 1 GAP AZASITE EYE DROPS 3 QL (5 ML per 15 bacitracin eye ointment 1 GAP bacitracin-polymyxin b eye ointment 1 GAP Page 100 of 128

101 BESIVANCE EYE DROPS 3 BLEPH-10 EYE DROPS 3 BLEPHAMIDE EYE DROPS 2 QL (20 ML per 30 BLEPHAMIDE S.O.P. EYE OINTMENT 2 CILOXAN EYE DROPS 3 CILOXAN EYE OINTMENT 2 QL (4 GM per 30 DUREZOL EYE DROPS 3 QL (10 ML per 30 GENTASOL EYE DROPS 1 GAP IQUIX EYE DROPS 3 LACRISERT EYE INSERTS 3 QL (60 EA per 30 levofloxacin eye drops 1 MAXITROL EYE DROPS 3 MAXITROL EYE OINTMENT 3 MOXEZA EYE DROPS 2 neomycin-bacitracin-poly-hc eye ointment 1 GAP neomycin-bacitracin-polymyxin eye oint 1 GAP neomycin-polymyxin-dexameth eye drops 1 GAP neomycin-polymyxin-dexameth eye ointment 1 GAP neomycin-polymyxin-gramicidin eye drops 1 GAP neomycin-polymyxin-hc eye drops, susp 1 GAP NEOSPORIN EYE DROPS 3 POLYCIN B EYE OINTMENT 1 GAP POLY-DEX EYE DROPS 1 GAP POLY-DEX EYE OINTMENT 1 GAP POLYTRIM EYE DROPS 3 QUIXIN EYE DROPS 3 RESTASIS EYE DROPPERETTE 2 QL (64 EA per 30 ROMYCIN EYE OINTMENT 1 GAP sulfacetamide sodium eye drops 1 GAP TOBRADEX EYE DROPS 3 QL (20 ML per 30 Page 101 of 128

102 TOBRADEX EYE OINTMENT 3 QL (4 GM per 30 TOBRADEX ST EYE DROPS 3 tobramycin-dexamethasone eye drops, susp 1 GAP; QL (20 ML per 30 TOBRASOL EYE DROPS 1 GAP TOBREX EYE DROPS 3 TOBREX EYE OINTMENT 2 trifluridine eye drops 1 GAP trimethoprim-polymyxin b eye drops 1 GAP VIGAMOX EYE DROPS 2 VIROPTIC EYE DROPS 3 ZIRGAN EYE GEL 3 ZYLET EYE DROPS 3 ZYMAR EYE DROPS 2 ZYMAXID EYE DROPS 3 Ophthalmic Anti-Allergy Agents ALAMAST EYE DROPS 3 QL (20 ML per 30 ALOCRIL EYE DROPS 3 QL (15 ML per 30 ALOMIDE EYE DROPS 2 ALREX EYE DROPS 3 QL (20 ML per 30 azelastine eye drops 1 GAP; QL (6 ML per 30 BEPREVE EYE DROPS 2 QL (10 ML per 30 cromolyn eye drops 1 GAP ELESTAT EYE DROPS 3 QL (10 ML per 30 EMADINE EYE DROPS 3 QL (10 ML per 30 epinastine eye drops 1 QL (10 ML per 30 LASTACAFT EYE DROPS 3 QL (3 ML per 30 LOTEMAX EYE OINTMENT 3 QL (3.5 GM per 30 OPTIVAR EYE DROPS 3 QL (6 ML per 30 PATADAY EYE DROPS 2 QL (10 ML per 30 PATANOL EYE DROPS 2 QL (10 ML per 30 Page 102 of 128

103 Ophthalmic Prostaglandin And Prostamide Analogs latanoprost eye drops 1 QL (5 ML per 30 LUMIGAN EYE DROPS 2 MO; QL (7.5 ML per 30 TRAVATAN Z EYE DROPS 2 MO; QL (5 ML per 30 XALATAN EYE DROPS 3 MO; QL (5 ML per 30 Otic Agents Otic Anti-Inflammatories acetic acid ear soln 1 GAP BOROFAIR EAR DROPS 1 GAP CORTISPORIN EAR SOLN 3 CORTOMYCIN EAR DROPS, SUSP 1 GAP CORTOMYCIN EAR SOLN 1 GAP DERMOTIC OIL EAR DROPS 3 hydrocortisone-acetic acid ear drops 1 GAP Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS FOR INHALATION 2 MO; QL (60 EA per 30 ADVAIR HFA AEROSOL INHALER 2 MO; QL (12 GM per 30 ALVESCO AEROSOL INHALER 3 ASMANEX TWISTHALER BREATH ACTIVATED 110 mcg (30 doses), 220 mcg (120 doses), 220 mcg (30 doses), 220 mcg (60 doses) ASMANEX TWISTHALER BREATH ACTIVATED 220 mcg (14 doses) 3 MO; QL (1 GM per 30 3 MO; QL (2 GM per 28 BECONASE AQ NASAL SPRAY 3 QL (50 GM per 30 budesonide neb suspension 1 B/D; GAP DULERA HFA AEROSOL INHALER 2 MO; QL (13 GM per 30 FLONASE NASAL SPRAY 3 QL (16 GM per 30 FLOVENT DISKUS FOR INHALATION 2 MO; QL (120 EA per 30 FLOVENT HFA AEROSOL INHALER 2 MO; QL (26 GM per 30 flunisolide nasal spray 1 GAP; QL (25 ML per 30 Page 103 of 128

104 fluticasone nasal spray, susp 1 GAP; QL (16 GM per 30 NASACORT AQ NASAL SPRAY AEROSOL 2 QL (16.5 GM per 30 NASONEX SPRAY 2 QL (34 GM per 30 OMNARIS NASAL SPRAY 3 PULMICORT NEB SUSPENSION 0.25 mg/2 ml, 0.5 mg/2 ml PULMICORT FLEXHALER BREATH ACTIVATED 3 B/D; MO 3 MO; QL (2 EA per 30 QVAR AEROSOL INHALER 3 MO; QL (29.2 GM per 30 RHINOCORT AQUA NASAL SPRAY 2 QL (17.2 GM per 30 SYMBICORT HFA AEROSOL INHALER 2 MO; QL (10.2 GM per 30 triamcinolone acetonide nasal spray aerosol 1 QL (16.5 GM per 30 VERAMYST NASAL SPRAY 3 QL (10 GM per 30 Bronchodilators, Anticholinergic ATROVENT NASAL SPRAY 3 QL (30 ML per 30 ATROVENT HFA AEROSOL INHALER 3 MO COMBIVENT AEROSOL INHALER 2 MO; QL (29.4 GM per 30 DUONEB NEB SOLUTION 3 B/D; MO; QL (540 ML per 30 ipratropium bromide nasal spray 1 GAP; QL (30 ML per 30 ipratropium-albuterol neb solution 1 B/D; MO; GAP; QL (540 ML per 30 SPIRIVA WITH HANDIHALER & INHALATION CAPS Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) 2 MO; QL (30 EA per 30 aminophylline tab 1 MO; GAP DALIRESP TAB 3 PA; QL (30 EA per 30 ELIXOPHYLLIN 3 MO THEOCHRON 12 HR TAB 1 MO; GAP theophylline er 12 hr tab 1 MO; GAP theophylline er tab 1 MO; GAP UNIPHYL TAB 3 MO Page 104 of 128

