2018 FORMULARIO (Lista de los medicamentos cubiertos) Texas

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1 2018 FORMULARIO (Lista de los medicamentos cubiertos) Texas Molina Dual Options STAR+Plus Medicare- Plan Versión 11 FECHA DE PUBLICACIÓN: 07/2018 Departamento de Servicios para Miembros: (866) , TTY / TDD al 711 De lunes a viernes, de 8:00 a. m. a 8:00 p. m., local time H8197_18_18203_0001_TXMMPFormulary es Accepted HPMS Approved Formulary File Submission , Version MMP0718

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3 Molina Healthcare of Texas (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This includes gender identity, pregnancy and sex stereotyping. To help you talk with us, Molina provides services free of charge: Aids and services to people with disabilities Skilled sign language interpreters Written material in other formats (large print, audio, accessible electronic formats, Braille) Language services to people who speak another language or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (866)) ; TTY/TDD: 711, Monday Friday, 8 a.m. to 8 p.m., local time. If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or . If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) , or TTY, 711. Mail your complaint to: Civil Rights Coordinator 200 Oceangate Long Beach, CA You can also your complaint to civil.rights@molinahealthcare.com. Or, fax your complaint to (562) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at / You can mail it to: U.S. Departmentt of Health and Human Services 200 Independence Avenue, SW Room 509F, HH HH Building Washington, D.C You can also send it to a website throughh the Office for Civil Rights Complaint Portal, available at If you need help, call ; TTY

4 English ATTENTION: If you speak English, language assistance services, free available to you. Call (TTY: 711). of charge, are Spanish ATENCIÓN: si habla español, tiene a su disposición servicioss gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese 注意 : 如果您使使用繁體中文, 您可以免費獲得語語言援助服務務請致電 (TTY:711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). French ATTENTION : Si vous parlez français, des services d'aide linguistique proposés gratuitement. Appelez le (ATS : 711). vous sont Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn Gọi số (TTY: 711). phí dành cho bạn. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны услуги перевода. Звоните (телетайп: 711). бесплатные Arabic المساعدة اللغوية تتوافر لك ببالمجان. اتصل برقم (رقم ھاتف الصم تتحدث اذكر اللغة فإن خدمات ملحوظة: إذا كنت ووالبكم: 711). H8197_17_17235_465_TXMMPMultiLang Accepted 9/5/ MMP0517

5 Hindi य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए उपल ध ह (TTY: 711) पर क ल कर Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Portugués ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Japanese 注意事項 : 日本語を話される場合無料の言語支援をご利用いただけます (TTY: 711 ) までお電話にてご連絡ください Farsi توجه: اگر به زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با (TTY: (711 تماس بگيريد. Gujarati ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ. ફ ન કર (TTY: 711). Laotian ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Urdu خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: 711) H8197_17_17235_465_TXMMPMultiLang Accepted 9/5/ MMP0517

6 H8197_18_18203_0001_TXMMPFormulary es Approved 08/18/17 Molina Dual Options STAR+PLUS Medicare- Plan 2018 Lista de medicamentos cubiertos (Formulario) Esta es una lista de medicamentos que los miembros pueden obtener en Molina Dual Options STAR+PLUS MMP. Molina Dual Options STAR+PLUS MMP es un plan de salud con contratos con ambos Medicare y de Texas para proporcionar los beneficios de ambos programas a las personas inscritas. La lista de medicamentos cubiertos o red de farmacias y de proveedores pueden cambiar durante el año. Le enviaremos una notificación antes de realizar cambios que le puedan afectar. Los beneficios o copagos pueden cambiar a partir del 1. o de enero de cada año. Usted siempre puede consultar la lista más reciente de medicamentos de Molina Dual Options STAR+PLUS MMP en línea Pueden aplicarse limitaciones, copagos y restricciones. Para obtener más información llame al Departamento de Servicios para Miembros de Molina Dual Options STAR+PLUS MMP o consulte el "Manual del miembro" de Molina Dual Options STAR+PLUS MMP. If you speak English, language assistance services, free of charge, are available to you. Call (866) , TTY/TDD: 711, Monday Friday, 8 a.m. to 8 p.m., local time. The call is free. Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (866) , TTY/TDD al 711, lunes a viernes, de 8:00 a.m. a 8:00 p.m., hora local. Esta es una llamada gratuita. Puede obtener este documento sin cargo en otros formatos, como letra grande, sistema braille o audio. Llame al (866) , servicio TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para hacer una solicitud continua de materiales en un lenguaje diferente al inglés o en un formato alternativo ahora y en el futuro, comuníquese con el Departamento de Servicios para Miembros al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite i

7 Las preguntas más frecuentes (FAQ) Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta lista de medicamentos cubiertos. Usted puede leer todas las preguntas frecuentes para saber más o buscar preguntas y respuestas. 1. Qué medicamentos recetados se encuentran en la Lista de Medicamentos cubiertos? (Llamamos "Lista de Medicamentos" a la lista de medicamentos que están cubiertos, para abreviar.) Los medicamentos de la Lista de Medicamentos cubiertos que comienza en la página insert page number son los medicamentos cubiertos por Molina Dual Options STAR+PLUS MMP. Los medicamentos están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ella, para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a estas farmacias como farmacias de la red. Molina Dual Options STAR+PLUS MMP cubrirá todos los medicamentos de la lista médicamente necesarios, si: su médico u otro proveedor recetador dice que usted los necesita para mejorar o para mantenerse sano, y usted surte la receta en una farmacia de la red de Molina Dual Options STAR+PLUS MMP. Molina Dual Options STAR+PLUS MMP puede tener pasos adicionales para tener acceso a ciertos tipos de medicamentos (consulte la pregunta #5 de abajo). También puede consultar la lista actualizada de medicamentos que cubrimos en nuestra página web, o llamando al Departamento de Servicios para Miembros al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. 2. La Lista de Medicamentos cambia alguna vez? Sí. Molina Dual Options STAR+PLUS MMP puede agregar o quitar medicamentos de la Lista de Medicamentos durante el año. Por lo general, la Lista de Medicamentos solo se modificará si: surge un medicamento más económico que sea tan efectivo como alguno de los medicamentos que se encuentran en la Lista de Medicamentos; o nos enteramos de que algún medicamento no es seguro.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite ii

8 También podemos cambiar nuestras reglas sobre los medicamentos. Por ejemplo, podríamos: Decidir si exigir o no autorización previa para algún medicamento. (La autorización previa es el permiso de Molina Dual Options STAR+PLUS MMP antes de que usted pueda obtener un medicamento). Añadir o cambiar la cantidad de un medicamento que usted puede obtener (llamado "límites de cantidades ). Añadir o cambiar restricciones de terapia escalonada con respecto a un medicamento. (La terapia escalonada significa que usted debe probar un medicamento antes de que cubramos otro medicamento.) (Para obtener más información acerca de estas restricciones, lea la página xi.) Le avisaremos cuando quitemos de la Lista de Medicamentos algún medicamento de Medicare Parte D que usted esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún medicamento de Medicare Parte D. En las siguientes preguntas 3, 4 y 7 usted obtendrá más información sobre lo que sucederá cuando cambie la Lista de Medicamentos. Usted siempre puede consultar la lista más reciente de medicamentos de Molina Dual Options STAR+PLUS MMP en línea También puede llamar al Departamento de Servicios para Miembros para revisar la Lista de Medicamentos actual al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. 3. Qué sucede si aparece un medicamento más barato que funcione tan bien como algún medicamento que actualmente se encuentra en la Lista de Medicamentos? Si usted toma algún medicamento de Medicare Parte D que hayamos quitado de la lista porque hay un medicamento más barato que funciona igual de bien, le avisaremos. Le diremos por lo menos 60 días antes de sacarlo de la lista de medicamentos o la próxima vez que pida una renovación. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de medicamentos. Usted recibirá esta notificación por correo al menos 60 días antes de que se realice este cambio.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite iii

