2016 LIST OF COVERED DRUGS (FORMULARY)

Transcription

1 2016 LIST OF COVERED DRUGS (FORMULARY) WELLCARE ADVOCATE COMPLETE FIDA (MEDICARE-MEDICAID PLAN) This formulary was updated on 9/01/2015. If you have any questions, please contact WellCare Advocate Complete FIDA at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday or visit H2751_NY030536_MMP_FOR_ENG CMS Approved WellCare 2015 NY_06_15 NY6MMPFOR67979E_0615

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3 v v v v v v v v v This is a list of drugs that Participants can get in WellCare Advocate Complete FIDA. WellCare is a managed care plan that contracts with both the Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check WellCare Advocate Complete FIDA s up-to-date List of Covered Drugs online at or by calling WellCare Advocate Complete FIDA Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. Limitations and restrictions may apply. For more information, call WellCare Participant Services or read the WellCare Advocate Complete FIDA Participant Handbook. There are no co-pays for any covered drugs. You can get this information for free in other formats, such as large print, Braille or audio. Call or TTY Our hours of operation are 8 a.m. to 8 p.m. Eastern, Monday Sunday. The call is free. You can get this information for free in other languages. Call and TTY/TDD 711 during 8 a.m. to 8 p.m. Eastern, Monday Sunday. The call is free. Puede obtener esta información gratis en otros idiomas. Llame al y TTY/TDD al 711 de 8 a.m. a 8 p.m., hora del este, de lunes a domingo. La llamada es gratis. v v v Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele nimewo ak TTY/TDD 711 depi 8 a.m. jiska 8 p.m. Lè Zòn Lès, Lendi Dimanch. Koutfil la gratis. Queste informazioni possono essere ottenute gratuitamente in altre lingue. Chiamare e TTY/TDD 711 dalle ore 8 alle 20, ora della costa orientale degli USA, dal lunedì alla domenica. La chiamata è gratuita. v v v The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by WellCare Advocate Complete FIDA. ICAN may be reached toll-free at or online at icannys.org.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 1

4 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 9 are the drugs covered by WellCare Advocate Complete FIDA. 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. u WellCare Advocate Complete FIDA will cover all drugs on the Drug List if: your doctor or other network prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a WellCare Advocate Complete FIDA network pharmacy. u WellCare Advocate Complete FIDA may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at wellcareny.com/ or call Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. 2. Does the Drug List ever change? Yes. WellCare Advocate Complete FIDA may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new 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 WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) 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.) (For more information on these drug rules, see page 3.)? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 2

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. u You can always check WellCare Advocate Complete FIDA s up-to-date Drug List online at You can also call Participant Services to check the current Drug List at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. WellCare Advocate Complete FIDA may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, 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. If there is a change to coverage for a drug you are taking, WellCare Advocate Complete FIDA will mail you a letter to tell you. 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 and call you to tell you that the unsafe drug was taken off the Drug List. Your provider will also know about this change. After you receive this notice in the mail, you can work with your provider to find another drug for your condition. 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 or other prescriber must get approval from WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, WellCare Advocate Complete FIDA may not cover the drug. Quantity limits: Sometimes WellCare Advocate Complete FIDA limits the amount of a drug you can get. Step therapy: Sometimes WellCare Advocate Complete FIDA 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.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 3

6 You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 9. You can also get more information by visiting our Web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can also ask for an exception from these limits. Please see question 11 for more information on exceptions. u If you are in a nursing facility 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 WellCare Advocate Complete FIDA Participant. 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 11 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 9 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 or other prescriber about what to do next. 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 on page 177. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 9. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 4

7 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 Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday and ask about it. If you learn that WellCare Advocate Complete FIDA will not cover the drug, you can do one of these things: Ask Participant 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 plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new WellCare Advocate Complete FIDA Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of WellCare Advocate Complete FIDA. 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 up to 90 days of temporary supplies 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 the drug requires prior approval by WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 93 days. You may refill the drug multiple times during your first 93 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days). 11. Can you ask for an exception to cover your drug? Yes. You can ask WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask WellCare Advocate Complete FIDA or your IDT to change the rules on your drug.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 5

8 For example, WellCare Advocate Complete FIDA may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get 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, you will get 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 your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 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). WellCare Advocate Complete FIDA covers both brand-name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. WellCare Advocate Complete FIDA covers some OTC drugs when they are written as prescriptions by your provider. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC drugs are covered. 16. Does WellCare Advocate Complete FIDA cover OTC non-drug products? WellCare Advocate Complete FIDA covers some OTC non-drug products when they are written as prescriptions by your provider, e.g., alcohol prep pads, gauze pads, and insulin syringes. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC non-drug products are covered. 17. What is your co-pay? You will not be charged a co-pay for drugs on the Drug List.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 6

9 18. What are drug tiers? Tier 1 (Generic) includes generic drugs covered under Medicare Part D. Tier 2 (Brand) includes brand drugs and generic drugs covered under Medicare Part D. Tier 3 (Non-Medicare Rx/OTC Drugs) includes generic & brand drugs covered under the Medicaid benefit. All tiers have no co-pay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by WellCare Advocate Complete FIDA. If you have trouble finding your drug in the list, turn to the Index that begins on page 177. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the necessary actions, restrictions, or limits on use column tells you if WellCare Advocate Complete FIDA has any rules for covering your drug. NM means the drug is not available by mail-order. Other pharmacies are available in our network. PA stands for Prior Authorization: Please see page 3 for details. B/D stands for Prior Authorization Restriction for Part B vs. Part D Determination: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellCare Advocate Complete FIDA to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, WellCare Advocate Complete FIDA may not cover this drug. QL stands for Quantity Limits: Please see page 3 for details. LA stands for Limited Access medication. This medication is available from the Specialty Pharmacy, and may be available from certain other pharmacies. For more information, please refer to the Pharmacy section of your Provider and Pharmacy Directory or contact Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. ST stands for Step Therapy: Please see page 3 for details.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 7

10 Note: The ^ symbol next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) 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 or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday or the Independent Consumer Advocacy Network (ICAN) at You can also read the Participant Handbook to learn how to appeal a decision. You can also read the Participant Handbook to learn how to appeal a decision.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 8

11 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. NAME OF DRUG ANALGESICS GOUT allopurinol oral tablet 100, 300 colchicine-probenecid oral tablet COLCRYS ORAL TABLET 0.6 MG QL (120 EA per 30 days) probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST NSAIDS celecoxib oral capsule 100, 200, 400, 50 QL (60 EA per 30 days) diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 100 diclofenac sodium oral tablet delayed release 25, 50, 75 diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hr* 400, 500, 600 9

12 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 ketoprofen oral capsule 50, 75 meloxicam oral suspension 7.5 /5ml meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 OPIOID ANALGESICS, CII duramorph injection solution 0.5 /ml, 1 /ml B/D 10

13 endocet oral tablet , 5-325, QL (360 EA per 30 days) fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 PA; QL (120 EA per 30 days) mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hr 100 mcg/hr, 50 mcg/hr, 75 mcg/hr PA; QL (10 EA per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr, 25 mcg/hr QL (10 EA per 30 days) FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 PA; QL (120 EA per 30 days) MCG, 800 MCG hydrocodone-acetaminophen oral solution /15ml QL (5400 ML per 30 days) hydrocodone-acetaminophen oral tablet , 5-325, QL (360 EA per 30 days) hydrocodone-ibuprofen oral tablet QL (150 EA per 30 days) hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 QL (270 EA per 30 days) hydromorphone hcl pf injection solution 500 /50ml B/D lorcet hd oral tablet QL (360 EA per 30 days) lorcet oral tablet QL (360 EA per 30 days) lorcet plus oral tablet QL (360 EA per 30 days) lortab oral tablet , 5-325, QL (360 EA per 30 days) methadone hcl intensol oral concentrate 10 /ml QL (120 ML per 30 days) 11

14 methadone hcl oral solution 10 /5ml, 5 /5ml QL (600 ML per 30 days) methadone hcl oral tablet 10, 5 QL (240 EA per 30 days) morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate (pf) injection solution 0.5 /ml, 1 /ml B/D morphine sulfate (pf) intravenous* solution 10 /ml, 15 /ml, 2 B/D /ml, 4 /ml, 8 /ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75 QL (60 EA per 30 days), 90 morphine sulfate er oral capsule extended release 24 hour 10, 20 QL (60 EA per 30 days), 30, 50, 60 morphine sulfate er oral capsule extended release 24 hour 100, QL (60 EA per 30 days) 80 morphine sulfate er oral tablet extendedrelease* 100, 15, QL (90 EA per 30 days) 30, 60 morphine sulfate er oral tablet extendedrelease* 200 QL (60 EA per 30 days) morphine sulfate intravenous* solution 1 /ml B/D morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 QL (180 EA per 30 days) oxycodone hcl oral capsule 5 QL (180 EA per 30 days) 12

15 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet , , QL (360 EA per 30 days) 5-325, roxicet oral solution /5ml QL (1800 ML per 30 days) OPIOID ANALGESICS acetaminophen-codeine #2 oral tablet QL (400 EA per 30 days) acetaminophen-codeine #3 oral tablet QL (400 EA per 30 days) acetaminophen-codeine #4 oral tablet QL (400 EA per 30 days) acetaminophen-codeine oral solution /5ml QL (5000 ML per 30 days) butorphanol tartrate injection solution 1 /ml, 2 /ml nalbuphine hcl injection solution 10 /ml, 20 /ml tramadol hcl oral tablet 50 QL (240 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 % B/D lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 % B/D 13

16 ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate injection solution 1 gm/4ml, 500 /2ml gentamicin in saline intravenous* solution /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-% gentamicin sulfate injection solution 10 /ml, 40 /ml gentamicin sulfate intravenous* solution 10 /ml neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 streptomycin sulfate intramuscular* solution reconstituted 1 gm sulfadiazine oral tablet 500 tobramycin inhalation nebulization solution 300 /5ml B/D tobramycin sulfate in saline intravenous* solution /ml-% tobramycin sulfate injection solution 1.2 gm/30ml, 10 /ml, 2 gm/50ml, 80 /2ml tobramycin sulfate injection solution reconstituted 1.2 gm 14

17 ANTIFUNGALS ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML B/D AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 B/D MG amphotericin b injection solution reconstituted 50 B/D CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG fluconazole in dextrose intravenous* solution 200 /100ml, 400 /200ml fluconazole in sodium chloride intravenous* solution /100ml-%, /200ml-% fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA ketoconazole oral tablet 200 PA 15

18 MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit terbinafine hcl oral tablet 250 QL (90 EA per 365 days) voriconazole intravenous* solution reconstituted 200 voriconazole oral suspension reconstituted 40 /ml voriconazole oral tablet 200, 50 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5ml AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM, 2 GM aztreonam injection solution reconstituted 1 gm, 2 gm BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG PA; LA 16

19 clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous* solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml, 9000 /60ml clindamycin phosphate intravenous* solution 300 /2ml, 600 /4ml, 900 /6ml colistimethate sodium injection solution reconstituted 150 CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100, 25 DARAPRIM ORAL TABLET 25 MG imipenem-cilastatin intravenous* solution reconstituted 250, 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet 3 linezolid intravenous* solution 2 /ml LINEZOLID ORAL TABLET 600 MG 17

20 meropenem intravenous* solution reconstituted 1 gm, 500 methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous* solution /100ml-% metronidazole oral tablet 250, 500 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG B/D nitrofurantoin macrocrystal oral capsule 100, 50 PA nitrofurantoin monohyd macro oral capsule 100 PA PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 200 MG SIVEXTRO ORAL TABLET 200 MG sulfamethoxazole-tmp ds oral tablet sulfamethoxazole-trimethoprim intravenous* solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED MG trimethoprim oral tablet

21 TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous* solution reconstituted 10 gm, 1000, 500, 5000, 750 vancomycin hcl oral capsule 125, 250 ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ZYVOX ORAL TABLET 600 MG ANTIMALARIALS atovaquone-proguanil hcl oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG mefloquine hcl oral tablet 250 PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 PA ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 300 APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine oral capsule delayed release 125, 200, 250, 400 EDURANT ORAL TABLET 25 MG 19

22 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release 24 hr* 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 20

23 RESCRIPTOR ORAL TABLET 100 MG, 200 MG RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15, 20, 30, 40 stavudine oral solution reconstituted 1 /ml SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 50 MG TYBOST ORAL TABLET 150 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule

24 zidovudine oral syrup 50 /5ml zidovudine oral tablet 300 ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine-zidovudine oral tablet ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG, MG lamivudine-zidovudine oral tablet PREZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG QL (30 EA per 30 days) ANTITUBERCULAR AGENTS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule

25 ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 paser oral packet 4 gm PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG PA; LA TRECATOR ORAL TABLET 250 MG ANTIVIRALS acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous* solution 50 /ml B/D acyclovir sodium intravenous* solution reconstituted 500 B/D adefovir dipivoxil oral tablet 10 23

26 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 125, 250, 500 foscarnet sodium intravenous* solution 24 /ml ganciclovir sodium intravenous* solution reconstituted 500 B/D HARVONI ORAL TABLET MG PA lamivudine oral tablet 100 MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG moderiba 800 dose pack oral tablet 400 moderiba oral 200 & 400, 400 & 600 moderiba oral tablet 200 PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 PA MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, PA 80 MCG/0.5ML PEG-INTRON SUBCUTANEOUS* KIT 50 MCG/0.5ML PA REBETOL ORAL SOLUTION 40 MG/ML 24

27 RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER ribasphere oral capsule 200 ribasphere oral tablet 200, 400 ribasphere oral tablet 600 ribasphere ribapak oral tablet 200 & 400, 400 & 600, 400, 600 ribavirin oral capsule 200 ribavirin oral tablet 200 rimantadine hcl oral tablet 100 SOVALDI ORAL TABLET 400 MG PA TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral tablet 450 CEPHALOSPORINS cefaclor er oral tablet extended release 12 hr* 500 cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml 25

28 cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 20 gm, 500 cefazolin sodium intravenous* solution 1-5 gm-% cefazolin sodium intravenous* solution reconstituted 1 gm cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 100 /5ml, 200 /5ml cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100,

29 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 CEFTAZIDIME AND DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM/50ML, 2 GM/50ML ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 cefuroxime sodium intravenous* solution reconstituted 1.5 gm, 7.5 gm cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML 27

30 suprax oral tablet chewable 100, 200 tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm tazicef intravenous* solution reconstituted 1 gm, 2 gm TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG ERYTHROMYCINS/MACROLIDES azithromycin intravenous* solution reconstituted 500 azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 500, 600 clarithromycin er oral tablet extended release 24 hr* 500 clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG e.e.s. 400 oral tablet 400 ery-tab oral tablet delayed release 250, 333, 500 erythrocin lactobionate intravenous* solution reconstituted 500 erythrocin stearate oral tablet

31 erythromycin base oral capsule delayed release particles 250 erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral tablet 400 FLUOROQUINOLONES ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin in d5w intravenous* solution 200 /100ml, 400 /200ml ciprofloxacin intravenous* solution 200 /20ml, 400 /40ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000, 500 levofloxacin in d5w intravenous* solution 250 /50ml, 500 /100ml, 750 /150ml levofloxacin intravenous* solution 25 /ml levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 PENICILLINS amoxicillin oral capsule 250,

32 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate er oral tablet extended release 12 hr* amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension reconstituted 125 /5ml, 250 /5ml ampicillin sodium injection solution reconstituted 1 gm, 125, 2 gm, 250, 500 ampicillin sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm 30

33 ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250, 500 nafcillin sodium injection solution reconstituted 1 gm nafcillin sodium injection solution reconstituted 10 gm, 2 gm nafcillin sodium intravenous* solution reconstituted 1 gm nafcillin sodium intravenous* solution reconstituted 2 gm oxacillin sodium injection solution reconstituted 1 gm, 2 gm oxacillin sodium injection solution reconstituted 10 gm PENICILLIN G POT IN DEXTROSE INTRAVENOUS* SOLUTION UNIT/ML, UNIT/ML penicillin g potassium injection solution reconstituted unit, unit 31

34 penicillin g procaine intramuscular* suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous* solution reconstituted gm, gm, gm, gm TETRACYCLINES doxy 100 intravenous* solution reconstituted 100 doxycycline hyclate intravenous* solution reconstituted 100 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 150, 50, 75 minocycline hcl oral capsule 100, 50, 75 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG B/D 32

35 BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML B/D cyclophosphamide injection solution reconstituted 1 gm, 500 B/D cyclophosphamide injection solution reconstituted 2 gm B/D CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG B/D dacarbazine intravenous* solution reconstituted 200 B/D EMCYT ORAL CAPSULE 140 MG HEXALEN ORAL CAPSULE 50 MG IFEX INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM B/D ifosfamide intravenous* solution 1 gm/20ml, 3 gm/60ml B/D ifosfamide intravenous* solution reconstituted 1 gm B/D IFOSFAMIDE INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM B/D LEUKERAN ORAL TABLET 2 MG lomustine oral capsule 10, 100, 40 melphalan hcl intravenous* solution reconstituted 50 B/D MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG B/D TREANDA INTRAVENOUS* SOLUTION 180 MG/2ML, 45 MG/0.5ML B/D TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 25 MG B/D 33

36 ANTHRACYCLINES adriamycin intravenous* solution reconstituted 50 daunorubicin hcl intravenous* injectable 5 /ml doxorubicin hcl intravenous* solution 2 /ml doxorubicin hcl intravenous* solution reconstituted 50 doxorubicin hcl liposomal intravenous* injectable 2 /ml epirubicin hcl intravenous* solution 200 /100ml, 50 /25ml idarubicin hcl intravenous* solution 10 /10ml, 20 /20ml, 5 /5ml ANTIBIOTICS bleomycin sulfate injection solution reconstituted 15 unit, 30 unit mitomycin intravenous* solution reconstituted 20, 40, 5 ANTIMETABOLITES adrucil intravenous* solution 2.5 gm/50ml, 5 gm/100ml, 500 /10ml ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG azacitidine injection suspension reconstituted 100 cladribine intravenous* solution 1 /ml B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 34

37 cytarabine injection solution 20 /ml B/D fludarabine phosphate intravenous* solution 50 /2ml B/D fludarabine phosphate intravenous* solution reconstituted 50 B/D fluorouracil intravenous* solution 1 gm/20ml, 2.5 gm/50ml, 500 B/D /10ml GEMCITABINE HCL INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 B/D GM/52.6ML, 200 MG/5.26ML gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, B/D 200 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 1 gm/40ml B/D methotrexate sodium injection solution 25 /ml B/D methotrexate sodium injection solution reconstituted 1 gm B/D NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D PURIXAN ORAL SUSPENSION 2000 MG/100ML TABLOID ORAL TABLET 40 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED 100 MG B/D 35

38 docetaxel intravenous* concentrate 140 /7ml DOCETAXEL INTRAVENOUS* CONCENTRATE 20 MG/ML, 80 MG/4ML DOCETAXEL INTRAVENOUS* SOLUTION 200 MG/20ML, 80 MG/8ML paclitaxel intravenous* concentrate 100 /16.7ml, 150 /25ml, 30 /5ml, 300 /50ml ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate intravenous* solution 1 /ml vincasar pfs intravenous* solution 1 /ml vincristine sulfate intravenous* solution 1 /ml vinorelbine tartrate intravenous* solution 10 /ml, 50 /5ml BIOLOGIC RESPONSE MODIFIERS B/D B/D B/D B/D B/D B/D B/D B/D AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML B/D; LA BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG PA ERIVEDGE ORAL CAPSULE 150 MG PA; LA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; LA HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 440 MG B/D IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; LA 36

