Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary)

Transcription

1 Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary) caid-mmaiformulary-1115 Version 25 November 1, 2015 H0073_14_11391a

2 caid-mmaiformulary-1115 Version 25 November 1, 2015 H0773_14_11391a Health Alliance Connect (Medicare-Medicaid Plan) 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Health Alliance Connect. Health Alliance Medical Plans is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. You can always check Health Alliance Connect s up-to-date List of Covered Drugs online at HealthAllianceConnect.org. You can ask for this information in other formats, such as Braille or large print. Call The call is free. Limitations, copayments, and restrictions may apply. For more information, call Health Alliance Connect Client Services or read the Health Alliance Connect Medicare- Medicaid Member Handbook. Copayments for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call The call is free. Puede obtener este documento en inglés o hablar con alguien sobre esta información en otro idioma de manera gratuita. Llame al La llamada es gratuita.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Health Alliance Connect. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Health Alliance Connect will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Health Alliance Connect network pharmacy. Health Alliance Connect may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at HealthAllianceConnect.org or call Client Services at Does the Drug List ever change? Yes. Health Alliance Connect may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Health Alliance Connect before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

4 (For more information on these drug rules, see question 5.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Health Alliance Connect s up to date Drug List online at HealthAllianceConnect.org. You can also call Client Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will send you a letter to tell you how we can work with you and your doctor or other prescriber to find a drug on the list that would be similar. This letter will also tell you how you can request an exception. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you receive this letter, contact your provider to discuss next steps. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from Health Alliance Connect before you fill your prescription. If you don t get approval, Health Alliance Connect may not cover the drug. Quantity limits: Sometimes Health Alliance Connect limits the amount of a drug you can get.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

5 Step therapy: Sometimes Health Alliance Connect requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables that start on page 1. You can also get more information by visiting our web site at HealthAllianceConnect.org. You can also ask for an exception from these limits. Please see question 10 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Health Alliance Connect member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 10 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor about what to do next.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

6 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by searching the name. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Client Services at and ask about it. If you learn that Health Alliance Connect will not cover the drug, you can do one of these things: Ask Client Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 10 for more information about exceptions. 10. What if you are a new Health Alliance Connect member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Health Alliance Connect. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

7 the drug requires prior approval by Health Alliance Connect, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 days. You may refill the drug multiple times during the 91 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may also receive a one-time emergency supply of drugs if you have a level of service change such as a discharge from a long-term care facility. 11. Can you ask for an exception to cover your drug? Yes. You can ask Health Alliance Connect to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Health Alliance Connect may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Health Alliance Client Services. A Client Services representative will work with you and your provider to help you ask for an exception.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

8 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Health Alliance Connect covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. You can buy OTC drugs without a prescription. Health Alliance Connect covers some OTC drugs. You can read the Health Alliance Connect Drug List to see what OTC drugs are covered. 16. Does Health Alliance Connect cover OTC non-drug products? Health Alliance Connect covers some OTC non-drug products. You can read the Health Alliance Connect Drug List to see what OTC non-drug products are covered. 17. What is your copayment? You can read the Health Alliance Connect Drug List to learn about the copayment for each drug. Health Alliance Connect members living in nursing homes or other long-term care facilities will have no copayments. Some members getting long-term care in the community will also have no copayments. Tier 1/$0- Part D Generic Drugs These drugs are the lowest prescription cost drugs on our formulary. Tier 2/$0-$6.35 (depending on your level of Extra Help)- Part D Brand Drugs These are drugs typically cost more than Tier 1 and some many have special rules, like preauthorization, before you can take them Tier 3/$0- Non-Part D Generic Drugs These are generic drugs that are covered by your medical benefit, not your drug benefit.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

9 Tier 4/$0-Non-Part D Brand Drugs These drugs typically cost more than Tier 3 Tier 5/$0-Generic Over-the-Counter Drugs These are the lowest cost OTC drugs on our Drug List Tier 6/$0-Brand Over-the-Counter Drugs These are brand name OTC drugs, and cost more than Tier 5 List of Covered Drugs The list of covered drugs, that begins on page 1, gives you information about the drugs covered by Health Alliance Connect. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CHANTIX) and generic drugs are listed in lower-case italics (e.g., acetaminophen). The information in the necessary actions, restrictions, or limits on use column tells you if Health Alliance Connect has any rules for covering your drug. EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered BvD = Preauthorization required to decide if the be covered by Part D or Part B = Preauthorization required for the first time it is prescribed QL = Quantity Limit applies, you may only be able to get a certain amount of this drug ST = Step-Therapy required, you may have to take a lower-tier drug first before Health Alliance Connect will cover a drug at a higher tier Note, when you see an * next to a drug means the drug is not a Part D drug. 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 these drugs. These drugs also have different rules for? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

10 appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Client Services at You can also read the Member Handbook to learn how to appeal a decision. Name of drug Analgesics What the (tier level) Necessary actions, restrictions, or limits on use Analgesics, Miscellaneous acetaminophen * (Acetaminophen) $0 (Tier 5) ; QL 480 in 1 day; solution acetaminophen * (Acetaminophen) $0 (Tier 5) ; drops: 80mg/0.8ml acetaminophen with codeine (Vopac) $0 (Tier 1) QL 180 in 30 days; tablet: 300mg-60mg Here are the meanings of the codes used in the Necessary actions, restrictions or limits on use column: EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered BvD = Preauthorization required to decide if the be covered by Part D or Part B = Preauthorization required for the first time it is prescribed QL = Quantity Limit applies, you may only be able to get a certain amount of this drug? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

11 ST = Step-Therapy required, you may have to take a lower-tier drug first before Health Alliance Connect will cover a drug at a higher tier Note, when you see a * next to a drug, it means the drug is not a Part D drug.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

12 What the Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with $0 (Tier 1) QL (4500 per 30 days) Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine $0 (Tier 1) QL (360 per 30 days) mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine $0 (Tier 1) QL (180 per 30 days) mg No.3) buprenorphine hcl injection (Buprenorphine HCl) $0 (Tier 1) butalbital-acetaminop-caf-cod oral capsule (Fioricet with $0 (Tier 1) mg Codeine) butalbital-acetaminophen-caff oral capsule (Esgic) $0 (Tier 1) butalbital-acetaminophen-caff oral tablet (Esgic) $0 (Tier 1) mg butalbital-aspirin-caffeine oral capsule (Fiorinal) $0 (Tier 1) butorphanol tartrate injection (Butorphanol $0 (Tier 1) Tartrate) butorphanol tartrate nasal (Butorphanol $0 (Tier 1) QL (5 per 28 days) Tartrate) CAPITAL WITH CODEINE codeine sulfate oral tablet (Codeine Sulfate) $0 (Tier 1) QL (180 per 30 days) codeine-butalbital-asa-caffein oral capsule (Fiorinal with $0 (Tier 1) mg Codeine #3) dihydrocodeine-aspirin-caff (Synalgos-Dc) $0 (Tier 1) QL (300 per 30 days) DISKETS $0 (Tier 1) QL (90 per 30 days) DURAMORPH (PF) fentanyl citrate (Actiq) ; QL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr (Duragesic) $0 (Tier 1) QL (20 per 30 days) 1

13 What the fentanyl transdermal patch 72 hour 12 (Duragesic) $0 (Tier 1) QL (10 per 30 days) mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution (Hycet) $0 (Tier 1) QL (2700 per 30 days) hydrocodone-acetaminophen oral tablet (Norco) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen (Ibudone) $0 (Tier 1) QL (150 per 30 days) hydromorphone (pf) injection solution 10 (Hydromorphone $0 (Tier 1) mg/ml HCl/PF) hydromorphone (pf) injection solution 4 (Dilaudid) $0 (Tier 1) mg/ml hydromorphone injection solution (Hydromorphone $0 (Tier 1) HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone $0 (Tier 1) HCl) hydromorphone oral liquid (Dilaudid) $0 (Tier 1) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) $0 (Tier 1) QL (180 per 30 days) hydromorphone oral tablet 8 mg (Dilaudid) $0 (Tier 1) QL (120 per 30 days) ibuprofen-oxycodone (Ibuprofen/Oxycodon $0 (Tier 1) QL (28 per 30 days) e HCl) INFUMORPH P/F INJECTION SOLUTION 25 MG/ML LAZANDA levorphanol tartrate (Levorphanol $0 (Tier 1) QL (180 per 30 days) Tartrate) methadone hcl oral concentrate 10 mg/ml (Methadose) $0 (Tier 1) QL (1800 per 30 days) methadone hcl oral tablet,soluble 40 mg (Diskets) $0 (Tier 1) QL (90 per 30 days) methadone injection (Methadone HCl) $0 (Tier 1) methadone oral (Methadone HCl) $0 (Tier 1) QL (1800 per 30 days) methadone oral (Diskets) $0 (Tier 1) QL (360 per 30 days) 2

14 What the $0 (Tier 1) morphine (pf) injection solution (Morphine Sulfate/PF) morphine (pf) intravenous (Morphine $0 (Tier 1) Sulfate/PF) morphine concentrate oral solution (Msir) $0 (Tier 1) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) $0 (Tier 1) QL (200 per 30 days) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) $0 (Tier 1) mg/ml morphine injection syringe 10 mg/ml, 2 (Morphine Sulfate) $0 (Tier 1) mg/ml morphine intramuscular (Morphine Sulfate) $0 (Tier 1) morphine intravenous (Morphine Sulfate) $0 (Tier 1) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) $0 (Tier 1) 50 mg/ml morphine intravenous (Morphine Sulfate) $0 (Tier 1) morphine oral capsule,extend.release (Kadian) $0 (Tier 1) QL (60 per 30 days) pellets 100 mg, 20 mg, 50 mg, 60 mg, 80 mg morphine oral capsule,extend.release (Kadian) $0 (Tier 1) QL (120 per 30 days) pellets 30 mg morphine oral solution 10 mg/5 ml (Msir) $0 (Tier 1) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Msir) $0 (Tier 1) QL (300 per 30 days) MORPHINE ORAL TABLET $0 (Tier 1) QL (180 per 30 days) morphine oral tablet extended release 100 (MS Contin) $0 (Tier 1) QL (120 per 30 days) mg, 60 mg morphine oral tablet extended release 15 (MS Contin) $0 (Tier 1) QL (180 per 30 days) mg, 200 mg morphine oral tablet extended release 30 (MS Contin) $0 (Tier 1) QL (60 per 30 days) mg morphine rectal (Morphine Sulfate) $0 (Tier 1) morphine sulfate-pf injection solution 0.5 mg/ml (Morphine Sulfate/PF) morphine sulfate-pf injection solution 1 mg/ml (Morphine Sulfate/PF) $0 (Tier 1) 3

15 What the nalbuphine injection (Nalbuphine HCl) $0 (Tier 1) nortemp oral (Acetaminophen) $0 (Tier 4) OFIRMEV oxycodone hcl-acetaminophen oral (Oxycodone $0 (Tier 1) QL (1800 per 30 days) solution mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg oxycodone hcl-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days) oxycodone oral capsule (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days) oxycodone oral concentrate (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days) oxycodone oral solution (Oxycodone HCl) $0 (Tier 1) QL (1300 per 30 days) oxycodone oral tablet (Percolone) $0 (Tier 1) QL (180 per 30 days) oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) $0 (Tier 1) QL (60 per 30 days) hr oxycodone-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg, mg oxycodone-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (180 per 30 days) mg oxycodone-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days) oxymorphone oral tablet (Opana) $0 (Tier 1) QL (180 per 30 days) oxymorphone oral tablet extended release (Opana ER) $0 (Tier 1) QL (60 per 30 days) 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) $0 (Tier 1) QL (120 per 30 days) 12 hr 30 mg, 40 mg PRIALT q-pap oral liquid (Tylenol Sore Throat) $0 (Tier 4) ; QL (480 per 1 day) SYNALGOS-DC QL (300 per 30 days) tramadol oral capsule,er biphase 24 hr (Conzip) $0 (Tier 1) ST; QL (60 per 30 days) 4

16 What the tramadol oral capsule,er biphase 24 hr (Conzip) $0 (Tier 1) ST; QL (60 per 30 days) tramadol oral tablet (Ultram) $0 (Tier 1) QL (240 per 30 days) tramadol oral tablet extended release 24 hr 100 mg (Ultram ER) $0 (Tier 1) ST; QL (90 per 30 days) tramadol oral tablet extended release 24 hr 200 mg, 300 mg (Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days) tramadol oral tablet, er multiphase 24 hr (Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days) tramadol-acetaminophen (Ultracet) $0 (Tier 1) ST; QL (240 per 30 days) xylon 10 (Ibudone) $0 (Tier 1) QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet,chewable (Bayer Chewable $0 (Tier 4) Aspirin) aspirin oral tablet,delayed release (dr/ec) (Ecotrin) $0 (Tier 4) 81 mg aspir-low (Ecotrin) $0 (Tier 4) CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) $0 (Tier 1) choline,magnesium salicylate (Choline Sal/Mag $0 (Tier 1) Salicylate) COMFORT C-IBUPROFEN $0 (Tier 1) COMFORT C-MELOXICAM $0 (Tier 1) COMFORT C-NAPROXEN $0 (Tier 1) diclofenac potassium (Cataflam) $0 (Tier 1) diclofenac sodium oral tablet extended (Voltaren-XR) $0 (Tier 1) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) $0 (Tier 1) release (dr/ec) diclofenac sodium topical gel (Solaraze) $0 (Tier 1) diclofenac-misoprostol (Arthrotec 50) $0 (Tier 1) 5

17 diflunisal (Diflunisal) $0 (Tier 1) ECOTRIN LOW STRENGTH $0 (Tier 4) etodolac (Etodolac) $0 (Tier 1) fenoprofen oral tablet (Fenoprofen $0 (Tier 1) Calcium) flurbiprofen (Ansaid) $0 (Tier 1) ibuprofen oral (Ibuprofen) $0 (Tier 1) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) $0 (Tier 1) mg ketoprofen oral capsule (Ketoprofen) $0 (Tier 1) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) $0 (Tier 1) hr 200 mg ketorolac injection (Toradol) $0 (Tier 1) QL (20 per 23 days) meclofenamate oral (Meclofenamate $0 (Tier 1) Sodium) mefenamic acid (Ponstel) $0 (Tier 1) meloxicam (Mobic) $0 (Tier 1) nabumetone (Nabumetone) $0 (Tier 1) naproxen oral suspension (Naprosyn) $0 (Tier 1) naproxen oral tablet (Naprosyn) $0 (Tier 1) naproxen oral tablet,delayed release (Ec-Naprosyn) $0 (Tier 1) (dr/ec) naproxen sodium oral tablet 275 mg, 550 (Anaprox) $0 (Tier 1) mg NEOPROFEN (IBUPROFEN LYSN)(PF) oxaprozin (Daypro) $0 (Tier 1) piroxicam (Feldene) $0 (Tier 1) salsalate (Salsalate) $0 (Tier 1) sulindac oral (Sulindac) $0 (Tier 1) tolmetin (Tolmetin Sodium) $0 (Tier 1) VOLTAREN TOPICAL 6

18 Anesthetics Local Anesthetics cocaine topical solution 4 % (Cocaine HCl) $0 (Tier 1) glydo (Lidocaine HCl) $0 (Tier 1) lidocaine (pf) injection solution (Xylocaine-MPF) $0 (Tier 1) BvD lidocaine (pf) intravenous syringe 100 (Lidocaine HCl/PF) $0 (Tier 1) mg/5 ml (2%) lidocaine hcl injection solution 10 mg/ml (Xylocaine) $0 (Tier 1) BvD (1 %) lidocaine hcl injection solution 20 mg/ml (Xylocaine) $0 (Tier 1) (2 %) lidocaine hcl laryngotracheal (Xylocaine) $0 (Tier 1) lidocaine hcl mucous membrane gel (Lidocaine HCl) $0 (Tier 1) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) $0 (Tier 1) applicator lidocaine hcl mucous membrane solution (Xylocaine) $0 (Tier 1) lidocaine hcl urethral (Lidocaine HCl) $0 (Tier 1) LIDOCAINE HCL-PF INJECTION BvD SOLUTION 15 MG/ML (1.5 %) lidocaine topical adhesive patch,medicated (Lidoderm) $0 (Tier 1) lidocaine topical ointment (Lidocaine) $0 (Tier 1) lidocaine-prilocaine topical (EMLA) $0 (Tier 1) lidocaine-prilocaine topical kit (Relador Pak) $0 (Tier 1) BvD lidocaine-tetracaine (Pliaglis) $0 (Tier 1) BvD PLIAGLIS BvD RELADOR K $0 (Tier 1) SYNERA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) $0 (Tier 1) buprenorphine hcl sublingual (Subutex) $0 (Tier 1) QL (90 per 30 days) 7

19 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) $0 (Tier 1) CAMPRAL CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH K CHANTIX STARTING MONTH BOX QL (90 per 30 days) disulfiram (Antabuse) $0 (Tier 1) naloxone (Naloxone HCl) $0 (Tier 1) naltrexone hcl (Revia) $0 (Tier 1) naltrexone (Revia) $0 (Tier 1) NICODERM CQ $0 (Tier 4) nicorelief buccal gum (Nicorette) $0 (Tier 4) nicorette buccal gum 2 mg (Nicorette) $0 (Tier 4) NICORETTE BUCCAL GUM 4 MG $0 (Tier 4) NICORETTE BUCCAL LOZENGE $0 (Tier 4) nicotine (polacrilex) buccal gum (Nicorette) $0 (Tier 4) QL (360 per 30 days) nicotine (polacrilex) buccal lozenge 4 mg (Nicorette) $0 (Tier 4) nicotine transdermal patch 24 hour 14 (Nicoderm Cq) $0 (Tier 4) mg/24 hr, 22 mg/24 hr, 7 mg/24 hr nicotine transdermal patch 24 hour 21 (Nicoderm Cq) $0 (Tier 4) QL (31 per 31 days) mg/24 hr NICOTROL QL (480 per 30 days) NICOTROL NS QL (720 per 365 days) 8

20 VIVITROL Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg (Xanax) $0 (Tier 1) QL (120 per 30 days) alprazolam oral tablet 2 mg (Xanax) $0 (Tier 1) QL (90 per 30 days) alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (120 per 30 days) hr 0.5 mg, 1 mg alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (150 per 30 days) hr 2 mg alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (90 per 30 days) hr 3 mg alprazolam oral tablet,disintegrating 0.25 (Alprazolam) $0 (Tier 1) QL (120 per 30 days) mg, 0.5 mg, 1 mg alprazolam oral tablet,disintegrating 2 mg (Alprazolam) $0 (Tier 1) QL (90 per 30 days) chlordiazepoxide hcl (Chlordiazepoxide $0 (Tier 1) QL (120 per 30 days) HCl) clonazepam oral tablet (Klonopin) $0 (Tier 1) clonazepam oral tablet,disintegrating (Clonazepam) $0 (Tier 1) clorazepate dipotassium (Tranxene T-Tab) $0 (Tier 1) QL (90 per 30 days) diazepam injection (Diazepam) $0 (Tier 1) diazepam intensol (Diazepam) $0 (Tier 1) diazepam oral solution (Diazepam) $0 (Tier 1) diazepam oral tablet (Valium) $0 (Tier 1) QL (120 per 30 days) diazepam rectal (Diastat) $0 (Tier 1) estazolam (Estazolam) $0 (Tier 1) QL (30 per 30 days) flurazepam (Flurazepam HCl) $0 (Tier 1) QL (30 per 30 days) lorazepam injection solution (Ativan) $0 (Tier 1) lorazepam injection syringe (Ativan) $0 (Tier 1) lorazepam oral tablet 0.5 mg (Ativan) $0 (Tier 1) QL (120 per 30 days) lorazepam oral tablet 1 mg (Ativan) $0 (Tier 1) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) $0 (Tier 1) QL (60 per 30 days) 9

21 midazolam (pf) injection (Midazolam HCl/PF) $0 (Tier 1) midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) $0 (Tier 1) ml (1 mg/ml) midazolam oral syrup 2 mg/ml (Midazolam HCl) $0 (Tier 1) ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxazepam (Oxazepam) $0 (Tier 1) QL (120 per 30 days) quazepam (Doral) temazepam (Restoril) $0 (Tier 1) QL (30 per 30 days) triazolam (Halcion) $0 (Tier 1) QL (30 per 30 days) Antibacterials Aminoglycosides amikacin (Amikacin Sulfate) $0 (Tier 1) BETHKIS gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, $0 (Tier 1) piggyback Iso-Osm) gentamicin injection solution (Garamycin) $0 (Tier 1) gentamicin sulfate (ped) (pf) (Gentamicin $0 (Tier 1) Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin $0 (Tier 1) solution Sulfate/PF) neomycin (Neomycin Sulfate) $0 (Tier 1) streptomycin intramuscular (Streptomycin $0 (Tier 1) Sulfate) TOBI PODHALER INHALATION tobramycin in % nacl (Tobi) 10

22 tobramycin in 0.9 % nacl (Tobramycin/Sodium $0 (Tier 1) Chloride) tobramycin sulfate injection solution (Nebcin) $0 (Tier 1) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) $0 (Tier 1) chloramphenicol sod succinate (Chloramphenicol $0 (Tier 1) Sod Succ) clindamycin hcl (Cleocin HCl) $0 (Tier 1) clindamycin in 5 % dextrose (Cleocin Phosphate $0 (Tier 1) In D5w) clindamycin palmitate hcl (Cleocin Palmitate) $0 (Tier 1) clindamycin phosphate injection (Cleocin Phosphate) $0 (Tier 1) clindamycin phosphate intravenous (Cleocin Phosphate) $0 (Tier 1) solution CLINDAMYCIN PHOSPHATE ORAL CAPSULE 150 MG, 300 MG, 75 MG colistin (colistimethate na) (Coly-Mycin M $0 (Tier 1) Parenteral) CUBICIN DALVANCE LINCOCIN linezolid intravenous (Zyvox) linezolid oral (Zyvox) methenamine hippurate (Hiprex) $0 (Tier 1) methenamine mandelate oral tablet 1 gram (Methenamine $0 (Tier 1) Mandelate) MONUROL nitrofurantoin macrocrystal oral capsule (Macrodantin) $0 (Tier 1) ; QL (56 per 28 days) 11

23 ORBACTIV polymyxin b sulfate (Polymyxin B Sulfate) $0 (Tier 1) PRIMSOL SIVEXTRO SYNERCID trimethoprim (Trimethoprim) $0 (Tier 1) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg (Vancomycin HCl/D5W) vancomycin oral capsule (Vancocin HCl) VIBATIV INTRAVENOUS RECON SOLN XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS RENTERAL SOLUTION ZYVOX ORAL SUSPENSION FOR RECONSTITUTION ZYVOX ORAL TABLET Cephalosporins AVYCAZ QL (6 per 30 days) ; QL (56 per 28 days) 12

