Formulary. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY

Transcription

1 Formulary IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY May 2016

2 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) HPMS Approved Formulary File Submission ID , Version 10 This is a list of drugs that members can get in IEHP DualChoice. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. 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 and/or co-payments may change on January 1 of each year. You can always check IEHP DualChoice s up-to-date List of Covered Drugs online at or by calling IEHP (4347), 8am-8pm (PST), 7 days week, including holidays. TTY/TDD users should call The call is free. You can get this information for free in other formats, such as large print, braille, or audio. Call IEHP (4347). The call is free. Limitations, copays, and restrictions may apply. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. Usted puede obtener esta información gratis en otros idiomas. Llame al IEHP (4347), 8am-8pm (Hora del Pacifico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 1

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by IEHP DualChoice. The 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. IEHP DualChoice will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an IEHP DualChoice network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at IEHP (4347). 2. Does the Drug List ever change? Yes. IEHP DualChoice may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from IEHP DualChoice before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). (For more information on these drug rules, see page 4.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check IEHP DualChoice s up to date Drug List online at You can also call Member Services to check the current Drug List at IEHP (4347). 2

4 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. You will receive a letter at least 60-days before the change is effective. This information is also available on our website at 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact the prescribing doctor after you receive your letter. 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 or your doctor or other prescriber 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 IEHP DualChoice before you fill your prescription. If you don t get approval, IEHP DualChoice may not cover the drug. Quantity limits: Sometimes IEHP DualChoice limits the amount of a drug you can get. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see Question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new IEHP DualChoice member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 3

5 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 that begins on page 11 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval) and/or quantity limits restrictions on a drug. We will tell you if we add prior approval and/or quantity limits restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules 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. You can find it in the index that begins on page 87. Look in the index and find your drug. Next to your drug, you will see the page number where you can find the coverage information. Turn to the page listed in the index and find the name of your drug in the first column of 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. 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 Member Services at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call and ask about it. If you learn that IEHP DualChoice will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 4

6 10. What if you are a new IEHP DualChoice member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a member of IEHP DualChoice. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 31-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by IEHP DualChoice. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. As a new member in our plan or continuing member who was affected by a formulary change from one year the next, you may be taking drugs that are not on our formulary. Or, you may be taking drugs that are on our formulary that are hard for you to get. For example, you may need our approval before you can get your drug. Either way, talk to your doctor. He or she can help you choose the right course of action. This could be changing to a drug we do cover or seeking a formulary exception so that we will cover the drug. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or is hard for you to get, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover your prescription refill until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days of your membership. If you need a drug that is not on our formulary or it is hard for you to get, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you ask for a formulary exception. 11. Can you ask for an exception to cover your drug? Yes. You can ask IEHP DualChoice to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 5

7 For example, IEHP DualChoice may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call IEHP DualChoice Member Services. IEHP DualChoice Member Services 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 their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). IEHP DualChoice covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. IEHP DualChoice covers some OTC drugs when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC drugs are covered. 16. Does IEHP DualChoice cover OTC non-drug products? IEHP DualChoice covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC non-drug products are covered. 6

8 17. What is your co-pay? You can read the IEHP DualChoice Drug List to learn about the co-pay for each drug. IEHP DualChoice members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no co-pays. Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay. Tier 1 are generic drugs. The co-pay will be from $0 to $2.95, depending on your level of Medi-Cal eligibility. Tier 2 are brand name drugs. The co-pay will be from $0 to $7.40, depending on your level of Medi-Cal eligibility. Tier 3 drugs have a co-pay of $0. List of Covered Drugs The list of covered drugs that begins on the page 11 gives you information about the drugs covered by IEHP DualChoice. If you have trouble finding your drug in the list, turn to the Index that begins on page 87. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., NEXIUM) and generic drugs are listed in lower-case italics (e.g., omeprazole). The information in the Necessary actions, restrictions, or limits on use column tells you if IEHP DualChoice has any rules for covering your drug. Below are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: UPPERCASE BOLD= Brand name drugs lowercase italics= Generic drugs Drug Tier 1= Tier 1; 2= Tier 2; 3= Tier 3 NC= Not Covered NF= Non-Formulary Requirements / Limits PA= Prior Authorization B vs D= Part B vs D Prior Authorization QL= Quantity Limit Tier 1: Drugs in this tier are generic drugs (including brand drugs treated as generic). The copay is a set payment you make for these generic drugs. For example, the copay is from $0 to $2.95. This amount depends on your income. Tier 2: Drugs in this tier are brand name drugs. The copay is from $0 to $7.40. This amount depends on your income.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 7

9 Tier 3: Drugs in this tier are drugs that are non-medicare drugs/over-the-counter (OTC) drugs. These drugs are covered by Medi-Cal. They have a $0 co-pay. NC: Not covered. These are drugs not covered by IEHP DualChoice. NF: Non-Formulary. Drugs that are not on our prescribed drugs list (known as a Formulary). PA: Prior Authorization. IEHP DualChoice requires you or your physician to get approval from us first before filling a certain drug. This extra step is called prior authorization. If you don't get approval, IEHP DualChoice may not cover the drug. B vs D: Part B vs D Prior Authorization. This is a drug that has a special PA requirement. It may be covered under one or two benefit programs: 1) Medicare Part B, and/or 2) Medicare Part D. This depends on many factors. Your physician may need to give us more details about the use and setting of the drug. QL: Quantity Limit. For certain drugs, IEHP DualChoice limits the amount of the drug that it will cover. This may be in addition to a standard one month or three month supply. Note: A drug in Tier 3 means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at IEHP (4347). You can also read the Member Handbook to learn how to appeal a decision. 8

10 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 Formulary Table of Contents Additional Demonstration Drugs Analgesics Anesthetics Anti-Addiction/ Substance Abuse Treatment Agents Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/ Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental And Oral Agents Dermatological Agents Enzyme Replacement/ Modifiers Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

11 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents Therapeutic Nutrients/ Minerals/ Electrolytes Index

12 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. Drug Name Additional Demonstration Drugs Additional Demonstration Drugs 12-HR DECONGEST 120 MG CAPLET NON-DROWSY,CAPLET 120 MG 3 QL (60 EA per 30 days) ABREVA 10% CREAM 10 % 3 QL (2 GM per 15 days) ACEPHEN 120 MG SUPPOSITORY OUTER 120 MG 3 ACEPHEN 325 MG SUPPOSITORY OUTER 325 MG 3 acetaminophen 160 mg/5 ml sol 160 mg/5 ml (5 ml) 3 QL (240 ML per 30 days) ACNE MEDICATION 10% GEL 10 % 3 ACNE MEDICATION 10% LOTION 10 % 3 ACNE MEDICATION 5% GEL 5 % 3 ADULT COUGH FORMULA DM MAX LIQ MG/5 ML 3 QL (240 ML per 30 days) ADULT ROBITUSSIN PEAK COLD LIQ NON-DROWSY MG/5 ML 3 QL (240 ML per 30 days) ALAVERT D-12 ALLERGY-SINUS TAB MG 3 QL (60 EA per 30 days) ALLER-CHLOR 2 MG/5 ML SYRUP 2 MG/5 ML 3 ALLER-CHLOR 4 MG TABLET 4 MG 3 ALLERCLEAR 10 MG TABLET NON-DROWSY, 24HR 10 MG 3 QL (30 EA per 30 days) ALLERGY 25 MG TABLET 25 MG 3 QL (100 EA per 30 days) ALLERGY MULTI-SYMPTOM CAPLET CAPLET MG 3 QL (60 EA per 30 days) ALLERGY RELIEF 10 MG ODT NON-DROWSY, 24HR 10 MG 3 QL (30 EA per 30 days) ALLERGY RELIEF 25 MG CAPSULE 25 MG 3 QL (100 EA per 30 days) AMLACTIN ULTRA BODY CREAM 3 ANTACID-ANTIGAS LIQUID REG STR, FAST ACTING MG/5 ML ANTIBIOTIC + PAIN RELIEF OINT MAX-STRENGTH ,000 MG-UNIT-UNIT/G 3 3 ANTIFUNGAL 2% CREAM 2 % 3 QL (60 GM per 30 days) AQUANIL HC 1% LOTION 1 % 3 QL (120 ML per 30 days) ARTIFICIAL TEARS 1.4 % DROPS 1.4 % 3 ARTIFICIAL TEARS DROPS % 3 11

13 aspirin 325 mg tablet 325 mg 3 QL (100 EA per 30 days) AYR SALINE 0.65% NOSE DROPS 0.65 % 3 bacitracin 500 unit/gm ointment 500 unit/gram 3 bacitracin zn 500 unit/gm oint 500 unit/gram 3 QL (30 GM per 30 days) bacitracin-polymyxin ointment u-d,144x.94gm pkt ,000 unit/gram 3 benzonatate 100 mg capsule softgel 100 mg 3 QL (180 EA per 30 days) benzonatate 200 mg capsule softgel 200 mg 3 QL (90 EA per 30 days) benzoyl peroxide 2.5% gel (otc) 2.5 % 3 benzoyl peroxide 5% lotion 5 % 3 benzoyl peroxide 5% wash (otc) 5 % 3 BIO-B KIDS LIQUID MG/5 ML 3 BIO-S-PRES DX PEDIATRIC DROPS MG/ML 3 bisacodyl ec 5 mg tablet 5 mg 3 QL (60 EA per 30 days) bromphenir-pseudoephed-dm syr (rx) mg/5 ml 3 QL (240 ML per 30 days) BROTAPP DM LIQUID MG/5 ML 3 BROTAPP LIQUID 1-15 MG/5 ML 3 CALCIUM 600 MG TABLET 600 MG (1,500 MG) 3 calcium gluconate 500 mg tab 45 mg (500 mg) 3 calcium lactate 648 mg tablet 84 mg (648 mg) 3 cetirizine hcl 10 mg tablet indoor-outdoor,24hr 10 mg 3 QL (30 EA per 30 days) cetirizine hcl 5 mg chew tab children's, outer, u-d 5 mg 3 QL (30 EA per 30 days) cetirizine hcl 5 mg tablet 5 mg 3 QL (30 EA per 30 days) CHEMSTRIP 10 WITH SG 3 CHILD MUCUS RELIEF COUGH LIQ A/F,CHERRY,CHILD MG/5 ML 3 QL (240 ML per 30 days) CHILD PAIN & FEVER 160 MG/5 ML 160 MG/5 ML 3 QL (240 ML per 30 days) CHILDREN'S BENEFIBER ORAL POWDER 3 GRAM/3.5 GRAM 3 CHILDREN'S COLD & COUGH ELIXIR A/F,RED GRAPE,CHILD MG/5 ML CHILDREN'S IRON 15 MG/ML DROPS 15 MG IRON (75 MG)/ML 3 QL (50 ML per 30 days) CHILDREN'S SILAPAP ELIXIR 160 MG/5 ML 3 QL (240 ML per 30 days) CHILDREN'S SILFEDRINE LIQ 15 MG/5 ML 3 QL (240 ML per 30 days) CHILD'S CLARITIN 5 MG TAB CHEW 5 MG 3 QL (30 EA per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page

14 CHLD MUCINEX STUFFY NOSE-COLD MG/5 ML 3 chlorpheniramine er 12 mg tab 12 mg 3 COMPLETE LICE TREATMENT KIT STEP % 3 QL (2 EA per 30 days) CONCEPTROL GEL 4 % 3 CONDOMS LUBRICATED 3 QL (24 EA per 30 days) cromolyn sodium nasal solution 200 metered sprays 5.2 mg/spray (4 %) 3 CVS ACNE FOAMING FACE 10% WASH 10 % 3 CVS ALLERGY RELIEF 5 MG/5 ML A/F, S/F. GLUTEN/F 5 MG/5 ML CVS ANTI-DANDRUFF 1% SHAMPOO 1 % 3 3 QL (150 ML per 30 days) cvs aspirin 81 mg chewable tab adult, 3x36 tri-pack 81 mg 3 QL (100 EA per 30 days) cvs aspirin ec 81 mg tablet coated, low dose 81 mg 3 QL (100 EA per 30 days) cvs calcium 500 mg tablet 500mg elemental ca 500 mg calcium (1,250 mg) 3 CVS CHILD ALLERGY 10 MG CHW TB 24 HR,INDOOR/OUTDOOR 10 MG CVS CHILD SUPPOSITORY 3 CVS CORN-CALLUS REMOVER LIQ 3 CVS FIBER LAXATIVE 625 MG CPLT CAPLET 625 MG 3 cvs glucose 4 gram tablet chew grape, s/f 4 gram 3 CVS KETONE CARE TEST STRIPS 3 3 QL (30 EA per 30 days) CVS LICE KILLING SHAMPOO MAXIMUM STRENGTH % 3 QL (472 ML per 30 days) CVS LUBRICANT 0.5% EYE DROPS 0.5 % 3 CVS LUBRICANT EYE OINTMENT % 3 cvs magnesium 500 mg tablet coated 500 mg 3 QL (30 EA per 30 days) cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) CVS MUCUS ER 600 MG TABLET 12 HOUR 600 MG 3 CVS NIACIN FLUSH FREE 500 MG 400 MG NIACIN (500 MG) 3 CVS NON-ASPIRIN JR TAB CHEW 160 MG 3 QL (100 EA per 30 days) cvs permethrin 1% lotion 1 % 3 QL (236 ML per 30 days) CVS PRENATAL VITAMINS TABLET WITH MINERALS 28 MG IRON- 800 MCG CVS STOOL SOFTENER 100 MG CAP 100 MG 3 QL (100 EA per 30 days) CVS STOOL SOFTENER 50 MG SFTGL 50 MG 3 QL (100 EA per 30 days)

15 CVS SUPER PAIN RELIEF TAB MG 3 QL (100 EA per 30 days) CVS TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM CVS VITAMIN B-6 50 MG TAB 50 MG 3 cvs vitamin d 400 unit/ml drop infant's, w/dropper 400 unit/ml 3 cvs vitamin d3 1,000 unit sfgl softgel 1,000 unit 3 cvs vitamin d3 400 unit sftgl 400 unit 3 cyanocobalamin 1,000 mcg/ml mdv,5's 1,000 mcg/ml 3 d ,000 units capsule s/f,d/f,p/f 50,000 unit 3 DESITIN 13% CREAM HYPOALLERGENIC 13 % 3 DIABETIC TUSSIN EX LIQUID A/F,D/F,NA/F,S/F 100 MG/5 ML 3 DIAPER RASH 40% OINTMENT MAXIMUM STRENGTH 40 % 3 DIMAPHEN ELIXIR A/F MG/5 ML 3 DIOCTO 60 MG/15 ML SYRUP 60 MG/15 ML 3 QL (480 ML per 30 days) diphenhydramine 50 mg tablet 50 mg 3 QL (100 EA per 30 days) DOCU LIQUID 100 MG/10 ML OUTER 50 MG/5 ML 3 QL (480 ML per 30 days) DOK 100 MG TABLET 100 MG 3 QL (100 EA per 30 days) ELLA 30 MG TABLET 30 MG 3 QL (1 EA per 30 days) EQ ARTIFICIAL TEARS DROPS STERILE % 3 eql natural zinc 50 mg tablet 50 mg 3 EYE ALLERGY RELIEF DROPS % 3 EYE ITCH RELIEF 0.025% DROPS UP TO 12HRS, STERILE % (0.035 %) EYE WASH-IRRIGATING SOLN 3 famotidine 10 mg tablet 10 mg 3 QL (120 EA per 30 days) ferrous sulf 220 mg/5 ml elix 220 mg (44 mg iron)/5 ml 3 QL (480 ML per 30 days) ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml 3 QL (450 ML per 30 days) ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) 3 QL (90 EA per 30 days) ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) 3 QL (90 EA per 30 days) ferrous sulfate 325 mg tablet u-d,10x10, film coat 325 mg (65 mg iron) 3 QL (90 EA per 30 days) FEVERALL 80 MG SUPPOSITORY INFANT'S, OUTER 80 MG 3 FLANDERS BUTTOCKS OINTMENT 3 FLEET GLYCERIN 2 GM ADULT SUPP 3 You can find information on what the symbols and abbreviations in this table mean by going to page

16 FLEET PEDIA-LAX ENEMA GRAM/59 ML 3 FLEET PEDIA-LAX STOOL SOFTENER 50 MG/15 ML 3 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg 3 FOR STY RELIEF EYE OINTMENT 3 FORA BLOOD GLUCOSE TEST STRIP 3 QL (100 EA per 90 days) FORACARE 30G LANCETS 30 GAUGE 3 QL (150 EA per 30 days) FULL SPECTRUM B WITH VIT C TAB 0.8 MG 3 QL (30 EA per 30 days) GAS RELIEF DROPS INFANTS, A/F 40 MG/0.6 ML 3 QL (30 ML per 30 days) GENTEAL MILD 0.2% EYE DROPS 0.2 % 3 GENTEAL MILD-MODERATE EYE DROP P/F, STRL 0.3 % 3 GENTLE LAXATIVE 5 MG TABLET 5 MG 3 QL (60 EA per 30 days) gnp calamine suspension 8-8 % 3 GNP PINK BISMUTH MAX-STR SUSP MAXIMUM STRENGTH 525 MG/15 ML gnp terbinafine 1% cream antifungal 1 % 3 gnp vit d3 400 unit tab chew 400 unit 3 GRX DYNE 10% SWAB 10 % 3 guaifenesin dm syrup 100's, u-d (otc) mg/5 ml 3 QL (240 ML per 30 days) GYNOL II 3% GEL 3 % 3 HIBICLENS 4% LIQUID 4 % 3 hm magnesium citrate solution pasteurized, cherry 3 HM STOOL SOFTENER 250 MG SFTGL SOFTGEL,MAX STRENGTH 250 MG 3 3 QL (100 EA per 30 days) hydrocortisone 0.5% cream 0.5 % 3 QL (30 GM per 30 days) hydrocortisone 0.5% ointment 0.5 % 3 QL (30 GM per 30 days) HYDROMET SYRUP MG/5 ML 3 ibuprofen 200 mg tablet 200 mg 3 QL (100 EA per 30 days) INTENSE COUGH RELIEVER LIQUID S/F, A/F, DOUBLE STR MG/5 ML 3 QL (240 ML per 30 days) IOPHEN-C NR LIQUID MG/5 ML 3 QL (240 ML per 30 days) ISOPTO TEARS 0.5% EYE DROPS 0.5 % 3 KETO-DIASTIX REAGENT STRIPS 3 KONSYL PSYLLIUM FIBER PACKET ORANGE, GLUTEN FREE 3.4 GRAM 3 15