39 ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 160 MG B/D KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA LYNPARZA ORAL CAPSULE 50 MG PA; LA PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED B/D UNIT RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML PA; LA VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG B/D YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML PA ZOLINZA ORAL CAPSULE 100 MG PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole oral tablet 1 bicalutamide oral tablet 50 DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML B/D exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML B/D flutamide oral capsule 125 letrozole oral tablet 2.5 leuprolide acetate injection kit 1 /0.2ml PA 37

40 LUPRON DEPOT INTRAMUSCULAR* KIT MG, 3.75 MG PA LUPRON DEPOT-PED INTRAMUSCULAR* KIT MG, MG (PED), 15 MG, 30 MG PA (PED), 7.5 MG LYSODREN ORAL TABLET 500 MG MEGACE ES ORAL SUSPENSION 625 MG/5ML PA megestrol acetate oral suspension 40 /ml PA megestrol acetate oral tablet 20, 40 PA NILANDRON ORAL TABLET 150 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10, 20 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED MG, 3.75 PA MG XTANDI ORAL CAPSULE 40 MG PA; LA ZYTIGA ORAL TABLET 250 MG PA; LA KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG BOSULIF ORAL TABLET 100 MG, 500 MG PA PA PA 38

41 CAPRELSA ORAL TABLET 100 MG, 300 MG PA; LA COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG PA; LA COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG PA; LA COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA; LA GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA; LA GLEEVEC ORAL TABLET 100 MG, 400 MG PA ICLUSIG ORAL TABLET 15 MG, 45 MG PA; LA IMBRUVICA ORAL CAPSULE 140 MG PA; LA INLYTA ORAL TABLET 1 MG, 5 MG PA; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; LA LENVIMA 10 MG DAILY DOSE ORAL 10 MG PA; LA LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG PA; LA LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG PA; LA LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG PA; LA MEKINIST ORAL TABLET 0.5 MG, 2 MG PA; LA NEXAVAR ORAL TABLET 200 MG PA; LA SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA 39

42 STIVARGA ORAL TABLET 40 MG PA; LA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; LA TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG PA; LA TASIGNA ORAL CAPSULE 150 MG, 200 MG PA TYKERB ORAL TABLET 250 MG PA; LA VOTRIENT ORAL TABLET 200 MG PA; LA XALKORI ORAL CAPSULE 200 MG, 250 MG PA; LA ZELBORAF ORAL TABLET 240 MG PA; LA ZYDELIG ORAL TABLET 100 MG, 150 MG PA; LA ZYKADIA ORAL CAPSULE 150 MG PA; LA MISCELLANEOUS DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG hydroxyurea oral capsule 500 MATULANE ORAL CAPSULE 50 MG LA mitoxantrone hcl intravenous* concentrate 20 /10ml, 25 B/D /12.5ml, 30 /15ml POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; LA SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 4 X 200 MCG, PA 4 X 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG PA 40

43 TARGRETIN ORAL CAPSULE 75 MG PA tretinoin oral capsule 10 TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML B/D PLATINUM-BASED AGENTS carboplatin intravenous* solution 150 /15ml, 450 /45ml, 50 /5ml, 600 /60ml cisplatin intravenous* solution 100 /100ml, 200 /200ml, 50 /50ml oxaliplatin intravenous* solution 100 /20ml, 50 /10ml oxaliplatin intravenous* solution reconstituted 100, 50 PROTECTIVE AGENTS amifostine intravenous* solution reconstituted 500 dexrazoxane intravenous* solution reconstituted 250 ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG leucovorin calcium injection solution reconstituted 100, 200, 350, 50, 500 leucovorin calcium oral tablet 10, 15, 25, 5 levoleucovorin calcium intravenous* solution 175 /17.5ml B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 41

44 mesna intravenous* solution 100 /ml B/D MESNEX ORAL TABLET 400 MG TOPOISOMERASE INHIBITORS etoposide intravenous* solution 500 /25ml irinotecan hcl intravenous* solution 100 /5ml, 40 /2ml, 500 /25ml toposar intravenous* solution 1 gm/50ml topotecan hcl intravenous* solution reconstituted 4 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besy-benazepril hcl oral capsule 10-20, , 5-10, 5-20, 5-40 amlodipine besy-benazepril hcl oral capsule benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, fosinopril sodium-hctz oral tablet , B/D B/D B/D B/D QL (30 EA per 30 days) 42

45 lisinopril-hydrochlorothiazide oral tablet , , moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , ACE INHIBITORS benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 trandolapril oral tablet 1, 2, 4 43

46 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone oral tablet 25, 50 spironolactone oral tablet 100, 25, 50 ALPHA BLOCKERS doxazosin mesylate oral tablet 1, 2, 4 QL (30 EA per 30 days) doxazosin mesylate oral tablet 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan oral tablet , 5-160, QL (30 EA per 30 days) amlodipine besylate-valsartan oral tablet amlodipine-valsartan-hctz oral tablet , QL (30 EA per 30 days), amlodipine-valsartan-hctz oral tablet amlodipine-valsartan-hctz oral tablet QL (60 EA per 30 days) AZOR ORAL TABLET MG, 5-20 MG, 5-40 MG QL (30 EA per 30 days) AZOR ORAL TABLET MG 44

47 BENICAR HCT ORAL TABLET MG, MG, MG irbesartan-hydrochlorothiazide oral tablet , losartan potassium-hctz oral tablet , , TRIBENZOR ORAL TABLET MG, MG, MG, MG TRIBENZOR ORAL TABLET MG valsartan-hydrochlorothiazide oral tablet , , , , ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 valsartan oral tablet 160, 320, 40, 80 ANTIARRHYTHMICS amiodarone hcl intravenous* solution 150 /3ml, 450 /9ml, 900 /18ml QL (30 EA per 30 days) 45

48 amiodarone hcl oral tablet 100, 200, 400 disopyramide phosphate oral capsule 100, 150 PA flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 MULTAQ ORAL TABLET 400 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 PA MG, 150 MG pacerone oral tablet 100, 200, 400 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extendedrelease* 324 quinidine sulfate oral tablet 200, 300 sorine oral tablet 120, 160, 240, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 46

49 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10, 20, 40, 80 QL (30 EA per 30 days) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG QL (30 EA per 30 days) lovastatin oral tablet 10 QL (30 EA per 30 days) lovastatin oral tablet 20 QL (120 EA per 30 days) lovastatin oral tablet 40 QL (60 EA per 30 days) pravastatin sodium oral tablet 10, 20, 40, 80 QL (30 EA per 30 days) simvastatin oral tablet 10, 20, 40, 5, 80 QL (30 EA per 30 days) ANTILIPEMICS, MISCELLANEOUS cholestyramine light oral packet 4 gm cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 48, 54 fenofibric acid oral capsule delayed release 135, 45 gemfibrozil oral tablet

50 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 PA; LA MG KYNAMRO SUBCUTANEOUS* 200 MG/ML PA niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000, 750 niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 QL (90 EA per 30 days) niacor oral tablet 500 omega-3-acid ethyl esters oral capsule 1 gm prevalite oral powder 4 gm/dose VASCEPA ORAL CAPSULE 1 GM WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG BETA-BLOCKER/DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , metoprolol-hydrochlorothiazide oral tablet , , propranolol-hctz oral tablet 40-25,

51 BETA-BLOCKERS acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hr* 100 QL (45 EA per 30 days) metoprolol succinate er oral tablet extended release 24 hr* 200 metoprolol succinate er oral tablet extended release 24 hr* 25, 50 QL (60 EA per 30 days) metoprolol tartrate intravenous* solution 1 /ml metoprolol tartrate oral tablet 100, 25, 50 nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous* solution 1 /ml 49

52 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 timolol maleate oral tablet 10, 20, 5 CALCIUM CHANNEL BLOCKERS afeditab cr oral tablet extended release 24 hr* 30 afeditab cr oral tablet extended release 24 hr* 60 amlodipine besylate oral tablet 10 amlodipine besylate oral tablet 2.5, 5 cartia xt oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120 QL (60 EA per 30 days) QL (45 EA per 30 days) 50

53 diltiazem hcl intravenous* solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 diltzac oral capsule extended release 24 hour 120, 180, 240, 300 felodipine er oral tablet extended release 24 hr* 10 felodipine er oral tablet extended release 24 hr* 2.5 QL (30 EA per 30 days) felodipine er oral tablet extended release 24 hr* 5 QL (60 EA per 30 days) isradipine oral capsule 2.5, 5 nicardipine hcl oral capsule 20, 30 nifedical xl oral tablet extended release 24 hr* 30 QL (30 EA per 30 days) nifedical xl oral tablet extended release 24 hr* 60 nifedipine er oral tablet extended release 24 hr* 30 QL (60 EA per 30 days) nifedipine er oral tablet extended release 24 hr* 60, 90 nifedipine er osmotic oral tablet extended release 24 hr* 30 QL (30 EA per 30 days) nifedipine er osmotic oral tablet extended release 24 hr* 60, 90 51

54 nimodipine oral capsule 30 NYMALIZE ORAL SOLUTION 60 MG/20ML taztia xt oral capsule extended release 24 hour 120, 180, 240, 300, 360 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300 verapamil hcl er oral capsule extended release 24 hour 360 verapamil hcl er oral tablet extendedrelease* 120, 180, 240 verapamil hcl intravenous* solution 2.5 /ml verapamil hcl oral tablet 120, 40, 80 DIGITALIS GLYCOSIDES digitek oral tablet 125 mcg QL (30 EA per 30 days) digitek oral tablet 250 mcg PA digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml PA digoxin oral tablet QL (30 EA per 30 days) digoxin oral tablet 250 mcg PA DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA HCT ORAL TABLET MG, MG QL (30 EA per 30 days) 52

55 TEKTURNA HCT ORAL TABLET MG QL (60 EA per 30 days) TEKTURNA HCT ORAL TABLET MG TEKTURNA ORAL TABLET 150 MG QL (30 EA per 30 days) TEKTURNA ORAL TABLET 300 MG DIURETICS acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125, 250 amiloride hcl oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 furosemide injection solution 10 /ml furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25, 50 53

56 indapamide oral tablet 1.25, 2.5 methazolamide oral tablet 25, 50 methyclothiazide oral tablet 5 metolazone oral tablet 10, 2.5, 5 spironolactone-hctz oral tablet torsemide intravenous* solution 50 /5ml torsemide oral tablet 10, 100, 20, 5 triamterene-hctz oral capsule triamterene-hctz oral tablet , MISCELLANEOUS clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr, 0.2 /24hr, 0.3 /24hr DEMSER ORAL CAPSULE 250 MG hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 midodrine hcl oral tablet 10, 2.5, 5 minoxidil oral tablet 10,

57 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG NITRATES isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 minitran transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitro-bid transdermal ointment 2 % NITRO-DUR TRANSDERMAL PATCH 24 HR 0.3 MG/HR, 0.8 MG/HR nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG PULMONARY ARTERIAL HYPERTENSION ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG PA; LA ; QL (90 EA per 30 days) LETAIRIS ORAL TABLET 10 MG, 5 MG PA; LA ; QL (30 EA per 30 days) OPSUMIT ORAL TABLET 10 MG PA; LA ; QL (30 EA per 30 days) 55

58 REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 B/D; LA MG/ML REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; QL (224 ML per 30 days) sildenafil citrate oral tablet 20 PA; QL (90 EA per 30 days) TRACLEER ORAL TABLET 125 MG PA; LA ; QL (60 EA per 30 days) TRACLEER ORAL TABLET 62.5 MG PA; LA ; QL (120 EA per 30 days) CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam oral tablet 0.25 QL (480 EA per 30 days) alprazolam oral tablet 0.5 QL (240 EA per 30 days) alprazolam oral tablet 1 QL (120 EA per 30 days) alprazolam oral tablet 2 QL (150 EA per 30 days) buspirone hcl oral tablet 10, 15, 30, 5, 7.5 fluvoxamine maleate oral tablet 100 fluvoxamine maleate oral tablet 25, 50 QL (45 EA per 30 days) lorazepam injection solution 2 /ml, 4 /ml lorazepam intensol oral concentrate 2 /ml QL (150 ML per 30 days) lorazepam oral tablet 0.5, 1, 2 QL (150 EA per 30 days) ANTICONVULSANTS APTIOM ORAL TABLET 200 MG QL (180 EA per 30 days) APTIOM ORAL TABLET 400 MG QL (90 EA per 30 days) APTIOM ORAL TABLET 600 MG QL (60 EA per 30 days) APTIOM ORAL TABLET 800 MG QL (30 EA per 30 days) 56

59 BANZEL ORAL SUSPENSION 40 MG/ML PA BANZEL ORAL TABLET 200 MG, 400 MG PA carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hr* 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 QL (240 EA per 30 days) clonazepam oral tablet 1 QL (120 EA per 30 days) clonazepam oral tablet 2 QL (300 EA per 30 days) clonazepam oral tablet dispersible QL (960 EA per 30 days) clonazepam oral tablet dispersible 0.25 QL (480 EA per 30 days) clonazepam oral tablet dispersible 0.5 QL (240 EA per 30 days) clonazepam oral tablet dispersible 1 QL (120 EA per 30 days) clonazepam oral tablet dispersible 2 QL (300 EA per 30 days) clorazepate dipotassium oral tablet 15 PA; QL (180 EA per 30 days) 57

60 clorazepate dipotassium oral tablet 3.75, 7.5 PA; QL (120 EA per 30 days) diazepam 10, 2.5, 20 diazepam injection solution 5 /ml diazepam intensol oral concentrate 5 /ml PA; QL (240 ML per 30 days) diazepam oral solution 1 /ml PA; QL (1200 ML per 30 days) diazepam oral tablet 10, 2, 5 PA; QL (120 EA per 30 days) dilantin infatabs oral tablet chewable 50 dilantin oral capsule 100, 30 DILANTIN ORAL SUSPENSION 125 MG/5ML divalproex sodium er oral tablet extended release 24 hr* 250, 500 divalproex sodium oral capsule sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 epitol oral tablet 200 ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml felbamate oral suspension 600 /5ml felbamate oral tablet 400 felbamate oral tablet 600 FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG PA; QL (30 EA per 30 days) 58

61 FYCOMPA ORAL TABLET 2 MG PA; QL (180 EA per 30 days) FYCOMPA ORAL TABLET 4 MG PA; QL (90 EA per 30 days) FYCOMPA ORAL TABLET 6 MG PA; QL (60 EA per 30 days) gabapentin oral capsule 100 QL (1080 EA per 30 days) gabapentin oral capsule 300 QL (360 EA per 30 days) gabapentin oral capsule 400 QL (270 EA per 30 days) gabapentin oral solution 250 /5ml QL (2160 ML per 30 days) gabapentin oral tablet 600 QL (180 EA per 30 days) gabapentin oral tablet 800 QL (120 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine er oral tablet extended release 24 hr* 100, 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 levetiracetam er oral tablet extended release 24 hr* 500, 750 LEVETIRACETAM IN NACL INTRAVENOUS* SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML levetiracetam intravenous* solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500,

62 LYRICA ORAL CAPSULE 100 MG, 150 MG, 25 MG, 50 MG, 75 MG QL (120 EA per 30 days) LYRICA ORAL CAPSULE 200 MG QL (90 EA per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG QL (60 EA per 30 days) LYRICA ORAL SOLUTION 20 MG/ML QL (946 ML per 30 days) ONFI ORAL SUSPENSION 2.5 MG/ML PA ONFI ORAL TABLET 10 MG, 20 MG PA oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 /5ml PA phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60 PA, 64.8, 97.2 phenobarbital sodium injection solution 130 /ml PA PHENOBARBITAL SODIUM INJECTION SOLUTION 65 MG/ML PA phenytek oral capsule 200, 300 phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml POTIGA ORAL TABLET 200 MG QL (180 EA per 30 days) 60

63 POTIGA ORAL TABLET 300 MG, 400 MG QL (90 EA per 30 days) POTIGA ORAL TABLET 50 MG primidone oral tablet 250, 50 SABRIL ORAL PACKET 500 MG PA; LA ; QL (180 EA per 30 days) SABRIL ORAL TABLET 500 MG PA; LA ; QL (180 EA per 30 days) TEGRETOL ORAL SUSPENSION 100 MG/5ML TEGRETOL ORAL TABLET 200 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 400 MG tiagabine hcl oral tablet 2, 4 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 valproate sodium intravenous* solution 500 /5ml valproic acid oral capsule 250 valproic acid oral syrup 250 /5ml VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 10 MG/ML QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG QL (60 EA per 30 days) VIMPAT ORAL TABLET 50 MG QL (180 EA per 30 days) zonisamide oral capsule 100, 25, 50 61

64 ANTIDEMENTIA donepezil hcl oral tablet 10, 23 donepezil hcl oral tablet 5 QL (30 EA per 30 days) donepezil hcl oral tablet dispersible 10 donepezil hcl oral tablet dispersible 5 QL (30 EA per 30 days) EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, QL (30 EA per 30 days) 9.5 MG/24HR galantamine hydrobromide er oral capsule extended release 24 hour QL (30 EA per 30 days) 16, 8 galantamine hydrobromide er oral capsule extended release 24 hour 24 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12 galantamine hydrobromide oral tablet 4 QL (180 EA per 30 days) galantamine hydrobromide oral tablet 8 QL (90 EA per 30 days) NAMENDA ORAL SOLUTION 10 MG/5ML PA NAMENDA ORAL TABLET 10 MG, 5 MG PA NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG PA 62

65 NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 ANTIDEPRESSANTS PA amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 PA amoxapine oral tablet 100, 150, 25, 50 BRINTELLIX ORAL TABLET 10 MG QL (60 EA per 30 days) BRINTELLIX ORAL TABLET 20 MG QL (30 EA per 30 days) BRINTELLIX ORAL TABLET 5 MG QL (120 EA per 30 days) bupropion hcl er (sr) oral tablet extended release 12 hr* 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hr* 150 QL (90 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hr* 300 QL (30 EA per 30 days) bupropion hcl oral tablet 100, 75 citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20 QL (45 EA per 30 days) citalopram hydrobromide oral tablet 40 QL (30 EA per 30 days) clomipramine hcl oral capsule 25, 50, 75 PA 63

66 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 PA doxepin hcl oral concentrate 10 /ml PA duloxetine hcl oral capsule delayed release particles 20, 30, 60 QL (60 EA per 30 days) EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 PA; QL (30 EA per 30 days) MG/24HR escitalopram oxalate oral solution 5 /5ml QL (600 ML per 30 days) escitalopram oxalate oral tablet 10, 5 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20 QL (60 EA per 30 days) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG QL (30 EA per 30 days) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG QL (180 EA per 30 days) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG QL (90 EA per 30 days) FETZIMA TITRATION ORAL 20 & 40 MG fluoxetine hcl oral capsule 10 QL (30 EA per 30 days) fluoxetine hcl oral capsule 20 QL (120 EA per 30 days) fluoxetine hcl oral capsule 40 fluoxetine hcl oral solution 20 /5ml 64