24 CEDAX cefaclor oral capsule (Cefaclor) $0 (Tier 1) cefaclor oral suspension for reconstitution (Cefaclor) $0 (Tier 1) 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr (Cefaclor) $0 (Tier 1) cefadroxil oral capsule (Cefadroxil) $0 (Tier 1) cefadroxil oral suspension for (Cefadroxil) $0 (Tier 1) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) $0 (Tier 1) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) $0 (Tier 1) piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) $0 (Tier 1) cefazolin injection recon soln (Ancef) $0 (Tier 1) cefazolin injection recon soln 100 gram, (Cefazolin Sodium) $0 (Tier 1) 300 g cefazolin intravenous (Cefazolin Sodium) $0 (Tier 1) cefdinir (Cefdinir) $0 (Tier 1) cefditoren pivoxil (Spectracef) $0 (Tier 1) cefepime (Maxipime) $0 (Tier 1) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefixime (Suprax) $0 (Tier 1) cefotaxime (Claforan) $0 (Tier 1) cefotetan (Cefotetan Disodium) $0 (Tier 1) cefotetan in dextrose, iso-osm (Cefotetan $0 (Tier 1) Disod/Dextrose, Iso) cefoxitin (Mefoxin) $0 (Tier 1) 13

25 cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) What the $0 (Tier 1) $0 (Tier 1) cefprozil (Cefprozil) $0 (Tier 1) ceftazidime (Fortaz) $0 (Tier 1) CEFTAZIDIME IN D5W ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln 2 gram, 6 (Fortaz) $0 (Tier 1) gram ceftibuten (Cedax) $0 (Tier 1) CEFTIN ORAL SUSPENSION FOR RECONSTITUTION ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM CEFUROXIME AXETIL ORAL $0 (Tier 1) SUSPENSION FOR RECONSTITUTION 125 MG/5 ML cefuroxime axetil oral tablet (Ceftin) $0 (Tier 1) cefuroxime sodium injection recon soln 1.5 (Zinacef) $0 (Tier 1) gram, 750 mg cefuroxime sodium intravenous (Zinacef) $0 (Tier 1) 14

26 cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) What the $0 (Tier 1) cephalexin oral capsule (Keflex) $0 (Tier 1) cephalexin oral suspension for (Cephalexin) $0 (Tier 1) reconstitution cephalexin oral tablet (Cephalexin) $0 (Tier 1) FORTAZ INJECTION RECON SOLN 1 GRAM FORTAZ INTRAVENOUS KEFLEX ORAL CAPSULE 750 MG MAXIPIME SUPRAX TEFLARO ZERBAXA ZINACEF IN STERILE WATER ZINACEF INTRAVENOUS RECON SOLN Macrolides azithromycin (Zithromax) $0 (Tier 1) clarithromycin oral suspension for (Biaxin) $0 (Tier 1) reconstitution clarithromycin oral tablet (Biaxin) $0 (Tier 1) clarithromycin oral tablet extended release (Biaxin XL) $0 (Tier 1) 24 hr DIFICID ST 15

27 ERYPED 200 ERYPED 400 ERYTHROCIN erythromycin base oral tablet,delayed (Erythromycin Base) $0 (Tier 1) release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) (Eryped 200) $0 (Tier 1) (Eryped 200) (Erythromycin $0 (Tier 1) Ethylsuccinate) (Erythromycin Base) $0 (Tier 1) erythromycin oral tablet (Erythromycin Base) $0 (Tier 1) erythromycin stearate oral tablet 250 mg (Erythromycin $0 (Tier 1) Stearate) erythromycin-sulfisoxazole (Ery $0 (Tier 1) E-Succ/Sulfisoxazole) KETEK PCE ZMAX Miscellaneous B-Lactam Antibiotics AZACTAM IN DEXTROSE (ISO-OSM) aztreonam (Azactam) $0 (Tier 1) 16

28 CAYSTON DORIBAX imipenem-cilastatin (Primaxin) $0 (Tier 1) INVANZ meropenem (Merrem) $0 (Tier 1) Penicillins amoxicillin oral capsule (Amoxicillin) $0 (Tier 1) amoxicillin oral suspension for (Amoxil) $0 (Tier 1) reconstitution amoxicillin oral tablet (Amoxicillin) $0 (Tier 1) amoxicillin oral tablet, er multiphase 24 hr (Moxatag) $0 (Tier 1) amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) $0 (Tier 1) 250 mg amoxicillin-pot clavulanate oral (Augmentin) $0 (Tier 1) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) $0 (Tier 1) amoxicillin-pot clavulanate oral tablet (Augmentin XR) $0 (Tier 1) extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassiu $0 (Tier 1) tablet,chewable m Clav) ampicillin (Ampicillin $0 (Tier 1) Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) $0 (Tier 1) ampicillin sodium intravenous recon soln (Totacillin-N) $0 (Tier 1) ampicillin-sulbactam injection (Unasyn) $0 (Tier 1) ampicillin-sulbactam intravenous recon (Unasyn) $0 (Tier 1) soln AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML 17

29 BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin $0 (Tier 1) Sodium) MOXATAG nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) $0 (Tier 1) nafcillin intravenous recon soln (Nallpen) $0 (Tier 1) oxacillin in dextrose(iso-osm) (Oxacillin $0 (Tier 1) Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) $0 (Tier 1) oxacillin intravenous recon soln (Oxacillin Sodium) $0 (Tier 1) penicillin g pot in dextrose (Pen G $0 (Tier 1) Pot/Dextrose-Water) penicillin g potassium (Penicillin G $0 (Tier 1) Potassium) penicillin g procaine (Penicillin G $0 (Tier 1) Procaine) penicillin v potassium (Penicillin V $0 (Tier 1) Potassium) piperacillin-tazobactam (Zosyn) $0 (Tier 1) TIMENTIN INTRAVENOUS RECON SOLN 31 GRAM Quinolones AVELOX IN NACL (ISO-OSMOTIC) CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 18

30 ciprofloxacin (Cipro) $0 (Tier 1) ciprofloxacin (mixture) (Cipro XR) $0 (Tier 1) ciprofloxacin hcl oral (Cipro) $0 (Tier 1) ciprofloxacin in 5 % dextrose (Cipro I.V.) $0 (Tier 1) ciprofloxacin lactate intravenous solution (Cipro I.V.) $0 (Tier 1) 400 mg/40 ml FACTIVE levofloxacin in d5w intravenous piggyback (Levaquin) $0 (Tier 1) levofloxacin intravenous (Levofloxacin) $0 (Tier 1) levofloxacin oral (Levaquin) $0 (Tier 1) moxifloxacin-sod.ace,sul-water (Moxifloxacin/Sod.A $0 (Tier 1) ce,sul/water) NOROXIN ofloxacin oral (Ofloxacin) $0 (Tier 1) Sulfonamides sulfadiazine oral (Sulfadiazine) $0 (Tier 1) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tr $0 (Tier 1) intravenous imethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tr $0 (Tier 1) suspension imethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) $0 (Tier 1) sulfasalazine (Azulfidine) $0 (Tier 1) sulfatrim (Sulfamethoxazole/Tr $0 (Tier 1) imethoprim) sulfazine (Azulfidine) $0 (Tier 1) sulfazine ec (Azulfidine) $0 (Tier 1) Tetracyclines demeclocycline oral (Demeclocycline $0 (Tier 1) HCl) doxycycline hyclate oral capsule 100 mg (Morgidox) $0 (Tier 1) doxycycline hyclate 100 mg tab f/c (Doryx) $0 (Tier 1) 19

31 doxycycline hyclate intravenous (Doxycycline $0 (Tier 1) Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) $0 (Tier 1) doxycycline hyclate oral capsule 50 mg (Morgidox) $0 (Tier 1) doxycycline hyclate oral tablet 100 mg, 50 (Adoxa) $0 (Tier 1) mg doxycycline hyclate oral tablet 20 mg (Doryx) $0 (Tier 1) doxycycline hyclate oral tablet,delayed (Doryx) $0 (Tier 1) release (dr/ec) doxycycline monohydrate oral capsule (Adoxa) $0 (Tier 1) doxycycline monohydrate oral suspension (Vibramycin) $0 (Tier 1) for reconstitution doxycycline monohydrate oral tablet (Adoxa) $0 (Tier 1) MINOCIN INTRAVENOUS minocycline oral capsule (Minocin) $0 (Tier 1) minocycline oral tablet (Minocycline HCl) $0 (Tier 1) minocycline oral tablet extended release (Minocycline HCl) $0 (Tier 1) 24 hr tetracycline (Ala-Tet) $0 (Tier 1) TYGACIL VIBRAMYCIN ORAL SYRUP Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS AFINITOR 20

32 AFINITOR DISPERZ ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) $0 (Tier 1) ARRANON ARZERRA AVASTIN azacitidine (Vidaza) BELEODAQ bexarotene (Targretin) bicalutamide (Casodex) $0 (Tier 1) BICNU bleomycin (Bleomycin Sulfate) $0 (Tier 1) BvD BLINCYTO BOSULIF BUSULFEX INTRAVENOUS CAPRELSA carboplatin intravenous solution (Carboplatin) $0 (Tier 1) cisplatin (Cisplatin) $0 (Tier 1) cladribine (Cladribine) $0 (Tier 1) BvD CLOLAR 21

33 COMETRIQ cyclophosphamide intravenous recon soln (Cyclophosphamide) $0 (Tier 1) CYCLOPHOSPHAMIDE ORAL CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) $0 (Tier 1) BvD CYRAMZA cytarabine (Cytarabine) $0 (Tier 1) BvD cytarabine (pf) injection recon soln (Cytarabine/PF) $0 (Tier 1) BvD cytarabine (pf) injection solution (Cytarabine/PF) $0 (Tier 1) BvD dacarbazine intravenous recon soln (Dtic-Dome IV) $0 (Tier 1) DACOGEN dactinomycin (Dactinomycin) $0 (Tier 1) daunorubicin intravenous (Cerubidine) $0 (Tier 1) DAUNOXOME decitabine (Dacogen) $0 (Tier 1) DEPOCYT (PF) BvD DOCEFREZ docetaxel intravenous solution (Taxotere) $0 (Tier 1) doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) $0 (Tier 1) BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) $0 (Tier 1) BvD suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) $0 (Tier 1) BvD DROXIA ELIGARD 22

34 ELOXATIN INTRAVENOUS SOLUTION ELSR EMCYT epirubicin intravenous solution 50 mg/25 (Ellence) $0 (Tier 1) ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous (Etoposide) $0 (Tier 1) exemestane (Aromasin) $0 (Tier 1) FARESTON FARYDAK FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) $0 (Tier 1) BvD fludarabine (Fludara) $0 (Tier 1) fluorouracil intravenous solution 2.5 (Fluorouracil) $0 (Tier 1) BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) $0 (Tier 1) FOLOTYN 23

35 GAZYVA gemcitabine intravenous recon soln 1 gram (Gemzar) $0 (Tier 1) GILOTRIF GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea (Hydrea) $0 (Tier 1) IBRANCE ICLUSIG idarubicin (Idamycin Pfs) $0 (Tier 1) ifosfamide intravenous recon soln (Ifex) $0 (Tier 1) ifosfamide intravenous solution (Ifex) $0 (Tier 1) ifosfamide-mesna (Ifosfamide/Mesna) $0 (Tier 1) IMBRUVICA INLYTA IRESSA irinotecan intravenous solution (Camptosar) $0 (Tier 1) ISTODAX IXEMPRA 24

36 JAKAFI JEVTANA KADCYLA KEYTRUDA KYPROLIS LENVIMA letrozole (Femara) $0 (Tier 1) LEUKERAN leuprolide (Leuprolide Acetate) $0 (Tier 1) lomustine (Gleostine) LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT LYNRZA LYSODREN ; QL (60 per 30 days) BvD BvD 25

37 MARQIBO MATULANE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (Megace Es) $0 (Tier 1) megestrol oral tablet (Megestrol Acetate) $0 (Tier 1) MEKINIST melphalan hcl intravenous (Alkeran) $0 (Tier 1) mercaptopurine (Purinethol) $0 (Tier 1) methotrexate sodium (pf) injection recon (Methotrexate $0 (Tier 1) soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate $0 (Tier 1) solution Sodium) methotrexate sodium injection (Methotrexate $0 (Tier 1) Sodium) methotrexate sodium oral (Methotrexate $0 (Tier 1) BvD Sodium) mitomycin intravenous recon soln (Mitomycin) $0 (Tier 1) mitoxantrone (Mitoxantrone HCl) $0 (Tier 1) MUSTARGEN NEXAVAR NILANDRON ONCASR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML 26

38 oxaliplatin intravenous solution 100 mg/20 (Eloxatin) $0 (Tier 1) ml paclitaxel (Paclitaxel) $0 (Tier 1) pentostatin (Pentostatin) $0 (Tier 1) PERJETA PHOTOFRIN POMALYST PROLEUKIN PURIXAN REVLIMID ORAL CAPSULE 10 MG, 20 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG RITUXAN SOLTAMOX SPRYCEL STIVARGA SUTENT SYLVANT SYNRIBO TABLOID ; QL (21 per 28 days) ; LA BvD 27

39 TAFINLAR tamoxifen (Tamoxifen Citrate) $0 (Tier 1) TARCEVA TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TEMODAR INTRAVENOUS teniposide (Teniposide) thiotepa (Thiotepa) $0 (Tier 1) toposar intravenous (Etoposide) $0 (Tier 1) topotecan intravenous (Hycamtin) $0 (Tier 1) TORISEL TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR tretinoin (chemotherapy) (Tretinoin) TREXALL TRISENOX TYKERB BvD 28

40 UNITUXIN VALSTAR VECTIBIX VELCADE vinblastine intravenous (Vinblastine Sulfate) $0 (Tier 1) BvD vincristine (Vincristine Sulfate) $0 (Tier 1) BvD vincristine sulfate intravenous solution 1 (Vincristine Sulfate) $0 (Tier 1) BvD mg/ml vinorelbine intravenous solution (Navelbine) $0 (Tier 1) VOTRIENT XALKORI XTANDI YERVOY ZALTRAP INTRAVENOUS BvD SOLUTION ZANOSAR ZELBORAF ZOLADEX ZOLINZA ZYDELIG 29

41 ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 MG/0.7 ML atropine 0.1 mg/ml syringe luer-jet syr (Atropine Sulfate) $0 (Tier 1) atropine injection solution (Atropine Sulfate) $0 (Tier 1) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) $0 (Tier 1) mg/ml edrophonium chloride-atropine (Edrophonium Chloride/Atropine) propantheline (Propantheline $0 (Tier 1) Bromide) Anticonvulsants Anticonvulsants APTIOM BANZEL carbamazepine (Tegretol) $0 (Tier 1) carbamazepine oral capsule, er multiphase (Carbatrol) $0 (Tier 1) 12 hr carbamazepine oral suspension (Tegretol) $0 (Tier 1) carbamazepine oral tablet extended (Tegretol XR) $0 (Tier 1) release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) $0 (Tier 1) CELONTIN ORAL CAPSULE 300 MG ST 30

42 CEREBYX DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN-125 divalproex oral capsule, sprinkle (Depakote Sprinkle) $0 (Tier 1) divalproex oral tablet extended release 24 (Depakote ER) $0 (Tier 1) hr divalproex oral tablet,delayed release (Depakote) $0 (Tier 1) (dr/ec) EQUETRO ethosuximide (Zarontin) $0 (Tier 1) felbamate (Felbatol) $0 (Tier 1) fosphenytoin (Cerebyx) $0 (Tier 1) FYCOM ORAL TABLET gabapentin oral capsule (Neurontin) $0 (Tier 1) gabapentin oral solution (Neurontin) $0 (Tier 1) gabapentin oral tablet 600 mg, 800 mg (Neurontin) $0 (Tier 1) GABITRIL ORAL TABLET 12 MG, 16 MG GRALISE GRALISE 30-DAY STARTER CK HORIZANT ST ST 31

43 LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) $0 (Tier 1) lamotrigine oral tablet extended release (Lamictal XR) $0 (Tier 1) 24hr 100 mg, 200 mg, 25 mg, 50 mg lamotrigine oral tablet extended release (Lamictal XR) 24hr 250 mg, 300 mg lamotrigine oral tablet, chewable (Lamictal) $0 (Tier 1) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) $0 (Tier 1) (35) levetiracetam in nacl (iso-os) (Levetiracetam In $0 (Tier 1) Nacl (Iso-Os)) levetiracetam intravenous (Keppra) $0 (Tier 1) levetiracetam oral solution (Keppra) $0 (Tier 1) levetiracetam oral tablet (Keppra) $0 (Tier 1) levetiracetam oral tablet extended release (Keppra XR) $0 (Tier 1) 24 hr LYRICA oxcarbazepine (Trileptal) $0 (Tier 1) OXTELLAR XR PEGANONE phenobarbital (Phenobarbital) $0 (Tier 1) phenobarbital sodium injection solution (Phenobarbital $0 (Tier 1) Sodium) PHENYTEK phenytoin oral suspension 125 mg/5 ml (Dilantin-125) $0 (Tier 1) phenytoin oral (Dilantin) $0 (Tier 1) phenytoin sodium (Phenytoin Sodium) $0 (Tier 1) 32

44 phenytoin sodium extended (Dilantin) $0 (Tier 1) POTIGA primidone (Mysoline) $0 (Tier 1) SABRIL STAVZOR tiagabine (Gabitril) $0 (Tier 1) topiramate oral capsule, sprinkle (Topamax) $0 (Tier 1) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) $0 (Tier 1) TRILEPTAL ORAL SUSPENSION TROKENDI XR valproate sodium (Depacon) $0 (Tier 1) valproic acid (Depakene) $0 (Tier 1) valproic acid (as sodium salt) oral (Depakene) $0 (Tier 1) solution 250 mg/5 ml VIMT INTRAVENOUS VIMT ORAL SOLUTION VIMT ORAL TABLET zonisamide (Zonegran) $0 (Tier 1) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 5 mg (Aricept) $0 (Tier 1) donepezil oral tablet,disintegrating (Aricept Odt) $0 (Tier 1) galantamine oral capsule,ext rel. pellets 24 (Razadyne ER) $0 (Tier 1) hr galantamine oral solution (Razadyne) $0 (Tier 1) 33

45 galantamine oral tablet (Razadyne) $0 (Tier 1) memantine (Namenda) $0 (Tier 1) NAMENDA NAMENDA TITRATION K NAMENDA XR rivastigmine tartrate (Exelon) $0 (Tier 1) Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) amitriptyline-chlordiazepoxide (Amitrip HCl/Chlordiazepoxid e) amoxapine (Amoxapine) $0 (Tier 1) APLENZIN BRINTELLIX ST BRISDELLE bupropion hcl oral tablet (Wellbutrin) $0 (Tier 1) bupropion hcl oral tablet extended release (Wellbutrin SR) $0 (Tier 1), 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) $0 (Tier 1) 24 hr citalopram oral solution (Citalopram $0 (Tier 1) QL (600 per 30 days) Hydrobromide) citalopram oral tablet (Celexa) $0 (Tier 1) QL (30 per 30 days) clomipramine (Anafranil) 34

46 desipramine oral (Norpramin) $0 (Tier 1) DESVENLAFAXINE FUMARATE DESVENLAFAXINE ORAL desvenlafaxine oral tablet extended release (Khedezla) $0 (Tier 1) 24hr doxepin oral (Doxepin HCl) duloxetine oral capsule,delayed (Irenka) $0 (Tier 1) release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg, 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM (Irenka) $0 (Tier 1) QL (30 per 30 days) (Irenka) $0 (Tier 1) QL (60 per 30 days) QL (30 per 30 days) escitalopram oxalate oral solution (Lexapro) $0 (Tier 1) QL (600 per 30 days) escitalopram oxalate oral tablet (Lexapro) $0 (Tier 1) QL (30 per 30 days) FETZIMA ST fluoxetine oral capsule (Prozac) $0 (Tier 1) fluoxetine oral capsule,delayed (Prozac Weekly) $0 (Tier 1) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) $0 (Tier 1) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) $0 (Tier 1) FLUOXETINE ORAL TABLET 60 $0 (Tier 1) MG fluvoxamine oral capsule,extended release (Luvox CR) ST 24hr fluvoxamine oral tablet (Fluvoxamine $0 (Tier 1) Maleate) FORFIVO XL 35

47 imipramine hcl (Tofranil) imipramine pamoate (Tofranil-Pm) IRENKA maprotiline (Maprotiline HCl) $0 (Tier 1) MARPLAN mirtazapine (Remeron) $0 (Tier 1) nefazodone (Nefazodone HCl) $0 (Tier 1) nortriptyline oral capsule (Pamelor) $0 (Tier 1) nortriptyline oral solution (Nortriptyline HCl) $0 (Tier 1) olanzapine-fluoxetine (Symbyax) $0 (Tier 1) paroxetine hcl oral tablet (Paxil) $0 (Tier 1) paroxetine hcl oral tablet extended release (Paxil CR) $0 (Tier 1) 24 hr XIL ORAL SUSPENSION perphenazine-amitriptyline (Perphenazine/Amitri ptyline HCl) PEXEVA phenelzine (Nardil) $0 (Tier 1) PRISTIQ protriptyline (Vivactil) $0 (Tier 1) sertraline (Zoloft) $0 (Tier 1) SILENOR SURMONTIL tranylcypromine (Parnate) $0 (Tier 1) ST ST ST ; QL (31 per 31 days) 36

48 trazodone (Trazodone HCl) $0 (Tier 1) venlafaxine oral capsule,extended release (Effexor XR) $0 (Tier 1) 24hr venlafaxine oral tablet (Venlafaxine HCl) $0 (Tier 1) VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE CK Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) $0 (Tier 1) AVANDIA BYDUREON BYETTA CYCLOSET GLUMETZA GLYSET INVOKAMET INVOKANA JENTADUETO KAZANO KORLYM ST ; QL (30 per 30 days) ST ST ; QL (60 per 30 days) ST 37

49 metformin oral tablet (Glucophage) $0 (Tier 1) metformin oral tablet extended release 24 (Glucophage XR) $0 (Tier 1) hr metformin oral tablet extended release (Fortamet) $0 (Tier 1) 24hr nateglinide (Starlix) $0 (Tier 1) NESINA OSENI pioglitazone (Actos) $0 (Tier 1) pioglitazone-glimepiride (Duetact) $0 (Tier 1) pioglitazone-metformin (Actoplus Met) $0 (Tier 1) PRANDIMET PRANDIN repaglinide (Prandin) $0 (Tier 1) RIOMET SYMLINPEN 120 SYMLINPEN 60 TANZEUM TRADJENTA VICTOZA Insulins APIDRA ST ST ST ST ; QL (30 per 30 days) ST QL (60 per 30 days) 38

50 APIDRA SOLOSTAR HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) LANTUS LANTUS SOLOSTAR LEVEMIR QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) 39