17 levonorgestrel 0.75 mg tablet 0.75 mg 3 QL (2 EA per 30 days) LIQUID WART REMOVER 17% LIQUID W/APPLICATOR 17 % 3 LOHIST-D LIQUID 2-30 MG/5 ML 3 loperamide 2 mg caplet caplet 2 mg 3 LORATADINE-D 24HR TABLET MG 3 QL (30 EA per 30 days) LUBRICANT PM EYE OINTMENT P/F % 3 magnesium oxide 250 mg caplet p/f, s/f, gluten/f 250 mg 3 QL (30 EA per 30 days) magnesium oxide 400 mg tablet 400 mg 3 QL (30 EA per 30 days) magnesium oxide 420 mg tablet 253mg elem magnesium 420 mg 3 QL (30 EA per 30 days) MEDI-CORTISONE 1% CREAM 1 % 3 QL (30 GM per 30 days) MEDI-FIRST ANTI-FUNGAL CRM 1 % 3 MEPHYTON 5 MG TABLET 5 MG 3 METAMUCIL POWDER GLUTEN-FREE, ORANGE 3.4 GRAM/12 GRAM miconazole 100 mg vag supp 100 mg 3 QL (7 EA per 30 days) MICONAZOLE 3 COMBO PACK 3 SUPP W/9GM CREAM 200 MG- 2 % (9 GRAM) You can find information on what the symbols and abbreviations in this table mean by going to page QL (1 EA per 30 days) MICONAZOLE 7 CREAM W/7 DISP APPLICATORS 2 % 3 QL (45 GM per 30 days) MILK OF MAGNESIA CONCENTRATED 2,400 MG/10 ML 3 MILK OF MAGNESIA SUSPENSION 400 MG/5 ML 3 MINTOX PLUS TABLET CHEWABLE MG 3 MOTION SICKNESS RELIEF TB CHEW CHEWABLE TABLET 25 MG MUCINEX COUGH MINI-MELT PACK MG 3 3 QL (60 EA per 30 days) MUCINEX D ER 1, MG TAB 120-1,200 MG 3 QL (60 EA per 30 days) MUCINEX D ER MG TABLET MG 3 QL (36 EA per 30 days) MUCINEX DM ER 1, MG TAB BI-LAYER, MAX-STR 60-1,200 MG MUCINEX DM ER MG TABLET MG 3 MUCINEX ER 1,200 MG TABLET MAX STR, BI-LAYER 1,200 MG 3 MURO-128 2% EYE DROPS 2 % 3 NASAL DECONGESTANT 0.05% SPRAY 12-HOUR 0.05 % 3 NASAL DECONGESTANT 30 MG TAB MAX-STR,NON-DROWSY 30 MG 3 3 QL (60 EA per 30 days)

18 NATURAL BALANCE TEARS DROPS 0.4 % 3 NEXT CHOICE ONE DOSE 1.5 MG TB (OTC) 1.5 MG 3 QL (1 EA per 30 days) niacin 250 mg tablet 250 mg 3 niacin 50 mg tablet 50 mg 3 niacin 500 mg capsule sa 500 mg 3 niacin 500 mg tablet 500 mg 3 niacin er 500 mg tablet 500 mg 3 niacin sa 250 mg capsule (otc) 250 mg 3 NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR 3 QL (180 EA per 365 days) nicotine 4 mg chewing gum coated, cinnamon 4 mg 3 QL (4320 EA per 365 days) nicotine 7 mg/24hr patch clear, step 3 (otc) 7 mg/24 hr 3 QL (180 EA per 365 days) nicotine transdermal system 24 hour patch kit mg/24 hr 3 QL (112 EA per 365 days) NON-ASA PAIN RELIEF TB CHEW 80 MG 3 QL (100 EA per 30 days) NON-ASPIRIN 100 MG/ML DROPS 100 MG/ML 3 QL (15 ML per 30 days) NUTRISOURCE FIBER POWDER 3 OCEAN 0.65% NASAL SPRAY 0.65 % 3 PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG 3 QL (240 EA per 30 days) PANDA MASK MEDIUM 3 QL (1 EA per 365 days) PEAK-AIR PEAK FLOW METER 3 QL (1 EA per 365 days) PEDIATRIC COUGH-COLD LIQUID MG/5 ML 3 PEDIATRIC ELECTROLYTE SOLUTION 8'S, A/F, GRAPE 3 QL (2000 ML per 30 days) PEDIATRIC MEDIUM MASK 3 QL (1 EA per 365 days) PHARBEDRYL 50 MG CAPSULE 50 MG 3 QL (100 EA per 30 days) phentermine 37.5 mg tablet 37.5 mg 3 PA; QL (31 EA per 31 days) PINK BISMUTH CAPLET CAPLET 262 MG 3 POLYSPORIN OINTMENT (OTC) ,000 UNIT/GRAM 3 POLY-VI-SOL DROPS UNIT-MG-UNIT/ML 3 POLYVITAMIN W-IRON DROPS 1,500 UNIT-400 UNIT-10 MG/ML 3 povidone-iodine 10% solution 10 % 3 PRENATAL CAPLET S/F,P/F,GLUTEN/FREE 28 MG IRON- 800 MCG PRENATAL TABLET (OTC) MG 3 PRILOSEC OTC 20.6 MG TABLET OTC 20 MG

19 PROMETHAZINE VC-CODEINE SYRUP MG/5 ML 3 QL (480 ML per 30 days) promethazine-codeine syrup mg/5 ml 3 QL (480 ML per 30 days) promethazine-dm syrup mg/5 ml 3 psyllium fiber 0.52 g capsule 0.52 gram 3 pv calamine lotion 3 PV LICE TREATMENT KIT W/ NIT COMB % 3 PYRETHRIN LICE TREATMENT % 3 pyridoxine 25 mg tablet 25 mg 3 QC 3 DAY VAGINAL 4% CREAM 200 MG/5 GRAM (4 %) 3 QL (25 GM per 30 days) QC NATURAL VEGETABLE POWDER 3.4 GRAM/12 GRAM 3 Q-PAP 325 MG TABLET 325 MG 3 RA ACNE TREATMENT 10% CREAM 10 % 3 RA ANTI-DIARRHEAL 1 MG/5 ML 1 MG/5 ML 3 ra aspirin ec 325 mg tablet regular strength 325 mg 3 QL (100 EA per 30 days) RA CETIRI-D ER TABLET MG 3 QL (60 EA per 30 days) ra folic acid 0.4 mg tablet p/f 400 mcg 3 ra ibuprofen 200 mg capsule softgel, mg 3 QL (100 EA per 30 days) ra naproxen sod 220 mg tablet 220 mg 3 ra niacin 100 mg tablet p/f 100 mg 3 ra nicotine 2 mg chewing gum mint 2 mg 3 QL (4320 EA per 365 days) ra nicotine 4 mg mini lozenge mini,mint,4 quittube 4 mg 3 QL (3600 EA per 365 days) ra omeprazole dr 20 mg tablet delayed release 20 mg 3 QL (60 EA per 30 days) RA SALINE ENEMA LATEX FREE 19-7 GRAM/118 ML 3 RA SLEEP TABLET 25 MG 3 QL (100 EA per 30 days) ra sodium chloride 5% eye drop 5 % 3 RA SOLUBLE FIBER 500 MG CPLT 500 MG 3 RA STOMACH RELIEF 262 MG/15 ML REG STRENGTH 262 MG/15 ML RA TUSSIN CF LIQUID A/F, MG/5 ML 3 QL (240 ML per 30 days) RA VITAMIN D3 2,000 UNIT SFGL 2,000 UNIT 3 ra vitamin d3 5,000 unit sftgl softgel 5,000 unit 3 RA WART REMOVER 17% GEL MAXIMUM STRENGTH 17 % 3 RA WART REMOVER LIQUID 3 You can find information on what the symbols and abbreviations in this table mean by going to page

20 ra zinc 50 mg tablet p/f 50 mg 3 ra zinc oxide ointment 3 ranitidine 75 mg tablet 75 mg 3 REESE'S PINWORM 144 MG/ML SUSP 50 MG/ML 3 REFRESH LACRI-LUBE OINTMENT % 3 ROBITUSSIN PEDIATRIC COUGH SYP A/F,LONG-ACTING 7.5 MG/5 ML SCALPICIN 1% ANTI-ITCH LIQUID 1 % 3 QL (74 ML per 30 days) SCOT-TUSSIN DM S-F LIQUID 2-15 MG/5 ML 3 SCOT-TUSSIN SENIOR LIQUID MG/5 ML 3 QL (240 ML per 30 days) SENNA 8.6 MG TABLET 8.6 MG 3 SENNA 8.8 MG/5 ML SYRUP 8.8 MG/5 ML 3 SENNA PLUS TABLET MG 3 QL (60 EA per 30 days) SILAPAP INFANT'S DROPS INFANT 80 MG/0.8 ML 3 QL (15 ML per 30 days) simethicone 80 mg tab chew 80 mg 3 QL (60 EA per 30 days) SM ANTACID ANTI-GAS LIQUID ORIGINAL, MAX STR MG/5 ML SM CHILD'S PAIN RELIEVER SUSP 160 MG/5 ML 3 QL (240 ML per 30 days) sm clotrimazole 1% cream 1 % 3 QL (45 GM per 30 days) SM EAR DROPS 6.5% 6.5 % 3 QL (15 ML per 30 days) SM INF PAIN RELV 80 MG/0.8 ML 80 MG/0.8 ML 3 QL (15 ML per 30 days) sm nicotine 2 mg lozenge 2 mg 3 QL (3600 EA per 365 days) sm nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr 3 QL (180 EA per 365 days) SM VITAMIN D3 4,000 UNIT SFTGL SOFTGEL, GLUTEN-FREE 4,000 UNIT sodium bicarb 325 mg tablet 325 mg 3 sodium bicarb 650 mg tablet 10 gr 650 mg 3 sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % 3 sodium chloride 5% eye oint 5 % 3 SOOTHE 262 MG CHEWABLE TABLET 262 MG 3 SUDOGEST 60 MG TABLET 60 MG 3 QL (60 EA per 30 days) SYSTANE NIGHTTIME EYE OINT 94-3 % 3 TEARS NATURALE FORTE DROPS % 3 TEARS NATURALE-II EYE DROPS

21 thiamine 250 mg tablet 250 mg 3 tolnaftate 1% solution 1 % 3 TRI-VITA DROPS 1, UNIT-MG-UNIT/ML 3 TRYMINE D LIQUID MG/5 ML 3 urea 10% lotion 10 % 3 VCF CONTRACEPTIVE FILM 28 % 3 VCF CONTRACEPTIVE FOAM 12.5 % 3 VISINE-A EYE DROPS % 3 vit d mg (50,000 unit) softgel 50,000 unit 3 QL (4 EA per 28 days) vitamin a 10,000 units softgel 10,000 unit 3 VITAMIN B MG TABLET 100 MG 3 VITAMIN B MG TABLET S/F,P/F,GLUTEN-FREE 100 MG 3 VITAMIN B-1 50 MG TABLET 50 MG 3 VITAMIN B MG TABLET GLUTEN-FREE 100 MG 3 VITAMIN B MG TABLET 100 MG 3 VITAMIN C-500 MG TABLET P/F, S/F, GLUTEN/F 500 MG 3 vitamin d 10,000 unit softgel softgel, p/f,s/f 10,000 unit 3 vitamin d2 400 unit tablet s/f,l/f,y/f, gluten/f 400 unit 3 VITAMIN D3 1,000 UNIT TABLET S/F,Y/F,P/F 1,000 UNIT 3 VITAMIN D3 2,000 UNIT TABLET W/ CALCIUM CARBONATE 2,000 UNIT VITAMIN D3 400 UNIT TABLET S/F,P/F 400 UNIT 3 vitamin d3 5,000 unit tablet p/f,s/f, gluten-free 5,000 unit 3 vitamin e 400 unit capsule 400 unit 3 WAL-ACT D COLD & ALLERGY TAB MG 3 WAL-FINATE-D TABLET 4-60 MG 3 QL (60 EA per 30 days) WAL-MUCIL 100% NATURAL FIBER S/F,180 DOSES,ORANGE 3.4 GRAM/5.8 GRAM zinc oxide paste 25 % 3 Analgesics Analgesics acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml 1 QL (4650 ML per 31 days) acetaminophen-codeine oral tablet mg 1 QL (413 EA per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page

22 acetaminophen-codeine oral tablet mg 1 QL (372 EA per 31 days) acetaminophen-codeine oral tablet mg 1 QL (186 EA per 31 days) hydrocodone-acetaminophen oral tablet mg, mg, mg 1 QL (372 EA per 31 days) hydrocodone-ibuprofen oral tablet mg 1 QL (155 EA per 31 days) oxycodone-acetaminophen oral tablet mg 1 QL (372 EA per 31 days) tramadol-acetaminophen oral tablet mg 1 QL (248 EA per 31 days) Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg 1 QL (62 EA per 31 days) diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 75 mg 1 diclofenac sodium topical drops 1.5 % 1 ibuprofen oral tablet 800 mg 1 indomethacin oral capsule 25 mg 1 PA; QL (124 EA per 31 days) meloxicam oral tablet 15 mg, 7.5 mg 1 QL (31 EA per 31 days) nabumetone oral tablet 500 mg, 750 mg 1 naproxen oral tablet 375 mg, 500 mg 1 Opioid Analgesics, Long-Acting DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML 2 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine oral capsule, extend. release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 1 QL (10 EA per 30 days) 1 QL (62 EA per 31 days) morphine oral solution 10 mg/5 ml 1 QL (3100 ML per 31 days) morphine oral tablet 15 mg, 30 mg 1 QL (186 EA per 31 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg 1 QL (93 EA per 31 days) morphine oral tablet extended release 200 mg 1 QL (62 EA per 31 days) tramadol oral tablet extended release 24 hr 100 mg 1 QL (93 EA per 31 days) tramadol oral tablet extended release 24 hr 200 mg 1 QL (31 EA per 31 days) Opioid Analgesics, Short-Acting butorphanol tartrate nasal spray, non-aerosol 10 mg/ml 1 QL (22.5 ML per 31 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 10 mg/ml 1 1 PA; QL (124 EA per 31 days) hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QL (279 EA per 31 days) 21

23 LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY ; QL (31 EA per 31 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg 1 QL (186 EA per 31 days) tramadol oral tablet 50 mg 1 QL (248 EA per 31 days) Anesthetics Local Anesthetics lidocaine (pf) injection solution 5 mg/ml (0.5 %) 1 lidocaine hcl injection solution 20 mg/ml (2 %) 1 lidocaine hcl mucous membrane gel 2 % 1 lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) 1 lidocaine topical adhesive patch, medicated 5 % 1 PA; QL (93 EA per 31 days) lidocaine topical ointment 5 % 1 lidocaine-prilocaine topical cream % 1 Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate oral tablet, delayed release (dr/ec) 333 mg 1 disulfiram oral tablet 250 mg, 500 mg 1 Opioid Dependence Treatments buprenorphine hcl injection syringe 0.3 mg/ml 1 buprenorphine hcl sublingual tablet 2 mg, 8 mg 1 QL (93 EA per 31 days) buprenorphine-naloxone sublingual tablet mg 1 QL (372 EA per 31 days) buprenorphine-naloxone sublingual tablet 8-2 mg 1 QL (93 EA per 31 days) naltrexone oral tablet 50 mg 1 Opioid Reversal Agents naloxone injection syringe 1 mg/ml 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Smoking Cessation Agents CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG ; QL (336 EA per 168 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (336 EA per 168 days) NICOTROL INHALATION CARTRIDGE 10 MG 2 NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML 2 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 22

24 Antibacterials Aminoglycosides amikacin injection solution 500 mg/2 ml 1 gentak ophthalmic ointment 0.3 % (3 mg/gram) 1 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml 1 gentamicin ophthalmic drops 0.3 % 1 gentamicin topical cream 0.1 % 1 gentamicin topical ointment 0.1 % 1 neomycin oral tablet 500 mg 1 neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml 1 paromomycin oral capsule 250 mg 1 streptomycin intramuscular recon soln 1 gram 1 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG TOBRADEX OPHTHALMIC OINTMENT % 2 tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic drops 0.3 % 1 tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml 1 TOBREX OPHTHALMIC OINTMENT 0.3 % 2 ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM Antibacterials colistin (colistimethate na) injection recon soln 150 mg 1 B vs D SYNERCID INTRAVENOUS RECON SOLN 500 MG Antibacterials, Other acetic acid otic solution 2 % 1 alcohol pads topical pads, medicated 1 bacitracin ophthalmic ointment 500 unit/gram 1 chloramphenicol sod succinate intravenous recon soln 1 gram 1 clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml 1 ; QL (224 EA per 28 days) 1 PA; QL (10 ML per 1 day) 1 23