9 4. Qué sucederá si nos enteramos que un medicamento no es seguro? Si la Administración de Medicamentos y Alimentos (FDA, por sus siglas en inglés) dice que cierto medicamento no es seguro, inmediatamente lo quitaremos de la Lista de Medicamentos. También le enviaremos una carta avisándole. Por favor, hable con su médico para encontrar una alternativa para usted que será segura. 5. La cobertura de medicamentos tiene alguna restricción o límite? O bien, hay que hacer algo en particular para poder obtener ciertos medicamentos? Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el medicamento. Por ejemplo: Autorización previa (o aprobación previa): Para algunos medicamentos, usted, su médico u otro proveedor recetador deben obtener una aprobación de Molina Dual Options STAR+PLUS MMP antes de surtir su receta. Si no recibe la aprobación, Molina Options STAR+PLUS MMP no podrá cubrir el medicamento. Límites de cantidades: A veces Molina Dual Options STAR+PLUS MMP limita la cantidad de un medicamento que usted puede obtener. Terapia escalonada: A veces Molina Dual Options STAR+PLUS MMP le exigirá realizar una terapia escalonada. Esto significa que usted tendrá que probar los medicamentos en un cierto orden para su enfermedad. Posiblemente tendría que probar un medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el primer medicamento no funciona para usted, entonces cubriremos el segundo. Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los cuadros de las páginas También puede obtener información en nuestra página web, Hemos publicado en línea los documentos que explican nuestras restricciones de autorización previa y terapia escalonada. También puede pedir que se le envíe una copia. También puede pedir una "excepción" de esos límites. Por favor lea la pregunta 11 para más información acerca de las excepciones.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite iv

10 Si usted está en una residencia para ancianos u otro centro de atención a largo plazo y necesita algún medicamento que no esté en la lista de medicamentos, o si no puede obtener fácilmente el medicamento que necesita, nosotros podemos ayudarle. Cubriremos un suministro de emergencia de 31 días del medicamento que usted necesite (a menos que tenga una receta para menos días), sin importar que usted sea o no un miembro nuevo de Molina Dual Options STAR+PLUS MMP. Esto le dará tiempo para hablar con su médico u otro proveedor recetador. Él o ella podrá ayudarle a decidir si hay algún otro medicamento similar en la lista de medicamentos que usted pueda tomar en su lugar o si tiene que solicitar una excepción. Por favor lea la pregunta 11 para obtener más información sobre las excepciones. 6. Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer algo para obtenerlo? La lista de medicamentos cubiertos de la página 1 tiene una columna llamada "Medidas necesarias, restricciones o límites de uso". 7. Qué sucederá si cambiamos nuestras reglas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos requisitos de autorización (aprobación) previa, límites de cantidad o restricciones de terapia escalonada sobre algún medicamento. Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidades y restricciones de terapia escalonada a un medicamento. Le avisaremos por lo menos 60 días antes de agregar la restricción o cuando pida su siguiente resurtido. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de Medicamentos. Esto le dará tiempo para hablar con su médico u otro proveedor recetador sobre qué hacer después. 8. Cómo puede encontrar un medicamento en la Lista de Medicamentos? Hay dos maneras de encontrar un medicamento: Puede buscar por orden alfabético (si sabe cómo se escribe el nombre del medicamento); o Puede buscar por condición médica.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite v

11 Para buscar por orden alfabético, vaya a la sección alfabética de la lista. Puede encontrarla en el índice. El índice ofrece una lista alfabética de todos los medicamentos incluidos en este documento. El índice incluye tanto los medicamentos de marca registrada como los genéricos. Consulte el índice y encuentre su medicamento. Al lado del nombre de su medicamento verá el número de la página donde encontrará información acerca de la cobertura. Vaya a la página que aparece en el índice y encuentre el nombre de su medicamento en la primera columna de la lista. Para buscar por enfermedad, consulte la sección Lista de medicamentos por enfermedad, en la página page number. Los medicamentos en esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si tiene una enfermedad del corazón, usted debe buscar en la categoría de bloqueadores beta. Ahí encontrará los medicamentos que traten enfermedades del corazón. 9. Qué pasa si el medicamento que usted quiere tomar no está en la Lista de Medicamentos? Si no encuentra su medicamento en la Lista de Medicamentos, llame al Departamento de Servicios para Miembros al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local y consulte sobre el tema. Si le informan que Molina Dual Options STAR+PLUS MMP no cubrirá el medicamento, podrá optar por una de las siguientes: Solicite al Departamento de Servicios para Miembros una lista de medicamentos similares al que desea tomar. Luego, enséñele la lista a su médico u otro recetador. Éste podrá recetarle un medicamento de la lista de medicamentos similar al que usted quiere tomar; O También puede pedir al plan de salud que haga una excepción para cubrir su medicamento. Por favor lea la pregunta 11 para obtener más información sobre las excepciones. 10. Qué pasa si usted es un miembro nuevo de Molina Dual Options STAR+PLUS MMP y no puede encontrar su medicamento en la Lista de Medicamentos o tiene problemas para obtener su medicamento? Nosotros podemos ayudarle. Es posible que cubramos un suministro provisional de 60 días de su medicamento durante los primeros 90 días de ser un miembro de Molina Dual Options STAR+PLUS MMP. Esto le dará tiempo para hablar con su médico u otro proveedor recetador. Él o ella podrá ayudarle a decidir si hay algún otro medicamento similar en la lista de medicamentos que usted pueda tomar en su lugar o si tiene que solicitar una excepción. Cubriremos un suministro de 60 días de su medicamento si usted:? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite vi

12 está tomando algún medicamento que no esté en nuestra lista de medicamentos, o las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor recetador, o el medicamento requiere autorización previa de Molina Dual Options STAR+PLUS MMP, o toma algún medicamento que forme parte de una restricción de terapia escalonada. Si usted vive en un hogar para personas mayores u otra institución de cuidados a largo plazo, usted puede volver a surtir su receta médica hasta por 98 días. Usted puede realizar la renovación del medicamento varias veces durante los primeros 90 días en el plan. Esto le dará tiempo a su proveedor médico para cambiar su medicamento por alguno que esté en la Lista de Medicamentos o para pedir una excepción. Política de transición Los miembros nuevos de nuestro plan podrían estar tomando medicamentos no incluidos en nuestro formulario o medicamentos sujetos a determinadas restricciones, como una autorización previa o terapia escalonada. Los miembros actuales también pueden estar afectados por los cambios en nuestro formulario de un año al siguiente. Los miembros deberían hablar con sus médicos para determinar si deben cambiar su medicamento a uno distinto que cubramos o si deben solicitar una excepción al formulario para recibir cobertura para ese medicamento. Consulte el Manual del miembro para conocer más sobre cómo pedir una excepción. Comuníquese con el Departamento de Servicios para Miembros si su medicamento no está en nuestro formulario, si está sujeto a ciertas restricciones, tales como autorización previa o terapia escalonada, o si ya no se incluirá en nuestro formulario el próximo año y necesita ayuda para cambiar el medicamento a uno distinto que cubramos o para pedir una excepción al formulario. Durante el tiempo que un miembro esté hablando con su médico para determinar la medida de acción correcta, es posible que podamos proporcionar un suministro provisional del medicamento no incluido en el formulario si esos miembros necesitan una renovación del medicamento durante los primeros 90 días de membresía con nuestro plan de medicamentos de Parte D (categoría 1 y 2) y 180 días para sus medicamentos de (categoría 3). Si usted es un miembro actual afectado por un cambio en el formulario de un año al siguiente, le proporcionaremos un suministro provisional del medicamento no incluido en el formulario si necesita una renovación del medicamento durante los primeros 90 días del nuevo año del plan. Cuando un miembro va a una farmacia que participa en la red y le proporcionamos un suministro provisional del medicamento que ya no está incluido en el formulario, o que tiene restricciones en cobertura o límites (pero de lo contrario, se considera ser un "medicamento de Parte D"),? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite vii