51 LEVEMIR FLEXTOUCH TOUJEO SOLOSTAR Sulfonylureas glimepiride (Amaryl) $0 (Tier 1) glipizide oral tablet (Glucotrol) $0 (Tier 1) glipizide oral tablet extended release 24hr (Glucotrol XL) $0 (Tier 1) glipizide-metformin (Glipizide/Metformin $0 (Tier 1) HCl) tolazamide (Tolazamide) $0 (Tier 1) tolbutamide (Tolbutamide) $0 (Tier 1) Antifungals Antifungals 3 day vaginal (Miconazole Nitrate) $0 (Tier 4) ABELCET aloe vesta topical ointment 2 % (Miconazole Nitrate) $0 (Tier 4) AMBISOME amphotericin b (Amphotericin B) $0 (Tier 1) BvD anti-fungal topical powder (Lotrimin AF) $0 (Tier 4) azolen tincture (Fungoid Tincture) $0 (Tier 4) baza antifungal (Nuzole) $0 (Tier 4) CANCIDAS ciclopirox topical cream (Ciclodan) $0 (Tier 1) ciclopirox topical gel (Loprox) $0 (Tier 1) ciclopirox topical shampoo (Loprox) $0 (Tier 1) ciclopirox topical solution (Penlac) $0 (Tier 1) ciclopirox topical suspension (Ciclopirox Olamine) $0 (Tier 1) ciclopirox-ure-camph-menth-euc (Ciclodan) $0 (Tier 1) clotrimazole 1% solution (otc) (Clotrimazole) $0 (Tier 4) QL (27 per 30 days) 40

52 clotrimazole 3 day (Gyne-Lotrimin-7) $0 (Tier 4) clotrimazole mucous membrane (Clotrimazole) $0 (Tier 1) clotrimazole topical cream (Clotrimazole) $0 (Tier 1) clotrimazole topical solution 1 % (Lotrimin) $0 (Tier 1) clotrimazole vaginal cream (Gyne-Lotrimin-7) $0 (Tier 4) clotrimazole-betamethasone topical cream (Lotrisone) $0 (Tier 1) clotrimazole-betamethasone topical lotion (Clotrimazole/Betame $0 (Tier 1) thasone Dip) CRESEMBA critic-aid clear af (Miconazole Nitrate) $0 (Tier 4) dermafungal (Miconazole Nitrate) $0 (Tier 4) desenex spray (Lotrimin AF) $0 (Tier 4) desenex topical powder (Lotrimin AF) $0 (Tier 4) econazole topical (Econazole Nitrate) $0 (Tier 1) ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN fluconazole in dextrose(iso-o) intravenous (Fluconazole In $0 (Tier 1) piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) intravenous (Fluconazole In $0 (Tier 1) piggyback Nacl,Iso-Osm) fluconazole oral suspension for (Diflucan) $0 (Tier 1) reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 (Diflucan) $0 (Tier 1) mg fluconazole oral tablet 150 mg (Diflucan) $0 (Tier 1) QL (3 per 23 days) flucytosine (Ancobon) $0 (Tier 1) fungi cure (Clotrimazole) $0 (Tier 4) FUNGOID TINCTURE TOPICAL $0 (Tier 4) gentian viol-brlnt grn-proflav (Gentian Viol/Brlnt Grn/Proflav) griseofulvin microsize oral suspension (Griseofulvin, Microsize) $0 (Tier 1) 41

53 griseofulvin microsize oral tablet (Grifulvin V) $0 (Tier 1) griseofulvin ultramicrosize (Gris-Peg) $0 (Tier 1) GYNE-LOTRIMIN 7 $0 (Tier 4) GYNE-LOTRIMIN VAGINAL $0 (Tier 4) CREAM 2 % itraconazole (Sporanox) $0 (Tier 1) ketoconazole oral (Ketoconazole) $0 (Tier 1) ketoconazole topical cream (Ketoconazole) $0 (Tier 1) ketoconazole topical shampoo (Nizoral) $0 (Tier 1) LAMISIL AT TOPICAL $0 (Tier 4) LAMISIL ORAL GRANULES IN CKET LOTRIMIN AF TOPICAL CREAM $0 (Tier 4) MENTAX ST miconazole 7 vaginal suppository (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate topical cream (Nuzole) $0 (Tier 4) miconazole nitrate vaginal (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate vaginal (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate vaginal kit 1,200-2 (Monistat 3) $0 (Tier 4) mg-%, 200 mg- 2 % (9 gram) miconazole nitrate vaginal suppository 200 (Monistat 3) $0 (Tier 1) mg micro-guard (Lotrimin AF) $0 (Tier 4) MYCAMINE naftifine (Naftin) $0 (Tier 1) NAFTIN ST NOXAFIL NYSTATIN (BULK) POWDER 1 BILLION UNIT $0 (Tier 1) 42

54 nystatin oral (Nystatin) $0 (Tier 1) nystatin oral (Nystatin) $0 (Tier 1) nystatin topical (Nystatin) $0 (Tier 1) nystatin topical powder 100,000 unit/gram (Nystatin) $0 (Tier 1) nystatin-triamcinolone (Nystatin/Triamcin) $0 (Tier 1) ONMEL ORAVIG OXISTAT SPORANOX ORAL SOLUTION terbinafine hcl oral (Lamisil) $0 (Tier 1) tioconazole (Tioconazole) $0 (Tier 4) triple paste af (Miconazole Nitrate) $0 (Tier 4) vagistat-1 (Tioconazole) $0 (Tier 4) voriconazole intravenous (Vfend IV) $0 (Tier 1) voriconazole oral (Vfend) VUSION ST XOLEGEL ST Antihistamines Antihistamines allerclear d-24hr (Claritin-D 24 Hour) $0 (Tier 4) allergy relief (loratadine) oral (Claritin) $0 (Tier 4) cetirizine hcl 1 mg/1 ml soln children, s/f, (Children'S Zyrtec) $0 (Tier 4) grape (otc) cetirizine oral solution (Cetirizine HCl) $0 (Tier 1) children's aller-tec (Children'S Zyrtec) $0 (Tier 4) ST 43

55 What the CHILDREN'S ZYRTEC ALLERGY $0 (Tier 4) ORAL cyproheptadine (Cyproheptadine $0 (Tier 1) HCl) diphenhydramine hcl injection solution 50 (Diphenhydramine $0 (Tier 1) mg/ml HCl) fexofenadine oral tablet 30 mg, 60 mg (Allegra) $0 (Tier 1) loratadine-d oral tablet extended release (Claritin-D 24 Hour) $0 (Tier 4) 24 hr virdec (Dallergy) $0 (Tier 4) wal-itin d (Claritin-D 24 Hour) $0 (Tier 4) wal-itin oral tablet,disintegrating (Claritin) $0 (Tier 4) wal-zyr (cetirizine) oral (Children'S Zyrtec) $0 (Tier 4) Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL clindamycin phosphate vaginal (Cleocin) $0 (Tier 1) CLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY 100 MG metronidazole vaginal (Metrogel-Vaginal) $0 (Tier 1) NUVESSA terconazole vaginal cream (Terazol 7) $0 (Tier 1) terconazole vaginal suppository (Terconazole) $0 (Tier 1) Antimigraine Agents Antimigraine Agents CAFERGOT dihydroergotamine injection (D.H.E.45) $0 (Tier 1) dihydroergotamine nasal (Migranal) QL (8 per 23 days) 44

56 ERGOMAR ergotamine-caffeine (Ergotamine $0 (Tier 1) Tartrate/Caffeine) MIGERGOT $0 (Tier 1) naratriptan (Amerge) $0 (Tier 1) QL (18 per 30 days) rizatriptan oral tablet (Maxalt) $0 (Tier 1) QL (18 per 30 days) rizatriptan oral tablet,disintegrating (Maxalt Mlt) $0 (Tier 1) QL (18 per 30 days) sumatriptan 4 mg/0.5 ml inject latex-free (Imitrex) $0 (Tier 1) QL (2 per 30 days) sumatriptan 4 mg/0.5 ml refill (Imitrex) $0 (Tier 1) QL (2 per 30 days) sumatriptan nasal spray,non-aerosol 20 (Imitrex) $0 (Tier 1) QL (12 per 30 days) mg/actuation sumatriptan nasal spray,non-aerosol 5 (Imitrex) $0 (Tier 1) QL (18 per 30 days) mg/actuation sumatriptan oral tablet (Imitrex) $0 (Tier 1) QL (9 per 30 days) sumatriptan succinate subcutaneous (Imitrex) $0 (Tier 1) QL (2 per 30 days) cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) $0 (Tier 1) QL (4 per 30 days) cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) $0 (Tier 1) QL (4 per 30 days) injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous (Imitrex) $0 (Tier 1) QL (6 per 30 days) solution zolmitriptan oral tablet (Zomig) $0 (Tier 1) QL (9 per 30 days) zolmitriptan oral tablet,disintegrating (Zomig Zmt) $0 (Tier 1) QL (9 per 30 days) Antimycobacterials Antimycobacterials CASTAT cycloserine (Cycloserine) $0 (Tier 1) dapsone (Dapsone) $0 (Tier 1) ethambutol (Myambutol) $0 (Tier 1) 45

57 isoniazid (Isoniazid) $0 (Tier 1) SER PRIFTIN pyrazinamide (Pyrazinamide) $0 (Tier 1) rifabutin (Mycobutin) $0 (Tier 1) rifampin (Rifadin) $0 (Tier 1) rifampin (Rifadin) $0 (Tier 1) RIFATER TRECATOR Antinausea Agents Antinausea Agents anti-nausea (Emetrol) $0 (Tier 4) CESAMET COMZINE RECTAL dimenhydrinate injection solution (Dimenhydrinate) $0 (Tier 1) DRAMAMINE ORAL $0 (Tier 4) TABLET,CHEWABLE 50 MG driminate (Dimenhydrinate) $0 (Tier 4) dronabinol oral capsule 10 mg (Marinol) dronabinol oral capsule 2.5 mg, 5 mg (Marinol) EMEND INTRAVENOUS EMEND ORAL QL (60 per 30 days) QL (90 per 30 days) ; ST 46

58 granisetron (pf) intravenous solution What the (Granisetron $0 (Tier 1) HCl/PF) (Kytril) $0 (Tier 1) granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral (Granisetron HCl) $0 (Tier 1) BvD; ST meclizine 12.5 mg caplet caplet (otc) (Meclizine HCl) $0 (Tier 4) meclizine oral tablet 12.5 mg, 25 mg (Antivert) $0 (Tier 1) motion sickness (Dimenhydrinate) $0 (Tier 4) ondansetron (Zofran Odt) $0 (Tier 1) BvD ondansetron hcl (pf) (Ondansetron $0 (Tier 1) HCl/PF) ondansetron hcl oral (Zofran) $0 (Tier 1) BvD prochlorperazine (Compazine) $0 (Tier 1) prochlorperazine edisylate injection (Compazine) $0 (Tier 1) solution prochlorperazine maleate (Compazine) $0 (Tier 1) prochlorperazine maleate oral (Compazine) $0 (Tier 1) SANCUSO ST scopolamine hbr (Scopolamine $0 (Tier 1) Hydrobromide) TRANSDERM-SCOP travel sickness (meclizine) (Bonine) $0 (Tier 4) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) $0 (Tier 1) atovaquone-proguanil (Malarone) $0 (Tier 1) 47

59 BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) $0 (Tier 1) COARTEM DARAPRIM FLAGYL ER hydroxychloroquine oral (Plaquenil) $0 (Tier 1) ivermectin oral (Stromectol) $0 (Tier 1) mefloquine (Mefloquine HCl) $0 (Tier 1) metronidazole in nacl (iso-os) (Metronidazole/Sodiu $0 (Tier 1) m Chloride) metronidazole oral (Flagyl) $0 (Tier 1) NEBUPENT paromomycin (Paromomycin $0 (Tier 1) Sulfate) PENTAM PRIMAQUINE quinine sulfate (Qualaquin) $0 (Tier 1) STROMECTOL tinidazole (Tindamax) $0 (Tier 1) YODOXIN Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) $0 (Tier 1) BvD 48

60 APOKYN AZILECT benztropine oral (Benztropine $0 (Tier 1) Mesylate) bromocriptine (Parlodel) $0 (Tier 1) cabergoline (Cabergoline) $0 (Tier 1) carbidopa (Lodosyn) $0 (Tier 1) carbidopa-levodopa oral tablet (Sinemet CR) $0 (Tier 1) carbidopa-levodopa oral tablet extended (Sinemet CR) $0 (Tier 1) release carbidopa-levodopa oral (Carbidopa/Levodop $0 (Tier 1) tablet,disintegrating a) carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) $0 (Tier 1) MIRAPEX ER NEUPRO pramipexole oral tablet (Mirapex) $0 (Tier 1) pramipexole oral tablet extended release (Mirapex ER) $0 (Tier 1) 24 hr ropinirole oral tablet (Requip) $0 (Tier 1) ropinirole oral tablet extended release 24 (Requip XL) $0 (Tier 1) hr selegiline hcl oral capsule (Eldepryl) $0 (Tier 1) selegiline hcl oral tablet (Selegiline HCl) $0 (Tier 1) TASMAR ORAL TABLET 100 MG tolcapone (Tasmar) $0 (Tier 1) 49

61 ZELAR Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ABILIFY INTRAMUSCULAR ABILIFY MAINTENA ABILIFY ORAL ADASUVE aripiprazole oral solution (Abilify) $0 (Tier 1) aripiprazole oral tablet (Abilify) $0 (Tier 1) chlorpromazine (Chlorpromazine $0 (Tier 1) HCl) clozapine oral tablet (Clozaril) $0 (Tier 1) clozapine oral tablet,disintegrating (Fazaclo) $0 (Tier 1) FANAPT FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG fluphenazine decanoate (Fluphenazine $0 (Tier 1) Decanoate) fluphenazine hcl (Fluphenazine HCl) $0 (Tier 1) GEODON INTRAMUSCULAR haloperidol (Haloperidol) $0 (Tier 1) haloperidol decanoate intramuscular solution 100 mg/ml (Haloperidol Decanoate) $0 (Tier 1) ST ST ST 50

62 What the haloperidol decanoate intramuscular (Haldol Decanoate $0 (Tier 1) solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) $0 (Tier 1) INVEGA ST INVEGA SUSTENNA ST INVEGA TRINZA ST LATUDA ST loxapine succinate (Loxitane) $0 (Tier 1) olanzapine intramuscular (Zyprexa) $0 (Tier 1) olanzapine oral tablet (Zyprexa) $0 (Tier 1) olanzapine oral tablet,disintegrating (Zyprexa Zydis) $0 (Tier 1) ORAP paliperidone oral tablet extended release (Invega) $0 (Tier 1) ST 24hr 1.5 mg, 3 mg, 6 mg paliperidone oral tablet extended release (Invega) ST 24hr 9 mg perphenazine (Perphenazine) $0 (Tier 1) quetiapine (Seroquel) $0 (Tier 1) REXULTI ST RISPERDAL CONSTA ST risperidone oral solution (Risperdal) $0 (Tier 1) risperidone oral tablet (Risperdal) $0 (Tier 1) risperidone oral (Risperdal M-Tab) $0 (Tier 1) SAPHRIS (BLACK CHERRY) ST 51

63 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR thioridazine (Thioridazine HCl) $0 (Tier 1) thiothixene (Thiothixene) $0 (Tier 1) trifluoperazine (Trifluoperazine HCl) $0 (Tier 1) VERSACLOZ ziprasidone hcl (Geodon) $0 (Tier 1) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) $0 (Tier 1) abacavir-lamivudine-zidovudine (Trizivir) APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) $0 (Tier 1) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION ST 52

64 EPIVIR ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir) $0 (Tier 1) lamivudine-zidovudine (Combivir) LEXIVA nevirapine oral suspension (Viramune) $0 (Tier 1) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) $0 (Tier 1) hr NORVIR PREZCOBIX PREZISTA RESCRIPTOR 53

65 RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN CKET SELZENTRY stavudine (Zerit) $0 (Tier 1) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA 54

66 ZIAGEN ORAL SOLUTION zidovudine oral capsule (Retrovir) $0 (Tier 1) zidovudine oral syrup (Retrovir) $0 (Tier 1) zidovudine oral tablet (Zidovudine) $0 (Tier 1) Antivirals, Miscellaneous foscarnet (Foscavir) RAPIVAB RELENZA DISKHALER rimantadine (Flumadine) $0 (Tier 1) SYNAGIS TAMIFLU Hcv Antivirals HARVONI OLYSIO SOVALDI VIEKIRA K Interferons ALFERON N INFERGEN SUBCUTANEOUS SOLUTION INTRON A INJECTION QL (56 per 180 days) 55

67 PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN SYLATRON Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) $0 (Tier 1) acyclovir oral suspension 200 mg/5 ml (Zovirax) $0 (Tier 1) acyclovir oral tablet (Zovirax) $0 (Tier 1) acyclovir sodium intravenous recon soln (Acyclovir Sodium) $0 (Tier 1) BvD acyclovir sodium intravenous solution (Acyclovir Sodium) $0 (Tier 1) BvD adefovir (Hepsera) BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET 0.5 MG cidofovir (Vistide) $0 (Tier 1) entecavir (Baraclude) $0 (Tier 1) famciclovir (Famvir) $0 (Tier 1) ganciclovir sodium (Cytovene) $0 (Tier 1) HEPSERA REBETOL ORAL SOLUTION ribavirin oral capsule 200 mg (Rebetol) $0 (Tier 1) ribavirin oral tablet 200 mg (Copegus) $0 (Tier 1) 56

68 ribavirin oral tablet 400 mg, 600 mg (Copegus) ribavirin oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28), mg (28)-mg (28) (Ribatab) TYZEKA valacyclovir (Valtrex) $0 (Tier 1) VALCYTE ORAL RECON SOLN valganciclovir (Valcyte) $0 (Tier 1) VIRAZOLE Blood Products/Modifiers/Volume Expanders Anticoagulants ANGIOMAX ATRYN INTRAVENOUS RECON SOLN 525 UNIT bivalirudin (Angiomax) $0 (Tier 1) CEPROTIN (BLUE BAR) COUMADIN enoxaparin (Lovenox) fondaparinux (Arixtra) FRAGMIN SUBCUTANEOUS SOLUTION FRAGMIN SUBCUTANEOUS SYRINGE QL (30 per 90 days) 57

69 heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) HERIN (PORCINE) IN 5 % DEX INTRAVENOUS RENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection (Heparin Sodium in 5% Dextrose) (Heparin Sodium,Porcine/Ns/P F) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF) (Heparin Sodium,Porcine/PF) (Heparin Sodium,Porcine/PF) What the $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD heparin, porcine (pf) intravenous syringe $0 (Tier 1) 100 unit/ml HERIN-0.45% NACL 25,000 $0 (Tier 1) UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HERIN-0.45% NACL 25,000 $0 (Tier 1) UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 (Heparin Sodium in $0 (Tier 1) units/ml) bag excel container 5% Dextrose) heparin-d5w 25,000 units/500 ml (50 (Heparin Sodium in $0 (Tier 1) units/ml) bag excel container 5% Dextrose) IPRIVASK jantoven (Coumadin) $0 (Tier 1) PRADAXA 58

70 REFLUDAN THROMBATE III INTRAVENOUS RECON SOLN warfarin (Coumadin) $0 (Tier 1) XARELTO ORAL TABLET 10 MG XARELTO ORAL TABLET 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE CK Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION ARANESP (IN POLYSORBATE) INJECTION SYRINGE BERINERT INTRAVENOUS CINRYZE EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE BvD QL (35 per 180 days) BvD 59

71 NEUMEGA NEUPOGEN PROCRIT PROMACTA RUCONEST Hematologic Agents, Miscellaneous aminocaproic acid intravenous (Aminocaproic Acid) $0 (Tier 1) aminocaproic acid oral solution (Aminocaproic Acid) $0 (Tier 1) aminocaproic acid oral tablet (Amicar) $0 (Tier 1) anagrelide (Agrylin) $0 (Tier 1) protamine (Protamine Sulfate) $0 (Tier 1) BvD tranexamic acid intravenous (Tranexamic Acid) $0 (Tier 1) tranexamic acid oral (Lysteda) $0 (Tier 1) Platelet-Aggregation Inhibitors AGGRENOX aspirin-dipyridamole (Aggrenox) $0 (Tier 1) BRILINTA cilostazol (Pletal) $0 (Tier 1) clopidogrel (Plavix) $0 (Tier 1) pentoxifylline (Pentoxifylline) $0 (Tier 1) Volume Expanders ALBUKED-25 BvD ALBUKED-5 BvD 60

72 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % PLASMANATE Caloric Agents Caloric Agents ACD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD 61

73 AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD 62

74 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD 63

75 cysteine (l-cysteine) intravenous solution (Cysteine HCl) $0 (Tier 1) d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % NaCl) d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in Water) dextrose 20 % in water (d20w) (Dextrose 20 % in Water) dextrose 25 % in water (d25w) (Dextrose 25 % in Water) dextrose 40 % in water (d40w) (Dextrose 40 % in Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) dextrose 5 %-lactated ringers (Dextrose 5%-Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2% NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD $0 (Tier 1) BvD 64

76 What the dextrose 50 % in water (d50w) (Dextrose 50 % in $0 (Tier 1) BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in $0 (Tier 1) BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2% $0 (Tier 1) BvD NaCl) FREAMINE HBC 6.9 % BvD FREAMINE III 10 % BvD glucose gel (Dextrose) $0 (Tier 4) glucose oral tablet,chewable (Dextrose) $0 (Tier 4) glutose 15 (Dextrose) $0 (Tier 4) HETAMINE 8% BvD HETASOL 8 % BvD insta-glucose (Dextrose/Dextrin/M $0 (Tier 4) altose) INTRALIPID INTRAVENOUS BvD EMULSION 20 %, 30 % LIPOSYN II BvD LIPOSYN III BvD NEPHRAMINE 5.4 % BvD potassium chloride in lr-d5 intravenous (Potassium Chloride $0 (Tier 1) parenteral solution In Lr-D5) PREMASOL 10 % BvD PREMASOL 6 % BvD 65

77 PROCALAMINE 3% PROSOL 20 % TRAVASOL 10 % TROPHAMINE 10 % TROPHAMINE 6% Cardiovascular Agents Alpha-Adrenergic Agents clonidine (Catapres-Tts 1) $0 (Tier 1) clonidine hcl oral tablet (Catapres) $0 (Tier 1) clonidine hcl-chlorthalidone (Clonidine $0 (Tier 1) HCl/Chlorthalidone) DIBENZYLINE doxazosin (Cardura) $0 (Tier 1) midodrine (Midodrine HCl) $0 (Tier 1) MINIPRESS nasal decongestant (pe) oral tablet 5 mg (Medi-Phenyl) $0 (Tier 4) NEO-SYNEPHRINE (PHENYLEPHRINE) INJECTION phenoxybenzamine (Dibenzyline) $0 (Tier 1) phenylephrine hcl injection (Vazculep) $0 (Tier 1) prazosin oral (Minipress) $0 (Tier 1) Angiotensin Ii Receptor Antagonists ATACAND candesartan (Atacand) $0 (Tier 1) candesartan-hydrochlorothiazid (Atacand HCT) $0 (Tier 1) BvD BvD BvD BvD BvD ST 66