25 clindamycin phosphate intravenous solution 600 mg/4 ml 1 clindamycin phosphate topical foam 1 % 1 clindamycin phosphate topical gel 1 % 1 clindamycin phosphate topical lotion 1 % 1 clindamycin phosphate topical solution 1 % 1 clindamycin phosphate topical swab 1 % 1 clindamycin phosphate vaginal cream 2 % 1 CUBICIN INTRAVENOUS RECON SOLN 500 MG LINCOCIN INJECTION SOLUTION 300 MG/ML 2 lincomycin injection solution 300 mg/ml 1 linezolid intravenous parenteral solution 600 mg/300 ml 1 PA linezolid oral suspension for reconstitution 100 mg/5 ml 1 PA; QL (1680 ML per 28 days) linezolid oral tablet 600 mg 1 PA; QL (28 EA per 14 days) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole topical cream 0.75 % 1 metronidazole topical gel 0.75 %, 1 % 1 metronidazole topical lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium topical cream 2 % 1 mupirocin topical ointment 2 % 1 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 PA nitrofurantoin monohyd/m-cryst oral capsule 100 mg, 100 mg (75/25) 1 PA nitrofurantoin oral suspension 25 mg/5 ml 1 PA PRIMSOL ORAL SOLUTION 50 MG/5 ML 2 trimethoprim oral tablet 100 mg 1 TYGACIL INTRAVENOUS RECON SOLN 50 MG vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg 1 B vs D vancomycin oral capsule 125 mg 1 PA; QL (56 EA per 14 days) vancomycin oral capsule 250 mg 1 PA; QL (40 EA per 10 days) Beta-Lactam, Cephalosporins cefaclor oral capsule 250 mg, 500 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 24

26 cefaclor oral tablet extended release 12 hr 500 mg 1 cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1 cefadroxil oral tablet 1 gram 1 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml 1 cefazolin injection recon soln 1 gram, 10 gram, 500 mg 1 cefdinir oral capsule 300 mg 1 cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cefepime injection recon soln 1 gram, 2 gram 1 cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 1 cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram 1 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml 1 cefpodoxime oral tablet 100 mg, 200 mg 1 cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cefprozil oral tablet 250 mg, 500 mg 1 ceftazidime in d5w intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 1 ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg 1 ceftriaxone intravenous recon soln 1 gram, 2 gram 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 cefuroxime sodium injection recon soln 1.5 gram, 750 mg 1 cefuroxime sodium intravenous recon soln 7.5 gram 1 cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cephalexin oral tablet 250 mg, 500 mg 1 SUPRAX ORAL CAPSULE 400 MG 2 SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG 2 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 2 Beta-Lactam, Other aztreonam injection recon soln 1 gram 1 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 1 ; QL (84 ML per 28 days) 25

27 imipenem-cilastatin intravenous recon soln 250 mg, 500 mg 1 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg 1 Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet, chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet, chewable mg, mg 1 ampicillin oral capsule 250 mg, 500 mg 1 ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg 1 ampicillin-sulbactam injection recon soln 15 gram, 3 gram 1 BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg 1 nafcillin injection recon soln 1 gram, 10 gram 1 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram 1 oxacillin intravenous recon soln 2 gram 1 penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit 1 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml 1 penicillin g sodium injection recon soln 5 million unit 1 You can find information on what the symbols and abbreviations in this table mean by going to page

28 penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml 1 penicillin v potassium oral tablet 250 mg, 500 mg 1 piperacillin-tazobactam intravenous recon soln gram, 4.5 gram 1 Macrolides azithromycin intravenous recon soln 500 mg, 500 mg (2 mg/ml) 1 azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml 1 azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 600 mg 1 clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg 1 clarithromycin oral tablet extended release 24 hr 500 mg 1 ery pads topical swab 2 % 1 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG erythrocin (as stearate) oral tablet 250 mg 1 erythrocin intravenous recon soln 500 mg 1 erythromycin ophthalmic ointment 5 mg/gram (0.5 %) 1 erythromycin oral capsule, delayed release(dr/ec) 250 mg 1 erythromycin oral tablet 250 mg, 500 mg 1 erythromycin with ethanol topical gel 2 % 1 erythromycin with ethanol topical solution 2 % 1 Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg 1 ciprofloxacin hcl ophthalmic drops 0.3 % 1 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml 1 ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml 1 levofloxacin intravenous solution 25 mg/ml 1 levofloxacin ophthalmic drops 0.5 % 1 levofloxacin oral solution 250 mg/10 ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 ofloxacin ophthalmic drops 0.3 % 1 ofloxacin oral tablet 400 mg

29 ofloxacin otic drops 0.3 % 1 VIGAMOX OPHTHALMIC DROPS 0.5 % 2 Sulfonamides silver sulfadiazine topical cream 1 % 1 SSD TOPICAL CREAM 1 % 2 sulfacetamide sodium (acne) topical suspension 10 % 1 sulfacetamide sodium ophthalmic drops 10 % 1 sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim intravenous solution mg/5 ml 1 sulfamethoxazole-trimethoprim oral suspension mg/5 ml 1 sulfamethoxazole-trimethoprim oral tablet mg, mg 1 Tetracyclines doxycycline hyclate intravenous recon soln 100 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg 1 doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml 1 doxycycline monohydrate oral tablet 150 mg, 75 mg 1 minocycline oral capsule 100 mg, 50 mg, 75 mg 1 minocycline oral tablet 100 mg, 50 mg, 75 mg 1 tetracycline oral capsule 250 mg, 500 mg 1 Anticonvulsants Anticonvulsants, Other DIAZEPAM RECTAL KIT MG, 2.5 MG, MG 2 levetiracetam intravenous solution 500 mg/5 ml 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg 1 levetiracetam oral tablet extended release 24 hr 500 mg 1 QL (155 EA per 31 days) levetiracetam oral tablet extended release 24 hr 750 mg 1 QL (124 EA per 31 days) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG ; QL (93 EA per 31 days) Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG 2 ethosuximide oral capsule 250 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 28

30 ethosuximide oral solution 250 mg/5 ml 1 LYRICA ORAL CAPSULE 100 MG 2 QL (186 EA per 31 days) LYRICA ORAL CAPSULE 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (93 EA per 31 days) LYRICA ORAL CAPSULE 225 MG, 300 MG 2 QL (62 EA per 31 days) LYRICA ORAL SOLUTION 20 MG/ML 2 QL (930 ML per 31 days) zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 QL (310 EA per 31 days) clonazepam oral tablet, disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 QL (310 EA per 31 days) clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 QL (186 EA per 31 days) diazepam intensol oral concentrate 5 mg/ml 1 QL (248 ML per 31 days) diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 QL (1240 ML per 31 days) diazepam oral tablet 10 mg, 2 mg, 5 mg 1 QL (124 EA per 31 days) divalproex oral capsule, sprinkle 125 mg 1 divalproex oral tablet extended release 24 hr 250 mg, 500 mg 1 divalproex oral tablet, delayed release (dr/ec) 125 mg, 250 mg, 500 mg 1 gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 QL (279 EA per 31 days) gabapentin oral solution 250 mg/5 ml 1 QL (2232 ML per 31 days) gabapentin oral tablet 600 mg 1 QL (186 EA per 31 days) gabapentin oral tablet 800 mg 1 QL (124 EA per 31 days) GABITRIL ORAL TABLET 12 MG, 16 MG 2 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 QL (155 EA per 31 days) ONFI ORAL SUSPENSION 2.5 MG/ML ; QL (496 ML per 31 days) ONFI ORAL TABLET 10 MG, 20 MG ; QL (62 EA per 31 days) phenobarbital oral elixir 20 mg/5 ml 1 PA phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg 1 1 PA SABRIL ORAL POWDER IN PACKET 500 MG ; QL (1860 EA per 31 days) SABRIL ORAL TABLET 500 MG ; QL (186 EA per 31 days) tiagabine oral tablet 2 mg, 4 mg 1 valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) 1 29

31 valproic acid (as sodium salt) oral solution 250 mg/5 ml 1 valproic acid oral capsule 250 mg 1 Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml 1 felbamate oral tablet 400 mg, 600 mg 1 FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 1 topiramate oral capsule, sprinkle 15 mg, 25 mg 1 ; QL (31 EA per 31 days) topiramate oral tablet 100 mg, 200 mg, 50 mg 1 QL (62 EA per 31 days) topiramate oral tablet 25 mg 1 Sodium Channel Agents APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG ; QL (31 EA per 31 days) APTIOM ORAL TABLET 600 MG ; QL (62 EA per 31 days) BANZEL ORAL SUSPENSION 40 MG/ML 2 QL (2480 ML per 31 days) BANZEL ORAL TABLET 200 MG, 400 MG 2 QL (248 EA per 31 days) carbamazepine oral suspension 100 mg/5 ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg 1 carbamazepine oral tablet, chewable 100 mg 1 DILANTIN ORAL CAPSULE 30 MG 2 fosphenytoin injection solution 100 mg pe/2 ml 1 oxcarbazepine oral suspension 300 mg/5 ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 PEGANONE ORAL TABLET 250 MG 2 phenytoin oral suspension 125 mg/5 ml 1 phenytoin oral tablet, chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg 1 phenytoin sodium intravenous solution 50 mg/ml 1 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML 2 QL (1240 ML per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page

32 VIMPAT ORAL SOLUTION 10 MG/ML 2 QL (1240 ML per 31 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 2 QL (62 EA per 31 days) Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 mg 1 PA Cholinesterase Inhibitors donepezil oral tablet 10 mg, 5 mg 1 QL (31 EA per 31 days) donepezil oral tablet, disintegrating 10 mg, 5 mg 1 QL (31 EA per 31 days) galantamine oral capsule, ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg 1 QL (31 EA per 31 days) galantamine oral solution 4 mg/ml 1 QL (200 ML per 31 days) galantamine oral tablet 12 mg, 4 mg, 8 mg 1 QL (62 EA per 31 days) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1 QL (62 EA per 31 days) N-Methyl-D-Aspartate (NMDA) Receptor Antagonist memantine oral solution 2 mg/ml 1 memantine oral tablet 10 mg, 5 mg 1 memantine oral tablets, dose pack 5-10 mg 1 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG Antidepressants Antidepressants 2 QL (28 EA per 28 days) 2 QL (31 EA per 31 days) fluoxetine oral tablet 60 mg 1 QL (31 EA per 31 days) olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 mg, 6-50 mg Antidepressants, Other ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG 1 QL (31 EA per 31 days) ; QL (1 EA per 28 days) buproban oral tablet extended release 150 mg 1 QL (62 EA per 31 days) bupropion hcl oral tablet 100 mg 1 QL (124 EA per 31 days) bupropion hcl oral tablet 75 mg 1 QL (93 EA per 31 days) bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg 1 QL (62 EA per 31 days) bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg 1 QL (31 EA per 31 days) maprotiline oral tablet 25 mg 1 QL (279 EA per 31 days) 31

33 maprotiline oral tablet 50 mg 1 QL (124 EA per 31 days) maprotiline oral tablet 75 mg 1 QL (93 EA per 31 days) mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 QL (31 EA per 31 days) mirtazapine oral tablet, disintegrating 15 mg, 30 mg, 45 mg 1 QL (31 EA per 31 days) nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 1 QL (62 EA per 31 days) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR ; QL (30 EA per 30 days) MARPLAN ORAL TABLET 10 MG 2 QL (186 EA per 31 days) phenelzine oral tablet 15 mg 1 tranylcypromine oral tablet 10 mg 1 SSRIs/ SNRIs BRINTELLIX ORAL TABLET 10 MG ; QL (62 EA per 31 days) BRINTELLIX ORAL TABLET 20 MG ; QL (31 EA per 31 days) BRINTELLIX ORAL TABLET 5 MG ; QL (124 EA per 31 days) citalopram oral solution 10 mg/5 ml 1 QL (620 ML per 31 days) citalopram oral tablet 10 mg, 20 mg, 40 mg 1 QL (31 EA per 31 days) desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg 1 QL (124 EA per 31 days) duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg, 60 mg 1 QL (62 EA per 31 days) escitalopram oxalate oral solution 5 mg/5 ml 1 QL (620 ML per 31 days) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 QL (31 EA per 31 days) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG ; QL (28 EA per 28 days) ; QL (31 EA per 31 days) fluoxetine oral capsule 10 mg, 40 mg 1 QL (31 EA per 31 days) fluoxetine oral capsule 20 mg 1 QL (124 EA per 31 days) fluoxetine oral capsule, delayed release(dr/ec) 90 mg 1 QL (31 EA per 31 days) fluoxetine oral solution 20 mg/5 ml 1 QL (620 ML per 31 days) fluoxetine oral tablet 10 mg 1 QL (31 EA per 31 days) fluoxetine oral tablet 20 mg 1 QL (124 EA per 31 days) fluvoxamine oral tablet 100 mg 1 QL (93 EA per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 32

34 fluvoxamine oral tablet 25 mg 1 QL (31 EA per 31 days) fluvoxamine oral tablet 50 mg 1 QL (62 EA per 31 days) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 QL (62 EA per 31 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 37.5 mg 1 QL (62 EA per 31 days) paroxetine hcl oral tablet extended release 24 hr 25 mg 1 QL (93 EA per 31 days) PAXIL ORAL SUSPENSION 10 MG/5 ML 2 QL (930 ML per 31 days) sertraline oral concentrate 20 mg/ml 1 QL (310 ML per 31 days) sertraline oral tablet 100 mg 1 QL (62 EA per 31 days) sertraline oral tablet 25 mg, 50 mg 1 QL (31 EA per 31 days) venlafaxine oral capsule, extended release 24hr 150 mg, 37.5 mg, 75 mg 1 QL (31 EA per 31 days) venlafaxine oral tablet 100 mg 1 QL (93 EA per 31 days) venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg 1 QL (31 EA per 31 days) venlafaxine oral tablet 75 mg 1 QL (155 EA per 31 days) venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg 1 QL (31 EA per 31 days) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG ; QL (31 EA per 31 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Tricyclics amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 PA desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA doxepin oral concentrate 10 mg/ml 1 PA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg 1 PA nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 nortriptyline oral solution 10 mg/5 ml 1 protriptyline oral tablet 10 mg, 5 mg 1 SURMONTIL ORAL CAPSULE 50 MG ; QL (124 EA per 31 days) trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 PA Antiemetics Antiemetics, Other 33

35 chlorpromazine injection solution 25 mg/ml 1 chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 50 mg 1 chlorpromazine oral tablet 25 mg 1 B vs D compro rectal suppository 25 mg 1 diphenhydramine hcl injection solution 50 mg/ml 1 hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml 1 PA hydroxyzine hcl oral solution 10 mg/5 ml 1 PA hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 PA meclizine oral tablet 12.5 mg, 25 mg 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 1 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 promethazine injection solution 25 mg/ml, 50 mg/ml 1 PA promethazine oral syrup 6.25 mg/5 ml 1 PA promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA promethazine rectal suppository 12.5 mg, 25 mg 1 PA promethegan rectal suppository 25 mg, 50 mg 1 PA Emetogenic Therapy Adjuncts dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 PA EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) granisetron (pf) intravenous solution 100 mcg/ml 1 B vs D granisetron hcl intravenous solution 1 mg/ml (1 ml) 1 B vs D granisetron hcl oral tablet 1 mg 1 B vs D ondansetron hcl (pf) injection solution 4 mg/2 ml 1 ondansetron hcl oral solution 4 mg/5 ml 1 B vs D ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 B vs D ondansetron oral tablet, disintegrating 4 mg, 8 mg 1 B vs D Antifungals Antifungals You can find information on what the symbols and abbreviations in this table mean by going to page 7. 34

36 ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg 1 PA CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % 1 ciclopirox topical gel 0.77 % 1 ciclopirox topical shampoo 1 % 1 ciclopirox topical suspension 0.77 % 1 clotrimazole mucous membrane troche 10 mg 1 clotrimazole topical cream 1 % 1 clotrimazole topical solution 1 % 1 econazole topical cream 1 % 1 fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml 1 fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml 1 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 flucytosine oral capsule 250 mg, 500 mg 1 griseofulvin microsize oral suspension 125 mg/5 ml 1 itraconazole oral capsule 100 mg 1 QL (124 EA per 31 days) ketoconazole oral tablet 200 mg 1 ketoconazole topical cream 2 % 1 ketoconazole topical shampoo 2 % 1 miconazole-3 vaginal suppository 200 mg 1 MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % 2 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) nystatin oral suspension 100,000 unit/ml 1 nystatin oral tablet 500,000 unit 1 nystatin topical cream 100,000 unit/gram 1 nystatin topical ointment 100,000 unit/gram 1 nystatin topical powder 100,000 unit/gram 1 SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 250 mg 1 35