67 fluoxetine hcl oral tablet 10 QL (45 EA per 30 days) fluoxetine hcl oral tablet 20 imipramine hcl oral tablet 10, 25, 50 PA maprotiline hcl oral tablet 25, 50, 75 MARPLAN ORAL TABLET 10 MG QL (180 EA per 30 days) mirtazapine oral tablet 15, 7.5 QL (45 EA per 30 days) mirtazapine oral tablet 30, 45 mirtazapine oral tablet dispersible 15 QL (30 EA per 30 days) mirtazapine oral tablet dispersible 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml paroxetine hcl oral tablet 10, 20, 40 QL (45 EA per 30 days) paroxetine hcl oral tablet 30 QL (60 EA per 30 days) PAXIL ORAL SUSPENSION 10 MG/5ML QL (900 ML per 30 days) phenelzine sulfate oral tablet 15 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 25 MG, QL (30 EA per 30 days) 50 MG protriptyline hcl oral tablet 10, 5 65

68 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100 sertraline hcl oral tablet 25, 50 QL (45 EA per 30 days) SURMONTIL ORAL CAPSULE 100 MG PA; QL (60 EA per 30 days) SURMONTIL ORAL CAPSULE 25 MG PA; QL (240 EA per 30 days) SURMONTIL ORAL CAPSULE 50 MG PA; QL (120 EA per 30 days) tranylcypromine sulfate oral tablet 10 trazodone hcl oral tablet 100, 150, 50 venlafaxine hcl er oral capsule extended release 24 hour 150 QL (60 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 37.5, QL (30 EA per 30 days) 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 VIIBRYD ORAL KIT 10 & 20 & 40 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG QL (30 EA per 30 days) ANTIPARKINSONIAN AGENTS amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML PA; LA AZILECT ORAL TABLET 0.5 MG, 1 MG 66

69 benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, 2 PA bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 carbidopa-levodopa er oral tablet extendedrelease* , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet , , , , , entacapone oral tablet 200 NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 selegiline hcl oral capsule 5 67

70 selegiline hcl oral tablet 5 trihexyphenidyl hcl oral elixir 0.4 /ml PA trihexyphenidyl hcl oral tablet 2, 5 PA ANTIPSYCHOTICS ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG QL (60 EA per 30 days) ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION QL (1 EA per 28 days) RECONSTITUTED 300 MG, 400 MG aripiprazole oral tablet 10, 15, 2, 20, 30, 5 QL (30 EA per 30 days) chlorpromazine hcl injection solution 25 /ml chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 clozapine oral tablet 100 QL (270 EA per 30 days) clozapine oral tablet 200 QL (135 EA per 30 days) clozapine oral tablet 25, 50 clozapine oral tablet dispersible 100 PA; QL (270 EA per 30 days) clozapine oral tablet dispersible 12.5, 25 PA CLOZAPINE ORAL TABLET DISPERSIBLE 150 MG PA; QL (180 EA per 30 days) CLOZAPINE ORAL TABLET DISPERSIBLE 200 MG PA; QL (135 EA per 30 days) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG ST; QL (60 EA per 30 days) 68

71 FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG FAZACLO ORAL TABLET DISPERSIBLE 150 MG FAZACLO ORAL TABLET DISPERSIBLE 200 MG fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 6 MG ST PA; QL (180 EA per 30 days) PA; QL (135 EA per 30 days) QL (6 EA per 3 days) QL (30 EA per 30 days) QL (60 EA per 30 days) 69

72 INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION QL (0.75 ML per 28 days) 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION QL (1 ML per 28 days) 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION QL (1.5 ML per 28 days) 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 QL (0.25 ML per 28 days) MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 78 QL (0.5 ML per 28 days) MG/0.5ML LATUDA ORAL TABLET 120 MG, 40 MG QL (30 EA per 30 days) LATUDA ORAL TABLET 20 MG QL (240 EA per 30 days) LATUDA ORAL TABLET 60 MG, 80 MG QL (60 EA per 30 days) loxapine succinate oral capsule 10, 25, 5, 50 olanzapine intramuscular* solution reconstituted 10 QL (3 EA per 1 day) olanzapine oral tablet 10, 15, 20 QL (60 EA per 30 days) olanzapine oral tablet 2.5, 5, 7.5 QL (30 EA per 30 days) olanzapine oral tablet dispersible 10, 15, 20 QL (60 EA per 30 days) olanzapine oral tablet dispersible 5 QL (30 EA per 30 days) 70

73 ORAP ORAL TABLET 1 MG, 2 MG perphenazine oral tablet 16, 2, 4, 8 quetiapine fumarate oral tablet 100, 200, 25, 300, 400 QL (90 EA per 30 days), 50 RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, QL (2 EA per 28 days) 37.5 MG, 50 MG risperidone oral solution 1 /ml QL (240 ML per 30 days) risperidone oral tablet 0.25, 0.5 QL (90 EA per 30 days) risperidone oral tablet 1, 2, 3 QL (60 EA per 30 days) risperidone oral tablet 4 QL (120 EA per 30 days) risperidone oral tablet dispersible 0.25, 0.5 QL (90 EA per 30 days) risperidone oral tablet dispersible 1, 2, 3 QL (60 EA per 30 days) risperidone oral tablet dispersible 4 QL (120 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG QL (60 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG QL (240 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG QL (120 EA per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG QL (30 EA per 30 days) 71

74 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 50 MG thioridazine hcl oral tablet 10, 100, 25, 50 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine hcl oral tablet 1, 10, 2, 5 VERSACLOZ ORAL SUSPENSION 50 MG/ML ziprasidone hcl oral capsule 20, 40 ziprasidone hcl oral capsule 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 405 MG ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 15, 20, 25, 30 QL (60 EA per 30 days) QL (120 EA per 30 days) PA PA; QL (600 ML per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) PA; QL (2 EA per 28 days) PA; QL (1 EA per 28 days) QL (90 EA per 30 days) QL (30 EA per 30 days) 72

75 amphetamine-dextroamphetamine oral tablet 10 amphetamine-dextroamphetamine oral tablet 12.5 amphetamine-dextroamphetamine oral tablet 15 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 amphetamine-dextroamphetamine oral tablet 5 amphetamine-dextroamphetamine oral tablet 7.5 guanfacine hcl er oral tablet extended release 24 hr* 1, 2, 3, 4 metadate er oral tablet extendedrelease* 20 methylphenidate hcl er oral tablet extendedrelease* 10, 20 methylphenidate hcl oral solution 10 /5ml methylphenidate hcl oral solution 5 /5ml methylphenidate hcl oral tablet 10, 5 methylphenidate hcl oral tablet 20 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG QL (180 EA per 30 days) QL (144 EA per 30 days) QL (120 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (360 EA per 30 days) QL (240 EA per 30 days) PA QL (90 EA per 30 days) QL (90 EA per 30 days) QL (900 ML per 30 days) QL (1800 ML per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) QL (120 EA per 30 days) 73

76 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG QL (30 EA per 30 days) STRATTERA ORAL CAPSULE 40 MG QL (60 EA per 30 days) HYPNOTICS HETLIOZ ORAL CAPSULE 20 MG PA; LA ROZEREM ORAL TABLET 8 MG QL (30 EA per 30 days) SILENOR ORAL TABLET 3 MG QL (60 EA per 30 days) SILENOR ORAL TABLET 6 MG QL (30 EA per 30 days) temazepam oral capsule 15 PA; QL (60 EA per 30 days) temazepam oral capsule 7.5 PA; QL (30 EA per 30 days) zolpidem tartrate oral tablet 10, 5 PA; QL (30 EA per 30 days) MIGRAINE dihydroergotamine mesylate injection solution 1 /ml naratriptan hcl oral tablet 1, 2.5 QL (9 EA per 30 days) RELPAX ORAL TABLET 20 MG, 40 MG QL (12 EA per 30 days) rizatriptan benzoate oral tablet 10, 5 QL (18 EA per 30 days) rizatriptan benzoate oral tablet dispersible 10, 5 QL (18 EA per 30 days) sumatriptan nasal solution 20 /act QL (12 EA per 30 days) sumatriptan nasal solution 5 /act QL (24 EA per 30 days) sumatriptan succinate oral tablet 100, 25, 50 QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* 4 /0.5ml, 6 /0.5ml QL (6 ML per 30 days) 74

77 sumatriptan succinate subcutaneous* 4 /0.5ml QL (6 ML per 30 days) sumatriptan succinate subcutaneous* 6 /0.5ml QL (6 ML per 30 days) sumatriptan succinate subcutaneous* solution 6 /0.5ml QL (6 ML per 30 days) zolmitriptan oral tablet 2.5, 5 QL (12 EA per 30 days) zolmitriptan oral tablet dispersible 2.5, 5 QL (12 EA per 30 days) MISCELLANEOUS lithium carbonate er oral tablet extendedrelease* 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 LITHIUM ORAL SOLUTION 8 MEQ/5ML NUEDEXTA ORAL CAPSULE MG PA pyridostigmine bromide oral tablet 60 riluzole oral tablet 50 XENAZINE ORAL TABLET 12.5 MG PA; LA ; QL (240 EA per 30 days) XENAZINE ORAL TABLET 25 MG PA; LA ; QL (120 EA per 30 days) MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG BETASERON SUBCUTANEOUS* KIT 0.3 MG COPAXONE SUBCUTANEOUS* 40 MG/ML PA; LA PA; QL (14 EA per 28 days) PA; QL (12 ML per 28 days) 75

78 GILENYA ORAL CAPSULE 0.5 MG PA; QL (28 EA per 28 days) glatopa subcutaneous* 20 /ml PA; QL (30 ML per 30 days) TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML PA; LA MUSCULOSKELETAL THERAPY AGENTS baclofen oral tablet 10, 20 dantrolene sodium oral capsule 100, 25, 50 tizanidine hcl oral tablet 2, 4 NARCOLEPSY/CATAPLEXY NUVIGIL ORAL TABLET 150 MG PA; QL (60 EA per 30 days) NUVIGIL ORAL TABLET 200 MG, 250 MG PA; QL (30 EA per 30 days) NUVIGIL ORAL TABLET 50 MG PA; QL (150 EA per 30 days) XYREM ORAL SOLUTION 500 MG/ML PA; LA ; QL (540 ML per 30 days) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release 333 buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 buproban oral tablet extended release 12 hr* 150 CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG PA PA; QL (120 EA per 30 days) PA PA 76

79 CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG PA X 42 disulfiram oral tablet 250, 500 naloxone hcl injection solution 0.4 /ml, 1 /ml naltrexone hcl oral tablet 50 NICOTROL INHALATION INHALER 10 MG NICOTROL NS NASAL SOLUTION 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG PA; QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG PA; QL (120 EA per 30 days) ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 PA; QL (30 EA per 30 days) MG/24HR AXIRON TRANSDERMAL SOLUTION 30 MG/ACT PA; QL (440 ML per 30 days) oxandrolone oral tablet 10 PA oxandrolone oral tablet 2.5 PA testosterone cypionate intramuscular* solution 100 /ml, PA 200 /ml testosterone enanthate intramuscular* solution 200 /ml PA 77

80 ANTIDIABETICS, INJECTABLE ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML BYDUREON SUBCUTANEOUS* 2 MG QL (4 EA per 28 days) BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG QL (4 EA per 28 days) BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML QL (2.4 ML per 30 days) BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML QL (1.2 ML per 30 days) EXCEL COMFORT POINT PEN NEEDLE 29G X 12MM GLOBAL ALCOHOL PREP EASE PAD 70 % HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* B/D SOLUTION 500 UNIT/ML INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML 78

81 NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML RA STERILE PAD 2"X2" SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML PA; QL (10.8 ML per 30 days) SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML PA; QL (12 ML per 30 days) VICTOZA SUBCUTANEOUS* 18 MG/3ML QL (9 ML per 30 days) ANTIDIABETICS, ORAL acarbose oral tablet 100, 25, 50 FARXIGA ORAL TABLET 10 MG QL (30 EA per 30 days) FARXIGA ORAL TABLET 5 MG QL (60 EA per 30 days) glimepiride oral tablet 1 QL (240 EA per 30 days) glimepiride oral tablet 2 QL (120 EA per 30 days) glimepiride oral tablet 4 QL (60 EA per 30 days) 79

82 glipizide er oral tablet extended release 24 hr* 10 QL (60 EA per 30 days) glipizide er oral tablet extended release 24 hr* 2.5 QL (240 EA per 30 days) glipizide er oral tablet extended release 24 hr* 5 QL (120 EA per 30 days) glipizide oral tablet 10 QL (120 EA per 30 days) glipizide oral tablet 5 QL (240 EA per 30 days) glipizide-metformin hcl oral tablet QL (240 EA per 30 days) glipizide-metformin hcl oral tablet , QL (120 EA per 30 days) INVOKAMET ORAL TABLET MG, MG, QL (60 EA per 30 days) MG INVOKAMET ORAL TABLET MG QL (120 EA per 30 days) INVOKANA ORAL TABLET 100 MG QL (90 EA per 30 days) INVOKANA ORAL TABLET 300 MG QL (30 EA per 30 days) JANUMET ORAL TABLET MG, MG QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* QL (30 EA per 30 days) MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* QL (60 EA per 30 days) MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG QL (30 EA per 30 days) JENTADUETO ORAL TABLET MG, MG, MG QL (60 EA per 30 days) 80

83 metformin hcl er oral tablet extended release 24 hr* 500 QL (120 EA per 30 days) metformin hcl er oral tablet extended release 24 hr* 750 QL (60 EA per 30 days) metformin hcl oral tablet 1000 QL (75 EA per 30 days) metformin hcl oral tablet 500 QL (150 EA per 30 days) metformin hcl oral tablet 850 QL (90 EA per 30 days) nateglinide oral tablet 120, 60 QL (90 EA per 30 days) pioglitazone hcl oral tablet 15, 30, 45 QL (30 EA per 30 days) repaglinide oral tablet 0.5, 1 QL (120 EA per 30 days) repaglinide oral tablet 2 QL (240 EA per 30 days) TRADJENTA ORAL TABLET 5 MG QL (30 EA per 30 days) ANTIDIABETICS, TESTING SUPPLIES ONETOUCH ULTRA 2 KIT W/DEVICE Part B $0 ONETOUCH ULTRA BLUE IN VITRO STRIP ONETOUCH ULTRA MINI KIT W/DEVICE ONETOUCH ULTRA SYSTEM KIT W/DEVICE ONETOUCH ULTRASMART KIT W/DEVICE Part B $0 Part B $0 Part B $0 Part B $0 NDC ( ); QL (1 EA per 365 days) NDC ( , , ); QL (100 EA per 25 days) NDC ( , , , , , ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) 81

84 ONETOUCH VERIO IN VITRO STRIP Part B $0 ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE Part B $0 ONETOUCH VERIO KIT W/DEVICE Part B $0 ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE BISPHOSPHONATES alendronate sodium oral tablet 10, 40, 5 alendronate sodium oral tablet 35, 70 ibandronate sodium oral tablet 150 pamidronate disodium intravenous* solution 30 /10ml, 6 /ml, 90 /10ml zoledronic acid intravenous* concentrate 4 /5ml zoledronic acid intravenous* solution 5 /100ml CALCIUM RECEPTOR AGONISTS Part B $0 NDC ( , , ); QL (100 EA per 25 days) NDC ( ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) QL (4 EA per 28 days) B/D; QL (1 EA per 30 days) B/D B/D B/D SENSIPAR ORAL TABLET 30 MG, 90 MG QL (120 EA per 30 days) SENSIPAR ORAL TABLET 60 MG QL (60 EA per 30 days) CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 250 MG 82

85 EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG PA; LA FERRIPROX ORAL TABLET 500 MG PA; LA kionex oral powder kionex oral suspension 15 gm/60ml sodium polystyrene sulfonate oral suspension 15 gm/60ml sps oral suspension 15 gm/60ml SYPRINE ORAL CAPSULE 250 MG CONTRACEPTIVES altavera oral tablet mcg apri oral tablet mcg aranelle oral tablet 0.5/1/ mcg aubra oral tablet mcg aviane oral tablet mcg balziva oral tablet mcg briellyn oral tablet mcg camila oral tablet 0.35 cryselle-28 oral tablet mcg cyclafem 1/35 oral tablet mcg cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 -mcg deblitane oral tablet 0.35 delyla oral tablet mcg desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) drospirenone-ethinyl estradiol oral tablet

86 emoquette oral tablet mcg enpresse-28 oral tablet errin oral tablet 0.35 falmina oral tablet mcg gianvi oral tablet gildagia oral tablet mcg gildess 1.5/30 oral tablet mcg heather oral tablet 0.35 introvale oral tablet jolessa oral tablet jolivette oral tablet 0.35 junel 1.5/30 oral tablet mcg junel 1/20 oral tablet mcg junel fe 1.5/30 oral tablet mcg junel fe 1/20 oral tablet mcg kariva oral tablet /0.01 (21/5) kelnor 1/35 oral tablet mcg larin 1.5/30 oral tablet mcg larin 1/20 oral tablet mcg larin fe 1.5/30 oral tablet mcg larin fe 1/20 oral tablet mcg 84

87 leena oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet levonorgestrel oral tablet 0.75, 1.5 levonorgestrel-ethinyl estrad oral tablet mcg levora 0.15/30 (28) oral tablet mcg loryna oral tablet low-ogestrel oral tablet mcg lutera oral tablet mcg lyza oral tablet 0.35 marlissa oral tablet mcg medroxyprogesterone acetate intramuscular* suspension 150 /ml microgestin 1.5/30 oral tablet mcg microgestin 1/20 oral tablet mcg microgestin fe 1.5/30 oral tablet mcg microgestin fe 1/20 oral tablet mcg mononessa oral tablet mcg 85

88 myzilra oral tablet necon 0.5/35 (28) oral tablet mcg necon 1/35 (28) oral tablet mcg necon 1/50 (28) oral tablet mcg necon 10/11 (28) oral tablet 35 mcg necon 7/7/7 oral tablet 0.5/0.75/1-35 -mcg next choice one dose oral tablet 1.5 nikki oral tablet nora-be oral tablet 0.35 norethindrone oral tablet 0.35 norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg norlyroc oral tablet 0.35 nortrel 0.5/35 (28) oral tablet mcg nortrel 1/35 (21) oral tablet mcg nortrel 1/35 (28) oral tablet mcg nortrel 7/7/7 oral tablet 0.5/0.75/1-35 -mcg NUVARING VAGINAL RING MG/24HR ocella oral tablet orsythia oral tablet mcg philith oral tablet mcg 86

89 pimtrea oral tablet /0.01 (21/5) pirmella 1/35 oral tablet mcg portia-28 oral tablet mcg previfem oral tablet mcg quasense oral tablet reclipsen oral tablet mcg sharobel oral tablet 0.35 solia oral tablet mcg sprintec 28 oral tablet mcg sronyx oral tablet mcg syeda oral tablet tarina fe 1/20 oral tablet mcg tri-legest fe oral tablet 1-20/1-30/1-35 -mcg trinessa (28) oral tablet 0.18/0.215/ mcg tri-previfem oral tablet 0.18/0.215/ mcg tri-sprintec oral tablet 0.18/0.215/ mcg trivora (28) oral tablet velivet oral tablet 0.1/0.125/ vestura oral tablet

90 viorele oral tablet /0.01 (21/5) vyfemla oral tablet mcg xulane transdermal patch weekly mcg/24hr zarah oral tablet zenchent oral tablet mcg zovia 1/35e (28) oral tablet mcg zovia 1/50e (28) oral tablet mcg ENDOMETRIOSIS danazol oral capsule 100, 200, 50 SYNAREL NASAL SOLUTION 2 MG/ML ENZYME REPLACEMENTS ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML PA; LA ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML PA; LA CARBAGLU ORAL TABLET 200 MG PA; LA CERDELGA ORAL CAPSULE 84 MG PA CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 200 PA; LA UNIT, 400 UNIT CYSTADANE ORAL POWDER LA CYSTAGON ORAL CAPSULE 150 MG, 50 MG PA; LA FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG, PA; LA 5 MG 88

