2015 List of Covered Drugs (Formulary)

Transcription

1 L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan) 05 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This Formulary was updated on September 9, 0. If you have questions, please call L.A. Care Cal MediConnect Plan Member Services at (TTY: ), hours a day, 7 days a week, including holidays. For more information, visit H858_560_05Formulary Accepted Formulary ID 00058, Version 5

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3 This is a list of drugs that members can get in L.A. Care Cal MediConnect Plan. L.A. Care Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, and pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January of each year. You can always check L.A. Care Cal MediConnect Plan s up-to-date List of Covered Drugs online at or by calling (TTY: ). You can ask for this information in other formats, such as Braille or large print. Call (TTY: ). The call is free. Limitations and restrictions may apply. For more information, call L.A. Care Cal MediConnect Plan Member Services or read the L.A. Care Cal MediConnect Plan 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 (TTY: ). The call is free. Puede obtener esta información gratis en otros idiomas. Llame al (TTY: ). La llamada es gratis. Այս տեղեկությունները անվճար կարող եք ստանալ այլ լեզուներով: Զանգահարեք հեռախոսահամարով (TTY` ): Զանգն անվճար է: អ នកអ ចទទ លព ត ម នន ជ ភ ស ផ ស ងៗដ យឥតគ តថ ល ស មហ ល ខ (TTY: ) ក រហ ន គ ឥតគ តថ ល ឡ យ 이 정보는 다른 언어로도 무료로 구하실 수 있습니다 (TTY: )로 전화하시면 되며 통화료는 무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по номеру телефона (TTY: ). Звонок бесплатный. Makukuha ninyo ang impormasyong ito nang libre sa ibang mga wika. Tumawag sa (TTY: ). Ang tawag ay libre. 本 資 訊 備 有 其 他 語 言 版 本 供 您 免 費 索 取 請 致 電 (TTY: ) 這 是 免 費 電 話? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit i

4 Quý vị có thể được cấp thông tin này miễn phí bằng nhiều ngôn ngữ. Vui lòng gọi số (TTY: ). Số điện thoại này miễn phí. يمكنك الحصول على هذه المعلومات مجان ا بلغات ا خرٮاتصل على الرقم (رقم الهاتف النصي: ). هذه المكالمة مجانية. ii? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

5 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.. 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 L.A. Care Cal MediConnect Plan. 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. L.A. Care Cal MediConnect Plan 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 L.A. Care Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see Question 5). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY: ).. Does the Drug List ever change? Yes. L.A. Care Cal MediConnect Plan 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 L.A. Care Cal MediConnect Plan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page iv.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit iii

6 iv? you when we change our rules for covering a drug. Questions 3,, and 7 below have more information on what happens when the Drug List changes. You can always check L.A. Care Cal MediConnect Plan s up-to-date Drug List online at You can also call Member Services to check the current Drug List at (TTY: ). 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. You will be notified of this change in a document called the Explanation of Benefits which shows drugs to be removed from the Drug List in 60 days. The list of drugs to be removed is also posted on L.A. Care Cal MediConnect Plan s website, 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. We will also notify your provider so you can consult him/her to change to a drug on the Drug List that is safe to use. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases, you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from L.A. Care Cal MediConnect Plan before you fill your prescription. If you don t get approval, L.A. Care Cal MediConnect Plan may not cover the drug. Quantity limits: Sometimes L.A. Care Cal MediConnect Plan limits the amount of a drug you can get. Step therapy: Sometimes L.A. Care Cal MediConnect Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages -6. You can also get more information by visiting our website at We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

7 You can also ask for an exception from these limits. Please see Question 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 3-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new L.A. Care Cal MediConnect Plan 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 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page has a column labeled 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), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask 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 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 by looking at the index at the end of the list. The medications are listed in alphabetical order. To search by medical condition, find the section labeled List of drugs by medical condition on page. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit v

8 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 (TTY: ) and ask about it. If you learn that L.A. Care Cal MediConnect Plan 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 for more information about exceptions. 0. What if you are a new L.A. Care Cal MediConnect Plan member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of L.A. Care Cal MediConnectPlan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by L.A. Care Cal MediConnect Plan, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. Level of Care Changes We will provide a transition supply of your drugs when you experience a change in level of care. Examples of level of care changes may include the following:. Members who enter long-term care facilities from hospitals. Members who are discharged from a hospital to a home 3. Members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary. Members who give up hospice status to revert to standard Medicare Part A and B benefits vi? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

9 5. Members who end a long-term care facility stay and return to the community 6. Members who are discharged from psychiatric hospitals with drug regimens that are highly individualized. Pharmacies may contact L.A. Care Cal MediConnect Plan Pharmacy Services at to process point-of-sale overrides to ensure members receive access to their medications without any delays.. Can you ask for an exception to cover your drug? Yes. You can ask L.A. Care Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, L.A. Care Cal MediConnect Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.. 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 7 hours. If you or your prescriber think your health may be harmed if you have to wait 7 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 hours of receiving your prescriber s supporting statement. 3. How can you ask for an exception? To ask for an exception, call Member Services or our Pharmacy Department. Your care team will work with you and your provider to help you ask for an exception.. 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). L.A. Care Cal MediConnect Plan covers both brand-name drugs and generic drugs.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit vii

10 5. What are OTC drugs? OTC stands for over-the-counter. You can buy OTC drugs without a prescription. L.A. Care Cal MediConnect Plan covers some OTC drugs. You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC drugs are covered. 6. Does L.A. Care Cal MediConnect Plan cover OTC non-drug products? L.A. Care Cal MediConnect Plan covers some OTC non-drug products. You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC non-drug products are covered. 7. What is your co-pay? You can read the L.A. Care Cal MediConnect Plan Drug List to learn about the co-pay for each drug. L.A. Care Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no co-pays. 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 drugs are generic drugs. The co-pay will be from $0 to $.65, depending on your level of Medicaid eligibility. Tier drugs are brand name drugs. The co-pay will be from $0 to $6.60, depending on your level of Medicaid eligibility. Tier 3 drugs are Non-Medicare Rx Generic drugs. For Tier 3 drugs you pay nothing. Tier drugs are Non-Medicare OTC drugs. For Tier drugs you pay nothing. List of Covered Drugs The list of covered drugs below or that begins on the next page gives you information about the drugs covered by L.A. Care Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., CYMBALTA) and generic drugs are listed in lowercase italics (e.g., metformin). The information in the column tells you if L.A. Care Cal MediConnect Plan has any rules for covering your drug. viii? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

11 COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION NSO Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for New Starts Only Utilization Management Restrictions You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. If this is a new prescription for you, i.e., the first time this drug is prescribed for you, you (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. QL Quantity Limit Restriction L.A. Care Cal MediConnect Plan limits the quantity to be covered within a specific time frame for this drug. ST Step Therapy Restriction Before L.A. Care Cal MediConnect Plan will provide coverage for this drug, you must first try another drug(s) on the formulary to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage LD Limited Distribution Drug This prescription may be available only at certain pharmacies. For more information, consult your Provider/Pharmacy Directory or call Member Services at (TTY: ), hours a day, 7 days a week, including holidays. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). 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 (TTY: ). You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit ix

12 ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS AMPHETAMINES ADDERALL XR CAP amphetamine/ dextroamphetamine tab dextroamphetamine ER cap dextroamphetamine tab methamphetamine tab VYVANSE CAP ANOREXIANTS NON-AMPHETAMINE phentermine cap 5mg* 3 phentermine cap 30mg* 3 phentermine tab 37.5mg* 3 QSYMIA CAP* 3 ANTI-OBESITY AGENTS XENICAL CAP 0MG* 3 ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS INTUNIV TAB MG, MG ST INTUNIV TAB 3MG, MG NSO ST STRATTERA CAP QL=60 Caps/30 Days STIMULANTS - MISC. dexmethylphenidate ER cap dexmethylphenidate tab metadate ER tab methylphenidate CD cap methylphenidate ER cap methylphenidate ER tab methylphenidate soln. methylphenidate tab NUVIGIL TAB QL=30 Tabs/30 Days AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin inj. gentamicin inj. gentamicin/ nacl inj. gentamicin/ nacl inj..6mg/ ml gentamycin/ nacl inj. isotonic gentamicin neomycin tab paromomycin cap STREPTOMYCIN INJ. TOBI NEB NM TOBI PODHALER NM tobramycin inj TOBRAMYCIN/ NACL INJ.

13 ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA KIT NM SIMPONI INJ. NM GOLD COMPOUNDS RIDAURA CAP INTERLEUKIN- BLOCKERS ARCALYST INJ. NM INTERLEUKIN-BETA BLOCKERS ILARIS INJ. NM NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELEBREX CAP QL=60 Caps/30 Days diclofenac ec tab diclofenac potassium tab diclofenac XR tab diclofenac/ misoprostol tab etodolac cap etodolac ER tab etodolac tab fenoprofen tab flurbiprofen tab ibuprofen cap 00mg* ibuprofen chew tab 00mg* ibuprofen susp. ibuprofen tab ibuprofen tab 00mg* ibuprofen tab 00mg* QL=00 Tabs/00 Days INDOCIN SUSP. indomethacin cap indomethacin ER cap ketoprofen cap ketorolac inj. ketorolac tab QL=0 Tabs/5 Days MECLOFENAMATE SODIUM CAP mefenamic acid cap MELOXICAM SUSP meloxicam tab nabumetone tab naproxen dr tab naproxen sodium tab naproxen susp. naproxen tab oxaprozin tab piroxicam cap

14 sulindac tab tolmetin cap tolmetin tab TOLMETIN TAB 00MG PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab SELECTIVE COSTIMULATION MODULATORS ORENCIA INJ. ORENCIA SUB-Q INJ. SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ. ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS aspirin/ acetaminophen/ caffeine tab mg* ANALGESICS OTHER acetaminophen cap 500mg* acetaminophen chew tab 60mg* acetaminophen CR tab 650mg* acetaminophen elixir 60mg/ 5ml* acetaminophen liquid 60mg/ 5ml* ACETAMINOPHEN LIQUID 500MG/ 5ML* acetaminophen soln. 60mg/ 5ml* acetaminophen suppository 0mg* acetaminophen suppository 35mg* acetaminophen suppository 650mg* acetaminophen suppository 80mg* acetaminophen susp. 60mg/ 5ml* acetaminophen susp. 80mg/ 0.8ml* acetaminophen tab 35mg* acetaminophen tab 500mg* SALICYLATES ASCRIPTIN TAB 35MG* aspirin 8mg tab* aspirin DR tab 35mg* aspirin DR tab 8mg* aspirin tab 35mg* aspirin tab 500mg* diflunisal tab ANALGESICS - OPIOID OPIOID AGONISTS codeine sulfate tab duramorph inj. EXALGO TAB fentanyl lollipop 3 NM QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=0 Lozenges/30 Days

15 fentanyl patch hydromorphone ER tab hydromorphone inj. hydromorphone oral liquid hydromorphone tab LAZANDA SPRAY LEVORPHANOL TAB meperitab tab methadone soln. methadone tab morphine sulfate ER cap morphine sulfate ER tab MORPHINE SULFATE PF INJ. MG, MG morphine sulfate soln. morphine sulfate tab NUCYNTA ER TAB oxycodone cap oxycodone soln. oxycodone tab OXYCONTIN TAB OXYCONTIN TAB 80MG oxymorphone ER tab oxymorphone tab tramadol ER tab tramadol hcl tab OPIOID COMBINATIONS acetaminophen/ codeine soln. acetaminophen/ codeine tab endocet tab endodan tab hydrocodone/ acetaminophen soln mg/ 5ml hydrocodone/ acetaminophen tab 5-300mg, mg, 0-300mg hydrocodone/ acetaminophen tab 5-35mg, mg, 0-35mg hydrocodone/ ibuprofen tab oxycodone / aspirin tab oxycodone / ibuprofen tab oxycodone/ acetaminophen tab ROXICET SOLN tramadol/ acetaminophen tab OPIOID RTIAL AGONISTS buprenorphine inj. buprenorphine sl tab butorphanol inj QL=30 Bottles/30 Days QL=60 Caps/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days QL=60 Tabs/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days

16 butorphanol soln. BUTRANS TCH pentazocine/ naloxone tab SUBOXONE SL FILM ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 TAB oxandrolone tab ANDROGENS ANDRODERM TCH MG/ HR ANDRODERM TCH MG/ HR ANDROGEL GEL %(50MG) ANDROGEL PUMP ANDROXY TAB danazol cap testosterone cypionate inj. testosterone enanthate inj. ANORECTAL AGENTS INTRARECTAL STEROIDS colocort enema hydrocortisone enema RECTAL STEROIDS procto-pak proctozone-hc cream ANTACIDS ANTACID COMBINATIONS aluminum hydroxide/ magnesium carbonate chew tab* aluminum/ mag hydroxide/ simethicone susp mg/ 5ml* antacid susp.* GELUSIL CHEW TAB* MAALOX ADVANCED MAXIMUM STRENGTH CHEW TAB* maalox max susp* ANTACIDS - ALUMINUM SALTS ALUMINUM HYDROXIDE GEL SUSP. 30MG/ 5ML* aluminum hydroxide gel susp. 600mg/ 5ml* ANTACIDS - BICARBONATE sodium bicarbonate tab 650mg* ANTACIDS - CALCIUM SALTS calcium carbonate chew tab 000mg* calcium carbonate chew tab 0mg* QL= Bottles/30 Days QL= Patches/8 Days QL=60 Patches/30 Days QL=30 Patches/30 Days QL=60 Patches/30 Days QL= Bottles/30 Days 5

17 calcium carbonate chew tab 500mg* calcium carbonate chew tab 750mg* calcium carbonate tab 68mg* ANTHELMINTICS ANTHELMINTICS ALBENZA TAB STROMECTOL TAB ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA TAB NITRATES isosorbide dinitrate ER tab isosorbide dinitrate tab isosorbide mononitrate ER tab isosorbide mononitrate tab minitran patch NITRO-DUR TCH 0.3MG/ HR, 0.8MG/ HR nitroglycerin inj. nitroglycerin lingual spray nitroglycerin patch NITROSTAT SL TAB ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone tab hydroxyzine inj. hydroxyzine pamoate cap hydroxyzine syrup hydroxyzine tab meprobamate tab BENZODIAZEPINES alprazolam ER tab alprazolam odt tab alprazolam tab chlordiazepoxide cap clorazepate tab DIAZEM INTENSOL DIAZEM SOLN. diazepam tab lorazepam conc lorazepam tab oxazepam cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A 6

18 disopyramide cap NORCE CR PROCAINAMIDE INJ. quinidine gluconate CR tab QUINIDINE GLUCONATE INJ. quinidine sulfate tab ANTIARRHYTHMICS TYPE I-B mexiletine cap ANTIARRHYTHMICS TYPE I-C flecainide tab propafenone ER cap propafenone tab ANTIARRHYTHMICS TYPE III amiodarone inj amiodarone tab MULTAQ TAB NEXTERONE INJ. TIKOSYN CAP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR INJ. NM ANTI-INFLAMMATORY AGENTS cromolyn neb BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALER ipratropium neb SPIRIVA CAP HANDIHALER TUDORZA INHALER LEUKOTRIENE MODULATORS montelukast chew tab montelukast granules montelukast tab zafirlukast tab SELECTIVE PHOSPHODIESTERASE (PDE) INHIBITORS DALIRESP TAB STEROID INHALANTS ASMANEX INHALER budesonide neb QL=60 Neb/30 Days FLOVENT DISKUS QL= Inhalers/30 Days FLOVENT HFA INHALER 0MCG QL= Inhalers/30 Days FLOVENT HFA INHALER MCG, 0MCG QL= Inhalers/30 Days PULMICORT NEB MG/ ML QL=60 Neb/30 Days QVAR INHALER QL= Inhalers/30 Days SYMTHOMIMETICS 7

19 ADVAIR DISKUS ADVAIR HFA INHALER albuterol neb albuterol sulfate ER tab albuterol syrup albuterol tab COMBIVENT RESPIMAT DULERA INHALER EPHEDRINE SULFATE CAP 5MG* FORADIL CAP ipratropium/ albuterol neb. levalbuterol neb METAPROTERENOL SYRUP SEREVENT INHALER SYMBICORT INHALER terbutaline inj. terbutaline tab VENTOLIN HFA INHALER XANTHINES aminophylline inj. ELIXOPHYLLIN SOLN. theophylline ER tab theophylline soln. ANTICOAGULANTS COUMARIN ANTICOAGULANTS COUMADIN INJ. jantoven tab warfarin tab DIRECT FACTOR XA INHIBITORS ELIQUIS TAB XARELTO TAB HERINS AND HERINOID-LIKE AGENTS enoxaparin inj. fondaparinux inj. FRAGMIN INJ. heparin inj. heparin/ d5w inj. heparin/ nacl inj. THROMBIN INHIBITORS argatroban inj. 00mg/ ml ARGATROBAN INJ. 5MG/ 5ML PRADAXA CAP ANTICONVULSANTS AM GLUTAMATE RECEPTOR ANTAGONISTS 8 QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL=35 Syringes/7 Days NM NM

20 FYCOM TAB ANTICONVULSANTS - BENZODIAZEPINES clonazepam odt tab clonazepam tab DIASTAT RECTAL GEL DIAZEM RECTAL GEL ONFI SUSPENSION ONFI TAB ANTICONVULSANTS - MISC. APTIOM TAB BANZEL SUSP. BANZEL TAB carbamazepine chew tab carbamazepine ER cap carbamazepine ER tab carbamazepine susp. carbamazepine tab epitol tab gabapentin cap gabapentin soln. gabapentin tab LAMICTAL ODT LAMICTAL STARTER KIT LAMICTAL XR KIT lamotrigine chew tab lamotrigine ER tab lamotrigine tab levetiracetam ER tab levetiracetam inj levetiracetam soln. levetiracetam tab LYRICA CAP LYRICA SOLN. oxcarbazepine oral susp. oxcarbazepine tab OXTELLAR XR TAB POTIGA TAB primidone tab TEGRETOL-XR TAB topiramate sprinkle cap topiramate tab TROKENDI XR CAP VIMT INJ. VIMT SOLN. VIMT TAB 9 NSO NSO NSO NSO NSO QL=90 Tabs/30 Days NSO QL=60 Tabs/30 Days

21 zonisamide cap CARBAMATES felbamate susp. felbamate tab GABA MODULATORS GABITRIL TAB SABRIL POWDER SABRIL TAB tiagabine tab HYDANTOINS DILANTIN CAP fosphenytoin inj. PEGANONE TAB phenytoin cap phenytoin chew tab phenytoin inj. phenytoin susp. SUCCINIMIDES CELONTIN CAP ethosuximide cap ethosuximide soln. VALPROIC ACID divalproex dr tab divalproex ER tab divalproex sprinkle cap valproate sodium inj. valproic acid cap valproic acid syrup ANTIDEPRESSANTS ALPHA- RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine odt tab mirtazapine tab ANTIDEPRESSANTS - MISC. APLENZIN TAB bupropion SR tab bupropion tab bupropion XL tab maprotiline tab MODIFIED CYCLICS BRINTELLIX TAB NEFAZODONE TAB trazodone tab VIIBRYD STARTER CK VIIBRYD TAB 0 NM NM ST ST NSO ST