105 Bronchodilators, Sympathomimetic ACCUNEB NEB SOLUTION 3 B/D; MO; QL (375 ML per 30 albuterol sulfate er 12 hour tab 1 MO; GAP albuterol sulfate neb solution 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) 1 B/D; MO; GAP; QL (375 ML per 30 albuterol sulfate neb solution 5 mg/ml 1 B/D; MO; GAP; QL (60 ML per 30 albuterol sulfate syrup 1 MO; GAP albuterol sulfate tab 1 MO; GAP EPIPEN IM INJECTOR 2 QL (2 EA per 30 EPIPEN JR IM INJECTOR 2 QL (2 EA per 30 FORADIL AEROLIZER INHALATION CAPS 2 MO levalbuterol neb solution 1 B/D; MO; GAP MAXAIR AUTOHALER BREATH ACTIVATED 3 MO; QL (14 GM per 25 PROAIR HFA AEROSOL INHALER 2 MO; QL (34 GM per 30 PROVENTIL HFA AEROSOL INHALER 3 MO; QL (28 GM per 30 SEREVENT DISKUS FOR INHALATION 2 MO; QL (60 EA per 30 terbutaline tab 1 MO; GAP TWINJECT AUTOINJECTOR IM PEN 3 QL (4 EA per 365 VENTOLIN HFA AEROSOL INHALER 2 MO; QL (36 GM per 30 VOSPIRE ER 12 HR TAB 3 MO XOPENEX HFA AEROSOL INHALER 3 MO; QL (30 GM per 30 H1 Blocking Agents, Sedating cyproheptadine syrup 1 GAP cyproheptadine tab 1 GAP diphenhydramine cap 1 GAP diphenhydramine elixir 1 GAP diphenhydramine injection 1 B/D; GAP hydroxyzine im 25 mg/ml 1 B/D; GAP Page 105 of 128

106 hydroxyzine im 50 mg/ml 1 GAP hydroxyzine syrup 1 GAP hydroxyzine tab 1 GAP hydroxyzine pamoate cap 1 GAP VISTARIL CAP 3 Histamine1 (H1) Blocking Agents, Mildly/Non-Sedating ASTELIN NASAL SPRAY AEROSOL 3 ASTEPRO NASAL SPRAY 2 QL (30 ML per 25 azelastine nasal spray aerosol 1 GAP fexofenadine tab 180 mg 1 GAP; QL (30 EA per 30 fexofenadine tab 30 mg, 60 mg 1 GAP; QL (60 EA per 30 levocetirizine tab 1 GAP; QL (30 EA per 30 PATANASE NASAL SPRAY 3 XYZAL TAB 3 QL (30 EA per 30 Mast Cell Stabilizers cromolyn neb solution 1 B/D; GAP GASTROCROM ORAL SOLN 2 Pulmonary Antihypertensives ADCIRCA TAB 2 QL (60 EA per 30 LETAIRIS TAB 4 QL (30 EA per 30 REVATIO IV 2 REVATIO TAB 2 QL (90 EA per 30 TRACLEER TAB 62.5 mg 4 LA; QL (120 EA per 30 TRACLEER TAB 125 mg 4 LA; QL (60 EA per 30 Receptor Antagonists ACCOLATE TAB 3 MO; QL (60 EA per 30 SINGULAIR CHEWABLE TAB 2 QL (30 EA per 30 SINGULAIR ORAL GRANULES IN PACKET 2 MO; QL (30 EA per 30 SINGULAIR TAB 2 MO; QL (30 EA per 30 Page 106 of 128

107 zafirlukast tab 1 MO; GAP; QL (60 EA per 30 Respiratory Tract Agents, Other ARALAST NP IV SUSP 2 B/D; LA GLASSIA IV 4 B/D LUMIZYME IV SOLUTION 4 PROLASTIN IV SUSP 3 B/D PROLASTIN C IV SUSP 3 B/D TYZINE NASAL DROPS 0.1 % 3 XOLAIR SUB-Q SOLN 4 B/D; LA ZEMAIRA IV SUSP 3 B/D Synthesis Inhibitors ZYFLO CR 12 HR TAB 2 MO; QL (120 EA per 30 Sedatives/Hypnotics Sedatives/Hypnotics AMBIEN TAB 3 QL (30 EA per 30 AMBIEN CR TAB 3 QL (30 EA per 30 estazolam tab 1 E; QL (30 EA per 30 flurazepam cap 1 E; QL (30 EA per 30 LUNESTA TAB 3 QL (30 EA per 30 ROZEREM TAB 2 QL (30 EA per 30 SONATA CAP 3 QL (30 EA per 30 temazepam cap 30 mg 1 E; QL (30 EA per 30 temazepam cap 15 mg 1 E; QL (60 EA per 30 zaleplon cap 1 GAP; QL (30 EA per 30 zolpidem er multiphase tab 1 GAP; QL (30 EA per 30 zolpidem tab 1 GAP; QL (30 EA per 30 Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol tab 1 GAP Page 107 of 128

108 chlorzoxazone tab 1 GAP cyclobenzaprine tab 1 GAP FLEXERIL TAB 3 metaxalone tab 1 GAP methocarbamol tab 1 GAP orphenadrine citrate er tab 1 GAP ORPHENADRINE COMPOUND TAB 1 GAP ORPHENADRINE COMPOUND-DS TAB 1 GAP PARAFON FORTE DSC TAB 3 ROBAXIN TAB 3 SKELAXIN TAB 3 SOMA TAB 350 mg 3 Therapeutic Nutrients/Minerals/ Electrolytes Electrolytes/Minerals 0.45 % sodium chloride with potassium chloride iv 1 B/D; GAP AMINOSYN 10 % IV 2 B/D AMINOSYN 3.5 % IV 2 B/D AMINOSYN 5 % (SULFITE-FREE) IV 2 B/D AMINOSYN 7 % IV 2 B/D AMINOSYN 7 % WITH ELECTROLYTES IV 2 B/D AMINOSYN 8.5 % IV 2 B/D AMINOSYN 8.5 % WITH ELECTROLYTES IV 2 B/D AMINOSYN II 10 % IV 2 B/D AMINOSYN II 15% IV 2 B/D AMINOSYN II 3.5 %/DEXTROSE 5 % IV 2 B/D AMINOSYN II 3.5 % IN DEXTROSE 25 % IV 2 B/D AMINOSYN II 3.5% M/DEXTROSE 5% IV 2 B/D AMINOSYN II 3.5% WITH LYTES & CALCIUM IN D25W IV 2 B/D AMINOSYN II 4.25%/DEXTROSE 20% IV 2 B/D Page 108 of 128