91 KUVAN ORAL PACKET 100 MG, 500 MG PA; LA KUVAN ORAL TABLET SOLUBLE 100 MG PA; LA levocarnitine intravenous* solution 200 /ml B/D levocarnitine oral solution 1 gm/10ml B/D levocarnitine oral tablet 330 B/D LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA; LA MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA; LA NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML PA; LA ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG PA; LA RAVICTI ORAL LIQUID 1.1 GM/ML PA sodium phenylbutyrate oral powder 3 gm/tsp ZAVESCA ORAL CAPSULE 100 MG PA; LA ESTROGENS DELESTROGEN INTRAMUSCULAR* OIL 10 MG/ML estrace vaginal cream 0.1 /gm estradiol oral tablet 0.5, 1, 2 PA estradiol transdermal patch weekly /24hr, /24hr, 0.05 /24hr, 0.06 /24hr, /24hr, 0.1 /24hr PA 89

92 estradiol valerate intramuscular* oil 20 /ml, 40 /ml jinteli oral tablet 1-5 -mcg PA norethindrone-eth estradiol oral tablet 1-5 -mcg PA VAGIFEM VAGINAL TABLET 10 MCG GLUCOCORTICOIDS a-hydrocort injection solution reconstituted 100 cortisone acetate oral tablet 25 dexamethasone intensol oral concentrate 1 /ml dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 dexamethasone sod phosphate pf injection solution 10 /ml dexamethasone sodium phosphate injection solution 10 /ml, 100 /10ml, 120 /30ml, 20 /5ml fludrocortisone acetate oral tablet 0.1 hydrocortisone oral tablet 10, 20, 5 methylprednisolone (pak) oral tablet 4 B/D methylprednisolone acetate injection suspension 40 /ml, 80 /ml B/D 90

93 methylprednisolone oral tablet 16, 32, 4, 8 B/D methylprednisolone sodium succ injection solution reconstituted 1 B/D gm, 125, 40 prednisolone oral solution 15 /5ml B/D prednisolone sodium phosphate oral solution 15 /5ml, 25 /5ml, 6.7 B/D (5 base) /5ml prednisone (pak) oral tablet 10, 5 B/D prednisone intensol oral concentrate 5 /ml B/D prednisone oral solution 5 /5ml B/D prednisone oral tablet 1, 10, 2.5, 20, 5, 50 B/D SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 250 MG GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG KORLYM ORAL TABLET 300 MG PA; LA PROGLYCEM ORAL SUSPENSION 50 MG/ML HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML PA 91

94 NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS* SOLUTION 30 MG/3ML MISCELLANEOUS PA cabergoline oral tablet 0.5 calcitonin (salmon) nasal solution 200 unit/act FORTICAL NASAL SOLUTION 200 UNIT/ACT INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML PA; LA methylergonovine maleate oral tablet 0.2 MIACALCIN INJECTION SOLUTION 200 UNIT/ML B/D octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml PA octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml, 500 PA mcg/ml PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML QL (1 ML per 180 days) raloxifene hcl oral tablet 60 SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 PA MG, 30 MG SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML PA; LA 92

95 SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML PARATHYROID HORMONES FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML NATPARA SUBCUTANEOUS* 100 MCG, 25 MCG, 50 MCG, 75 MCG PHOSPHATE BINDER AGENTS calcium acetate oral capsule 667 RENVELA ORAL PACKET 0.8 GM, 2.4 GM RENVELA ORAL TABLET 800 MG PROGESTINS medroxyprogesterone acetate oral tablet 10, 2.5, 5 norethindrone acetate oral tablet 5 THYROID AGENTS levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg PA PA; LA PA PA; QL (2.4 ML per 28 days) PA 93

96 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 sodium oral tablet 25 mcg, 5 mcg, 50 mcg methimazole oral tablet 10, 5 propylthiouracil oral tablet 50 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg VASOPRESSINS desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % GASTROINTESTINAL ANTIEMETICS compro suppository 25 94

97 dronabinol oral capsule 10 B/D; QL (60 EA per 30 days) dronabinol oral capsule 2.5, 5 B/D; QL (60 EA per 30 days) EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG B/D granisetron hcl intravenous* solution 0.1 /ml, 1 /ml, 4 /4ml granisetron hcl oral tablet 1 B/D meclizine hcl oral tablet 12.5, 25 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5ml metoclopramide hcl oral tablet 10, 5 ondansetron hcl injection solution 4 /2ml, 40 /20ml ondansetron hcl oral solution 4 /5ml B/D ondansetron hcl oral tablet 24, 4, 8 B/D ondansetron oral tablet dispersible 4, 8 B/D phenadoz suppository 12.5 PA phenergan suppository 12.5, 25, 50 PA prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine suppository 25 95

98 promethazine hcl injection solution 25 /ml, 50 /ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl suppository 12.5, 25, 50 promethegan suppository 25, 50 TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1 MG/3DAYS ANTISPASMODICS CUVPOSA ORAL SOLUTION 1 MG/5ML dicyclomine hcl oral capsule 10 dicyclomine hcl oral solution 10 /5ml dicyclomine hcl oral tablet 20 glycopyrrolate injection solution 4 /20ml glycopyrrolate oral tablet 1, 2 H2-RECEPTOR ANTAGONISTS famotidine intravenous* solution 20 /2ml, 200 /20ml, 40 /4ml famotidine oral suspension reconstituted 40 /5ml famotidine oral tablet 20, 40 famotidine premixed intravenous* solution /50ml-% PA PA PA PA PA PA; QL (10 EA per 30 days) 96

99 ranitidine hcl injection solution 150 /6ml, 50 /2ml ranitidine hcl oral syrup 15 /ml ranitidine hcl oral tablet 150, 300 INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG balsalazide disodium oral capsule 750 budesonide er oral capsule extended release 24 hour 3 CANASA SUPPOSITORY 1000 MG colocort enema 100 /60ml DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG DIPENTUM ORAL CAPSULE 250 MG hydrocortisone enema 100 /60ml mesalamine enema 4 gm mesalamine-cleanser kit 4 gm sulfasalazine oral tablet 500 sulfazine ec oral tablet delayed release 500 UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9 MG LAXATIVES constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml 97

100 gavilyte-c oral solution reconstituted 240 gm gavilyte-g oral solution reconstituted 236 gm gavilyte-h oral kit gm gavilyte-n with flavor pack oral solution reconstituted 420 gm generlac oral solution 10 gm/15ml GOLYTELY ORAL SOLUTION RECONSTITUTED GM, 236 GM lactulose encephalopathy oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML, 8 MG/0.4ML PA 98

101 SUPREP BOWEL PREP ORAL SOLUTION trilyte oral solution reconstituted 420 gm MISCELLANEOUS alosetron hcl oral tablet 0.5, 1 PA AMITIZA ORAL CAPSULE 24 MCG, 8 MCG QL (60 EA per 30 days) cromolyn sodium oral concentrate 100 /5ml diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet GATTEX SUBCUTANEOUS* KIT 5 MG PA; LA LINZESS ORAL CAPSULE 145 MCG QL (60 EA per 30 days) LINZESS ORAL CAPSULE 290 MCG QL (30 EA per 30 days) loperamide hcl oral capsule 2 misoprostol oral tablet 100 mcg, 200 mcg MOVANTIK ORAL TABLET 12.5 MG QL (60 EA per 30 days) MOVANTIK ORAL TABLET 25 MG QL (30 EA per 30 days) SUCRAID ORAL SOLUTION 8500 UNIT/ML LA sucralfate oral tablet 1 gm ursodiol oral capsule 300 ursodiol oral tablet 250, 500 XIFAXAN ORAL TABLET 550 MG PA 99

102 PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole sodium intravenous* solution reconstituted 20, 40 NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 MG NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG NEXIUM ORAL PACKET 2.5 MG, 5 MG omeprazole oral capsule delayed release 10, 40 omeprazole oral capsule delayed release 20 pantoprazole sodium oral tablet delayed release 20, 40 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) alfuzosin hcl er oral tablet extended release 24 hr* 10 QL (30 EA per 30 days) AVODART ORAL CAPSULE 0.5 MG QL (30 EA per 30 days) 100

103 finasteride oral tablet 5 JALYN ORAL CAPSULE MG QL (30 EA per 30 days) tamsulosin hcl oral capsule 0.4 MISCELLANEOUS bethanechol chloride oral tablet 10, 25, 5, 50 ELMIRON ORAL CAPSULE 100 MG potassium citrate er oral tablet extendedrelease* 10 meq (1080 ), 5 meq (540 ) URINARY ANTISPASMODICS MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 MG QL (60 EA per 30 days) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 50 MG QL (30 EA per 30 days) oxybutynin chloride er oral tablet extended release 24 hr* 10, 15 QL (60 EA per 30 days) oxybutynin chloride er oral tablet extended release 24 hr* 5 QL (30 EA per 30 days) oxybutynin chloride oral syrup 5 /5ml oxybutynin chloride oral tablet 5 tolterodine tartrate er oral capsule extended release 24 hour 2, 4 QL (30 EA per 30 days) tolterodine tartrate oral tablet 1, 2 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR* 4 MG, 8 MG QL (30 EA per 30 days) trospium chloride oral tablet 20 QL (60 EA per 30 days) 101

104 VESICARE ORAL TABLET 10 MG, 5 MG VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2 % metronidazole vaginal 0.75 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 vandazole vaginal 0.75 % zazole vaginal cream 0.4 % zazole vaginal cream 0.8 % HEMATOLOGIC ANTICOAGULANTS COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous* solution 100 /ml, 120 /0.8ml, 150 /ml enoxaparin sodium subcutaneous* solution 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous* solution 10 /0.8ml, 5 /0.4ml, 7.5 /0.6ml QL (30 EA per 30 days) 102

105 fondaparinux sodium subcutaneous* solution 2.5 /0.5ml HEPARIN (PORCINE) IN D5W INTRAVENOUS* SOLUTION 40-5 UNIT/ML-%, 50-5 UNIT/ML-% HEPARIN (PORCINE) IN NACL INJECTION SOLUTION UNIT/ML-%, UNIT/ML-% HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS* SOLUTION 100 UNIT/ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml HEPARIN SODIUM (PORCINE) INJECTION SOLUTION 2500 UNIT/ML HEPARIN SODIUM (PORCINE) INTRAVENOUS* SOLUTION 2000 UNIT/ML jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 150 MG, 75 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER PACK ORAL 15 & 20 MG B/D B/D B/D 103

106 HEMATOPOIETIC GROWTH FACTORS GRANIX SUBCUTANEOUS* 300 MCG/0.5ML, 480 MCG/0.8ML LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML PROCRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ML MISCELLANEOUS PA PA PA PA PA anagrelide hcl oral capsule 0.5, 1 cilostazol oral tablet 100, 50 CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT PA; LA FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML PA pentoxifylline er oral tablet extendedrelease* 400 PROMACTA ORAL TABLET 12.5 MG PA; LA ; QL (360 EA per 30 days) PROMACTA ORAL TABLET 25 MG PA; LA ; QL (180 EA per 30 days) PROMACTA ORAL TABLET 50 MG PA; LA ; QL (90 EA per 30 days) PROMACTA ORAL TABLET 75 MG PA; LA ; QL (60 EA per 30 days) 104

107 tranexamic acid intravenous* solution 100 /ml tranexamic acid oral tablet 650 PLATELET AGGREGATION INHIBITORS AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR MG BRILINTA ORAL TABLET 90 MG clopidogrel bisulfate oral tablet 75 EFFIENT ORAL TABLET 10 MG, 5 MG ZONTIVITY ORAL TABLET 2.08 MG IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200 MG/ML CIMZIA STARTER KIT SUBCUTANEOUS* KIT 6 X 200 MG/ML CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML PA PA PA PA PA PA 105

108 HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 PA MG/0.8ML hydroxychloroquine sulfate oral tablet 200 leflunomide oral tablet 10, 20 methotrexate oral tablet 2.5 REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG PA IMMUNOGLOBULINS BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 5 GM/50ML CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML FLEBOGAMMA INTRAVENOUS* SOLUTION 0.5 GM/10ML GAMASTAN S/D INTRAMUSCULAR* INJECTABLE GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML GAMMAGARD S/D INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM PA PA PA PA B/D PA PA 106

109 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/200ML, 5 GM/100ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML PRIVIGEN INTRAVENOUS* SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS* SOLUTION UNIT/0.5ML ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA PA PA PA PA PA PA; LA PA B/D B/D 107

110 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG IMMUNOSUPPRESSANTS PA; LA PA azathioprine oral tablet 50 B/D BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 120 MG PA cyclosporine intravenous* solution 50 /ml B/D cyclosporine modified oral capsule 100, 25, 50 B/D cyclosporine modified oral solution 100 /ml B/D cyclosporine oral capsule 100, 25 B/D gengraf oral capsule 100, 25 B/D gengraf oral solution 100 /ml B/D mycophenolate mofetil oral capsule 250 B/D mycophenolate mofetil oral suspension reconstituted 200 /ml B/D mycophenolate mofetil oral tablet 500 B/D mycophenolic acid oral tablet delayed release 180 B/D mycophenolic acid oral tablet delayed release 360 B/D NEORAL ORAL CAPSULE 100 MG, 25 MG B/D 108

111 NEORAL ORAL SOLUTION 100 MG/ML B/D NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG B/D PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG B/D RAPAMUNE ORAL SOLUTION 1 MG/ML B/D SANDIMMUNE ORAL SOLUTION 100 MG/ML B/D sirolimus oral tablet 0.5, 1 B/D SIROLIMUS ORAL TABLET 2 MG B/D tacrolimus oral capsule 0.5, 1 B/D tacrolimus oral capsule 5 B/D ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG B/D VACCINES ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED NM ADACEL INTRAMUSCULAR* SUSPENSION LF-MCG/0.5 NM BCG VACCINE INJECTION INJECTABLE NM BEXSERO INTRAMUSCULAR* NM BOOSTRIX INTRAMUSCULAR* SUSPENSION NM CERVARIX INTRAMUSCULAR* SUSPENSION NM COMVAX INTRAMUSCULAR* SUSPENSION MCG/0.5ML NM 109

112 DAPTACEL INTRAMUSCULAR* SUSPENSION NM DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION B/D; NM 25-5 LFU/0.5ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML B/D; NM GARDASIL 9 INTRAMUSCULAR* NM GARDASIL 9 INTRAMUSCULAR* SUSPENSION NM GARDASIL INTRAMUSCULAR* SUSPENSION NM HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML, 720 EL NM U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG NM IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5 UNIT/ML NM INFANRIX INTRAMUSCULAR* SUSPENSION NM IPOL INJECTION INJECTABLE NM IXIARO INTRAMUSCULAR* SUSPENSION NM MENACTRA INTRAMUSCULAR* INJECTABLE NM MENOMUNE SUBCUTANEOUS* INJECTABLE NM MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED NM M-M-R II SUBCUTANEOUS* INJECTABLE NM 110

113 PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML NM PROQUAD SUBCUTANEOUS* INJECTABLE NM RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED NM RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 B/D; NM MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED NM ROTATEQ ORAL SOLUTION NM SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 NM MG/0.5ML TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU B/D; NM TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION 2-2 B/D; NM LF/0.5ML TRUMENBA INTRAMUSCULAR* NM TWINRIX INTRAMUSCULAR* SUSPENSION NM TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML NM VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 NM UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML NM YF-VAX SUBCUTANEOUS* INJECTABLE NM 111

114 ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED UNT/0.65ML NON-MEDICARE RX/OTC NON-MEDICARE RX/OTC 12 hour decongestant oral tablet extended release 12 hr* 120 ABREVA EXTERNAL CREAM 10 % ACEPHEN SUPPOSITORY 120 MG, 325 MG, 650 MG ACEROLA C 500 ORAL WAFER 500 MG acetaminophen 8 hour oral tablet 650 acetaminophen junior strength oral tablet dispersible 160 acetaminophen oral solution 160 /5ml ACID GONE ORAL SUSPENSION MG/15ML ACID GONE ORAL TABLET CHEWABLE MG acid reducer oral tablet 10 acidophilus/l-sporogenes oral tablet acne medication 5 external lotion 5 % acne medication external lotion 10 % advanced calcium formula oral tablet 200 ADVIL ALLERGY & CONGESTION ORAL TABLET MG NM; QL (1 EA per 999 days) 112

115 ADVIL ALLERGY SINUS ORAL TABLET MG ADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE MG ADVIL JUNIOR STRENGTH ORAL TABLET 100 MG AFRIN CHILDRENS NASAL SOLUTION 0.25 % ALA-HIST IR ORAL TABLET 2 MG ALA-HIST PE ORAL TABLET 2-10 MG all day allergy-d oral tablet extended release 12 hr* all day pain relief oral tablet 220 ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG aller-ease oral tablet 60 allergy relief oral capsule 25 allergy relief oral tablet 10, 25 aluminum hydroxide gel oral suspension 320 /5ml ambi 12.5cpd/1dcpm/30pse oral liquid /5ml ambi 40pse/400gfn/20dm oral tablet antacid maximum strength oral suspension /5ml anti-diarrheal oral liquid 1 /5ml anti-diarrheal oral tablet 2 antifungal external cream 2 % antioxidant formula sg oral capsule extended release* 113

116 apap 500 oral liquid 500 /5ml ap-hist dm oral liquid /5ml AQUADEKS ORAL LIQUID AQUA-E ORAL LIQUID 30-2 MG/ML AQUANIL HC EXTERNAL LOTION 1 % artificial tears ophthalmic solution 1.4 % ascorbic acid oral powder aspirin ec oral tablet delayed release 325 aspirin oral tablet 325, 81 aspirin suppository 300, 600 athletes foot spray external aerosol 1 % AXID AR ORAL TABLET 75 MG AYR SALINE NASAL DROPS NASAL SOLUTION 0.65 % AYR SALINE NASAL NASAL b complex oral capsule b complex oral tablet B-12 DOTS ORAL TABLET DISPERSIBLE 500 MCG b-12 oral tablet 2000 mcg b-12 oral tablet dispersible 5000 mcg b-12 sublingual tablet sublingual 2500 mcg bacitracin external ointment 500 unit/gm 114

117 bacitracin zinc external ointment 500 unit/gm b-complex/vitamin c oral tablet bee zee oral tablet benzonatate oral capsule 100, 200 benzoyl peroxide cleanser external lotion 6 % benzoyl peroxide external 2.5 % benzoyl peroxide wash external liquid 5 % beta carotene oral capsule unit biospec dmx oral liquid /5ml biotin oral tablet 300 mcg B-NATAL MOUTH/THROAT LOLLIPOP 25 MG B-NATAL MOUTH/THROAT LOZENGE 25 MG BONE DENSITY ORAL TABLET MG-UNIT bone meal oral tablet BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 16 % brohist d oral tablet 4-10 c-500 oral tablet chewable 500 cal/mag oral tablet CALCET CREAMY BITES ORAL TABLET CHEWABLE MG-UNIT 115

118 CALCET PETITES ORAL TABLET MG-UNIT CALCI-MIX ORAL CAPSULE 1250 MG calcionate oral syrup 1.8 gm/5ml cal-citrate plus vitamin d oral tablet unit calcium + d oral tablet chewable unt-mcg calcium + d3 oral tablet unit calcium d oral tablet unit calcium 500 oral tablet unit calcium 500/d oral tablet chewable unit calcium 500+d high potency oral tablet unit calcium 600 oral tablet 600 calcium 600/vitamin d oral tablet chewable unit calcium 600+d plus minerals oral tablet unit calcium 600+d plus minerals oral tablet chewable unit calcium antacid extra strength oral tablet chewable 750 calcium antacid oral tablet chewable 500 calcium antacid ultra max st oral tablet chewable