22 MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TCH MARPLAN TAB phenelzine tab tranylcypromine tab SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram soln. citalopram tab escitalopram soln. escitalopram tab fluoxetine cap fluoxetine soln. fluoxetine tab fluvoxamine ER cap fluvoxamine tab paroxetine ER tab paroxetine tab XIL SUSP. PEXEVA TAB sertraline conc. sertraline tab SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER TAB duloxetine cap FETZIMA CAP FETZIMA CK KHEDEZYLA TAB PRISTIQ TAB venlafaxine ER cap venlafaxine ER tab VENLAFAXINE ER TAB 5MG venlafaxine tab TRICYCLIC AGENTS amitriptyline tab amoxapine tab clomipramine cap desipramine tab doxepin conc. doxepine cap imipramine pamoate imipramine tab nortriptyline cap nortriptyline soln. protriptyline tab SURMONTIL CAP ST ST ST QL=60 Caps/30 Days ST ST ST ST NSO NSO NSO NSO NSO NSO NSO

23 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose tab GLYSET TAB ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN ANTIDIABETIC COMBINATIONS AVANDAMET TAB AVANDARYL TAB glipizide/ metformin tab glyburide/ metformin tab JANUMET TAB JANUMET XR TAB pioglitazone/ glimepiride tab pioglitazone/ metformin tab BIGUANIDES metformin ER osmotic tab 000mg metformin ER tab metformin tab DIABETIC OTHER GLUCAGEN HYPOKIT GLUCAGON KIT KORLYM TAB PROGLYCEM SUSP. DIPEPTIDYL PEPTIDASE- (DPP-) INHIBITORS JANUVIA TAB ONGLYZA TAB TRADJENTA TAB INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON INJ. VICTOZA INJ. INSULIN HUMALOG PEN HUMALOG VIAL HUMULIN 70/ 30 PEN HUMULIN N PEN HUMULIN R U-500 VIAL LANTUS SOLOSTAR LANTUS VIAL LEVEMIR FLEXPEN LEVEMIR INJ. NOVOLIN 70/ 30 VIAL NOVOLIN N VIAL NOVOLIN R VIAL NM QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days ST ST

24 NOVOLOG FLEXPEN NOVOLOG MIX 70/ 30 PEN NOVOLOG MIX 70/ 30 VIAL NOVOLOG VIAL INSULIN SENSITIZING AGENTS AVANDIA TAB pioglitazone tab MEGLITINIDE ANALOGUES nateglinide tab repaglinide tab SODIUM-GLUCOSE CO-TRANSPORTER (SGLT) INHIBITORS FARXIGA TAB INVOKANA TAB SULFONYLUREAS chlorpropamide tab glimepiride tab glipizide ER tab glipizide tab glyburide micronized tab glyburide tab tolazamide tab TOLBUTAMIDE TAB ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC. bismuth subsalicylate chew tab 6mg* bismuth subsalicylate susp 6mg/ 5ml* bismuth subsalicylate susp 55mg/ 5ml* bismuth subsalicylate tab 6mg* ANTIPERISTALTIC AGENTS diphenoxylate/ atropine liquid diphenoxylate/ atropine tab loperamide cap loperamide tab mg* ANTIDOTES ANTIDOTES fomepizole inj. ANTIDOTES - CHELATING AGENTS CHEMET CAP EXJADE ORAL SUSP. FERRIPROX OPIOID ANTAGONISTS naloxone inj. naltrexone tab ST QL=30 Tabs/30 Days NM LD 3

25 ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron inj. granisetron tab QL=9 Tabs/ Days ondansetron inj. ondansetron odt tab ondansetron soln. ondansetron tab ANTIEMETICS - ANTICHOLINERGIC BONINE CHEW TAB 5MG* dimenhydrinate tab 50mg* meclizine tab TRANSDERM SCOP trimethobenzamide cap ANTIEMETICS - MISCELLANEOUS CESAMET CAP dronabinol cap SUBSTANCE P/ NEUROKININ (NK) RECEPTOR ANTAGONISTS EMEND CAP QL=3 Caps/ Days EMEND CK QL=3 Caps/ Days ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS INJ. NM ERAXIS INJ. MYCAMINE INJ. ANTIFUNGALS ABELCET INJ. AMBISOME INJ. AMPHOTERICIN B INJ. flucytosine cap griseofulvin microsize susp. griseofulvin tab nystatin tab terbinafine tab IMIDAZOLE-RELATED ANTIFUNGALS fluconazole susp. fluconazole tab fluconazole/ dextrose inj. itraconazole cap ketoconazole tab NOXAFIL SUSP NOXAFIL TAB NM voriconazole inj. voriconazole susp.

26 voriconazole tab ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES chlorpheniramine syrup mg/ 5ml* chlorpheniramine tab mg* ANTIHISTAMINES - ETHANOLAMINES BENADRYL CHEW TAB.5MG* carbinoxamine soln. carbinoxamine tab CLEMASTINE SYRUP clemastine tab clemastine tab.3mg* diphenhydramine cap 5mg* diphenhydramine cap 50mg* diphenhydramine elixir.5mg/ 5ml* diphenhydramine inj. diphenhydramine liquid.5mg/ 5ml* diphenhydramine oral soln (Rx only) diphenhydramine tab 5mg* ANTIHISTAMINES - NON-SEDATING ALLEGRA TAB 30MG* 3 cetirizine chew tab 0mg* cetirizine chew tab 5mg* cetirizine oral soln (Rx only) cetirizine soln mg/ ml* cetirizine tab 0mg* cetirizine tab 5mg* desloratadine ODT tab desloratatine tab fexofenadine tab 80mg* 3 fexofenadine tab 60mg* 3 levocetirizine soln. levocetirizine tab loratadine ODT tab 0mg* loratadine syrup 5mg/ 5ml* loratadine tab 0mg* ANTIHISTAMINES - PHENOTHIAZINES phenadoz supp. promethazine inj. promethazine supp. promethazine syrup promethazine tab PROMETHAZINE VC CODEINE promethegan supp. NM QL=300 ml/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=300 ml/30 Days QL=30 Tabs/30 Days 5

27 PROMETHEGAN SUPP. 50MG ANTIHISTAMINES - PIPERIDINES cyproheptadine syrup cyproheptadine tab ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS LIPTRUZET TAB ANTIHYPERLIPIDEMICS - MISC. LOVAZA CAP omega-3 acid cap VASCE BILE ACID SEQUESTRANTS cholestyramine light powder cholestyramine lite powder packet colestipol granule colestipol tab WELCHOL TAB FIBRIC ACID DERIVATIVES fenofibrate micronized cap fenofibrate tab gemfibrozil tab LOFIBRA CAP LOFIBRA TAB TRIGLIDE TAB TRILIPIX CAP HMG COA REDUCTASE INHIBITORS atorvastatin tab CRESTOR TAB CRESTOR TAB 0MG fluvastatin cap LESCOL XL TAB lovastatin tab pravastatin tab SIMCOR TAB simvastatin tab INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB NICOTINIC ACID DERIVATIVES NIACOR TAB NIASN ER TAB ANTIHYPERTENSIVES ACE INHIBITORS benazepril tab QL=30 Tabs/30 Days QL=5 Tabs/30 Days QL=30 Tabs/30 Days 6

28 captopril tab enalapril tab fosinopril tab lisinopril tab moexipril tab perindopril tab quinapril tab ramipril cap trandolapril tab AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP DIBENZYLINE CAP ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan tab DIOVAN TAB eprosartan mesylate tab irbesartan tab losartan tab telmisartan tab ANTIADRENERGIC ANTIHYPERTENSIVES clonidine patch clonidine tab doxazosin tab guanfacine IR tab methyldopa tab prazosin cap terazosin cap ANTIHYPERTENSIVE COMBINATIONS amlodipine/ benazepril cap atenolol/ chlorthalidone tab benazepril/ hctz tab bisoprolol/ hctz tab candesartan/ hctz tab captopril/ hctz tab DUTOPROL TAB enalapril/ hctz tab EXFORGE HCT TAB EXFORGE TAB fosinopril/ hctz tab irbesartan/ hctz tab lisinopril/ hctz tab losartan/ hctz tab methyldopa/ hctz tab metoprolol/ hctz tab moexipril/ hctz tab 7

29 nadolol/ bendroflumethiazide tab propranolol/ hctz tab quinapril/ hctz tab telmisartan/ amlodipine tab telmisartan/ hctz tab valsartan/ hctz tab SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab VASODILATORS hydralazine inj hydralazine tab minoxidil tab ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AZACTAM/ DEXTROSE INJ. aztreonam inj. baciim inj colistimethate inj. metronidazole cap metronidazole tab metronidazole/ nacl inj. NEBUPENT NEB PENTAM INJ. tinidazole tab trimethoprim tab vancomycin cap vancomycin inj. ANTI-INFECTIVE MISC. - COMBINATIONS e.s.p susp. sulfamethoxazole/ trimethoprim DS tab SULFAMETHOXAZOLE/ TRIMETHOPRIM INJ. sulfamethoxazole/ trimethoprim susp. sulfamethoxazole/ trimethoprim tab ANTIPROTOZOAL AGENTS ALINIA SUSP. ALINIA TAB atovaquone susp CARBAPENEMS DORIBAX INJ. imipenem/ cilastatin inj. INVANZ INJ. meropenem inj. CHLORAMPHENICOLS CHLORAMPHENICAL INJ. 8 ST QL=56 Caps/0 Days

30 CYCLIC LIPOPEPTIDES CUBICIN INJ. GLYCYLCYCLINES TYGACIL INJ. LEPROSTATICS dapsone tab LINCOSAMIDES clindamycin cap clindamycin inj clindamycin soln. LINCOCIN OXAZOLIDINONES ZYVOX INJ. ZYVOX SUSP. ZYVOX TAB POLYMYXINS polymyxin b inj. STREPTOGRAMINS SYNERCID INJ ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone/ proguanil tab COARTEM TAB ANTIMALARIALS chloroquine tab DARAPRIM TAB hydroxychloroquine tab mefloquine tab PRIMAQUINE TAB quinine sulfate cap ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS GUANIDINE TAB MESTINON TIMESN TAB pyridostigmine tab ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS RIFAMATE CAP RIFATER TAB ANTIMYCOBACTERIAL AGENTS CASTAT INJ. ethambutol tab isoniazid inj. 9 NM NM NM NM

31 isoniazid syrup isoniazid tab SER GRANULE PRIFTIN TAB pyrazinamide tab rifabutin cap rifampin cap rifampin inj. TRECATOR TAB ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS BICNU INJ. BUSULFEX INJ. carboplatin inj. cisplatin inj CYCLOPHOSPHAMIDE CAP cyclophosphamide tab HEXALEN CAP NM IFEX INJ. ifosfamide inj. LEUKERAN TAB LOMUSTINE CAP melphalan inj. MYSTARGEN INJ. oxaliplatin inj TREANDA INJ. NM NSO ZANOSAR INJ ANTIMETABOLITES ALIMTA INJ. ARRANON INJ azacitidine inj. cladribine inj. CLOLAR INJ. cytarabine inj. decitabine inj. fludarabine inj. fluorouracil inj. FOLOTYN INJ. NM NSO gemcitabine inj. mercaptopurine tab methotrexate inj. methotrexate PF inj. methotrexate tab TABLOID TAB TREXALL TAB 0

32 ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ ZALTRAP INJ. ANTINEOPLASTIC - ANTIBODIES ARZERRA INJ. ERBITUX SOLN HERCEPTIN INJ. KADCYLA INJ. PERJETA INJ. RITUXAN INJ. VECTIBIX INJ YERVOY INJ. ANTINEOPLASTIC - HEDGEHOG THWAY INHIBITORS ERIVEDGE CAP ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole tab bicalutamide tab ELIGARD INJ. EMCYT CAP exemestane tab FARESTON TAB FASLODEX INJ FIRMAGON INJ. flutamide cap letrozole tab leuprolide inj. LUPRON DEPOT (3 MONTH) KIT.5MG,.5MG LUPRON DEPOT ( MONTH) KIT 30MG LUPRON DEPOT (6 MONTH) KIT 5MG LUPRON DEPOT INJ. LYSODREN TAB megestrol acetate susp. megestrol acetate tab NILANDRON TAB SOLTAMOX ORAL SOLN. tamoxifen citrate tab TRELSTAR DEPOT MIXJECT INJ. TRELSTAR LA MIXJECT INJ. TRELSTAR MIXJECT INJ. XTANDI CAP ZYTIGA TAB ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP ANTINEOPLASTIC ANTIBIOTICS NM NM NSO NM NM NSO NM NSO NSO NM NSO NM NM NM NSO NM NM NM NSO NSO NSO NM NSO QL=0 Caps/30 Days NM NSO NM NSO

33 bleomycin sulfate inj. COSMEGEN INJ. 0.5MG daunorubicin inj doxorubicin inj. edirubicin inj idarubicin inj mitomycin inj. mitoxantrone inj ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DISPERZ AFINITOR TAB BOSULIF TAB CAPRELSA TAB COMETRIQ CK GILOTRIF TAB GLEEVEC TAB IMBRUVICA CAP INLYTA TAB ISTODAX INJ. JAKAFI TAB MEKINIST TAB NEXAVAR TAB SPRYCEL TAB STIVARGA TAB SUTENT CAP TAFINLAR CAP TARCEVA TAB TASIGNA CAP TORISEL SOLN TYKERB TAB VELCADE INJ. VOTRIENT TAB XALKORI CAP ZELBORAF TAB ZOLINZA CAP ZYKADIA CAP ANTINEOPLASTIC ENZYMES ERWINAZE INJ. ONCASR INJ. ANTINEOPLASTICS MISC. ACTIMMUNE INJ. dacarbazine inj. hydroxyurea cap INTRON-A INJ. MATULANE CAP NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO NM NSO QL=60 Tabs/30 Days NM NSO LD NM NSO NM NSO NM NSO QL=0 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO LD NM NSO NM NM NSO NM NSO NM NSO NM NSO NM NSO NM NSO

34 PROLEUKINE IV SOLN. SYLATRON INJ. SYNRIBO INJ. TARGRETIN CAP tretinoin cap TRISENOX INJ. UVADEX SOLN CHEMOTHERAPY ADJUNCTS ELITEK INJ. KEPIVANCE INJ CHEMOTHERAPY RESCUE/ ANTIDOTE AGENTS amifostine inj. dexrazoxane inj. FUSILEV INJ. leucovorin inj. leucovorin tab mesna inj. MESNEX TAB MITOTIC INHIBITORS ABRAXANE SUSP DOCEFREZ INJ. DOCETAXEL INJ. ETOPOPHOS INJ. etoposide inj. HALAVEN INJ. IXEMPRA INJ JEVTANA INJ. paclitaxel inj TAXOTERE INJ toposar inj. vinblastine inj. vincasar pfs inj. vincristine inj. vinorelbine inj TOPOISOMERASE I INHIBITORS irinotecan inj. topotecan inj. ANTIRKINSON AGENTS ANTIRKINSON ADJUVANTS carbidopa tab ANTIRKINSON ANTICHOLINERGICS benztropine inj. benztropine tab trihexyphenidyl soln 3 NM NM NSO NM NM NSO NM NM NM NM NM NM

35 trihexyphenidyl tab ANTIRKINSON COMT INHIBITORS entacapone tab TASMAR ANTIRKINSON DOMINERGICS amantadine cap amantadine syrup APOKYN INJ. bromocriptine cap bromocriptine tab CARBIDO/ ENTACAPONE/ LEVODO TAB carbidopa/ levodopa ER tab carbidopa/ levodopa ODT tab carbidopa/ levodopa tab NEUPRO TCH pramipexole tab ropinirole ER tab ropinirole tab STALEVO TAB ANTIRKINSON MONOAMINE OXIDASE INHIBITORS AZILECT TAB selegiline cap selegiline tab ANTIPSYCHOTICS/ ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate cap lithium carbonate ER tab lithium carbonate tab lithium citrate soln. ANTIPSYCHOTICS - MISC. EQUETRO CAP GEODON INJ. LATUDA TAB NSO QL=30 Tabs/30 Days ziprasidone cap BENZISOXAZOLES FANAPT TAB NSO FANAPT TITRATION CK NSO INVEGA SUSTENNA INJ. NSO INVEGA TAB NSO RISPERDAL CONSTA INJ. risperidone odt risperidone soln. risperidone tab BUTYROPHENONES

36 haloperidol decanoate inj. haloperidol inj. haloperidol oral conc. haloperidol tab DIBENZAPINES clozapine tab FAZACLO TAB loxapine cap olanzapine inj. olanzapine ODT tab olanzapine tab quetiapine tab SAPHRIS SL TAB NSO QL=60 Tabs/30 Days SEROQUEL XR TAB VERSACLOZ SUSP PHENOTHIAZINES chlorpromazine inj. chlorpromazine tab compro suppository FLUPHENAZINE DECANOATE INJ. fluphenazine elixir FLUPHENAZINE INJ. fluphenazine oral conc. fluphenazine tab perphenazine tab prochlorperazine edisylate inj. prochlorperazine suppository prochlorperazine tab thioridazine tab NSO trifluoperazine tab QUINOLINONE DERIVATIVES ABILIFY DISC TAB NM QL=60 Tabs/30 Days ABILIFY INJ. ABILIFY MAINTENANCE INJ. ABILIFY SOLN. ABILIFY TAB QL=60 Tabs/30 Days THIOXANTHENES thiothixene cap ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID %* QL=0 ml/365 Days chlorhexidine gluconate liquid %* QL=0 ml/30 Days CHLORHEXIDINE GLUCONATE DS %* chlorhexidine gluconate soln. 0%* 3 QL=0 ml/30 Days 5

37 ANTIRETROVIRALS abacavir tab abacavir/ lamivudine/ zidovudine tab APTIVUS CAP APTIVUS SOLN. ATRIPLA TAB COMPLERA TAB CRIXIVAN CAP didanosine cap EDURANT TAB EMTRIVA CAP EMTRIVA SOLN. EPIVIR HBV SOLN. EPIVIR SOLN. EPZICOM TAB FUZEON INJ. INTELENCE TAB INVIRASE CAP INVIRASE TAB ISENTRESS CHEW TAB ISENTRESS POWDER CK ISENTRESS TAB KALETRA SOLN. KALETRA TAB lamivudine tab lamivudine/ zidovudine tab LEXIVA SUSP. LEXIVA TAB nevirapine er tab nevirapine tab NORVIR CAP NORVIR SOLN. NORVIR TAB PREZISTA SUSP. PREZISTA TAB RESCRIPTOR TAB RETROVIR INJ. REYATAZ CAP SELZENTRY TAB stavudine cap stavudine soln. STRIBILD TAB SUSTIVA CAP SUSTIVA TAB ANTIVIRALS 6 NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM QL=30 Tabs/30 Days