109 AMINOSYN II 4.25% IN DEXTROSE 10% IV 2 B/D AMINOSYN II 4.25 % IN DEXTROSE 25 % IV 2 B/D AMINOSYN II 4.25 % WITH LYTES & CALCIUM IN D25W IV 2 B/D AMINOSYN II 5%/DEXTROSE 25% IV 2 B/D AMINOSYN II 7 % IV 2 B/D AMINOSYN II 8.5 % IV 2 B/D AMINOSYN II 8.5 % WITH ELECTROLYTES IV 2 B/D AMINOSYN M 3.5 % IV 2 B/D AMINOSYN-HBC 7% IV 2 B/D AMINOSYN-HF 8 % IV 2 B/D AMINOSYN-PF 10 % IV 2 B/D AMINOSYN-PF 7 % (SULFITE-FREE) IV 2 B/D CARNITOR TAB 3 CLINIMIX 2.75%/D5 SULFITE FREE IV 2 B/D CLINIMIX 4.25%/D5 SULFITE FREE IV 2 B/D CLINIMIX 4.25%/D10 SULFITE FREE IV 2 B/D CLINIMIX 4.25%/D20 SULFITE FREE IV 2 B/D CLINIMIX 4.25%/D25 SULFITE FREE IV 2 B/D CLINIMIX 5%/D15 SULFITE FREE IV 2 B/D CLINIMIX 5%/D20 SULFITE FREE IV 2 B/D CLINIMIX 5%/D25 SULFITE FREE IV 2 B/D CLINIMIX E 2.75%/D10 SULFITE FREE IV 2 B/D CLINIMIX E 2.75%/D5 SULFITE FREE IV 2 B/D CLINIMIX E 4.25%/D25 SULFITE FREE IV 2 B/D CLINIMIX E 4.25%/D5 SULFITE FREE IV 2 B/D CLINIMIX E 5%/D15 SULFITE FREE IV 2 B/D CLINIMIX E 5%/D20 SULFITE FREE IV 2 B/D CLINIMIX E 5%/D25 SULFITE FREE IV 2 B/D CLINISOL SF 15% IV 1 B/D; GAP Page 109 of 128

110 dextrose 10 %-0.45 % sodium chloride iv 1 B/D; GAP d % sodium chloride & potassium chloride iv 1 B/D; GAP dextrose 2.5 %-0.45 % sodium chloride iv 1 B/D; GAP dextrose 5 %-0.45 % sodium chloride iv 1 B/D; GAP dextrose 5 %-0.9 % sodium chloride iv 1 B/D; GAP d5-1/2 ns and potassium chloride iv 1 B/D; GAP d5-1/3 ns & potassium chloride iv 1 B/D; GAP d5-1/4 ns & potassium chloride iv 10 meq/l, 20 meq/l, 40 meq/l 1 B/D; GAP d5-lr with potassium chloride iv 1 B/D; GAP d5-ns with potassium chloride iv 1 B/D; GAP d5w with potassium chloride iv 1 B/D; GAP dextrose 10% in water (d10w) iv soln 1 B/D; GAP dextrose 10%-1/4 normal saline iv 1 B/D; GAP dextrose 5% in water (d5w) iv 1 B/D; GAP dextrose 5%-0.3 % sodium chloride iv 1 B/D; GAP dextrose 5%-1/4 normal saline iv 1 B/D; GAP ED K+10 TAB 1 MO; GAP FREAMINE HBC 6.9 % IV 2 B/D FREAMINE III 3 % WITH ELECTROLYTES IV 2 B/D FREAMINE III 8.5 % IV 2 B/D HEPATAMINE 8% IV 1 B/D; GAP HEPATASOL 8 % IV 2 B/D INTRALIPID IV 20 % 1 B/D; GAP INTRALIPID IV 30 % 3 B/D ISOLYTE-H IN D5W IV 2 B/D ISOLYTE-M IN D5W IV 2 B/D ISOLYTE-P IN D5W IV 2 B/D ISOLYTE-S IV 2 B/D ISOLYTE-S IN D5W IV 2 B/D Page 110 of 128

111 KAON CL-10 TAB 1 MO; GAP KLOR-CON TAB 1 MO; GAP KLOR-CON 10 TAB 1 MO; GAP KLOR-CON M15 TAB 1 MO; GAP KLOR-CON M20 TAB 1 MO; GAP K-TAB 3 MO lactated ringers irrigation soln 1 GAP lactated ringers iv 1 B/D; GAP levocarnitine tab 1 GAP LIPOSYN II IV 10 % 1 B/D; GAP LIPOSYN II IV 20 % 3 B/D LIPOSYN III IV 1 B/D; GAP NEPHRAMINE 5.4 % IV 2 B/D NORMOSOL-M IN D5W IV 2 B/D NORMOSOL-R IN D5W IV 1 B/D; GAP NORMOSOL-R PH 7.4 IV 1 B/D; GAP NOVAMINE 15 % (HOSPIRA) IV 1 B/D; GAP ns with potassium chloride iv 1 B/D; GAP PHYSIOLYTE IRRIGATION SOLN 1 B/D; GAP PLASMA-LYTE 148 IV 2 B/D PLASMA-LYTE 148 IN D5W IV 2 B/D PLASMA-LYTE 56 IV 2 B/D PLASMA-LYTE A IV 2 B/D PLASMA-LYTE R IV 1 B/D; GAP PLASMA-LYTE-56 IN D5W IV 2 B/D potassium chloride er cap 1 MO; GAP potassium chloride er tab 1 MO; GAP potassium chloride er tab, particles/crystals 1 MO; GAP potassium chloride iv piggy back 1 B/D; GAP potassium chloride iv soln 1 B/D; GAP Page 111 of 128

112 potassium citrate er tab 1 GAP PREMASOL 10 % IV 2 B/D PREMASOL 6 % IV 1 B/D; GAP PRENATABS OBN TAB 1 GAP PROCALAMINE 3% IV 2 B/D PROSOL 20% IV 2 B/D RENAMIN 6.5 % IV 2 B/D ringers irrigation soln 1 GAP ringers iv 1 B/D; GAP sodium bicarbonate iv syringe 1 GAP sodium chloride iv 1 B/D; GAP sodium chloride 0.45 % iv 1 B/D; GAP sodium chloride 0.9 % iv 1 B/D; GAP sodium chloride 3 % iv 1 B/D; GAP sodium chloride 5 % iv 1 B/D; GAP TIS-U-SOL IRRIGATION SOLN 1 B/D; GAP TPN ELECTROLYTES IV 1 B/D; GAP TRAVASOL 10 % IV 2 B/D TROPHAMINE 10 % IV 3 B/D TROPHAMINE 6% IV 3 B/D Page 112 of 128