37 terconazole vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 voriconazole intravenous solution 200 mg 1 PA voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) 1 QL (600 ML per 30 days) voriconazole oral tablet 200 mg, 50 mg 1 QL (62 EA per 31 days) ZOLINZA ORAL CAPSULE 100 MG ; QL (124 EA per 31 days) Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg 1 colchicine oral capsule 0.6 mg 1 colchicine oral tablet 0.6 mg 1 colchicine-probenecid oral tablet mg 1 COLCRYS ORAL TABLET 0.6 MG 2 QL (124 EA per 31 days) probenecid oral tablet 500 mg 1 Anti-Inflammatory Agents Nonsteroidal Anti-Inflammatory Drugs diclofenac potassium oral tablet 50 mg 1 diclofenac sodium oral tablet extended release 24 hr 100 mg 1 diclofenac sodium oral tablet, delayed release (dr/ec) 50 mg 1 flurbiprofen oral tablet 100 mg, 50 mg 1 ibuprofen oral suspension 100 mg/5 ml 1 ibuprofen oral tablet 400 mg, 600 mg 1 indomethacin oral capsule 50 mg 1 PA; QL (124 EA per 31 days) indomethacin oral capsule, extended release 75 mg 1 PA; QL (62 EA per 31 days) naproxen oral suspension 125 mg/5 ml 1 naproxen oral tablet 250 mg 1 sulindac oral tablet 150 mg, 200 mg 1 Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution 1 mg/ml 1 ERGOMAR SUBLINGUAL TABLET 2 MG 2 QL (20 EA per 31 days) Serotonin (5-HT) 1B/1D Receptor Agonists You can find information on what the symbols and abbreviations in this table mean by going to page 7. 36

38 rizatriptan oral tablet 10 mg, 5 mg 1 QL (18 EA per 30 days) rizatriptan oral tablet, disintegrating 10 mg, 5 mg 1 QL (18 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml 1 QL (4 ML per 28 days) sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) 1 QL (4 ML per 28 days) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml 1 QL (4 ML per 28 days) Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 mg 1 pyridostigmine bromide oral tablet 60 mg 1 Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100 mg, 25 mg 1 rifabutin oral capsule 150 mg 1 Antituberculars CAPASTAT INJECTION RECON SOLN 1 GRAM ethambutol oral tablet 100 mg, 400 mg 1 isoniazid injection solution 100 mg/ml 1 isoniazid oral solution 50 mg/5 ml 1 isoniazid oral tablet 100 mg, 300 mg 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM 2 pyrazinamide oral tablet 500 mg 1 RIFAMATE ORAL CAPSULE MG 2 rifampin intravenous recon soln 600 mg 1 rifampin oral capsule 150 mg, 300 mg 1 RIFATER ORAL TABLET MG 2 SIRTURO ORAL TABLET 100 MG ; QL (188 EA per 168 days) TRECATOR ORAL TABLET 250 MG 2 Antineoplastics Alkylating Agents BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML 2 cyclophosphamide oral capsule 25 mg, 50 mg 1 B vs D 37

39 HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG 2 MATULANE ORAL CAPSULE 50 MG melphalan hcl intravenous recon soln 50 mg 1 thiotepa injection recon soln 15 mg 1 PA Antiandrogens bicalutamide oral tablet 50 mg 1 flutamide oral capsule 125 mg 1 NILANDRON ORAL TABLET 150 MG XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 250 MG ; QL (124 EA per 31 days) Antiangiogenic Agents POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG ; QL (21 EA per 28 days) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG ; LA THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG Antiestrogens/Modifiers EMCYT ORAL CAPSULE 140 MG FARESTON ORAL TABLET 60 MG 2 SOLTAMOX ORAL SOLUTION 10 MG/5 ML 2 tamoxifen oral tablet 10 mg, 20 mg 1 Antimetabolites gemcitabine intravenous recon soln 1 gram 1 B vs D hydroxyurea oral capsule 500 mg 1 LONSURF ORAL TABLET MG, MG PURIXAN ORAL SUSPENSION 20 MG/ML TABLOID ORAL TABLET 40 MG Antineoplastics ALIMTA INTRAVENOUS RECON SOLN 500 MG 2 B vs D ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg 1 B vs D BELEODAQ INTRAVENOUS RECON SOLN 500 MG You can find information on what the symbols and abbreviations in this table mean by going to page 7. 38

40 BICNU INTRAVENOUS RECON SOLN 100 MG 2 B vs D bleomycin injection recon soln 30 unit 1 PA carboplatin intravenous solution 10 mg/ml 1 B vs D cisplatin intravenous solution 1 mg/ml 1 B vs D cladribine intravenous solution 10 mg/10 ml 1 B vs D COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) 1 B vs D cytarabine injection solution 20 mg/ml 1 B vs D dacarbazine intravenous recon soln 200 mg 1 B vs D daunorubicin intravenous solution 5 mg/ml 1 B vs D DAUNOXOME INTRAVENOUS SOLUTION 2 MG/ML 2 B vs D decitabine intravenous recon soln 50 mg 1 B vs D dexrazoxane hcl intravenous recon soln 250 mg 1 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG DOCETAXEL INTRAVENOUS SOLUTION 80 MG/4 ML (20 MG/ML) docetaxel intravenous solution 80 mg/8 ml (10 mg/ml) 1 PA DOXIL INTRAVENOUS SUSPENSION 2 MG/ML 2 doxorubicin intravenous solution 50 mg/25 ml 1 B vs D ELITEK INTRAVENOUS RECON SOLN 1.5 MG 2 B vs D epirubicin intravenous solution 50 mg/25 ml 1 PA ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERWINAZE INJECTION RECON SOLN 10,000 UNIT FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML GLEOSTINE ORAL CAPSULE 5 MG 2 HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) 2 B vs D HERCEPTIN INTRAVENOUS RECON SOLN 440 MG 2 B vs D idarubicin intravenous solution 1 mg/ml 1 B vs D ifosfamide intravenous recon soln 1 gram 1 irinotecan intravenous solution 100 mg/5 ml 1 ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML IXEMPRA INTRAVENOUS RECON SOLN 45 MG JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) 2 B vs D 39

41 KADCYLA INTRAVENOUS RECON SOLN 100 MG levoleucovorin calcium intravenous solution 10 mg/ml 1 PA LYNPARZA ORAL CAPSULE 50 MG mesna intravenous solution 100 mg/ml 1 B vs D MESNEX ORAL TABLET 400 MG 2 mitomycin intravenous recon soln 20 mg 1 B vs D MUSTARGEN INJECTION RECON SOLN 10 MG NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG oxaliplatin intravenous solution 100 mg/20 ml 1 PA paclitaxel intravenous concentrate 6 mg/ml 1 B vs D PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML 2 B vs D VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML) 2 B vs D VELCADE INJECTION RECON SOLN 3.5 MG vinblastine intravenous solution 1 mg/ml 1 B vs D vincristine intravenous solution 1 mg/ml 1 B vs D vinorelbine intravenous solution 50 mg/5 ml 1 B vs D Antineoplastics, Other ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG amifostine crystalline intravenous recon soln 500 mg 1 fludarabine intravenous recon soln 50 mg 1 leucovorin calcium injection recon soln 100 mg, 350 mg 1 B vs D leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 mitoxantrone intravenous concentrate 2 mg/ml 1 B vs D ONCASPAR INJECTION SOLUTION 750 UNIT/ML REVLIMID ORAL CAPSULE 2.5 MG, 20 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 40

42 Aromatase Inhibitors, 3 RD Generation anastrozole oral tablet 1 mg 1 QL (31 EA per 31 days) exemestane oral tablet 25 mg 1 letrozole oral tablet 2.5 mg 1 QL (31 EA per 31 days) Enzyme Inhibitors etoposide intravenous solution 20 mg/ml 1 B vs D FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG toposar intravenous solution 20 mg/ml 1 B vs D topotecan intravenous recon soln 4 mg 1 ZYDELIG ORAL TABLET 100 MG, 150 MG Molecular Target Inhibitors AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ; QL (31 EA per 31 days) ALECENSA ORAL CAPSULE 150 MG BOSULIF ORAL TABLET 100 MG, 500 MG CAPRELSA ORAL TABLET 100 MG, 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY) COTELLIC ORAL TABLET 20 MG ERIVEDGE ORAL CAPSULE 150 MG ; QL (31 EA per 31 days) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ; QL (31 EA per 31 days) GLEEVEC ORAL TABLET 100 MG ; QL (93 EA per 31 days) GLEEVEC ORAL TABLET 400 MG ; QL (62 EA per 31 days) ICLUSIG ORAL TABLET 15 MG ; QL (93 EA per 31 days) ICLUSIG ORAL TABLET 45 MG ; QL (31 EA per 31 days) imatinib oral tablet 100 mg 1 PA; QL (93 EA per 31 days) imatinib oral tablet 400 mg 1 PA; QL (62 EA per 31 days) IMBRUVICA ORAL CAPSULE 140 MG ; QL (124 EA per 31 days) INLYTA ORAL TABLET 1 MG, 5 MG ; QL (62 EA per 31 days) IRESSA ORAL TABLET 250 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG ; QL (62 EA per 31 days) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY), 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) ; QL (60 EA per 30 days) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY ; QL (90 EA per 30 days) 41

43 MEKINIST ORAL TABLET 0.5 MG ; QL (93 EA per 31 days) MEKINIST ORAL TABLET 2 MG ; QL (31 EA per 31 days) NEXAVAR ORAL TABLET 200 MG ; QL (124 EA per 31 days) ODOMZO ORAL CAPSULE 200 MG SPRYCEL ORAL TABLET 100 MG, 140 MG ; QL (31 EA per 31 days) SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG ; QL (62 EA per 31 days) STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG ; QL (31 EA per 31 days) TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ; QL (31 EA per 31 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG ; QL (124 EA per 31 days) TYKERB ORAL TABLET 250 MG ; QL (186 EA per 31 days) VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG ; QL (62 EA per 31 days) ZELBORAF ORAL TABLET 240 MG ; QL (248 EA per 31 days) ZYKADIA ORAL CAPSULE 150 MG ; QL (155 EA per 31 days) Monoclonal Antibodies CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) 2 B vs D DARZALEX INTRAVENOUS SOLUTION 20 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML 2 B vs D SYLVANT INTRAVENOUS RECON SOLN 100 MG Retinoids bexarotene oral capsule 75 mg 1 PANRETIN TOPICAL GEL 0.1 % TARGRETIN TOPICAL GEL 1 % 2 tretinoin (chemotherapy) oral capsule 10 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 42

44 tretinoin topical cream %, 0.05 %, 0.1 % 1 tretinoin topical gel 0.01 %, % 1 Antiparasitics Anthelmintics ALBENZA ORAL TABLET 200 MG 2 BILTRICIDE ORAL TABLET 600 MG 2 ivermectin oral tablet 3 mg 1 Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG 2 atovaquone oral suspension 750 mg/5 ml 1 PA atovaquone-proguanil oral tablet mg, mg 1 chloroquine phosphate oral tablet 250 mg, 500 mg 1 COARTEM ORAL TABLET MG 2 DARAPRIM ORAL TABLET 25 MG 2 hydroxychloroquine oral tablet 200 mg 1 mefloquine oral tablet 250 mg 1 NEBUPENT INHALATION RECON SOLN 300 MG 2 B vs D PENTAM INJECTION RECON SOLN 300 MG 2 primaquine oral tablet 26.3 mg 1 quinine sulfate oral capsule 324 mg 1 PA Pediculicides/ Scabicides malathion topical lotion 0.5 % 1 permethrin topical cream 5 % 1 Antiparkinson Agents Anticholinergics benztropine injection solution 2 mg/2 ml 1 benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PA trihexyphenidyl oral elixir 0.4 mg/ml 1 PA trihexyphenidyl oral tablet 2 mg, 5 mg 1 PA Antiparkinson Agents, Other entacapone oral tablet 200 mg

45 tolcapone oral tablet 100 mg 1 PA Dopamine Agonists APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML ; QL (60 ML per 30 days) bromocriptine oral capsule 5 mg 1 bromocriptine oral tablet 2.5 mg 1 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1 ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet mg, mg, mg 1 carbidopa-levodopa oral tablet extended release mg, mg 1 carbidopa-levodopa oral tablet, disintegrating mg, mg, mg Monoamine Oxidase B (MAO-B) Inhibitors ; QL (31 EA per 31 days) AZILECT ORAL TABLET 0.5 MG, 1 MG 2 QL (31 EA per 31 days) selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG 2 Antipsychotics 1 ST Generation/ Typical fluphenazine decanoate injection solution 25 mg/ml 1 fluphenazine hcl injection solution 2.5 mg/ml 1 fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5 ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml 1 haloperidol lactate injection solution 5 mg/ml 1 haloperidol lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1 loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 molindone oral tablet 10 mg, 25 mg, 5 mg 1 PA You can find information on what the symbols and abbreviations in this table mean by going to page

46 pimozide oral tablet 1 mg, 2 mg 1 thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 PA thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 2 ND Generation/ Atypical ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ; QL (2 EA per 28 days) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 1 PA; QL (31 EA per 31 days) aripiprazole oral tablet, disintegrating 10 mg 1 PA FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML ; QL (62 EA per 31 days) ; QL (8 EA per 4 days) ; QL (0.75 ML per 28 days) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML ; QL (1 ML per 28 days) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML ; QL (1.5 ML per 28 days) ; QL (0.25 ML per 28 days) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML ; QL (0.5 ML per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML ; QL (0.875 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML ; QL (1.315 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML ; QL (1.75 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML ; QL (2.625 ML per 84 days) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG ; QL (31 EA per 31 days) olanzapine intramuscular recon soln 10 mg 1 PA olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 QL (31 EA per 31 days) olanzapine oral tablet, disintegrating 10 mg, 15 mg, 20 mg, 5 mg 1 QL (31 EA per 31 days) paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg 1 PA quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg 1 QL (62 EA per 31 days) 45

47 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml 1 QL (496 ML per 31 days) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QL (62 EA per 31 days) risperidone oral tablet 4 mg 1 QL (124 EA per 31 days) risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QL (62 EA per 31 days) risperidone oral tablet, disintegrating 4 mg 1 QL (124 EA per 31 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG ; QL (62 EA per 31 days) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG ; QL (31 EA per 31 days) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 QL (62 EA per 31 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG Treatment-Resistant clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 clozapine oral tablet, disintegrating 100 mg 1 QL (279 EA per 31 days) clozapine oral tablet, disintegrating 12.5 mg 1 QL (62 EA per 31 days) clozapine oral tablet, disintegrating 150 mg 1 QL (186 EA per 31 days) clozapine oral tablet, disintegrating 200 mg 1 QL (124 EA per 31 days) clozapine oral tablet, disintegrating 25 mg 1 QL (93 EA per 31 days) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG ; QL (279 EA per 31 days) FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG ; QL (62 EA per 31 days) FAZACLO ORAL TABLET,DISINTEGRATING 150 MG ; QL (186 EA per 31 days) FAZACLO ORAL TABLET,DISINTEGRATING 200 MG ; QL (124 EA per 31 days) FAZACLO ORAL TABLET,DISINTEGRATING 25 MG ; QL (93 EA per 31 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML ; QL (558 ML per 31 days) Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg 1 dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 tizanidine oral tablet 2 mg, 4 mg 1 Antivirals You can find information on what the symbols and abbreviations in this table mean by going to page 7. 46

48 Anti-Cytomegalovirus (CMV) Agents cidofovir intravenous solution 75 mg/ml 1 PA ganciclovir sodium intravenous recon soln 500 mg 1 VALCYTE ORAL RECON SOLN 50 MG/ML 2 valganciclovir oral tablet 450 mg 1 ZIRGAN OPHTHALMIC GEL 0.15 % 2 Anti-Hepatitis B (HBV) Agents adefovir oral tablet 10 mg 1 PA BARACLUDE ORAL SOLUTION 0.05 MG/ML ; QL (630 ML per 30 days) entecavir oral tablet 0.5 mg, 1 mg 1 PA; QL (31 EA per 31 days) EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) 2 INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML lamivudine oral tablet 100 mg, 150 mg, 300 mg 1 ribavirin oral capsule 200 mg 1 PA ribavirin oral tablet 200 mg 1 PA TYZEKA ORAL TABLET 600 MG ; QL (31 EA per 31 days) VIRAZOLE INHALATION RECON SOLN 6 GRAM VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) 2 QL (240 GM per 31 days) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG 2 QL (31 EA per 31 days) Anti-Hepatitis C (HCV) Agents DAKLINZA ORAL TABLET 30 MG, 60 MG HARVONI ORAL TABLET MG ; QL (31 EA per 31 days) INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) OLYSIO ORAL CAPSULE 150 MG ; QL (31 EA per 31 days) PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML ; QL (2 ML per 28 days) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML ; QL (4 ML per 28 days) PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML ; QL (2 ML per 28 days) PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML ; QL (4 EA per 28 days) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML ; QL (4 EA per 28 days) 47