13 cubriremos un suministro de 60 días (a menos que la receta médica sea para menos días). Después de cubrir el suministro provisional de 60 días, comúnmente no pagaremos por estos medicamentos de nuevo como parte de nuestra política de transición. Le proporcionaremos un aviso por escrito después de cubrir su suministro provisional. Este aviso le explicará los pasos que puede tomar para solicitar una excepción y cómo trabajar con su médico para decidir si debería cambiarse a un medicamento que sea apropiado y que cubramos. Si un miembro nuevo es residente de un centro de atención médica a largo plazo (tal como una residencia para ancianos), cubriremos un suministro provisional de transición para 31 días (a menos que la receta médica sea para menos días). Conforme sea necesario, cubriremos más de una renovación de estos medicamentos durante los primeros 90 días que un miembro nuevo esté inscrito en nuestro plan. Si el residente ha estado inscrito en nuestro plan durante más de 90 días y necesita un medicamento que ya no está incluido en nuestro formulario o está sujeto a otras restricciones, tal como una terapia escalonada o límites en dosificación, cubriremos un suministro provisional de emergencia de 31 días para ese medicamento (a menos que la receta médica sea para menos días) mientras que el nuevo miembro solicite una excepción de formulario. Se considerarán excepciones a las situaciones donde usted está pasando por un cambio en el nivel de cuidado que recibe, el cual también requiere que usted sea trasladado de un centro de atención a otro. En dichas circunstancias, usted será elegible para una excepción provisional una sola vez, aun si han pasado los primeros 90 días de su membresía con el plan. 11. Puede pedir al plan que sea haga una excepción para cubrir su medicamento? Sí. Puede solicitarle a Molina Dual Options STAR+PLUS MMP que haga una excepción para cubrir su medicamento que no está en la Lista de Medicamentos. Usted también puede pedirnos un cambio en las reglas sobre su medicamento. Por ejemplo, Molina Dual Options STAR+PLUS MMP podría limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, usted puede pedirnos que cambiemos el límite y extendamos la cobertura. Otros ejemplos: usted puede solicitarnos que quitemos las restricciones de la terapia escalonada o los requisitos de autorización previa.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite viii

14 12. Cuánto tiempo toma obtener una excepción? Primero, debemos obtener una declaración de su proveedor recetador apoyando su solicitud de una excepción. Después de obtener la declaración, le daremos una decisión sobre su solicitud de excepción a más tardar en 72 horas. Si usted o su proveedor recetador piensa que su salud puede estar en peligro si esperar 72 horas para una decisión, puede solicitar una excepción acelerada. Se trata de una decisión más rápida. Si su recetador apoya su solicitud, le daremos una decisión dentro de las primeras 24 horas de haber recibido la declaración de apoyo de su recetador. 13. Cómo se puede solicitar una excepción? Para solicitar una excepción, comuníquese con el Departamento de Servicios para Miembros. Un representante del Departamento de Servicios para Miembros trabajará con usted y su proveedor para ayudarle a solicitar una excepción. 14. Qué son los medicamentos genéricos? Los medicamentos genéricos están hechos con los mismos ingredientes que los medicamentos de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidos. Los medicamentos genéricos son aprobados por la Administración de Medicamentos y Alimentos (FDA). Molina Medicare Options STAR+PLUS MMP cubre tanto medicamentos de marca registrada como medicamentos genéricos. 15. Qué son los medicamentos de venta libre (OTC)? OTC son siglas en inglés que significan "medicamentos de venta libre. Molina Dual Options STAR+PLUS MMP cubre algunos medicamentos de venta libre cuando su proveedor recetador los escribe como recetas. Usted puede leer la Lista de Medicamentos de Molina Dual Options STAR+PLUS MMP para ver qué medicamentos de venta libre tienen cobertura.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite ix

15 16. Molina Dual Options STAR+PLUS MMP cubre los productos no farmacológicos de venta libre? Molina Dual Options STAR+PLUS MMP cubre algunos productos no farmacológicos de venta libre cuando su proveedor recetador los escribe como recetas. Usted puede leer la Lista de Medicamentos de Molina Dual Options STAR+PLUS MMP para ver cuáles productos no farmacológicos de venta libre tienen cobertura. 17. Qué es su copago? Como miembro de Molina Dual Options STAR+PLUS MMP, usted no tiene copagos por medicamentos recetados y medicamentos de venta libre, siempre y cuando usted siga las reglas de Molina Dual Options STAR+PLUS MMP. 18. Qué son las categorías de medicamentos? Las categorías son grupos de medicamentos en nuestra lista de medicamentos. Los medicamentos de categoría 1 son los medicamentos genéricos. Para medicamentos de categoría 1, usted no paga nada. Los medicamentos de categoría 2 son medicamentos de marca comercial. Para medicamentos de categoría 2, usted no paga nada. Los medicamentos de la categoría 3 son medicamentos recetados o medicamentos de venta libre (OTC) no cubiertos por Medicare. Para medicamentos de categoría 3, usted no paga nada. Lista de los medicamentos cubiertos La siguiente lista de medicamentos cubiertos le proporciona información sobre los medicamentos cubiertos por Molina Dual Options STAR+PLUS MMP. Si usted no puede encontrar su medicamento en la lista, consulte el índice que comienza en la página 125. La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de marca registrada están escritos en mayúsculas (p. ej.: BYSTOLIC) y los medicamentos genéricos están escritos en cursivas minúsculas (p. ej.: metoprolol).? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite x

16 La información de la columna titulada Medidas necesarias, Restricciones o Límites de uso, le indica si Molina Dual Options STAR+PLUS MMP tiene alguna regla para cubrir su medicamento. Nota: El (*) junto a un medicamento significa que el medicamento no es un "Medicamento de la Parte D". La cantidad que usted paga cuándo surta una receta de este medicamento no cuenta hacia el costo total de sus medicamentos (o sea, la cantidad que usted paga no le ayuda para ser elegible para cobertura catastrófica). Además, si recibe Ayuda Adicional para pagar sus medicamentos recetados, usted no recibirá ninguna Ayuda Adicional para pagar estos medicamentos. Estos medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una manera formal de solicitarnos la revisión de una decisión de cobertura y cambiarlo si usted piensa que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted quiere ya no está cubierto por Medicare o de Texas. Si usted o su médico no están de acuerdo con nuestra decisión, puede apelar. Para pedir instrucciones sobre cómo presentar una apelación, comuníquese con el Departamento de Servicios para Miembros al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. Usted también puede saber cómo apelar una decisión leyendo el Manual del miembro. La información en la columna "Restricciones y límites" indica si Molina Dual Options STAR+PLUS MMP tiene algún requerimiento especial para la cobertura de su medicamento. PA significa "autorización previa" QL significa "límites de cantidades" ST significa "criterios de terapia escalonada" NM significa "no disponible para servicio por correo" B/D Este medicamento puede ser cubierto bajo Medicare Parte B o Parte D, dependiendo de las circunstancias LA significa "medicamento con acceso limitado" NDS significa que es para un suministro diario no extendido * - Medicamentos no incluidos en la parte D, o artículos OTC que están cubiertos por. Lista de medicamentos por condición médica Los medicamentos en esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si tiene una enfermedad del corazón, usted debe buscar en la categoría de bloqueadores beta. Ahí encontrará los medicamentos que traten enfermedades del corazón.? Si usted tiene cualquier pregunta acerca de esta carta, comuníquese con el Molina Dual Options STAR+PLUS MMP al (866) , TTY / TDD al 711, de lunes a viernes, de 8:00 a. m. a 8:00 p. m., hora local. La llamada es gratuita. Para obtener más información, visite xi

17 MOLINA_TX_CY18_2T_MMP eff 07/01/2018 Drug Name (By Medical Condition) WHAT THE ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 100 mg $0 (1) allopurinol tab 300 mg $0 (1) colchicine w/ probenecid tab mg $0 (1) COLCRYS TAB 0.6MG $0 (2) QL (120 tabs / 30 days) MITIGARE CAP 0.6MG $0 (2) QL (60 caps / 30 days) probenecid tab 500 mg $0 (1) ULORIC TAB 40MG $0 (2) ST ULORIC TAB 80MG $0 (2) ST MISCELLANEOUS acephen sup 120mg $0 (3) NM; * acephen sup 325mg $0 (3) NM; * acephen sup 650mg $0 (3) NM; * acetaminophen tab 325 mg $0 (3) NM; * arthrts pain tab 650mg $0 (3) NM; * aspir-low tab 81mg ec $0 (3) NM; * aspirin chew tab 81 mg $0 (3) NM; * aspirin chw 81mg $0 (3) NM; * aspirin low chw 81mg $0 (3) NM; * aspirin low tab 81mg ec $0 (3) NM; * aspirin tab 325 mg $0 (3) NM; * aspirin tab delayed release 81 mg $0 (3) NM; * aspirin tab delayed release 325 mg $0 (3) NM; * child asa chw 81mg $0 (3) NM; * chlds mapap tab 80mg rt $0 (3) NM; * ed-apap liq 80mg/2.5 $0 (3) NM; * junior mapap tab 160mg rt $0 (3) NM; * mapap apap liq 500/15ml $0 (3) NM; * mapap cap 500mg $0 (3) NM; * mapap child tab 80mg rt $0 (3) NM; * mapap childr sus 160/5ml $0 (3) NM; * mapap chw 80mg $0 (3) NM; * mapap liq 160/5ml $0 (3) NM; * mapap tab 325mg $0 (3) NM; * mapap tab 500mg $0 (3) NM; * migraine tab formula $0 (3) NM; * pain & fever chw 80mg $0 (3) NM; * pain & fever sol 160/5ml $0 (3) NM; * 1