38 TIVICAY TAB TRUVADA TAB VIDEX SOLN. VIRACEPT TAB VIRAMUNE SUSP. VIRAMUNE XR TAB VIREAD POWDER VIREAD TAB ZIAGEN SOLN. zidovudine cap zidovudine syrup zidovudine tab CMV AGENTS cidofovir inj. FOSCARNET INJ. ganciclovir inj. VALCYTE SOLN. VALCYTE TAB HETITIS AGENTS adefovir tab BARACLUDE SOLN. BARACLUDE TAB moderiba tab 00mg MODERIBA TAB 00MG, 600MG OLYSIO TAB PEG-INTRON INJ. PEGASYS INJ. PEGASYS PROCLICK INJ. ribasphere cap ribasphere tab ribavirin cap ribavirin tab SOVALDI TAB TYZEKA TAB HERPES AGENTS acyclovir cap acyclovir inj. acyclovir inj. acyclovir susp. acyclovir tab famciclovir tab valacyclovir tab INFLUENZA AGENTS RELENZA DISKHALER rimantadine tab 7 NM QL=60 Tabs/30 Days NM NM NM NM NM NM NM NM NM NM NM QL=30 Tabs/30 Days QL=56 Blisters/80 Days

39 TAMIFLU CAP 30MG TAMIFLU CAP 5MG, 75MG TAMIFLU SUSP. RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE INH. ASSORTED CLASSES CHELATING AGENTS CUPRIMINE CAP DEPEN TITRATABS SYPRINE CAP IMMUNOMODULATORS REVLIMID CAP REVLIMID CAP.5MG, 0MG THALOMID CAP IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL CAP ATGAM INJ AZASAN TAB azathioprine tab CELLCEPT IV INJ CELLCEPT SUSP. cyclosporine cap cyclosporine inj. cyclosporine modified cap CYCLOSPORINE MODIFIED CAP 50MG cyclosporine modified soln. gengraf cap gengraf soln. mycophenolate cap mycophenolate sodium tab mycophenolate tab NULOJIX INJ. PROGRAF INJ RAMUNE SOLN. RAMUNE TAB SANDIMMUNE SOLN. SIMULECT INJ sirolimus cap tacrolimus cap THYMOGLOBULIN INJ. ZORTRESS TAB IRRIGATION SOLUTIONS lactated ringers irrigation physiolyte irrigation soln. QL=8 Caps/80 Days QL=8 Caps/80 Days QL=6 Bottles/80 Days ST LD NM NSO QL=30 Caps/30 Days NM NSO QL=30 Caps/30 Days NM NSO NM NM NM NSO 8

40 physiosol irrigation soln. ringers irrigation sterile water irrigation LYMPHATIC AGENTS SYLVANT INJ. POTASSIUM REMOVING RESINS kionex powder sodium polystyrene sulfonate susp. BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol tab labetalol inj. labetalol tab BETA BLOCKERS CARDIO-SELECTIVE acebutolol cap atenolol tab betaxolol tab bisoprolol tab BYSTOLIC TAB metoprolol ER tab metoprolol inj. metoprolol tab BETA BLOCKERS NON-SELECTIVE INNOPRAN XL CAP nadolol tab pindolol tab propranolol ER cap propranolol inj. propranolol oral soln. propranolol tab sorine tab sotalol tab timolol maleate tab BIOLOGICALS MISC BIOLOGICALS MISC ADAGEN INJ. CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS afeditab CR tab amlodipine tab CARDENE INJ. cartia xt cap dilt-xr cap diltiazem CD cap 9 NM NM

41 diltiazem ER cap diltiazem inj diltiazem tab felodipine ER tab isradipine cap matzim la tab nicardipine cap nicardipine inj. nifedical XL tab nifedipine cap nifedipine ER tab nimodipine cap nisoldipine ER tab taztia-xt cap verapamil ER cap verapamil ER tab verapamil inj. verapamil tab CARDIOTONICS CARDIAC GLYCOSIDES digoxin inj. digoxin oral soln digoxin tab 0.5mg QL=30 Tabs/30 Days digoxin tab 0.5mg CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine/ atorvastatin tab BIDIL TAB PROSTAGLANDIN VASODILATORS REMODULIN INJ. NM TYVASO INH. NM VENTAVIS INH. NM PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB NM TRACLEER TAB LD NM PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB NM sildenafil tab CEPHALOSPORINS CEPHALOSPORINS - ST GENERATION cefadroxil cap cefadroxil susp. cefadroxil tab cefazolin inj. 30

42 CEFAZOLIN/ D5W INJ. cephalexin cap cephalexin susp cephalexin tab CEPHALOSPORINS - ND GENERATION cefaclor cap CEFOTETAN INJ. cefoxitin inj. CEFOXITIN/ DEXTROSE INJ. cefprozil susp. cefprozil tab cefuroxime inj. cefuroxime tab CEPHALOSPORINS - 3RD GENERATION CEDAX SUSP. cefdinir cap cefdinir susp. cefotaxime inj. cefpodoxime susp. cefpodoxime tab ceftazidime inj. CEFTAZIDIME/ DEXTROSE INJ. ceftriaxone inj. SUPRAX CAP CEPHALOSPORINS - TH GENERATION cefepime inj. CEPHALOSPORINS - 5TH GENERATION TEFLARO INJ. CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL amethia tab apri tab aranelle tab aviane tab balziva tab BEYAZ TAB briellyn tab cryselle-8 tab cyclafem tab emoquette tab enpresse-8 tab gildagia tab introvale tab junel fe tab 3

43 junel tab kariva tab kelnor tab larin fe tab larin tab leena tab lessina levonest tab levonorgestrel/ ethinyl estradiol tab levora-8 tab LO MINASTRIN FE TAB low-ogestrel tab lutera tab marlissa tab microgestin tab mononessa tab NATAZIA TAB necon tab nortrel tab orsythia tab ORTHO-TRI CYCLEN LO pimtrea tab pirmella tab portia-8 tab previfem tab QUARTETTE TAB quasense tab reclipsen tab sprintec-8 tab sronyx tab tri-legest fe tab tri-previfem tab tri-sprintec tab trinessa tab trivora-8 tab velivet tab vyfemla tab YASMIN TAB zenchent fe tab zenchent tab zovia tab COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane patch COMBINATION CONTRACEPTIVES - VAGINAL NUVARING 3

44 EMERGENCY CONTRACEPTIVES ELLA PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone inj. PROGESTIN CONTRACEPTIVES - ORAL camila tab errin tab jolivette tab lyza tab nora-be tab norethindrone tab CORTICOSTEROIDS GLUCOCORTICOSTEROIDS A-HYDROCORT INJ. budesonide EC cap CORTEF TAB cortisone tab dexamethasone conc. dexamethasone elixir dexamethasone inj. dexamethasone tab hydrocortisone tab MEDROL TAB MG methylprednisolone acetate inj. methylprednisolone dose pak methylprednisolone sodium succinate inj. methylprednisolone tab ORAPRED ODT prednisolone sodium phosphate soln. PREDNISONE INTENSOL prednisone soln. prednisone tab SOLU-CORTEF INJ. triamcinolone acetonide inj. UCERIS TAB MINERALOCORTICOIDS fludrocortisone tab COUGH/ COLD/ ALLERGY ANTITUSSIVES benzonatate cap 00mg, 00mg* dextromethorphan liquid 5mg/ 5ml* dextromethorphan syrup 0mg/ 5ml* dextromethorphan syrup 5mg/ 5ml* dextromethorphan syrup 7.5mg/ 5ml* 33 NM QL=30 Tabs/30 Days QL=90 Caps/30 Days

45 hydrocodone/ homatropine syrup 5-.5mg/ 5ml* ZONATUSS CAP 50MG* COUGH/ COLD/ ALLERGY COMBINATIONS brompheniramine/ pseudoephedrine elixir -5mg/ 5ml* chlorpheniramine DM liquid -5mg/ 5ml* chlorpheniramine/ pseudoephedrine tab -60mg* dextromethorphan/ guaifensen syrup 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 5-00mg/ 5ml* dextromethorphan/ guaifensin liquid 30-00mg/ 5ml* dextromethorphan/ guaifensin liquid 5-00mg/ 5ml* ED A-HIST LIQUID -0MG/ 5ML* guaifensin/ codeine soln 00-0mg/ 5ml* LOHIST-D LIQUID -30MG* loratadine-d tab 0-0mg* loratadine-d tab 5-0mg* phenylephrine chlorpheniramine soln 0--5mg/ 5ml* phenylephrine chlorpheniramine soln 0--5mg/ 5ml* phenylephrine DM/ guaifenesin liquid mg/ 5ml* phenylephrine/ guaifenesin liquid 5-00mg/ 5ml* promethazine DM syrup 6.5-5mg/ 5ml* promethazine/ codeine syrup 6.5-0mg/ 5ml* pseudoephedrine DM/ guaifenesin liquid mg/ 5ml* pseudoephedrine/ brompheniramine DM elixir 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM liquid 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM syrup 30--0mg/ 5ml* pseudoephedrine/ doxylamine/ DM/ acetaminophen liquid mg/ 30ml* pseudoephedrine/ guaifensen liquid mg/ ml* pseudoephedrine/ guaifensin syrup 30-00mg/ 5ml* triprolidine/ pseudoephedrine syrup.5-30mg/ 5ml* triprolidine/ pseudoephedrine tab.5-60mg* EXPECTORANTS guaifenesin liquid 00mg/ 5ml* guaifenesin liquid 00mg/ 5ml* guaifenesin tab 00mg* MUCOLYTICS acetylcysteine soln. DERMATOLOGICALS QL=90 Caps/30 Days QL=60 Tabs/30 Days QL=60 Tabs/30 Days 3

46 ACNE PRODUCTS adapalene cream adapalene gel amnesteem cap avita cream avita gel benzoyl peroxide gel 0%* BENZOYL PEROXIDE GEL.5%* benzoyl peroxide liquid 0%* benzoyl peroxide liquid 5%* BENZOYL PEROXIDE LOTION 0%* BENZOYL PEROXIDE LOTION 5%* claravis cap clindamycin foam clindamycin phosphate gel clindamycin phosphate lotion clindamycin phosphate soln. clindamycin phosphate swab clindamycin/ benzoyl peroxide gel DIFFERIN LOTION EPIDUO GEL ery pad erythromycin topical gel erythromycin topical soln. erythromycin/ benzoyl peroxide gel myorisan RETIN-A MICRO GEL sulfacetamide sodium lotion tretinoin cream tretinoin gel zenatane cap ANTIBIOTICS - TOPICAL bacitracin ointment 500unit/ gm* bacitracin zinc ointment 500unit/ gm* bacitracin/ polymyxin b oint.* gentamicin sulfate cream gentamicin sulfate oint. mupirocin cream mupirocin oint. ANTIFUNGALS - TOPICAL ciclopirox cream ciclopirox gel ciclopirox nail lacquer ciclopirox shampoo ciclopirox susp. 35

47 clotrimazole cream clotrimazole soln. clotrimazole/ betamethasone cream clotrimazole/ betamethasone lotion econazole nitrate cream ERTACZO CR ketoconazole cream ketoconazole shampoo ketoconazole shampoo %* miconazole cream %* miconazole powder %* NAFTIN CREAM NAFTIN GEL nyamyc powder nystatin cream nystatin oint. nystatin topical powder nystatin/ triamcinolone cream nystatin/ triamcinolone oint. nystop topical powder OXISTAT CREAM OXISTAT LOTION pedi-dri topical powder tolnaftate cream %* tolnaftate soln %* ANTIHISTAMINES-TOPICAL diphenhydramine cream %* diphenhydramine gel %* diphenhydramine soln. %* diphenhydramine/ zinc acetate cream -0.%* ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium topical soln. PENNSAID SOLN. VOLTAREN GEL QL=5 Tubes/ Days ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL CARAC CREAM diclofenac gel fluorouracil cream fluorouracil solution NRETIN GEL NM PICATO GEL 0.05% QL=3 Tubes/0 Days PICATO GEL 0.05% QL= Tubes/0 Days TARGRETIN GEL % NM ANTIPRURITICS - TOPICAL prudoxin cream 36

48 ANTIPSORIATICS 8-MOP CAP acitretin cap calcipotriene cream calcipotriene oint. calcipotriene soln. CALCITRIOL OINTMENT methoxsalen cap STELARA INJ. TAZORAC CREAM TAZORAC GEL VECTICAL OINT. ANTISEBORRHEIC PRODUCTS selenium sulfide shampoo ANTIVIRALS - TOPICAL DENAVIR CREAM ZOVIRAX OINT. BURN PRODUCTS mafenide topical solution silver sulfadiazine cream ssd cream SULFAMYLON CREAM CORTICOSTEROIDS - TOPICAL ala cort cream alclometasone cream alclometasone oint. amcinonide cream AMCINONIDE OINTMENT augmented betamethasone cream augmented betamethasone gel augmented betamethasone lotion augmented betamethasone oint betamethasone dipropionate cream betamethasone dipropionate gel betamethasone dipropionate lotion betamethasone valerate cream betamethasone valerate foam betamethasone valerate lotion betamethasone valerate oint calcipotriene/ betamethasone oint clobetasol e cream clobetasol gel clobetasol lotion clobetasol oint 37 NM

49 clobetasol shampoo clobetasol soln. clobetasol topical foam DESONATE GEL desonide cream desonide lotion desonide oint. desoximetasone cream DESOXIMETASONE CREAM 0.05% desoximetasone gel desoximetasone oint diflorasone cream diflorasone oint fluocinolone acetonide cream fluocinolone acetonide oil fluocinolone acetonide oint. fluocinolone acetonide soln. fluocinonide cream fluocinonide e cream fluocinonide gel fluocinonide oint fluocinonide soln. fluticasone propionate cream fluticasone propionate lotion fluticasone propionate oint. halobetasol cream halobetasol oint hydrocortisone acetate oint. %* hydrocortisone butyrate lipo cream hydrocortisone butyrate oint. hydrocortisone butyrate soln. hydrocortisone cream hydrocortisone cream 0.5%* hydrocortisone lotion hydrocortisone lotion %* hydrocortisone oint 0.5%* hydrocortisone oint. hydrocortisone soln %* hydrocortisone valerate cream hydrocortisone valerate oint hydrocortisone/ aloe cream %* lokara lotion mometasone furoate cream mometasone furoate lotion mometasone furoate oint. 38 QL= Tubes/30 Days QL= Tubes/30 Days QL= Tubes/30 Days

50 prednicarbate oint. prenicarbate cream TOPICORT CREAM triamcinolone cream triamcinolone lotion triamcinolone oint triderm cream u-cort cream EMOLLIENTS ammonium lactate cream ammonium lactate lotion ENZYMES - TOPICAL SANTYL OINT. IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream ZYCLARA CREAM IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL CREAM PROTOPIC OINT KERATOLYTIC/ ANTIMITOTIC AGENTS podofilox soln. salicylic acid soln 3%* LOCAL ANESTHETICS - TOPICAL lidocaine gel lidocaine oint. lidocaine patch lidocaine soln. lidocaine/ prilocaine cream MISC. TOPICAL aluminum acetate soln* CALAMINE LOTION* zinc oxide ointment 0%* ROSACEA AGENTS FINACEA GEL metronidazole cream metronidazole gel metronidazole lotion SCABICIDES & PEDICULICIDES EURAX CREAM lice treatment creme rinse* lice treatment shampoo* lindane lotion lindane shampoo malathion lotion 39 QL=90 Patches/30 Days

51 permethrin cream permethrin creme rinse %* SPINOSAD SUSP. WOUND CARE PRODUCTS REGRANEX GEL WOUND CLEANSER LIQUID* DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS DIASTIX* KETOCARE URINE TEST STRIP* DIGESTIVE AIDS DIGESTIVE ENZYMES CREON CAP NCREAZE CAP ULTRESA CAP DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide inj. acetazolamide SR cap acetazolamide tab methazolamide tab DIURETIC COMBINATIONS amiloride/ hctz tab spironolactone/ hctz tab triamterene/ hctz cap triamterene/ hctz tab LOOP DIURETICS bumetanide inj. bumetanide tab EDECRIN TAB furosemide inj furosemide soln. furosemide tab TORSEMIDE INJ. torsemide tab POTASSIUM SRING DIURETICS amiloride tab DYRENIUM CAP spironolactone tab THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide inj. chlorothiazide tab chlorthalidone tab QL= Tubes/5 Days QL= Bottles/30 Days ST ST 0

52 DIURIL SUSP. hydrochlorothiazide cap hydrochlorothiazide tab indapamide tab METHYCLOTHIAZIDE TAB metolazone tab ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS ACTONEL TAB ST alendronate soln. alendronate tab ALENDRONATE TAB 0MG calcitonin nasal spray etidronate disodium tab FORTEO INJ. NM FORTICAL NASAL SPRAY ibandronate inj. ST ibandronate tab ST QL= Tabs/30 Days MIACALCIN INJ. pamidronate inj pamidronate inj. PROLIA INJ. risedronate sodium tab ST XGEVA INJ. zoledronic acid inj. NM ZOMETA INJ. MG/ 00ML NM GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT INJ. NM GROWTH HORMONES NORDITROPIN INJ. NM HORMONE RECEPTOR MODULATORS raloxifene tab INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ. LD NM LHRH/ GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT-PED KIT NM SYNAREL NASAL SOLN. NM METABOLIC MODIFIERS ALDURAZYME INJ. NM calcitriol cap calcitriol inj. calcitriol soln. doxercalciferol cap doxercalciferol inj.