49 SOVALDI ORAL TABLET 400 MG ; QL (31 EA per 31 days) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ; QL (4 EA per 28 days) TECHNIVIE ORAL TABLET MG Antiherpetic Agents acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 400 mg, 800 mg 1 acyclovir sodium intravenous solution 50 mg/ml 1 acyclovir topical ointment 5 % 1 famciclovir oral tablet 125 mg, 250 mg 1 QL (62 EA per 31 days) famciclovir oral tablet 500 mg 1 QL (21 EA per 31 days) trifluridine ophthalmic drops 1 % 1 valacyclovir oral tablet 1 gram 1 QL (31 EA per 31 days) valacyclovir oral tablet 500 mg 1 QL (62 EA per 31 days) Anti-HIV Agents, Integrase Inhibitors (INSTI) GENVOYA ORAL TABLET MG 2 ISENTRESS ORAL POWDER IN PACKET 100 MG 2 ISENTRESS ORAL TABLET 400 MG 2 QL (62 EA per 31 days) ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 2 QL (186 EA per 31 days) STRIBILD ORAL TABLET MG 2 QL (31 EA per 31 days) TIVICAY ORAL TABLET 50 MG 2 QL (62 EA per 31 days) VITEKTA ORAL TABLET 150 MG, 85 MG 2 QL (31 EA per 31 days) Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA ORAL TABLET MG 2 QL (31 EA per 31 days) EDURANT ORAL TABLET 25 MG 2 QL (31 EA per 31 days) INTELENCE ORAL TABLET 100 MG, 200 MG 2 QL (62 EA per 31 days) INTELENCE ORAL TABLET 25 MG 2 QL (124 EA per 31 days) nevirapine oral suspension 50 mg/5 ml 1 nevirapine oral tablet 200 mg 1 nevirapine oral tablet extended release 24 hr 100 mg, 400 mg 1 RESCRIPTOR ORAL TABLET 200 MG 2 QL (186 EA per 31 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG 2 QL (93 EA per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 48

50 SUSTIVA ORAL CAPSULE 200 MG 2 QL (124 EA per 31 days) SUSTIVA ORAL CAPSULE 50 MG 2 QL (93 EA per 31 days) SUSTIVA ORAL TABLET 600 MG 2 QL (31 EA per 31 days) Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir oral tablet 300 mg 1 abacavir-lamivudine-zidovudine oral tablet mg 1 QL (62 EA per 31 days) ATRIPLA ORAL TABLET MG 2 QL (31 EA per 31 days) didanosine oral capsule, delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG 2 QL (31 EA per 31 days) EMTRIVA ORAL SOLUTION 10 MG/ML 2 QL (744 ML per 31 days) EPZICOM ORAL TABLET MG 2 QL (31 EA per 31 days) lamivudine oral solution 10 mg/ml 1 lamivudine-zidovudine oral tablet mg 1 QL (62 EA per 31 days) RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 2 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 stavudine oral recon soln 1 mg/ml 1 TRUVADA ORAL TABLET MG 2 QL (31 EA per 31 days) VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) 1 2 QL (1240 ML per 31 days) ZIAGEN ORAL SOLUTION 20 MG/ML 2 QL (930 ML per 31 days) zidovudine oral capsule 100 mg 1 zidovudine oral syrup 10 mg/ml 1 zidovudine oral tablet 300 mg 1 Anti-HIV Agents, Other FUZEON SUBCUTANEOUS RECON SOLN 90 MG 2 QL (62 EA per 31 days) SELZENTRY ORAL TABLET 150 MG 2 QL (62 EA per 31 days) SELZENTRY ORAL TABLET 300 MG 2 QL (124 EA per 31 days) TRIUMEQ ORAL TABLET MG 2 QL (31 EA per 31 days) TYBOST ORAL TABLET 150 MG 2 QL (31 EA per 31 days) Anti-HIV Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 250 MG 2 QL (124 EA per 31 days) APTIVUS ORAL SOLUTION 100 MG/ML 2 QL (310 ML per 31 days) CRIXIVAN ORAL CAPSULE 200 MG 2 QL (465 EA per 31 days) 49

51 CRIXIVAN ORAL CAPSULE 400 MG 2 QL (279 EA per 31 days) EVOTAZ ORAL TABLET MG 2 QL (31 EA per 31 days) INVIRASE ORAL CAPSULE 200 MG 2 QL (310 EA per 31 days) INVIRASE ORAL TABLET 500 MG 2 QL (124 EA per 31 days) KALETRA ORAL SOLUTION MG/5 ML 2 QL (387.5 ML per 31 days) KALETRA ORAL TABLET MG 2 QL (248 EA per 31 days) KALETRA ORAL TABLET MG 2 QL (124 EA per 31 days) LEXIVA ORAL SUSPENSION 50 MG/ML 2 QL (1736 ML per 31 days) LEXIVA ORAL TABLET 700 MG 2 QL (124 EA per 31 days) NORVIR ORAL CAPSULE 100 MG 2 QL (372 EA per 31 days) NORVIR ORAL SOLUTION 80 MG/ML 2 QL (465 ML per 31 days) NORVIR ORAL TABLET 100 MG 2 QL (372 EA per 31 days) PREZCOBIX ORAL TABLET MG-MG 2 QL (31 EA per 31 days) PREZISTA ORAL SUSPENSION 100 MG/ML 2 QL (496 ML per 31 days) PREZISTA ORAL TABLET 150 MG 2 QL (155 EA per 31 days) PREZISTA ORAL TABLET 600 MG, 800 MG 2 QL (62 EA per 31 days) PREZISTA ORAL TABLET 75 MG 2 QL (310 EA per 31 days) REYATAZ ORAL CAPSULE 150 MG, 300 MG 2 QL (31 EA per 31 days) REYATAZ ORAL CAPSULE 200 MG 2 QL (62 EA per 31 days) REYATAZ ORAL POWDER IN PACKET 50 MG 2 QL (248 EA per 31 days) VIRACEPT ORAL TABLET 250 MG 2 QL (279 EA per 31 days) VIRACEPT ORAL TABLET 625 MG 2 QL (124 EA per 31 days) Anti-Influenza Agents amantadine hcl oral capsule 100 mg 1 amantadine hcl oral solution 50 mg/5 ml 1 amantadine hcl oral tablet 100 mg 1 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg 1 2 QL (120 EA per 365 days) TAMIFLU ORAL CAPSULE 30 MG 2 QL (56 EA per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG 2 QL (28 EA per 180 days) Anxiolytics Anxiolytics, Other You can find information on what the symbols and abbreviations in this table mean by going to page 7. 50

52 buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 meprobamate oral tablet 200 mg, 400 mg 1 PA triazolam oral tablet mg, 0.25 mg 1 QL (7 EA per 31 days) Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 QL (155 EA per 31 days) alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg 1 QL (31 EA per 31 days) alprazolam oral tablet extended release 24 hr 2 mg 1 QL (62 EA per 31 days) alprazolam oral tablet extended release 24 hr 3 mg 1 QL (124 EA per 31 days) Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg 1 lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 lithium carbonate oral tablet 300 mg 1 lithium carbonate oral tablet extended release 300 mg, 450 mg 1 lithium citrate oral solution 8 meq/5 ml 1 Blood Glucose Regulators Antidiabetic Agents BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 ; QL (3 ML per 28 days) glipizide oral tablet 10 mg 1 QL (124 EA per 31 days) glipizide oral tablet 5 mg 1 QL (62 EA per 31 days) glipizide oral tablet extended release 24hr 10 mg 1 QL (62 EA per 31 days) glipizide oral tablet extended release 24hr 2.5 mg, 5 mg 1 QL (31 EA per 31 days) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 PA glyburide oral tablet 1.25 mg, 2.5 mg 1 PA; QL (124 EA per 31 days) glyburide oral tablet 5 mg 1 PA; QL (248 EA per 31 days) INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG ; QL (62 EA per 31 days) INVOKAMET ORAL TABLET MG ; QL (124 EA per 31 days) INVOKANA ORAL TABLET 100 MG, 300 MG ; QL (31 EA per 31 days) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 2 QL (31 EA per 31 days) metformin oral tablet 1,000 mg, 500 mg, 850 mg 1 51

53 metformin oral tablet extended release 24 hr 500 mg, 750 mg 1 nateglinide oral tablet 120 mg, 60 mg 1 QL (93 EA per 31 days) pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 QL (31 EA per 31 days) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1 QL (248 EA per 31 days) SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML Blood Glucose Regulators glipizide-metformin oral tablet mg 1 QL (93 EA per 31 days) glipizide-metformin oral tablet mg, mg 1 QL (124 EA per 31 days) glyburide-metformin oral tablet mg 1 PA; QL (93 EA per 31 days) glyburide-metformin oral tablet mg, mg 1 PA; QL (124 EA per 31 days) JANUMET ORAL TABLET 50-1,000 MG, MG 2 QL (62 EA per 31 days) pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg 1 QL (31 EA per 31 days) pioglitazone-metformin oral tablet mg, mg 1 QL (93 EA per 31 days) Glycemic Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG 2 GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG 2 QL (2 EA per 30 days) KORLYM ORAL TABLET 300 MG ; QL (124 EA per 31 days) PROGLYCEM ORAL SUSPENSION 50 MG/ML 2 Insulins APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 2 QL (48 ML per 31 days) APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" 2 QL (100 EA per 30 days) gauze pad topical bandage 2 x 2 " 1 HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) 2 QL (40 ML per 31 days) 2 QL (40 ML per 31 days) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) 2 QL (40 ML per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 52

54 HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 2 QL (40 ML per 31 days) HUMULIN R INJECTION SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29, 1 ML 29 X 1/2", 1/2 ML 28 GAUGE LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML QL (100 EA per 30 days) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) 2 2 QL (40 ML per 31 days) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 2 QL (40 ML per 31 days) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) NOVOLOG MIX SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) 2 QL (40 ML per 31 days) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 QL (40 ML per 31 days) PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2 " 2 QL (100 EA per 30 days) Blood Products/ Modifiers/ Volume Expanders Anticoagulants ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS SOLUTION 125 MG/125 ML (1 MG/ML) ARGATROBAN INTRAVENOUS SOLUTION 100 MG/ML 2 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 2 QL (62 EA per 31 days) ELIQUIS ORAL TABLET 5 MG 2 QL (76 EA per 31 days) enoxaparin subcutaneous solution 300 mg/3 ml 1 QL (60 ML per 10 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml 1 QL (20 ML per 10 days) enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml 1 QL (16 ML per 10 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml 1 QL (6 ML per 10 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml 1 QL (8 ML per 10 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml 1 QL (12 ML per 10 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

55 FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 B vs D 1 B vs D PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG ; QL (62 EA per 31 days) warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 20 MG ; QL (31 EA per 31 days) XARELTO ORAL TABLET 15 MG ; QL (42 EA per 31 days) XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) ; QL (51 EA per 30 days) Blood Formation Modifiers anagrelide oral capsule 0.5 mg, 1 mg 1 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML 1 1 LEUKINE INJECTION RECON SOLN 250 MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML You can find information on what the symbols and abbreviations in this table mean by going to page 7. 54

56 Coagulants tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) 1 tranexamic acid oral tablet 650 mg 1 Platelet Modifying Agents aspirin-dipyridamole oral capsule, er multiphase 12 hr mg 1 QL (62 EA per 31 days) BRILINTA ORAL TABLET 60 MG, 90 MG 2 QL (62 EA per 31 days) cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel oral tablet 300 mg, 75 mg 1 QL (31 EA per 31 days) dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr guanfacine oral tablet 1 mg, 2 mg 1 PA methyldopa oral tablet 250 mg, 500 mg 1 PA midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG Alpha-Adrenergic Blocking Agents phenoxybenzamine oral capsule 10 mg 1 prazosin oral capsule 1 mg, 2 mg, 5 mg 1 Angiotensin II Receptor Antagonists eprosartan oral tablet 600 mg 1 QL (62 EA per 31 days) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 QL (31 EA per 31 days) losartan oral tablet 100 mg, 25 mg, 50 mg 1 QL (31 EA per 31 days) Angiotensin-Converting Enzyme (ACE) Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 QL (62 EA per 31 days) captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 QL (62 EA per 31 days) moexipril oral tablet 15 mg, 7.5 mg 1 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 QL (62 EA per 31 days) 1 55

57 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 QL (62 EA per 31 days) trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 QL (62 EA per 31 days) Antiarrhythmics amiodarone intravenous solution 50 mg/ml 1 amiodarone oral tablet 200 mg, 400 mg 1 disopyramide phosphate oral capsule 100 mg, 150 mg 1 PA flecainide oral tablet 100 mg, 150 mg, 50 mg 1 mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 MULTAQ ORAL TABLET 400 MG procainamide injection solution 100 mg/ml, 500 mg/ml 1 propafenone oral capsule, extended release 12 hr 225 mg, 325 mg, 425 mg 1 propafenone oral tablet 150 mg, 225 mg, 300 mg 1 quinidine gluconate oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 sotalol af oral tablet 120 mg 1 sotalol oral tablet 160 mg, 240 mg, 80 mg 1 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 2 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 betaxolol oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg 1 labetalol intravenous solution 5 mg/ml 1 labetalol oral tablet 100 mg, 200 mg, 300 mg 1 metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg 1 QL (31 EA per 31 days) metoprolol succinate oral tablet extended release 24 hr 200 mg 1 QL (62 EA per 31 days) metoprolol tartrate intravenous solution 5 mg/5 ml 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol intravenous solution 1 mg/ml 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 56

58 propranolol oral capsule, extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml, 40 mg/5 ml 1 propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 Calcium Channel Blocking Agents afeditab cr oral tablet extended release 30 mg, 60 mg 1 QL (62 EA per 31 days) amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 QL (31 EA per 31 days) cartia xt oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl intravenous solution 5 mg/ml 1 diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg 1 diltiazem hcl oral capsule, extended release 12 hr 120 mg, 60 mg, 90 mg 1 diltiazem hcl oral capsule, extended release 24hr 120 mg, 240 mg, 300 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule, ext release degradable 120 mg, 180 mg, 240 mg 1 felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg 1 QL (31 EA per 31 days) nicardipine oral capsule 20 mg, 30 mg 1 nifedical xl oral tablet extended release 24hr 30 mg, 60 mg 1 QL (62 EA per 31 days) nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg 1 QL (62 EA per 31 days) taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous solution 2.5 mg/ml 1 verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg 1 verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 80 mg 1 verapamil oral tablet extended release 180 mg, 240 mg 1 Cardiovascular Agents amlodipine-benazepril oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg atenolol-chlorthalidone oral tablet mg, mg 1 benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg QL (31 EA per 31 days) 1 57

59 bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg DEMSER ORAL CAPSULE 250 MG enalapril-hydrochlorothiazide oral tablet mg, mg 1 fosinopril-hydrochlorothiazide oral tablet mg, mg 1 QL (124 EA per 31 days) lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan-hydrochlorothiazide oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, mg 1 PA metoprolol ta-hydrochlorothiazide oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg 1 propranolol-hydrochlorothiazide oral tablet mg, mg 1 quinapril-hydrochlorothiazide oral tablet mg, mg, mg spironolacton-hydrochlorothiazide oral tablet mg 1 triamterene-hydrochlorothiazide oral capsule mg, mg 1 triamterene-hydrochlorothiazide oral tablet mg, mg 1 valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg You can find information on what the symbols and abbreviations in this table mean by going to page QL (31 EA per 31 days) QL (62 EA per 31 days) 1 QL (31 EA per 31 days) VYTORIN ORAL TABLET MG 2 QL (31 EA per 31 days) VYTORIN ORAL TABLET MG 2 QL (31 EA per 31 days) VYTORIN ORAL TABLET MG 2 QL (31 EA per 31 days) Cardiovascular Agents, Other digitek oral tablet 125 mcg, 250 mcg 1 PA digoxin injection solution 250 mcg/ml 1 PA digoxin oral solution 50 mcg/ml 1 PA digoxin oral tablet 125 mcg, 250 mcg 1 PA LANOXIN ORAL TABLET 125 MCG, 250 MCG LANOXIN ORAL TABLET MCG, 62.5 MCG 2

60 pentoxifylline oral tablet extended release 400 mg 1 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 acetazolamide sodium injection recon soln 500 mg 1 KEVEYIS ORAL TABLET 50 MG methazolamide oral tablet 25 mg, 50 mg 1 Diuretics, Loop bumetanide injection solution 0.25 mg/ml 1 bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 EDECRIN ORAL TABLET 25 MG 2 furosemide injection solution 10 mg/ml 1 furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 Diuretics, Potassium-Sparing amiloride oral tablet 5 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 Diuretics, Thiazide chlorothiazide oral tablet 250 mg, 500 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg 1 QL (31 EA per 31 days) fenofibrate micronized oral capsule 43 mg 1 QL (62 EA per 31 days) 59

61 fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 1 QL (31 EA per 31 days) fenofibrate oral tablet 160 mg, 54 mg 1 QL (31 EA per 31 days) gemfibrozil oral tablet 600 mg 1 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 Dyslipidemics, Other cholestyramine light oral powder in packet 4 gram 1 colestipol oral granules 5 gram 1 colestipol oral tablet 1 gram 1 JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 5 MG, 60 MG ; QL (31 EA per 31 days) JUXTAPID ORAL CAPSULE 20 MG ; QL (93 EA per 31 days) KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML ; QL (4 ML per 28 days) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg 1 QL (62 EA per 31 days) niacor oral tablet 500 mg 1 omega-3 acid ethyl esters oral capsule 1 gram 1 QL (124 EA per 31 days) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML WELCHOL ORAL POWDER IN PACKET 3.75 GRAM 2 WELCHOL ORAL TABLET 625 MG 2 ; QL (2 ML per 28 days) ; QL (2 ML per 28 days) ZETIA ORAL TABLET 10 MG 2 QL (31 EA per 31 days) Vasodilators, Direct-Acting Arterial hydralazine injection solution 20 mg/ml 1 hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 minoxidil oral tablet 10 mg, 2.5 mg 1 Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1 isosorbide dinitrate oral tablet extended release 40 mg 1 isosorbide mononitrate oral tablet 10 mg, 20 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 60