113 OTC Drugs Drug Name Tier Notes ALAVERT D-12 ALLERGY-SINUS 12 HR TAB 1 QL (60 EA per 30 cetirizine oral soln 1 mg/ml 1 QL (120 ML per 30 cetirizine tab 10 mg 1 QL (30 EA per 30 EYE ITCH RELIEF DROPS 1 QL (5 ML per 30 loratadine tab 1 QL (30 EA per 30 omeprazole tab, delayed release 1 QL (56 EA per 28 PREVACID 24HR CAP 1 QL (28 EA per 28 WAL-ITIN D 24 HR TAB 1 QL (30 EA per 30 ZADITOR EYE DROPS 1 QL (5 ML per 30 Page 113 of 128

114 Index 0.45 % NaCl-potassium chloride Abilify Abilify Discmelt Abraxane Abstral... 7 acarbose Accolate AccuNeb Accupril Accuretic acebutolol Aceon acetaminophen-codeine... 7 acetazolamide acetic acid acetylcysteine Aciphex Aclovate ActHIB Actigall Actimmune Actiq... 7 Activella Actonel Actoplus MET Actoplus Met XR Actos Acular Acular LS acyclovir acyclovir sodium Aczone Adacel (Adolescent & Adult) 94 Adagen Adalat CC Adcirca Adderall Adderall XR Adoxa Adoxa Pak Adriamycin PFS Advair Diskus Advair HFA Advicor Afeditab CR Afinitor Aggrenox Page 114 of 128 Agrylin A-Hydrocort AK-Tob Alamast Alavert D-12 Allergy-Sinus 113 Albenza albuterol sulfate alclometasone alcohol swabs Aldactazide Aldactone Aldara Aldurazyme alendronate alfuzosin Alimta Alinia... 40, 41 allopurinol allopurinol sodium Alocril Alomide Aloprim Alora Alphagan P alprazolam Alrex Altabax Altace Alvesco amantadine Amaryl Ambien Ambien CR amcinonide Amerge A-Methapred Amethia Amethyst amifostine crystalline amikacin amiloride amiloride-hydrochlorothiazide aminophylline Aminosyn 10 % Aminosyn 3.5 % Aminosyn 5 % (sulfite-free) 108 Aminosyn 7 % Aminosyn 7 % with Electrolytes Aminosyn 8.5 % Aminosyn 8.5 %-Electrolytes Aminosyn II 10 % Aminosyn II 15% Aminosyn II 3.5 %/Dextrose 5 % Aminosyn II 3.5 %-Dextrose 25% Aminosyn II 3.5% M/Dextrose 5% Aminosyn II 3.5%-Lytes-Ca- D25W Aminosyn II 4.25%/Dextrose 20% Aminosyn II 4.25%-Dextrose 10% Aminosyn II 4.25%-Dextrose 25% Aminosyn II 4.25%-Lytes-Ca- D Aminosyn II 5%/Dextrose 25% Aminosyn II 7 % Aminosyn II 8.5 % Aminosyn II 8.5 %-Electrolytes Aminosyn M 3.5 % Aminosyn-HBC 7% Aminosyn-HF 8 % Aminosyn-PF 10 % Aminosyn-PF 7 % (Sulfite- Free) amiodarone Amitiza amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-benazepril ammonium lactate Amnesteem amoxapine amoxicillin amoxicillin-pot clavulanate Amphetamine Salt Combo... 69

115 ampicillin ampicillin sodium ampicillin-sulbactam Ampyra Amturnide Anadrol Anafranil anagrelide Anaprox Anaprox DS anastrozole Ancobon Androderm AndroGel Androxy ANGELIQ Antabuse Antara Antizol Anusol-HC Anzemet Apidra Apidra SoloStar APOKYN apraclonidine Apri Apriso Aptivus Aralast NP Aralen Aranesp (polysorbate) Arava Arcalyst Aricept Aricept ODT Arimidex Arixtra Aromasin Arranon Arthrotec Arthrotec Arzerra Asacol Asacol HD Ascomp w/codeine... 7 Asmanex Twisthaler Astelin Astepro Atacand Atacand HCT Page 115 of 128 Atelvia atenolol atenolol-chlorthalidone Atgam ATRIPLA atropine Atrovent Atrovent HFA Attenuvax (PF) Augmentin ES Avalide AvandaMet Avandaryl... 53, 54 Avandia Avapro AVASTIN Avelox Avelox ABC Pack Avelox in NaCl (iso-osmotic) Aviane Avinza... 7 Avodart Avonex Avonex Administration Pack 94 Axid Axiron Aygestin Azactam Azactam-iso-osmotic dextrose Azasite azathioprine azathioprine sodium azelastine , 106 Azelex AZILECT azithromycin Azopt Azor aztreonam Azulfidine Azulfidine EN-tabs Baci-IM bacitracin... 16, 100 bacitracin-polymyxin B baclofen Bactrim Bactrim DS Bactroban Bactroban Nasal balsalazide Banzel Baraclude Beconase AQ benazepril benazepril-hydrochlorothiazide Benicar Benicar HCT Bentyl benztropine Bepreve Besivance Betagan betamethasone dipropionate. 81, 82 betamethasone valerate... 80, 81 betamethasone, augmented Betapace Betaseron Beta-Val betaxolol... 63, 99 bethanechol chloride Betimol Betoptic S Beyaz Biaxin Biaxin XL bicalutamide Bicillin C-R BiCNU BiDil Biltricide bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin Bleph Blephamide Blephamide S.O.P Boniva... 97, 98 BOOSTRIX Borofair Brevicon (28) Briellyn brimonidine Bromday bromfenac bromocriptine... 41

116 Budeprion SR Budeprion XL budesonide... 76, 103 bumetanide Buphenyl buprenorphine... 7 bupropion HCl BuSpar buspirone Busulfex Byetta Bystolic cabergoline Caduet Cafergot Calan Calan SR calcipotriene calcitonin (salmon) calcitriol calcium acetate Camila Campath Campral Canasa Cancidas Capastat Capex captopril captopril-hydrochlorothiazide Carac Carafate carbamazepine carbidopa-levodopa carboplatin Cardizem Cardizem CD Cardizem LA Cardura carisoprodol Carnitor carteolol Cartia XT carvedilol Casodex Cataflam Catapres Catapres-TTS Catapres-TTS Page 116 of 128 Catapres-TTS Cedax CeeNU cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os) 12 cefdinir cefepime cefotaxime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime... 13, 14 cefprozil ceftazidime Ceftin ceftriaxone cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) Celebrex Celestone Celexa CellCept CellCept Intravenous Celontin Cenestin cephalexin Cerebyx Ceredase Cerezyme Cervarix Vaccine Cesamet Cesia cetirizine Chantix Chantix Starting Month Pak. 27 chlordiazepoxide HCl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorpropamide chlorthalidone chlorzoxazone Cholestyramine Light Cialis ciclopirox... 29, 30 cilostazol Ciloxan Cimzia Cimzia Powder for Reconst.. 76 Cinryze Cipro Cipro HC CIPRODEX ciprofloxacin ciprofloxacin (mixture) cisplatin citalopram cladribine Claforan Claravis clarithromycin Cleocin Cleocin in D5W Cleocin T... 70, 71 Climara Climara Pro clindamycin HCl clindamycin phosphate... 15, 71 Clindesse Clinimix 2.75%/D5 Sulfite Free Clinimix 4.25%/D5 Sulfite Free Clinimix 4.25/D10 Sulfite Free Clinimix 4.25/D20 Sulfite Free Clinimix 4.25/D25 Sulfite Free Clinimix 5%/D15 Sulfite Free Clinimix 5%/D20 Sulfite Free Clinimix 5%/D25 Sulfite Free Clinimix E 2.75/D10 SulfitFree Clinimix E 2.75/D5 SulfiteFree Clinimix E 4.25/D25 SulfitFree Clinimix E 4.25/D5 SulfiteFree