53 ELAPRASE INJ. FABRAZYME INJ. KUVAN TAB levocarnitine inj. levocarnitine soln. levocarnitine tab LUMIZYME INJ. MYOZYME INJ. NAGLAZYME INJ. ORFADIN CAP paricalcitol cap SENSIR TAB sodium phenylbutyrate powder ZEMPLAR INJ. POSTERIOR PITUITARY HORMONES desmopressin inj. desmopressin nasal spray desmopressin tab STIMATE NASAL SOLN. PROLACTIN INHIBITORS cabergoline tab SOMATOSTATIC AGENTS octreotide inj. SIGNIFOR INJ. SOMATULINE DEPOT INJ. ESTROGENS ESTROGEN COMBINATIONS ANGELIQ TAB COMBITCH estradiol/ norethindrone tab JINTELI TAB mimvey lo tab mimvey tab PREMPHASE TAB PREMPRO TAB ESTROGENS estradiol inj. estradiol patch estradiol tab estradiol valerate inj. estropipate tab PREMARIN TAB VIVELLE-DOT TCH FLUOROQUINOLONES NM NM NM NM NM NM NM NM QL=60 Vials/30 Days NM

54 FLUOROQUINOLONES AVELOX INJ. ciprofloxacin ER tab ciprofloxacin IV soln. ciprofloxacin oral susp. ciprofloxacin tab ciprofloxacin/ D5W inj. levofloxacin inj. levofloxacin soln. levofloxacin tab moxifloxacin tab ofloxacin tab GASTROINTESTINAL AGENTS - MISC. ANTIFLATULENTS simethicone cap 5mg* simethicone susp. 0mg/ 0.6ml* GALLSTONE SOLUBILIZING AGENTS CHENODAL TAB NM ursodiol cap ursodiol tab GASTROINTESTINAL ANTIALLERGY AGENTS cromoyln sodium oral solution GASTROINTESTINAL STIMULANTS metoclopramide inj. metoclopramide soln. metoclopramide tab INFLAMMATORY BOWEL AGENTS APRISO CAP ASACOL HD balsalazide cap CANASA SUPP. CIMZIA INJ. DELZICOL CAP LIALDA TAB mesalamine kit PENTASA CAP ST REMICADE INJ. NM sulfasalazine tab sulfazine EC tab INTESTINAL ACIDIFIERS enulose soln. generlac soln. IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS CAP QL=30 Caps/30 Days 3

55 LOTRONEX TAB PERIPHERAL OPIOID RECEPTOR ANTAGONISTS RELISTOR INJ. PHOSPHATE BINDER AGENTS calcium acetate cap FOSRENOL CHEW TAB PHOSLYRA SOLN. RENVELA CKET RENVELA TAB GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS potassium citrate CR tab UROCIT-K 5 TAB CYSTINOSIS AGENTS CYSTAGON CAP GENITOURINARY IRRIGANTS neomycin/ polymyxin B GU irrigation soln. sodium chloride irrigation soln. INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP PROSTATIC HYPERTROPHY AGENTS alfuzosin ER tab AVODART CAP finasteride tab JALYN CAP RAFLO CAP tamsulosin cap URINARY STONE AGENTS LITHOSTAT TAB THIOLA TAB GOUT AGENTS GOUT AGENT COMBINATIONS colchicine/ probenecid tab GOUT AGENTS allopurinol tab COLCRYS ULORIC TAB URICOSURICS probenecid tab HEMATOLOGICAL AGENTS - MISC. BRADYKININ B RECEPTOR ANTAGONISTS FIRAZYR INJ. COMPLEMENT INHIBITORS ST NM

56 CINRYZE INJ. HEMATORHEOLOGIC AGENTS pentoxifylline ER tab PLATELET AGGREGATION INHIBITORS AGGRENOX CAP anagrelide cap BRILINTA TAB cilostazol tab clopidogrel tab 75mg dipyridamole tab EFFIENT TAB ticlopidine tab HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CEREZYME INJ. ZAVESCA CAP AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP COBALAMINS cyanocobalamin inj.* FOLIC ACID/ FOLATES folic acid tab mg* HEMATOPOIETIC GROWTH FACTORS ARANESP INJ. LEUKINE INJ. NEULASTA INJ. NEUMEGA INJ. NEUPOGEN INJ. PROCRIT INJ. PROMACTA TAB IRON ferrous sulfate ec tab 35mg* ferrous sulfate elixir 0mg/ 5ml* ferrous sulfate soln. 75mg/ ml* FERROUS SULFATE SYRUP 300MG/ 5ML* ferrous sulfate tab 35mg* STEM CELL MOBILIZERS MOZOBIL INJ. HEMOSTATICS HEMOSTATICS - SYSTEMIC tranexamic acid inj. tranexamic acid tab HYPNOTICS NM NM NM NM ST NM NM NM NM NM NM QL=00 Tabs/00 Days QL=00 ml/00 Days QL=50 ml/50 Days QL=00 ml/00 Days QL=00 Tabs/00 Days NM 5

57 ANTIHISTAMINE HYPNOTICS diphenhydramine (sleep) cap 50mg* diphenhydramine (sleep) tab 50mg* BARBITURATE HYPNOTICS BUTISOL ELIXIR BUTISOL TAB phenobarbital elixir phenobarbital tab SECONAL CAP NON-BARBITURATE HYPNOTICS estazolam tab eszopiclone tab flurazepam cap temazepam cap triazolam tab zaleplon cap zolpidem tab LAXATIVES BULK LAXATIVES calcium polycarbophil tab 65mg* METAMUCIL SMOOTH POWDER CKET 8%* METAMUCIL WAFER* psyllium cap 0.5gm* psyllium powder 8.3%* psyllium powder 30.9%* psyllium powder 9%* psyllium powder 58.6%* PSYLLIUM POWDER CKET 00%* LAXATIVE COMBINATIONS gavilyte-c powder gavilyte-g soln gavilyte-n powder GOLYTELY CKET METAMUCIL PLUS CALCIUM CAP* peg 3350/ electrolyte soln. SUCLEAR SUPREP BOWEL PREP trilyte soln. LAXATIVES - MISCELLANEOUS constulose soln. glycerin suppository.gm* lactulose soln. polyethylene glycol powder 3350 sorbitol soln 70%* 6 NSO NSO NSO NSO NSO QL=30 Tabs/30 Days QL=90 Caps/365 Days QL=90 Tabs/365 Days

58 LUBRICANT LAXATIVES MINERAL OIL* SALINE LAXATIVES magnesium citrate soln.* magnesium hydroxide susp. 00mg/ 5ml* sodium phosphate enema* STIMULANT LAXATIVES bisacodyl DR tab 5mg* bisacodyl suppository 0mg* senna syrup 8.8mg/ 5ml* senna tab 8.6mg* SURFACTANT LAXATIVES COLACE CAP 50MG* docusate cap 00mg* docusate cap 50mg* docusate enema 83mg* docusate sodium liquid 50mg/ 5ml* docusate sodium syrup 60mg/ 5ml* docusate tab 00mg* LOCAL ANESTHETICS-RENTERAL LOCAL ANESTHETICS - AMIDES lidocaine inj. MACROLIDES AZITHROMYCIN azithromycin inj. azithromycin susp. azithromycin tab CLARITHROMYCIN clarithromycin ER tab clarithromycin susp. clarithromycin tab ERYTHROMYCINS E.E.S GRANULES e.e.s. ERY-TAB ERYPED SUSP. ERYTHROCIN LACTOBIONATE INJ. ERYTHROCIN STEARATE TAB erythromycin tab MEDICAL DEVICES BANDAGES-DRESSINGS-TAPE GAUZE D CONTRACEPTIVES 7

59 CONDOMS* MISC. DEVICES ALCOHOL SWAB RENTERAL THERAPY SUPPLIES B-D INSULIN SYRINGE NOVOFINE PEN NEEDLES PRECISION INSULIN SYRINGE RESPIRATORY THERAPY SUPPLIES SCER HOLDING CHAMBER* MIGRAINE PRODUCTS MIGRAINE COMBINATIONS CAFERGOT TAB MIGERGOT SUPP TREXIMET TAB MIGRAINE PRODUCTS dihydroergotamine inj. ERGOMAR TAB SEROTONIN AGONISTS IMITREX NASAL SPRAY naratriptan tab rizatriptan odt tab rizatriptan tab sumatriptan inj. SUMATRIPTAN NASAL SPRAY sumatriptan tab zolmitriptan odt tab zolmitriptan tab ZOMIG NASAL SPRAY MINERALS & ELECTROLYTES BICARBONATES sodium lactate inj. CALCIUM calcium carbonate susp. 50mg/ 5ml* calcium carbonate tab 50mg* calcium carbonate tab 600mg* calcium chew tab 500mg* calcium citrate+vit D tab 35mg-00unit* calcium citrate+vit D tab 35mg-50unit* CALCIUM GLUBIONATE SYRUP.8MG/ 5ML* CALCIUM GLUCONATE TAB 500MG* calcium+d tab 50-5mg* calcium+d tab mg* calcium+d tab mg* calcium+d tab unit* 8 QL= Fills/30 Days ST QL=8 Tabs/30 Days QL= Sprays/30 Days QL=8 Tabs/30 Days QL=36 Tabs/60 Days QL=36 Tabs/60 Days QL=0 Injections/30 Days QL= Sprays/30 Days QL=8 Tabs/30 Days QL=8 Tabs/30 Days QL=8 Tabs/30 Days QL= Sprays/30 Days

60 calcium/ cholecalciferol tab 50mg-5unit* calcium/ cholecalciferol tab 500mg-5unit* calcium/ cholecalciferol tab 500mg-00unit* CITRACAL/ VITAMIN D TAB 50MG-00UNIT* vitamin D with calcium tab* CHLORIDE AMMONIUM CHLORIDE INJ. ELECTROLYTE MIXTURES dextrose/ sodium chloride inj. electrolyte oral soln.* IONOSOL-B/ D5W INJ. IONOSOL-MB/ D5W INJ. ISOLYTE-S INJ. ISOLYTE/ D5W INJ. lactated ringers soln. lactated ringers/ d5w inj. normosol-m/ d5w inj. NORMOSOL-R INJ. NORMOSOL/ D5W INJ. PLASMA-LYTE INJ. PLASMA-LYTE/ D5W INJ. POTASSIUM CHLORIDE (0MEQ)/ D5W/ NACL INJ. potassium chloride/ d5w inj. POTASSIUM CHLORIDE/ D5W/ LACTATED RINGERS SOLN. potassium chloride/ d5w/ nacl inj. potassium chloride/ nacl inj. ringers solution tpn electrolytes soln. FLUORIDE sodium fluoride tab MAGNESIUM magnesium oxide tab 00mg* magnesium sulfate inj. POTASSIUM K-TAB ER TAB KLOR-CON M5 TAB klor-con tab potassium chloride ER cap potassium chloride ER tab potassium chloride inj. meq SODIUM sodium chloride inj. MOUTH/ THROAT/ DENTAL AGENTS 9

61 ANESTHETICS TOPICAL ORAL lidocaine viscous ANTI-INFECTIVES - THROAT clotrimazole troche nystatin susp. ANTISEPTICS - MOUTH/ THROAT chlorhexidine gluconate soln. periogard soln. STEROIDS - MOUTH/ THROAT triamcinolone in orabase paste THROAT PRODUCTS - MISC. cevimeline cap pilocarpine tab MULTIVITAMINS B-COMPLEX W/ C vitamin B complex w/ C cap* MULTIPLE VITAMINS W/ MINERALS multivitamin w/ minerals tab* QL=00 Tabs/00 Days multivitamins w/ minerals tab* QL=00 Tabs/00 Days MULTIVITAMINS multivitamin liquid* QL=00 ml/00 Days multivitamin tab* QL=00 Tabs/00 Days PED MV W/ IRON pediatric multivitamin w/ iron drops 0mg/ ml* QL=50 ml/50 Days PEDIATRIC MULTIPLE VITAMINS pediatric multivitamin soln 35mg/ ml* QL=50 ml/50 Days PEDIATRIC VITAMINS tri-vitamin pediatric drops* PRENATAL VITAMINS PRENATAL VITAMIN PRENATAL VITAMINS (OTC)* MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen tab carisoprodol tab chlorzoxazone tab cyclobenzaprine tab metaxalone tab methocarbamol tab orphenadrine citrate inj. orphenadrine ER tab tizanidine cap tizanidine tab 50

62 DIRECT MUSCLE RELAXANTS dantrolene cap MUSCLE RELAXANT COMBINATIONS carisoprodol/ aspirin tab carisoprodol/ aspirin/ codeine tab NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENTS - MISC. saline nasal spray 0.65%* NASAL ANTIALLERGY ASTEPRO NASAL SPRAY cromolyn nasal soln 5.mg* TANASE NASAL SOLN. NASAL ANTICHOLINERGICS ipratropium nasal spray NASAL STEROIDS flunisolide nasal spray QL= Bottles/5 Days fluticasone nasal spray QL= Bottles/5 Days NASONEX NASAL QL= Bottles/5 Days triamcinolone nasal spray QL= Bottles/5 Days VERAMYST NASAL QL= Bottles/5 Days SYMTHOMIMETIC DECONGESTANTS pseudoephedrine hr tab 0mg* pseudoephedrine liquid 5mg/ 5ml* pseudoephedrine tab 30mg* pseudoephedrine tab 60mg* NEUROMUSCULAR AGENTS ALS AGENTS riluzole tab NUTRIENTS CARBOHYDRATES dextrose inj. LIPIDS intralipid inj. MISC. NUTRITIONAL SUBSTANCES omega-3 fatty acid cap 000mg* QL=60 Caps/30 Days omega-3 fatty acid cap 00mg* QL=60 Caps/30 Days PROTEINS AMINO ACID ORAL LIQUID* 3 AMINO ACID POWDER* 3 AMINOSYN II INJ. AMINOSYN INJ. AMINOSYN-HBC INJ. AMINOSYN-PF INJ. 5

63 CLINIMIX E INJ. CLINIMIX INJ. clinisol sf inj. hepatasol inj. heptamine inj NEPHRAMINE INJ. PREMASOL SOLN 0% premasol soln. 6% PROCALAMINE INJ. PROSOL INJ. TRAVASOL INJ. TROPHAMINE INJ OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS artificial tears* LACRISERT BETA-BLOCKERS - OPHTHALMIC betaxolol ophth soln. BETIMOL SOLN BETOPTIC-S OPHTH SUSP. carteolol ophth soln. COMBIGAN OPHTH SOLN dorzolamide/ timolol ophth soln. ISTALOL OPHTH SOLN. levobunolol ophth soln. metipranolol ophth soln. timolol maleate ophth gel timolol maleate ophth soln. MIOTICS PHOSPHOLINE IODIDE OPHTH SOLN. pilocarpine ophth soln. OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P OPHTH SOLN. 0.% apraclonidine ophth soln. brimonidine ophth soln. IOPIDINE OPHTH SOLN. % OPHTHALMIC ANTI-INFECTIVES AZASITE OPHTH SOLN bacitracin ophth oint. bacitracin/ polymyxin B ophth oint. BESIVANCE OPHTH SUSP. ciprofloxacin ophth soln erythromycin ophth oint. gatifloxacin ophth soln. ST ST 5

64 gentak ophth oint gentamicin ophth oint. gentamicin ophth soln. levofloxacin ophth soln. MOXEZA OPHTH SOLN NATACYN OPHTH SUSP. neomycin/ bacitracin/ polymyxin ophth oint. neomycin/ polymyxin/ gramicidin ophth soln. ofloxacin ophth soln. polymyxin B/ trimethoprim ophth soln. sodium sulfacetamide ophth soln. sulfacetamide sodium ophth oint. tobramycin ophth soln. trifluridine ophth soln. VIGAMOX OPHTH SOLN. ZIRGAN OPHTH GEL OPHTHALMIC DECONGESTANTS CLEAR EYES OPHTH SOLN* NAPHAZOLINE OPHTH SOLN. naphazoline-glycerin ophth soln* naphazoline/ pheniramine ophth soln* OPHTHALMIC IMMUNOMODULATORS RESTASIS EMULSION OPHTHALMIC LOCAL ANESTHETICS proparacaine ophth soln OPHTHALMIC STEROIDS ALREX OPHTH SUSP. BLEPHAMIDE OPHTH SUSP. dexamethasone sodium phosphate ophth soln DUREZOL OPHTH EMULSION LOTEMAX OPHTH GEL LOTEMAX OPHTH OINTMENT LOTEMAX OPHTH SUSP. MAXIDEX OPHTH SUSP. neomycin/ polymyxin/ bacitracin/ hc ophth oint. neomycin/ polymyxin/ dexamethasone ophth oint. neomycin/ polymyxin/ dexamethasone ophth soln. neomycin/ polymyxin/ hc ophth susp. PRED MILD OPHTH SUSP. PRED-G OPHTH SUSP. PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN. prednisolone susp sulfacetamide sodium/ prednisolone ophth soln. tobramycin/ dexamethasone ophth soln. 53

65 TOBREX OPHTH OINT. VEXOL OPHTH SUSP. ZYLET OPHTH SOLN OPHTHALMICS - MISC. ALOCRIL OPHTH SOLN. ALOMIDE OPHTH SOLN. azelastine ophth soln. AZOPT OPHTH SUSP. bromfenac ophth soln cromolyn sodium ophth soln. diclofenac ophth soln. dorzolamide ophth soln. ENUCLENE OPHTH SOLN 0.5%* epinastine ophth soln flurbiprofen ophth soln. ILEVRO OPHTH SUSP. ketorolac ophth soln. NEVANAC OPHTH SUSP. TADAY OPHTH SOLN. sodium chloride hypertonic ophth oint. 5%* sodium chloride hypertonic ophth soln 5%* PROSTAGLANDINS - OPHTHALMIC latanoprost ophth soln. LUMIGAN OPHTH SOLN. TRAVATAN Z OPHTH SOLN TRAVOPROST OPHTH SOLN. OTIC AGENTS - MISCELLANEOUS acetic acid otic soln. OTIC ANTI-INFECTIVES ofloxacin otic soln. OTIC COMBINATIONS CIPRODEX OTIC SUSP. COLY-MYCIN S OTIC SOLN. CORTISPORIN-TC OTIC SOLN. neomycin/ polymyxin/ hc otic soln. neomycin/ polymyxin/ hc otic susp. OTIC STEROIDS fluocinolone acetonide otic oil hydrocortisone/ acetic acid otic soln. OXYTOCICS methylergonovine tab OTIC AGENTS OXYTOCICS SSIVE IMMUNIZING AGENTS 5 QL=5 ml/30 Days QL=5 ml/30 Days QL=5 ml/30 Days QL=5 ml/30 Days

66 IMMUNE SERUMS BIVIGAM INJ. GAMASTAN S/ D GAMMAGARD INJ. GAMMAPLEX INJ. GAMUNEX-C PRIVIGEN INJ. MONOCLONAL ANTIBODIES SYNAGIS INJ. PENICILLINS AMINOPENICILLINS amoxicillin cap amoxicillin chew tab AMOXICILLIN CHEW TAB 50MG amoxicillin susp. amoxicillin tab ampicillin cap ampicillin inj. AMPICILLIN INJ. 5MG ampicillin susp. NATURAL PENICILLINS BICILLIN L-A INJ. penicillin g potassium inj. PENICILLIN G PROCAINE INJ. PENICILLIN G SODIUM INJ. PENICILLIN G/ DEXTROSE INJ. penicillin v potassium soln. penicillin v potassium tab PENICILLIN COMBINATIONS amoxicillin/ clavulanate chew tab amoxicillin/ clavulanate ER tab amoxicillin/ clavulanate susp. amoxicillin/ clavulanate tab ampicillin/ sulbactam inj. AUGMENTIN SUSP 5MG BICILLIN C-R INJ. piperacillin/ tazobactam inj. TIMENTIN INJ. 3.GM ZOSYN INJ. PENICILLINASE-RESISTANT PENICILLINS dicloxacillin cap nafcillin inj. NAFCILLIN/ DEXTROSE INJ. oxacillin inj. 55 NM NM NM NM

67 OXACILLIN/ DEXTROSE INJ. PROGESTINS PROGESTINS medroxyprogesterone tab norethindrone tab progesterone cap PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate tab disulfiram tab ANTI-CATAPLECTIC AGENTS XYREM ORAL SOLN. NM ANTIDEMENTIA AGENTS donepezil odt tab QL=30 Tabs/30 Days donepezil tab QL=60 Tabs/30 Days donepezil tab 3mg ST QL=30 Tabs/30 Days EXELON TCH galantamine ER cap galantamine soln. galantamine tab NAMENDA SOLN. NAMENDA XR QL=30 Caps/30 Days rivastigmine tab COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide / amitriptyline tab NSO olanzapine/ fluoxetine cap perphenazine/ amitriptyline tab NSO FIBROMYALGIA AGENTS SAVELLA TAB QL=60 Tabs/30 Days SAVELLA TITRATION CK MOVEMENT DISORDER DRUG THERAPY XENAZINE TAB NM MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB NM QL=30 Tabs/30 Days AVONEX INJ. NM QL= Injections/8 Days COXONE INJ. NM QL=30 Injections/30 Days EXTAVIA INJ. NM ST QL=5 Injections/30 Days GILENYA CAP NM QL=30 Caps/30 Days REBIF INJ. NM QL= Injections/8 Days REBIF TITRATION CK NM QL= Injections/8 Days TECFIDERA CAP NM TECFIDERA STARTER CK NM TYSABRI INJ. NM 56