78 EDARBI EDARBYCLOR ENTRESTO eprosartan (Teveten) $0 (Tier 1) irbesartan (Avapro) $0 (Tier 1) irbesartan-hydrochlorothiazide (Avalide) $0 (Tier 1) losartan (Cozaar) $0 (Tier 1) losartan-hydrochlorothiazide (Hyzaar) $0 (Tier 1) telmisartan (Micardis) $0 (Tier 1) telmisartan-hydrochlorothiazid (Micardis HCT) $0 (Tier 1) TEVETEN HCT valsartan (Diovan) $0 (Tier 1) valsartan-hydrochlorothiazide (Diovan HCT) $0 (Tier 1) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) $0 (Tier 1) benazepril-hydrochlorothiazide (Lotensin HCT) $0 (Tier 1) captopril (Captopril) $0 (Tier 1) captopril-hydrochlorothiazide (Captopril/Hydrochlo $0 (Tier 1) rothiazide) enalapril maleate (Vasotec) $0 (Tier 1) enalaprilat intravenous injectable (Enalaprilat $0 (Tier 1) Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) $0 (Tier 1) fosinopril (Fosinopril Sodium) $0 (Tier 1) fosinopril-hydrochlorothiazide (Fosinopril/Hydrochl $0 (Tier 1) orothiazide) lisinopril (Zestril) $0 (Tier 1) lisinopril-hydrochlorothiazide (Zestoretic) $0 (Tier 1) moexipril (Univasc) $0 (Tier 1) ST ST ST ST 67

79 moexipril-hydrochlorothiazide (Uniretic) $0 (Tier 1) perindopril erbumine (Aceon) $0 (Tier 1) quinapril (Accupril) $0 (Tier 1) quinapril-hydrochlorothiazide (Accuretic) $0 (Tier 1) ramipril (Altace) $0 (Tier 1) TARKA trandolapril (Mavik) $0 (Tier 1) trandolapril-verapamil oral tablet, ir & er, (Tarka) $0 (Tier 1) biphasic 24hr mg, mg, mg, mg trandolapr-verapam er mg $0 (Tier 1) trandolapr-verapam er mg $0 (Tier 1) trandolapr-verapam er mg $0 (Tier 1) trandolapr-verapam er mg $0 (Tier 1) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 (Cordarone) $0 (Tier 1) mg, 400 mg amiodarone intravenous (Amiodarone HCl) $0 (Tier 1) amiodarone oral (Cordarone) $0 (Tier 1) flecainide (Flecainide Acetate) $0 (Tier 1) lidocaine (pf) in d7.5w (Lidocaine $0 (Tier 1) HCl/D7.5w/PF) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) $0 (Tier 1) ml (1%) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 4 mg/ml (0.4 %) HCl/D5w/PF) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine $0 (Tier 1) parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine (Mexiletine HCl) $0 (Tier 1) MULTAQ ST 68

80 NEXTERONE procainamide injection (Procainamide HCl) $0 (Tier 1) propafenone oral capsule,extended release (Rythmol SR) $0 (Tier 1) 12 hr propafenone oral tablet (Rythmol) $0 (Tier 1) quinidine gluconate (Quinidine $0 (Tier 1) Gluconate) quinidine sulfate (Quinidine Sulfate) $0 (Tier 1) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol (Sectral) $0 (Tier 1) atenolol (Tenormin) $0 (Tier 1) atenolol-chlorthalidone (Tenoretic 50) $0 (Tier 1) betaxolol oral (Kerlone) $0 (Tier 1) bisoprolol fumarate (Zebeta) $0 (Tier 1) bisoprolol-hydrochlorothiazide (Ziac) $0 (Tier 1) BREVIBLOC IN NACL (ISO-OSM) BYSTOLIC carvedilol (Coreg) $0 (Tier 1) DUTOPROL esmolol intravenous (Esmolol HCl) $0 (Tier 1) HEMANGEOL INNOPRAN XL labetalol intravenous solution (Trandate) $0 (Tier 1) labetalol oral (Trandate) $0 (Tier 1) 69

81 LEVATOL metoprolol succinate (Toprol XL) $0 (Tier 1) metoprolol ta-hydrochlorothiaz (Lopressor HCT) $0 (Tier 1) metoprolol tartrate intravenous (Metoprolol Tartrate) $0 (Tier 1) metoprolol tartrate oral (Lopressor) $0 (Tier 1) nadolol (Corgard) $0 (Tier 1) nadolol-bendroflumethiazide (Corzide) $0 (Tier 1) pindolol (Pindolol) $0 (Tier 1) propranolol intravenous (Propranolol HCl) $0 (Tier 1) propranolol oral capsule,extended release (Inderal LA) $0 (Tier 1) 24 hr propranolol oral solution (Propranolol HCl) $0 (Tier 1) propranolol oral tablet (Propranolol HCl) $0 (Tier 1) propranolol-hydrochlorothiazid (Propranolol/Hydroc $0 (Tier 1) hlorothiazid) sotalol hcl oral tablet 120 mg, 160 mg, 240 (Betapace) $0 (Tier 1) mg, 80 mg SOTALOL INTRAVENOUS sotalol oral (Betapace) $0 (Tier 1) SOTYLIZE timolol maleate oral (Timolol Maleate) $0 (Tier 1) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) $0 (Tier 1) diltiazem hcl intravenous (Diltiazem HCl) $0 (Tier 1) diltiazem hcl oral capsule, extended (Cardizem CD) $0 (Tier 1) release 180 mg, 360 mg diltiazem hcl oral capsule, extended (Tiazac) $0 (Tier 1) release 420 mg diltiazem hcl oral capsule,extended release (Diltiazem HCl) $0 (Tier 1) 12 hr 70

82 diltiazem hcl oral capsule,extended release (Cardizem CD) $0 (Tier 1) 24hr diltiazem hcl oral tablet (Cardizem) $0 (Tier 1) diltiazem hcl oral tablet extended release (Cardizem LA) $0 (Tier 1) 24 hr dilt-xr (Dilacor XR) $0 (Tier 1) matzim la (Cardizem LA) $0 (Tier 1) taztia xt (Tiazac) $0 (Tier 1) verapamil intravenous (Verapamil HCl) $0 (Tier 1) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) $0 (Tier 1) verapamil oral capsule,ext rel. pellets 24 (Verelan) $0 (Tier 1) hr verapamil oral tablet (Calan) $0 (Tier 1) verapamil oral tablet extended release (Calan SR) $0 (Tier 1) Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV $0 (Tier 1) ADRENALIN INJECTION $0 (Tier 1) SOLUTION 1 MG/ML (1:1,000) adrenalin injection solution 1 mg/ml (Epinephrine) $0 (Tier 1) (1:1,000)(1ml) AUVI-Q CORLANOR DEMSER DIGIFAB digitek oral tablet 125 mcg (Lanoxin) $0 (Tier 1) DIGOXIN ORAL SOLUTION digoxin oral tablet 125 mcg (Lanoxin) $0 (Tier 1) 71

83 dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) (Dobutamine HCl/D5W) What the $0 (Tier 1) BvD dobutamine intravenous solution (Dobutamine HCl) $0 (Tier 1) BvD dopamine in 5 % dextrose intravenous (Dopamine $0 (Tier 1) BvD solution 200 mg/250 ml (800 mcg/ml), 800 HCl/D5W) mg/250 ml (3,200 mcg/ml) dopamine in 5 % dextrose intravenous (Dopamine $0 (Tier 1) solution 400 mg/250 ml (1,600 mcg/ml) HCl/D5W) dopamine intravenous solution 200 mg/5 (Dopamine HCl) $0 (Tier 1) BvD ml (40 mg/ml), 800 mg/5 ml (160 mg/ml) dopamine intravenous solution 800 mg/10 (Dopamine HCl) $0 (Tier 1) ml (80 mg/ml) ephedrine sulfate injection solution (Ephedrine Sulfate) $0 (Tier 1) epinephrine 1 mg/ml ampul latex-free (Epinephrine) $0 (Tier 1) epinephrine hcl (pf) intravenous (Epinephrine $0 (Tier 1) HCl/PF) epinephrine injection auto-injector (Adrenaclick) $0 (Tier 1) epinephrine injection syringe 0.1 mg/ml (Epinephrine) $0 (Tier 1) (1:10,000) EPIPEN 2-K EPIPEN JR 2-K ethamolin (Ethanolamine $0 (Tier 1) Oleate) FIRAZYR ; QL (3 per 1 day) hydralazine (Hydralazine HCl) $0 (Tier 1) LANOXIN ORAL TABLET 125 MCG LANOXIN PEDIATRIC 72

84 What the milrinone (Milrinone Lactate) $0 (Tier 1) BvD milrinone in 5 % dextrose intravenous (Milrinone $0 (Tier 1) BvD piggyback 40 mg/200 ml (200 mcg/ml) Lactate/D5W) norepinephrine bitartrate (Levophed Bitartrate) $0 (Tier 1) papaverine injection solution (Papaverine HCl) $0 (Tier 1) papaverine oral (Papaverine HCl) $0 (Tier 1) RANEXA Dihydropyridines amlodipine (Norvasc) $0 (Tier 1) amlodipine-benazepril (Lotrel) $0 (Tier 1) amlodipine-valsartan (Exforge) $0 (Tier 1) AZOR ST CARDENE IV IN SODIUM CHLORIDE CARDENE SR CLEVIPREX INTRAVENOUS EMULSION isradipine (Isradipine) $0 (Tier 1) nicardipine (Nicardipine HCl) $0 (Tier 1) nifedipine oral tablet extended release (Procardia XL) $0 (Tier 1) 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) $0 (Tier 1) mg, 60 mg nimodipine (Nimotop) $0 (Tier 1) NYMALIZE Diuretics amiloride oral (Midamor) $0 (Tier 1) amiloride-hydrochlorothiazide (Amiloride/Hydrochl orothiazide) $0 (Tier 1) 73

85 bumetanide (Bumetanide) $0 (Tier 1) chlorothiazide (Chlorothiazide) $0 (Tier 1) chlorothiazide sodium (Sodium Diuril) $0 (Tier 1) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) $0 (Tier 1) DIURIL DYRENIUM EDECRIN ethacrynate sodium (Sodium Edecrin) $0 (Tier 1) furosemide injection (Furosemide) $0 (Tier 1) furosemide oral solution (Furosemide) $0 (Tier 1) furosemide oral tablet (Lasix) $0 (Tier 1) hydrochlorothiazide oral capsule (Microzide) $0 (Tier 1) hydrochlorothiazide oral tablet (Hydrochlorothiazide $0 (Tier 1) ) indapamide (Indapamide) $0 (Tier 1) methyclothiazide (Methyclothiazide) $0 (Tier 1) metolazone (Zaroxolyn) $0 (Tier 1) SAMSCA SODIUM EDECRIN torsemide intravenous solution (Torsemide) $0 (Tier 1) torsemide oral (Demadex) $0 (Tier 1) triamterene-hydrochlorothiazid oral (Dyazide) $0 (Tier 1) capsule triamterene-hydrochlorothiazid oral tablet (Maxzide) $0 (Tier 1) VAPRISOL Dyslipidemics amlodipine-atorvastatin (Caduet) $0 (Tier 1) 74

86 atorvastatin (Lipitor) $0 (Tier 1) cholestyramine (with sugar) oral (Questran) $0 (Tier 1) cholestyramine-aspartame oral powder 4 (Cholestyramine/Asp $0 (Tier 1) gram artame) cholestyramine-aspartame oral powder in (Cholestyramine/Asp $0 (Tier 1) packet 4 gram artame) colestipol (Colestid) $0 (Tier 1) CRESTOR fenofibrate micronized (Antara) $0 (Tier 1) fenofibrate nanocrystallized (Tricor) $0 (Tier 1) fenofibrate oral capsule (Lipofen) $0 (Tier 1) fenofibrate oral tablet (Lofibra) $0 (Tier 1) fenofibric acid (Fibricor) $0 (Tier 1) fluvastatin oral tablet extended release 24 (Lescol XL) $0 (Tier 1) hr gemfibrozil oral (Lopid) $0 (Tier 1) LIPOFEN lovastatin (Mevacor) $0 (Tier 1) LOVAZA niacin oral tablet extended release 24 hr (Niaspan) $0 (Tier 1) omega-3 acid ethyl esters (Lovaza) $0 (Tier 1) PRALUENT PEN PRALUENT SYRINGE pravastatin (Pravachol) $0 (Tier 1) RETHA SURECLICK RETHA SYRINGE 75

87 simvastatin (Zocor) $0 (Tier 1) WELCHOL ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) $0 (Tier 1) spironolactone (Aldactone) $0 (Tier 1) spironolacton-hydrochlorothiaz (Aldactazide) $0 (Tier 1) Vasodilators BIDIL DILATRATE-SR ISORDIL isosorbide dinitrate oral (Isochron) $0 (Tier 1) isosorbide dinitrate sublingual (Isosorbide Dinitrate) $0 (Tier 1) isosorbide mononitrate oral tablet (Isosorbide $0 (Tier 1) Mononitrate) isosorbide mononitrate oral tablet (Imdur) $0 (Tier 1) extended release 24 hr minitran (Nitro-Dur) $0 (Tier 1) minoxidil oral (Minoxidil) $0 (Tier 1) NITRO-BID NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin in 5 % dextrose intravenous solution (Nitroglycerin/D5W) $0 (Tier 1) nitroglycerin intravenous (Nitroglycerin) $0 (Tier 1) nitroglycerin transdermal patch 24 hour (Nitro-Dur) $0 (Tier 1) 76

88 nitroglycerin translingual (Nitromist) $0 (Tier 1) NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) $0 (Tier 1) QL (60 per 30 days) AMPYRA caffeine citrated intravenous (Cafcit) $0 (Tier 1) caffeine citrated oral (Cafcit) $0 (Tier 1) caffeine-sodium benzoate (Caffeine/Sodium $0 (Tier 1) Benzoate) clonidine hcl oral tablet extended release (Kapvay) $0 (Tier 1) 12 hr DAYTRANA ; QL (30 per 30 days) dexmethylphenidate oral capsule,er (Focalin XR) $0 (Tier 1) QL (30 per 30 days) biphasic dexmethylphenidate oral tablet (Focalin) $0 (Tier 1) QL (60 per 30 days) dextroamphetamine oral capsule, extended (Dexedrine) $0 (Tier 1) QL (180 per 30 days) release dextroamphetamine oral solution (Procentra) dextroamphetamine oral tablet (Dexedrine) $0 (Tier 1) QL (180 per 30 days) dextroamphetamine-amphetamine oral (Adderall XR) $0 (Tier 1) QL (120 per 30 days) capsule,extended release 24hr flumazenil (Romazicon) $0 (Tier 1) FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 20 MG, 25 ; QL (30 per 30 days) MG, 30 MG, 35 MG lithium carbonate oral capsule (Eskalith) $0 (Tier 1) 77

89 lithium carbonate oral tablet (Lithobid) $0 (Tier 1) lithium carbonate oral tablet extended (Lithobid) $0 (Tier 1) release lithium citrate oral solution (Lithium Citrate) $0 (Tier 1) LITHOBID methamphetamine (Desoxyn) $0 (Tier 1) QL (150 per 30 days) METHYLPHENIDATE HCL ORAL TABLET,CHEWABLE 10 MG ; QL (180 per 30 days) METHYLPHENIDATE HCL ORAL TABLET,CHEWABLE 2.5 MG, 5 MG ; QL (90 per 30 days) methylphenidate oral capsule, er biphasic (Metadate Cd) $0 (Tier 1) QL (30 per 30 days) methylphenidate oral capsule,er biphasic (Metadate Cd) $0 (Tier 1) QL (30 per 30 days) mg, 30 mg methylphenidate oral capsule,er biphasic (Ritalin LA) $0 (Tier 1) QL (30 per 30 days) mg methylphenidate oral solution (Methylin) $0 (Tier 1) QL (900 per 30 days) methylphenidate oral tablet (Ritalin) $0 (Tier 1) QL (90 per 30 days) methylphenidate oral tablet extended (Ritalin-SR) $0 (Tier 1) QL (90 per 30 days) release methylphenidate oral tablet extended (Concerta) $0 (Tier 1) QL (30 per 30 days) release 24hr methylphenidate oral tablet,chewable 10 (Methylin) $0 (Tier 1) QL (180 per 30 days) mg methylphenidate oral tablet,chewable 2.5 (Methylin) $0 (Tier 1) QL (90 per 30 days) mg, 5 mg NUEDEXTA PROCENTRA RILUTEK 78

90 riluzole (Rilutek) RITALIN LA ORAL CAPSULE,ER BIPHASIC MG SAVELLA STRATTERA tetrabenazine (Xenazine) $0 (Tier 1) XENAZINE Contraceptives Contraceptives ashlyna (Seasonique) $0 (Tier 1) cyred (Desogen) $0 (Tier 1) deblitane (Nor-Q-D) $0 (Tier 1) desog-e.estradiol/e.estradiol (Mircette) $0 (Tier 1) desogestrel-ethinyl estradiol oral tablet (Desogen) $0 (Tier 1) 0.1/.125/ mg-mcg, mg drospirenone-ethinyl estradiol (Yaz) $0 (Tier 1) ELLA ethinyl estradiol/drospirenone (Yaz) $0 (Tier 1) ethynodiol d-ethinyl estradiol (Ethynodiol $0 (Tier 1) D-Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) $0 (Tier 1) junel fe 24 (Loestrin Fe) $0 (Tier 1) kimidess (28) (Mircette) $0 (Tier 1) l norgest/e.estradiol-e.estrad (Seasonique) $0 (Tier 1) larin 24 fe (Loestrin Fe) $0 (Tier 1) levonorgestrel (Plan B One-Step) $0 (Tier 1) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) $0 (Tier 1) ; QL (30 per 30 days) 79

91 levonorgestrel oral tablet 1.5 mg (Plan B One-Step) levonorgestrel-ethin estradiol oral tablet (Amethyst) $0 (Tier 1) mg-mcg, mg, (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethi $0 (Tier 1) tablets,dose pack,3 month mg-mcg n Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) $0 (Tier 1) levonorgestrel-ethinyl estrad oral (Levonorgestrel-Ethi $0 (Tier 1) tablets,dose pack,3 month n Estradiol) l-norgest-eth estr/ethin estra (Seasonique) $0 (Tier 1) norelgestromin/ethin.estradiol (Ortho Evra) $0 (Tier 1) noreth-ethinyl estradiol/iron (Femcon Fe) $0 (Tier 1) norethindrone (Nor-Q-D) $0 (Tier 1) norethindrone (contraceptive) (Nor-Q-D) $0 (Tier 1) norethindrone ac-eth estradiol oral tablet (Loestrin) $0 (Tier 1) 1-20 mg-mcg, mg-mcg norethindrone-e.estradiol-iron (Loestrin Fe) $0 (Tier 1) norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) $0 (Tier 1) 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) $0 (Tier 1) mg-mcg, mg-mcg, /1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) $0 (Tier 1) norgestimate-ethinyl estradiol (Ortho-Cyclen) $0 (Tier 1) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl $0 (Tier 1) Estradiol) QUARTETTE $0 (Tier 1) setlakin (Levonorgestrel-Ethi $0 (Tier 1) n Estradiol) tarina fe (Loestrin Fe) $0 (Tier 1) 80

92 Cough And Cold Products Cough And Cold Products expectorant oral (Robitussin Mucus-Chest Congest) What the $0 (Tier 4) guaiatussin ac (M-Clear Wc) $0 (Tier 4) phenylhistine dh (P-Ephed $0 (Tier 4) HCl/Cod/Chlorpheni r) promethazine-codeine (Promethazine $0 (Tier 3) HCl/Codeine) promethazine-dm (Promethazine/Dextr $0 (Tier 3) omethorphan) Dental And Oral Agents Dental And Oral Agents ARESTIN cevimeline (Evoxac) $0 (Tier 1) chlorhexidine gluconate mucous (Peridex) $0 (Tier 1) membrane gel-kam (Stannous Fluoride) $0 (Tier 4) PHOS-FLUR DENTAL SOLUTION $0 (Tier 4) pilocarpine hcl oral (Salagen) $0 (Tier 1) sodium fluoride dental cream 1.1 % (Sodium Fluoride) $0 (Tier 1) sodium fluoride dental gel 1.1 % (Phos-Flur) $0 (Tier 1) sodium fluoride dental solution (Prevident) $0 (Tier 1) stannous fluoride (Stannous Fluoride) $0 (Tier 1) triamcinolone acetonide dental (Triamcinolone $0 (Tier 1) Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP 81

93 a + d (lan, pet) (Vits A and D/White $0 (Tier 4) Pet/Lanolin) acitretin (Soriatane) acne cleansing pads (Salicylic Acid) $0 (Tier 4) acyclovir topical (Zovirax) ALCOHOL DS ALCOHOL PREP DS ALCOH-WIPE aloe vesta skin conditioner 2 (Dimethicone) $0 (Tier 4) aluminum chloride (Aluminum Chloride) $0 (Tier 1) AMERIGEL PREMIUM CARE $0 (Tier 4) amerigel preventive barrier (Dimethicone) $0 (Tier 4) ammonium lactate (Lac-Hydrin) $0 (Tier 1) ANACAINE anu-med (Phenylephrine HCl) $0 (Tier 4) AZELEX baza cleanse & protect topical (Dimethicone) $0 (Tier 4) BAZA CLEANSE & PROTECT $0 (Tier 4) TOPICAL BAZA PROTECT $0 (Tier 4) BETADINE $0 (Tier 4) BETADINE SKIN CLEANSER $0 (Tier 4) BETADINE SPRAY $0 (Tier 4) BETADINE SWABSTICKS $0 (Tier 4) betasept surgical scrub (Hibiclens) $0 (Tier 4) boro-packs (Domeboro) $0 (Tier 4) 82

94 What the (Boudreauxs) $0 (Tier 4) boudreauxs butt paste topical ointment 16 % calamine (Calamine) $0 (Tier 4) calcipotriene topical ointment (Calcipotriene) calcipotriene topical solution (Calcipotriene) $0 (Tier 1) calcitriol topical (Vectical) $0 (Tier 1) CALICYLIC $0 (Tier 4) capsaicin topical cream % (Capzasin-Hp) $0 (Tier 4) CASTELLANI INT MODIFIED $0 (Tier 4) chlorhexidine gluconate topical liquid 2 % (Hibiclens) $0 (Tier 4) chlorhexidine gluconate topical (Chlorhexidine $0 (Tier 4) Gluconate) cool bottoms (Dimethicone) $0 (Tier 4) corn-callus remover topical liquid (Oil-Free Acne Wash) $0 (Tier 4) critic-aid (Zinc $0 (Tier 4) Oxide/Petrolatum, Yellow) DENAVIR ST dermamed (aluminum hydroxide) (Aluminum $0 (Tier 4) Hydroxide) DERMAREST PSORIASIS $0 (Tier 4) MEDICATED TOPICAL GEL dermarest psoriasis medicated topical (Betasal) $0 (Tier 4) shampoo dibucaine (Nupercainal) $0 (Tier 4) DRITHOCREME HP fast clearing spot (Salicylic Acid) $0 (Tier 4) FINACEA PLUS 83