117 Clinimix E 5%/D15 Sulfite Free Clinimix E 5%/D20 Sulfite Free Clinimix E 5%/D25 Sulfite Free Clinisol SF 15% Clinoril clobetasol clobetasol-emollient CLOBEX CLOLAR clomipramine clonazepam clonidine clorazepate dipotassium clotrimazole clotrimazole-betamethasone.. 30 clozapine Clozaril Coartem cod-butalbital-acetaminop-caf 7 codeine sulfate... 7 Co-Gesic... 7 Cognex Colazal colchicine-probenecid Colcrys Colestid colestipol colistimethate sodium Coly-Mycin M Parenteral Colyte with Flavor Packs Combigan CombiPatch Combivent Combivir Combunox... 8 Compro Comtan Comvax Concerta Condylox Copaxone Copegus Cordarone Cordran Coreg Coreg CR Corgard Page 117 of 128 Cortef Cortenema Cortifoam cortisone Cortisporin Cortomycin Corzide Cosmegen Cosopt Coumadin Cozaar Creon Crestor Crinone Crixivan cromolyn , 106 Cryselle (28) CUBICIN Cuprimine Curity Gauze Cutivate Cuvposa Cyclafem 1/35 (28) Cyclafem 7/7/7 (28) Cyclessa cyclobenzaprine cyclophosphamide cyclosporine cyclosporine modified Cyklokapron Cymbalta cyproheptadine Cystagon cytarabine (PF) Cytomel Cytotec Cytovene D.H.E D10 %-0.45 % sodium chloride D % NaCl & Potassium Cl D2.5 %-0.45 % sodium chloride D5 %-0.45 % sodium chloride D5 %-0.9 % sodium chloride D5-1/2 NS & potassium chloride D5-1/3 NS & potassium chloride D5-1/4 NS & potassium chloride D5-LR with potassium chloride D5-NS with potassium chloride D5W with potassium chloride dacarbazine Dacogen Daliresp danazol Dantrium dantrolene dapsone Daptacel (Pediatric) (PF) Daraprim daunorubicin DaunoXome Daypro DDAVP DECAVAC Demadex demeclocycline Demerol... 8 Denavir Depacon Depade Depakene Depakote Depakote ER Depakote Sprinkles Depen Titratabs Depo-Medrol Depo-Provera Depo-Testosterone Derma-Smooth/FS Body Oil. 81 DERMATOP DermOtic Oil desipramine desmopressin Desogen desonide... 80, 81 desoximetasone... 80, 81 Detrol Detrol LA dexamethasone... 79

118 dexamethasone sodium phosphate Dexedrine Spansule Dexilant dexmethylphenidate DexPak dexrazoxane dextroamphetamine dextrose 10% in water (D10W) dextrose 10%-1/4 normal saline dextrose 5% in water (D5W) dextrose 5%-0.3 % sod.chloride dextrose 5%-1/4 normal saline Diastat AcuDial diazepam diclofenac potassium diclofenac sodium... 32, 33, 100 dicloxacillin dicyclomine didanosine Didronel Dificid diflorasone Diflucan diflunisal digoxin dihydroergotamine Dilacor XR Dilantin Dilantin Extended Dilantin Infatabs Dilantin Dilaudid... 8 Dilaudid Dilaudid-HP... 8 DILT-CD diltiazem HCl... 61, 62 DILT-XR Diovan Diovan HCT Dipentum diphenhydramine HCl diphenoxylate-atropine Diprolene Diprolene AF Page 118 of 128 dipyridamole disopyramide disulfiram Ditropan XL Diuril IV divalproex Divigel Docefrez docetaxel Dolophine... 8 donepezil dorzolamide dorzolamide-timolol Dovonex doxazosin doxepin Doxil doxorubicin doxycycline hyclate... 19, 20 doxycycline monohydrate dronabinol Droxia DUETACT Dulera DuoNeb Duragesic... 7 Duramorph... 8 Durezol Dyazide Dynacin DynaCirc CR Dyrenium EC-Naprosyn econazole ED K Edarbi Edurant Effexor Effexor XR... 25, 26 Effient Efudex Eldepryl ELESTAT Elestrin Elidel Elitek Elixophyllin Ella Elmiron Elocon Elspar Emadine Embeda... 7 Emcyt Emend EMLA Emoquette Emsam Emtriva Enablex enalapril maleate enalapril-hydrochlorothiazide Enbrel Endocet... 8 Endodan... 8 Engerix-B (PF) Enjuvia enoxaparin Enpresse Entocort EC Enulose epinastine EpiPen EpiPen Jr epirubicin Epitol Epivir Epivir HBV eplerenone Epogen Epzicom Eraxis(Water Diluent) Erbitux ergoloid ergotamine-caffeine Errin Ery Pads Ery-Tab Erythrocin Erythrocin Stearate erythromycin... 15, 16 erythromycin ethylsuccinate. 16 erythromycin with ethanol erythromycin-sulfisoxazole estazolam Estrace estradiol estradiol-norethindrone acet.. 85 Estring... 85

119 estropipate Estrostep Fe ethambutol ethosuximide Ethyol etidronate disodium etodolac Etopophos etoposide Eurax Evamist Evista Evoxac Exalgo ER... 7 Exelderm Exelon exemestane Exforge Exforge HCT Exjade Eye Itch Relief Fabrazyme Factive famciclovir famotidine famotidine (PF) famotidine(pf) in sal (iso-os) 75 Famvir... 45, 46 Fanapt Fareston Faslodex FazaClo Felbatol Feldene felodipine Femara Femcon Fe Femhrt 1/ Femhrt Low Dose Femring Femtrace fenofibrate fenofibrate micronized fenoprofen fentanyl... 7 fentanyl citrate... 8 Fentora... 8 fexofenadine Fibricor Finacea Page 119 of 128 finasteride Fioricet-Codeine... 8 Fiorinal-Codeine # Firmagon Flagyl Flarex flavoxate flecainide Flector Flexeril Flomax Flonase Flo-Pred Flovent Diskus Flovent HFA fluconazole fluconazole in dextrose(iso-o) fludarabine fludrocortisone Flumadine flunisolide fluocinolone... 80, 81 fluocinonide fluocinonide-emollient fluorometholone Fluoroplex fluorouracil... 37, 72 fluoxetine... 48, 49 fluphenazine decanoate fluphenazine HCl flurazepam flurbiprofen flurbiprofen sodium flutamide fluticasone... 82, 104 fluvoxamine FML Forte FML Liquifilm FML S.O.P Focalin Focalin XR fomepizole fondaparinux Foradil Aerolizer Fortaz Fortaz in D5W Forteo Fortesta FORTICAL Fosamax foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL Fragmin Freamine HBC 6.9 % Freamine III 3 %-Electrolytes Freamine III 8.5 % Frova Furadantin furosemide Fuzeon gabapentin... 21, 22 Gabitril galantamine Gammagard Liquid Gammaplex ganciclovir ganciclovir sodium Gardasil Gastrocrom Gavilyte-C GaviLyte-G GaviLyte-N Gelnique gemcitabine gemfibrozil Gemzar Generlac Gengraf gentamicin gentamicin in NaCl (iso-osm)... 11, 12 gentamicin sulfate (PF) Gentasol Geodon Gianvi Gilenya Glassia Gleevec glimepiride glipizide glipizide-metformin GlucaGen HypoKit Glucagon Emergency Glucophage... 50, 51