68 PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ERGOLOID MESYLATE TAB ORAP TAB SMOKING DETERRENTS buproban tab CHANTIX K CHANTIX TAB nicotine gum mg* nicotine gum mg* nicotine patch mg* nicotine patch mg* nicotine patch 7mg* NICOTROL INHALER NICOTROL NASAL SPRAY RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST NP INJ. GLASSIA INJ. ZEMAIRA INJ. CYSTIC FIBROSIS AGENTS KALYDECO TAB PULMOZYME SOLN. SULFONAMIDES SULFONAMIDES SULFADIAZINE TAB TETRACYCLINES TETRACYCLINES demeclocycline tab doxycycline cap 75mg doxycycline hyclate cap 50mg, 00mg doxycycline hyclate dr tab doxycycline hyclate inj. doxycycline hyclate tab 0mg, 00mg doxycycline monohydrate tab 50mg, 75mg, 50mg doxycycline susp. minocycline cap minocycline ER tab minocycline tab tetracycline cap THYROID AGENTS ANTITHYROID AGENTS QL=60 Caps/30 Days QL=360 Blisters/30 Days QL=360 Blisters/30 Days QL=56 Patches/8 Days QL=56 Patches/8 Days QL=56 Patches/8 Days NM NM NM NM NM 57

69 methimazole tab propylthiouracil tab THYROID HORMONES levothyroxine tab levoxyl tab liothyronine inj. liothyronine tab SYNTHROID TAB THYROLAR TAB unithroid tab TOXOID COMBINATIONS ADACEL INJ. BOOSTRIX INJ. DAPTACEL INJ. DIPHTHERIA/ TETANUS VACCINE INFANRIX INJ. TETANUS/ DIPHTHERIA TOXOID INJ. TOXOIDS TETANUS TOXOID ADSORBED ANTISSMODICS atropine inj. dicyclomine cap DICYCLOMINE SOLN. dicyclomine tab glycopyrrolate inj. glycopyrrolate tab methscopolamine tab PRONTHELINE TAB H- ANTAGONISTS cimetidine oral soln. cimetidine tab famotidine inj. famotidine susp. famotidine tab famotidine tab 0mg* FAMOTIDINE/ NACL INJ. nizatidine cap nizatidine soln. ranitidine cap ranitidine inj. ranitidine syrup ranitidine tab TOXOIDS ULCER DRUGS 58

70 MISC. ANTI-ULCER sucralfate tab PROTON PUMP INHIBITORS esomeprazole inj. lansoprazole cap ST omeprazole cap OMEPRAZOLE TAB 0MG* pantoprazole inj. pantoprazole tab PREVACID SOLUTAB rabeprazole tab ULCER DRUGS - PROSTAGLANDINS misoprostol tab ULCER THERAPY COMBINATIONS lansoprazole/ amoxicillin/ clarithromycin tab PYLERA CAP URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES MACRODANTIN CAP QL=80 Caps/365 Days methenamine hippurate tab nitrofurantoin macro cap QL=80 Caps/365 Days nitrofurantoin mono cap QL=80 Caps/365 Days nitrofurantoin susp. URINARY ANTISSMODICS URINARY ANTISSMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) oxybutynin ER tab oxybutynin syrup oxybutynin tab tolterodine tartrate er cap trospium chloride er cap URINARY ANTISSMODICS bethanechol tab flavoxate tab tolterodine tab TOVIAZ TAB trospium tab VESICARE TAB VACCINES BACTERIAL VACCINES ACTHIB INJ. BCG VACCINE INJ. MENACTRA MENOMUNE A-C-Y-W INJ. 59

71 MENVEO INJ. PEDVAX HIB INJ. TYPHIM VI INJ. MIXED VACCINE COMBINATIONS COMVAX INJ. VIRAL VACCINES CERVARIX INJ. ENGERIX-B INJ. GARDASIL INJ. HAVRIX INJ. IMOVAX RABIES (H.D.C.V.) IPOL INJ IXIARO INJ. M-M-R II WITH DILUENT PROQUAD INJ. RABAVERT INJ. RECOMBIVAX-HB INJ. ROTARIX SUSP. ROTATEQ ORAL SUSP. TWINRIX INJ. VAQTA INJ. VARIVAX INJ. YF-VAX INJ. ZOSTAVAX INJ. VAGINAL PRODUCTS SPERMICIDES NONOXYNOL-9 FOAM.5%* nonoxynol-9 gel 3%* VAGINAL ANTI-INFECTIVES clindamycin vaginal cream clotrimazole vaginal cream %* clotrimazole vaginal cream %* metronidazole vaginal gel miconazole cream kit* miconazole nitrate vaginal suppository 00mg* miconazole vaginal cream %* miconazole vaginal cream %* miconazole vaginal kit* terconazole vaginal cream terconazole vaginal suppository tioconazole vaginal oint. 6.5%* vandazole vaginal gel zazole vaginal cream VAGINAL ESTROGENS 60

72 ESTRACE VAGINAL CREAM ESTRING PREMARIN VAGINAL CREAM VAGINAL PROGESTINS CRINONE GEL ENDOMETRIN SUPP. ANAPHYLAXIS THERAPY AGENTS EPIPEN INJ. EPIPEN JR INJ. VASOPRESSORS midodrine tab OIL SOLUBLE VITAMINS cholecalciferol cap 000unit* cholecalciferol cap 5000unit* cholecalciferol tab 000unit* cholecalciferol tab 00unit* ergocalciferol cap 50000unit* ergocalciferol soln 8000unit/ ml* phytonadione tab 00mcg* WATER SOLUBLE VITAMINS niacin CR cap 50mg* niacin CR cap 500mg* NIACIN CR TAB 000MG* niacin CR tab 500mg* niacin CR tab 750mg* niacin tab 00mg* niacin tab 50mg* niacin tab 500mg* niacin tab 50mg* pyridoxine tab 00mg* pyridoxine tab 5mg* pyridoxine tab 50mg* thiamine tab 00mg* VASOPRESSORS VITAMINS 3 QL= Injections/5 Days QL= Injections/5 Days 6

73 ALPHABETICAL LISTING OF DRUGS Other 8-MOP CAP 37 A abacavir tab 6 abacavir/ lamivudine/ 6 zidovudine tab ABELCET INJ. ABILIFY DISC TAB 5 ABILIFY INJ. 5 ABILIFY 5 MAINTENANCE INJ. ABILIFY SOLN. 5 ABILIFY TAB 5 ABRAXANE SUSP 3 acamprosate tab 56 acarbose tab acebutolol cap 9 acetaminophen cap 3 500mg* acetaminophen chew tab 3 60mg* acetaminophen CR tab 3 650mg* acetaminophen elixir 3 60mg/ 5ml* acetaminophen liquid 3 60mg/ 5ml* ACETAMINOPHEN 3 LIQUID 500MG/ 5ML* acetaminophen soln. 3 60mg/ 5ml* acetaminophen suppository 3 0mg* acetaminophen suppository 3 35mg* acetaminophen suppository 3 650mg* acetaminophen suppository 3 80mg* acetaminophen susp. 3 60mg/ 5ml* acetaminophen susp. 80mg/ 3 0.8ml* acetaminophen tab 35mg* 3 acetaminophen tab 500mg* 3 acetaminophen/ codeine soln. acetaminophen/ codeine tab acetazolamide inj. 0 acetazolamide SR cap 0 acetazolamide tab 0 acetic acid otic soln. 5 acetylcysteine soln. 3 acitretin cap 37 ACTHIB INJ. 59 ACTIMMUNE INJ. ACTONEL TAB acyclovir cap 7 acyclovir inj. 7 acyclovir inj. 7 acyclovir susp. 7 acyclovir tab 7 ADACEL INJ. 58 ADAGEN INJ. 9 adapalene cream 35 adapalene gel 35 ADCIRCA TAB 30 ADDERALL XR CAP adefovir tab 7 ADVAIR DISKUS 8 ADVAIR HFA INHALER 8 afeditab CR tab 9 AFINITOR DISPERZ AFINITOR TAB AGGRENOX CAP 5 A-HYDROCORT INJ. 33 ala cort cream 37 ALBENZA TAB 6 albuterol neb 8 albuterol sulfate ER tab 8 albuterol syrup 8 albuterol tab 8 alclometasone cream 37 alclometasone oint. 37 ALCOHOL SWAB 8 ALDURAZYME INJ. alendronate soln. alendronate tab ALENDRONATE TAB 0MG alfuzosin ER tab 6 ALIMTA INJ. 0 ALINIA SUSP. 8 ALINIA TAB 8 ALLEGRA TAB 30MG* 5 allopurinol tab ALOCRIL OPHTH SOLN. 5 ALOMIDE OPHTH 5 SOLN. ALPHAGAN P OPHTH 5 SOLN. 0.% alprazolam ER tab 6 alprazolam odt tab 6 alprazolam tab 6 ALREX OPHTH SUSP. 53 aluminum acetate soln* 39 ALUMINUM 5 HYDROXIDE GEL SUSP. 30MG/ 5ML* aluminum hydroxide gel 5 susp. 600mg/ 5ml* aluminum hydroxide/ 5 magnesium carbonate chew tab* aluminum/ mag hydroxide/ 5 simethicone susp mg/ 5ml* amantadine cap amantadine syrup AMBISOME INJ. amcinonide cream 37 AMCINONIDE 37 OINTMENT amethia tab 3 amifostine inj. 3 amikacin inj. amiloride tab 0 amiloride/ hctz tab 0 AMINO ACID ORAL 5 LIQUID* AMINO ACID POWDER* 5 aminophylline inj. 8 AMINOSYN II INJ. 5 AMINOSYN INJ. 5 AMINOSYN-HBC INJ. 5 AMINOSYN-PF INJ. 5 amiodarone inj 7 amiodarone tab 7

74 ALPHABETICAL LISTING OF DRUGS amitriptyline tab amlodipine tab 9 amlodipine/ atorvastatin 30 tab amlodipine/ benazepril cap 7 AMMONIUM 9 CHLORIDE INJ. ammonium lactate cream 39 ammonium lactate lotion 39 amnesteem cap 35 amoxapine tab amoxicillin cap 55 amoxicillin chew tab 55 AMOXICILLIN CHEW 55 TAB 50MG amoxicillin susp. 55 amoxicillin tab 55 amoxicillin/ clavulanate 55 chew tab amoxicillin/ clavulanate 55 ER tab amoxicillin/ clavulanate 55 susp. amoxicillin/ clavulanate 55 tab amphetamine/ dextroamphetamine tab AMPHOTERICIN B INJ. ampicillin cap 55 ampicillin inj. 55 AMPICILLIN INJ. 5MG 55 ampicillin susp. 55 ampicillin/ sulbactam inj. 55 ANADROL-50 TAB 5 anagrelide cap 5 anastrozole tab ANDRODERM TCH 5 MG/ HR ANDRODERM TCH 5 MG/ HR ANDROGEL GEL % 5 (50MG) ANDROGEL PUMP 5 ANDROXY TAB 5 ANGELIQ TAB antacid susp.* 5 APLENZIN TAB 0 APOKYN INJ. apraclonidine ophth soln. 5 apri tab 3 APRISO CAP 3 APTIOM TAB 9 APTIVUS CAP 6 APTIVUS SOLN. 6 ARALAST NP INJ. 57 aranelle tab 3 ARANESP INJ. 5 ARCALYST INJ. argatroban inj. 00mg/ ml 8 ARGATROBAN INJ. 8 5MG/ 5ML ARRANON INJ 0 artificial tears* 5 ARZERRA INJ. ASACOL HD 3 ASCRIPTIN TAB 3 35MG* ASMANEX INHALER 7 aspirin 8mg tab* 3 aspirin DR tab 35mg* 3 aspirin DR tab 8mg* 3 aspirin tab 35mg* 3 aspirin tab 500mg* 3 aspirin/ acetaminophen/ 3 caffeine tab mg* ASTAGRAF XL CAP 8 ASTEPRO NASAL 5 SPRAY atenolol tab 9 atenolol/ chlorthalidone 7 tab ATGAM INJ 8 atorvastatin tab 6 atovaquone susp 8 atovaquone/ proguanil tab 9 ATRIPLA TAB 6 atropine inj. 58 ATROVENT HFA 7 INHALER AUBAGIO TAB 56 augmented betamethasone 37 cream augmented betamethasone 37 gel 63 augmented betamethasone 37 lotion augmented betamethasone 37 oint AUGMENTIN SUSP 55 5MG AVANDAMET TAB AVANDARYL TAB AVANDIA TAB 3 AVASTIN INJ AVELOX INJ. 3 aviane tab 3 avita cream 35 avita gel 35 AVODART CAP AVONEX INJ. 56 azacitidine inj. 0 AZACTAM/ DEXTROSE 8 INJ. AZASAN TAB 8 AZASITE OPHTH SOLN 5 azathioprine tab 8 azelastine ophth soln. 5 AZILECT TAB azithromycin inj. 7 azithromycin susp. 7 azithromycin tab 7 AZOPT OPHTH SUSP. 5 aztreonam inj. 8 B baciim inj 8 bacitracin ointment unit/ gm* bacitracin ophth oint. 5 bacitracin zinc ointment unit/ gm* bacitracin/ polymyxin b 35 oint.* bacitracin/ polymyxin B 5 ophth oint. baclofen tab 50 balsalazide cap 3 balziva tab 3 BANZEL SUSP. 9 BANZEL TAB 9 BARACLUDE SOLN. 7 BARACLUDE TAB 7

75 ALPHABETICAL LISTING OF DRUGS BCG VACCINE INJ. 59 B-D INSULIN SYRINGE 8 BENADRYL CHEW TAB 5.5MG* benazepril tab 6 benazepril/ hctz tab 7 benzonatate cap 00mg, 33 00mg* benzoyl peroxide gel 0%* 35 BENZOYL PEROXIDE 35 GEL.5%* benzoyl peroxide liquid 35 0%* benzoyl peroxide liquid 5% 35 * BENZOYL PEROXIDE 35 LOTION 0%* BENZOYL PEROXIDE 35 LOTION 5%* benztropine inj. 3 benztropine tab 3 BESIVANCE OPHTH 5 SUSP. betamethasone 37 dipropionate cream betamethasone 37 dipropionate gel betamethasone 37 dipropionate lotion betamethasone valerate 37 cream betamethasone valerate 37 foam betamethasone valerate 37 lotion betamethasone valerate 37 oint betaxolol ophth soln. 5 betaxolol tab 9 bethanechol tab 59 BETIMOL SOLN 5 BETOPTIC-S OPHTH 5 SUSP. BEYAZ TAB 3 bicalutamide tab BICILLIN C-R INJ. 55 BICILLIN L-A INJ. 55 BICNU INJ. 0 BIDIL TAB 30 bisacodyl DR tab 5mg* 7 bisacodyl suppository 7 0mg* bismuth subsalicylate chew 3 tab 6mg* bismuth subsalicylate susp 3 6mg/ 5ml* bismuth subsalicylate susp 3 55mg/ 5ml* bismuth subsalicylate tab 3 6mg* bisoprolol tab 9 bisoprolol/ hctz tab 7 BIVIGAM INJ. 55 bleomycin sulfate inj. BLEPHAMIDE OPHTH 53 SUSP. BONINE CHEW TAB 5MG* BOOSTRIX INJ. 58 BOSULIF TAB briellyn tab 3 BRILINTA TAB 5 brimonidine ophth soln. 5 BRINTELLIX TAB 0 bromfenac ophth soln 5 bromocriptine cap bromocriptine tab brompheniramine/ 3 pseudoephedrine elixir -5mg/ 5ml* budesonide EC cap 33 budesonide neb 7 bumetanide inj. 0 bumetanide tab 0 buprenorphine inj. buprenorphine sl tab buproban tab 57 bupropion SR tab 0 bupropion tab 0 bupropion XL tab 0 buspirone tab 6 BUSULFEX INJ. 0 BUTISOL ELIXIR 6 BUTISOL TAB 6 butorphanol inj butorphanol soln. 5 6 BUTRANS TCH 5 BYDUREON INJ. BYSTOLIC TAB 9 C cabergoline tab CAFERGOT TAB 8 CALAMINE LOTION* 39 calcipotriene cream 37 calcipotriene oint. 37 calcipotriene soln. 37 calcipotriene/ 37 betamethasone oint calcitonin nasal spray calcitriol cap calcitriol inj. CALCITRIOL 37 OINTMENT calcitriol soln. calcium acetate cap calcium carbonate chew 5 tab 000mg* calcium carbonate chew 5 tab 0mg* calcium carbonate chew 6 tab 500mg* calcium carbonate chew 6 tab 750mg* calcium carbonate susp. 8 50mg/ 5ml* calcium carbonate tab 8 50mg* calcium carbonate tab 8 600mg* calcium carbonate tab 6 68mg* calcium chew tab 500mg* 8 calcium citrate+vit D tab 8 35mg-00unit* calcium citrate+vit D tab 8 35mg-50unit* CALCIUM 8 GLUBIONATE SYRUP.8MG/ 5ML* CALCIUM GLUCONATE 8 TAB 500MG* calcium polycarbophil tab 6 65mg*

76 ALPHABETICAL LISTING OF DRUGS calcium/ cholecalciferol 9 tab 50mg-5unit* calcium/ cholecalciferol 9 tab 500mg-5unit* calcium/ cholecalciferol 9 tab 500mg-00unit* calcium+d tab mg* calcium+d tab mg* calcium+d tab mg* calcium+d tab unit* camila tab 33 CANASA SUPP. 3 CANCIDAS INJ. candesartan tab 7 candesartan/ hctz tab 7 CASTAT INJ. 9 CAPRELSA TAB captopril tab 7 captopril/ hctz tab 7 CARAC CREAM 36 carbamazepine chew tab 9 carbamazepine ER cap 9 carbamazepine ER tab 9 carbamazepine susp. 9 carbamazepine tab 9 carbidopa tab 3 CARBIDO/ ENTACAPONE/ LEVODO TAB carbidopa/ levodopa ER tab carbidopa/ levodopa ODT tab carbidopa/ levodopa tab carbinoxamine soln. 5 carbinoxamine tab 5 carboplatin inj. 0 CARDENE INJ. 9 carisoprodol tab 50 carisoprodol/ aspirin tab 5 carisoprodol/ aspirin/ 5 codeine tab carteolol ophth soln. 5 cartia xt cap 9 carvedilol tab 9 CEDAX SUSP. 3 cefaclor cap 3 cefadroxil cap 30 cefadroxil susp. 30 cefadroxil tab 30 cefazolin inj. 30 CEFAZOLIN/ D5W INJ. 3 cefdinir cap 3 cefdinir susp. 3 cefepime inj. 3 cefotaxime inj. 3 CEFOTETAN INJ. 3 cefoxitin inj. 3 CEFOXITIN/ DEXTROSE 3 INJ. cefpodoxime susp. 3 cefpodoxime tab 3 cefprozil susp. 3 cefprozil tab 3 ceftazidime inj. 3 CEFTAZIDIME/ 3 DEXTROSE INJ. ceftriaxone inj. 3 cefuroxime inj. 3 cefuroxime tab 3 CELEBREX CAP CELLCEPT IV INJ 8 CELLCEPT SUSP. 8 CELONTIN CAP 0 cephalexin cap 3 cephalexin susp 3 cephalexin tab 3 CEREZYME INJ. 5 CERVARIX INJ. 60 CESAMET CAP cetirizine chew tab 0mg* 5 cetirizine chew tab 5mg* 5 cetirizine oral soln (Rx 5 only) cetirizine soln mg/ ml* 5 cetirizine tab 0mg* 5 cetirizine tab 5mg* 5 cevimeline cap 50 CHANTIX K 57 CHANTIX TAB 57 CHEMET CAP 3 CHENODAL TAB 3 65 CHLORAMPHENICAL 8 INJ. chlordiazepoxide / 56 amitriptyline tab chlordiazepoxide cap 6 CHLORHEXIDINE 5 GLUCONATE LIQUID %* chlorhexidine gluconate 5 liquid %* CHLORHEXIDINE 5 GLUCONATE DS %* chlorhexidine gluconate 50 soln. chlorhexidine gluconate 5 soln. 0%* chloroquine tab 9 chlorothiazide inj. 0 chlorothiazide tab 0 chlorpheniramine DM 3 liquid -5mg/ 5ml* chlorpheniramine syrup 5 mg/ 5ml* chlorpheniramine tab 5 mg* chlorpheniramine/ 3 pseudoephedrine tab -60mg* chlorpromazine inj. 5 chlorpromazine tab 5 chlorpropamide tab 3 chlorthalidone tab 0 chlorzoxazone tab 50 cholecalciferol cap 6 000unit* cholecalciferol cap unit* cholecalciferol tab 6 000unit* cholecalciferol tab 6 00unit* cholestyramine light 6 powder cholestyramine lite powder 6 packet ciclopirox cream 35 ciclopirox gel 35 ciclopirox nail lacquer 35