95 FINACEA TOPICAL GEL fluorouracil topical cream (Carac) $0 (Tier 1) fluorouracil topical solution (Fluorouracil) $0 (Tier 1) grx dyne topical solution 7.5 % (Betadine) $0 (Tier 4) imiquimod (Aldara) $0 (Tier 1) IODEX $0 (Tier 4) KERALYT $0 (Tier 4) lidocream topical (Lmx 4) $0 (Tier 4) mafenide acetate (Mafenide Acetate) medicated cleansing pads (Salicylic Acid) $0 (Tier 4) methoxsalen rapid (Oxsoralen-Ultra) $0 (Tier 1) mexsana (Zinc Oxide) $0 (Tier 4) natural cold sore (Dimethicone) $0 (Tier 4) NEUTROGENA OIL-FREE ACNE $0 (Tier 4) WASH neutrogena t-gel conditner(sa) (Betasal) $0 (Tier 4) NORMLSHIELD $0 (Tier 4) NUPERCAINAL $0 (Tier 4) OXSORALEN OXSORALEN ULTRA NRETIN pedi-boro soak (Domeboro) $0 (Tier 4) periguard (Vit A/Vitamin $0 (Tier 4) D3/E/Aloe V/Znox) pharmabase barrier (Boudreauxs) $0 (Tier 4) plantar wart remover (Salicylic Acid) $0 (Tier 4) podofilox (Condylox) $0 (Tier 1) podophyllum resin (Podophyllum Resin) $0 (Tier 1) 84

96 potassium hydroxide (Potassium $0 (Tier 1) Hydroxide) povidone-iodine topical (Povidone-Iodine) $0 (Tier 4) povidone-iodine topical (Povidone-Iodine) $0 (Tier 4) povidone-iodine topical solution 7.5 % (Betadine) $0 (Tier 4) povidone-iodine topical swab 10 % (Betadine) $0 (Tier 4) POVIDONE-IODINE TOPICAL $0 (Tier 4) SWAB 7.5 % povidone-iodine vaginal (Betadine) $0 (Tier 4) proshield plus (Vaniply) $0 (Tier 4) PRUDOXIN PYROGALLIC ACID RASH RELIEF-ZINC OXIDE $0 (Tier 4) REGRANEX REMEDY 4-IN-1 (DIMETHICONE) $0 (Tier 4) REMEDY CLEANSING BODY $0 (Tier 4) REMEDY NUTRASHIELD SKIN $0 (Tier 4) PROTEC REMEDY SKIN REIR $0 (Tier 4) RESTORE DIMETHICREME $0 (Tier 4) RIMSO-50 SALJET SALINE RINSE $0 (Tier 4) SANTYL scalp relief topical liquid (Oil-Free Acne Wash) $0 (Tier 4) sea-clens wound cleanser (Nacl Irrigat/Decyl $0 (Tier 4) Glucoside) sebex (Ala Seb) $0 (Tier 4) SECURA EXTRA PROTECTIVE $0 (Tier 4) 85

97 silver nitrate applicators (Silver Nitrate Applicator) What the $0 (Tier 1) SILVERMED TOPICAL $0 (Tier 4) GEL,EXTENDED RELEASE SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG SULFAMYLON TOPICAL CREAM surgilube (Surgical Lubricant) $0 (Tier 4) SWEEN 24 $0 (Tier 4) TRIPLE STE TOPICAL $0 (Tier 4) OINTMENT 12.8 % trixaicin hp (Capzasin-Hp) $0 (Tier 4) UVADEX VALCHLOR VEREGEN vits a and d-white pet-lanolin topical (Vits A and D/White $0 (Tier 4) ointment Pet/Lanolin) wart remover topical liquid (Salicylic $0 (Tier 4) Acid/Collodion, Flex) wart remover topical liquid 17 % (Oil-Free Acne Wash) $0 (Tier 4) wart remover topical plaster (Salicylic Acid) $0 (Tier 4) wart stick (Salicylic Acid) $0 (Tier 4) XERAC AC zinc oxide topical ointment (Boudreauxs) $0 (Tier 4) zinc oxide topical paste (Zinc Oxide) $0 (Tier 4) ZONALON zostrix-hp (Capzasin-Hp) $0 (Tier 4) 86

98 ZOVIRAX TOPICAL Dermatological Antibacterials antibiotic plus (pramoxine) (Neomycin Su/Plymx $0 (Tier 4) B Su/Pram) bacitracin topical (Bacitracin) $0 (Tier 4) bacitracin-polymyxin b topical (Bacitracin/Polymyxi $0 (Tier 4) n B Sulfate) BACTROBAN NASAL clindamycin phosphate topical foam (Evoclin) $0 (Tier 1) clindamycin phosphate topical gel (Cleocin T) $0 (Tier 1) clindamycin phosphate topical lotion (Cleocin T) $0 (Tier 1) clindamycin phosphate topical solution (Cleocin T) $0 (Tier 1) clindamycin phosphate topical swab (Cleocin T) $0 (Tier 1) erythromycin with ethanol topical gel (Emgel) $0 (Tier 1) erythromycin with ethanol topical solution (Erythromycin $0 (Tier 1) Base/Ethanol) erythromycin with ethanol topical swab (Erythromycin $0 (Tier 1) Base/Ethanol) first aid antibiotic topical ointment (Neomycin $0 (Tier 4) Su/Bacitrac Zn/Poly) gentamicin topical (Gentamicin Sulfate) $0 (Tier 1) metronidazole topical (Metrocream) $0 (Tier 1) metronidazole topical (Nydamax) $0 (Tier 1) metronidazole topical (Metrolotion) $0 (Tier 1) mupirocin (Centany) $0 (Tier 1) mupirocin calcium (Bactroban) $0 (Tier 1) neomycin-polymyxin b gu (Neosporin G.U. $0 (Tier 1) Irrigant) selenium sulfide (Selenium Sulfide) $0 (Tier 1) silver nitrate topical (Silver Nitrate) $0 (Tier 1) silver sulfadiazine topical cream 1 % (Thermazene) $0 (Tier 1) 87

99 sulfacetamide sodium (acne) (Klaron) $0 (Tier 1) TERSI FOAM THERMAZENE $0 (Tier 1) triple antibiotic plus (Neomycn/Baci $0 (Tier 4) Zn/Pmyx Bs/Pramox) triple antibiotic topical ointment (Neomycin $0 (Tier 4) Su/Bacitrac Zn/Poly) Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) $0 (Tier 1) alclometasone topical ointment (Alclometasone $0 (Tier 1) Dipropionate) amcinonide topical ointment (Amcinonide) $0 (Tier 1) beta-hc (Cortizone-10) $0 (Tier 4) betamethasone dipropionate topical cream (Diprosone) $0 (Tier 1) betamethasone dipropionate topical lotion (Betamethasone $0 (Tier 1) Dipropionate) betamethasone dipropionate topical (Betamethasone $0 (Tier 1) ointment Dipropionate) betamethasone valerate topical cream (Betamethasone $0 (Tier 1) Valerate) betamethasone valerate topical lotion (Betamethasone $0 (Tier 1) Valerate) betamethasone valerate topical ointment (Betamethasone $0 (Tier 1) Valerate) betamethasone, augmented topical cream (Diprolene AF) $0 (Tier 1) betamethasone, augmented topical gel (Betamethasone $0 (Tier 1) Dipropionate) betamethasone, augmented topical lotion (Diprolene) $0 (Tier 1) betamethasone, augmented topical (Diprolene) $0 (Tier 1) ointment clobetasol topical cream (Temovate) $0 (Tier 1) 88

100 clobetasol topical foam (Olux) clobetasol topical gel (Temovate) $0 (Tier 1) clobetasol topical ointment (Temovate) $0 (Tier 1) clobetasol topical solution (Clobetasol $0 (Tier 1) Propionate) clobetasol-emollient topical (Temovate) $0 (Tier 1) CORDRAN TAPE LARGE ROLL CORDRAN TOPICAL CREAM CORDRAN TOPICAL LOTION CORDRAN TOPICAL OINTMENT CORTIFOAM desonide topical cream (Desowen) $0 (Tier 1) desonide topical ointment (Tridesilon) $0 (Tier 1) desoximetasone topical cream 0.25 % (Topicort) $0 (Tier 1) ELIDEL fluocinolone topical cream (Synalar) $0 (Tier 1) fluocinolone topical oil (Derma-Smoothe-Fs) $0 (Tier 1) fluocinolone topical ointment (Synalar) $0 (Tier 1) fluocinolone topical solution (Synalar) $0 (Tier 1) fluocinonide topical cream (Vanos) $0 (Tier 1) fluocinonide topical gel (Fluocinonide) $0 (Tier 1) fluocinonide topical ointment (Fluocinonide) $0 (Tier 1) fluocinonide topical solution (Fluocinonide) $0 (Tier 1) fluocinonide-emollient base (Vanos) $0 (Tier 1) fluticasone topical cream (Cutivate) $0 (Tier 1) 89

101 What the fluticasone topical ointment (Fluticasone $0 (Tier 1) Propionate) halobetasol propionate (Ultravate) $0 (Tier 1) hc-1% hemorrhoid (Hydrocortisone $0 (Tier 4) Acetate) hydrocortisone 1% cream maximum (Hydrocortisone) $0 (Tier 4) strength (otc) hydrocortisone acet-aloe vera topical gel (Hydrocortisone $0 (Tier 1) Acetate/Aloe V) hydrocortisone acetate topical cream 0.5 (Hydrocortisone $0 (Tier 4) % Acetate) hydrocortisone acetate-aloe (Hydrocortisone $0 (Tier 4) Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone $0 (Tier 1) Acetate/Urea) hydrocortisone butyrate (Locoid) $0 (Tier 1) hydrocortisone butyr-emollient (Locoid) $0 (Tier 1) hydrocortisone rectal cream 1 % (Anusol-HC) $0 (Tier 1) hydrocortisone rectal cream 2.5 % (Hydrocortisone) $0 (Tier 1) hydrocortisone rectal enema (Cortenema) $0 (Tier 1) hydrocortisone topical cream 0.5 % (Hydrocortisone) $0 (Tier 4) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) $0 (Tier 1) hydrocortisone topical lotion 1 % (Cortizone-10) $0 (Tier 4) hydrocortisone topical lotion 2.5 % (Rederm) $0 (Tier 1) hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) $0 (Tier 1) % hydrocortisone valerate topical cream (Hydrocortisone $0 (Tier 1) Valerate) hydroskin topical lotion (Cortizone-10) $0 (Tier 4) mometasone (Elocon) $0 (Tier 1) noble formula hc topical (Cortaid) $0 (Tier 4) prednicarbate (Dermatop) $0 (Tier 1) preparation h hydrocortisone (Hydrocortisone) $0 (Tier 4) 90

102 RECTACORT-HC scalp relief topical solution (Hydrocortisone) $0 (Tier 4) tacrolimus topical (Protopic) $0 (Tier 1) TEXACORT triamcinolone acetonide topical cream (Triamcinolone $0 (Tier 1) Acetonide) triamcinolone acetonide topical lotion (Kenalog) $0 (Tier 1) triamcinolone acetonide topical ointment (Triderm) $0 (Tier 1) %, 0.1 %, 0.5 % Dermatological Retinoids adapalene topical cream (Differin) $0 (Tier 1) adapalene topical gel 0.1 % (Differin) $0 (Tier 1) avita (Retin-A) $0 (Tier 1) TAZORAC tretinoin (emollient) (Tretinoin/Emollient $0 (Tier 1) Base) tretinoin microspheres (Retin-A Micro) tretinoin topical (Retin-A) $0 (Tier 1) Scabicides And Pediculicides bedding spray (Permethrin) $0 (Tier 4) EURAX lice bedding spray (Permethrin) $0 (Tier 4) lice treatment (permethrin) (Nix) $0 (Tier 4) lice treatment (resmethrin) (Pip $0 (Tier 4) Butox/Pyrethrins/Res meth) lice treatment topical kit % (Piperonyl Butoxide/Pyrethrins) $0 (Tier 4) 91

103 lice treatment topical (Piperonyl $0 (Tier 4) Butoxide/Pyrethrins) lindane (Lindane) $0 (Tier 1) malathion (Ovide) $0 (Tier 1) permethrin topical cream (Elimite) $0 (Tier 1) permethrin topical liquid (Nix) $0 (Tier 4) SKLICE SOOLANTRA spinosad (Natroba) $0 (Tier 1) Devices Devices ACE AEROSOL CLOUD $0 (Tier 4) ENHANCER AEROCHAMBER PLUS Z STAT MD $0 (Tier 4) MSK ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" BREATHERITE MDI SCER $0 (Tier 4) EASIVENT HOLDING CHAMBER $0 (Tier 4) E-Z SCER $0 (Tier 4) E-Z SCER PEDSK $0 (Tier 4) INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE 92

104 INSULIN SYRINGE-NEEDLE U-100 SYRINGE MICROCHAMBER $0 (Tier 4) MONAGHAN Z STAT $0 (Tier 4) CHAMBER-MD MSK NESSI SCER $0 (Tier 4) PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U-100 VORTEX HOLDING CHAMBER $0 (Tier 4) WATCHHALER $0 (Tier 4) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CHENODAL CIMZIA CIMZIA POWDER FOR RECONST CREON CYSTAGON ELAPRASE 93

105 ELELYSO ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS lipase-protease-amylase (Zenpep) $0 (Tier 1) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME SUCRAID VIMIZIM VPRIV XIAFLEX 94

106 ZAVESCA Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine (Tetcaine) $0 (Tier 1) apraclonidine (Iopidine) $0 (Tier 1) artificial tears (petro/min) (Genteal Pm) $0 (Tier 4) artificial tears ophthalmic drops % (Tears Naturale) $0 (Tier 4) artificial tears ophthalmic drops % (Polyvinyl $0 (Tier 4) Alcohol/Povidone) atropine ophthalmic drops (Isopto Atropine) $0 (Tier 1) atropine ophthalmic ointment (Atropine Sulfate) $0 (Tier 1) ayr saline nasal aerosol,spray (Little Remedies) $0 (Tier 4) ayr saline nasal drops (Sodium Chloride) $0 (Tier 4) azelastine nasal (Astepro) $0 (Tier 1) azelastine ophthalmic (Optivar) $0 (Tier 1) carteolol (Carteolol HCl) $0 (Tier 1) cromolyn ophthalmic (Cromolyn Sodium) $0 (Tier 1) cyclopentolate (Cyclogyl) $0 (Tier 1) deep sea nasal (Little Remedies) $0 (Tier 4) epinastine (Elestat) $0 (Tier 1) GENTEAL MILD TO MODERATE $0 (Tier 4) GENTEAL SEVERE $0 (Tier 4) homatropine hbr (Isopto $0 (Tier 1) Homatropine) ipratropium bromide nasal (Atrovent) $0 (Tier 1) isopto tears (Genteal Mild To $0 (Tier 4) Moderate) liquitears (Polyvinyl Alcohol) $0 (Tier 4) little noses (Phenylephrine HCl) $0 (Tier 4) lubrifresh pm (Genteal Pm) $0 (Tier 4) 95

107 muro 128 (Sodium Chloride) $0 (Tier 4) naphazoline (Naphazoline HCl) $0 (Tier 1) natural balance (Genteal Mild To $0 (Tier 4) Moderate) natural tears (pf) (Dextran $0 (Tier 4) 70/Hypromellose/PF) nature's tears (Genteal Mild To $0 (Tier 4) Moderate) ocean nasal (Little Remedies) $0 (Tier 4) phenylephrine hcl ophthalmic (Mydfrin) $0 (Tier 1) proparacaine (Proparacaine HCl) $0 (Tier 1) proparacaine hcl (Proparacaine HCl) $0 (Tier 1) proparacaine-fluorescein sod (Proparacaine/Fluore $0 (Tier 1) scein Sod) REFRESH CLASSIC (PF) $0 (Tier 4) REFRESH LACRI-LUBE $0 (Tier 4) REFRESH LIQUIGEL $0 (Tier 4) REFRESH TEARS $0 (Tier 4) RHINARIS NASAL $0 (Tier 4) SPRAY,NON-AEROSOL saline mist (Little Remedies) $0 (Tier 4) sea soft nasal mist (Little Remedies) $0 (Tier 4) sodium chloride ophthalmic (Sodium Chloride) $0 (Tier 4) sterile saline nasal (0.9 % Sodium $0 (Tier 4) Chloride) SYSTANE $0 (Tier 4) TEARS NATURALE II $0 (Tier 4) tetracaine hcl (Tetcaine) $0 (Tier 1) TETRAVISC FORTE OPHTHALMIC tropicamide ophthalmic (Mydriacyl) $0 (Tier 1) TYZINE 96

108 visine-lr (Oxymetazoline HCl) $0 (Tier 4) VISUDYNE Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) $0 (Tier 1) acetic acid-hydrocortisone (Vosol HC) $0 (Tier 1) auro eardrops (Carbamide Peroxide) $0 (Tier 4) bacitracin ophthalmic (Bacitracin) $0 (Tier 1) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxi $0 (Tier 1) n B Sulfate) ciprofloxacin hcl ophthalmic (Ciloxan) $0 (Tier 1) ciprofloxacin hcl otic (Cetraxal) $0 (Tier 1) debrox (Carbamide Peroxide) $0 (Tier 4) ear drops (carbamide peroxide) (Carbamide Peroxide) $0 (Tier 4) ear wax removal system otic (Carbamide $0 (Tier 4) Peroxide/Sea Water) erythromycin ophthalmic (Ilotycin) $0 (Tier 1) gentamicin ophthalmic (Garamycin) $0 (Tier 1) gentamicin sulfate ophthalmic ointment (Garamycin) $0 (Tier 1) 0.3 % (3 mg/gram) hydrocortisone-acetic acid (Vosol HC) $0 (Tier 1) levofloxacin ophthalmic (Quixin) $0 (Tier 1) neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci $0 (Tier 1) Zn/Poly/HC) neomycin-bacitracin-poly-hc (Neomycin Su/Baci $0 (Tier 1) Zn/Poly/HC) neomycin-bacitracin-polymyxin (Neomycin $0 (Tier 1) Su/Bacitra/Polymyxin ) neomycin-polymyxin b-dexameth (Maxitrol) $0 (Tier 1) neomycin-polymyxin-gramicidin (Neosporin) $0 (Tier 1) neomycin-polymyxin-hc (Oticin HC) $0 (Tier 1) ofloxacin ophthalmic (Ocuflox) $0 (Tier 1) 97

109 ofloxacin otic (Ocuflox) $0 (Tier 1) polymyxin b sulf-trimethoprim (Polytrim) $0 (Tier 1) sulfacetamide sodium (Sulfacetamide $0 (Tier 1) Sodium) sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide $0 (Tier 1) % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Predn $0 (Tier 1) isolone Sp) tobramycin (Tobrex) $0 (Tier 1) tobramycin-dexamethasone (Tobradex) $0 (Tier 1) trifluridine (Viroptic) $0 (Tier 1) Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALOCRIL bromfenac (Bromfenac Sodium) $0 (Tier 1) dexamethasone sodium phosphate (Dexasol) $0 (Tier 1) ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) $0 (Tier 1) flunisolide nasal spray,non-aerosol 25 mcg (Flunisolide) $0 (Tier 1) (0.025 %) fluocinolone acetonide oil (Dermotic) $0 (Tier 1) fluorometholone (FML) $0 (Tier 1) flurbiprofen sodium (Ocufen) $0 (Tier 1) fluticasone nasal (Flonase) $0 (Tier 1) ketorolac ophthalmic (Acular) $0 (Tier 1) prednisolone acetate (Omnipred) $0 (Tier 1) prednisolone sodium phosphate ophthalmic (Prednisolone Sod $0 (Tier 1) Phosphate) RESTASIS triamcinolone acetonide nasal (Nasacort Aq) $0 (Tier 1) 98

110 What the Gastrointestinal Agents Antiflatulents GAS-X EXTRA STRENGTH $0 (Tier 4) GAS-X ORAL TABLET,CHEWABLE $0 (Tier 4) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) oral tablet (Pepcid Ac) $0 (Tier 4) cimetidine (Tagamet) $0 (Tier 1) cimetidine hcl oral (Cimetidine HCl) $0 (Tier 1) esomeprazole sodium (Nexium I.V.) $0 (Tier 1) famotidine (pf) (Famotidine/PF) $0 (Tier 1) famotidine (pf)-nacl (iso-os) (Famotidine In $0 (Tier 1) Nacl,Iso-Osm/PF) famotidine oral suspension (Pepcid) $0 (Tier 1) famotidine oral tablet 20 mg, 40 mg (Pepcid) $0 (Tier 1) lansoprazole oral capsule,delayed (Prevacid) $0 (Tier 1) release(dr/ec) misoprostol (Cytotec) $0 (Tier 1) NEXIUM IV nizatidine oral capsule (Axid) $0 (Tier 1) nizatidine oral solution (Nizatidine) $0 (Tier 1) omeprazole magnesium (Omeprazole $0 (Tier 4) Magnesium) omeprazole oral capsule,delayed (Prilosec) $0 (Tier 1) release(dr/ec) omeprazole-sodium bicarbonate (Zegerid) $0 (Tier 1) pantoprazole intravenous (Pantoprazole $0 (Tier 1) Sodium) pantoprazole oral (Protonix) $0 (Tier 1) PRILOSEC OTC $0 (Tier 4) ; QL (62 per 31 days) pub famotidine 20 mg tablet max strength (otc) (Pepcid Ac) $0 (Tier 4) 99

111 What the rabeprazole (Aciphex) $0 (Tier 1) ranitidine hcl injection (Zantac) $0 (Tier 1) ranitidine hcl oral capsule (Ranitidine HCl) $0 (Tier 1) ranitidine hcl oral syrup (Ranitidine HCl) $0 (Tier 1) ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) $0 (Tier 1) ranitidine hcl oral tablet 75 mg (Zantac) $0 (Tier 4) sucralfate oral suspension (Sucralfate) $0 (Tier 1) sucralfate oral tablet (Carafate) $0 (Tier 1) ZANTAC IN 0.45 % SOD. CHLORIDE Gastrointestinal Agents, Other almacone oral suspension (Maalox Maximum $0 (Tier 4) Strength) almacone-2 (Maalox Maximum $0 (Tier 4) Strength) aluminum hydroxide gel (Aluminum $0 (Tier 4) Hydroxide) AMITIZA QL (60 per 30 days) antacid extra-strength oral (Tums Ultra) $0 (Tier 4) tablet,chewable 300 mg (750 mg) antacid oral (Tums Ultra) $0 (Tier 4) antacid plus anti-gas oral suspension (Maalox Maximum $0 (Tier 4) Strength) anti-diarrheal (loperamide) oral (Imodium A-D) $0 (Tier 4) bismatrol (Pepto-Bismol) $0 (Tier 4) BUPHENYL ORAL TABLET calci-chew (Tums Ultra) $0 (Tier 4) CALCIUM CARBONATE-VITAMIN $0 (Tier 4) D3 ORAL TABLET,CHEWABLE MG-UNIT cal-gest antacid (Tums Ultra) $0 (Tier 4) 100

112 CANTIL CARBAGLU CHOLBAM cromolyn oral (Gastrocrom) $0 (Tier 1) CUVPOSA dicyclomine oral capsule (Bentyl) $0 (Tier 1) dicyclomine oral solution (Dicyclomine HCl) $0 (Tier 1) dicyclomine oral tablet (Bentyl) $0 (Tier 1) diotame instydose (Bismuth $0 (Tier 4) Subsalicylate) diphenoxylate-atropine oral liquid (Diphenoxylate $0 (Tier 1) HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) $0 (Tier 1) foaming antacid oral tablet,chewable (Gaviscon) $0 (Tier 4) GAVISCON $0 (Tier 4) glycopyrrolate (Robinul) $0 (Tier 1) glycopyrrolate (Robinul) $0 (Tier 1) KRISTALOSE lactulose oral solution (Lactulose) $0 (Tier 1) loperamide oral (Loperamide HCl) $0 (Tier 1) loperamide oral (Loperamide HCl) $0 (Tier 4) MAALOX MAXIMUM STRENGTH $0 (Tier 4) magnesium oxide oral tablet 400 mg, 500 (Magox 400) $0 (Tier 4) mg methscopolamine oral (Pamine) $0 (Tier 1) metoclopramide hcl injection (Reglan) $0 (Tier 1) metoclopramide hcl oral (Metoclopramide HCl) $0 (Tier 1) 101