120 Glucophage XR Glucotrol Glucotrol XL Glucovance Glumetza glyburide glyburide micronized glyburide-metformin glycopyrrolate Glycron Glynase Glyset Golytely granisetron Granisol Grifulvin V griseofulvin microsize guanabenz guanfacine guanidine Halaven Haldol Haldol Decanoate HalfLytely-Bisacodyl Bowel Kit Halflytely-Bisacodyl w-flav Pk halobetasol propionate Halog haloperidol haloperidol decanoate haloperidol lactate Havrix (PF) Hectorol Helidac heparin (porcine) heparin (porcine) in D5W heparin (porcine) in NS (PF). 56 heparin (porcine)-0.45% NaCl heparin, porcine (PF) Hepatamine 8% Hepatasol 8 % Hepsera Herceptin Hexalen Hiprex Hizentra Humalog Humalog KwikPen Page 120 of 128 Humalog Mix Humalog Mix KwikPen Humalog Mix Humalog Mix KwikPen Humira Humira Crohn's Dis Start Pck Humulin 70/ Humulin 70/30 Pen Humulin N Humulin N Pen Humulin R Hycamtin hydralazine Hydrea hydrochlorothiazide hydrocodone-acetaminophen.. 8 hydrocodone-ibuprofen... 8 hydrocortisone... 79, 81 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone... 8 hydromorphone (PF)... 8 hydroxychloroquine hydroxyurea hydroxyzine HCl , 106 hydroxyzine pamoate Hyzaar ibuprofen ibuprofen-oxycodone... 8 idarubicin ifosfamide ifosfamide-mesna Ilaris (PF) Imdur imipramine HCl imipramine pamoate imiquimod Imitrex Imovax Rabies Vaccine Imuran Incivek Increlex indapamide Inderal LA indomethacin Infanrix (PF) INSPRA Insulin Pen Needle insulin syringe-needle U Intelence Intralipid Intron A Introvale Intuniv ER Invanz Invega Invega Sustenna Invirase Iopidine IPOL ipratropium bromide ipratropium-albuterol Iquix IRESSA irinotecan Isentress Ismo Isolyte-H in D5W Isolyte-M in D5W Isolyte-P in D5W Isolyte-S Isolyte-S in D5W IsonaRif isoniazid Isopto Carpine Isordil Titradose isosorbide dinitrate isosorbide mononitrate isradipine Istalol Istodax itraconazole Ixempra Ixiaro (PF) Jalyn Jantoven Janumet Januvia Je-Vax Jevtana Jinteli Jolivette Junel 1.5/30 (21) Junel 1/20 (21) Junel FE 1.5/30 (28) Junel FE 1/20 (28)... 88

121 Kadian... 7 Kaletra kanamycin Kaon Cl Kapvay Kariva Kayexalate Keflex Kelnor 1/35 (28) Kepivance Keppra Keppra XR Kerlone KETEK ketoconazole ketoprofen ketorolac... 33, 100 Kineret Klor-Con Klor-Con Klor-Con M Klor-Con M Kombiglyze XR Kristalose K-Tab Kuric Kuvan Kytril labetalol Lac-Hydrin Lacrisert lactated ringers lactulose Lamictal Lamisil lamotrigine Lanoxin lansoprazole Lantus Lantus Solostar Lasix Lastacaft latanoprost Latuda Leena leflunomide Lescol Lescol XL Lessina Letairis Page 121 of 128 letrozole leucovorin calcium Leukeran Leukine leuprolide levalbuterol HCl Levaquin Levaquin in D5W Levemir Levemir Flexpen levetiracetam... 20, 21 levobunolol levocarnitine levocetirizine levofloxacin... 19, 101 levofloxacin in D5W Levora Levothroid levothyroxine Levoxyl Lexapro Lexiva Lialda lidocaine HCl... 10, 11 lidocaine-prilocaine Lidoderm Lincocin liothyronine Lipitor... 56, 57 Liposyn II Liposyn III lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate Lithobid Lo Loestrin Fe Locoid Loestrin 1.5/30 (21) Loestrin 1/20 (21) Loestrin Fe 1.5/30 (28) Loestrin Fe 1/20 (28) Lofibra LoKara Lomotil Lo-Ovral (28) Lopid Lopressor... 60, 63 Lopressor HCT Loprox loratadine lorazepam Lorcet 10/ Lorcet Plus... 8 Lortab... 9 Lortab Elixir... 9 losartan losartan-hydrochlorothiazide 59 LoSeasonique Lotemax , 102 Lotensin Lotensin HCT Lotrel Lotrisone... 30, 31 Lotronex lovastatin Lovaza Lovenox Low-Ogestrel (28) loxapine succinate Loxitane Lumigan Lumizyme Lunesta Lupron Depot Lupron Depot (3 Month) Lupron Depot (4 Month) Lupron Depot (6 Month) Lupron Depot-Ped Lutera (28) Luxiq Lyrica Lysodren Lysteda Macrobid Macrodantin maprotiline Margesic-H... 9 Marinol Marplan Matulane Matzim LA Mavik Maxair Autohaler Maxalt Maxalt-MLT Maxidone... 9 Maxipime Maxitrol