77 ALPHABETICAL LISTING OF DRUGS ciclopirox shampoo 35 ciclopirox susp. 35 cidofovir inj. 7 cilostazol tab 5 cimetidine oral soln. 58 cimetidine tab 58 CIMZIA INJ. 3 CINRYZE INJ. 5 CIPRODEX OTIC SUSP. 5 ciprofloxacin ER tab 3 ciprofloxacin IV soln. 3 ciprofloxacin ophth soln 5 ciprofloxacin oral susp. 3 ciprofloxacin tab 3 ciprofloxacin/ D5W inj. 3 cisplatin inj 0 citalopram soln. citalopram tab CITRACAL/ VITAMIN D 9 TAB 50MG-00UNIT* cladribine inj. 0 claravis cap 35 clarithromycin ER tab 7 clarithromycin susp. 7 clarithromycin tab 7 CLEAR EYES OPHTH 53 SOLN* CLEMASTINE SYRUP 5 clemastine tab 5 clemastine tab.3mg* 5 clindamycin cap 9 clindamycin foam 35 clindamycin inj 9 clindamycin phosphate gel 35 clindamycin phosphate 35 lotion clindamycin phosphate 35 soln. clindamycin phosphate 35 swab clindamycin soln. 9 clindamycin vaginal cream 60 clindamycin/ benzoyl 35 peroxide gel CLINIMIX E INJ. 5 CLINIMIX INJ. 5 clinisol sf inj. 5 clobetasol e cream 37 clobetasol gel 37 clobetasol lotion 37 clobetasol oint 37 clobetasol shampoo 38 clobetasol soln. 38 clobetasol topical foam 38 CLOLAR INJ. 0 clomipramine cap clonazepam odt tab 9 clonazepam tab 9 clonidine patch 7 clonidine tab 7 clopidogrel tab 75mg 5 clorazepate tab 6 clotrimazole cream 36 clotrimazole soln. 36 clotrimazole troche 50 clotrimazole vaginal cream 60 %* clotrimazole vaginal cream 60 %* clotrimazole/ 36 betamethasone cream clotrimazole/ 36 betamethasone lotion clozapine tab 5 COARTEM TAB 9 codeine sulfate tab 3 COLACE CAP 50MG* 7 colchicine/ probenecid tab COLCRYS colestipol granule 6 colestipol tab 6 colistimethate inj. 8 colocort enema 5 COLY-MYCIN S OTIC 5 SOLN. COMBIGAN OPHTH 5 SOLN COMBITCH COMBIVENT 8 RESPIMAT COMETRIQ CK COMPLERA TAB 6 compro suppository 5 COMVAX INJ. 60 CONDOMS* 8 constulose soln COXONE INJ. 56 CORTEF TAB 33 cortisone tab 33 CORTISPORIN-TC OTIC 5 SOLN. COSMEGEN INJ. 0.5MG COUMADIN INJ. 8 CREON CAP 0 CRESTOR TAB 6 CRESTOR TAB 0MG 6 CRINONE GEL 6 CRIXIVAN CAP 6 cromolyn nasal soln 5 5.mg* cromolyn neb 7 cromolyn sodium ophth 5 soln. cromoyln sodium oral 3 solution cryselle-8 tab 3 CUBICIN INJ. 9 CUPRIMINE CAP 8 cyanocobalamin inj.* 5 cyclafem tab 3 cyclobenzaprine tab 50 CYCLOPHOSPHAMIDE 0 CAP cyclophosphamide tab 0 cyclosporine cap 8 cyclosporine inj. 8 cyclosporine modified cap 8 CYCLOSPORINE 8 MODIFIED CAP 50MG cyclosporine modified soln. 8 cyproheptadine syrup 6 cyproheptadine tab 6 CYSTAGON CAP cytarabine inj. 0 D dacarbazine inj. DALIRESP TAB 7 danazol cap 5 dantrolene cap 5 dapsone tab 9 DAPTACEL INJ. 58 DARAPRIM TAB 9 daunorubicin inj

78 ALPHABETICAL LISTING OF DRUGS decitabine inj. 0 DELZICOL CAP 3 demeclocycline tab 57 DEMSER CAP 7 DENAVIR CREAM 37 DEPEN TITRATABS 8 desipramine tab desloratadine ODT tab 5 desloratatine tab 5 desmopressin inj. desmopressin nasal spray desmopressin tab DESONATE GEL 38 desonide cream 38 desonide lotion 38 desonide oint. 38 desoximetasone cream 38 DESOXIMETASONE 38 CREAM 0.05% desoximetasone gel 38 desoximetasone oint 38 DESVENLAFAXINE ER TAB dexamethasone conc. 33 dexamethasone elixir 33 dexamethasone inj. 33 dexamethasone sodium 53 phosphate ophth soln dexamethasone tab 33 dexmethylphenidate ER cap dexmethylphenidate tab dexrazoxane inj. 3 dextroamphetamine ER cap dextroamphetamine tab dextromethorphan liquid 33 5mg/ 5ml* dextromethorphan syrup 33 0mg/ 5ml* dextromethorphan syrup 33 5mg/ 5ml* dextromethorphan syrup mg/ 5ml* dextromethorphan/ 3 guaifensen syrup 0-00mg/ 5ml* dextromethorphan/ 3 guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ 3 guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ 3 guaifensin liquid 5-00mg/ 5ml* dextromethorphan/ 3 guaifensin liquid 30-00mg/ 5ml* dextromethorphan/ 3 guaifensin liquid 5-00mg/ 5ml* dextrose inj. 5 dextrose/ sodium chloride 9 inj. DIASTAT RECTAL GEL 9 DIASTIX* 0 DIAZEM INTENSOL 6 DIAZEM RECTAL 9 GEL DIAZEM SOLN. 6 diazepam tab 6 DIBENZYLINE CAP 7 diclofenac ec tab diclofenac gel 36 diclofenac ophth soln. 5 diclofenac potassium tab diclofenac sodium topical 36 soln. diclofenac XR tab diclofenac/ misoprostol tab dicloxacillin cap 55 dicyclomine cap 58 DICYCLOMINE SOLN. 58 dicyclomine tab 58 didanosine cap 6 DIFFERIN LOTION 35 diflorasone cream 38 diflorasone oint 38 diflunisal tab 3 digoxin inj. 30 digoxin oral soln 30 digoxin tab 0.5mg 30 digoxin tab 0.5mg 30 dihydroergotamine inj DILANTIN CAP 0 diltiazem CD cap 9 diltiazem ER cap 30 diltiazem inj 30 diltiazem tab 30 dilt-xr cap 9 dimenhydrinate tab 50mg* DIOVAN TAB 7 diphenhydramine (sleep) 6 cap 50mg* diphenhydramine (sleep) 6 tab 50mg* diphenhydramine cap 5 5mg* diphenhydramine cap 5 50mg* diphenhydramine cream 36 %* diphenhydramine elixir 5.5mg/ 5ml* diphenhydramine gel %* 36 diphenhydramine inj. 5 diphenhydramine liquid 5.5mg/ 5ml* diphenhydramine oral soln 5 (Rx only) diphenhydramine soln. % 36 * diphenhydramine tab 5 5mg* diphenhydramine/ zinc 36 acetate cream -0.%* diphenoxylate/ atropine 3 liquid diphenoxylate/ atropine tab 3 DIPHTHERIA/ TETANUS 58 VACCINE dipyridamole tab 5 disopyramide cap 7 disulfiram tab 56 DIURIL SUSP. divalproex dr tab 0 divalproex ER tab 0 divalproex sprinkle cap 0 DOCEFREZ INJ. 3 DOCETAXEL INJ. 3 docusate cap 00mg* 7 docusate cap 50mg* 7

79 ALPHABETICAL LISTING OF DRUGS docusate enema 83mg* 7 docusate sodium liquid 7 50mg/ 5ml* docusate sodium syrup 7 60mg/ 5ml* docusate tab 00mg* 7 donepezil odt tab 56 donepezil tab 56 donepezil tab 3mg 56 DORIBAX INJ. 8 dorzolamide ophth soln. 5 dorzolamide/ timolol ophth 5 soln. doxazosin tab 7 doxepin conc. doxepine cap doxercalciferol cap doxercalciferol inj. doxorubicin inj. doxycycline cap 75mg 57 doxycycline hyclate cap 57 50mg, 00mg doxycycline hyclate dr tab 57 doxycycline hyclate inj. 57 doxycycline hyclate tab 57 0mg, 00mg doxycycline monohydrate 57 tab 50mg, 75mg, 50mg doxycycline susp. 57 dronabinol cap DROXIA CAP 5 DULERA INHALER 8 duloxetine cap duramorph inj. 3 DUREZOL OPHTH 53 EMULSION DUTOPROL TAB 7 DYRENIUM CAP 0 E E.E.S GRANULES 7 e.e.s. 7 e.s.p susp. 8 econazole nitrate cream 36 ED A-HIST LIQUID 3-0MG/ 5ML* EDECRIN TAB 0 edirubicin inj EDURANT TAB 6 EFFIENT TAB 5 ELAPRASE INJ. electrolyte oral soln.* 9 ELIDEL CREAM 39 ELIGARD INJ. ELIQUIS TAB 8 ELITEK INJ. 3 ELIXOPHYLLIN SOLN. 8 ELLA 33 ELMIRON CAP EMCYT CAP EMEND CAP EMEND CK emoquette tab 3 EMSAM TCH EMTRIVA CAP 6 EMTRIVA SOLN. 6 enalapril tab 7 enalapril/ hctz tab 7 ENBREL INJ. 3 endocet tab endodan tab ENDOMETRIN SUPP. 6 ENGERIX-B INJ. 60 enoxaparin inj. 8 enpresse-8 tab 3 entacapone tab ENUCLENE OPHTH 5 SOLN 0.5%* enulose soln. 3 EPHEDRINE SULFATE 8 CAP 5MG* EPIDUO GEL 35 epinastine ophth soln 5 EPIPEN INJ. 6 EPIPEN JR INJ. 6 epitol tab 9 EPIVIR HBV SOLN. 6 EPIVIR SOLN. 6 eplerenone tab 8 eprosartan mesylate tab 7 EPZICOM TAB 6 EQUETRO CAP ERAXIS INJ. ERBITUX SOLN ergocalciferol cap unit* 68 ergocalciferol soln unit/ ml* ERGOLOID MESYLATE 57 TAB ERGOMAR TAB 8 ERIVEDGE CAP errin tab 33 ERTACZO CR 36 ERWINAZE INJ. ery pad 35 ERYPED SUSP. 7 ERY-TAB 7 ERYTHROCIN 7 LACTOBIONATE INJ. ERYTHROCIN 7 STEARATE TAB erythromycin ophth oint. 5 erythromycin tab 7 erythromycin topical gel 35 erythromycin topical soln. 35 erythromycin/ benzoyl 35 peroxide gel escitalopram soln. escitalopram tab esomeprazole inj. 59 estazolam tab 6 ESTRACE VAGINAL 6 CREAM estradiol inj. estradiol patch estradiol tab estradiol valerate inj. estradiol/ norethindrone tab ESTRING 6 estropipate tab eszopiclone tab 6 ethambutol tab 9 ethosuximide cap 0 ethosuximide soln. 0 etidronate disodium tab etodolac cap etodolac ER tab etodolac tab ETOPOPHOS INJ. 3 etoposide inj. 3 EURAX CREAM 39 EXALGO TAB 3

80 ALPHABETICAL LISTING OF DRUGS EXELON TCH 56 exemestane tab EXFORGE HCT TAB 7 EXFORGE TAB 7 EXJADE ORAL SUSP. 3 EXTAVIA INJ. 56 F FABRAZYME INJ. famciclovir tab 7 famotidine inj. 58 famotidine susp. 58 famotidine tab 58 famotidine tab 0mg* 58 FAMOTIDINE/ NACL 58 INJ. FANAPT TAB FANAPT TITRATION CK FARESTON TAB FARXIGA TAB 3 FASLODEX INJ FAZACLO TAB 5 felbamate susp. 0 felbamate tab 0 felodipine ER tab 30 fenofibrate micronized cap 6 fenofibrate tab 6 fenoprofen tab fentanyl lollipop 3 fentanyl patch FERRIPROX 3 ferrous sulfate ec tab 5 35mg* ferrous sulfate elixir 5 0mg/ 5ml* ferrous sulfate soln. 75mg/ 5 ml* FERROUS SULFATE 5 SYRUP 300MG/ 5ML* ferrous sulfate tab 35mg* 5 FETZIMA CAP FETZIMA CK fexofenadine tab 80mg* 5 fexofenadine tab 60mg* 5 FINACEA GEL 39 finasteride tab FIRAZYR INJ. FIRMAGON INJ. flavoxate tab 59 flecainide tab 7 FLOVENT DISKUS 7 FLOVENT HFA 7 INHALER 0MCG FLOVENT HFA 7 INHALER MCG, 0MCG fluconazole susp. fluconazole tab fluconazole/ dextrose inj. flucytosine cap fludarabine inj. 0 fludrocortisone tab 33 flunisolide nasal spray 5 fluocinolone acetonide 38 cream fluocinolone acetonide oil 38 fluocinolone acetonide 38 oint. fluocinolone acetonide otic 5 oil fluocinolone acetonide 38 soln. fluocinonide cream 38 fluocinonide e cream 38 fluocinonide gel 38 fluocinonide oint 38 fluocinonide soln. 38 fluorouracil cream 36 fluorouracil inj. 0 fluorouracil solution 36 fluoxetine cap fluoxetine soln. fluoxetine tab FLUPHENAZINE 5 DECANOATE INJ. fluphenazine elixir 5 FLUPHENAZINE INJ. 5 fluphenazine oral conc. 5 fluphenazine tab 5 flurazepam cap 6 flurbiprofen ophth soln. 5 flurbiprofen tab flutamide cap fluticasone nasal spray 5 69 fluticasone propionate 38 cream fluticasone propionate 38 lotion fluticasone propionate oint. 38 fluvastatin cap 6 fluvoxamine ER cap fluvoxamine tab folic acid tab mg* 5 FOLOTYN INJ. 0 fomepizole inj. 3 fondaparinux inj. 8 FORADIL CAP 8 FORTEO INJ. FORTICAL NASAL SPRAY FOSCARNET INJ. 7 fosinopril tab 7 fosinopril/ hctz tab 7 fosphenytoin inj. 0 FOSRENOL CHEW TAB FRAGMIN INJ. 8 furosemide inj 0 furosemide soln. 0 furosemide tab 0 FUSILEV INJ. 3 FUZEON INJ. 6 FYCOM TAB 9 G gabapentin cap 9 gabapentin soln. 9 gabapentin tab 9 GABITRIL TAB 0 galantamine ER cap 56 galantamine soln. 56 galantamine tab 56 GAMASTAN S/ D 55 GAMMAGARD INJ. 55 GAMMAPLEX INJ. 55 GAMUNEX-C 55 ganciclovir inj. 7 GARDASIL INJ. 60 gatifloxacin ophth soln. 5 GAUZE D 7 gavilyte-c powder 6 gavilyte-g soln 6 gavilyte-n powder 6

81 ALPHABETICAL LISTING OF DRUGS GELUSIL CHEW TAB* 5 gemcitabine inj. 0 gemfibrozil tab 6 generlac soln. 3 gengraf cap 8 gengraf soln. 8 gentak ophth oint 53 gentamicin inj. gentamicin ophth oint. 53 gentamicin ophth soln. 53 gentamicin sulfate cream 35 gentamicin sulfate oint. 35 gentamicin/ nacl inj. gentamicin/ nacl inj..6mg/ ml gentamycin/ nacl inj. GEODON INJ. gildagia tab 3 GILENYA CAP 56 GILOTRIF TAB GLASSIA INJ. 57 GLEEVEC TAB glimepiride tab 3 glipizide ER tab 3 glipizide tab 3 glipizide/ metformin tab GLUCAGEN HYPOKIT GLUCAGON KIT glyburide micronized tab 3 glyburide tab 3 glyburide/ metformin tab glycerin suppository 6.gm* glycopyrrolate inj. 58 glycopyrrolate tab 58 GLYSET TAB GOLYTELY CKET 6 granisetron inj. granisetron tab griseofulvin microsize susp. griseofulvin tab guaifenesin liquid 00mg/ 3 5ml* guaifenesin liquid 00mg/ 3 5ml* guaifenesin tab 00mg* 3 guaifensin/ codeine soln mg/ 5ml* guanfacine IR tab 7 GUANIDINE TAB 9 H HALAVEN INJ. 3 halobetasol cream 38 halobetasol oint 38 haloperidol decanoate inj. 5 haloperidol inj. 5 haloperidol oral conc. 5 haloperidol tab 5 HAVRIX INJ. 60 heparin inj. 8 heparin/ d5w inj. 8 heparin/ nacl inj. 8 hepatasol inj. 5 heptamine inj 5 HERCEPTIN INJ. HEXALEN CAP 0 HUMALOG PEN HUMALOG VIAL HUMIRA KIT HUMULIN 70/ 30 PEN HUMULIN N PEN HUMULIN R U-500 VIAL hydralazine inj 8 hydralazine tab 8 hydrochlorothiazide cap hydrochlorothiazide tab hydrocodone/ acetaminophen soln mg/ 5ml hydrocodone/ acetaminophen tab 5-300mg, mg, 0-300mg hydrocodone/ acetaminophen tab 5-35mg, mg, 0-35mg hydrocodone/ homatropine 3 syrup 5-.5mg/ 5ml* hydrocodone/ ibuprofen tab hydrocortisone acetate 38 oint. %* hydrocortisone butyrate 38 lipo cream 70 hydrocortisone butyrate 38 oint. hydrocortisone butyrate 38 soln. hydrocortisone cream 38 hydrocortisone cream 0.5% 38 * hydrocortisone enema 5 hydrocortisone lotion 38 hydrocortisone lotion %* 38 hydrocortisone oint 0.5%* 38 hydrocortisone oint. 38 hydrocortisone soln %* 38 hydrocortisone tab 33 hydrocortisone valerate 38 cream hydrocortisone valerate 38 oint hydrocortisone/ acetic acid 5 otic soln. hydrocortisone/ aloe cream 38 %* hydromorphone ER tab hydromorphone inj. hydromorphone oral liquid hydromorphone tab hydroxychloroquine tab 9 hydroxyurea cap hydroxyzine inj. 6 hydroxyzine pamoate cap 6 hydroxyzine syrup 6 hydroxyzine tab 6 I ibandronate inj. ibandronate tab ibuprofen cap 00mg* ibuprofen chew tab 00mg* ibuprofen susp. ibuprofen tab ibuprofen tab 00mg* ibuprofen tab 00mg* idarubicin inj IFEX INJ. 0 ifosfamide inj. 0 ILARIS INJ. ILEVRO OPHTH SUSP. 5