113 metoclopramide hcl oral (Reglan) $0 (Tier 1) metoclopramide hcl oral (Metozolv Odt) $0 (Tier 1) tablet,disintegrating METOZOLV ODT ORAL TABLET,DISINTEGRATING 5 MG mi-acid oral suspension (Maalox Maximum Strength) $0 (Tier 4) mi-acid oral tablet,chewable (Rolaids) $0 (Tier 4) mintox (Maalox Maximum $0 (Tier 4) Strength) mintox maximum strength (Maalox Maximum $0 (Tier 4) Strength) mintox plus (Almacone) $0 (Tier 4) MOTOFEN NUTRESTORE PEPTO-BISMOL MAX ST $0 (Tier 4) PEPTO-BISMOL ORAL $0 (Tier 4) PEPTO-BISMOL ORAL $0 (Tier 4) PYLERA RELISTOR SUBCUTANEOUS RELISTOR SUBCUTANEOUS sodium bicarbonate oral (Sodium Bicarbonate) $0 (Tier 4) TUMS ULTRA ORAL $0 (Tier 4) TABLET,CHEWABLE 400 MG (1,000 MG) ursodiol oral capsule (Actigall) $0 (Tier 1) ursodiol oral tablet (Urso) $0 (Tier 1) 102

114 What the Laxatives BENEFIBER SUGAR FREE $0 (Tier 4) (DEXTRIN) ORAL POWDER BENEFIBER SUGAR FREE(GUAR $0 (Tier 4) GUM) bisac-evac (Dulcolax) $0 (Tier 4) bisacodyl oral (Dulcolax) $0 (Tier 4) bisacodyl rectal (Dulcolax) $0 (Tier 4) biscolax (Dulcolax) $0 (Tier 4) BLACK DRAUGHT SENNA $0 (Tier 4) LAXATIVE child's fiber select gummies (Inulin) $0 (Tier 4) CITRUCEL ORAL POWDER $0 (Tier 4) CITRUCEL ORAL TABLET $0 (Tier 4) COLACE CLEAR $0 (Tier 4) cvs magnesium citrate soln (Magnesium Citrate) $0 (Tier 4) doc-q-lace (Colace Clear) $0 (Tier 4) docu (Docusate Sodium) $0 (Tier 4) dok oral capsule (Colace Clear) $0 (Tier 4) dok oral tablet (Docusate Sodium) $0 (Tier 4) easy fiber (wheat dextrin) (Wheat $0 (Tier 4) Dextrin/Calcium Carb) equalactin (Calcium $0 (Tier 4) Polycarbophil) ex-lax (sennosides) oral tablet (Senokot) $0 (Tier 4) fiber (calcium polycarbophil) (Fibercon) $0 (Tier 4) fiber gummies (Inulin) $0 (Tier 4) fiber laxative (methylcellulo) (Citrucel) $0 (Tier 4) fiber therapy oral powder 2 gram/19 gram (Citrucel) $0 (Tier 4) fiber therapy sugar free (Methylcellulose) $0 (Tier 4) FIBERCON $0 (Tier 4) fiber-lax (Fibercon) $0 (Tier 4) 103

115 What the fleet glycerin (adult) (Glycerin) $0 (Tier 4) fleet glycerin (child) (Glycerin) $0 (Tier 4) FLEET MINERAL OIL $0 (Tier 4) glycerin (adult) rectal suppository (Glycerin) $0 (Tier 4) GOLYTELY ORAL POWDER IN CKET konsyl (sugar) oral (Metamucil) $0 (Tier 4) konsyl sugar-free oral capsule (Metamucil) $0 (Tier 4) konsyl sugar-free oral powder in packet (Psyllium Husk) $0 (Tier 4) magnesium citrate oral solution (Magnesium Citrate) $0 (Tier 4) METAMUCIL ORAL CAPSULE $0 (Tier 4) METAMUCIL ORAL WAFER $0 (Tier 4) METAMUCIL SMOOTH (WITH $0 (Tier 4) SUGAR) milk of magnesia (Milk Of Magnesia) $0 (Tier 4) MOVIPREP natural fiber laxative therapy (Psyllium Seed (With $0 (Tier 4) Sugar)) NUTRISOURCE FIBER ORAL $0 (Tier 4) POWDER oral saline laxative oral (Na Phos,M-B/Na $0 (Tier 4) Phos,Di-Ba) OSMOPREP PEDIA-LAX RECTAL $0 (Tier 4) peg 3350-electrolytes (Golytely) $0 (Tier 1) PEG 3350-GRX $0 (Tier 1) peg 3350-na sulf,bicarb,cl-kcl (Golytely) $0 (Tier 1) peg-electrolyte soln (Nulytely with Flavor $0 (Tier 1) Packs) peri-colace (Sennosides/Docusate Sodium) $0 (Tier 4) 104

116 What the polyethylene glycol 3350 oral (Polyethylene Glycol $0 (Tier 1) 3350) PREPOPIK pub glycerin suppositories adult (Glycerin) $0 (Tier 4) reguloid oral capsule (Metamucil) $0 (Tier 4) reguloid oral powder (Psyllium Seed (With $0 (Tier 4) Sugar)) sani-supp (adult) (Glycerin) $0 (Tier 4) senexon oral syrup (Sennosides) $0 (Tier 4) senexon oral tablet (Senokot) $0 (Tier 4) senna lax (Senokot) $0 (Tier 4) senna laxative oral tablet 8.6 mg (Senokot) $0 (Tier 4) senna oral syrup 8.8 mg/5 ml (Sennosides) $0 (Tier 4) senna with docusate sodium (Sennosides/Docusate $0 (Tier 4) Sodium) silace oral liquid (Docusate Sodium) $0 (Tier 4) silace oral syrup (Colace) $0 (Tier 4) sodium chloride-nahco3-kcl-peg oral recon (Nulytely with Flavor $0 (Tier 1) soln 420 gram Packs) stool softener oral capsule 240 mg (Surfak) $0 (Tier 4) SUCLEAR SUPREP BOWEL PREP KIT Phosphate Binders calcium acetate oral capsule (Phoslo) $0 (Tier 1) calcium acetate oral tablet 667 mg (Calcium Acetate) $0 (Tier 1) calcium carbonate-mag carb-fa (Calcium $0 (Tier 1) Carbonate/Mag Carb/Fa) FOSRENOL 105

117 PHOSLYRA RENAGEL RENVELA sevelamer carbonate (Sevelamer $0 (Tier 1) Carbonate) sodium polystyrene sulfonate oral powder (Sodium Polystyrene $0 (Tier 1) Sulfonate) sodium polystyrene sulfonate oral (Sodium Polystyrene $0 (Tier 1) suspension 15 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema 30 gram/120 ml (Sodium Polystyrene Sulfonate) $0 (Tier 1) Genitourinary Agents Antispasmodics, Urinary flavoxate (Flavoxate HCl) $0 (Tier 1) GELNIQUE oxybutynin chloride oral syrup (Oxybutynin $0 (Tier 1) Chloride) oxybutynin chloride oral tablet (Oxybutynin $0 (Tier 1) Chloride) oxybutynin chloride oral tablet extended (Ditropan XL) $0 (Tier 1) release 24hr tolterodine oral tablet (Detrol) $0 (Tier 1) trospium oral capsule,extended release (Sanctura XR) $0 (Tier 1) 24hr trospium oral tablet (Sanctura) $0 (Tier 1) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) $0 (Tier 1) tamsulosin (Flomax) $0 (Tier 1) terazosin (Terazosin HCl) $0 (Tier 1) 106

118 What the Heavy Metal Antagonists Heavy Metal Antagonists BAL IN OIL CA-DT CHEMET CUPRIMINE deferoxamine injection recon soln (Desferal) $0 (Tier 1) DEPEN TITRATABS EXJADE FERRIPROX GALZIN sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate) $0 (Tier 1) gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE ZN-DT Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDROGEL danazol oral (Danazol) $0 (Tier 1) fluoxymesterone (Fluoxymesterone) $0 (Tier 1) 107

119 oxandrolone oral tablet 2.5 mg (Oxandrin) testosterone cypionate (Depo-Testosterone) $0 (Tier 1) testosterone enanthate (Delatestryl) $0 (Tier 1) Estrogens And Antiestrogens DEPO-ESTRADIOL ESTRACE VAGINAL estradiol oral tablet 2 mg (Estrace) $0 (Tier 1) estradiol valerate (Delestrogen) $0 (Tier 1) ESTRASORB ESTRING ESTROGEL FEMHRT LOW DOSE FEMRING norethindrone ac-eth estradiol oral tablet (Femhrt) $0 (Tier 1) mg-mcg, 1-5 mg-mcg PREMARIN INJECTION PREMARIN VAGINAL raloxifene (Evista) $0 (Tier 1) VAGIFEM Glucocorticoids/Mineralocorticoids ARISTOSN INTRA-ARTICULAR ; QL (240 per 30 days) 108

120 ARISTOSN INTRALESIONAL betamethasone acet,sod phos (Celestone) $0 (Tier 1) cortisone (Cortisone Acetate) $0 (Tier 1) deltasone oral tablet 20 mg (Prednisone) $0 (Tier 1) DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML DEXAMETHASONE INTENSOL dexamethasone oral (Dexamethasone) $0 (Tier 1) dexamethasone oral (Dexamethasone) $0 (Tier 1) dexamethasone sodium phosphate (Dexamethasone Sod $0 (Tier 1) injection Phosphate) DEXK 10 DAY DEXK 13 DAY DEXK 6 DAY FLO-PRED fludrocortisone (Fludrocortisone $0 (Tier 1) Acetate) hydrocortisone oral (Cortef) $0 (Tier 1) hydrocortisone sod succinate (Hydrocortisone Sod $0 (Tier 1) Succinate) MEDROL ORAL TABLET 2 MG methylprednisolone (Medrol) $0 (Tier 1) methylprednisolone acetate (Depo-Medrol) $0 (Tier 1) methylprednisolone sodium succ injection (A-Methapred) $0 (Tier 1) recon soln 125 mg, 40 mg methylprednisolone sodium succ (A-Methapred) $0 (Tier 1) intravenous 109

121 MILLIPRED MILLIPRED DP ORAPRED ODT prednisolone sodium phosphate oral (Orapred) $0 (Tier 1) solution prednisolone sodium phosphate oral (Orapred Odt) $0 (Tier 1) tablet,disintegrating PREDNISONE INTENSOL prednisone (Prednisone) $0 (Tier 1) RAYOS SOLU-CORTEF (PF) INJECTION RECON SOLN SOLU-MEDROL (PF) INJECTION RECON SOLN 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS SOLU-MEDROL INTRAVENOUS RECON SOLN triamcinolone acetonide injection (Triamcinolone $0 (Tier 1) Acetonide) VERIPRED 20 Pituitary CHORIONIC GONADOTROPIN, HUMAN desmopressin injection (Desmopressin $0 (Tier 1) Acetate) desmopressin nasal (DDAVP) $0 (Tier 1) 110

122 desmopressin nasal (Desmopressin $0 (Tier 1) Acetate) desmopressin oral (DDAVP) $0 (Tier 1) GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE INCRELEX NORDITROPIN FLEXPRO NOVAREL NUTROPIN NUTROPIN AQ NUSPIN NUTROPIN AQ SUBCUTANEOUS octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml (Sandostatin) (Octreotide Acetate) octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE PREGNYL SAIZEN 111

123 SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT STIMATE SUPPRELIN LA TEV-TROPIN VANTAS vasopressin (Pitressin) $0 (Tier 1) VASOSTRICT $0 (Tier 1) ZORBTIVE Progestins CRINONE VAGINAL GEL 4 % DEPO-PROVERA INTRAMUSCULAR SOLUTION DEPO-SUBQ PROVERA

124 ENDOMETRIN medroxyprogesterone intramuscular (Depo-Provera) $0 (Tier 1) suspension medroxyprogesterone intramuscular (Medroxyprogesteron $0 (Tier 1) syringe e Acetate) medroxyprogesterone oral (Provera) $0 (Tier 1) norethindrone acetate (Aygestin) $0 (Tier 1) progesterone (Progesterone) $0 (Tier 1) progesterone micronized capsules (Prometrium) $0 (Tier 1) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine $0 (Tier 1) Sodium) levothyroxine oral (Synthroid) $0 (Tier 1) LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine intravenous (Triostat) $0 (Tier 1) liothyronine oral (Cytomel) $0 (Tier 1) methimazole oral tablet 10 mg, 5 mg (Tapazole) $0 (Tier 1) propylthiouracil (Propylthiouracil) $0 (Tier 1) SYNTHROID THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 113

125 TIROSINT TRIOSTAT UNITHROID Immunological Agents Immunological Agents ANASCORP ANTIVENIN LATRODECTUS MACTANS ANTIVENIN MICRURUS FULVIUS ARCALYST ASTAGRAF XL ATGAM AZASAN BvD BvD BvD BvD azathioprine (Imuran) $0 (Tier 1) BvD azathioprine sodium (Azathioprine $0 (Tier 1) BvD Sodium) BIVIGAM BvD CARIMUNE NF NANOFILTERED BvD INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS BvD CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION BvD 114

126 What the CROFAB cyclosporine intravenous (Sandimmune) $0 (Tier 1) BvD cyclosporine modified (Neoral) $0 (Tier 1) BvD cyclosporine oral capsule (Sandimmune) $0 (Tier 1) BvD cyclosporine, modified (Neoral) $0 (Tier 1) BvD CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % FLEBOGAMMA DIF BvD INTRAVENOUS SOLUTION 5 % GAMASTAN S/D BvD GAMMAGARD LIQUID BvD GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 20 GRAM/200 ML (10 %) GAMMAPLEX GAMUNEX-C INJECTION SOLUTION HEGAM B INJECTION SOLUTION GREATR THAN 312 UNIT/ML (5 ML) HIZENTRA SUBCUTANEOUS SOLUTION HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START BvD BvD BvD 115

127 HYPERHEP B S/D INTRAMUSCULAR SOLUTION HYPERHEP B S/D INTRAMUSCULAR SYRINGE HYPERHEP B S-D NEONATAL HYPERRAB S/D (PF) HYPERRHO S/D HYPERTET S/D (PF) HYQVIA ILARIS (PF) IMOGAM RABIES-HT (PF) leflunomide (Arava) $0 (Tier 1) MICRHOGAM ULTRA-FILTERED PLUS BvD mycophenolate mofetil (Cellcept) $0 (Tier 1) BvD mycophenolate sodium (Myfortic) $0 (Tier 1) BvD NABI-HB INTRAMUSCULAR SOLUTION GREATR THAN 312 UNIT/ML NULOJIX BvD OCTAGAM BvD PRIVIGEN BvD RAMUNE ORAL SOLUTION BvD 116

128 What the RAMUNE ORAL TABLET 1 MG, 2 BvD MG RHOGAM ULTRA-FILTERED PLUS RHOPHYLAC RIDAURA sirolimus (Rapamune) $0 (Tier 1) BvD tacrolimus oral (Hecoria) $0 (Tier 1) BvD THYMOGLOBULIN TYSABRI WINRHO SDF INJECTION SOLUTION ZORTRESS Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) BEXSERO (PF) BIOTHRAX BOOSTRIX TDAP CERVARIX VACCINE (PF) ; LA BvD 117

129 COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) BvD BvD 118

130 MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD BvD 119

131 THERACYS TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) VIVOTIF BERNA VACCINE YF-VAX (PF) ZOSTAVAX (PF) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron (Alosetron HCl) APRISO ASACOL HD balsalazide (Colazal) $0 (Tier 1) budesonide oral (Entocort EC) $0 (Tier 1) DELZICOL DIPENTUM 120

132 mesalamine rectal (Mesalamine) mesalamine with cleansing wipe (Mesalamine) UCERIS ORAL Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) $0 (Tier 1) LACTATED RINGERS IRRIGATION RENACIDIN RESECTISOL ringers irrigation (Tis-U-Sol) $0 (Tier 1) sodium chloride irrigation (Sodium Chloride $0 (Tier 1) Irrig Solution) sorbitol irrigation (Sorbitol Solution) $0 (Tier 1) sorbitol-mannitol (Mannitol/Sorbitol $0 (Tier 1) Solution) water for irrigation, sterile (Water For $0 (Tier 1) Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents ACTONEL ORAL TABLET 35 MG alendronate oral solution (Alendronate $0 (Tier 1) Sodium) alendronate oral tablet (Fosamax) $0 (Tier 1) calcitonin (salmon) (Miacalcin) $0 (Tier 1) calcitriol intravenous solution 1 mcg/ml (Calcitriol) $0 (Tier 1) BvD calcitriol oral (Rocaltrol) $0 (Tier 1) BvD 121

133 What the doxercalciferol intravenous (Doxercalciferol) $0 (Tier 1) BvD doxercalciferol oral (Hectorol) $0 (Tier 1) BvD etidronate disodium (Etidronate $0 (Tier 1) Disodium) FORTEO FORTICAL HECTOROL INTRAVENOUS BvD SOLUTION HECTOROL ORAL BvD; ST ibandronate oral (Boniva) $0 (Tier 1) MIACALCIN INJECTION BvD NATRA pamidronate intravenous (Pamidronate $0 (Tier 1) BvD Disodium) RICALCITOL HEMODIALYSIS PORT INJECTION paricalcitol oral (Zemplar) PROLIA XGEVA ZEMPLAR INTRAVENOUS zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback (Zoledronic Acid/Mannitol and Water) 122

134 zoledronic acid-mannitol-water (Reclast) intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE allopurinol (Zyloprim) $0 (Tier 1) allopurinol sodium (Allopurinol Sodium) $0 (Tier 1) amifostine crystalline (Amifostine $0 (Tier 1) Crystalline) ammonium chloride (Ammonium $0 (Tier 1) Chloride) amobarbital sodium (Amobarbital $0 (Tier 1) Sodium) anticoag citrate phos dextrose (Citrate Phosphate $0 (Tier 1) Dextros Soln) BENLYSTA INTRAVENOUS RECON SOLN bethanechol chloride (Urecholine) $0 (Tier 1) BLOXIVERZ BOTOX buspirone (Buspirone HCl) $0 (Tier 1) CERDELGA colchicine oral tablet (Colcrys) $0 (Tier 1) colchicine-probenecid (Colchicine/Probeneci $0 (Tier 1) d) COLCRYS 123

135 COXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE dexrazoxane hcl intravenous recon soln (Totect) $0 (Tier 1) droperidol injection solution (Droperidol) $0 (Tier 1) DUODOTE DYSPORT ELMIRON fiber gummies (with chromium) (Inulin/Chromium $0 (Tier 4) Picolinate) finasteride oral tablet 5 mg (Proscar) $0 (Tier 1) fomepizole (Fomepizole) $0 (Tier 1) FUSILEV glatopa (Copaxone) GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycerin topical solution (Glycerin) $0 (Tier 4) GRASTEK guanidine (Guanidine HCl) $0 (Tier 1) KALBITOR KEPIVANCE 124

136 What the leucovorin calcium injection recon soln 100 (Leucovorin Calcium) $0 (Tier 1) mg, 200 mg, 350 mg leucovorin calcium oral (Leucovorin Calcium) $0 (Tier 1) levocarnitine (with sugar) (Levocarnitine (With $0 (Tier 1) BvD Sugar)) levocarnitine intravenous (Carnitor) $0 (Tier 1) levocarnitine oral (Carnitor) $0 (Tier 1) BvD levoleucovorin calcium (Levoleucovorin $0 (Tier 1) Calcium) licide spray (Piperonyl $0 (Tier 4) Butoxide/Pyrethrins) LITHOSTAT mesna (Mesnex) $0 (Tier 1) MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESN methylene blue (antidote) (Methylene Blue) $0 (Tier 1) methylergonovine (Methylergonovine $0 (Tier 1) Maleate) MIFEPREX morrhuate sodium (Sodium Morrhuate) $0 (Tier 1) MYALEPT MYOBLOC INTRAMUSCULAR SOLUTION neostigmine methylsulfate (Neostigmine $0 (Tier 1) Methylsulfate) NITHIODOTE 125

137 NPLATE SUBCUTANEOUS RECON SOLN ORALAIR OTEZLA OTEZLA STARTER NHEMATIN physostigmine salicylate (Physostigmine $0 (Tier 1) Salicylate) PRALIDOXIME probenecid (Probenecid) $0 (Tier 1) PROCYSBI PROSTIN E2 PROTOM CHLORIDE pyridostigmine bromide (Mestinon) $0 (Tier 1) RAGWITEK REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION CK RECTIV REGONOL 126

138 REMICADE SCLEROSOL INTRAPLEURAL SENSIR SIMULECT INTRAVENOUS RECON SOLN SODIUM TETRADECYL SULFATE INTRAVENOUS SOLUTION 1 % (10 MG/ML) sodium tetradecyl sulfate intravenous solution 3 % (30 mg/ml) (Sodium Tetradecyl $0 (Tier 1) Sulfate) SOLIRIS STERILE DS TOPICAL BANDAGE 2 X 2 " sterile talc (Talc) $0 (Tier 1) SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID THAM THIOLA BvD QL (60 per 30 days) 127

139 TYBOST ULESFIA ULORIC VORAXAZE XEOMIN INTRAMUSCULAR RECON SOLN Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) $0 (Tier 1) acetazolamide oral tablet (Acetazolamide) $0 (Tier 1) acetazolamide sodium (Acetazolamide $0 (Tier 1) Sodium) betaxolol ophthalmic (Betaxolol HCl) $0 (Tier 1) brimonidine (Alphagan P) $0 (Tier 1) dorzolamide (Trusopt) $0 (Tier 1) dorzolamide-timolol (Cosopt) $0 (Tier 1) latanoprost (Xalatan) $0 (Tier 1) levobunolol (Betagan) $0 (Tier 1) methazolamide oral (Neptazane) $0 (Tier 1) metipranolol (Metipranolol) $0 (Tier 1) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, (Isopto Carpine) $0 (Tier 1) 4 % timolol maleate ophthalmic drops (Timolol Maleate) $0 (Tier 1) timolol maleate ophthalmic gel forming solution (Timoptic-Xe) $0 (Tier 1) ST 128