18 Drug Name (By Medical Condition) WHAT THE pain & fever sus 160/5ml $0 (3) NM; * pain & fever tab 325mg $0 (3) NM; * pain & fever tab 500mg $0 (3) NM; * q-pap child sus 160/5ml $0 (3) NM; * q-pap tab 325mg $0 (3) NM; * q-pap tab 500mg $0 (3) NM; * NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION all day relf tab 220mg $0 (3) NM; * celecoxib cap 50 mg $0 (1) QL (240 caps / 30 days) celecoxib cap 100 mg $0 (1) QL (120 caps / 30 days) celecoxib cap 200 mg $0 (1) QL (60 caps / 30 days) celecoxib cap 400 mg $0 (1) QL (30 caps / 30 days) diclofenac potassium tab 50 mg $0 (1) QL (120 tabs / 30 days) diclofenac sodium tab delayed release 25 $0 (1) mg diclofenac sodium tab delayed release 50 $0 (1) mg diclofenac sodium tab delayed release 75 $0 (1) mg diclofenac sodium tab er 24hr 100 mg $0 (1) diflunisal tab 500 mg $0 (1) etodolac cap 200 mg $0 (1) etodolac cap 300 mg $0 (1) etodolac tab 400 mg $0 (1) etodolac tab 500 mg $0 (1) etodolac tab er 24hr 400 mg $0 (1) etodolac tab er 24hr 500 mg $0 (1) etodolac tab er 24hr 600 mg $0 (1) flurbiprofen tab 50 mg $0 (1) flurbiprofen tab 100 mg $0 (1) ibu-200 tab 200mg $0 (3) NM; * ibu-drops dro 40mg/ml $0 (3) NM; * ibu-drops dro 50/1.25 $0 (3) NM; * ibuprofen cap 200 mg $0 (3) NM; * ibuprofen dro 50/1.25 $0 (3) NM; * ibuprofen jr chw 100mg $0 (3) NM; * ibuprofen sus 100/5ml $0 (3) NM; * ibuprofen susp 100 mg/5ml $0 (1) ibuprofen susp 100 mg/5ml $0 (3) NM; * ibuprofen tab 200 mg $0 (3) NM; * ibuprofen tab 200mg $0 (3) NM; * ibuprofen tab 400 mg $0 (1) 2

19 Drug Name (By Medical Condition) WHAT THE ibuprofen tab 600 mg $0 (1) ibuprofen tab 800 mg $0 (1) ketoprofen cap 50 mg $0 (1) ketoprofen cap 75 mg $0 (1) meloxicam tab 7.5 mg $0 (1) meloxicam tab 15 mg $0 (1) nabumetone tab 500 mg $0 (1) nabumetone tab 750 mg $0 (1) naproxen dr tab 375mg $0 (1) naproxen dr tab 500mg $0 (1) naproxen sod tab 220mg $0 (3) NM; * naproxen sodium tab 275 mg $0 (1) naproxen sodium tab 550 mg $0 (1) naproxen susp 125 mg/5ml $0 (1) naproxen tab 250 mg $0 (1) naproxen tab 375 mg $0 (1) naproxen tab 500 mg $0 (1) piroxicam cap 10 mg $0 (1) piroxicam cap 20 mg $0 (1) sulindac tab 150 mg $0 (1) sulindac tab 200 mg $0 (1) OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine soln $0 (1) QL (5000 ml / 30 days) mg/5ml acetaminophen w/ codeine tab $0 (1) QL (400 tabs / 30 days) mg acetaminophen w/ codeine tab $0 (1) QL (400 tabs / 30 days) mg acetaminophen w/ codeine tab $0 (1) QL (400 tabs / 30 days) mg butorphanol tartrate inj 1 mg/ml $0 (2) butorphanol tartrate inj 2 mg/ml $0 (2) BUTRANS DIS 5MCG/HR $0 (2) QL (16 patches / 28 days) BUTRANS DIS 7.5/HR $0 (2) QL (8 patches / 28 days) BUTRANS DIS 10MCG/HR $0 (2) QL (8 patches / 28 days) BUTRANS DIS 15MCG/HR $0 (2) QL (4 patches / 28 days) BUTRANS DIS 20MCG/HR $0 (2) QL (4 patches / 28 days) nalbuphine hcl inj 10 mg/ml $0 (2) nalbuphine hcl inj 20 mg/ml $0 (2) tramadol hcl tab 50 mg $0 (1) QL (240 tabs / 30 days) 3

20 Drug Name (By Medical Condition) WHAT THE tramadol-acetaminophen tab mg $0 (1) QL (240 tabs / 30 days) OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet tab $0 (1) QL (360 tabs / 30 days) endocet tab 5-325mg $0 (1) QL (360 tabs / 30 days) endocet tab $0 (1) QL (360 tabs / 30 days) endocet tab mg $0 (1) QL (360 tabs / 30 days) fentanyl citrate lozenge on a handle 200 $0 (2) NDS, QL (120 lozenges / mcg 30 days), PA fentanyl citrate lozenge on a handle 400 $0 (2) NDS, QL (120 lozenges / mcg 30 days), PA fentanyl citrate lozenge on a handle 600 $0 (2) NDS, QL (120 lozenges / mcg 30 days), PA fentanyl citrate lozenge on a handle 800 $0 (2) NDS, QL (120 lozenges / mcg 30 days), PA fentanyl citrate lozenge on a handle 1200 mcg $0 (2) NDS, QL (120 lozenges / 30 days), PA fentanyl citrate lozenge on a handle 1600 mcg $0 (2) NDS, QL (120 lozenges / 30 days), PA fentanyl td patch 72hr 12 mcg/hr $0 (1) QL (10 patches / 30 days) fentanyl td patch 72hr 25 mcg/hr $0 (1) QL (10 patches / 30 days) fentanyl td patch 72hr 50 mcg/hr $0 (1) QL (10 patches / 30 days), PA fentanyl td patch 72hr 75 mcg/hr $0 (1) QL (10 patches / 30 days), PA fentanyl td patch 72hr 100 mcg/hr $0 (1) QL (10 patches / 30 days), PA FENTORA TAB 100MCG $0 (2) NDS, QL (120 tabs / 30 days), PA FENTORA TAB 200MCG $0 (2) NDS, QL (120 tabs / 30 days), PA FENTORA TAB 400MCG $0 (2) NDS, QL (120 tabs / 30 days), PA FENTORA TAB 600MCG $0 (2) NDS, QL (120 tabs / 30 days), PA FENTORA TAB 800MCG $0 (2) NDS, QL (120 tabs / 30 days), PA hydrocodone-acetaminophen soln 7.5- $0 (1) QL (5400 ml / 30 days) 325 mg/15ml hydrocodone-acetaminophen tab mg $0 (1) QL (360 tabs / 30 days) 4