122 Maxzide Maxzide-25mg mebendazole meclofenamate Medrol Medrol (Pak) medroxyprogesterone Megace ES Megace Oral megestrol meloxicam melphalan Menactra (PF) Menest Menomune - A/C/Y/W-135 (PF) Menveo A-C-Y-W-135-Dip (PF) meperidine... 9 meperidine (PF)... 9 meprobamate Mepron mercaptopurine meropenem Merrem Meruvax II (PF) mesalamine mesna Mesnex Mestinon METADATE ER Metaglip metaxalone metformin methadone... 9 Methadose... 9 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium... 92, 93 methotrexate sodium (PF) methscopolamine methyclothiazide methyldopa methyldopahydrochlorothiazide Methylin Methylin ER methylphenidate Page 122 of 128 methylprednisolone methylprednisolone acetate.. 79 methylprednisolone sodium succ metipranolol metoclopramide metolazone metoprolol succinate metoprolol tartrate... 60, 63 metoprolol-hydrochlorothiazide MetroCream Metrogel Vaginal MetroLotion metronidazole metronidazole in NaCl (iso-os) Mevacor mexiletine Miacalcin Micardis Micardis HCT Miconazole Microgestin 1.5/30 (21) Microgestin 1/20 (21) Microgestin Fe 1.5/30 (28) Microgestin FE 1/20 (28) Microzide midodrine Migergot Migranal Minipress Minocin minocycline minoxidil Mirapex Mirapex ER mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) Mobic moexipril moexipril-hydrochlorothiazide mometasone Monoket Mononessa (28) Monopril Monurol morphine... 7, 9 morphine (PF)... 9 morphine concentrate... 9 MoviPrep Moxeza Mozobil MS Contin... 7 Multaq mupirocin Mustargen Myambutol Mycobutin mycophenolate mofetil Myfortic Mysoline Mytelase nabumetone nadolol nadolol-bendroflumethiazide 66 nafcillin Naftin Naglazyme Nalfon naloxone naltrexone Namenda Namenda Titration Pak Naprosyn naproxen naproxen sodium naratriptan Nardil Nasacort AQ Nasonex Natacyn nateglinide Navane Nebupent Necon 0.5/35 (28) Necon 1/35 (28) Necon 10/11 (28) Necon 7/7/7 (28) nefazodone Neo-Fradin neomycin neomycin-bacitracin-poly-hc neomycin-bacitracinpolymyxin

123 neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc... 17, 101 Neoral Neosporin Nephramine 5.4 % Neulasta Neumega Neupogen Neurontin Nevanac Nexavar Nexium Nexium IV Nexium Packet Next Choice Niaspan Extended-Release nicardipine Nicotrol Nicotrol NS Nifediac CC Nifedical XL nifedipine Nilandron nimodipine nisoldipine Nitro-Bid Nitro-Dur nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/mcryst nitroglycerin Nitrolingual Nitromist Nitrostat nizatidine Nizoral Nora-BE Norco... 9 Nordette norethindrone acetate Norinyl 1+35 (28) Normosol-M in D5W Normosol-R in D5W Normosol-R ph Norpace Page 123 of 128 Norpramin Nor-QD Nortrel 0.5/35 (28) Nortrel 1/35 (21) Nortrel 1/35 (28) Nortrel 7/7/7 (28) nortriptyline Norvasc Norvir Novamine 15 % (Hospira) Novantrone Novolin 70/ Novolin N Novolin R Novolog Novolog Flexpen Novolog Mix Novolog Mix FlexPen 52 Noxafil NS with potassium chloride 111 Nulojix NuLYTELY with Flavor Packs NuvaRing Nuvigil nystatin... 31, 32 nystatin-triamcinolone Nystop Ocella octreotide acetate Ocufen Ocuflox ofloxacin Ogen Ogestrel (28) Oleptro ER omeprazole... 77, 113 omeprazole-sodium bicarbonate Omnaris Omnicef Omnipred Omnitrope Oncaspar ondansetron ondansetron HCl ondansetron HCl (PF) Onglyza Onsolis... 9 Ontak Opana... 9 Opana ER... 7 Optipranolol Optivar Orap Orapred Orencia Orfadin orphenadrine citrate Orphenadrine Compound Orphenadrine Compound-DS Orsythia Ortho Evra Orthoclone OKT Ortho-Cyclen (28) Ortho-Novum 7/7/7 (28) OsmoPrep Ovide oxacillin oxacillin in dextrose, iso-osm18 oxaliplatin Oxandrin oxandrolone oxaprozin oxazepam oxcarbazepine Oxistat Oxsoralen Ultra oxybutynin chloride oxycodone... 9 oxycodone HCl-oxycodone- ASA... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OxyContin... 7 oxymorphone... 9 Oxytrol Pacerone paclitaxel Pamelor pamidronate Pamine Pamine Forte Pancreaze Panretin pantoprazole Parafon Forte DSC Parcopa Parlodel... 41

124 Parnate paromomycin paroxetine HCl Paser Pataday Patanase Patanol Paxil Paxil CR Pediapred Pediarix (PF) Pedi-Dri Pedvax HIB (PF) Peganone Pegasys Pegasys Convenience Pack PegIntron PegIntron Redipen penicillin G pot in dextrose penicillin G potassium penicillin G procaine penicillin G sodium penicillin V potassium Penlac Pennsaid Pentam Pentasa pentazocine-acetaminophen.. 10 pentazocine-naloxone pentostatin pentoxifylline Pepcid... 75, 76 Pepcid in NaCl (iso-osmotic) 76 Percocet Percodan perindopril erbumine Periogard Periostat permethrin perphenazine perphenazine-amitriptyline Persantine Pfizerpen-G Phenadoz phenelzine Phenergan Phenytek phenytoin phenytoin sodium phenytoin sodium extended.. 23 Page 124 of 128 PhosLo Phoslyra Phospholine Iodide Photofrin Physiolyte pilocarpine HCl Pilopine HS pindolol piperacillin piperacillin-tazobactam piroxicam Plaquenil Plasma-Lyte Plasma-Lyte 148 in D5W Plasma-Lyte Plasma-Lyte A Plasma-Lyte R Plasma-Lyte-56 in D5W Plavix Pletal podofilox Polycin B Poly-Dex polyethylene glycol polymyxin B sulfate Polytrim Portia potassium chloride potassium citrate Pradaxa pramipexole Prandin Pravachol pravastatin prazosin Precose Pred Mild Pred-G Pred-G S.O.P prednicarbate prednisolone acetate prednisolone sodium phosphate... 79, 100 prednisone Prednisone Intensol Prefest Premarin Premasol 10 % Premasol 6 % Premphase Prempro Prenatabs OBN Prevacid Prevacid 24Hr Prevacid SoluTab Previfem Prevpac Prezista Priftin Prilosec Primaxin IM Primaxin IV primidone Primsol Prinivil Prinzide Pristiq Privigen ProAir HFA ProAmatine probenecid Procalamine 3% Procardia Procardia XL prochlorperazine prochlorperazine Edisylate prochlorperazine maleate Procrit Proctosol HC Proctozone-HC Proglycem Prograf Prolastin Prolastin C Proleukin Prolia Promacta promethazine Promethazine VC Promethegan Prometrium propafenone propantheline propranolol... 60, 66, 67 propranolol-hydrochlorothiazid propylthiouracil ProQuad Proscar Prosol 20%