140 TRAVATAN Z travoprost (benzalkonium) (Travoprost $0 (Tier 1) (Benzalkonium)) Replacement Preparations Replacement Preparations AMMONUL calcionate (Calcium Glubionate) $0 (Tier 4) calcium 500 with d (Os-Cal 500+D) $0 (Tier 4) calcium carbonate oral (Calcium Carbonate) $0 (Tier 4) calcium carbonate oral tablet 260 mg (Caltrate 600) $0 (Tier 4) calcium (648 mg) calcium chloride intravenous (Calcium Chloride) $0 (Tier 1) calcium citrate-vitamin d3 oral tablet 250 (Citracal-Vitamin D) $0 (Tier 4) mg calcium- 200 unit calcium gluconate intravenous (Calcium Gluconate) $0 (Tier 1) BvD CALTRATE 600 $0 (Tier 4) CALTRATE 600+D PLUS $0 (Tier 4) MINERALS CALTRATE D VIT D3 (800) $0 (Tier 4) citric acid-sodium citrate (Citric Acid/Sodium $0 (Tier 1) Citrate) citrus calcium oral tablet (Citracal-Vitamin D) $0 (Tier 4) electrolyte-48 in d5w (Electrolyte-48 $0 (Tier 1) Solution/D5W) HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W 129

141 ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KAOCHLOR EFFERVESCENT KLOR-CON $0 (Tier 1) klor-con 10 (Potassium Chloride) $0 (Tier 1) KLOR-CON 8 $0 (Tier 1) klor-con m10 (Potassium Chloride) $0 (Tier 1) klor-con m15 (Potassium Chloride) $0 (Tier 1) klor-con m20 (Potassium Chloride) $0 (Tier 1) klor-con sprinkle (Micro-K) $0 (Tier 1) KLOR-CON/EF $0 (Tier 1) K-PHOS NO 2 K-PHOS ORIGINAL mag-delay (Magnesium Chloride) magnesium chloride injection (Magnesium $0 (Tier 1) Chloride) magnesium sulf in 0.45% nacl (Magnesium Sulf In $0 (Tier 1) 0.45% NaCl) magnesium sulfate in d5w intravenous (Magnesium $0 (Tier 1) piggyback 1 gram/100 ml, 4 gram/100 ml Sulfate/D5W) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) (Magnesium Sulfate in Water) $0 (Tier 4) $0 (Tier 1) magnesium sulfate injection (Magnesium Sulfate) $0 (Tier 1) 130

142 NEUT NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II ORACIT oralyte (Pedialyte) $0 (Tier 4) OS-CAL D3 ORAL TABLET,CHEWABLE $0 (Tier 4) oysco d (Os-Cal 500+D) $0 (Tier 4) oyster shell calcium 500 (Caltrate 600) $0 (Tier 4) PEDIALYTE FREEZER POPS $0 (Tier 4) PEDIALYTE ORAL SOLUTION $0 (Tier 4) pediatric electrolyte oral solution (Pedialyte) $0 (Tier 4) phosphorus #1 oral tablet 250 mg (K-Phos Neutral) $0 (Tier 1) PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) $0 (Tier 1) potassium bicarb and chloride (Pot Chloride/Pot $0 (Tier 1) Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) $0 (Tier 1) 131

143 POTASSIUM BICARBONATE-CIT AC ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l What the (Klor-Con-Ef) $0 (Tier 1) (Potassium Chloride/D5-0.45nacl ) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) potassium chloride intravenous (Potassium Chloride) $0 (Tier 1) potassium chloride oral capsule, extended (Micro-K) $0 (Tier 1) release potassium chloride oral liquid (Kaochlor) $0 (Tier 1) potassium chloride oral packet (Klor-Con) $0 (Tier 1) potassium chloride oral tablet extended (Klor-Con 8) $0 (Tier 1) release potassium chloride oral tablet,er (Klor-Con 8) $0 (Tier 1) particles/crystals 10 meq potassium chloride oral tablet,er (Potassium Chloride) $0 (Tier 1) particles/crystals 20 meq potassium chloride-0.45 % nacl (Potassium $0 (Tier 1) Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium $0 (Tier 1) Chloride/D5-0.2%Na Cl) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l (Potassium Chloride/D5-0.3%Na Cl) $0 (Tier 1) 132

144 potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%Na Cl) What the $0 (Tier 1) potassium citrate (Urocit-K) $0 (Tier 1) potassium citrate-citric acid oral packet (Potassium $0 (Tier 1) 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral solution (Potassium $0 (Tier 1) 1, mg/5 ml Citrate/Citric Acid) potassium phosphate m-/d-basic (Potassium $0 (Tier 1) Phos,M-Basic-D-Basi c) ringers intravenous (Ringers Solution) $0 (Tier 1) SHOHL'S MODIFIED $0 (Tier 1) SLOW-MAG $0 (Tier 4) sodium acetate intravenous (Sodium Acetate) $0 (Tier 1) sodium bicarbonate intravenous (Sodium Bicarbonate) $0 (Tier 1) sodium chloride 0.45 % intravenous (Sodium Chloride $0 (Tier 1) 0.45 %) sodium chloride 0.9 % injection solution (0.9 % Sodium $0 (Tier 1) Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium $0 (Tier 1) Chloride) sodium chloride 3 % (Sodium Chloride 3 $0 (Tier 1) %) sodium chloride 5 % (Sodium Chloride 5 $0 (Tier 1) %) sodium chloride intravenous (Sodium Chloride) $0 (Tier 1) sodium citrate-citric acid (Citric Acid/Sodium $0 (Tier 1) Citrate) sodium lactate intravenous solution (Sodium Lactate) $0 (Tier 1) sodium phosphate (Sodium Phos,M-Basic-D-Basi c) $0 (Tier 1) 133

145 What the $0 (Tier 1) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II UROCIT-K 15 zinc chloride (Zinc Chloride) $0 (Tier 3) zinc sulfate intravenous (Zinc Sulfate) $0 (Tier 3) zinc sulfate oral (Zinc Sulfate) $0 (Tier 3) Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids AEROSN budesonide inhalation (Pulmicort) $0 (Tier 1) BvD DULERA PULMICORT FLEXHALER PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML QVAR SYMBICORT Antileukotrienes montelukast (Singulair) $0 (Tier 1) zafirlukast (Accolate) $0 (Tier 1) ZYFLO 134

146 ZYFLO CR Bronchodilators albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) $0 (Tier 1) albuterol sulfate oral tablet (Albuterol Sulfate) $0 (Tier 1) albuterol sulfate oral tablet extended (Vospire ER) $0 (Tier 1) release 12 hr aminophylline intravenous solution (Aminophylline) $0 (Tier 1) ANORO ELLIPTA ATROVENT HFA BROVANA COMBIVENT RESPIMAT ipratropium bromide inhalation (Ipratropium Bromide) ipratropium-albuterol (Ipratropium/Albuter ol Sulfate) ISUPREL levalbuterol hcl (Xopenex) LUFYLLIN metaproterenol oral (Metaproterenol $0 (Tier 1) Sulfate) SEREVENT DISKUS STRIVERDI RESPIMAT (Albuterol Sulfate) $0 (Tier 1) BvD BvD $0 (Tier 1) BvD $0 (Tier 1) BvD BvD 135

147 terbutaline oral (Terbutaline Sulfate) $0 (Tier 1) terbutaline subcutaneous (Terbutaline Sulfate) $0 (Tier 1) THEO-24 theophylline anhydrous oral elixir 80 (Theophylline $0 (Tier 1) mg/15 ml Anhydrous) theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral (Theophylline Anhydrous) $0 (Tier 1) (Theophylline/D5W) $0 (Tier 1) (Theophylline $0 (Tier 1) Anhydrous) theophylline oral (Theophylline $0 (Tier 1) Anhydrous) theophylline oral (Theophylline $0 (Tier 1) Anhydrous) TUDORZA PRESSAIR VENTOLIN HFA Respiratory Tract Agents, Other acetylcysteine (Acetadote) $0 (Tier 1) BvD acetylcysteine (Acetadote) $0 (Tier 1) BvD ARALAST NP cromolyn inhalation (Cromolyn Sodium) $0 (Tier 1) BvD CUROSURF INTRATRACHEAL SUSPENSION DALIRESP ST 136

148 GLASSIA INFASURF KALYDECO OFEV ORKAMBI PROLASTIN-C sodium chloride inhalation solution for (Pulmosal) $0 (Tier 4) nebulization 0.9 % SURFAXIN SURVANTA XOLAIR ZEMAIRA ; QL (60 per 30 days) BvD Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) $0 (Tier 1) COMFORT C-TIZANIDINE $0 (Tier 1) cyclobenzaprine oral tablet (Fexmid) $0 (Tier 1) dantrolene (Dantrium) $0 (Tier 1) dantrolene sodium (Dantrium) $0 (Tier 1) GABLOFEN INTRATHECAL SOLUTION BvD GABLOFEN INTRATHECAL SYRINGE BvD 137

149 LIORESAL tizanidine (Zanaflex) $0 (Tier 1) Sleep Disorder Agents Sleep Disorder Agents NEMBUTAL SODIUM NUVIGIL ROZEREM XYREM BvD QL (30 per 30 days) ; LA zolpidem oral tablet (Ambien) $0 (Tier 1) QL (90 per 180 days) Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents phentolamine injection (Phentolamine Mesylate) $0 (Tier 1) Urine And Feces Contents Ph CHEMSTRIP 2 $0 (Tier 4) Urine And Feces Contents AZO TEST STRIPS $0 (Tier 4) CHEMSTRIP 9 $0 (Tier 4) Vasodilating Agents Vasodilating Agents ADCIRCA ADEMS CIALIS ORAL TABLET 2.5 MG, 5 MG 138

150 epoprostenol (glycine) (Flolan) LETAIRIS OPSUMIT ORENITRAM REMODULIN REVATIO INTRAVENOUS REVATIO ORAL SUSPENSION FOR RECONSTITUTION sildenafil oral (Revatio) TRACLEER TYVASO TYVASO REFILL KIT TYVASO STARTER KIT VELETRI VENTAVIS Vitamins And Minerals Vitamins And Minerals AQUADEKS ORAL CAPSULE $0 (Tier 4) b complex-vitamin c-folic acid (Dialyvite 800) $0 (Tier 4) centrum silver oral tablet (Biocel) $0 (Tier 4) ; LA 139

151 CENTRUM SILVER ORAL TABLET,CHEWABLE cerovite cerovite advanced formula (Multivits W-Min/Ferrous Gluc) (Multivitamin/Iron/F olic Acid) What the $0 (Tier 4) $0 (Tier 4) $0 (Tier 4) chewable-vite (Multivitamin) $0 (Tier 4) complete oral tablet (Multivits $0 (Tier 4) W-Iron,Hematinic) feosol oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) $0 (Tier 4) ferrimin 150 (Ferrous Fumarate) $0 (Tier 4) ferrous fumarate oral tablet 324 mg (106 (Ferrous Fumarate) $0 (Tier 4) mg iron) FERROUS FUMARATE ORAL $0 (Tier 4) TABLET 89 MG (29 MG IRON) ferrous gluconate oral tablet 236 mg (27 (Fergon) $0 (Tier 4) mg iron), 324 mg (36 mg iron), 325 mg (36 mg iron) ferrous sulfate oral (Fer-In-Sol) $0 (Tier 4) ferrous sulfate oral (Ferrous Sulfate) $0 (Tier 4) ferrous sulfate oral (Ferrous Sulfate) $0 (Tier 4) ferrous sulfate oral tablet 325 mg (65 mg (Ferrous Sulfate) $0 (Tier 4) iron) ferrous sulfate oral tablet,delayed release (Ferrous Sulfate) $0 (Tier 4) (dr/ec) 324 mg (65 mg iron) folic acid injection (Folic Acid) $0 (Tier 3) FOLIC ACID ORAL CAPSULE 20 $0 (Tier 4) MG folic acid oral tablet 1 mg (Folic Acid) $0 (Tier 4) folic acid-vitamin b comp w-c oral tablet mg, 5 mg (Folic Acid/Vitamin B Comp W-C) $0 (Tier 3) 140

152 folic acid-vitamin b comp w-c oral tablet mg-mg-mcg-mg (Vit B Cplx #11/Fa/C/Biot/Zn Ox) What the $0 (Tier 3) hydroxocobalamin (Hydroxocobalamin) INFUVITE PEDIATRIC $0 (Tier 4) iron dextran complex intravenous solution (Infed) $0 (Tier 3) 100 mg/2 ml (50 mg/ml) iron ps cmplx-vit b12-fa oral capsule (Niferex-150 Forte) $0 (Tier 3) mg-mcg-mg i-vite (Ocuvite with Lutein) $0 (Tier 4) multi-delyn with iron (Multivitamin/Ferrou $0 (Tier 4) s Gluconate) multivit-fluor 0.25 mg/ml drop 0.25 mg/ml (Pedi Mvi No.82 with $0 (Tier 1) Fluoride) MVI, ADULT NO.4 WITH VIT K $0 (Tier 3) nu-iron (Pic 200) $0 (Tier 4) one-a-day womens formula oral tablet 18 (Multivits,Ca,Mineral $0 (Tier 4) mg iron-400 mcg-500 mg ca s/iron/fa) phytonadione oral tablet 100 mcg (Phytonadione) $0 (Tier 4) prenatal vitamins oral tablet 27 mg iron- 1 (Pnv with $0 (Tier 1) mg Ca,No.72/Iron/Fa) sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) $0 (Tier 1) sodium fluoride oral tablet 1 mg fluoride (Pedi Mvi No.82 with $0 (Tier 1) (2.2 mg) Fluoride) thera-m oral tablet 9 mg iron-400 mcg (Multivits,Ca,Mineral $0 (Tier 4) s/iron/fa) tri-vi-sol (Vit A Palmitate/Vit $0 (Tier 4) C/Vit D3) TRI-VI-SOL WITH IRON $0 (Tier 4) vit b cmplx 3-fa-vit c-biotin oral tablet (Vit B Cmplx $0 (Tier 3) mg-mg-mcg 3/Fa/Vit C/Biotin) vitamin d3 oral tablet 1,000 unit (Vitamin D3) $0 (Tier 4) 141

153 VITAMIN D3 ORAL TABLET 5,000 UNIT vitamins & minerals (Multivitamins,Ther W-Minerals) What the $0 (Tier 4) $0 (Tier 4) 142

154 3 day vaginal MOP a + d (lan, pet) abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE acamprosate... 7 acarbose ACD ACE AEROSOL CLOUD ENHANCER acebutolol acetaminophen-codeine... 1 acetazolamide acetazolamide sodium acetic acid... 97, 121 acetic acid-hydrocortisone acetylcysteine acid reducer (famotidine) acitretin acne cleansing pads ACTHIB (PF) ACTIMMUNE ACTONEL acyclovir... 56, 82 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADASUVE ADCETRIS ADCIRCA adefovir ADEMS ADRENALIN adrenalin INDEX AEROCHAMBER PLUS Z STAT MD MSK AEROSN AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 %.. 61 ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone ALCOHOL DS ALCOHOL PREP DS ALCOH-WIPE ALDURAZYME alendronate ALFERON N alfuzosin ALIMTA ALINIA allerclear d-24hr allergy relief (loratadine) allopurinol allopurinol sodium almacone almacone ALOCRIL aloe vesta aloe vesta skin conditioner alosetron alprazolam... 9 altacaine aluminum chloride aluminum hydroxide gel amantadine hcl AMBISOME amcinonide AMERIGEL PREMIUM CARE amerigel preventive barrier amifostine crystalline amikacin amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % aminocaproic acid aminophylline AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-atorvastatin I-1

155 amlodipine-benazepril amlodipine-valsartan ammonium chloride ammonium lactate AMMONUL amobarbital sodium amoxapine amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide ANASCORP anastrozole ANDROGEL ANGIOMAX ANORO ELLIPTA antacid antacid extra-strength antacid plus anti-gas antibiotic plus (pramoxine) anticoag citrate phos dextrose anti-diarrheal (loperamide) anti-fungal anti-nausea ANTIVENIN LATRODECTUS MACTANS ANTIVENIN MICRURUS FULVIUS anu-med APIDRA APIDRA SOLOSTAR APLENZIN APOKYN apraclonidine APRISO APTIOM APTIVUS AQUADEKS ARALAST NP ARANESP (IN POLYSORBATE) ARCALYST ARESTIN aripiprazole ARISTOSN INTRA-ARTICULAR ARISTOSN INTRALESIONAL ARRANON artificial tears artificial tears (petro/min) ARZERRA ASACOL HD ashlyna aspirin... 5 aspirin-dipyridamole aspir-low... 5 ASSURE ID INSULIN SAFETY ASTAGRAF XL ATACAND atenolol atenolol-chlorthalidone ATGAM atorvastatin atovaquone atovaquone-proguanil ATRIPLA ATROPEN atropine... 30, 95 ATROVENT HFA ATRYN AUGMENTIN auro eardrops AUVI-Q AVANDIA AVASTIN AVC VAGINAL AVELOX IN NACL (ISO-OSMOTIC) avita AVYCAZ ayr saline azacitidine AZACTAM IN DEXTROSE (ISO-OSM) AZASAN azathioprine azathioprine sodium azelastine AZELEX AZILECT azithromycin AZO TEST STRIPS azolen tincture AZOR aztreonam b complex-vitamin c-folic acid bacitracin... 11, 87, 97 bacitracin-polymyxin b... 87, 97 baclofen BACTROBAN NASAL BAL IN OIL balsalazide BANZEL BARACLUDE baza antifungal baza cleanse & protect BAZA CLEANSE & PROTECT BAZA PROTECT BCG VACCINE, LIVE (PF) BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bedding spray BELEODAQ benazepril benazepril-hydrochlorothiazide BENEFIBER SUGAR FREE (DEXTRIN) BENEFIBER SUGAR FREE(GUAR GUM) I-2

156 BENLYSTA benztropine BERINERT BETADINE BETADINE SKIN CLEANSER BETADINE SPRAY BETADINE SWABSTICKS beta-hc betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented betasept surgical scrub betaxolol... 69, 128 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIDIL BILTRICIDE BIOTHRAX bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bivalirudin BIVIGAM BLACK DRAUGHT SENNA LAXATIVE bleomycin BLINCYTO BLOXIVERZ BOOSTRIX TDAP boro-packs BOSULIF BOTOX boudreauxs butt paste BREATHERITE MDI SCER BREVIBLOC IN NACL (ISO-OSM) BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac bromocriptine BROVANA budesonide , 134 bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 1, 7 buprenorphine-naloxone... 8 bupropion hcl... 8, 34 buspirone BUSULFEX INTRAVENOUS butalbital-acetaminop-caf-cod... 1 butalbital-acetaminophen-caff... 1 butalbital-aspirin-caffeine... 1 butorphanol tartrate... 1 BYDUREON BYETTA BYSTOLIC cabergoline CA-DT CAFERGOT caffeine citrated caffeine-sodium benzoate calamine calci-chew calcionate calcipotriene calcitonin (salmon) calcitriol... 83, 121 calcium 500 with d calcium acetate calcium carbonate calcium carbonate-mag carb-fa CALCIUM CARBONATE-VITAMIN D calcium chloride calcium citrate-vitamin d calcium gluconate CALDOLOR... 5 cal-gest antacid CALICYLIC CALTRATE CALTRATE 600+D PLUS MINERALS CALTRATE D VIT D3 (800) CAMPRAL... 8 CANCIDAS candesartan candesartan-hydrochlorothiazid CANTIL CASTAT CAPITAL WITH CODEINE... 1 CAPRELSA capsaicin captopril captopril-hydrochlorothiazide CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARDENE IV IN SODIUM CHLORIDE CARDENE SR CARIMUNE NF NANOFILTERED carteolol cartia xt carvedilol CASTELLANI INT MODIFIED I-3

157 CAYSTON CEDAX cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os).. 13 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefixime cefotaxime cefotetan cefotetan in dextrose, iso-osm cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime CEFTAZIDIME IN D5W ceftibuten CEFTIN ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os.. 14 CEFTRIAXONE IN DEXTROSE,ISO-OS CEFUROXIME AXETIL cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... 5 CELLCEPT CELLCEPT INTRAVENOUS CELONTIN centrum silver CENTRUM SILVER cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREBYX CEREZYME cerovite cerovite advanced formula CERVARIX VACCINE (PF) CESAMET cetirizine cevimeline CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX CONTINUING MONTH K... 8 CHANTIX STARTING MONTH BOX... 8 CHEMET CHEMSTRIP CHEMSTRIP CHENODAL chewable-vite children's aller-tec CHILDREN'S ZYRTEC ALLERGY child's fiber select gummies chloramphenicol sod succinate chlordiazepoxide hcl... 9 chlorhexidine gluconate... 81, 83 chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone CHOLBAM cholestyramine (with sugar) cholestyramine-aspartame choline,magnesium salicylate... 5 CHORIONIC GONADOTROPIN, HUMAN CIALIS ciclopirox ciclopirox-ure-camph-menth-euc cidofovir cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 19, 97 ciprofloxacin in 5 % dextrose.. 19 ciprofloxacin lactate cisplatin citalopram citric acid-sodium citrate CITRUCEL citrus calcium cladribine clarithromycin CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate... 11, 44, 87 CLINDAMYCIN PHOSPHATE... 11, 44 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE I-4

158 CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol... 88, 89 clobetasol-emollient CLOLAR clomipramine clonazepam... 9 clonidine clonidine hcl... 66, 77 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium... 9 clotrimazole... 40, 41 clotrimazole 3 day clotrimazole-betamethasone clozapine COARTEM cocaine... 7 codeine sulfate... 1 codeine-butalbital-asa-caffein... 1 COLACE CLEAR colchicine colchicine-probenecid COLCRYS colestipol colistin (colistimethate na) COMBIVENT RESPIMAT COMETRIQ COMFORT C-IBUPROFEN... 5 COMFORT C-MELOXICAM... 5 COMFORT C-NAPROXEN... 5 COMFORT C-TIZANIDINE COMZINE COMPLERA complete COMVAX (PF) cool bottoms COXONE CORDRAN CORDRAN TAPE LARGE ROLL CORLANOR corn-callus remover CORTIFOAM cortisone COUMADIN CREON CRESEMBA CRESTOR CRINONE critic-aid critic-aid clear af CRIXIVAN CROFAB cromolyn... 95, 101, 136 CUBICIN CUPRIMINE CURITY GAUZE CUROSURF CUVPOSA cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE cycloserine CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTAGON cysteine (l-cysteine) cytarabine cytarabine (pf) CYTOGAM d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride.. 64 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride.. 64 dacarbazine DACOGEN dactinomycin DALIRESP DALVANCE danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM daunorubicin DAUNOXOME DAYTRANA deblitane debrox decitabine deep sea nasal deferoxamine deltasone DELZICOL demeclocycline DEMSER DENAVIR I-5