21 Drug Name (By Medical Condition) WHAT THE hydrocodone-acetaminophen tab mg $0 (1) QL (360 tabs / 30 days) hydrocodone-acetaminophen tab $0 (1) QL (360 tabs / 30 days) mg hydrocodone-ibuprofen tab mg $0 (1) QL (150 tabs / 30 days) hydromorphone hcl liqd 1 mg/ml $0 (1) hydromorphone hcl preservative free $0 (2) B/D (pf) inj 10 mg/ml hydromorphone hcl tab 2 mg $0 (1) QL (270 tabs / 30 days) hydromorphone hcl tab 4 mg $0 (1) QL (270 tabs / 30 days) hydromorphone hcl tab 8 mg $0 (1) QL (270 tabs / 30 days) HYSINGLA ER TAB 20 MG $0 (2) QL (60 tabs / 30 days) HYSINGLA ER TAB 30 MG $0 (2) QL (60 tabs / 30 days) HYSINGLA ER TAB 40 MG $0 (2) QL (60 tabs / 30 days) HYSINGLA ER TAB 60 MG $0 (2) QL (60 tabs / 30 days) HYSINGLA ER TAB 80 MG $0 (2) QL (30 tabs / 30 days) HYSINGLA ER TAB 100 MG $0 (2) QL (30 tabs / 30 days) HYSINGLA ER TAB 120 MG $0 (2) QL (30 tabs / 30 days) methadone con 10mg/ml $0 (1) QL (120 ml / 30 days) methadone hcl soln 5 mg/5ml $0 (1) QL (450 ml / 30 days) methadone hcl soln 10 mg/5ml $0 (1) QL (450 ml / 30 days) methadone hcl tab 5 mg $0 (1) QL (180 tabs / 30 days) methadone hcl tab 10 mg $0 (1) QL (180 tabs / 30 days) MORPHINE SUL INJ 2MG/ML $0 (2) B/D MORPHINE SUL INJ 4MG/ML $0 (2) B/D MORPHINE SUL INJ 5MG/ML $0 (2) B/D MORPHINE SUL INJ 8MG/ML $0 (2) B/D MORPHINE SUL INJ 10MG/ML $0 (2) B/D MORPHINE SUL INJ 150/30ML $0 (2) B/D morphine sulfate inj 8 mg/ml $0 (2) B/D morphine sulfate inj 10 mg/ml $0 (2) B/D morphine sulfate iv soln 1 mg/ml $0 (2) B/D morphine sulfate iv soln pf 4 mg/ml $0 (2) B/D morphine sulfate iv soln pf 8 mg/ml $0 (2) B/D morphine sulfate iv soln pf 10 mg/ml $0 (2) B/D morphine sulfate oral soln 10 mg/5ml $0 (1) morphine sulfate oral soln 20 mg/5ml $0 (1) morphine sulfate oral soln 100 mg/5ml $0 (1) (20 mg/ml) morphine sulfate tab 15 mg $0 (1) QL (180 tabs / 30 days) morphine sulfate tab 30 mg $0 (1) QL (180 tabs / 30 days) morphine sulfate tab er 15 mg $0 (1) QL (90 tabs / 30 days) 5

22 Drug Name (By Medical Condition) WHAT THE morphine sulfate tab er 30 mg $0 (1) QL (90 tabs / 30 days) morphine sulfate tab er 60 mg $0 (1) QL (90 tabs / 30 days) morphine sulfate tab er 100 mg $0 (1) QL (90 tabs / 30 days) morphine sulfate tab er 200 mg $0 (1) QL (60 tabs / 30 days) NUCYNTA ER TAB 50MG $0 (2) QL (120 tabs / 30 days) NUCYNTA ER TAB 100MG $0 (2) QL (120 tabs / 30 days) NUCYNTA ER TAB 150MG $0 (2) QL (60 tabs / 30 days) NUCYNTA ER TAB 200MG $0 (2) QL (60 tabs / 30 days) NUCYNTA ER TAB 250MG $0 (2) QL (60 tabs / 30 days) oxycodone hcl cap 5 mg $0 (1) QL (180 caps / 30 days) oxycodone hcl conc 100 mg/5ml (20 $0 (1) mg/ml) oxycodone hcl soln 5 mg/5ml $0 (1) oxycodone hcl tab 5 mg $0 (1) QL (180 tabs / 30 days) oxycodone hcl tab 10 mg $0 (1) QL (180 tabs / 30 days) oxycodone hcl tab 15 mg $0 (1) QL (180 tabs / 30 days) oxycodone hcl tab 20 mg $0 (1) QL (180 tabs / 30 days) oxycodone hcl tab 30 mg $0 (1) QL (180 tabs / 30 days) oxycodone w/ acetaminophen tab mg $0 (1) QL (360 tabs / 30 days) oxycodone w/ acetaminophen tab $0 (1) QL (360 tabs / 30 days) mg oxycodone w/ acetaminophen tab 7.5- $0 (1) QL (360 tabs / 30 days) 325 mg oxycodone w/ acetaminophen tab 10- $0 (1) QL (360 tabs / 30 days) 325 mg OXYCONTIN TAB 10MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 15MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 20MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 30MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 40MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 60MG CR $0 (2) QL (120 tabs / 30 days) OXYCONTIN TAB 80MG CR $0 (2) QL (120 tabs / 30 days) ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl local inj 0.5% $0 (1) B/D lidocaine hcl local inj 1% $0 (1) B/D lidocaine hcl local inj 2% $0 (1) B/D lidocaine hcl local preservative free (pf) $0 (1) B/D inj 0.5% lidocaine hcl local preservative free (pf) inj 1% $0 (1) B/D 6

23 Drug Name (By Medical Condition) WHAT THE lidocaine hcl local preservative free (pf) inj 1.5% $0 (1) B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 $0 (1) mg/ml) amikacin sulfate inj 500 mg/2ml (250 $0 (1) mg/ml) gentamicin in saline inj 0.8 mg/ml $0 (1) gentamicin in saline inj 1 mg/ml $0 (1) gentamicin in saline inj 1.2 mg/ml $0 (1) gentamicin in saline inj 1.6 mg/ml $0 (1) gentamicin in saline inj 2 mg/ml $0 (1) gentamicin sulfate inj 10 mg/ml $0 (1) gentamicin sulfate inj 40 mg/ml $0 (1) neomycin sulfate tab 500 mg $0 (1) paromomycin sulfate cap 250 mg $0 (1) streptomycin sulfate for inj 1 gm $0 (1) SULFADIAZINE TAB 500MG $0 (2) tobramycin nebu soln 300 mg/5ml $0 (2) NDS, NM, PA tobramycin sulfate for inj 1.2 gm $0 (2) NDS tobramycin sulfate inj 1.2 gm/30ml (40 $0 (1) mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 $0 (1) mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base $0 (1) equivalent) tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) $0 (1) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG $0 (2) NDS ALINIA SUS 100/5ML $0 (2) NDS ALINIA TAB 500MG $0 (2) NDS atovaquone susp 750 mg/5ml $0 (2) NDS AZACTAM INJ 1GM $0 (2) AZACTAM INJ 2GM $0 (2) AZACTAM/DEX INJ 1GM $0 (2) AZACTAM/DEX INJ 2GM $0 (2) aztreonam for inj 1 gm $0 (1) aztreonam for inj 2 gm $0 (1) BILTRICIDE TAB 600MG $0 (2) CAYSTON INH 75MG $0 (2) NDS, LA, PA 7

24 Drug Name (By Medical Condition) WHAT THE clindamycin hcl cap 75 mg $0 (1) clindamycin hcl cap 150 mg $0 (1) clindamycin hcl cap 300 mg $0 (1) clindamycin palmitate hcl for soln 75 $0 (1) mg/5ml (base equiv) clindamycin phosphate in d5w iv soln $0 (1) 300 mg/50ml clindamycin phosphate in d5w iv soln $0 (1) 600 mg/50ml clindamycin phosphate in d5w iv soln $0 (1) 900 mg/50ml clindamycin phosphate inj 9 gm/60ml $0 (1) clindamycin phosphate inj 300 mg/2ml $0 (1) clindamycin phosphate inj 600 mg/4ml $0 (1) clindamycin phosphate inj 900 mg/6ml $0 (1) clindamycin phosphate iv soln 300 $0 (1) mg/2ml clindamycin phosphate iv soln 900 $0 (1) mg/6ml CLINDMYC/NAC INJ 300/50ML $0 (2) CLINDMYC/NAC INJ 600/50ML $0 (2) CLINDMYC/NAC INJ 900/50ML $0 (2) colistimethate sod for inj 150 mg $0 (1) (colistin base activity) dapsone tab 25 mg $0 (1) dapsone tab 100 mg $0 (1) daptomycin for iv soln 500 mg $0 (2) NDS EMVERM CHW 100MG $0 (2) NDS imipenem-cilastatin intravenous for soln $0 (1) 250 mg imipenem-cilastatin intravenous for soln $0 (1) 500 mg INVANZ INJ 1GM $0 (2) ivermectin tab 3 mg $0 (1) linezolid for susp 100 mg/5ml $0 (2) NDS linezolid in sodium chloride iv soln 600 $0 (2) NDS mg/300ml-0.9% linezolid iv soln 600 mg/300ml (2 $0 (2) NDS mg/ml) linezolid tab 600 mg $0 (2) NDS meropenem iv for soln 1 gm $0 (1) meropenem iv for soln 500 mg $0 (1) 8