119 calcium ascorbate oral tablet 500 calcium carbonate oral powder 800 /2gm calcium carbonate oral suspension 1250 /5ml calcium carbonate oral tablet 1250 calcium carbonate oral tablet chewable 260 calcium carbonate-vitamin d oral tablet unit calcium citrate + d oral tablet unit, unit calcium citrate malate-vit d oral tablet unit calcium citrate oral granules 760 /3.5gm calcium citrate oral tablet 250 calcium citrate-vitamin d oral tablet unit calcium for women oral tablet chewable calcium gluconate oral tablet 50, 500 calcium gummies oral tablet chewable unit calcium lactate oral tablet 100, 648, 650 calcium oral tablet 500 calcium pantothenate oral tablet

120 calcium soft chews oral tablet chewable unt-mcg calcium/c/d oral tablet chewable unit calcium+d3 gradual release oral tablet extended release 24 hr* unit calcium-magnesium oral tablet , calcium-magnesium-vitamin d oral tablet unit calcium-magnesium-zinc oral tablet calcium-vitamin d3 oral tablet unit, unit calmag thins oral tablet CAL-QUICK ORAL LIQUID MG-UNT/5ML CALTRATE 600+D SOFT ORAL TABLET CHEWABLE MG-UNIT castellani paint modified external liquid 1.5 % CENTRUM KIDS COMPLETE ORAL TABLET CHEWABLE 60 MG CENTRUM SILVER ORAL TABLET CHEWABLE CEROVITE ADVANCED FORMULA ORAL LIQUID cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 118

121 chelated calcium oral tablet 200 chewable calcium oral tablet chewable unt-mcg chewable vite childrens oral tablet chewable chewable vite/iron childrens oral tablet chewable 15 childrens acetaminophen oral tablet dispersible 80 childrens cold & allergy oral elixir /5ml childrens complete allergy oral tablet chewable 12.5 childrens non-aspirin oral tablet chewable 80 childrens plus cold & allergy oral suspension /5ml childrens plus cold oral suspension /5ml chlo tuss ex oral liquid /5ml chlorpheniramine maleate er oral tablet extendedrelease* 12 CITRACAL CALCIUM GUMMIES ORAL TABLET CHEWABLE MG-MG-UNIT CITRACAL PLUS HEART HEALTH ORAL TABLET MG-UNIT-MG citrus calcium +d oral tablet unit 119

122 citrus calcium/vitamin d oral tablet unit CLARITIN ORAL TABLET CHEWABLE 5 MG CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG classic prenatal oral tablet clotrimazole 3 vaginal cream 2 % clotrimazole vaginal cream 1 % cod liver oil oral capsule codituss dm oral syrup /5ml cold head congestion severe oral tablet cold/cough childrens oral elixir /5ml cold/cough/sore throat child oral liquid /10ml complete sinus relief oral tablet COMTREX SEVERE COLD & SINUS ORAL & MG CONEX COLD/ALLERGY ORAL SOLUTION 1-30 MG/5ML CONEX COLD/ALLERGY ORAL TABLET 2-60 MG CONTAC COLD+FLU MAX ST ORAL TABLET MG 120

123 coral calcium oral capsule unit, unit, unit coral calcium plus oral capsule unit CORICIDIN HBP CONGESTION/COUGH ORAL CAPSULE MG CORTIZONE-10 EXTERNAL 1 % cough & cold oral tablet 4-30 cough & sore throat day oral liquid /15ml cough dm oral liquid extendedrelease* 30 /5ml cromolyn sodium nasal aerosol, solution 5.2 /act cvs calcium citrate oral tablet 200 cvs easy fiber/calcium oral tablet chewable cvs hydrocortisone acetate external cream 0.5 % cvs laxative dietary supplemnt oral tablet 500 cvs lubricant drops ophthalmic 1 % cvs lubricating/dry eye ophthalmic solution % cvs nasal mist nasal aerosol, solution 0.9 % cvs pain relief adult oral liquid 500 /15ml 121

124 cvs probiotic (lactobacillus) oral capsule cvs senna-extra oral tablet 17.2 cvs stool softener oral capsule 50 cvs vitamin b-6 oral tablet 200 cvs vitamin c oral tablet chewable 1000 cyanocobalamin injection solution 1000 mcg/ml CYTO B2 ORAL POWDER 343 MG/GM d 1000 oral tablet chewable 1000 unit d oral capsule unit d 400 oral tablet chewable 400 unit D3-50 ORAL CAPSULE UNIT d-5000 oral tablet 5000 unit daily-vite/iron/beta-carotene oral tablet day-time sinus oral capsule DELTUSS DP ORAL LIQUID 1-30 MG/5ML DESENEX EXTERNAL POWDER 2 % DESENEX SPRAY EXTERNAL AEROSOL 2 % DESITIN EXTERNAL CREAM 13 % DIALYVITE 800 ORAL TABLET 0.8 MG DIALYVITE 800-ZINC 15 ORAL TABLET 122

125 DIALYVITE VITAMIN D3 MAX ORAL TABLET UNIT DIMETAPP LONG ACT COUGH/COLD ORAL SYRUP MG/5ML DIMETAPP NIGHT COLD/CONGESTION ORAL LIQUID MG/5ML diphenhydramine hcl oral capsule 50 docusate sodium oral liquid 50 /5ml DOK ORAL TABLET 100 MG double antibiotic external ointment unit/gm DRAMAMINE LESS DROWSY ORAL TABLET 25 MG dual action complete oral tablet chewable DURAFLU ORAL TABLET MG ecee plus oral tablet ECOTRIN MAXIMUM STRENGTH ORAL TABLET DELAYED RELEASE 500 MG ed bron gp oral liquid /5ml ED CHLORPED D ORAL LIQUID 2-5 MG/ML ed chlorped jr oral syrup 2 /5ml ED CHLORPED ORAL LIQUID 2 MG/ML 123

126 ed-a-hist dm oral liquid /5ml ed-apap oral liquid 160 /5ml ELDERTONIC ORAL ELIXIR enema enema 7-19 gm/118ml enema mineral oil enema ENEMEEZ MINI ENEMA 283 MG ENEMEEZ PLUS ENEMA MG entre-cough oral liquid /5ml entre-hist pse oral liquid /ml ENUCLENE OPHTHALMIC SOLUTION 0.25 % e-oil oral oil 100 unt/0.25ml epsom salt oral granules eq allergy relief childrens oral tablet dispersible 12.5 eql antifungal (tolnaftate) external cream 1 % eql calcium/vitamin d oral capsule unit eql childrens calcium gummies oral tablet chewable unit eql childrens multivitamins oral tablet chewable eql iron supplement therapy oral tablet 200 (65 fe) eql lice solution combination kit % 124

127 eql oyster shell calcium/d oral tablet unit EQUALACTIN ORAL TABLET CHEWABLE 625 MG exefen-ir oral tablet EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG eye drops allergy relief ophthalmic solution % eye drops ophthalmic solution 0.05 % eye wash ophthalmic solution EZFE 200 ORAL CAPSULE (200 FE) MG ezfe forte oral capsule FEBROL ORAL SOLUTION 325 MG/5ML fer-iron oral solution 75 (15 fe) /ml ferretts ips oral solution 40 /15ml ferretts oral tablet 325 (106 fe) FERRIMIN 150 ORAL TABLET 150 MG ferrous fumarate oral tablet 29, 90 ferrous gluconate oral tablet 225 (27 fe), 240 (27 fe), 324 (38 fe) ferrous sulfate er oral tablet extendedrelease* 140 (45 fe) ferrous sulfate oral elixir 220 (44 fe) /5ml 125

128 ferrous sulfate oral liquid 220 (44 fe) /5ml ferrous sulfate oral syrup 300 (60 fe) /5ml ferrous sulfate oral tablet delayed release 324 (65 fe), 325 (65 fe) FEVERALL INFANTS SUPPOSITORY 80 MG fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180 fiber (corn dextrin) oral powder fiber (guar gum) oral tablet chewable fiber laxative oral tablet 625 fiber oral powder FLEET BISACODYL ENEMA 10 MG/30ML FLORANEX ORAL PACKET FLORASTOR KIDS ORAL PACKET 250 MG FOLGARD ORAL TABLET folic acid injection solution 5 /ml folic acid oral capsule 20 folic acid oral tablet 1, 400 mcg, 800 mcg FOLITAB 500 ORAL TABLET EXTENDEDRELEASE* MG FOLTABS 800 ORAL TABLET MCG-MG-MCG 126

129 FRESHKOTE OPHTHALMIC SOLUTION % FUNGICURE INTENSIVE/NAILGUARD EXTERNAL SOLUTION 1 % FUNGOID TINCTURE EXTERNAL KIT 2 % FUNGOID TINCTURE EXTERNAL SOLUTION 2 % GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION MG/10ML GAVISCON ORAL TABLET CHEWABLE MG gentian violet external solution 1 %, 2 % gentle laxative suppository 10 geravim oral liquid gnp antacid & anti-gas oral tablet chewable gnp artificial tears ophthalmic solution 5-6 /ml gnp calcium 1200 oral tablet chewable unit gnp childrens chewables/ex c oral tablet chewable gnp childrens pain relief/cold oral suspension /5ml gnp cold multi-sympt day/night oral gnp cold multi-symptom night oral tablet

130 gnp foaming antacid oral tablet chewable gnp iron oral tablet extendedrelease* 142 (45 fe) gnp multi-symptom cold night oral liquid /15ml gnp stool softener oral syrup 60 /15ml GONIOTAIRE OPHTHALMIC SOLUTION 2.5 % goodsense all day allergy oral tablet 10 goodsense pain relief pm ex st oral tablet guaifenesin dm oral tablet guaifenesin-codeine oral solution /5ml GUMMI BEAR MULTIVITAMIN/MIN ORAL TABLET CHEWABLE headache pm oral tablet hm allergy childrens oral liquid 12.5 /5ml hm famotidine oral tablet 20 hm rapid melts junior oral tablet dispersible 160 HONEY BEARS ORAL TABLET CHEWABLE HONEY BEARS W/IRON-ZINC ORAL TABLET CHEWABLE HYDROCIL ORAL PACKET 95 % 128

131 hydrocortisone external cream 0.5 % hydrocortisone external ointment 0.5 % hydrocortisone-aloe external cream 0.5 %, 1 % hydroxocobalamin intramuscular* solution 1000 mcg/ml HYPOTEARS OPHTHALMIC SOLUTION 1-1 % ibuprofen junior strength oral tablet chewable 100 ibuprofen oral capsule 200 ibuprofen pm oral tablet ICAPS LUTEIN-ZEAXANTHIN ORAL TABLET EXTENDEDRELEASE* ICAPS MV ORAL TABLET ICAPS ORAL CAPSULE infants ibuprofen oral suspension 50 /1.25ml infants pain relief oral suspension 80 /0.8ml INTEGRA ORAL CAPSULE MG intense cold/flu medicine oral tablet intense cough reliever ex st oral liquid /5ml IROMIN-G ORAL TABLET iron (ferrous gluconate) oral tablet 256 (28 fe) 129

132 iron 100 plus oral tablet iron 100/c oral tablet iron chews pediatric oral tablet chewable 15 iron oral tablet 90 (18 fe) IRON UP ORAL LIQUID 15 MG/0.5ML ISOPTO TEARS OPHTHALMIC SOLUTION 0.5 % J-MAX ORAL SYRUP MG/5ML J-TAN D PD ORAL LIQUID MG/ML J-TAN PD ORAL LIQUID 1 MG/ML k 100 oral tablet 100 mcg KAOPECTATE ORAL SUSPENSION 262 MG/15ML kidkare cough/cold oral liquid /5ml kls acid reducer max st oral tablet 150 KONSYL ORAL CAPSULE 520 MG KONSYL ORAL PACKET 100 %, 28.3 % KONSYL ORAL POWDER 28.3 %, 30.9 %, 60.3 %, % KONSYL-D ORAL POWDER 52.3 % kp b complex-c oral tablet kp benzoyl peroxide external 10 %, 5 % kp calcium 600+d oral capsule unit 130

133 kp calcium 600+d oral tablet unit kp calcium-magnesium-zinc oral tablet kp ferrous gluconate oral tablet 324 (37.5 fe) kp ferrous sulfate oral tablet 325 (65 fe) kp hydrocortisone external cream 1 % kp ketotifen fumarate ophthalmic solution % kp pseudoephedrine hcl oral tablet 60 kp terbinafine hydrochloride external cream 1 % kp vitamin d oral capsule 1000 unit kp vitamin e oral capsule 100 unit kpn prenatal oral tablet 0.1 LAMISIL ADVANCED EXTERNAL 1 % LAMISIL AF DEFENSE EXTERNAL AEROSOL, POWDER 1 % laxative pills oral tablet 25 lice killing maximum strength external liquid % lice killing maximum strength external shampoo % lice treatment external liquid 1 % liquid calcium with d3 oral capsule unit liquid calcium/vitamin d oral capsule unit 131

134 liquituss gg oral liquid 200 /5ml localnesium oral tablet localnesium-c oral tablet LODRANE D ORAL CAPSULE 4-60 MG LOHIST-D ORAL LIQUID 2-30 MG/5ML lohist-dm oral syrup /5ml lohist-peb oral liquid 4-10 /5ml loperamide hcl oral suspension 1 /7.5ml loratadine oral tablet 10 loratadine-pseudoephedrine er oral tablet extended release 24 hr* LOTRIMIN ULTRA EXTERNAL CREAM 1 % lubricating plus eye drops ophthalmic solution 0.5 % LUMITENE ORAL CAPSULE 30 MG MAALOX CHILDRENS ORAL TABLET CHEWABLE 400 MG MAALOX REGULAR STRENGTH ORAL SUSPENSION MG/5ML mag-al oral liquid /5ml mag-delay oral tablet extendedrelease* 535 (64 ) MAGINEX ORAL TABLET DELAYED RELEASE 615 MG 132

135 MAGNEBIND 300 ORAL TABLET MG magnesium citrate oral solution gm/30ml magnesium citrate oral tablet 100 magnesium oral capsule 300, 400 magnesium oral tablet 200, 30 magnesium oxide oral capsule 400 magnesium oxide oral tablet 250, 400 (240 ), 400, 420, 500 MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) MAPAP COLD FORMULA MULTI-SYMPT ORAL TABLET MG m-end dmx oral liquid /5ml MEPHYTON ORAL TABLET 5 MG MERIBIN ORAL CAPSULE 5 MG METAMUCIL MULTIHEALTH FIBER ORAL POWDER 63 % METAMUCIL ORAL WAFER METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % MEXSANA EXTERNAL POWDER 10.8 % 133

136 MI-ACID ORAL TABLET CHEWABLE MG miconazole 1 vaginal kit % miconazole 3 combo pack vaginal kit % (9gm) miconazole 3 vaginal cream 4 % miconazole 3 vaginal kit miconazole 7 vaginal cream 2 % miconazole 7 vaginal suppository 100 milk of magnesia concentrate oral suspension 2400 /10ml milk of magnesia oral suspension 1200 /15ml mineral oil oral oil MINTOX PLUS ORAL TABLET CHEWABLE MG MISSION PRENATAL HP ORAL TABLET MISSION PRENATAL ORAL TABLET motion sickness relief oral tablet chewable 25 MOTRIN IB ORAL TABLET 200 MG mucaphed oral tablet MUCINEX COUGH FOR KIDS ORAL PACKET MG MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR* MG, MG MUCINEX FAST-MAX COLD & SINUS ORAL TABLET MG 134

137 MUCINEX FOR KIDS ORAL PACKET 100 MG MUCINEX MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR* 1200 MG mucus relief cold/sinus max st oral liquid /20ml mucus relief cough childrens oral liquid /5ml mucus relief er oral tablet extended release 12 hr* 600 mucus relief oral tablet 400 mucus-dm max oral tablet extended release 12 hr* mucus-dm oral tablet extended release 12 hr* multi-delyn oral liquid multi-delyn/iron oral liquid multi-symptom cold childrens oral liquid /10ml MURO 128 OPHTHALMIC SOLUTION 2 % my way oral tablet 1.5 MYKIDZ IRON 10 ORAL SUSPENSION 15 MG/1.5ML MYKIDZ IRON ORAL SUSPENSION 10 MG/2ML naproxen sodium oral capsule 220 nasal decongestant oral liquid 30 /5ml 135

138 nasal decongestant oral syrup 30 /5ml nasal decongestant pe max st oral tablet 10 nasal spray extra moisturizing nasal solution 0.05 % NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NASOPEN PE ORAL LIQUID MG/15ML natural fiber laxative oral powder 68 % natural fiber therapy oral powder % natures tears ophthalmic solution 0.4 % neotuss oral liquid /5ml NEPHRONEX ORAL LIQUID NEXAFED ORAL 30 MG NEXAFED SINUS PRESSURE + PAIN ORAL TABLET MG niacin er oral capsule extended release* 250, 500 niacin er oral tablet extendedrelease* 1000, 500, 750 niacin oral tablet 100, 50, 500 niacinamide oral tablet 100, 500 nicotine polacrilex mouth/throat gum 2, 4 136

139 nicotine polacrilex mouth/throat lozenge 2, 4 nicotine transdermal kit /24hr nicotine transdermal patch 24 hr 14 /24hr, 21 /24hr, 7 /24hr night-time sinus oral capsule nohist-lq oral liquid 4-10 /5ml NOREL AD ORAL TABLET MG NOVAFERRUM 125 ORAL LIQUID MG-UNT/5ML NOVAFERRUM PEDIATRIC DROPS ORAL LIQUID 15 MG/ML NU-IRON ORAL CAPSULE 150 MG NUTRISOURCE FIBER ORAL PACKET NUTRISOURCE FIBER ORAL POWDER omeprazole oral tablet delayed release 20 organ-i nr oral tablet 200 OS-CAL EXTRA D3 ORAL TABLET MG-UNIT OSTEO-PORETICAL ORAL TABLET MG-UNIT OYSCO 500 ORAL TABLET 500 MG oyster shell calcium 250+d oral tablet unit oyster shell calcium/d oral tablet unit pain relief 8 hour oral tablet extendedrelease*

140 pain relief childrens oral suspension 160 /5ml pain relief extra strength oral tablet 500 pain reliever oral tablet 325 PANOXYL EXTERNAL BAR 10 % PANOXYL WASH EXTERNAL LIQUID 10 % PANOXYL-4 CREAMY WASH EXTERNAL LIQUID 4 % parva-cal oral tablet unit PEDIACARE CHILDRENS LONG-ACT ORAL LIQUID 7.5 MG/5ML PEDIA-LAX ORAL LIQUID 50 MG/15ML PEPCID AC ORAL TABLET CHEWABLE 10 MG peptic relief oral tablet chewable 262 PERDIEM OVERNIGHT RELIEF ORAL TABLET 15 MG permethrin external lotion 1 % PERRY PRENATAL ORAL CAPSULE MG PHENAGIL ORAL TABLET MG phos-nak oral packet polyvitamin oral solution 35 /ml polyvitamin/iron oral solution 10 /ml prenatal oral tablet