62 isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray, non-aerosol 400 mcg/spray 1 NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG 2 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg 1 dextroamphetamine oral tablet 10 mg, 5 mg 1 Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines clonidine hcl oral tablet extended release 12 hr 0.1 mg 1 QL (124 EA per 31 days) dexmethylphenidate oral capsule, er biphasic mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg QL (31 EA per 31 days) FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 35 MG ; QL (31 EA per 31 days) guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg 1 PA; QL (31 EA per 31 days) methylphenidate oral capsule, er biphasic mg, 30 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg, 40 mg 1 methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml 1 methylphenidate oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate oral tablet extended release 10 mg, 20 mg 1 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG 2 QL (124 EA per 31 days) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 2 QL (31 EA per 31 days) STRATTERA ORAL CAPSULE 40 MG 2 QL (62 EA per 31 days) Central Nervous System, Other NUEDEXTA ORAL CAPSULE MG riluzole oral tablet 50 mg 1 tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA Fibromyalgia Agents duloxetine oral capsule, delayed release(dr/ec) 40 mg 1 QL (62 EA per 31 days) Multiple Sclerosis Agents 1 61

63 AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 14 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG GILENYA ORAL CAPSULE 0.5 MG glatopa subcutaneous syringe 20 mg/ml 1 QL (31 ML per 31 days) REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous membrane mouthwash 0.12 % 1 pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 triamcinolone acetonide dental paste 0.1 % 1 Dermatological Agents Dermatological Agents acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 PA amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 betamethasone dipropionate topical lotion 0.05 % 1 calcipotriene scalp solution % 1 QL (120 ML per 30 days) calcipotriene topical cream % 1 QL (240 GM per 30 days) calcipotriene topical ointment % 1 QL (240 GM per 30 days) clindamycin-benzoyl peroxide topical gel 1-5 % 1 clotrimazole-betamethasone topical cream % 1 clotrimazole-betamethasone topical lotion % 1 diclofenac sodium topical gel 3 % 1 PA doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral tablet 100 mg, 50 mg 1 ELIDEL TOPICAL CREAM 1 % You can find information on what the symbols and abbreviations in this table mean by going to page 7. 62

64 erythromycin-benzoyl peroxide topical gel 3-5 % 1 fluorouracil intravenous solution 2.5 gram/50 ml 1 fluorouracil topical cream 5 % 1 fluorouracil topical solution 2 %, 5 % 1 fluticasone topical cream 0.05 % 1 fluticasone topical ointment % 1 imiquimod topical cream in packet 5 % 1 QL (12 EA per 28 days) methoxsalen rapid oral capsule 10 mg 1 nystatin-triamcinolone topical cream 100, unit/g-% 1 nystatin-triamcinolone topical ointment 100, unit/gram-% 1 podofilox topical solution 0.5 % 1 prednicarbate topical cream 0.1 % 1 SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 2 selenium sulfide topical lotion 2.5 % 1 tacrolimus topical ointment 0.03 %, 0.1 % 1 PA TAZORAC TOPICAL CREAM 0.05 %, 0.1 % TAZORAC TOPICAL GEL 0.05 %, 0.1 % UVADEX INJECTION SOLUTION 20 MCG/ML 2 B vs D VALCHLOR TOPICAL GEL % Enzyme Replacement/ Modifiers Enzyme Replacement/ Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CERDELGA ORAL CAPSULE 84 MG CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT CYSTADANE ORAL POWDER 1 GRAM/1.7 ML 2 CYSTAGON ORAL CAPSULE 150 MG, 50 MG ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KUVAN ORAL POWDER IN PACKET 500 MG 2 63

65 KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG RAVICTI ORAL LIQUID 1.1 GRAM/ML ; QL (525 ML per 30 days) STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML, 80 MG/0.8 ML VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT Gastrointestinal Agents Antispasmodics, Gastrointestinal atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1 dicyclomine oral capsule 10 mg 1 dicyclomine oral solution 10 mg/5 ml 1 dicyclomine oral tablet 20 mg 1 glycopyrrolate injection solution 0.2 mg/ml 1 glycopyrrolate oral tablet 1 mg, 2 mg 1 TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) Gastrointestinal Agents, Other diphenoxylate-atropine oral liquid mg/5 ml 1 diphenoxylate-atropine oral tablet mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page QL (10 EA per 30 days) GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG ; QL (31 EA per 31 days) loperamide oral capsule 2 mg 1 metoclopramide hcl injection solution 5 mg/ml 1 metoclopramide hcl oral solution 5 mg/5 ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 proctozone-hc rectal cream 2.5 % 1

66 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML ; QL (31 ML per 31 days) ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 Histamine2 (H2) Receptor Antagonists cimetidine hcl oral solution 300 mg/5 ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 famotidine (pf) intravenous solution 20 mg/2 ml 1 famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml 1 famotidine oral suspension 40 mg/5 ml 1 famotidine oral tablet 20 mg, 40 mg 1 ranitidine hcl oral syrup 15 mg/ml 1 ranitidine hcl oral tablet 150 mg, 300 mg 1 Irritable Bowel Syndrome Agents alosetron oral tablet 0.5 mg, 1 mg 1 PA; QL (62 EA per 31 days) AMITIZA ORAL CAPSULE 24 MCG, 8 MCG ; QL (62 EA per 31 days) budesonide oral capsule, delayed, extend. release 3 mg 1 DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG 2 QL (186 EA per 31 days) LINZESS ORAL CAPSULE 145 MCG, 290 MCG ; QL (31 EA per 31 days) Laxatives gavilyte-c oral recon soln gram 1 gavilyte-g oral recon soln gram 1 gavilyte-n oral recon soln 420 gram 1 lactulose oral solution 10 gram/15 ml 1 peg-electrolyte soln oral recon soln 420 gram 1 polyethylene glycol 3350 oral powder 17 gram/dose 1 trilyte with flavor packets oral recon soln 420 gram 1 Protectants misoprostol oral tablet 100 mcg, 200 mcg 1 sucralfate oral tablet 1 gram 1 Proton Pump Inhibitors esomeprazole sodium intravenous recon soln 20 mg, 40 mg 1 lansoprazole oral capsule, delayed release(dr/ec) 15 mg, 30 mg 1 QL (31 EA per 31 days) 65

67 omeprazole oral capsule, delayed release(dr/ec) 10 mg 1 QL (62 EA per 31 days) omeprazole oral capsule, delayed release(dr/ec) 20 mg, 40 mg 1 QL (124 EA per 31 days) pantoprazole oral tablet, delayed release (dr/ec) 20 mg, 40 mg 1 QL (31 EA per 31 days) Genitourinary Agents Antispasmodics, Urinary flavoxate oral tablet 100 mg 1 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml 1 oxybutynin chloride oral tablet 5 mg 1 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg 1 ; QL (31 EA per 31 days) tolterodine oral capsule, extended release 24hr 2 mg, 4 mg 1 QL (31 EA per 31 days) tolterodine oral tablet 1 mg, 2 mg 1 QL (62 EA per 31 days) trospium oral capsule, extended release 24hr 60 mg 1 QL (62 EA per 31 days) trospium oral tablet 20 mg 1 QL (62 EA per 31 days) Benign Prostatic Hypertrophy Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 dutasteride oral capsule 0.5 mg 1 PA; QL (31 EA per 31 days) finasteride oral tablet 5 mg 1 QL (31 EA per 31 days) tamsulosin oral capsule, extended release 24hr 0.4 mg 1 QL (62 EA per 31 days) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 Genitourinary Agents, Other bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 DEPEN TITRATABS ORAL TABLET 250 MG 2 ELMIRON ORAL CAPSULE 100 MG 2 potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) sodium phenylbutyrate oral powder 0.94 gram/gram 1 Phosphate Binders calcium acetate oral capsule 667 mg 1 FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG 2 FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG You can find information on what the symbols and abbreviations in this table mean by going to page

68 RENAGEL ORAL TABLET 400 MG 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) a-hydrocort injection recon soln 100 mg 1 B vs D betamethasone dipropionate topical cream 0.05 % 1 betamethasone dipropionate topical ointment 0.05 % 1 betamethasone valerate topical cream 0.1 % 1 betamethasone valerate topical lotion 0.1 % 1 betamethasone valerate topical ointment 0.1 % 1 betamethasone, augmented topical cream 0.05 % 1 betamethasone, augmented topical gel 0.05 % 1 betamethasone, augmented topical lotion 0.05 % 1 betamethasone, augmented topical ointment 0.05 % 1 clobetasol scalp solution 0.05 % 1 clobetasol topical foam 0.05 % 1 clobetasol topical gel 0.05 % 1 clobetasol topical lotion 0.05 % 1 clobetasol topical ointment 0.05 % 1 clobetasol topical shampoo 0.05 % 1 clobetasol-emollient topical cream 0.05 % 1 DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 2 B vs D desonide topical cream 0.05 % 1 desonide topical lotion 0.05 % 1 desonide topical ointment 0.05 % 1 desoximetasone topical cream 0.05 %, 0.25 % 1 desoximetasone topical gel 0.05 % 1 desoximetasone topical ointment 0.05 %, 0.25 % 1 dexamethasone intensol oral drops 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5 ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1 dexamethasone sodium phosphate injection solution 10 mg/ml 1 B vs D dexamethasone sodium phosphate injection solution 4 mg/ml 1 fludrocortisone oral tablet 0.1 mg 1 67

69 fluocinolone topical cream 0.01 %, % 1 fluocinolone topical oil 0.01 % 1 fluocinolone topical ointment % 1 fluocinolone topical solution 0.01 % 1 fluocinonide topical gel 0.05 % 1 fluocinonide topical ointment 0.05 % 1 fluocinonide topical solution 0.05 % 1 fluocinonide-e topical cream 0.05 % 1 halobetasol propionate topical cream 0.05 % 1 halobetasol propionate topical ointment 0.05 % 1 hydrocortisone butyrate topical ointment 0.1 % 1 hydrocortisone butyrate topical solution 0.1 % 1 hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 hydrocortisone topical cream 1 %, 2.5 % 1 hydrocortisone topical lotion 2.5 % 1 hydrocortisone topical ointment 1 %, 2.5 % 1 hydrocortisone valerate topical cream 0.2 % 1 hydrocortisone valerate topical ointment 0.2 % 1 methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml 1 B vs D methylprednisolone oral tablet 16 mg, 32 mg, 8 mg 1 methylprednisolone oral tablets, dose pack 4 mg 1 mometasone topical cream 0.1 % 1 mometasone topical ointment 0.1 % 1 mometasone topical solution 0.1 % 1 prednicarbate topical ointment 0.1 % 1 prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone intensol oral concentrate 5 mg/ml 1 prednisone oral solution 5 mg/5 ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg 1 prednisone oral tablet 50 mg 1 B vs D SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML You can find information on what the symbols and abbreviations in this table mean by going to page B vs D

70 SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 500 MG/4 ML 2 B vs D 2 B vs D SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM 2 B vs D triamcinolone acetonide topical cream %, 0.1 %, 0.5 % 1 triamcinolone acetonide topical lotion %, 0.1 % 1 triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % 1 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin injection solution 4 mcg/ml 1 desmopressin nasal spray, non-aerosol 10 mcg/spray (0.1 ml) 1 desmopressin oral tablet 0.1 mg, 0.2 mg 1 GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG 2 oxandrolone oral tablet 10 mg, 2.5 mg 1 PA Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML METHITEST ORAL TABLET 10 MG 2 testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml 1 PA

71 testosterone enanthate intramuscular oil 200 mg/ml 1 PA Estrogens ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.9 MG, 1.25 MG estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr 1 PA estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 PA MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) apri oral tablet mg 1 aubra oral tablet mg-mcg 1 aviane oral tablet mg-mcg 1 balziva (28) oral tablet mg-mcg 1 cryselle (28) oral tablet mg-mcg 1 delyla (28) oral tablet mg-mcg 1 enpresse oral tablet (6)/75-40 (5)/125-30(10) 1 falmina (28) oral tablet mg-mcg 1 gildess 1.5/30 (21) oral tablet mg-mcg 1 jinteli oral tablet 1-5 mg-mcg 1 PA junel 1.5/30 (21) oral tablet mg-mcg 1 junel 1/20 (21) oral tablet 1-20 mg-mcg 1 junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) 1 junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) 1 larin 1.5/30 (21) oral tablet mg-mcg 1 larin 1/20 (21) oral tablet 1-20 mg-mcg 1 leena 28 oral tablet 0.5/1/ mg-mcg 1 lessina oral tablet mg-mcg 1 levonorgestrel-ethinyl estrad oral tablet mg-mcg 1 levora-28 oral tablet mg 1 microgestin 1.5/30 (21) oral tablet mg-mcg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 70

72 microgestin 1/20 (21) oral tablet 1-20 mg-mcg 1 microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) 1 microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) 1 necon 0.5/35 (28) oral tablet mg-mcg 1 necon 1/35 (28) oral tablet 1-35 mg-mcg 1 necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg 1 necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 norlyroc oral tablet 0.35 mg 1 nortrel 0.5/35 (28) oral tablet mg-mcg 1 nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 portia oral tablet mg 1 PREMPRO ORAL TABLET MG, MG, MG, MG previfem oral tablet mg-mcg 1 quasense oral tablets, dose pack,3 month mg-mcg 1 reclipsen (28) oral tablet mg 1 sprintec (28) oral tablet mg-mcg 1 sronyx oral tablet mg-mcg 1 tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) 1 trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 trivora (28) oral tablet (6)/75-40 (5)/125-30(10) 1 zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 zovia 1/50e (28) oral tablet 1-50 mg-mcg 1 Progestins camila oral tablet 0.35 mg 1 DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML 2 QL (10 ML per 28 days) errin oral tablet 0.35 mg 1 medroxyprogesterone intramuscular suspension 150 mg/ml 1 QL (1 ML per 90 days) medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg 1 71

73 megestrol oral suspension 400 mg/10 ml (40 mg/ml) 1 PA megestrol oral tablet 20 mg, 40 mg 1 PA norethindrone acetate oral tablet 5 mg 1 Selective Estrogen Receptor Modifying Agents raloxifene oral tablet 60 mg 1 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) levothyroxine 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 LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine intravenous solution 10 mcg/ml 1 B vs D liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 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 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN ORAL TABLET 500 MG 2 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG 2 QL (124 EA per 31 days) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 mg 1 ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH), 30 MG (4 MONTH), 45 MG (6 MONTH), 7.5 MG (1 MONTH) FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG You can find information on what the symbols and abbreviations in this table mean by going to page B vs D leuprolide subcutaneous kit 1 mg/0.2 ml 1 PA LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG

74 LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG 1 B vs D 2 B vs D ; QL (62 ML per 31 days) SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 Immunological Agents Angioedema (HAE) Agents CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML Immune Suppressants ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG ATGAM INTRAVENOUS SOLUTION 50 MG/ML azathioprine oral tablet 50 mg 1 B vs D BENLYSTA INTRAVENOUS RECON SOLN 120 MG 73

75 CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG 2 B vs D cyclosporine intravenous solution 250 mg/5 ml 1 B vs D cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 B vs D cyclosporine modified oral solution 100 mg/ml 1 B vs D cyclosporine oral capsule 100 mg, 25 mg 1 B vs D ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML 2 B vs D KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML mercaptopurine oral tablet 50 mg 1 methotrexate sodium (pf) injection recon soln 1 gram 1 B vs D methotrexate sodium (pf) injection solution 25 mg/ml 1 B vs D methotrexate sodium oral tablet 2.5 mg 1 B vs D mycophenolate mofetil oral capsule 250 mg 1 B vs D mycophenolate mofetil oral suspension for reconstitution 200 mg/ml 1 B vs D mycophenolate mofetil oral tablet 500 mg 1 B vs D mycophenolate sodium oral tablet, delayed release (dr/ec) 180 mg, 360 mg 1 B vs D NULOJIX INTRAVENOUS RECON SOLN 250 MG ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG 2 B vs D ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML ; QL (4 ML per 28 days) PROGRAF INTRAVENOUS SOLUTION 5 MG/ML 2 B vs D RAPAMUNE ORAL SOLUTION 1 MG/ML 2 B vs D REMICADE INTRAVENOUS RECON SOLN 100 MG You can find information on what the symbols and abbreviations in this table mean by going to page 7. 74

76 SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 B vs D tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 B vs D TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG 2 B vs D; QL (62 EA per 31 days) Immunizing Agents, Passive CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM GAMMAGARD LIQUID INJECTION SOLUTION 10 % THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG 2 B vs D Immunological Agents leflunomide oral tablet 10 mg, 20 mg 1 SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML Immunomodulators ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) RIDAURA ORAL CAPSULE 3 MG 2 TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ; LA Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML 2 ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG- LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML

77 COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML 2 2 GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML 2 IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML 2 MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML 2 MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML You can find information on what the symbols and abbreviations in this table mean by going to page 7. 76