25 Drug Name (By Medical Condition) WHAT THE methenamine hippurate tab 1 gm $0 (1) metronidazole in nacl 0.79% iv soln 500 $0 (1) mg/100ml metronidazole tab 250 mg $0 (1) metronidazole tab 500 mg $0 (1) NEBUPENT INH 300MG $0 (2) B/D nitrofurantoin macrocrystalline cap 50 mg $0 (2) PA; PA applies if 65 years and after a 90 day supply in a calendar year nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg $0 (2) PA; PA applies if 65 years and after a 90 day supply in a calendar year $0 (2) PA; PA applies if 65 years and after a 90 day supply in a calendar year PENTAM 300 INJ 300MG $0 (2) praziquantel tab 600 mg $0 (1) SIVEXTRO INJ 200MG $0 (2) NDS SIVEXTRO TAB 200MG $0 (2) NDS sulfamethoxazole-trimethoprim iv soln $0 (1) mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml $0 (1) sulfamethoxazole-trimethoprim tab 400- $0 (1) 80 mg sulfamethoxazole-trimethoprim tab 800- $0 (1) 160 mg SYNERCID INJ 500MG $0 (2) NDS tigecycline for iv soln 50 mg $0 (2) NDS TIGECYCLINE INJ 50MG $0 (2) NDS trimethoprim tab 100 mg $0 (1) vancomycin hcl cap 125 mg $0 (2) NDS vancomycin hcl cap 250 mg $0 (2) NDS vancomycin hcl for inj 10 gm $0 (1) vancomycin hcl for inj 500 mg $0 (1) vancomycin hcl for inj 750 mg $0 (1) vancomycin hcl for inj 1000 mg $0 (1) vancomycin hcl for inj 5000 mg $0 (1) VANCOMYCIN INJ 1 GM $0 (2) VANCOMYCIN INJ 500MG $0 (2) 9

26 Drug Name (By Medical Condition) WHAT THE VANCOMYCIN INJ 750MG $0 (2) ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET INJ 5MG/ML $0 (2) NDS, B/D AMBISOME INJ 50MG $0 (2) NDS, B/D amphotericin b for inj 50 mg $0 (1) B/D CANCIDAS INJ 50MG $0 (2) NDS CANCIDAS INJ 70MG $0 (2) NDS caspofungin acetate for iv soln 50 mg $0 (2) NDS caspofungin acetate for iv soln 70 mg $0 (2) NDS CASPOFUNGIN INJ 50MG $0 (2) NDS CASPOFUNGIN INJ 70MG $0 (2) NDS fluconazole for susp 10 mg/ml $0 (1) fluconazole for susp 40 mg/ml $0 (1) fluconazole in dextrose inj 200 $0 (1) mg/100ml fluconazole in dextrose inj 400 $0 (1) mg/200ml fluconazole in nacl 0.9% inj 200 $0 (1) mg/100ml fluconazole in nacl 0.9% inj 400 $0 (1) mg/200ml fluconazole tab 50 mg $0 (1) fluconazole tab 100 mg $0 (1) fluconazole tab 150 mg $0 (1) fluconazole tab 200 mg $0 (1) FLUCONAZOLE/ INJ NACL 100 $0 (2) flucytosine cap 250 mg $0 (2) NDS flucytosine cap 500 mg $0 (2) NDS griseofulvin microsize susp 125 mg/5ml $0 (1) griseofulvin microsize tab 500 mg $0 (1) griseofulvin ultramicrosize tab 125 mg $0 (1) griseofulvin ultramicrosize tab 250 mg $0 (1) itraconazole cap 100 mg $0 (1) PA ketoconazole tab 200 mg $0 (1) PA MYCAMINE INJ 50MG $0 (2) NDS MYCAMINE INJ 100MG $0 (2) NDS NOXAFIL SUS 40MG/ML $0 (2) NDS, QL (630 ml / 30 days) NOXAFIL TAB 100MG $0 (2) NDS, QL (93 tabs / 30 days) nystatin tab unit $0 (1) terbinafine hcl tab 250 mg $0 (1) QL (90 tabs / 365 days) 10

27 Drug Name (By Medical Condition) WHAT THE voriconazole for inj 200 mg $0 (1) voriconazole for susp 40 mg/ml $0 (2) NDS voriconazole tab 50 mg $0 (2) NDS voriconazole tab 200 mg $0 (2) NDS ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab $0 (1) mg atovaquone-proguanil hcl tab $0 (1) mg chloroquine phosphate tab 250 mg $0 (1) chloroquine phosphate tab 500 mg $0 (1) COARTEM TAB MG $0 (2) mefloquine hcl tab 250 mg $0 (1) PRIMAQUINE TAB 26.3MG $0 (2) quinine sulfate cap 324 mg $0 (1) PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate soln 20 mg/ml (base $0 (1) equiv) abacavir sulfate tab 300 mg (base equiv) $0 (1) APTIVUS CAP 250MG $0 (2) NDS APTIVUS SOL $0 (2) NDS atazanavir sulfate cap 150 mg (base $0 (2) NDS equiv) atazanavir sulfate cap 200 mg (base $0 (2) NDS equiv) atazanavir sulfate cap 300 mg (base $0 (2) NDS equiv) CRIXIVAN CAP 200MG $0 (2) CRIXIVAN CAP 400MG $0 (2) didanosine delayed release capsule 200 $0 (1) mg didanosine delayed release capsule 250 $0 (1) mg didanosine delayed release capsule 400 $0 (1) mg EDURANT TAB 25MG $0 (2) NDS efavirenz cap 50 mg $0 (1) efavirenz cap 200 mg $0 (2) NDS efavirenz tab 600 mg $0 (2) NDS EMTRIVA CAP 200MG $0 (2) EMTRIVA SOL 10MG/ML $0 (2) 11

28 Drug Name (By Medical Condition) WHAT THE fosamprenavir calcium tab 700 mg (base equiv) $0 (2) NDS FUZEON INJ 90MG $0 (2) NDS, NM INTELENCE TAB 25MG $0 (2) NM INTELENCE TAB 100MG $0 (2) NDS, NM INTELENCE TAB 200MG $0 (2) NDS, NM INVIRASE CAP 200MG $0 (2) NDS INVIRASE TAB 500MG $0 (2) NDS ISENTRESS CHW 25MG $0 (2) ISENTRESS CHW 100MG $0 (2) NDS ISENTRESS HD TAB 600MG $0 (2) NDS ISENTRESS POW 100MG $0 (2) NDS ISENTRESS TAB 400MG $0 (2) NDS lamivudine oral soln 10 mg/ml $0 (1) lamivudine tab 150 mg $0 (1) lamivudine tab 300 mg $0 (1) LEXIVA SUS 50MG/ML $0 (2) LEXIVA TAB 700MG $0 (2) NDS nevirapine tab 200 mg $0 (1) nevirapine tab er 24hr 100 mg $0 (1) nevirapine tab er 24hr 400 mg $0 (1) NORVIR CAP 100MG $0 (2) NORVIR SOL 80MG/ML $0 (2) NORVIR TAB 100MG $0 (2) PREZISTA SUS 100MG/ML $0 (2) NDS, QL (400 ml / 30 days) PREZISTA TAB 75MG $0 (2) QL (480 tabs / 30 days) PREZISTA TAB 150MG $0 (2) NDS, QL (240 tabs / 30 days) PREZISTA TAB 600MG $0 (2) NDS, QL (60 tabs / 30 days) PREZISTA TAB 800MG $0 (2) NDS, QL (30 tabs / 30 days) RESCRIPTOR TAB 100 MG $0 (2) RESCRIPTOR TAB 200MG $0 (2) RETROVIR INJ 10MG/ML $0 (2) REYATAZ POW 50MG $0 (2) NDS ritonavir tab 100 mg $0 (1) SELZENTRY SOL 20MG/ML $0 (2) NDS SELZENTRY TAB 25MG $0 (2) SELZENTRY TAB 75MG $0 (2) NDS SELZENTRY TAB 150MG $0 (2) NDS 12