159 DEPEN TITRATABS DEPOCYT (PF) DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA dermafungal dermamed (aluminum hydroxide) DERMAREST PSORIASIS MEDICATED dermarest psoriasis medicated desenex desenex spray desipramine desmopressin , 111 desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone DESVENLAFAXINE desvenlafaxine DESVENLAFAXINE FUMARATE dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phosphate... 98, 109 dexmethylphenidate DEXK 10 DAY DEXK 13 DAY DEXK 6 DAY dexrazoxane hcl dextroamphetamine dextroamphetamine-amphetamine dextrose 10 % and 0.2 % nacl. 64 dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride diazepam... 9 diazepam intensol... 9 DIBENZYLINE dibucaine diclofenac potassium... 5 diclofenac sodium... 5, 98 diclofenac-misoprostol... 5 dicloxacillin dicyclomine didanosine DIFICID diflunisal... 6 DIGIFAB digitek DIGOXIN digoxin dihydrocodeine-aspirin-caff... 1 dihydroergotamine DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN DILATRATE-SR diltiazem hcl... 70, 71 dilt-xr dimenhydrinate diotame instydose DIPENTUM diphenhydramine hcl diphenoxylate-atropine DISKETS... 1 disulfiram... 8 DIURIL divalproex dobutamine dobutamine in d5w DOCEFREZ docetaxel doc-q-lace docu dok donepezil dopamine dopamine in 5 % dextrose DORIBAX dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate... 19, 20 doxycycline monohydrate DRAMAMINE driminate DRITHOCREME HP dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine DUODOTE DURAMORPH (PF)... 1 DUTOPROL DYRENIUM DYSPORT ear drops (carbamide peroxide) ear wax removal system I-6

160 EASIVENT HOLDING CHAMBER easy fiber (wheat dextrin) econazole ECOTRIN LOW STRENGTH... 6 EDARBI EDARBYCLOR EDECRIN edrophonium chloride-atropine EDURANT ELAPRASE electrolyte-48 in d5w ELELYSO ELIDEL ELIGARD ELITEK ELLA ELMIRON ELOXATIN ELSR EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide.. 67 ENDOMETRIN ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin entacapone entecavir ENTRESTO ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-K EPIPEN JR 2-K epirubicin EPIVIR EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) eprosartan EPZICOM equalactin EQUETRO ERAXIS(WATER DILUENT) ERBITUX ERGOMAR ergotamine-caffeine ERIVEDGE ERWINAZE ERYPED ERYPED ERYTHROCIN erythromycin... 16, 97 erythromycin base ERYTHROMYCIN BASE erythromycin ethylsuccinate erythromycin stearate erythromycin with ethanol erythromycin-sulfisoxazole escitalopram oxalate esmolol esomeprazole sodium estazolam... 9 ESTRACE estradiol estradiol valerate ESTRASORB ESTRING ESTROGEL ethacrynate sodium ethambutol ethamolin ethinyl estradiol/drospirenone ethosuximide ethynodiol d-ethinyl estradiol etidronate disodium etodolac... 6 ETOPOPHOS etoposide EURAX EVOTAZ exemestane EXJADE ex-lax (sennosides) expectorant E-Z SCER E-Z SCER PEDSK FABRAZYME FACTIVE famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON FARYDAK FASLODEX fast clearing spot FAZACLO felbamate FEMHRT LOW DOSE FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenoprofen... 6 fentanyl... 1, 2 fentanyl citrate... 1 feosol ferrimin FERRIPROX ferrous fumarate FERROUS FUMARATE ferrous gluconate ferrous sulfate FETZIMA fexofenadine fiber (calcium polycarbophil) fiber gummies fiber gummies (with chromium) I-7

161 fiber laxative (methylcellulo) fiber therapy fiber therapy sugar free FIBERCON fiber-lax FINACEA FINACEA PLUS finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE first aid antibiotic FLAGYL ER flavoxate FLEBOGAMMA DIF flecainide fleet glycerin (adult) fleet glycerin (child) FLEET MINERAL OIL FLEXBUMIN 25 % FLEXBUMIN 5 % FLO-PRED floxuridine fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) flucytosine fludarabine fludrocortisone flumazenil flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-emollient base fluorometholone fluorouracil... 23, 84 fluoxetine FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam... 9 flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone... 89, 90, 98 fluvastatin fluvoxamine foaming antacid FOCALIN XR folic acid FOLIC ACID folic acid-vitamin b comp w-c , 141 FOLOTYN fomepizole fondaparinux FORFIVO XL FORTAZ FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FRAGMIN FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure FUNGOID TINCTURE furosemide FUSILEV FUZEON FYCOM gabapentin GABITRIL GABLOFEN galantamine... 33, 34 GALZIN GAMASTAN S/D GAMMAGARD LIQUID GAMMAKED GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) GAS-X GAS-X EXTRA STRENGTH GAVISCON GAZYVA gel-kam GELNIQUE gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentamicin... 10, 87, 97 gentamicin in nacl (iso-osm) gentamicin sulfate gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) GENTEAL MILD TO MODERATE GENTEAL SEVERE gentian viol-brlnt grn-proflav.. 41 GEODON gildess 24 fe GILOTRIF GLASSIA glatopa GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glucose glucose gel GLUMETZA glutose glycerin glycerin (adult) , 105 glycopyrrolate glydo... 7 GLYSET GOLYTELY I-8

162 GRALISE GRALISE 30-DAY STARTER CK granisetron (pf) granisetron hcl GRANIX GRASTEK griseofulvin microsize... 41, 42 griseofulvin ultramicrosize grx dyne guaiatussin ac guanidine GYNE-LOTRIMIN GYNE-LOTRIMIN HALAVEN halobetasol propionate haloperidol haloperidol decanoate... 50, 51 haloperidol lactate HARVONI HAVRIX (PF) hc-1% hemorrhoid HECTOROL HEMANGEOL HEGAM B heparin (porcine) heparin (porcine) in 5 % dex HERIN (PORCINE) IN 5 % DEX heparin (porcine) in nacl (pf) HERIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HETAMINE 8% HETASOL 8 % HEPSERA HERCEPTIN HEXALEN HIZENTRA homatropine hbr HORIZANT HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 2 hydrocodone-ibuprofen... 2 hydrocortisone... 90, 109 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone acetate-aloe hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone... 2 hydromorphone (pf)... 2 hydroskin hydroxocobalamin hydroxychloroquine hydroxyurea HYPERHEP B S/D HYPERHEP B S-D NEONATAL HYPERLYTE CR HYPERRAB S/D (PF) HYPERRHO S/D HYPERTET S/D (PF) HYQVIA ibandronate IBRANCE ibuprofen... 6 ibuprofen-oxycodone... 2 ICLUSIG idarubicin ifosfamide ifosfamide-mesna ILARIS (PF) IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) INFASURF INFERGEN INFUMORPH P/F... 2 INFUVITE PEDIATRIC INLYTA INNOPRAN XL insta-glucose INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET I-9

163 INVOKANA IODEX IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 95, 135 ipratropium-albuterol IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRENKA IRESSA irinotecan iron dextran complex iron ps cmplx-vit b12-fa ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears ISORDIL isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX ISUPREL itraconazole ivermectin i-vite IXEMPRA IXIARO (PF) JAKAFI jantoven JENTADUETO JEVTANA junel fe KADCYLA KALBITOR KALETRA KALYDECO KAOCHLOR EFFERVESCENT KAZANO KEDBUMIN KEFLEX KEPIVANCE KERALYT KETEK ketoconazole ketoprofen... 6 ketorolac... 6, 98 KEYTRUDA kimidess (28) KINRIX (PF) KLOR-CON klor-con KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KLOR-CON/EF konsyl (sugar) konsyl sugar-free KORLYM K-PHOS NO K-PHOS ORIGINAL KRISTALOSE KRYSTEXXA KUVAN KYPROLIS l norgest/e.estradiol-e.estrad labetalol LACTATED RINGERS lactulose LAMICTAL LAMISIL LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN LANOXIN PEDIATRIC lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost LATUDA LAZANDA... 2 leflunomide LENVIMA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVATOL LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in nacl (iso-os).. 32 levobunolol levocarnitine levocarnitine (with sugar) levofloxacin... 19, 97 levofloxacin in d5w levoleucovorin calcium levonorgestrel... 79, 80 levonorgestrel-ethin estradiol.. 80 levonorgestrel-ethinyl estrad levorphanol tartrate... 2 levothyroxine LEVOXYL LEXIVA lice bedding spray lice treatment... 91, 92 lice treatment (permethrin) lice treatment (resmethrin) licide spray lidocaine... 7 lidocaine (pf) in d7.5w lidocaine (pf)... 7, 68 lidocaine hcl... 7 LIDOCAINE HCL-PF... 7 lidocaine in 5 % dextrose (pf) I-10

164 lidocaine-prilocaine... 7 lidocaine-tetracaine... 7 lidocream LINCOCIN lindane linezolid LINZESS LIORESAL liothyronine lipase-protease-amylase...94 LIPOFEN LIPOSYN II LIPOSYN III liquitears lisinopril lisinopril-hydrochlorothiazide.. 67 lithium carbonate... 77, 78 lithium citrate LITHOBID LITHOSTAT little noses l-norgest-eth estr/ethin estra lomustine loperamide loratadine-d lorazepam oral solution... 9 losartan losartan-hydrochlorothiazide LOTRIMIN AF LOTRONEX lovastatin LOVAZA loxapine succinate lubrifresh pm LUFYLLIN LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNRZA LYRICA LYSODREN MAALOX MAXIMUM STRENGTH mafenide acetate mag-delay magnesium chloride magnesium citrate , 104 magnesium oxide magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline MARPLAN MARQIBO MATULANE matzim la MAXIPIME meclizine meclofenamate... 6 medicated cleansing pads MEDROL medroxyprogesterone mefenamic acid... 6 mefloquine MEGACE ES megestrol MEKINIST meloxicam... 6 melphalan hcl intravenous memantine MENACTRA (PF) MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENTAX MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) mercaptopurine meropenem mesalamine mesalamine with cleansing wipe mesna MESNEX MESTINON MESTINON TIMESN METAMUCIL METAMUCIL SMOOTH (WITH SUGAR) metaproterenol metformin methadone... 2 methadone hcl... 2 methamphetamine methazolamide methenamine hippurate methenamine mandelate methimazole methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylene blue (antidote) methylergonovine methylphenidate METHYLPHENIDATE HCL methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl , 102 metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz I-11

165 metoprolol tartrate METOZOLV ODT metronidazole... 44, 48, 87 metronidazole in nacl (iso-os) mexiletine mexsana MIACALCIN mi-acid miconazole miconazole nitrate MICRHOGAM ULTRA-FILTERED PLUS MICROCHAMBER micro-guard midazolam midazolam (pf) midodrine MIFEPREX MIGERGOT milk of magnesia MILLIPRED MILLIPRED DP milrinone milrinone in 5 % dextrose MINIPRESS minitran MINOCIN minocycline minoxidil mintox mintox maximum strength mintox plus MIRAPEX ER MIRCERA mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone MONAGHAN Z STAT CHAMBER-MD MSK montelukast MONUROL morphine... 3 MORPHINE... 3 morphine (pf)... 3 morphine concentrate... 3 morphine sulfate-pf... 3 morrhuate sodium motion sickness MOTOFEN MOVIPREP MOXATAG moxifloxacin-sod.ace,sul-water MOZOBIL MULTAQ multi-delyn with iron mupirocin mupirocin calcium muro MUSTARGEN MVI, ADULT NO.4 WITH VIT K MYALEPT MYCAMINE mycophenolate mofetil mycophenolate sodium MYOBLOC MYOZYME NABI-HB nabumetone... 6 nadolol nadolol-bendroflumethiazide nafcillin nafcillin in dextrose iso-osm naftifine NAFTIN NAGLAZYME nalbuphine... 4 naloxone... 8 naltrexone... 8 naltrexone hcl... 8 NAMENDA NAMENDA TITRATION K NAMENDA XR naphazoline naproxen... 6 naproxen sodium... 6 naratriptan nasal decongestant (pe) nateglinide NATRA natural balance natural cold sore natural fiber laxative therapy natural tears (pf) nature's tears NEBUPENT nefazodone NEMBUTAL SODIUM neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc NEOPROFEN (IBUPROFEN LYSN)(PF)... 6 neostigmine methylsulfate NEO-SYNEPHRINE (PHENYLEPHRINE) NEPHRAMINE 5.4 % NESINA NESSI SCER NEULASTA NEUMEGA NEUPOGEN NEUPRO NEUT I-12

166 NEUTROGENA OIL-FREE ACNE WASH neutrogena t-gel conditner(sa) nevirapine NEXAVAR NEXIUM IV NEXTERONE niacin nicardipine NICODERM CQ... 8 nicorelief... 8 nicorette... 8 NICORETTE... 8 nicotine... 8 nicotine (polacrilex)... 8 NICOTROL... 8 NICOTROL NS... 8 nifedipine NILANDRON nimodipine NITHIODOTE NITRO-BID NITRO-DUR nitrofurantoin macrocrystal nitroglycerin... 76, 77 nitroglycerin in 5 % dextrose NITROSTAT nizatidine noble formula hc NORDITROPIN FLEXPRO norelgestromin/ethin.estradiol norepinephrine bitartrate noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 80, 108 norethindrone-e.estradiol-iron norethindrone-ethinyl estrad norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol NORMLSHIELD NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH NOROXIN nortemp... 4 nortriptyline NORVIR NOVAREL NOXAFIL NPLATE NUEDEXTA nu-iron NULOJIX NUPERCAINAL NUTRESTORE NUTRILYTE NUTRILYTE II NUTRISOURCE FIBER NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVESSA NUVIGIL NYMALIZE nystatin NYSTATIN (BULK) nystatin-triamcinolone ocean nasal OCTAGAM octreotide acetate OFEV OFIRMEV... 4 ofloxacin... 19, 97, 98 olanzapine olanzapine-fluoxetine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate OMNITROPE ONCASR ondansetron ondansetron hcl ondansetron hcl (pf) one-a-day womens formula ONFI ONMEL OPDIVO OPSUMIT ORACIT oral saline laxative ORALAIR oralyte ORAP ORAPRED ODT ORAVIG ORBACTIV ORENITRAM ORFADIN ORKAMBI OS-CAL D OSENI OSMOPREP OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxaprozin... 6 oxazepam oxcarbazepine OXISTAT OXSORALEN OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxycodone... 4 oxycodone hcl-acetaminophen... 4 oxycodone hcl-aspirin... 4 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 oxymorphone... 4 oysco d I-13

167 oyster shell calcium paclitaxel paliperidone pamidronate NHEMATIN NRETIN pantoprazole papaverine RICALCITOL paricalcitol paromomycin paroxetine hcl SER XIL PCE pedi m.vit no.17 with fluoride PEDIA-LAX PEDIALYTE PEDIALYTE FREEZER POPS PEDIARIX (PF) pediatric electrolyte pedi-boro soak PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentostatin pentoxifylline PEPTO-BISMOL PEPTO-BISMOL MAX ST peri-colace periguard perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline PEXEVA pharmabase barrier phenelzine phenobarbital phenobarbital sodium phenoxybenzamine phentolamine phenylephrine hcl... 66, 96 phenylhistine dh PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended PHOS-FLUR PHOSLYRA PHOSPHOLINE IODIDE phosphorus # PHOTOFRIN physostigmine salicylate phytonadione pilocarpine hcl... 81, 128 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam... 6 plantar wart remover PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLASMANATE PLIAGLIS... 7 podofilox podophyllum resin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid POTASSIUM BICARBONATE-CIT AC potassium bicarbonate-cit ac potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid potassium hydroxide potassium phosphate m-/d-basic POTIGA povidone-iodine POVIDONE-IODINE PRADAXA PRALIDOXIME PRALUENT PEN PRALUENT SYRINGE pramipexole I-14

168 PRANDIMET PRANDIN pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 98, 110 prednisone PREDNISONE INTENSOL PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % prenatal vitamins preparation h hydrocortisone PREPOPIK PREZCOBIX PREZISTA PRIALT... 4 PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRIMSOL PRISTIQ PRIVIGEN probenecid procainamide PROCALAMINE 3% PROCENTRA prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized capsules PROGLYCEM PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine-codeine promethazine-dm propafenone propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) proshield plus PROSOL 20 % PROSTIN E protamine PROTOM CHLORIDE protriptyline PRUDOXIN PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN PYLERA pyrazinamide pyridostigmine bromide PYROGALLIC ACID q-pap... 4 QUADRACEL (PF) QUARTETTE quazepam quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR RABAVERT (PF) rabeprazole RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAMUNE , 117 RAPIVAB RASH RELIEF-ZINC OXIDE RAYOS REBETOL REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION CK RECOMBIVAX HB (PF) RECTACORT-HC RECTIV REFLUDAN REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH LIQUIGEL REFRESH TEARS REGONOL REGRANEX reguloid RELADOR K... 7 RELENZA DISKHALER RELISTOR REMEDY 4-IN-1 (DIMETHICONE) REMEDY CLEANSING BODY REMEDY NUTRASHIELD SKIN PROTEC REMEDY SKIN REIR REMICADE REMODULIN RENACIDIN RENAGEL RENVELA repaglinide RETHA SURECLICK RETHA SYRINGE RESCRIPTOR RESECTISOL RESTASIS I-15

169 RESTORE DIMETHICREME RETROVIR REVATIO REVLIMID REXULTI REYATAZ RHINARIS RHOGAM ULTRA-FILTERED PLUS RHOPHYLAC ribavirin... 56, 57 RIDAURA rifabutin rifampin RIFATER RILUTEK riluzole rimantadine RIMSO ringers , 133 RIOMET RISPERDAL CONSTA risperidone RITALIN LA RITUXAN rivastigmine tartrate...34 rizatriptan ropinirole ROTARIX ROTATEQ VACCINE ROZEREM RUCONEST SABRIL SAIZEN SAIZEN CLICK.EASY saline mist SALJET SALINE RINSE salsalate... 6 SAMSCA SANCUSO SANDOSTATIN LAR DEPOT sani-supp (adult) SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scalp relief... 85, 91 SCLEROSOL INTRAPLEURAL scopolamine hbr sea soft nasal mist sea-clens wound cleanser sebex SECURA EXTRA PROTECTIVE selegiline hcl selenium sulfide SELZENTRY senexon senna senna lax senna laxative senna with docusate sodium SENSIR SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin sevelamer carbonate SHOHL'S MODIFIED silace sildenafil oral tablet 20 mg SILENOR silver nitrate silver nitrate applicators silver sulfadiazine SILVERMED SIMULECT simvastatin sirolimus SIVEXTRO SKLICE SLOW-MAG sodium acetate sodium bicarbonate , 133 sodium chloride... 96, 121, 133, 137 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid SODIUM EDECRIN sodium fluoride... 81, 141 sodium lactate sodium phosphate sodium polystyrene sulfonate SODIUM TETRADECYL SULFATE sodium tetradecyl sulfate sodium thiosulfate sod-pot-k cit-sod cit-cit acid SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT SOOLANTRA sorbitol sorbitol-mannitol SORIATANE SOTALOL sotalol sotalol hcl SOTYLIZE SOVALDI spinosad spironolactone spironolacton-hydrochlorothiaz SPORANOX SPRYCEL stannous fluoride stavudine STAVZOR I-16

170 STERILE DS sterile saline sterile talc STIMATE STIVARGA stool softener STRATTERA streptomycin STRIBILD STRIVERDI RESPIMAT STROMECTOL SUCLEAR SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 88 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulfatrim sulfazine sulfazine ec sulindac... 6 sumatriptan nasal spray sumatriptan succinate SUPPRELIN LA SUPRAX SUPREP BOWEL PREP KIT SURE COMFORT INS. SYR. U SURFAXIN surgilube SURMONTIL SURVANTA SUSTIVA SUTENT SWEEN SYLATRON SYLVANT SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNALGOS-DC... 4 SYNAREL SYNERA... 7 SYNERCID SYNRIBO SYNTHROID SYPRINE SYSTANE TABLOID tacrolimus... 91, 117 TAFINLAR TAMIFLU tamoxifen tamsulosin TANZEUM TARCEVA TARGRETIN tarina fe TARKA TASIGNA TASMAR TAZORAC taztia xt TEARS NATURALE II TECFIDERA TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam TEMODAR teniposide TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole TERSI FOAM testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracaine hcl tetracycline TETRAVISC FORTE TEVETEN HCT TEV-TROPIN TEXACORT THALOMID THAM THEO theophylline theophylline anhydrous theophylline in dextrose 5 % THERACYS thera-m THERMAZENE THIOLA thioridazine thiotepa thiothixene THROMBATE III THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine TICE BCG TIKOSYN TIMENTIN timolol maleate... 70, 128 tinidazole tioconazole TIROSINT TIVICAY tizanidine TOBI PODHALER tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl I-17

171 tobramycin sulfate tobramycin-dexamethasone tolazamide tolbutamide tolcapone tolmetin... 6 tolterodine topiramate toposar intravenous topotecan TORISEL torsemide TOUJEO SOLOSTAR TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 4, 5 tramadol-acetaminophen... 5 trandolapril trandolapril-verapamil tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin (emollient) tretinoin microspheres TREXALL triamcinolone acetonide... 81, 91, 98, 110 triamterene-hydrochlorothiazid triazolam trifluoperazine trifluridine TRILEPTAL trimethoprim TRIOSTAT triple antibiotic triple antibiotic plus TRIPLE STE triple paste af TRISENOX TRIUMEQ tri-vi-sol TRI-VI-SOL WITH IRON trixaicin hp TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% tropicamide trospium TRUMENBA TRUVADA TUDORZA PRESSAIR TUMS ULTRA TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA TYZINE UCERIS ULESFIA ULORIC UNITHROID UNITUXIN UROCIT-K ursodiol UVADEX VAGIFEM vagistat valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALSTAR vancomycin vancomycin in d5w VANTAS VAPRISOL VAQTA (PF) VARIVAX (PF) vasopressin VASOSTRICT VECTIBIX VELCADE VELETRI venlafaxine VENTAVIS VENTOLIN HFA verapamil VEREGEN VERIPRED VERSACLOZ VIBATIV VIBRAMYCIN VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA K VIIBRYD VIMIZIM VIMT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE VIRAMUNE XR VIRAZOLE virdec VIREAD I-18

172 visine-lr VISUDYNE vit b cmplx 3-fa-vit c-biotin vitamin d VITAMIN D vitamins & minerals VITEKTA vits a and d-white pet-lanolin VIVITROL... 9 VIVOTIF BERNA VACCINE VOLTAREN... 6 VORAXAZE voriconazole VORTEX HOLDING CHAMBER VOTRIENT VPRIV VUSION wal-itin wal-itin d wal-zyr (cetirizine) warfarin wart remover wart stick WATCHHALER water for irrigation, sterile WELCHOL WINRHO SDF XALKORI XARELTO XENAZINE XEOMIN XERAC AC XGEVA XIAFLEX XIFAXAN XOLAIR XOLEGEL XTANDI xylon XYREM YERVOY YF-VAX (PF) YODOXIN zafirlukast ZALTRAP ZANOSAR ZANTAC IN 0.45 % SOD. CHLORIDE ZAVESCA ZELAR ZELBORAF ZEMAIRA ZEMPLAR ZERBAXA ZETIA ZIAGEN zidovudine ZINACEF ZINACEF IN STERILE WATER zinc chloride zinc oxide zinc sulfate ziprasidone hcl ZMAX ZN-DT ZOLADEX zoledronic acid zoledronic acid-mannitol-water , 123 ZOLINZA zolmitriptan zolpidem ZOMETA ZONALON zonisamide ZORBTIVE ZORTRESS ZOSTAVAX (PF) zostrix-hp ZOVIRAX ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYPREXA RELPREVV ZYTIGA ZYVOX I-19