141 PRETZ NASAL SOLUTION PRILOSEC OTC ORAL TABLET DELAYED RELEASE 20 MG pro-chlo oral liquid /5ml PROFE ORAL CAPSULE (180 FE) MG PRONUTRIENTS CALCIUM+D3 ORAL TABLET MG-UNIT pseudoeph-bromphen-dm oral syrup /5ml psyldex oral powder 30 % PURE & GENTLE LUBRICANT OPHTHALMIC SOLUTION 0.3 % pyrethins-piperonyl butoxide external liquid % pyridoxine hcl injection solution 100 /ml pyrilamine-phenylephrine oral suspension 5-16 /5ml pyrilamine-phenylephrine oral tablet qc 3 day vaginal cream 4 % qc natural vegetable oral powder 95 % q-pap infants oral solution 80 /0.8ml Q-TAPP DM ORAL ELIXIR MG/5ML ra anti-itch maximum strength external ointment 1 % 139

142 ra b-complex/vitamin c cr oral tablet extendedrelease* ra beta carotene oral capsule 15 ra calamine external lotion % ra calcium 600/vit d/minerals oral tablet unit ra calcium-boron oral tablet ra central-vite performance oral tablet ra col-rite oral capsule 50 ra coral calcium oral capsule unit ra high potency iron oral tablet 27 ra hydrocortisone plus external cream 0.5 % ra ibuprofen childrens oral suspension 100 /5ml ra lubricant eye ophthalmic solution % ra magnesium oral capsule 500 ra multi-symptom day/night oral ra omeprazole-sodium bicarb oral capsule ra ophthalmic ophthalmic solution 5 % ra oyster shell calcium/d oral tablet unit, unit ra probiotic complex oral capsule 140

143 ra severe cold/sinus relief pe oral tablet ra slow release iron oral tablet extendedrelease* 45, 47.5 ra soluble fiber oral tablet 500 ra vitamin c drops mouth/throat lozenge 60 ra vitamin c/rose hips cr oral tablet extendedrelease* 1000 ranitidine hcl oral tablet 75 REFRESH CELLUVISC OPHTHALMIC SOLUTION 1 % REFRESH OPTIVE ADVANCED OPHTHALMIC SOLUTION % REFRESH P.M. OPHTHALMIC OINTMENT REGULOID ORAL POWDER %, 58.6 % REHYDRALYTE ORAL SOLUTION RESCON DM ORAL SYRUP MG/5ML RESCON ORAL TABLET 2-60 MG RESPAIRE-30 ORAL CAPSULE MG RETAINE MGD OPHTHALMIC EMULSION % RHINARIS NASAL 0.2 % RHINARIS NASAL SOLUTION 0.2 % RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT % RISA-BID PROBIOTIC ORAL TABLET 141

144 RISAMINE EXTERNAL OINTMENT % robafen cf cough/cold oral syrup /5ml robafen cough oral capsule 15 ROBITUSSIN CHILD COUGH/COLD CF ORAL LIQUID MG/5ML ROBITUSSIN CHILD COUGH/COLD LA ORAL LIQUID MG/5ML ROBITUSSIN CHILDRENS COUGH LA ORAL SYRUP 7.5 MG/5ML ROBITUSSIN COLD+FLU DAYTIME ORAL CAPSULE MG ROBITUSSIN LINGERING LA COUGH ORAL LIQUID 15 MG/5ML ROBITUSSIN MUCUS+CHEST CONGEST ORAL LIQUID 100 MG/5ML ROBITUSSIN MULTI-SYMPTOM MAX ORAL LIQUID MG/5ML ROBITUSSIN PEAK COLD MULTI-SYM ORAL LIQUID MG/5ML rymed oral tablet 2-10 rynex dm oral liquid /5ml rynex pse oral liquid 1-15 /5ml saline laxative oral solution gm/5ml sb fib lax orange oral powder 33 % sb lice treatment external liquid % 142

145 sb natural fiber laxative oral powder 49 % SCOOBY-DOO ONE A DAY ORAL TABLET CHEWABLE SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5ML SCOT-TUSSIN SENIOR ORAL LIQUID MG/5ML SECURA EXTRA PROTECTIVE EXTERNAL CREAM 30.6 % SECURA PROTECTIVE EXTERNAL CREAM 10 % selenium er oral tablet extendedrelease* 200 mcg selenium oral tablet 100 mcg senna laxative oral tablet 8.6 senna oral capsule 8.6 senna oral syrup 176 /5ml, 8.8 /5ml SENNA PROMPT ORAL CAPSULE MG senna s oral tablet SENSI-CARE PROTECTIVE BARRIER EXTERNAL OINTMENT % sleep aid oral tablet 25 SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG slow magnesium/calcium oral tablet delayed release slow release iron oral tablet extendedrelease* 140 (45 fe),

146 SLOW-MAG ORAL TABLET DELAYED RELEASE MG sm adult nasal decongestant oral liquid 15 /5ml sm calcium/vitamin d3 oral tablet unit sm calcium-magnesium-zinc oral tablet SM CORAL CALCIUM ORAL TABLET 1000 (390 CA) MG sm iron slow release oral tablet extendedrelease* 160 (50 fe) sm lansoprazole oral capsule delayed release 15 sm magnesium oxide oral tablet 250 sm motion sickness relief oral tablet 50 sm redness relief ophthalmic solution % sm slow release iron oral tablet extendedrelease* 143 (45 fe) sm vitamin b12 tr oral tablet extendedrelease* 2000 mcg sm vitamin c cr oral tablet extendedrelease* 500 sm vitamin d3 oral capsule 4000 unit sodium bicarbonate oral powder sodium chloride (hypertonic) ophthalmic ointment 5 % 144

147 SOLUBLE FIBER THERAPY ORAL POWDER SOOTHE OPHTHALMIC SOLUTION % SOOTHE ORAL TABLET 262 MG sorbulax oral powder 100 % stahist ad oral liquid /5ml stahist ad oral tablet STERILE LUBRICANT OPHTHALMIC LIQUID 0.7 % stomach relief max st oral suspension 525 /15ml stool softener laxative dc oral capsule 240 stool softener oral capsule 100 SUMMERS EVE DISP MEDICATED VAGINAL SOLUTION 0.3 % SYSTANE BALANCE OPHTHALMIC SOLUTION 0.6 % SYSTANE NIGHTTIME OPHTHALMIC OINTMENT SYSTANE OVERNIGHT THERAPY OPHTHALMIC 0.3 % TEARS AGAIN NIGHT & DAY OPHTHALMIC % tg 10peh/380gfn oral tablet tg 10peh/380gfn/15dm oral tablet tgt cough formula dm max adult oral liquid /5ml 145

148 tgt eye allergy relief ophthalmic solution % tgt flu/severe cold/cough rlf oral packet tgt lubricant eye drops ophthalmic solution % tgt pain reliever pm ex st oral tablet th calcium-magnesium-zinc oral tablet th eye drop tears ophthalmic solution % THERA/BETA-CAROTENE ORAL TABLET THERA-D 4000 ORAL TABLET 4000 UNIT THERANATAL CORE NUTRITION ORAL TABLET 27-1 MG THERATEARS OPHTHALMIC SOLUTION 0.25 % thiamine hcl injection solution 100 /ml tioconazole-1 vaginal ointment 6.5 % TITRALAC ORAL TABLET CHEWABLE 420 MG tolnaftate external cream 1 % tolnaftate external powder 1 % tolnaftate external solution 1 % total b/c oral tablet triacting day time cold/cough oral solution /5ml 146

149 TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG TRIAMINIC FEVER REDUCER ORAL SYRUP 160 MG/5ML TRIAMINIC NIGHT TIME COLD/CGH ORAL SYRUP MG/5ML tri-buffered aspirin oral tablet 325 triple antibiotic external ointment triple paste af external ointment 2 % TRIPLE PASTE EXTERNAL OINTMENT 12.8 % TRI-VI-SOL ORAL SOLUTION UNIT-MG/ML TRI-VITA ORAL SOLUTION UNIT-MG/ML tri-vitamin oral solution TUSNEL ORAL LIQUID MG/5ML TUSNEL PEDIATRIC ORAL LIQUID MG/5ML, MG/ML TUSNEL-DM PEDIATRIC ORAL LIQUID MG/ML tussin cf cough & cold oral liquid /5ml tussin dm oral syrup /5ml tussi-pres b oral liquid /5ml 147

150 UPCAL D ORAL PACKET MG-UNIT UPCAL D ORAL POWDER MG-UNT/5GM VAGISTAT-3 VAGINAL KIT MG-% (9GM) VICKS DAYQUIL MUCUS CONTROL DM ORAL LIQUID MG/15ML VICKS NYQUIL D COLD & FLU ORAL LIQUID MG/30ML VICKS VAPORUB EXTERNAL OINTMENT % VISINE-LR OPHTHALMIC SOLUTION % VITALETS ORAL TABLET CHEWABLE 40 MG VITAMELTS ENERGY VITAMIN B-12 ORAL TABLET DISPERSIBLE 1500 MCG vitamin a & d oral capsule unit vitamin a palmitate oral tablet unit vitamin b-1 oral tablet 100, 50 vitamin b-12 oral liquid 1000 mcg/15ml vitamin b-12 oral tablet 250 mcg, 500 mcg 148

151 vitamin b-12 sublingual tablet sublingual 1000 mcg vitamin b12-folic acid oral tablet mcg vitamin b-2 oral tablet 25, 50 vitamin b-6 er oral tablet extendedrelease* 200 vitamin b-6 oral tablet 100, 25, 50 vitamin c (calcium ascorbate) oral solution reconstituted vitamin c oral syrup 500 /5ml vitamin c oral tablet 100, 250, 500 vitamin c oral tablet chewable 100, 250 vitamin d (ergocalciferol) oral capsule unit vitamin d oral tablet 1000 unit, 2000 unit vitamin d2 oral tablet 2000 unit, 400 unit vitamin d3 oral capsule 2000 unit, 400 unit, 5000 unit vitamin d3 oral liquid 1200 unit/15ml, 400 unit/ml, 5000 unit/ml vitamin d3 oral tablet 3000 unit, 400 unit vitamin e oral capsule 1000 unit, 200 unit vitamin e oral solution 15 unit/0.3ml 149

152 vitamin e oral tablet 100 unit vitamin e-selenium oral capsule unit-mcg vitamin k (phytonadione) oral tablet 100 mcg vitamin k1 injection solution 1 /0.5ml, 10 /ml vitatrum oral tablet chewable WAL-ACT ORAL TABLET MG WAL-DRYL ALLRGY/SINUS HEADACHE ORAL TABLET MG WAL-DRYL-D ALLERGY/SINUS ORAL TABLET MG WAL-FEX D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* MG WAL-FLU SEVERE COLD DAYTIME ORAL PACKET MG WAL-ITIN D ORAL TABLET EXTENDED RELEASE 12 HR* MG WAL-ITIN ORAL SYRUP 5 MG/5ML WAL-PHED PE SINUS/ALLERGY ORAL TABLET 4-10 MG WAL-PHED SINUS/ALLERGY ORAL TABLET 4-60 MG wal-som maximum strength oral capsule 50 wee care oral suspension 15 /1.25ml 150

153 zinc oxide external ointment 20 %, 40 % zinc oxide external paste 25 % ZONATUSS ORAL CAPSULE 150 MG zoo friends complete oral tablet chewable 30 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 10 oral tablet extendedrelease* 10 meq klor-con m15 oral tablet extendedrelease* 15 meq klor-con m20 oral tablet extendedrelease* 20 meq klor-con oral packet 20 meq klor-con oral tablet extendedrelease* 8 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS* SOLUTION 10-5 MG/ML-%, 20-5 MG/ML-% MAGNESIUM SULFATE INJECTION SOLUTION 40 MG/ML, 80 MG/ML magnesium sulfate injection solution 50 % potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq potassium chloride er oral capsule extended release* 10 meq, 8 meq potassium chloride er oral tablet extendedrelease* 10 meq, 20 meq 151

154 potassium chloride er oral tablet extendedrelease* 8 meq potassium chloride oral liquid 20 meq/15ml (10%), 40 meq/15ml (20%) sodium chloride injection solution 2.5 meq/ml sodium fluoride oral tablet 2.2 (1 f) TPN ELECTROLYTES INTRAVENOUS* SOLUTION IV NUTRITION AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 % AMINOSYN M INTRAVENOUS* SOLUTION 3.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 % B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 152

155 CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS* SOLUTION 4.25 % B/D CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS* SOLUTION 4.25 % B/D CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION 4.25 % B/D CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION 4.25 % B/D CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % B/D CLINIMIX/DEXTROSE (5/20) INTRAVENOUS* SOLUTION 5 % B/D CLINIMIX/DEXTROSE (5/25) INTRAVENOUS* SOLUTION 5 % B/D FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % B/D FREAMINE III INTRAVENOUS* SOLUTION 10 % B/D HEPATAMINE INTRAVENOUS* SOLUTION 8 % B/D INTRALIPID INTRAVENOUS* EMULSION 20 %, 30 % B/D NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % B/D NUTRILIPID INTRAVENOUS* EMULSION 20 % B/D premasol intravenous* solution 10 % B/D premasol intravenous* solution 6 % B/D PROCALAMINE INTRAVENOUS* SOLUTION 3 % B/D 153

156 PROSOL INTRAVENOUS* SOLUTION 20 % TRAVASOL INTRAVENOUS* SOLUTION 10 % TROPHAMINE INTRAVENOUS* SOLUTION 10 % IV REPLACEMENT SOLUTIONS DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS* SOLUTION dextrose in lactated ringers intravenous* solution 5 % dextrose intravenous* solution 10 %, 5 %, 50 %, 70 % DEXTROSE-NACL INTRAVENOUS* SOLUTION % dextrose-nacl intravenous* solution %, %, %, %, %, %, %, % IONOSOL-B IN D5W INTRAVENOUS* SOLUTION IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION ISOLYTE-S INTRAVENOUS* SOLUTION B/D B/D B/D 154

157 kcl in dextrose-nacl intravenous* solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION MEQ/L-%-% lactated ringers intravenous* solution normosol-m in d5w intravenous* solution NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION PLASMA-LYTE 148 INTRAVENOUS* SOLUTION PLASMA-LYTE A INTRAVENOUS* SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous* solution meq/l-%, meq/l-%, meq/l-% 155

158 potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 20 meq/100ml, 40 meq/100ml potassium chloride intravenous* solution 2 meq/ml ringers intravenous* solution sodium chloride intravenous* solution 0.45 %, 0.9 %, 3 %, 5 % VITAMINS calcitriol intravenous* solution 1 mcg/ml B/D calcitriol oral capsule 0.25 mcg, 0.5 mcg B/D calcitriol oral solution 1 mcg/ml B/D paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg B/D prenatal oral tablet 27-1 OPHTHALMIC ANTIALLERGICS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % cromolyn sodium ophthalmic solution 4 % LASTACAFT OPHTHALMIC SOLUTION 0.25 % PATADAY OPHTHALMIC SOLUTION 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % 156

159 ANTIGLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % brimonidine tartrate ophthalmic solution 0.15 % brimonidine tartrate ophthalmic solution 0.2 % carteolol hcl ophthalmic solution 1 % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution /ml ISTALOL OPHTHALMIC SOLUTION 0.5 % latanoprost ophthalmic solution % levobunolol hcl ophthalmic solution 0.25 % levobunolol hcl ophthalmic solution 0.5 % LUMIGAN OPHTHALMIC SOLUTION 0.01 % 157

160 metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC SOLUTION % ANTI-INFECTIVE/ANTI-INFLAMMA TORY bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % blephamide s.o.p. ophthalmic ointment % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % 158

161 TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % ANTI-INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % CILOXAN OPHTHALMIC OINTMENT 0.3 % ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 /gm gatifloxacin ophthalmic solution 0.5 % gentak ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % ilotycin ophthalmic ointment 5 /gm MOXEZA OPHTHALMIC SOLUTION 0.5 % NATACYN OPHTHALMIC SUSPENSION 5 % 159

162 neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % tobramycin ophthalmic solution 0.3 % TOBREX OPHTHALMIC OINTMENT 0.3 % trifluridine ophthalmic solution 1 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC 0.15 % ANTI-INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION 0.2 % bromfenac sodium (once-daily) ophthalmic solution 0.09 % bromfenac sodium ophthalmic solution 0.09 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % 160

163 DUREZOL OPHTHALMIC EMULSION 0.05 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % MAXIDEX OPHTHALMIC SUSPENSION 0.1 % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % MISCELLANEOUS naphazoline hcl ophthalmic solution 0.1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % QL (64 EA per 30 days) 161

164 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT ipratropium-albuterol inhalation solution (3) /3ml ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCR ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % ipratropium bromide nasal solution 0.03 %, 0.06 % ANTIHISTAMINES QL (60 EA per 30 days) QL (8 GM per 30 days) B/D QL (25.8 GM per 30 days) QL (30 EA per 30 days) B/D ASTEPRO NASAL SOLUTION 0.15 % azelastine hcl nasal solution 0.1 %, 0.15 % cetirizine hcl oral syrup 1 /ml diphenhydramine hcl injection solution 50 /ml hydroxyzine hcl intramuscular* solution 25 /ml, 50 /ml PA hydroxyzine hcl oral solution 10 /5ml PA 162

165 hydroxyzine hcl oral tablet 10, 25, 50 PA hydroxyzine pamoate oral capsule 100, 25, 50 PA levocetirizine dihydrochloride oral solution 2.5 /5ml levocetirizine dihydrochloride oral tablet 5 olopatadine hcl nasal solution 0.6 % BETA AGONISTS albuterol sulfate er oral tablet extended release 12 hr* 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 levalbuterol hcl inhalation nebulization solution 1.25 /0.5ml PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 B/D B/D B/D QL (60 EA per 30 days) 163

166 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 20 /2ml MISCELLANEOUS QL (36 GM per 30 days) QL (30 GM per 30 days) B/D acetylcysteine inhalation solution 10 %, 20 % B/D ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 1000 PA; LA MG, 400 MG, 500 MG, 800 MG AUVI-Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML DALIRESP ORAL TABLET 500 MCG EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML ESBRIET ORAL CAPSULE 267 MG PA 164

167 KALYDECO ORAL PACKET 50 MG, 75 MG PA KALYDECO ORAL TABLET 150 MG PA OFEV ORAL CAPSULE 100 MG, 150 MG PA PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 PA; LA MG PULMOZYME INHALATION SOLUTION 1 MG/ML B/D XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG PA; LA ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG PA; LA NASAL STEROIDS flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act STEROID INHALANTS ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST QL (50 ML per 30 days) QL (16 GM per 30 days) QL (30 EA per 30 days) B/D QL (120 EA per 30 days) 165

168 FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH, MCG/INH SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT XANTHINES aminophylline intravenous* solution 25 /ml elixophyllin oral elixir 80 /15ml QL (240 EA per 30 days) QL (24 GM per 30 days) QL (21.2 GM per 30 days) QL (2 EA per 30 days) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (60 EA per 30 days) QL (10.2 GM per 30 days) 166

169 theo-24 oral capsule extended release 24 hour 100, 200, 300, 400 theophylline er oral tablet extended release 12 hr* 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr* 400, 600 theophylline oral solution 80 /15ml TOPICAL DERMATOLOGY, ACNE adapalene external 0.1 % adapalene external cream 0.1 % amnesteem oral capsule 10, 20, 40 avita external % avita external cream % benzoyl peroxide-erythromycin external 5-3 % claravis oral capsule 10, 20, 30, 40 clindamax external 1 % clindamycin phosphate external 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % ery external pad 2 % 167