29 Drug Name (By Medical Condition) WHAT THE SELZENTRY TAB 300MG $0 (2) NDS stavudine cap 15 mg $0 (1) stavudine cap 20 mg $0 (1) stavudine cap 30 mg $0 (1) stavudine cap 40 mg $0 (1) SUSTIVA TAB 600MG $0 (2) NDS tenofovir disoproxil fumarate tab 300 mg $0 (2) NDS TIVICAY TAB 10MG $0 (2) TIVICAY TAB 25MG $0 (2) NDS TIVICAY TAB 50MG $0 (2) NDS TROGARZO INJ 150MG/ML $0 (2) NDS, LA TYBOST TAB 150MG $0 (2) VIDEX EC CAP 125MG $0 (2) VIDEX SOL 2GM $0 (2) VIDEX SOL 4GM $0 (2) VIRACEPT TAB 250MG $0 (2) NDS VIRACEPT TAB 625MG $0 (2) NDS VIRAMUNE SUS 50MG/5ML $0 (2) VIREAD POW 40MG/GM $0 (2) NDS VIREAD TAB 150MG $0 (2) NDS VIREAD TAB 200MG $0 (2) NDS VIREAD TAB 250MG $0 (2) NDS VIREAD TAB 300MG $0 (2) NDS ZERIT SOL 1MG/ML $0 (2) NDS zidovudine cap 100 mg $0 (1) zidovudine syrup 10 mg/ml $0 (1) zidovudine tab 300 mg $0 (1) ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine tab $0 (2) NDS mg abacavir sulfate-lamivudine-zidovudine $0 (2) NDS tab mg ATRIPLA TAB $0 (2) NDS BIKTARVY TAB $0 (2) NDS COMPLERA TAB $0 (2) NDS DESCOVY TAB 200/25 $0 (2) NDS EVOTAZ TAB $0 (2) NDS GENVOYA TAB $0 (2) NDS JULUCA TAB 50-25MG $0 (2) NDS KALETRA TAB MG $0 (2) KALETRA TAB MG $0 (2) NDS 13

30 Drug Name (By Medical Condition) WHAT THE lamivudine-zidovudine tab mg $0 (1) lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) $0 (2) NDS ODEFSEY TAB $0 (2) NDS PREZCOBIX TAB $0 (2) NDS STRIBILD TAB $0 (2) NDS SYMFI LO TAB $0 (2) NDS TRIUMEQ TAB $0 (2) NDS TRUVADA TAB $0 (2) NDS, QL (60 tabs / 30 days) TRUVADA TAB $0 (2) NDS, QL (30 tabs / 30 days) TRUVADA TAB $0 (2) NDS, QL (30 tabs / 30 days) TRUVADA TAB $0 (2) NDS, QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM $0 (2) cycloserine cap 250 mg $0 (2) NDS ethambutol hcl tab 100 mg $0 (1) ethambutol hcl tab 400 mg $0 (1) isoniazid inj 100 mg/ml $0 (1) isoniazid syrup 50 mg/5ml $0 (1) isoniazid tab 100 mg $0 (1) isoniazid tab 300 mg $0 (1) PASER GRA 4GM $0 (2) PRIFTIN TAB 150MG $0 (2) pyrazinamide tab 500 mg $0 (1) rifabutin cap 150 mg $0 (1) rifampin cap 150 mg $0 (1) rifampin cap 300 mg $0 (1) rifampin for inj 600 mg $0 (1) RIFATER TAB $0 (2) SIRTURO TAB 100MG $0 (2) NDS, LA, PA TRECATOR TAB 250MG $0 (2) ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg $0 (1) acyclovir sodium iv soln 50 mg/ml $0 (1) B/D acyclovir susp 200 mg/5ml $0 (1) acyclovir tab 400 mg $0 (1) acyclovir tab 800 mg $0 (1) adefovir dipivoxil tab 10 mg $0 (2) NDS 14

31 Drug Name (By Medical Condition) WHAT THE BARACLUDE SOL.05MG/ML $0 (2) NDS DAKLINZA TAB 30MG $0 (2) NDS, PA DAKLINZA TAB 60MG $0 (2) NDS, PA DAKLINZA TAB 90MG $0 (2) NDS, PA entecavir tab 0.5 mg $0 (2) NDS entecavir tab 1 mg $0 (2) NDS EPCLUSA TAB $0 (2) NDS, PA EPIVIR HBV SOL 5MG/ML $0 (2) famciclovir tab 125 mg $0 (1) famciclovir tab 250 mg $0 (1) famciclovir tab 500 mg $0 (1) GANCICLOVIR INJ 500MG $0 (1) B/D ganciclovir sodium for inj 500 mg $0 (1) B/D HARVONI TAB MG $0 (2) NDS, NM, PA lamivudine tab 100 mg (hbv) $0 (1) MAVYRET TAB MG $0 (2) NDS, PA oseltamivir phosphate cap 30 mg (base $0 (1) QL (168 caps / year) equiv) oseltamivir phosphate cap 45 mg (base $0 (1) QL (84 caps / year) equiv) oseltamivir phosphate cap 75 mg (base equiv) $0 (1) QL (84 caps / year) oseltamivir phosphate for susp 6 mg/ml $0 (1) QL (1080 ml / year) (base equiv) PEGASYS INJ $0 (2) NDS, NM, PA PEGASYS INJ 180MCG/M $0 (2) NDS, NM, PA PEGASYS INJ PROCLICK $0 (2) NDS, NM, PA REBETOL SOL 40MG/ML $0 (2) NDS, NM RELENZA MIS DISKHALE $0 (2) QL (6 inhalers / year) ribasphere cap 200mg $0 (1) NM ribasphere tab 200mg $0 (1) NM ribasphere tab 400mg $0 (2) NDS, NM ribasphere tab 600mg $0 (2) NDS, NM ribavirin cap 200 mg $0 (1) NM ribavirin tab 200 mg $0 (1) NM rimantadine hydrochloride tab 100 mg $0 (1) SOVALDI TAB 400MG $0 (2) NDS, NM, PA valacyclovir hcl tab 1 gm $0 (1) valacyclovir hcl tab 500 mg $0 (1) valganciclovir hcl for soln 50 mg/ml (base equiv) $0 (2) NDS 15

32 Drug Name (By Medical Condition) WHAT THE valganciclovir hcl tab 450 mg (base $0 (2) NDS equivalent) VEMLIDY TAB 25MG $0 (2) NDS VOSEVI TAB $0 (2) NDS, PA ZEPATIER TAB MG $0 (2) NDS, PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor cap 250 mg $0 (1) cefaclor cap 500 mg $0 (1) CEFACLOR ER TAB 500MG $0 (2) cefaclor for susp 125 mg/5ml $0 (1) cefaclor for susp 250 mg/5ml $0 (1) cefaclor for susp 375 mg/5ml $0 (1) cefadroxil cap 500 mg $0 (1) cefadroxil for susp 250 mg/5ml $0 (1) cefadroxil for susp 500 mg/5ml $0 (1) cefadroxil tab 1 gm $0 (1) CEFAZOLIN INJ 1GM/50ML $0 (2) cefazolin sodium for inj 1 gm $0 (1) cefazolin sodium for inj 10 gm $0 (1) cefazolin sodium for inj 20 gm $0 (1) cefazolin sodium for inj 500 mg $0 (1) cefazolin sodium for iv soln 1 gm $0 (1) CEFAZOLIN SOL $0 (2) cefdinir cap 300 mg $0 (1) cefdinir for susp 125 mg/5ml $0 (1) cefdinir for susp 250 mg/5ml $0 (1) cefepime hcl for inj 1 gm $0 (1) cefepime hcl for inj 2 gm $0 (1) cefixime for susp 100 mg/5ml $0 (1) cefixime for susp 200 mg/5ml $0 (1) cefotaxime sodium for inj 1 gm $0 (1) cefotaxime sodium for inj 2 gm $0 (1) cefotaxime sodium for inj 500 mg $0 (1) cefoxitin sodium for inj 10 gm $0 (1) cefoxitin sodium for iv soln 1 gm $0 (1) cefoxitin sodium for iv soln 2 gm $0 (1) cefpodoxime proxetil for susp 50 mg/5ml $0 (1) cefpodoxime proxetil for susp 100 $0 (1) mg/5ml cefpodoxime proxetil tab 100 mg $0 (1) cefpodoxime proxetil tab 200 mg $0 (1) 16