78 RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML 2 TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML 2 TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML 2 VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2 ML 2 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Aminosalicylates balsalazide oral capsule 750 mg 1 CANASA RECTAL SUPPOSITORY 1,000 MG B vs D 2 B vs D DIPENTUM ORAL CAPSULE 250 MG mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml 1 Glucocorticoids hydrocortisone rectal enema 100 mg/60 ml 1 methylprednisolone oral tablet 4 mg 1 prednisolone acetate ophthalmic drops, suspension 1 % 1 proctosol hc rectal cream 2.5 % QL (1 EA per 365 days) 77

79 Sulfonamides sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet, delayed release (dr/ec) 500 mg 1 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral tablet 10 mg, 40 mg, 5 mg 1 QL (31 EA per 31 days) alendronate oral tablet 35 mg, 70 mg 1 QL (4 EA per 28 days) calcitonin (salmon) nasal spray, non-aerosol 200 unit/actuation 1 calcitriol intravenous solution 1 mcg/ml 1 B vs D calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 B vs D calcitriol oral solution 1 mcg/ml 1 B vs D etidronate disodium oral tablet 200 mg, 400 mg 1 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate intravenous solution 3 mg/3 ml 1 PA ibandronate oral tablet 150 mg 1 QL (1 EA per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML 2 NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol hemodialysis port injection solution 2 mcg/ml, 5 mcg/ml 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 ; QL (2 EA per 28 days) 1 PA PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML ; QL (1 ML per 180 days) risedronate oral tablet 150 mg 1 QL (1 EA per 28 days) risedronate oral tablet 30 mg, 5 mg 1 QL (31 EA per 31 days) risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) 1 QL (4 EA per 28 days) risedronate oral tablet, delayed release (dr/ec) 35 mg 1 QL (4 EA per 28 days) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous solution 4 mg/5 ml 1 B vs D ; QL (5.1 ML per 28 days) zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml 1 B vs D; QL (200 ML per 365 days) ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML 2 B vs D You can find information on what the symbols and abbreviations in this table mean by going to page 7. 78

80 Ophthalmic Agents Ophthalmic Agents bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram 1 BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION % 2 BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % 2 neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mgunit/g-1% neomycin-polymyxin b-dexameth ophthalmic drops, suspension 3.5mg/ml- 10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit mg/ml neomycin-polymyxin-hc ophthalmic drops, suspension , mgunit-mg/ml polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml 1 sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) 1 tobramycin-dexamethasone ophthalmic drops, suspension % 1 Ophthalmic Agents, Other LACRISERT OPHTHALMIC INSERT 5 MG 2 naphazoline ophthalmic drops 0.1 % 1 proparacaine ophthalmic drops 0.5 % 1 RESTASIS OPHTHALMIC DROPPERETTE 0.05 % ; QL (60 EA per 30 days) Ophthalmic Anti-Allergy Agents ALOMIDE OPHTHALMIC DROPS 0.1 % 2 azelastine ophthalmic drops 0.05 % 1 cromolyn ophthalmic drops 4 % 1 olopatadine ophthalmic drops 0.1 % 1 PATADAY OPHTHALMIC DROPS 0.2 % 2 PAZEO OPHTHALMIC DROPS 0.7 % 2 Ophthalmic Antiglaucoma Agents apraclonidine ophthalmic drops 0.5 % 1 betaxolol ophthalmic drops 0.5 % 1 BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 0.25 % 2 brimonidine ophthalmic drops 0.15 %, 0.2 %

81 carteolol ophthalmic drops 1 % 1 dorzolamide ophthalmic drops 2 % 1 dorzolamide-timolol ophthalmic drops mg/ml 1 levobunolol ophthalmic drops 0.5 % 1 metipranolol ophthalmic drops 0.3 % 1 PHOSPHOLINE IODIDE OPHTHALMIC DROPS % 2 timolol maleate ophthalmic drops 0.25 %, 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 1 Ophthalmic Anti-Inflammatories bromfenac ophthalmic drops 0.09 % 1 dexamethasone sodium phosphate ophthalmic drops 0.1 % 1 diclofenac sodium ophthalmic drops 0.1 % 1 DUREZOL OPHTHALMIC DROPS 0.05 % flurbiprofen sodium ophthalmic drops 0.03 % 1 FML FORTE OPHTHALMIC DROPS,SUSPENSION 0.25 % 2 ketorolac ophthalmic drops 0.4 %, 0.5 % 1 prednisolone sodium phosphate ophthalmic drops 1 % 1 Ophthalmic Prostaglandin And Prostamide Analogs latanoprost ophthalmic drops % 1 TRAVATAN Z OPHTHALMIC DROPS % 2 travoprost (benzalkonium) ophthalmic drops % 1 Otic Agents Otic Agents CIPRODEX OTIC DROPS,SUSPENSION % 2 hydrocortisone-acetic acid otic drops 1-2 % 1 neomycin-polymyxin-hc otic drops, suspension ,000-1 mg/ml-unit/ml- % neomycin-polymyxin-hc otic solution ,000-1 mg/ml-unit/ml-% 1 Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol, spray 137 mcg (0.1 %) 1 QL (30 ML per 30 days) carbinoxamine maleate oral liquid 4 mg/5 ml 1 PA carbinoxamine maleate oral tablet 4 mg 1 PA You can find information on what the symbols and abbreviations in this table mean by going to page

82 cetirizine oral solution 1 mg/ml 1 clemastine oral tablet 2.68 mg 1 PA cyproheptadine oral syrup 2 mg/5 ml 1 PA cyproheptadine oral tablet 4 mg 1 PA levocetirizine oral solution 2.5 mg/5 ml 1 levocetirizine oral tablet 5 mg 1 Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (60 DOSES) ; QL (60 EA per 30 days) ; QL (12 GM per 30 days) 2 QL (1 EA per 30 days) budesonide inhalation suspension for nebulization 0.25 mg/2 ml 1 B vs D; QL (248 ML per 31 days) budesonide inhalation suspension for nebulization 0.5 mg/2 ml 1 B vs D; QL (130 ML per 31 days) budesonide inhalation suspension for nebulization 1 mg/2 ml 1 B vs D; QL (62 ML per 31 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray, non-aerosol 25 mcg (0.025 %) 1 fluticasone nasal spray, suspension 50 mcg/actuation 1 QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes 2 QL (12 GM per 30 days) 2 QL (24 GM per 30 days) 2 QL (10.6 GM per 30 days) 2 QL (17.4 GM per 30 days) montelukast oral tablet 10 mg 1 QL (31 EA per 31 days) montelukast oral tablet, chewable 4 mg, 5 mg 1 QL (31 EA per 31 days) zafirlukast oral tablet 10 mg, 20 mg 1 QL (62 EA per 31 days) Bronchodilators, Anticholinergic 81

83 ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % 1 B vs D; QL (570 ML per 31 days) ipratropium bromide nasal spray, non-aerosol 0.03 %, 0.06 % 1 QL (30 ML per 30 days) SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) Bronchodilators, Sympathomimetic albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) You can find information on what the symbols and abbreviations in this table mean by going to page QL (4 GM per 30 days) 2 QL (31 EA per 31 days) 2 QL (1 EA per 30 days) 2 QL (2 EA per 30 days) 1 B vs D; QL (575 ML per 31 days) albuterol sulfate inhalation solution for nebulization 5 mg/ml 1 B vs D; QL (100 ML per 31 days) albuterol sulfate oral syrup 2 mg/5 ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 1 epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml 1 QL (2 EA per 31 days) EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML 2 QL (2 EA per 31 days) EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML 2 QL (2 EA per 31 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml 1 B vs D; QL (744 ML per 31 days) levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml 1 B vs D; QL (90 EA per 30 days) metaproterenol oral syrup 10 mg/5 ml 1 metaproterenol oral tablet 10 mg, 20 mg 1 SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE terbutaline oral tablet 2.5 mg, 5 mg 1 terbutaline subcutaneous solution 1 mg/ml 1 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 2 QL (60 EA per 30 days) 2 QL (36 GM per 31 days)

84 Cystic Fibrosis Agents KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG ; QL (62 EA per 31 days) KALYDECO ORAL TABLET 150 MG ; QL (62 EA per 31 days) Mast Cell Stabilizers cromolyn inhalation solution for nebulization 20 mg/2 ml 1 B vs D cromolyn oral concentrate 100 mg/5 ml 1 Phosphodiesterase Inhibitors, Airways Disease aminophylline intravenous solution 250 mg/10 ml 1 DALIRESP ORAL TABLET 500 MCG theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 400 mg, 600 mg 1 Pulmonary Antihypertensives ADCIRCA ORAL TABLET 20 MG ; QL (62 EA per 31 days) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG ; QL (93 EA per 31 days) LETAIRIS ORAL TABLET 10 MG, 5 MG OPSUMIT ORAL TABLET 10 MG ; QL (31 EA per 31 days) REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML 1 sildenafil oral tablet 20 mg 1 PA TRACLEER ORAL TABLET 125 MG, 62.5 MG ; LA; QL (62 EA per 31 days) Respiratory Tract Agents, Other acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 1 B vs D ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG 2 B vs D Respiratory Tract/ Pulmonary Agents COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION ESBRIET ORAL CAPSULE 267 MG ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG 2 2 QL (60 EA per 30 days) 2 QL (4 GM per 20 days) 1 B vs D; QL (570 ML per 31 days) 83

85 promethazine vc oral syrup mg/5 ml 1 PA PULMOZYME INHALATION SOLUTION 1 MG/ML 2 B vs D XOLAIR SUBCUTANEOUS RECON SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol oral tablet 350 mg 1 PA; QL (93 EA per 31 days) cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA; QL (93 EA per 31 days) methocarbamol oral tablet 500 mg, 750 mg 1 PA Sleep Disorder Agents GABA Receptor Modulators temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 QL (7 EA per 31 days) zaleplon oral capsule 10 mg, 5 mg 1 PA; QL (31 EA per 31 days) zolpidem oral tablet 10 mg, 5 mg 1 PA; QL (31 EA per 31 days) zolpidem oral tablet, ext release multiphase 12.5 mg, 6.25 mg 1 PA; QL (31 EA per 31 days) Sleep Disorders, Other HETLIOZ ORAL CAPSULE 20 MG ; QL (31 EA per 31 days) modafinil oral tablet 100 mg, 200 mg 1 PA; QL (62 EA per 31 days) ROZEREM ORAL TABLET 8 MG 2 QL (31 EA per 31 days) XYREM ORAL SOLUTION 500 MG/ML Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/ Mineral Modifiers EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG sodium polystyrene (sorb free) oral suspension 15 gram/60 ml 1 SYPRINE ORAL CAPSULE 250 MG Electrolyte/ Mineral Replacement CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION 2 B vs D KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 2 KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ 2 klor-con m15 oral tablet, er particles/crystals 15 meq 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 84

86 klor-con m20 oral tablet, er particles/crystals 20 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ 2 magnesium sulfate injection solution 4 meq/ml (50 %) 1 magnesium sulfate injection syringe 4 meq/ml 1 PHYSIOLYTE IRRIGATION SOLUTION MEQ/L 2 B vs D PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION 2 B vs D PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION 2 B vs D potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml 1 potassium chloride oral capsule, extended release 10 meq, 8 meq 1 potassium chloride oral tablet extended release 8 meq 1 potassium chloride oral tablet, er particles/crystals 10 meq, 20 meq 1 sodium chloride 0.45 % intravenous parenteral solution 0.45 % 1 sodium chloride 0.9 % intravenous parenteral solution 0.9 % 1 sodium chloride 3 % intravenous parenteral solution 3 % 1 sodium chloride 5 % intravenous parenteral solution 5 % 1 sodium chloride intravenous parenteral solution 2.5 meq/ml 1 sodium chloride irrigation solution 0.9 % 1 sodium fluoride oral tablet 1 mg fluoride (2.2 mg) 1 Therapeutic Nutrients/ Minerals/ Electrolytes AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % d10 %-0.45 % sodium chloride intravenous parenteral solution 1 d2.5 %-0.45 % sodium chloride intravenous parenteral solution 1 d5 % and 0.9 % sodium chloride intravenous parenteral solution 1 d5 %-0.45 % sodium chloride intravenous parenteral solution 1 dextrose 10 % and 0.2 % nacl intravenous parenteral solution B vs D 2 B vs D 2 B vs D dextrose 10 % in water (d10w) intravenous parenteral solution 10 % 1 B vs D dextrose 5 % in water (d5w) intravenous parenteral solution 1 85

87 dextrose 5 %-lactated ringers intravenous parenteral solution 1 dextrose 5%-0.2 % sod chloride intravenous parenteral solution 1 dextrose 5%-0.3 % sod. chloride intravenous parenteral solution 1 dextrose with sodium chloride intravenous parenteral solution % 1 dextrose-kcl-nacl intravenous solution % 1 INTRALIPID INTRAVENOUS EMULSION 30 % lactated ringers irrigation solution 1 levocarnitine oral tablet 330 mg 1 B vs D NUTRILIPID INTRAVENOUS EMULSION 20 % potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l 1 potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l 1 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg 1 ringers intravenous parenteral solution 1 ringers irrigation solution You can find information on what the symbols and abbreviations in this table mean by going to page 7. 86

88 Index 1 12 HOUR DECONGESTANT DAY VAGINAL A abacavir abacavir-lamivudinezidovudine ABELCET ABILIFY MAINTENA.. 31, 45 ABRAXANE ABREVA acamprosate acebutolol ACEPHEN acetaminophen acetaminophen-codeine.. 20, 21 acetazolamide acetazolamide sodium acetic acid acetylcysteine acitretin ACNE MEDICATION ACNE TREATMENT (BENZOYL PEROX) ACTEMRA... 73, 75 ACTHIB (PF) ACTIMMUNE acyclovir acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 75 ADAGEN ADCIRCA adefovir ADEMPAS ADULT COUGH FORMULA DM MAX ADULT ROBITUSSIN PEAK COLD DM ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort ALAVERT D-12 ALLERGY- SINUS ALBENZA albuterol sulfate alcohol pads ALDURAZYME ALECENSA alendronate ALIMTA ALINIA ALLER-CHLOR ALLERCLEAR ALLERGY (DIPHENHYDRAMINE) 11 ALLERGY MULTI- SYMPTOM ALLERGY RELIEF (LORATADINE)... 11, 13 ALLERGY RELIEF(DIPHENHYDRA MIN) allopurinol ALOMIDE alosetron alprazolam amantadine hcl AMBISOME amifostine crystalline amikacin amiloride aminophylline AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% amiodarone AMITIZA amitriptyline AMLACTIN amlodipine amlodipine-benazepril amnesteem amoxapine amoxicillin amoxicillin-pot clavulanate.. 26 amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANADROL anagrelide anastrozole ANDRODERM ANORO ELLIPTA ANTACID ANTI-GAS.. 11, 19 ANTIBIOTIC + PAIN RELIEF ANTI-DANDRUFF WITH MENTHOL ANTI-DIARRHEAL (LOPERAMIDE) ANTIFUNGAL CREAM APIDRA APIDRA SOLOSTAR APOKYN apraclonidine apri APTIOM APTIVUS AQUANIL HC ARCALYST ARGATROBAN ARGATROBAN IN 0.9 % SOD CHLOR aripiprazole ARRANON ARTIFICIAL TEARS ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS(GLYCERIN-PEG) ASMANEX TWISTHALER 81 aspirin... 12, 13, 18 aspirin-dipyridamole ASSURE ID INSULIN SAFETY atenolol atenolol-chlorthalidone ATGAM atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine ATROVENT HFA AUBAGIO aubra AVASTIN aviane AVONEX

89 AVONEX (WITH ALBUMIN) AYR SALINE azacitidine azathioprine azelastine... 79, 80 AZILECT azithromycin aztreonam B bacitracin... 12, 23 bacitracin zinc bacitracin-polymyxin b.. 12, 79 baclofen balsalazide balziva (28) BANZEL BARACLUDE BELEODAQ benazepril benazepril-hydrochlorothiazide BENLYSTA benzonatate benzoyl peroxide benztropine betamethasone dipropionate 62, 67 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 56, 79 bethanechol chloride BETOPTIC S bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BICNU BILTRICIDE BIO-B KIDS BIO-S-PRES DX bisacodyl bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLEPHAMIDE BLEPHAMIDE S.O.P BOOSTRIX TDAP BOSULIF BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine brompheniramine-pseudoephdm BROTAPP BROTAPP DM budesonide... 65, 81 bumetanide buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl buspirone BUSULFEX butorphanol tartrate BYETTA C cabergoline calamine calamine-zinc oxide calcipotriene calcitonin (salmon) calcitriol CALCIUM calcium acetate calcium carbonate calcium gluconate calcium lactate camila CANASA CANCIDAS CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide CARBAGLU carbamazepine... 30, 51 carbidopa-levodopa carbinoxamine maleate carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CAYSTON cefaclor... 24, 25 cefadroxil cefazolin cefazolin in dextrose (iso-os) 25 cefdinir cefepime cefotaxime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftazidime in d5w ceftriaxone cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT INTRAVENOUS CELONTIN cephalexin CERDELGA CEREZYME CERVARIX VACCINE (PF) CETIRI-D cetirizine... 12, 81 CHANTIX CHANTIX CONTINUING MONTH BOX CHEMSTRIP 10/SG CHILD ALLERGY RELF(CETIRIZINE) CHILD MUCINEX STUFFY NOSE-COLD CHILD MUCUS RELIEF COUGH CHILD SUPPOSITORY CHILDREN'S BENEFIBER 12 CHILDREN'S CLARITIN CHILDREN'S COLD AND COUGH (PE) CHILDREN'S IRON CHILDREN'S NON-ASPIRIN PAIN CHILDREN'S PAIN RELIEVER CHILDREN'S PAIN-FEVER RELIEF CHILDREN'S SILAPAP CHILDREN'S SILFEDRINE chloramphenicol sod succinate chlorhexidine gluconate... 62