170 erythromycin external 2 % erythromycin external solution 2 % myorisan oral capsule 10, 20, 40 sulfacetamide sodium external suspension 10 % tretinoin external 0.01 %, % tretinoin external cream %, 0.05 %, 0.1 % zenatane oral capsule 10, 20, 30, 40 DERMATOLOGY, ANTIBIOTICS gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % mupirocin external ointment 2 % silver sulfadiazine external cream 1 % ssd external cream 1 % SULFAMYLON EXTERNAL CREAM 85 MG/GM SULFAMYLON EXTERNAL PACKET 5 % DERMATOLOGY, ANTIFUNGALS ciclopirox external 0.77 % ciclopirox external shampoo 1 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % 168

171 clotrimazole external cream 1 % clotrimazole external solution 1 % econazole nitrate external cream 1 % ketoconazole external cream 2 % nyamyc external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystop external powder unit/gm DERMATOLOGY, ANTIPRURITIC procto-pak cream 1 % proctosol hc cream 2.5 % proctozone-hc cream 2.5 % prudoxin external cream 5 % DERMATOLOGY, ANTIPSORIATICS 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10, 17.5, 25 PA calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % 169

172 calcitrene external ointment % TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % DERMATOLOGY, ANTISEBORRHEICS ketoconazole external shampoo 2 % selenium sulfide external lotion 2.5 % DERMATOLOGY, CORTICOSTEROIDS ala cort external cream 1 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % apexicon external ointment 0.05 % betamethasone dipropionate aug external 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % PA 170

173 betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate e external cream 0.05 % clobetasol propionate external 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % cormax scalp application external solution 0.05 % desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external ointment 0.05 % desoximetasone external ointment 0.25 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % 171

174 fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide external 0.05 % fluocinonide external cream 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % 172

175 hydrocortisone external cream 1 %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % lokara external lotion 0.05 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % texacort external solution 2.5 % triamcinolone acetonide external cream %, 0.1 %, 0.5 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment %, 0.1 %, 0.5 % triderm external cream 0.1 % DERMATOLOGY, LOCAL ANESTHETICS lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (3 EA per 1 day) lidocaine hcl external 2 % lidocaine hcl external solution 4 % lidocaine-prilocaine external cream % B/D 173

176 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir external ointment 5 % ammonium lactate external cream 12 % ammonium lactate external lotion 12 % ELIDEL EXTERNAL CREAM 1 % PA fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % imiquimod external cream 5 % laclotion external lotion 12 % metronidazole external 0.75 % metronidazole external cream 0.75 % metronidazole external lotion 0.75 % PANRETIN EXTERNAL 0.1 % podofilox external solution 0.5 % rosadan external cream 0.75 % tacrolimus external ointment 0.03 %, 0.1 % PA TARGRETIN EXTERNAL 1 % PA VALCHLOR EXTERNAL % PA; LA VOLTAREN TRANSDERMAL 1 % DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX EXTERNAL CREAM 10 % EURAX EXTERNAL LOTION 10 % malathion external lotion 0.5 % 174

177 permethrin external cream 5 % DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation solution 0.25 % REGRANEX EXTERNAL 0.01 % PA SANTYL EXTERNAL OINTMENT 250 UNIT/GM sodium chloride irrigation solution 0.9 % sterile water for irrigation irrigation solution MOUTH/THROAT/DENTAL AGENTS cevimeline hcl oral capsule 30 chlorhexidine gluconate mouth/throat solution 0.12 % clotrimazole mouth/throat troche 10 lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension unit/ml periogard mouth/throat solution 0.12 % pilocarpine hcl oral tablet 5 pilocarpine hcl oral tablet 7.5 triamcinolone acetonide mouth/throat paste 0.1 % OTIC acetic acid otic solution 2 % acetic acid-aluminum acetate otic solution 2 % 175

178 CIPRODEX OTIC SUSPENSION % fluocinolone acetonide otic oil 0.01 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % 176

179 xedni Index of Drugs 12 hour decongestant MOP abacavir sulfate abacavir-lamivudine-zidovudine ABELCET ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE ABREVA acamprosate calcium acarbose acebutolol hcl ACEPHEN ACEROLA C acetaminophen acetaminophen 8 hour acetaminophen junior strength acetaminophen-codeine acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetazolamide acetazolamide er acetic acid acetic acid-aluminum acetate acetylcysteine ACID GONE acid reducer acidophilus/l-sporogenes acitretin acne medication acne medication ACTHIB ACTIMMUNE acyclovir... 23, 174 acyclovir sodium ADACEL ADAGEN xedni adapalene adefovir dipivoxil ADEMPAS adriamycin adrucil ADVAIR DISKUS ADVAIR HFA advanced calcium formula ADVIL ALLERGY & CONGESTION ADVIL ALLERGY SINUS ADVIL COLD & SINUS LIQUI-GELS ADVIL JUNIOR STRENGTH afeditab cr AFINITOR AFINITOR DISPERZ AFRIN CHILDRENS AGGRENOX a-hydrocort ala cort ALA-HIST IR ALA-HIST PE ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate ALDURAZYME alendronate sodium alfuzosin hcl er ALIMTA ALINIA all day allergy-d all day pain relief ALLEGRA ALLERGY CHILDRENS aller-ease allergy relief allopurinol... 9 alosetron hcl xedni ALPHAGAN P alprazolam ALREX altavera aluminum hydroxide gel amantadine hcl ambi 12.5cpd/1dcpm/30pse ambi 40pse/400gfn/20dm AMBISOME amifostine amikacin sulfate amiloride hcl amiloride-hydrochlorothiazide aminophylline AMINOSYN AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN M AMINOSYN/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... 45, 46 AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-valsartan-hctz ammonium lactate amnesteem amoxapine amoxicillin... 29, 30 amoxicillin-pot clavulanate amoxicillin-pot clavulanate er

180 xedni amphetamine-dextroamphet er amphetamine-dextroamphetami ne amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam sodium AMPYRA anagrelide hcl anastrozole ANDRODERM ANORO ELLIPTA antacid maximum strength anti-diarrheal antifungal antioxidant formula sg apap apexicon ap-hist dm APOKYN apri APRISO APTIOM APTIVUS AQUADEKS AQUA-E AQUANIL HC ARALAST NP aranelle ARCALYST aripiprazole ARNUITY ELLIPTA artificial tears ASACOL HD ascorbic acid aspirin aspirin ec ASSURE ID INSULIN SAFETY SYR ASTEPRO xedni atenolol atenolol-chlorthalidone athletes foot spray atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA ATROVENT HFA aubra AUVI-Q AVASTIN aviane avita AVODART AXID AR AXIRON AYR SALINE NASAL AYR SALINE NASAL DROPS azacitidine AZACTAM IN DEXTROSE azathioprine azelastine hcl , 162 AZILECT azithromycin AZOPT AZOR aztreonam b complex b B-12 DOTS bacitracin , 159 bacitracin zinc bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen balsalazide disodium balziva BANZEL BARACLUDE BCG VACCINE b-complex/vitamin c xedni bee zee BELEODAQ benazepril hcl benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benzoyl peroxide cleanser benzoyl peroxide wash benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE beta carotene betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl bethanechol chloride BETOPTIC-S BEXSERO bicalutamide BICILLIN L-A BICNU BILTRICIDE biospec dmx biotin bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin sulfate blephamide s.o.p B-NATAL BONE DENSITY

181 xedni bone meal BOOSTRIX BOSULIF BOUDREAUXS BUTT PASTE BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRINTELLIX brohist d bromfenac sodium bromfenac sodium (once-daily) bromocriptine mesylate budesonide budesonide er bumetanide buprenorphine hcl buprenorphine hcl-naloxone hcl buproban bupropion hcl bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl BUSULFEX butorphanol tartrate BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN BYSTOLIC c cabergoline cal/mag CALCET CREAMY BITES CALCET PETITES CALCI-MIX calcionate calcipotriene calcitonin (salmon) cal-citrate plus vitamin d calcitrene xedni calcitriol calcium calcium + d calcium + d calcium d calcium calcium 500/d calcium 500+d high potency calcium calcium 600/vitamin d calcium 600+d plus minerals calcium acetate calcium antacid calcium antacid extra strength calcium antacid ultra max st calcium ascorbate calcium carbonate calcium carbonate-vitamin d calcium citrate calcium citrate + d calcium citrate malate-vit d calcium citrate-vitamin d calcium for women calcium gluconate calcium gummies calcium lactate calcium pantothenate calcium soft chews calcium/c/d calcium+d3 gradual release calcium-magnesium calcium-magnesium-vitamin d calcium-magnesium-zinc calcium-vitamin d xedni calmag thins CAL-QUICK CALTRATE 600+D SOFT camila CANASA CANCIDAS CAPASTAT SULFATE CAPRELSA captopril captopril-hydrochlorothiazide CARBAGLU carbamazepine carbamazepine er carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone carboplatin CARIMUNE NF carteolol hcl cartia xt carvedilol castellani paint modified CAYSTON cefaclor cefaclor er cefadroxil cefazolin sodium cefdinir cefepime hcl cefixime cefotaxime sodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME AND DEXTROSE ceftriaxone sodium cefuroxime axetil cefuroxime sodium

182 xedni celecoxib... 9 CELONTIN CENTRUM KIDS COMPLETE CENTRUM SILVER cephalexin CERDELGA CEREZYME CEROVITE ADVANCED FORMULA CERVARIX cetirizine hcl , 162 cevimeline hcl CHANTIX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH PAK chelated calcium CHEMET chewable calcium chewable vite childrens chewable vite/iron childrens childrens acetaminophen childrens cold & allergy childrens complete allergy childrens non-aspirin childrens plus cold childrens plus cold & allergy chlo tuss ex chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpheniramine maleate er chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light ciclopirox ciclopirox olamine xedni cilostazol CILOXAN CIMZIA CIMZIA PREFILLED CIMZIA STARTER KIT CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 29, 159 ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er cisplatin citalopram hydrobromide CITRACAL CALCIUM GUMMIES CITRACAL PLUS HEART HEALTH citrus calcium +d citrus calcium/vitamin d cladribine claravis clarithromycin clarithromycin er CLARITIN CLARITIN REDITABS classic prenatal clindamax clindamycin hcl clindamycin palmitate hcl clindamycin phosphate... 17, 102, 167 clindamycin phosphate in d5w CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/10) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) xedni CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) clobetasol propionate clobetasol propionate e clomipramine hcl clonazepam clonidine hcl clopidogrel bisulfate clorazepate dipotassium... 57, 58 clotrimazole , 169, 175 clotrimazole clozapine CLOZAPINE COARTEM cod liver oil codituss dm colchicine-probenecid... 9 COLCRYS... 9 cold head congestion severe cold/cough childrens cold/cough/sore throat child colestipol hcl colistimethate sodium colocort COMBIGAN COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMPLERA complete sinus relief compro COMTREX SEVERE COLD & SINUS

183 xedni COMVAX CONEX COLD/ALLERGY constulose CONTAC COLD+FLU MAX ST COPAXONE coral calcium coral calcium plus CORICIDIN HBP CONGESTION/COUGH cormax scalp application cortisone acetate CORTIZONE cough & cold cough & sore throat day cough dm COUMADIN CREON CRESTOR CRIXIVAN cromolyn sodium... 99, 121, 156, 164 cryselle CUBICIN CUVPOSA cvs calcium citrate cvs easy fiber/calcium cvs hydrocortisone acetate cvs laxative dietary supplemnt cvs lubricant drops cvs lubricating/dry eye cvs nasal mist cvs pain relief adult cvs probiotic (lactobacillus) cvs senna-extra cvs stool softener cvs vitamin b cvs vitamin c cyanocobalamin cyclafem 1/ cyclafem 7/7/ xedni cyclophosphamide CYCLOPHOSPHAMIDE cycloserine cyclosporine cyclosporine modified CYSTADANE CYSTAGON cytarabine CYTO B d d d D d dacarbazine daily-vite/iron/beta-carotene DALIRESP danazol dantrolene sodium dapsone DAPTACEL DARAPRIM daunorubicin hcl day-time sinus deblitane DELESTROGEN DELTUSS DP delyla DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA DESENEX DESENEX SPRAY desipramine hcl DESITIN desmopressin ace rhinal tube desmopressin ace spray refrig desmopressin acetate xedni desmopressin acetate spray desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sod phosphate pf dexamethasone sodium phosphate... 90, 160 DEXILANT dexrazoxane dextrose DEXTROSE 5%/ELECTROLYTE # dextrose in lactated ringers DEXTROSE-NACL dextrose-nacl DIALYVITE DIALYVITE 800-ZINC DIALYVITE VITAMIN D3 MAX diazepam diazepam intensol diclofenac potassium... 9 diclofenac sodium... 9, 160 diclofenac sodium er... 9 dicloxacillin sodium dicyclomine hcl didanosine DIFICID diflorasone diacetate diflunisal... 9 digitek digoxin dihydroergotamine mesylate dilantin DILANTIN dilantin infatabs diltiazem hcl diltiazem hcl er diltiazem hcl er beads

184 xedni diltiazem hcl er coated beads dilt-xr diltzac DIMETAPP LONG ACT COUGH/COLD DIMETAPP NIGHT COLD/CONGESTION DIPENTUM diphenhydramine hcl , 162 diphenoxylate-atropine DIPHTHERIA-TETANUS TOXOIDS DT disopyramide phosphate disulfiram divalproex sodium divalproex sodium er docetaxel DOCETAXEL docusate sodium DOK donepezil hcl dorzolamide hcl dorzolamide hcl-timolol mal double antibiotic doxazosin mesylate doxepin hcl doxorubicin hcl doxorubicin hcl liposomal doxy doxycycline hyclate doxycycline monohydrate DRAMAMINE LESS DROWSY dronabinol drospirenone-ethinyl estradiol DROXIA dual action complete duloxetine hcl DURAFLU xedni duramorph DUREZOL e.e.s ecee plus econazole nitrate ECOTRIN MAXIMUM STRENGTH ed bron gp ED CHLORPED ED CHLORPED D ed chlorped jr ed-a-hist dm ed-apap EDURANT EFFIENT ELDERTONIC ELIDEL ELIQUIS ELITEK elixophyllin ELMIRON EMCYT EMEND emoquette EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide endocet enema enema mineral oil ENEMEEZ MINI ENEMEEZ PLUS ENGERIX-B enoxaparin sodium enpresse entacapone entecavir entre-cough entre-hist pse ENUCLENE xedni enulose e-oil EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin hcl epitol EPIVIR HBV eplerenone epsom salt EPZICOM eq allergy relief childrens eql antifungal (tolnaftate) eql calcium/vitamin d eql childrens calcium gummies eql childrens multivitamins eql iron supplement therapy eql lice solution eql oyster shell calcium/d EQUALACTIN ERIVEDGE errin ery ery-tab erythrocin lactobionate erythrocin stearate erythromycin , 168 erythromycin base erythromycin ethylsuccinate ESBRIET escitalopram oxalate esomeprazole sodium estrace estradiol estradiol valerate ethambutol hcl ethosuximide etodolac etodolac er... 9 etoposide EURAX

185 xedni EVOTAZ EXCEL COMFORT POINT PEN NEEDLE exefen-ir EXELON exemestane EXJADE EX-LAX ULTRA eye drops eye drops allergy relief eye wash EZFE ezfe forte FABRAZYME falmina famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON FARXIGA FARYDAK FASLODEX FAZACLO FEBROL felbamate felodipine er fenofibrate fenofibrate micronized fenofibric acid fentanyl fentanyl citrate FENTORA fer-iron ferretts ferretts ips FERRIMIN FERRIPROX ferrous fumarate ferrous gluconate ferrous sulfate , 126 xedni ferrous sulfate er FETZIMA FETZIMA TITRATION FEVERALL INFANTS fexofenadine hcl fexofenadine hcl childrens fiber fiber (corn dextrin) fiber (guar gum) fiber laxative finasteride FIRAZYR FLEBOGAMMA FLEBOGAMMA DIF flecainide acetate FLEET BISACODYL FLORANEX FLORASTOR KIDS FLOVENT DISKUS , 166 FLOVENT HFA fluconazole fluconazole in dextrose fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide , 176 fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide-e fluorometholone fluorouracil... 35, 174 fluoxetine hcl... 64, 65 fluphenazine decanoate fluphenazine hcl flurbiprofen xedni flurbiprofen sodium flutamide fluticasone propionate , 172 fluvoxamine maleate FOLGARD folic acid FOLITAB FOLTABS fondaparinux sodium , 103 FORTEO FORTICAL foscarnet sodium fosinopril sodium fosinopril sodium-hctz FREAMINE HBC FREAMINE III FRESHKOTE FUNGICURE INTENSIVE/NAILGUARD FUNGOID TINCTURE furosemide FUSILEV FUZEON FYCOMPA... 58, 59 gabapentin GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMASTAN S/D GAMMAGARD GAMMAGARD S/D GAMMAGARD S/D LESS IGA GAMMAKED GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL GARDASIL gatifloxacin

186 xedni GATTEX gavilyte-c gavilyte-g gavilyte-h gavilyte-n with flavor pack GAVISCON GAVISCON EXTRA RELIEF FORMULA GEMCITABINE HCL gemcitabine hcl gemfibrozil generlac gengraf gentak gentamicin in saline gentamicin sulfate... 14, 159, 168 gentian violet gentle laxative GEODON geravim gianvi gildagia gildess 1.5/ GILENYA GILOTRIF glatopa GLEEVEC glimepiride glipizide glipizide er glipizide-metformin hcl GLOBAL ALCOHOL PREP EASE GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glycopyrrolate gnp antacid & anti-gas gnp artificial tears gnp calcium gnp childrens chewables/ex c xedni gnp childrens pain relief/cold gnp cold multi-sympt day/night gnp cold multi-symptom night gnp foaming antacid gnp iron gnp multi-symptom cold night gnp stool softener GOLYTELY GONIOTAIRE goodsense all day allergy goodsense pain relief pm ex st granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guaifenesin dm guaifenesin-codeine guanfacine hcl er GUMMI BEAR MULTIVITAMIN/MIN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX headache pm heather HEPARIN (PORCINE) IN D5W HEPARIN (PORCINE) IN NACL HEPARIN SOD (PORCINE) IN D5W heparin sodium (porcine) HEPARIN SODIUM (PORCINE) xedni HEPATAMINE HERCEPTIN HETLIOZ HEXALEN HIBERIX hm allergy childrens hm famotidine hm rapid melts junior HONEY BEARS HONEY BEARS W/IRON-ZINC HUMIRA HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER HUMULIN R U-500 (CONCENTRATED) hydralazine hcl hydrochlorothiazide HYDROCIL hydrocodone-acetaminophen hydrocodone-ibuprofen hydrocortisone... 90, 97, 129, 173 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-aloe hydromorphone hcl hydromorphone hcl pf hydroxocobalamin hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl , 163 hydroxyzine pamoate HYPOTEARS ibandronate sodium IBRANCE ibuprofen... 10, 129 ibuprofen junior strength