82 ALPHABETICAL LISTING OF DRUGS IMBRUVICA CAP imipenem/ cilastatin inj. 8 imipramine pamoate imipramine tab imiquimod cream 39 IMITREX NASAL 8 SPRAY IMOVAX RABIES 60 (H.D.C.V.) INCRELEX INJ. indapamide tab INDOCIN SUSP. indomethacin cap indomethacin ER cap INFANRIX INJ. 58 INLYTA TAB INNOPRAN XL CAP 9 INTELENCE TAB 6 intralipid inj. 5 INTRON-A INJ. introvale tab 3 INTUNIV TAB MG, MG INTUNIV TAB 3MG, MG INVANZ INJ. 8 INVEGA SUSTENNA INJ. INVEGA TAB INVIRASE CAP 6 INVIRASE TAB 6 INVOKANA TAB 3 IONOSOL-B/ D5W INJ. 9 IONOSOL-MB/ D5W INJ. 9 IOPIDINE OPHTH SOLN. 5 % IPOL INJ 60 ipratropium nasal spray 5 ipratropium neb 7 ipratropium/ albuterol 8 neb. irbesartan tab 7 irbesartan/ hctz tab 7 irinotecan inj. 3 ISENTRESS CHEW TAB 6 ISENTRESS POWDER 6 CK ISENTRESS TAB 6 ISOLYTE/ D5W INJ. 9 ISOLYTE-S INJ. 9 isoniazid inj. 9 isoniazid syrup 0 isoniazid tab 0 isosorbide dinitrate ER tab 6 isosorbide dinitrate tab 6 isosorbide mononitrate ER 6 tab isosorbide mononitrate tab 6 isotonic gentamicin isradipine cap 30 ISTALOL OPHTH SOLN. 5 ISTODAX INJ. itraconazole cap IXEMPRA INJ 3 IXIARO INJ. 60 J JAKAFI TAB JALYN CAP jantoven tab 8 JANUMET TAB JANUMET XR TAB JANUVIA TAB JEVTANA INJ. 3 JINTELI TAB jolivette tab 33 junel fe tab 3 junel tab 3 K KADCYLA INJ. KALETRA SOLN. 6 KALETRA TAB 6 KALYDECO TAB 57 kariva tab 3 kelnor tab 3 KEPIVANCE INJ 3 KETOCARE URINE 0 TEST STRIP* ketoconazole cream 36 ketoconazole shampoo 36 ketoconazole shampoo %* 36 ketoconazole tab ketoprofen cap ketorolac inj. ketorolac ophth soln. 5 ketorolac tab 7 KHEDEZYLA TAB kionex powder 9 KLOR-CON M5 TAB 9 klor-con tab 9 KORLYM TAB K-TAB ER TAB 9 KUVAN TAB L labetalol inj. 9 labetalol tab 9 LACRISERT 5 lactated ringers irrigation 8 lactated ringers soln. 9 lactated ringers/ d5w inj. 9 lactulose soln. 6 LAMICTAL ODT 9 LAMICTAL STARTER 9 KIT LAMICTAL XR KIT 9 lamivudine tab 6 lamivudine/ zidovudine tab 6 lamotrigine chew tab 9 lamotrigine ER tab 9 lamotrigine tab 9 lansoprazole cap 59 lansoprazole/ amoxicillin/ 59 clarithromycin tab LANTUS SOLOSTAR LANTUS VIAL larin fe tab 3 larin tab 3 latanoprost ophth soln. 5 LATUDA TAB LAZANDA SPRAY leena tab 3 leflunomide tab 3 LESCOL XL TAB 6 lessina 3 LETAIRIS TAB 30 letrozole tab leucovorin inj. 3 leucovorin tab 3 LEUKERAN TAB 0 LEUKINE INJ. 5 leuprolide inj. levalbuterol neb 8 LEVEMIR FLEXPEN

83 ALPHABETICAL LISTING OF DRUGS LEVEMIR INJ. levetiracetam ER tab 9 levetiracetam inj 9 levetiracetam soln. 9 levetiracetam tab 9 levobunolol ophth soln. 5 levocarnitine inj. levocarnitine soln. levocarnitine tab levocetirizine soln. 5 levocetirizine tab 5 levofloxacin inj. 3 levofloxacin ophth soln. 53 levofloxacin soln. 3 levofloxacin tab 3 levonest tab 3 levonorgestrel/ ethinyl 3 estradiol tab levora-8 tab 3 LEVORPHANOL TAB levothyroxine tab 58 levoxyl tab 58 LEXIVA SUSP. 6 LEXIVA TAB 6 LIALDA TAB 3 lice treatment creme rinse* 39 lice treatment shampoo* 39 lidocaine gel 39 lidocaine inj. 7 lidocaine oint. 39 lidocaine patch 39 lidocaine soln. 39 lidocaine viscous 50 lidocaine/ prilocaine cream 39 LINCOCIN 9 lindane lotion 39 lindane shampoo 39 LINZESS CAP 3 liothyronine inj. 58 liothyronine tab 58 LIPTRUZET TAB 6 lisinopril tab 7 lisinopril/ hctz tab 7 lithium carbonate cap lithium carbonate ER tab lithium carbonate tab lithium citrate soln. LITHOSTAT TAB LO MINASTRIN FE TAB 3 LOFIBRA CAP 6 LOFIBRA TAB 6 LOHIST-D LIQUID 3-30MG* lokara lotion 38 LOMUSTINE CAP 0 loperamide cap 3 loperamide tab mg* 3 loratadine ODT tab 0mg* 5 loratadine syrup 5mg/ 5ml* 5 loratadine tab 0mg* 5 loratadine-d tab 3 0-0mg* loratadine-d tab 5-0mg* 3 lorazepam conc 6 lorazepam tab 6 losartan tab 7 losartan/ hctz tab 7 LOTEMAX OPHTH GEL 53 LOTEMAX OPHTH 53 OINTMENT LOTEMAX OPHTH 53 SUSP. LOTRONEX TAB lovastatin tab 6 LOVAZA CAP 6 low-ogestrel tab 3 loxapine cap 5 LUMIGAN OPHTH 5 SOLN. LUMIZYME INJ. LUPRON DEPOT (3 MONTH) KIT.5MG,.5MG LUPRON DEPOT ( MONTH) KIT 30MG LUPRON DEPOT (6 MONTH) KIT 5MG LUPRON DEPOT INJ. LUPRON DEPOT-PED KIT lutera tab 3 LYRICA CAP 9 LYRICA SOLN. 9 LYSODREN TAB lyza tab 33 M 7 MAALOX ADVANCED 5 MAXIMUM STRENGTH CHEW TAB* maalox max susp* 5 MACRODANTIN CAP 59 mafenide topical solution 37 magnesium citrate soln.* 7 magnesium hydroxide susp. 7 00mg/ 5ml* magnesium oxide tab 9 00mg* magnesium sulfate inj. 9 malathion lotion 39 maprotiline tab 0 marlissa tab 3 MARPLAN TAB MATULANE CAP matzim la tab 30 MAXIDEX OPHTH 53 SUSP. meclizine tab MECLOFENAMATE SODIUM CAP MEDROL TAB MG 33 medroxyprogesterone inj. 33 medroxyprogesterone tab 56 mefenamic acid cap mefloquine tab 9 megestrol acetate susp. megestrol acetate tab MEKINIST TAB MELOXICAM SUSP meloxicam tab melphalan inj. 0 MENACTRA 59 MENOMUNE A-C-Y-W 59 INJ. MENVEO INJ. 60 meperitab tab meprobamate tab 6 mercaptopurine tab 0 meropenem inj. 8 mesalamine kit 3 mesna inj. 3 MESNEX TAB 3 MESTINON TIMESN 9 TAB metadate ER tab

84 ALPHABETICAL LISTING OF DRUGS METAMUCIL PLUS 6 CALCIUM CAP* METAMUCIL SMOOTH 6 POWDER CKET 8%* METAMUCIL WAFER* 6 METAPROTERENOL 8 SYRUP metaxalone tab 50 metformin ER osmotic tab 000mg metformin ER tab metformin tab methadone soln. methadone tab methamphetamine tab methazolamide tab 0 methenamine hippurate tab 59 methimazole tab 58 methocarbamol tab 50 methotrexate inj. 0 methotrexate PF inj. 0 methotrexate tab 0 methoxsalen cap 37 methscopolamine tab 58 METHYCLOTHIAZIDE TAB methyldopa tab 7 methyldopa/ hctz tab 7 methylergonovine tab 5 methylphenidate CD cap methylphenidate ER cap methylphenidate ER tab methylphenidate soln. methylphenidate tab methylprednisolone acetate 33 inj. methylprednisolone dose 33 pak methylprednisolone sodium 33 succinate inj. methylprednisolone tab 33 metipranolol ophth soln. 5 metoclopramide inj. 3 metoclopramide soln. 3 metoclopramide tab 3 metolazone tab metoprolol ER tab 9 metoprolol inj. 9 metoprolol tab 9 metoprolol/ hctz tab 7 metronidazole cap 8 metronidazole cream 39 metronidazole gel 39 metronidazole lotion 39 metronidazole tab 8 metronidazole vaginal gel 60 metronidazole/ nacl inj. 8 mexiletine cap 7 MIACALCIN INJ. miconazole cream %* 36 miconazole cream kit* 60 miconazole nitrate vaginal 60 suppository 00mg* miconazole powder %* 36 miconazole vaginal cream 60 %* miconazole vaginal cream 60 %* miconazole vaginal kit* 60 microgestin tab 3 midodrine tab 6 MIGERGOT SUPP 8 mimvey lo tab mimvey tab MINERAL OIL* 7 minitran patch 6 minocycline cap 57 minocycline ER tab 57 minocycline tab 57 minoxidil tab 8 mirtazapine odt tab 0 mirtazapine tab 0 misoprostol tab 59 mitomycin inj. mitoxantrone inj M-M-R II WITH 60 DILUENT moderiba tab 00mg 7 MODERIBA TAB 7 00MG, 600MG moexipril tab 7 moexipril/ hctz tab 7 mometasone furoate cream 38 mometasone furoate lotion 38 mometasone furoate oint. 38 mononessa tab 3 73 montelukast chew tab 7 montelukast granules 7 montelukast tab 7 morphine sulfate ER cap morphine sulfate ER tab MORPHINE SULFATE PF INJ. MG, MG morphine sulfate soln. morphine sulfate tab MOXEZA OPHTH SOLN 53 moxifloxacin tab 3 MOZOBIL INJ. 5 MULTAQ TAB 7 multivitamin liquid* 50 multivitamin tab* 50 multivitamin w/ minerals 50 tab* multivitamins w/ minerals 50 tab* mupirocin cream 35 mupirocin oint. 35 MYCAMINE INJ. mycophenolate cap 8 mycophenolate sodium tab 8 mycophenolate tab 8 myorisan 35 MYOZYME INJ. MYSTARGEN INJ. 0 N nabumetone tab nadolol tab 9 nadolol/ 8 bendroflumethiazide tab nafcillin inj. 55 NAFCILLIN/ DEXTROSE 55 INJ. NAFTIN CREAM 36 NAFTIN GEL 36 NAGLAZYME INJ. naloxone inj. 3 naltrexone tab 3 NAMENDA SOLN. 56 NAMENDA XR 56 NAPHAZOLINE OPHTH 53 SOLN. naphazoline/ pheniramine 53 ophth soln*

85 ALPHABETICAL LISTING OF DRUGS naphazoline-glycerin ophth 53 soln* naproxen dr tab naproxen sodium tab naproxen susp. naproxen tab naratriptan tab 8 NASONEX NASAL 5 NATACYN OPHTH 53 SUSP. NATAZIA TAB 3 nateglinide tab 3 NEBUPENT NEB 8 necon tab 3 NEFAZODONE TAB 0 neomycin tab neomycin/ bacitracin/ 53 polymyxin ophth oint. neomycin/ polymyxin B GU irrigation soln. neomycin/ polymyxin/ 53 bacitracin/ hc ophth oint. neomycin/ polymyxin/ 53 dexamethasone ophth oint. neomycin/ polymyxin/ 53 dexamethasone ophth soln. neomycin/ polymyxin/ 53 gramicidin ophth soln. neomycin/ polymyxin/ hc 53 ophth susp. neomycin/ polymyxin/ hc 5 otic soln. neomycin/ polymyxin/ hc 5 otic susp. NEPHRAMINE INJ. 5 NEULASTA INJ. 5 NEUMEGA INJ. 5 NEUPOGEN INJ. 5 NEUPRO TCH NEVANAC OPHTH 5 SUSP. nevirapine er tab 6 nevirapine tab 6 NEXAVAR TAB NEXTERONE INJ. 7 niacin CR cap 50mg* 6 niacin CR cap 500mg* 6 NIACIN CR TAB 6 000MG* niacin CR tab 500mg* 6 niacin CR tab 750mg* 6 niacin tab 00mg* 6 niacin tab 50mg* 6 niacin tab 500mg* 6 niacin tab 50mg* 6 NIACOR TAB 6 NIASN ER TAB 6 nicardipine cap 30 nicardipine inj. 30 nicotine gum mg* 57 nicotine gum mg* 57 nicotine patch mg* 57 nicotine patch mg* 57 nicotine patch 7mg* 57 NICOTROL INHALER 57 NICOTROL NASAL 57 SPRAY nifedical XL tab 30 nifedipine cap 30 nifedipine ER tab 30 NILANDRON TAB nimodipine cap 30 nisoldipine ER tab 30 NITRO-DUR TCH 6 0.3MG/ HR, 0.8MG/ HR nitrofurantoin macro cap 59 nitrofurantoin mono cap 59 nitrofurantoin susp. 59 nitroglycerin inj. 6 nitroglycerin lingual spray 6 nitroglycerin patch 6 NITROSTAT SL TAB 6 nizatidine cap 58 nizatidine soln. 58 NONOXYNOL-9 FOAM 60.5%* nonoxynol-9 gel 3%* 60 nora-be tab 33 NORDITROPIN INJ. norethindrone tab 33 norethindrone tab 33 NORMOSOL/ D5W INJ. 9 normosol-m/ d5w inj. 9 NORMOSOL-R INJ. 9 NORCE CR 7 7 nortrel tab 3 nortriptyline cap nortriptyline soln. NORVIR CAP 6 NORVIR SOLN. 6 NORVIR TAB 6 NOVOFINE PEN 8 NEEDLES NOVOLIN 70/ 30 VIAL NOVOLIN N VIAL NOVOLIN R VIAL NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/ 30 3 PEN NOVOLOG MIX 70/ 30 3 VIAL NOVOLOG VIAL 3 NOXAFIL SUSP NOXAFIL TAB NUCYNTA ER TAB NUEDEXTA CAP 57 NULOJIX INJ. 8 NUVARING 3 NUVIGIL TAB nyamyc powder 36 nystatin cream 36 nystatin oint. 36 nystatin susp. 50 nystatin tab nystatin topical powder 36 nystatin/ triamcinolone 36 cream nystatin/ triamcinolone 36 oint. nystop topical powder 36 O octreotide inj. ofloxacin ophth soln. 53 ofloxacin otic soln. 5 ofloxacin tab 3 olanzapine inj. 5 olanzapine ODT tab 5 olanzapine tab 5 olanzapine/ fluoxetine cap 56 OLYSIO TAB 7 omega-3 acid cap 6

86 ALPHABETICAL LISTING OF DRUGS omega-3 fatty acid cap 5 000mg* omega-3 fatty acid cap 5 00mg* omeprazole cap 59 OMEPRAZOLE TAB 59 0MG* ONCASR INJ. ondansetron inj. ondansetron odt tab ondansetron soln. ondansetron tab ONFI SUSPENSION 9 ONFI TAB 9 ONGLYZA TAB ORAP TAB 57 ORAPRED ODT 33 ORENCIA INJ. 3 ORENCIA SUB-Q INJ. 3 ORFADIN CAP orphenadrine citrate inj. 50 orphenadrine ER tab 50 orsythia tab 3 ORTHO-TRI CYCLEN 3 LO oxacillin inj. 55 OXACILLIN/ 56 DEXTROSE INJ. oxaliplatin inj 0 oxandrolone tab 5 oxaprozin tab oxazepam cap 6 oxcarbazepine oral susp. 9 oxcarbazepine tab 9 OXISTAT CREAM 36 OXISTAT LOTION 36 OXTELLAR XR TAB 9 oxybutynin ER tab 59 oxybutynin syrup 59 oxybutynin tab 59 oxycodone / aspirin tab oxycodone / ibuprofen tab oxycodone cap oxycodone soln. oxycodone tab oxycodone/ acetaminophen tab OXYCONTIN TAB OXYCONTIN TAB 80MG oxymorphone ER tab oxymorphone tab P paclitaxel inj 3 pamidronate inj pamidronate inj. NCREAZE CAP 0 NRETIN GEL 36 pantoprazole inj. 59 pantoprazole tab 59 paricalcitol cap paromomycin cap paroxetine ER tab paroxetine tab SER GRANULE 0 TADAY OPHTH 5 SOLN. TANASE NASAL 5 SOLN. XIL SUSP. pediatric multivitamin soln 50 35mg/ ml* pediatric multivitamin w/ 50 iron drops 0mg/ ml* pedi-dri topical powder 36 PEDVAX HIB INJ. 60 peg 3350/ electrolyte soln. 6 PEGANONE TAB 0 PEGASYS INJ. 7 PEGASYS PROCLICK 7 INJ. PEG-INTRON INJ. 7 penicillin g potassium inj. 55 PENICILLIN G 55 PROCAINE INJ. PENICILLIN G SODIUM 55 INJ. PENICILLIN G/ 55 DEXTROSE INJ. penicillin v potassium soln. 55 penicillin v potassium tab 55 PENNSAID SOLN. 36 PENTAM INJ. 8 PENTASA CAP 3 pentazocine/ naloxone tab 5 pentoxifylline ER tab 5 75 perindopril tab 7 periogard soln. 50 PERJETA INJ. permethrin cream 0 permethrin creme rinse % 0 * perphenazine tab 5 perphenazine/ amitriptyline 56 tab PEXEVA TAB phenadoz supp. 5 phenelzine tab phenobarbital elixir 6 phenobarbital tab 6 phentermine cap 5mg* phentermine cap 30mg* phentermine tab 37.5mg* phenylephrine 3 chlorpheniramine soln 0--5mg/ 5ml* phenylephrine 3 chlorpheniramine soln 0--5mg/ 5ml* phenylephrine DM/ 3 guaifenesin liquid mg/ 5ml* phenylephrine/ guaifenesin 3 liquid 5-00mg/ 5ml* phenytoin cap 0 phenytoin chew tab 0 phenytoin inj. 0 phenytoin susp. 0 PHOSLYRA SOLN. PHOSPHOLINE IODIDE 5 OPHTH SOLN. physiolyte irrigation soln. 8 physiosol irrigation soln. 9 phytonadione tab 00mcg* 6 PICATO GEL 0.05% 36 PICATO GEL 0.05% 36 pilocarpine ophth soln. 5 pilocarpine tab 50 pimtrea tab 3 pindolol tab 9 pioglitazone tab 3 pioglitazone/ glimepiride tab pioglitazone/ metformin tab