90 chloroquine phosphate chlorothiazide chlorpheniramine maleate chlorpromazine chlorthalidone cholecalciferol (vitamin d3) 14, 15, 18, 20 cholestyramine light ciclopirox cidofovir cilostazol cimetidine cimetidine hcl CINRYZE CIPRODEX ciprofloxacin (mixture) ciprofloxacin hcl ciprofloxacin in 5 % dextrose ciprofloxacin lactate cisplatin citalopram cladribine clarithromycin clemastine clindamycin hcl clindamycin in 5 % dextrose 23 clindamycin phosphate clindamycin-benzoyl peroxide CLINIMIX 4.25%-D25W SULF-FREE clobetasol clobetasol-emollient clomipramine clonazepam clonidine clonidine hcl... 55, 61 clopidogrel clorazepate dipotassium clotrimazole... 19, 35 clotrimazole-betamethasone. 62 clozapine COARTEM colchicine colchicine-probenecid COLCRYS colestipol colistin (colistimethate na) COMBIVENT RESPIMAT. 83 COMETRIQ COMPLERA COMPLETE LICE TREATMENT compro COMVAX (PF) CONCEPTROL CONDOMS-PREM LUBRICATED CORN-CALLUS REMOVER COSMEGEN COTELLIC COUMADIN CREON CRIXIVAN... 49, 50 cromolyn... 13, 79, 83 cryselle (28) CUBICIN cyanocobalamin (vitamin b-12) cyclobenzaprine cyclophosphamide CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA CYSTADANE CYSTAGON cytarabine cytarabine (pf) D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX daunorubicin DAUNOXOME decitabine delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-MEDROL DEPO-PROVERA DEPO-TESTOSTERONE desipramine DESITIN desmopressin desonide desoximetasone desvenlafaxine dexamethasone dexamethasone intensol dexamethasone sodium phosphate... 67, 80 dexmethylphenidate dexrazoxane hcl dextroamphetamine dextromethorphan-guaifenesin dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 5 % in water (d5w). 85 dextrose 5 %-lactated ringers86 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride dextrose-kcl-nacl DIABETIC TUSSIN EX DIAPER RASH diazepam DIAZEPAM diazepam intensol diclofenac potassium diclofenac sodium... 21, 36, 62, 80 dicloxacillin dicyclomine didanosine digitek digoxin dihydroergotamine DILANTIN diltiazem hcl dilt-xr DIMAPHEN (PE) DIOCTO

91 DIPENTUM diphenhydramine hcl... 14, 34 diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex DOCEFREZ docetaxel DOCETAXEL DOCU DOK donepezil dorzolamide dorzolamide-timolol doxazosin doxepin DOXIL doxorubicin doxycycline hyclate doxycycline monohydrate... 28, 62 dronabinol duloxetine... 32, 61 DURAMORPH (PF) DUREZOL dutasteride E EAR DROPS (CARBAMIDE PEROXIDE) econazole EDECRIN EDURANT ELAPRASE ELIDEL ELIGARD ELIQUIS ELITEK ELLA ELMIRON EMCYT EMEND EMPLICITI EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL ENEMA ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) ENJUVIA enoxaparin enpresse entacapone entecavir ENVARSUS XR epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR HBV EPOGEN eprosartan EPZICOM ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ERY-TAB erythrocin erythrocin (as stearate) erythromycin erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole sodium estradiol estropipate ethambutol ethosuximide... 28, 29 etidronate disodium etoposide EVOTAZ exemestane EXJADE EYE ALLERGY RELIEF EYE ITCH RELIEF EYE WASH F FABRAZYME falmina (28) famciclovir famotidine... 14, 65 famotidine (pf) famotidine (pf)-nacl (iso-os) 65 FANAPT FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 60 fentanyl fentanyl citrate FERRIPROX ferrous sulfate FETZIMA FEVERALL FIBER LAXATIVE (CA POLYCARBO) finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLANDERS BUTTOCKS flavoxate flecainide FLEET GLYCERIN (ADULT) FLEET PEDIATRIC FLOVENT HFA fluconazole fluconazole in dextrose(iso-o) flucytosine fludarabine fludrocortisone flunisolide fluocinolone fluocinonide fluocinonide-e fluorouracil fluoxetine... 31, 32 fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 63, 81 fluvoxamine... 32, 33 FML FORTE FOAMING ACNE FACE WASH FOCALIN XR folic acid... 15, 18 fondaparinux FOR STY RELIEF... 15

92 FORA TEST STRIP FORACARE LANCETS FORTEO fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FRAGMIN FULL SPECTRUM B- VITAMIN C furosemide FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMMAGARD LIQUID ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) GAS RELIEF GATTEX ONE-VIAL gauze pad gavilyte-c gavilyte-g gavilyte-n gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin gentamicin in nacl (iso-osm) 23 GENTEAL MILD TO MODERATE GENTEAL MILD GENVOYA GEODON gildess 1.5/30 (21) GILENYA GILOTRIF glatopa GLEEVEC GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glucose glyburide glyburide micronized glyburide-metformin glycopyrrolate granisetron (pf) granisetron hcl griseofulvin microsize GRX DYNE guanfacine... 55, 61 guanidine GYNOL II H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heparin (porcine) heparin (porcine) in 5 % dex 54 HERCEPTIN HETLIOZ HEXALEN HIBICLENS HUMALOG HUMALOG MIX HUMALOG MIX HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMULIN 70/ HUMULIN N HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocodone-acetaminophen 21 hydrocodone-ibuprofen hydrocortisone... 15, 68, 77 hydrocortisone acetate hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid HYDROMET hydromorphone hydromorphone (pf) hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate I ibandronate IBRANCE ibuprofen... 15, 18, 21, 36 ICLUSIG idarubicin ifosfamide ILARIS (PF) imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin... 21, 36 INFANRIX (DTAP) (PF) INFANT'S NON-ASPIRIN.. 17 INFANT'S PAIN RELIEVER INLYTA INSULIN SYRINGE- NEEDLE U INTELENCE INTENSE COUGH RELIEVER INTRALIPID INTRON A INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA IOPHEN C-NR IPOL ipratropium bromide ipratropium-albuterol irbesartan IRESSA irinotecan ISENTRESS ISOLYTE-S isoniazid ISOPTO TEARS isosorbide dinitrate isosorbide mononitrate... 60, 61 91

93 ISTODAX itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUVIA JEVTANA jinteli junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) JUXTAPID K KADCYLA KALETRA KALYDECO KANUMA ketoconazole KETO-DIASTIX KETONE CARE ketorolac KEVEYIS KEYTRUDA KINERET KLOR-CON KLOR-CON klor-con m klor-con m KONSYL (SUGAR) KORLYM K-TAB KUVAN... 63, 64 KYNAMRO L labetalol LACRISERT lactated ringers lactulose lamivudine... 47, 49 lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) latanoprost LATUDA LAXATIVE (BISACODYL)15 LAZANDA leena leflunomide LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVEMIR levetiracetam levobunolol levocarnitine levocetirizine levofloxacin levofloxacin in d5w levoleucovorin calcium levonorgestrel levonorgestrel-ethinyl estrad 70 levora levothyroxine LEVOXYL LEXIVA LICE KILLING LICE TREATMENT (RESMETHRIN) lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine LINCOCIN lincomycin linezolid LINZESS liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LOHIST - D LONSURF loperamide... 16, 64 LORATADINE-D lorazepam losartan losartan-hydrochlorothiazide 58 lovastatin loxapine succinate LUBRICANT EYE... 13, 16 LUBRICANT EYE DROPS. 13 LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LYNPARZA LYRICA LYSODREN M magnesium citrate magnesium oxide... 13, 16 magnesium sulfate malathion maprotiline... 31, 32 MARPLAN MATULANE meclizine MEDI-CORTISONE MEDI-FIRST ANTI-FUNGAL medroxyprogesterone mefloquine megestrol MEKINIST meloxicam melphalan hcl memantine MENACTRA (PF) MENEST MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON meprobamate mercaptopurine meropenem mesalamine with cleansing wipe mesna MESNEX METAMUCIL (WITH SUGAR) metaproterenol metformin... 51, 52 methazolamide methimazole... 73

94 METHITEST methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methyldopa methyldopahydrochlorothiazide methylphenidate methylprednisolone... 68, 77 methylprednisolone acetate.. 68 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole metronidazole in nacl (iso-os) mexiletine MIACALCIN MICONAZOLE miconazole nitrate... 13, 16 miconazole MICONAZOLE microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED minocycline minoxidil MINTOX PLUS mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) modafinil moexipril moexipril-hydrochlorothiazide molindone mometasone montelukast morphine MOTION SICKNESS RELIEF(MECLIZ) MOZOBIL MUCINEX MUCINEX COUGH MINI- MELTS MUCINEX D MUCINEX D MAXIMUM STRENGTH MUCINEX DM MUCUS RELIEF ER MULTAQ mupirocin mupirocin calcium MURO MUSTARGEN MYCAMINE mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ N nabumetone nadolol nadolol-bendroflumethiazide 58 nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR naphazoline naproxen... 21, 36 naproxen sodium NARCAN NASAL DECONGESTANT (OXYMETAZL) NASAL DECONGESTANT (PSEUDOEPH) NATACYN nateglinide NATPARA NATURAL BALANCE NATURAL VEGETABLE POWDER NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone neomycin neomycin-bacitracin-poly-hc 79 neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 79, 80 NEULASTA NEUPOGEN NEUPRO nevirapine NEXAVAR NEXT CHOICE ONE DOSE niacin... 17, 18, 60 NIACIN FLUSH FREE niacor nicardipine NICODERM CQ nicotine... 17, 19 nicotine (polacrilex).. 17, 18, 19 NICOTROL NICOTROL NS nifedical xl nifedipine NILANDRON NINLARO nitrofurantoin nitrofurantoin macrocrystal.. 24 nitrofurantoin monohyd/mcryst nitroglycerin NITROSTAT NON-ASPIRIN JR STRENGTH norethindrone acetate norlyroc NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX NOXAFIL NUCALA NUEDEXTA NULOJIX NUTRILIPID NUTRISOURCE FIBER nystatin nystatin-triamcinolone

95 O OCEAN NASAL octreotide acetate ODOMZO OFEV ofloxacin... 27, 28 olanzapine olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole... 18, 66 OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI OPDIVO OPSUMIT ORENCIA ORENCIA (WITH MALTOSE) ORFADIN oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxcarbazepine oxybutynin chloride oxycodone oxycodone-acetaminophen P paclitaxel PAIN RELIEVER EXTRA STRENGTH paliperidone pamidronate PANDA MASK PANRETIN pantoprazole paricalcitol paromomycin paroxetine hcl PASER PATADAY PAXIL PAZEO PEAK AIR PEAK FLOW METER PEDIA-LAX STOOL SOFTENER PEDIATRIC COUGH AND COLD PEDIATRIC ELECTROLYTE PEDIATRIC MEDIUM MASK PEDVAX HIB (PF) PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC. 53 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM pentoxifylline PERJETA permethrin... 13, 43 perphenazine PHARBEDRYL phenelzine phenobarbital phenoxybenzamine phentermine phenytoin phenytoin sodium phenytoin sodium extended.. 30 PHOSPHOLINE IODIDE PHYSIOLYTE pilocarpine hcl pimozide pindolol PINK BISMUTH... 15, 17 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam PLASMA-LYTE PLASMA-LYTE A podofilox polyethylene glycol polymyxin b sulf-trimethoprim POLYSPORIN POLY-VI-SOL POLY-VITAMIN WITH IRON POMALYST portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 5 % dex potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA povidone-iodine PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate... 63, 68 prednisolone acetate prednisolone sodium phosphate... 68, 80 prednisone prednisone intensol PREMARIN PREMPRO PRENATAL PRENATAL VITAMIN prenatal vitamin plus low iron PRENATAL VITAMIN WITH MINERALS previfem PREZCOBIX PREZISTA PRILOSEC OTC primaquine primidone PRIMSOL probenecid procainamide prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT proctosol hc proctozone-hc PROCYSBI PROGLYCEM PROGRAF... 74

96 PROLEUKIN PROLIA PROMACTA promethazine promethazine vc PROMETHAZINE VC- CODEINE promethazine-codeine promethazine-dm promethegan propafenone proparacaine propranolol... 56, 57 propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) protriptyline psyllium husk PULMOZYME PURIXAN pyrazinamide PYRETHRIN LICE TREATMENT M pyridostigmine bromide pyridoxine (vitamin b6) Q Q-PAP QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl... 19, 65 RAPAMUNE RAVICTI REBIF (WITH ALBUMIN). 62 REBIF REBIDOSE REBIF TITRATION PACK 62 reclipsen (28) RECOMBIVAX HB (PF) REESE'S PINWORM MEDICINE REFRESH LACRI-LUBE RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL repaglinide RESCRIPTOR RESTASIS RETROVIR REVLIMID... 38, 40 REXULTI REYATAZ ribavirin RIDAURA rifabutin RIFAMATE rifampin RIFATER riluzole rimantadine ringers risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan ROBITUSSIN PEDIATRIC. 19 ropinirole ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SCALPICIN ANTI-ITCH SCOT-TUSSIN DM SCOT-TUSSIN SENIOR selegiline hcl selenium sulfide SELZENTRY SENNA SENNA PLUS SENSIPAR SEREVENT DISKUS sertraline SIGNIFOR SIGNIFOR LAR SILAPAP sildenafil silver sulfadiazine simethicone SIMULECT simvastatin sirolimus SIRTURO SLEEP TABLET (DIPHENHYDRAMINE) 18 sodium bicarbonate sodium chloride... 18, 19, 85 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium phenylbutyrate sodium polystyrene (sorb free) SOLTAMOX SOLUBLE FIBER SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT SOOTHE (BISMUTH SUBSALICYLATE) sotalol sotalol af SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX sprintec (28) SPRYCEL sronyx SSD stavudine STIMATE STIVARGA STOMACH RELIEF STOOL SOFTENER... 13, 15 STRATTERA STRENSIQ streptomycin STRIBILD sucralfate

97 SUDOGEST sulfacetamide sodium sulfacetamide sodium (acne) 28 sulfacetamide-prednisolone.. 79 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulindac sumatriptan succinate SUPER PAIN RELIEF SUPRAX SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE SYSTANE NIGHTTIME T TABLOID tacrolimus... 63, 75 TAFINLAR TAGRISSO TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN TASIGNA TAZORAC taztia xt TEARS NATURALE FORTE TEARS NATURALE II TECHNIVIE TEFLARO temazepam terazosin terbinafine hcl... 15, 35 terbutaline terconazole testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID theophylline thiamine hcl (vitamin b1) thioridazine thiotepa thiothixene THYMOGLOBULIN tiagabine TIKOSYN timolol maleate... 57, 80 TIVICAY tizanidine TOBI PODHALER TOBRADEX tobramycin tobramycin in % nacl.. 23 tobramycin sulfate tobramycin-dexamethasone.. 79 TOBREX tolcapone tolnaftate tolterodine topiramate toposar topotecan TORISEL torsemide TRACLEER tramadol... 21, 22 tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR tretinoin tretinoin (chemotherapy) triamcinolone acetonide. 62, 69 triamterene-hydrochlorothiazid triazolam trifluoperazine trifluridine trihexyphenidyl tri-legest fe trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRIPLE ANTIBIOTIC tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ TRI-VITA trivora (28) trospium TRUMENBA TRUVADA TRYMINE D TUDORZA PRESSAIR TUSSIN CF TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA U UNITHROID UPTRAVI urea ursodiol UVADEX V VAGINAL CONTRACEPTIVE FILM VAGINAL CONTRACEPTIVE FOAM valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan-hydrochlorothiazide vancomycin VAQTA (PF) VARIVAX (PF) VARIZIG VECTIBIX VELCADE... 40

98 venlafaxine VENTOLIN HFA verapamil VERSACLOZ VIDEX 2 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMPAT... 30, 31 vinblastine vincristine vinorelbine VIRACEPT VIRAZOLE VIREAD VISINE-A vitamin a palmitate VITAMIN B VITAMIN B-1 (MONONITRATE) VITAMIN B VITAMIN B , 20 VITAMIN C VITAMIN D , 19, 20 vitamin e VITEKTA voriconazole VOTRIENT VPRIV VRAYLAR VYTORIN VYTORIN VYTORIN W WAL-ACT D COLD AND ALLERGY WAL-FINATE-D WAL-MUCIL FIBER (ASPARTAME) warfarin WART REMOVER... 16, 18 WELCHOL X XALKORI XARELTO XGEVA XOLAIR XTANDI XYREM Y YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP ZANOSAR ZARXIO ZAVESCA ZELAPAR ZELBORAF ZEMAIRA ZENPEP ZETIA ZIAGEN zidovudine zinc zinc gluconate zinc oxide... 19, 20 ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolpidem ZOMETA zonisamide ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA

99 IEHP DualChoice P.O. Box 1800, Rancho Cucamonga, CA Inland Empire Health Plan. All Rights Reserved. Updated: April 26, 2016 H5355_CMC_16_03445_Final_4 Approved