125 Protonix Protopic protriptyline Proventil HFA Provera Provigil Prozac Prozac Weekly Pulmicort Pulmicort Flexhaler Purinethol Pylera pyrazinamide pyridostigmine bromide Qualaquin Quasense quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate Quixin Qvar RabAvert (PF) ramipril Ranexa ranitidine HCl Rapamune Razadyne Razadyne ER REBETOL Rebif Rebif Titration Pack Reclast Reclipsen (28) Recombivax HB (PF) Reglan Regranex Relenza Diskhaler Relistor Relpax Remeron Remeron SolTab Remicade Renagel Renamin 6.5 % Renvela... 78, 79 Requip Requip XL Rescriptor Page 125 of 128 reserpine Restasis Retrovir Revatio Revia REVLIMID Reyataz Rhinocort Aqua Ribasphere ribavirin Ridaura Rifadin Rifamate rifampin Rifater Rilutek rimantadine ringers Risperdal Risperdal Consta Risperdal M-TAB risperidone Ritalin Ritalin LA Ritalin SR Rituxan rivastigmine Robaxin Robinul Robinul Forte Romycin ropinirole RotaTeq Vaccine Roxicet Roxicodone Rozerem Rythmol Rythmol SR Sabril safety needles Safyral Salagen Samsca Sanctura Sanctura XR Sancuso Sandimmune Sandostatin Santyl Saphris Savella Seasonale Seasonique Sectral selegiline HCl selenium sulfide Selsun Selzentry Sensipar Serevent Diskus Seromycin Seroquel Seroquel XR sertraline Silvadene silver sulfadiazine Simcor Simponi Simulect simvastatin Sinemet Sinemet CR Singulair Skelaxin sodium bicarbonate sodium chloride sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium polystyrene sulfonate 27 Solaraze Solia Solu-Cortef (PF) Solu-Medrol Solu-Medrol (PF) Soma Somatuline Depot SOMAVERT Sonata Soriatane Sorine sotalol Sotret Spectracef Spiriva with HandiHaler spironolactone spironolacton-hydrochlorothiaz Sporanox... 31

126 Sprintec (28) Sprycel SSD Stalevo Stalevo Stalevo Stalevo Stalevo Stalevo Starlix stavudine Strattera streptomycin Suboxone Subutex sucralfate Sular sulfacetamide sodium sulfacetamide-prednisolone.. 19 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine Sulfatrim Sulfazine EC sulindac sumatriptan succinate Suprax Surmontil Sustiva Sutent Sylatron Symbicort Symbyax Symlin SymlinPen SymlinPen Synarel Synera Synthroid Syprine Tabloid Taclonex Taclonex Scalp tacrolimus Talacen Talwin NX Tambocor Tamiflu tamoxifen Page 126 of 128 tamsulosin Tapazole Tarceva Targretin Tarka Tasigna Tasmar Taxotere TAZICEF Tazorac Taztia XT Teflaro Tegretol Tegretol XR Tekamlo Tekturna Tekturna HCT temazepam Temovate Tenex Tenoretic Tenoretic Tenormin Terazol Terazol terazosin terbinafine terbutaline terconazole testosterone cypionate tetanus toxoid,adsorbed (PF) 96 tetanus,diphtheria toxd ped-pf tetanus-diphtheria toxoids-td96 tetracycline Teveten Teveten HCT Thalomid Theochron theophylline Thermazene thioridazine thiotepa thiothixene Thymoglobulin Thyrolar Thyrolar-1/ Thyrolar Thyrolar Tiazac ticlopidine Tigan Tikosyn Timentin timolol maleate... 67, 99 Timoptic-XE Tirosint Tis-U-Sol tizanidine TobraDex , 102 Tobradex ST tobramycin in NS tobramycin sulfate tobramycin-dexamethasone 102 Tobrasol Tobrex Tofranil tolazamide tolmetin Topamax Topicort Topicort LP topiramate topotecan Toprol XL Torisel torsemide Toviaz TPN Electrolytes Tracleer tramadol... 7, 10 tramadol-acetaminophen Trandate trandolapril Transderm-Scop tranylcypromine Travasol 10 % Travatan Z trazodone Treanda Trecator Trelstar Trental tretinoin tretinoin (chemotherapy) triamcinolone acetonide. 70, 80, 82, 104 triamterene-hydrochlorothiazid Tribenzor... 65

127 Tricor Triderm trifluoperazine trifluridine trihexyphenidyl TriHIBit Preservative Free Tri-Legest Fe Trileptal Trilipix TriLyte With Flavor Packets. 75 trimethobenzamide trimethoprim trimethoprim-polymyxin B. 102 TriNessa (28) Tri-Norinyl (28) Tripedia (PF) Tri-Previfem (28) Trisenox Tri-Sprintec (28) Trivora (28) Trizivir TrophAmine 10 % Trophamine 6% trospium Trusopt Truvada Twinject Autoinjector Twinrix (PF) Tygacil Tykerb Tylenol-Codeine # Tylenol-Codeine # Tylox Typhim VI Tyzeka Tyzine Uloric Ultracet Ultram Ultram ER... 7 Ultravate Unasyn Uniphyl Uniretic Unithroid Univasc Urecholine Uroxatral URSO URSO Forte Page 127 of 128 ursodiol Uvadex Vagifem valacyclovir Valcyte valproate sodium valproic acid valproic acid (as sodium salt) 22 Valtrex Valturna Vancocin vancomycin Vandazole vandetanib Vantin Vaqta (PF) Varivax (PF) Vaseretic Vasotec Vectibix Vectical VELCADE Velivet venlafaxine Ventolin HFA Veramyst verapamil... 61, 62, 63 Veregen Verelan Verelan PM Vesicare Vexol Vfend Vfend IV Viagra Vibativ Vibramycin Vibra-Tabs Vicodin Vicodin ES Vicoprofen Victoza Victrelis Vidaza Videx 2 gram Pediatric Videx EC Vigamox Viibryd Vimpat vinblastine vincristine vinorelbine Viracept Viramune Viramune XR Viread Viroptic Vistaril Vistide Vivactil Vivaglobin Vivelle-Dot Voltaren... 34, 100 Voltaren-XR voriconazole Vospire ER Votrient VPRIV Vytorin Vytorin Vytorin Vytorin Wal-itin D warfarin WelChol Wellbutrin Wellbutrin SR Wellbutrin XL Westcort Xalatan Xarelto Xenazine Xgeva Xifaxan Xolair Xopenex HFA Xylocaine Jelly Xyrem Xyzal YAZ YF-Vax Zaditor zafirlukast zaleplon Zanaflex Zanosar Zantac Zarontin Zaroxolyn ZAVESCA... 73

128 ZAZOLE Zebeta Zegerid Zemaira Zemplar Zenpep Zeosa Zerit Zestoretic Zestril Zetia Ziac Ziagen zidovudine Zirgan Zithromax Zithromax TRI-PAK Zithromax Z-Pak Zmax Adult-Pediatric Zocor Zofran ZOFRAN ODT Zolinza Zoloft zolpidem Zometa Zomig Zomig ZMT Zonalon Zonegran zonisamide Zortress ZOSTAVAX Zosyn Zosyn in dextrose (iso-osm).. 14 Zovia 1/35E (28) Zovia 1/50E (28) Zovirax Zyflo CR Zylet Zyloprim Zymar Zymaxid Zyprexa... 43, 44 Zyprexa Zydis Zytiga Zyvox Page 128 of 128