87 ALPHABETICAL LISTING OF DRUGS piperacillin/ tazobactam 55 inj. pirmella tab 3 piroxicam cap PLASMA-LYTE INJ. 9 PLASMA-LYTE/ D5W 9 INJ. podofilox soln. 39 polyethylene glycol powder polymyxin b inj. 9 polymyxin B/ trimethoprim 53 ophth soln. POMALYST CAP portia-8 tab 3 POTASSIUM CHLORIDE 9 (0MEQ)/ D5W/ NACL INJ. potassium chloride ER cap 9 potassium chloride ER tab 9 potassium chloride inj. 9 meq potassium chloride/ d5w 9 inj. POTASSIUM 9 CHLORIDE/ D5W/ LACTATED RINGERS SOLN. potassium chloride/ d5w/ 9 nacl inj. potassium chloride/ nacl 9 inj. potassium citrate CR tab POTIGA TAB 9 PRADAXA CAP 8 pramipexole tab pravastatin tab 6 prazosin cap 7 PRECISION INSULIN 8 SYRINGE PRED MILD OPHTH 53 SUSP. PRED-G OPHTH SUSP. 53 prednicarbate oint. 39 PREDNISOLONE 53 SODIUM PHOSPHATE OPHTH SOLN. prednisolone sodium 33 phosphate soln. prednisolone susp 53 PREDNISONE 33 INTENSOL prednisone soln. 33 prednisone tab 33 PREMARIN TAB PREMARIN VAGINAL 6 CREAM PREMASOL SOLN 0% 5 premasol soln. 6% 5 PREMPHASE TAB PREMPRO TAB PRENATAL VITAMIN 50 PRENATAL VITAMINS 50 (OTC)* prenicarbate cream 39 PREVACID SOLUTAB 59 previfem tab 3 PREZISTA SUSP. 6 PREZISTA TAB 6 PRIFTIN TAB 0 PRIMAQUINE TAB 9 primidone tab 9 PRISTIQ TAB PRIVIGEN INJ. 55 probenecid tab PROCAINAMIDE INJ. 7 PROCALAMINE INJ. 5 prochlorperazine edisylate 5 inj. prochlorperazine 5 suppository prochlorperazine tab 5 PROCRIT INJ. 5 procto-pak 5 proctozone-hc cream 5 progesterone cap 56 PROGLYCEM SUSP. PROGRAF INJ 8 PROLEUKINE IV SOLN. 3 PROLIA INJ. PROMACTA TAB 5 promethazine DM syrup mg/ 5ml* promethazine inj. 5 promethazine supp promethazine syrup 5 promethazine tab 5 PROMETHAZINE VC 5 CODEINE promethazine/ codeine 3 syrup 6.5-0mg/ 5ml* promethegan supp. 5 PROMETHEGAN SUPP. 6 50MG propafenone ER cap 7 propafenone tab 7 PRONTHELINE TAB 58 proparacaine ophth soln 53 propranolol ER cap 9 propranolol inj. 9 propranolol oral soln. 9 propranolol tab 9 propranolol/ hctz tab 8 propylthiouracil tab 58 PROQUAD INJ. 60 PROSOL INJ. 5 PROTOPIC OINT 39 protriptyline tab prudoxin cream 36 pseudoephedrine hr tab 5 0mg* pseudoephedrine DM/ 3 guaifenesin liquid mg/ 5ml* pseudoephedrine liquid 5 5mg/ 5ml* pseudoephedrine tab 5 30mg* pseudoephedrine tab 5 60mg* pseudoephedrine/ 3 brompheniramine DM elixir 5--5mg/ 5ml* pseudoephedrine/ 3 chlorpheniramine DM liquid 5--5mg/ 5ml* pseudoephedrine/ 3 chlorpheniramine DM syrup 30--0mg/ 5ml* pseudoephedrine/ 3 doxylamine/ DM/ acetaminophen liquid mg/ 30ml*

88 ALPHABETICAL LISTING OF DRUGS pseudoephedrine/ 3 guaifensen liquid mg/ ml* pseudoephedrine/ 3 guaifensin syrup 30-00mg/ 5ml* psyllium cap 0.5gm* 6 psyllium powder 8.3%* 6 psyllium powder 30.9%* 6 psyllium powder 9%* 6 psyllium powder 58.6%* 6 PSYLLIUM POWDER 6 CKET 00%* PULMICORT NEB MG/ 7 ML PULMOZYME SOLN. 57 PYLERA CAP 59 pyrazinamide tab 0 pyridostigmine tab 9 pyridoxine tab 00mg* 6 pyridoxine tab 5mg* 6 pyridoxine tab 50mg* 6 Q QSYMIA CAP* QUARTETTE TAB 3 quasense tab 3 quetiapine tab 5 quinapril tab 7 quinapril/ hctz tab 8 quinidine gluconate CR tab 7 QUINIDINE 7 GLUCONATE INJ. quinidine sulfate tab 7 quinine sulfate cap 9 QVAR INHALER 7 R RABAVERT INJ. 60 rabeprazole tab 59 raloxifene tab ramipril cap 7 RANEXA TAB 6 ranitidine cap 58 ranitidine inj. 58 ranitidine syrup 58 ranitidine tab 58 RAFLO CAP RAMUNE SOLN. 8 RAMUNE TAB 8 REBIF INJ. 56 REBIF TITRATION 56 CK reclipsen tab 3 RECOMBIVAX-HB INJ. 60 REGRANEX GEL 0 RELENZA DISKHALER 7 RELISTOR INJ. REMICADE INJ. 3 REMODULIN INJ. 30 RENVELA CKET RENVELA TAB repaglinide tab 3 RESCRIPTOR TAB 6 RESTASIS EMULSION 53 RETIN-A MICRO GEL 35 RETROVIR INJ. 6 REVLIMID CAP 8 REVLIMID CAP.5MG, 8 0MG REYATAZ CAP 6 ribasphere cap 7 ribasphere tab 7 ribavirin cap 7 ribavirin tab 7 RIDAURA CAP rifabutin cap 0 RIFAMATE CAP 9 rifampin cap 0 rifampin inj. 0 RIFATER TAB 9 riluzole tab 5 rimantadine tab 7 ringers irrigation 9 ringers solution 9 risedronate sodium tab RISPERDAL CONSTA INJ. risperidone odt risperidone soln. risperidone tab RITUXAN INJ. rivastigmine tab 56 rizatriptan odt tab 8 rizatriptan tab 8 ropinirole ER tab ropinirole tab 77 ROTARIX SUSP. 60 ROTATEQ ORAL SUSP. 60 ROXICET SOLN S SABRIL POWDER 0 SABRIL TAB 0 salicylic acid soln 3%* 39 saline nasal spray 0.65%* 5 SANDIMMUNE SOLN. 8 SANTYL OINT. 39 SAPHRIS SL TAB 5 SAVELLA TAB 56 SAVELLA TITRATION 56 CK SECONAL CAP 6 selegiline cap selegiline tab selenium sulfide shampoo 37 SELZENTRY TAB 6 senna syrup 8.8mg/ 5ml* 7 senna tab 8.6mg* 7 SENSIR TAB SEREVENT INHALER 8 SEROQUEL XR TAB 5 sertraline conc. sertraline tab SIGNIFOR INJ. sildenafil tab 30 silver sulfadiazine cream 37 SIMCOR TAB 6 simethicone cap 5mg* 3 simethicone susp. 0mg/ 3 0.6ml* SIMPONI INJ. SIMULECT INJ 8 simvastatin tab 6 sirolimus cap 8 sodium bicarbonate tab 5 650mg* sodium chloride hypertonic 5 ophth oint. 5%* sodium chloride hypertonic 5 ophth soln 5%* sodium chloride inj. 9 sodium chloride irrigation soln. sodium fluoride tab 9

89 ALPHABETICAL LISTING OF DRUGS sodium lactate inj. 8 sodium phenylbutyrate powder sodium phosphate enema* 7 sodium polystyrene 9 sulfonate susp. sodium sulfacetamide 53 ophth soln. SOLTAMOX ORAL SOLN. SOLU-CORTEF INJ. 33 SOMATULINE DEPOT INJ. SOMAVERT INJ. sorbitol soln 70%* 6 sorine tab 9 sotalol tab 9 SOVALDI TAB 7 SCER HOLDING 8 CHAMBER* SPINOSAD SUSP. 0 SPIRIVA CAP 7 HANDIHALER spironolactone tab 0 spironolactone/ hctz tab 0 sprintec-8 tab 3 SPRYCEL TAB sronyx tab 3 ssd cream 37 STALEVO TAB stavudine cap 6 stavudine soln. 6 STELARA INJ. 37 sterile water irrigation 9 STIMATE NASAL SOLN. STIVARGA TAB STRATTERA CAP STREPTOMYCIN INJ. STRIBILD TAB 6 STROMECTOL TAB 6 SUBOXONE SL FILM 5 SUCLEAR 6 sucralfate tab 59 sulfacetamide sodium 35 lotion sulfacetamide sodium 53 ophth oint. sulfacetamide sodium/ 53 prednisolone ophth soln. SULFADIAZINE TAB 57 sulfamethoxazole/ 8 trimethoprim DS tab SULFAMETHOXAZOLE/ 8 TRIMETHOPRIM INJ. sulfamethoxazole/ 8 trimethoprim susp. sulfamethoxazole/ 8 trimethoprim tab SULFAMYLON CREAM 37 sulfasalazine tab 3 sulfazine EC tab 3 sulindac tab 3 sumatriptan inj. 8 SUMATRIPTAN NASAL 8 SPRAY sumatriptan tab 8 SUPRAX CAP 3 SUPREP BOWEL PREP 6 SURMONTIL CAP SUSTIVA CAP 6 SUSTIVA TAB 6 SUTENT CAP SYLATRON INJ. 3 SYLVANT INJ. 9 SYMBICORT INHALER 8 SYMLINPEN SYNAGIS INJ. 55 SYNAREL NASAL SOLN. SYNERCID INJ 9 SYNRIBO INJ. 3 SYNTHROID TAB 58 SYPRINE CAP 8 T TABLOID TAB 0 tacrolimus cap 8 TAFINLAR CAP TAMIFLU CAP 30MG 8 TAMIFLU CAP 5MG, 8 75MG TAMIFLU SUSP. 8 tamoxifen citrate tab tamsulosin cap TARCEVA TAB 78 TARGRETIN CAP 3 TARGRETIN GEL % 36 TASIGNA CAP TASMAR TAXOTERE INJ 3 TAZORAC CREAM 37 TAZORAC GEL 37 taztia-xt cap 30 TECFIDERA CAP 56 TECFIDERA STARTER 56 CK TEFLARO INJ. 3 TEGRETOL-XR TAB 9 telmisartan tab 7 telmisartan/ amlodipine tab 8 telmisartan/ hctz tab 8 temazepam cap 6 terazosin cap 7 terbinafine tab terbutaline inj. 8 terbutaline tab 8 terconazole vaginal cream 60 terconazole vaginal 60 suppository testosterone cypionate inj. 5 testosterone enanthate inj. 5 TETANUS TOXOID 58 ADSORBED TETANUS/ 58 DIPHTHERIA TOXOID INJ. tetracycline cap 57 THALOMID CAP 8 theophylline ER tab 8 theophylline soln. 8 thiamine tab 00mg* 6 THIOLA TAB thioridazine tab 5 thiothixene cap 5 THYMOGLOBULIN INJ. 8 THYROLAR TAB 58 tiagabine tab 0 ticlopidine tab 5 TIKOSYN CAP 7 TIMENTIN INJ. 3.GM 55 timolol maleate ophth gel 5 timolol maleate ophth soln. 5 timolol maleate tab 9

90 ALPHABETICAL LISTING OF DRUGS tinidazole tab 8 tioconazole vaginal oint %* TIVICAY TAB 7 tizanidine cap 50 tizanidine tab 50 TOBI NEB TOBI PODHALER tobramycin inj tobramycin ophth soln. 53 tobramycin/ 53 dexamethasone ophth soln. TOBRAMYCIN/ NACL INJ. TOBREX OPHTH OINT. 5 tolazamide tab 3 TOLBUTAMIDE TAB 3 tolmetin cap 3 tolmetin tab 3 TOLMETIN TAB 00MG 3 tolnaftate cream %* 36 tolnaftate soln %* 36 tolterodine tab 59 tolterodine tartrate er cap 59 TOPICORT CREAM 39 topiramate sprinkle cap 9 topiramate tab 9 toposar inj. 3 topotecan inj. 3 TORISEL SOLN TORSEMIDE INJ. 0 torsemide tab 0 TOVIAZ TAB 59 tpn electrolytes soln. 9 TRACLEER TAB 30 TRADJENTA TAB tramadol ER tab tramadol hcl tab tramadol/ acetaminophen tab trandolapril tab 7 tranexamic acid inj. 5 tranexamic acid tab 5 TRANSDERM SCOP tranylcypromine tab TRAVASOL INJ. 5 TRAVATAN Z OPHTH 5 SOLN TRAVOPROST OPHTH 5 SOLN. trazodone tab 0 TREANDA INJ. 0 TRECATOR TAB 0 TRELSTAR DEPOT MIXJECT INJ. TRELSTAR LA MIXJECT INJ. TRELSTAR MIXJECT INJ. tretinoin cap 3 tretinoin cream 35 tretinoin gel 35 TREXALL TAB 0 TREXIMET TAB 8 triamcinolone acetonide 33 inj. triamcinolone cream 39 triamcinolone in orabase 50 paste triamcinolone lotion 39 triamcinolone nasal spray 5 triamcinolone oint 39 triamterene/ hctz cap 0 triamterene/ hctz tab 0 triazolam tab 6 triderm cream 39 trifluoperazine tab 5 trifluridine ophth soln. 53 TRIGLIDE TAB 6 trihexyphenidyl soln 3 trihexyphenidyl tab tri-legest fe tab 3 TRILIPIX CAP 6 trilyte soln. 6 trimethobenzamide cap trimethoprim tab 8 trinessa tab 3 tri-previfem tab 3 triprolidine/ 3 pseudoephedrine syrup.5-30mg/ 5ml* triprolidine/ 3 pseudoephedrine tab.5-60mg* TRISENOX INJ. 3 tri-sprintec tab 3 79 tri-vitamin pediatric 50 drops* trivora-8 tab 3 TROKENDI XR CAP 9 TROPHAMINE INJ 5 trospium chloride er cap 59 trospium tab 59 TRUVADA TAB 7 TUDORZA INHALER 7 TWINRIX INJ. 60 TYGACIL INJ. 9 TYKERB TAB TYPHIM VI INJ. 60 TYSABRI INJ. 56 TYVASO INH. 30 TYZEKA TAB 7 U UCERIS TAB 33 u-cort cream 39 ULORIC TAB ULTRESA CAP 0 unithroid tab 58 UROCIT-K 5 TAB ursodiol cap 3 ursodiol tab 3 UVADEX SOLN 3 V valacyclovir tab 7 VALCYTE SOLN. 7 VALCYTE TAB 7 valproate sodium inj. 0 valproic acid cap 0 valproic acid syrup 0 valsartan/ hctz tab 8 vancomycin cap 8 vancomycin inj. 8 vandazole vaginal gel 60 VAQTA INJ. 60 VARIVAX INJ. 60 VASCE 6 VECTIBIX INJ VECTICAL OINT. 37 VELCADE INJ. velivet tab 3 venlafaxine ER cap venlafaxine ER tab

91 ALPHABETICAL LISTING OF DRUGS VENLAFAXINE ER TAB 5MG venlafaxine tab VENTAVIS INH. 30 VENTOLIN HFA 8 INHALER VERAMYST NASAL 5 verapamil ER cap 30 verapamil ER tab 30 verapamil inj. 30 verapamil tab 30 VERSACLOZ SUSP 5 VESICARE TAB 59 VEXOL OPHTH SUSP. 5 VICTOZA INJ. VIDEX SOLN. 7 VIGAMOX OPHTH 53 SOLN. VIIBRYD STARTER 0 CK VIIBRYD TAB 0 VIMT INJ. 9 VIMT SOLN. 9 VIMT TAB 9 vinblastine inj. 3 vincasar pfs inj. 3 vincristine inj. 3 vinorelbine inj 3 VIRACEPT TAB 7 VIRAMUNE SUSP. 7 VIRAMUNE XR TAB 7 VIRAZOLE INH. 8 VIREAD POWDER 7 VIREAD TAB 7 vitamin B complex w/ C 50 cap* vitamin D with calcium 9 tab* VIVELLE-DOT TCH VOLTAREN GEL 36 voriconazole inj. voriconazole susp. voriconazole tab 5 VOTRIENT TAB vyfemla tab 3 VYVANSE CAP W warfarin tab 8 WELCHOL TAB 6 WOUND CLEANSER 0 LIQUID* X XALKORI CAP XARELTO TAB 8 XENAZINE TAB 56 XENICAL CAP 0MG* XGEVA INJ. XOLAIR INJ. 7 XTANDI CAP xulane patch 3 XYREM ORAL SOLN. 56 Y YASMIN TAB 3 YERVOY INJ. YF-VAX INJ. 60 Z zafirlukast tab 7 zaleplon cap 6 ZALTRAP INJ. ZANOSAR INJ 0 ZAVESCA CAP 5 zazole vaginal cream 60 ZELBORAF TAB ZEMAIRA INJ. 57 ZEMPLAR INJ. zenatane cap 35 zenchent fe tab 3 zenchent tab 3 ZETIA TAB 6 ZIAGEN SOLN. 7 zidovudine cap 7 zidovudine syrup 7 zidovudine tab 7 zinc oxide ointment 0%* 39 ziprasidone cap ZIRGAN OPHTH GEL 53 zoledronic acid inj. ZOLINZA CAP zolmitriptan odt tab 8 zolmitriptan tab 8 zolpidem tab 6 ZOMETA INJ. MG/ 00ML 80 ZOMIG NASAL SPRAY 8 ZONATUSS CAP 3 50MG* zonisamide cap 0 ZORTRESS TAB 8 ZOSTAVAX INJ. 60 ZOSYN INJ. 55 zovia tab 3 ZOVIRAX OINT. 37 ZYCLARA CREAM 39 ZYKADIA CAP ZYLET OPHTH SOLN 5 ZYTIGA TAB ZYVOX INJ. 9 ZYVOX SUSP. 9 ZYVOX TAB 9

92 NOTES:

93 NOTES:

94 NOTES:

95

96 LA /