187 xedni ibuprofen pm ICAPS ICAPS LUTEIN-ZEAXANTHIN ICAPS MV ICLUSIG idarubicin hcl IFEX ifosfamide IFOSFAMIDE ILEVRO ilotycin IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IMOVAX RABIES INCRELEX INCR ELLIPTA indapamide INFANRIX infants ibuprofen infants pain relief INLYTA INSULIN SYRINGE INTEGRA INTELENCE intense cold/flu medicine intense cough reliever ex st INTRALIPID INTRON A introvale INVANZ INVEGA INVEGA SUSTENNA INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL xedni ipratropium bromide ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide irinotecan hcl IROMIN-G iron iron (ferrous gluconate) iron 100 plus iron 100/c iron chews pediatric IRON UP ISENTRESS ISOLYTE-P IN D5W ISOLYTE-S isoniazid ISOPTO TEARS isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine ISTALOL ISTODAX itraconazole ivermectin IXIARO JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JENTADUETO jinteli J-MAX jolessa jolivette J-TAN D PD J-TAN PD junel 1.5/ xedni junel 1/ junel fe 1.5/ junel fe 1/ JUXTAPID k KADCYLA KALETRA KALYDECO KAOPECTATE kariva kcl in dextrose-nacl KCL IN DEXTROSE-NACL kelnor 1/ ketoconazole... 15, 169, 170 ketoprofen ketorolac tromethamine KEYTRUDA kidkare cough/cold kionex klor-con klor-con klor-con m klor-con m kls acid reducer max st KONSYL KONSYL-D KORLYM kp b complex-c kp benzoyl peroxide kp calcium 600+d , 131 kp calcium-magnesium-zinc kp ferrous gluconate kp ferrous sulfate kp hydrocortisone kp ketotifen fumarate kp pseudoephedrine hcl kp terbinafine hydrochloride kp vitamin d kp vitamin e kpn prenatal

188 xedni KUVAN KYNAMRO labetalol hcl laclotion lactated ringers lactulose lactulose encephalopathy LAMISIL ADVANCED LAMISIL AF DEFENSE lamivudine... 20, 24 lamivudine-zidovudine lamotrigine lamotrigine er LANTUS LANTUS SOLOSTAR larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ LASTACAFT latanoprost LATUDA laxative pills leena leflunomide LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl LEVEMIR xedni LEVEMIR FLEXTOUCH levetiracetam levetiracetam er LEVETIRACETAM IN NACL levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levoleucovorin calcium levonest levonorgest-eth estrad 91-day levonorgestrel levonorgestrel-ethinyl estrad levora 0.15/30 (28) levothyroxine sodium levoxyl LEXIVA lice killing maximum strength lice treatment lidocaine lidocaine hcl... 13, 173 lidocaine hcl (pf) lidocaine viscous lidocaine-prilocaine linezolid LINEZOLID LINZESS liothyronine sodium liquid calcium with d liquid calcium/vitamin d liquituss gg lisinopril lisinopril-hydrochlorothiazide LITHIUM lithium carbonate lithium carbonate er localnesium xedni localnesium-c LODRANE D LOHIST-D lohist-dm lohist-peb lokara lomustine loperamide hcl... 99, 132 loratadine loratadine-pseudoephedrine er lorazepam lorazepam intensol lorcet lorcet hd lorcet plus lortab loryna losartan potassium losartan potassium-hctz LOTEMAX LOTRIMIN ULTRA lovastatin low-ogestrel loxapine succinate lubricating plus eye drops LUMIGAN LUMITENE LUMIZYME LUPRON DEPOT LUPRON DEPOT-PED lutera LYNPARZA LYRICA LYSODREN lyza MAALOX CHILDRENS MAALOX REGULAR STRENGTH mag-al mag-delay MAGINEX

189 xedni MAGNEBIND magnesium magnesium citrate magnesium oxide MAGNESIUM SULFATE magnesium sulfate MAGNESIUM SULFATE IN D5W MAG-TAB SR malathion MAPAP COLD FORMULA MULTI-SYMPT maprotiline hcl marlissa MARPLAN MATULANE MAXIDEX meclizine hcl medroxyprogesterone acetate... 85, 93 mefloquine hcl MEGACE ES megestrol acetate MEKINIST meloxicam melphalan hcl MENACTRA m-end dmx MENOMUNE MENVEO MEPHYTON mercaptopurine MERIBIN meropenem mesalamine mesalamine-cleanser mesna MESNEX metadate er METAMUCIL METAMUCIL MULTIHEALTH FIBER xedni METAMUCIL SMOOTH TEXTURE metformin hcl metformin hcl er methadone hcl methadone hcl intensol methazolamide methenamine hippurate methimazole methotrexate methotrexate sodium methotrexate sodium (pf) methyclothiazide methylergonovine maleate methylphenidate hcl methylphenidate hcl er methylprednisolone methylprednisolone (pak) methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 18, 102, 174 metronidazole in nacl mexiletine hcl MEXSANA MIACALCIN MI-ACID miconazole miconazole miconazole 3 combo pack miconazole microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ xedni midodrine hcl milk of magnesia milk of magnesia concentrate mineral oil minitran minocycline hcl minoxidil MINTOX PLUS mirtazapine misoprostol MISSION PRENATAL MISSION PRENATAL HP mitomycin mitoxantrone hcl M-M-R II moderiba MODERIBA 1200 DOSE PACK moderiba 800 dose pack moexipril hcl moexipril-hydrochlorothiazide mometasone furoate mononessa montelukast sodium morphine sulfate morphine sulfate (concentrate) morphine sulfate (pf) morphine sulfate er morphine sulfate er beads motion sickness relief MOTRIN IB MOVANTIK MOVIPREP MOXEZA MOZOBIL mucaphed MUCINEX COUGH FOR KIDS MUCINEX D

190 xedni MUCINEX FAST-MAX COLD & SINUS MUCINEX FOR KIDS MUCINEX MAXIMUM STRENGTH mucus relief mucus relief cold/sinus max st mucus relief cough childrens mucus relief er mucus-dm mucus-dm max MULTAQ multi-delyn multi-delyn/iron multi-symptom cold childrens mupirocin MURO MUSTARGEN my way MYCAMINE mycophenolate mofetil mycophenolic acid MYKIDZ IRON MYKIDZ IRON myorisan MYOZYME MYRBETRIQ myzilra nabumetone nadolol nafcillin sodium NAGLAZYME nalbuphine hcl naloxone hcl naltrexone hcl NAMENDA NAMENDA XR NAMENDA XR TITRATION PACK xedni naphazoline hcl naproxen naproxen dr naproxen sodium... 10, 135 naratriptan hcl nasal decongestant , 136 nasal decongestant pe max st nasal spray extra moisturizing NASCOBAL NASOPEN PE NATACYN nateglinide NATPARA natural fiber laxative natural fiber therapy natures tears NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/ nefazodone hcl neomycin sulfate neomycin-bacitracin zn-polymyx neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc , 176 NEORAL , 109 neotuss NEPHRAMINE NEPHRONEX NEUMEGA NEUPOGEN NEUPRO nevirapine xedni nevirapine er NEXAFED NEXAFED SINUS PRESSURE + PAIN NEXAVAR NEXIUM next choice one dose niacin niacin er niacin er (antihyperlipidemic) niacinamide niacor nicardipine hcl nicotine nicotine polacrilex , 137 NICOTROL NICOTROL NS nifedical xl nifedipine er nifedipine er osmotic night-time sinus nikki NILANDRON nimodipine NIPENT nitro-bid NITRO-DUR nitrofurantoin macrocrystal nitrofurantoin monohyd macro nitroglycerin NITROSTAT nohist-lq nora-be NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NOREL AD norethindrone norethindrone acetate norethindrone-eth estradiol

191 xedni norgestim-eth estrad triphasic norlyroc normosol-m in d5w NORMOSOL-R IN D5W NORMOSOL-R PH NORPACE CR nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/ nortriptyline hcl NORVIR NOVAFERRUM NOVAFERRUM PEDIATRIC DROPS NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL NUEDEXTA NU-IRON NULOJIX NULYTELY WITH FLAVOR PACKS NUTRILIPID NUTRISOURCE FIBER NUVARING NUVIGIL nyamyc NYMALIZE nystatin... 16, 169, 175 nystop ocella OCTAGAM octreotide acetate xedni OFEV ofloxacin , 176 olanzapine olopatadine hcl omega-3-acid ethyl esters omeprazole , 137 ondansetron ondansetron hcl ONETOUCH ULTRA ONETOUCH ULTRA BLUE ONETOUCH ULTRA MINI ONETOUCH ULTRA SYSTEM ONETOUCH ULTRASMART ONETOUCH VERIO ONETOUCH VERIO IQ SYSTEM ONETOUCH VERIO SYNC SYSTEM ONFI OPSUMIT ORAP ORFADIN organ-i nr orsythia OS-CAL EXTRA D OSTEO-PORETICAL oxacillin sodium oxaliplatin oxandrolone oxcarbazepine oxybutynin chloride oxybutynin chloride er oxycodone hcl... 12, 13 oxycodone-acetaminophen OYSCO oyster shell calcium 250+d oyster shell calcium/d pacerone paclitaxel pain relief 8 hour pain relief childrens pain relief extra strength xedni pain reliever pamidronate disodium PANOXYL PANOXYL WASH PANOXYL-4 CREAMY WASH PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate paroxetine hcl parva-cal paser PATADAY PAXIL PAZEO PEDIACARE CHILDRENS LONG-ACT PEDIA-LAX PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEGANONE PEGINTRON PEG-INTRON PEG-INTRON REDIPEN PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM pentoxifylline er PEPCID AC peptic relief PERDIEM OVERNIGHT RELIEF PERFOROMIST perindopril erbumine

192 xedni periogard permethrin , 175 perphenazine PERRY PRENATAL phenadoz PHENAGIL phenelzine sulfate phenergan phenobarbital phenobarbital sodium PHENOBARBITAL SODIUM phenytek phenytoin phenytoin sodium phenytoin sodium extended philith phos-nak PHOSPHOLINE IODIDE pilocarpine hcl , 175 pimtrea pindolol pioglitazone hcl piperacillin sod-tazobactam so pirmella 1/ piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN D5W podofilox polyethylene glycol polymyxin b-trimethoprim polyvitamin polyvitamin/iron POMALYST portia potassium chloride , 156 potassium chloride crys er potassium chloride er , 152 potassium chloride in dextrose potassium chloride in nacl xedni potassium citrate er POTIGA... 60, 61 PRADAXA pramipexole dihydrochloride pravastatin sodium prazosin hcl prednisolone prednisolone acetate prednisolone sodium phosphate... 91, 161 prednisone prednisone (pak) prednisone intensol PREFERRED PLUS INSULIN SYRINGE premasol prenatal , 156 PRETZ prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE PHOSPHATE primidone PRISTIQ PRIVIGEN probenecid... 9 PROCALAMINE pro-chlo prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-pak proctosol hc proctozone-hc PROFE PROGLYCEM PROGRAF PROLASTIN-C xedni PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl promethegan PRONUTRIENTS CALCIUM+D propafenone hcl propafenone hcl er proparacaine hcl propranolol hcl... 49, 50 propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl prudoxin pseudoeph-bromphen-dm psyldex PULMICORT FLEXHALER PULMOZYME PURE & GENTLE LUBRICANT PURIXAN pyrazinamide pyrethins-piperonyl butoxide pyridostigmine bromide pyridoxine hcl pyrilamine-phenylephrine qc 3 day qc natural vegetable q-pap infants Q-TAPP DM quasense quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate er

193 xedni quinidine sulfate quinine sulfate ra anti-itch maximum strength ra b-complex/vitamin c cr ra beta carotene ra calamine ra calcium 600/vit d/minerals ra calcium-boron ra central-vite performance ra col-rite ra coral calcium ra high potency iron ra hydrocortisone plus ra ibuprofen childrens ra lubricant eye ra magnesium ra multi-symptom day/night ra omeprazole-sodium bicarb ra ophthalmic ra oyster shell calcium/d ra probiotic complex ra severe cold/sinus relief pe ra slow release iron ra soluble fiber RA STERILE ra vitamin c drops ra vitamin c/rose hips cr RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl... 97, 141 RAPAMUNE RAVICTI REBETOL reclipsen xedni RECOMBIVAX HB REFRESH CELLUVISC REFRESH OPTIVE ADVANCED REFRESH P.M REGRANEX REGULOID REHYDRALYTE RELENZA DISKHALER RELISTOR RELPAX REMICADE REMODULIN RENVELA repaglinide RESCON RESCON DM RESCRIPTOR RESPAIRE RESTASIS RETAINE MGD RETROVIR REVATIO REVLIMID REYATAZ RHINARIS ribasphere ribasphere ribapak ribavirin RID ESSENTIAL LICE ELIMINATION rifabutin rifampin RIFATER riluzole rimantadine hcl ringers RISA-BID PROBIOTIC RISAMINE RISPERDAL CONSTA risperidone RITUXAN xedni rivastigmine tartrate rizatriptan benzoate robafen cf cough/cold robafen cough ROBITUSSIN CHILD COUGH/COLD CF ROBITUSSIN CHILD COUGH/COLD LA ROBITUSSIN CHILDRENS COUGH LA ROBITUSSIN COLD+FLU DAYTIME ROBITUSSIN LINGERING LA COUGH ROBITUSSIN MUCUS+CHEST CONGEST ROBITUSSIN MULTI-SYMPTOM MAX ROBITUSSIN PEAK COLD MULTI-SYM ropinirole hcl rosadan ROTARIX ROTATEQ roxicet ROZEREM rymed rynex dm rynex pse SABRIL saline laxative SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS sb fib lax orange sb lice treatment sb natural fiber laxative SCOOBY-DOO ONE A DAY SCOT-TUSSIN DM SCOT-TUSSIN SENIOR

194 xedni SECURA EXTRA PROTECTIVE SECURA PROTECTIVE selegiline hcl... 67, 68 selenium selenium er selenium sulfide SELZENTRY senna senna laxative SENNA PROMPT senna s SENSI-CARE PROTECTIVE BARRIER SENSIPAR SEREVENT DISKUS SEROQUEL XR... 71, 72 sertraline hcl sharobel SIGNIFOR sildenafil citrate SILENOR silver sulfadiazine SIMBRINZA simvastatin sirolimus SIROLIMUS SIRTURO SIVEXTRO sleep aid SLO-NIACIN slow magnesium/calcium slow release iron SLOW-MAG sm adult nasal decongestant sm calcium/vitamin d sm calcium-magnesium-zinc SM CORAL CALCIUM sm iron slow release sm lansoprazole xedni sm magnesium oxide sm motion sickness relief sm redness relief sm slow release iron sm vitamin b12 tr sm vitamin c cr sm vitamin d sodium bicarbonate sodium chloride , 156, 175 sodium chloride (hypertonic) sodium fluoride sodium phenylbutyrate sodium polystyrene sulfonate solia SOLTAMOX SOLUBLE FIBER THERAPY SOLU-CORTEF SOMATULINE DEPOT SOMAVERT SOOTHE sorbulax sorine sotalol hcl sotalol hcl (af) SOVALDI spironolactone spironolactone-hctz sprintec SPRYCEL sps sronyx ssd stahist ad stavudine STERILE LUBRICANT sterile water for irrigation STIVARGA stomach relief max st stool softener stool softener laxative dc xedni STRATTERA... 73, 74 streptomycin sulfate STRIBILD SUBOXONE SUCRAID sucralfate sulfacetamide sodium , 168 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-tmp ds sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulfazine ec sulindac sumatriptan sumatriptan succinate... 74, 75 sumatriptan succinate refill SUMMERS EVE DISP MEDICATED SUPRAX suprax SUPREP BOWEL PREP SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE SYSTANE BALANCE SYSTANE NIGHTTIME

195 xedni SYSTANE OVERNIGHT THERAPY TABLOID tacrolimus , 174 TAFINLAR TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN... 41, 174 tarina fe 1/ TASIGNA tazicef TAZORAC taztia xt TEARS AGAIN NIGHT & DAY TEFLARO TEGRETOL TEGRETOL-XR TEKTURNA TEKTURNA HCT... 52, 53 temazepam TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole testosterone cypionate testosterone enanthate TETANUS-DIPHTHERIA TOXOIDS TD texacort tg 10peh/380gfn tg 10peh/380gfn/15dm tgt cough formula dm max adult tgt eye allergy relief tgt flu/severe cold/cough rlf tgt lubricant eye drops tgt pain reliever pm ex st xedni th calcium-magnesium-zinc th eye drop tears THALOMID theo theophylline theophylline er THERA/BETA-CAROTENE THERA-D THERANATAL CORE NUTRITION THERATEARS thiamine hcl thioridazine hcl thiothixene tiagabine hcl TIKOSYN timolol maleate... 50, 158 tioconazole TITRALAC TIVICAY tizanidine hcl TOBRADEX TOBRADEX ST tobramycin... 14, 160 tobramycin sulfate tobramycin sulfate in saline tobramycin-dexamethasone TOBREX tolnaftate tolterodine tartrate tolterodine tartrate er topiramate toposar topotecan hcl torsemide total b/c TOVIAZ TPN ELECTROLYTES TRACLEER TRADJENTA xedni tramadol hcl tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl TREANDA TRECATOR TRELSTAR MIXJECT tretinoin... 41, 168 triacting day time cold/cough triamcinolone acetonide , 175 TRIAMINIC COUGH/RUNNY NOSE TRIAMINIC FEVER REDUCER TRIAMINIC NIGHT TIME COLD/CGH triamterene-hctz TRIBENZOR tri-buffered aspirin triderm trifluoperazine hcl trifluridine trihexyphenidyl hcl tri-legest fe trilyte trimethoprim trinessa (28) triple antibiotic TRIPLE PASTE triple paste af tri-previfem TRISENOX tri-sprintec TRIUMEQ TRI-VI-SOL

196 xedni TRI-VITA tri-vitamin trivora (28) TROPHAMINE trospium chloride TRUMENBA TRUVADA TUSNEL TUSNEL PEDIATRIC TUSNEL-DM PEDIATRIC tussin cf cough & cold tussin dm tussi-pres b TWINRIX TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA UCERIS ULORIC... 9 unithroid UPCAL D ursodiol VAGIFEM VAGISTAT valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide vancomycin hcl vandazole VAQTA VARIVAX VASCEPA VELCADE xedni velivet venlafaxine hcl venlafaxine hcl er VENTOLIN HFA verapamil hcl verapamil hcl er VERSACLOZ VESICARE vestura VICKS DAYQUIL MUCUS CONTROL DM VICKS NYQUIL D COLD & FLU VICKS VAPORUB VICTOZA VIDEX VIGAMOX VIIBRYD VIMPAT vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate viorele VIRACEPT VIRAMUNE XR VIREAD VISINE-LR VITALETS VITAMELTS ENERGY VITAMIN B vitamin a & d vitamin a palmitate vitamin b vitamin b , 149 vitamin b12-folic acid vitamin b vitamin b vitamin b-6 er vitamin c vitamin c (calcium ascorbate) xedni vitamin d vitamin d (ergocalciferol) vitamin d vitamin d vitamin e , 150 vitamin e-selenium vitamin k (phytonadione) vitamin k vitatrum VITEKTA VOLTAREN voriconazole VOTRIENT vyfemla WAL-ACT WAL-DRYL ALLRGY/SINUS HEADACHE WAL-DRYL-D ALLERGY/SINUS WAL-FEX D ALLERGY & CONGESTION WAL-FLU SEVERE COLD DAYTIME WAL-ITIN WAL-ITIN D WAL-PHED PE SINUS/ALLERGY WAL-PHED SINUS/ALLERGY wal-som maximum strength warfarin sodium wee care WELCHOL XALKORI XARELTO XARELTO STARTER PACK XENAZINE XGEVA XIFAXAN XOLAIR XOPENEX HFA

197 xedni XTANDI xulane XYREM YERVOY YF-VAX zafirlukast zarah ZAVESCA zazole ZELBORAF ZEMAIRA zenatane zenchent ZENPEP ZETIA ZIAGEN zidovudine... 21, 22 zinc oxide ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolmitriptan zolpidem tartrate ZONATUSS zonisamide ZONTIVITY zoo friends complete ZORTRESS ZOSTAVAX zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX

198

199 This formulary was updated on 9/01/2015. If you have any questions, please contact WellCare Advocate Complete FIDA at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday or visit