33 Drug Name (By Medical Condition) WHAT THE cefprozil for susp 125 mg/5ml $0 (1) cefprozil for susp 250 mg/5ml $0 (1) cefprozil tab 250 mg $0 (1) cefprozil tab 500 mg $0 (1) ceftazidime for inj 1 gm $0 (1) ceftazidime for inj 2 gm $0 (1) ceftazidime for inj 6 gm $0 (1) CEFTAZIDIME/ SOL D5W 1GM $0 (2) CEFTAZIDIME/ SOL D5W 2GM $0 (2) ceftriaxone sodium for inj 1 gm $0 (1) ceftriaxone sodium for inj 2 gm $0 (1) ceftriaxone sodium for inj 10 gm $0 (1) ceftriaxone sodium for inj 250 mg $0 (1) ceftriaxone sodium for inj 500 mg $0 (1) ceftriaxone sodium for iv soln 1 gm $0 (1) ceftriaxone sodium for iv soln 2 gm $0 (1) cefuroxime axetil tab 250 mg $0 (1) cefuroxime axetil tab 500 mg $0 (1) cefuroxime sodium for inj 7.5 gm $0 (1) cefuroxime sodium for inj 750 mg $0 (1) cefuroxime sodium for iv soln 1.5 gm $0 (1) cephalexin cap 250 mg $0 (1) cephalexin cap 500 mg $0 (1) cephalexin for susp 125 mg/5ml $0 (1) cephalexin for susp 250 mg/5ml $0 (1) SUPRAX CAP 400MG $0 (2) SUPRAX CHW 100MG $0 (2) SUPRAX CHW 200MG $0 (2) SUPRAX SUS 500/5ML $0 (2) tazicef inj 1gm $0 (1) tazicef inj 2gm $0 (1) tazicef inj 6gm $0 (1) TEFLARO INJ 400MG $0 (2) NDS TEFLARO INJ 600MG $0 (2) NDS ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml $0 (1) azithromycin for susp 200 mg/5ml $0 (1) azithromycin iv for soln 500 mg $0 (1) azithromycin powd pack for susp 1 gm $0 (1) azithromycin tab 250 mg $0 (1) azithromycin tab 500 mg $0 (1) 17

34 Drug Name (By Medical Condition) WHAT THE azithromycin tab 600 mg $0 (1) clarithromycin for susp 125 mg/5ml $0 (1) clarithromycin for susp 250 mg/5ml $0 (1) clarithromycin tab 250 mg $0 (1) clarithromycin tab 500 mg $0 (1) clarithromycin tab er 24hr 500 mg $0 (1) DIFICID TAB 200MG $0 (2) NDS ery-tab tab 250mg ec $0 (1) ery-tab tab 333mg ec $0 (1) ery-tab tab 500mg ec $0 (1) ERYTHROCIN INJ 500MG $0 (2) erythrocin tab 250mg $0 (1) erythromycin ethylsuccinate tab 400 mg $0 (1) erythromycin tab 250 mg $0 (1) erythromycin tab 500 mg $0 (1) erythromycin w/ delayed release $0 (1) particles cap 250 mg FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w $0 (1) ciprofloxacin 400 mg/200ml in d5w $0 (1) ciprofloxacin for oral susp 250 mg/5ml $0 (1) (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml $0 (1) (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base $0 (1) equiv) ciprofloxacin hcl tab 250 mg (base $0 (1) equiv) ciprofloxacin hcl tab 500 mg (base $0 (1) equiv) ciprofloxacin hcl tab 750 mg (base $0 (1) equiv) ciprofloxacin iv soln 200 mg/20ml (1%) $0 (1) ciprofloxacin iv soln 400 mg/40ml (1%) $0 (1) levofloxacin in d5w iv soln 250 mg/50ml $0 (1) levofloxacin in d5w iv soln 500 $0 (1) mg/100ml levofloxacin in d5w iv soln 750 $0 (1) mg/150ml levofloxacin iv soln 25 mg/ml $0 (1) levofloxacin oral soln 25 mg/ml $0 (1) levofloxacin tab 250 mg $0 (1) 18

35 Drug Name (By Medical Condition) WHAT THE levofloxacin tab 500 mg $0 (1) levofloxacin tab 750 mg $0 (1) moxifloxacin hcl tab 400 mg (base $0 (1) equiv) PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin & k clavulanate chew tab $0 (1) mg amoxicillin & k clavulanate chew tab $0 (1) mg amoxicillin & k clavulanate for susp 200- $0 (1) 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- $0 (1) 62.5 mg/5ml amoxicillin & k clavulanate for susp 400- $0 (1) 57 mg/5ml amoxicillin & k clavulanate for susp 600- $0 (1) 42.9 mg/5ml amoxicillin & k clavulanate tab $0 (1) mg amoxicillin & k clavulanate tab $0 (1) mg amoxicillin & k clavulanate tab $0 (1) mg amoxicillin & k clavulanate tab er 12hr $0 (1) mg amoxicillin (trihydrate) cap 250 mg $0 (1) amoxicillin (trihydrate) cap 500 mg $0 (1) amoxicillin (trihydrate) chew tab 125 mg $0 (1) amoxicillin (trihydrate) chew tab 250 mg $0 (1) amoxicillin (trihydrate) for susp 125 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 200 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 250 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 400 $0 (1) mg/5ml amoxicillin (trihydrate) tab 500 mg $0 (1) amoxicillin (trihydrate) tab 875 mg $0 (1) ampicillin & sulbactam sodium for inj 1.5 $0 (1) (1-0.5) gm ampicillin & sulbactam sodium for inj 3 $0 (1) (2-1) gm 19

36 Drug Name (By Medical Condition) WHAT THE ampicillin & sulbactam sodium for inj 15 $0 (1) (10-5) gm ampicillin & sulbactam sodium for iv soln $0 (1) 15 (10-5) gm ampicillin cap 250 mg $0 (1) ampicillin cap 500 mg $0 (1) ampicillin for susp 125 mg/5ml $0 (1) ampicillin for susp 250 mg/5ml $0 (1) ampicillin sodium for inj 1 gm $0 (1) ampicillin sodium for inj 2 gm $0 (1) ampicillin sodium for inj 10 gm $0 (1) ampicillin sodium for inj 125 mg $0 (1) ampicillin sodium for inj 250 mg $0 (1) ampicillin sodium for inj 500 mg $0 (1) ampicillin sodium for iv soln 1 gm $0 (1) ampicillin sodium for iv soln 2 gm $0 (1) ampicillin sodium for iv soln 10 gm $0 (1) BICILLIN L-A INJ $0 (2) BICILLIN L-A INJ $0 (2) BICILLIN L-A INJ $0 (2) dicloxacillin sodium cap 250 mg $0 (1) dicloxacillin sodium cap 500 mg $0 (1) nafcillin sodium for inj 1 gm $0 (1) nafcillin sodium for inj 2 gm $0 (1) nafcillin sodium for iv soln 1 gm $0 (1) nafcillin sodium for iv soln 2 gm $0 (1) nafcillin sodium for iv soln 10 gm $0 (2) NDS oxacillin sodium for inj 1 gm (base $0 (1) equivalent) oxacillin sodium for inj 2 gm (base $0 (1) equivalent) oxacillin sodium for inj 10 gm (base $0 (2) NDS equivalent) PEN G PROC INJ $0 (2) PENICILL GK/ INJ DEX 2MU $0 (2) PENICILL GK/ INJ DEX 3MU $0 (2) penicillin g potassium for inj $0 (1) unit penicillin g potassium for inj unit $0 (1) penicillin g sodium for inj unit $0 (1) 20

37 Drug Name (By Medical Condition) WHAT THE penicillin v potassium for soln 125 $0 (1) mg/5ml penicillin v potassium for soln 250 $0 (1) mg/5ml penicillin v potassium tab 250 mg $0 (1) penicillin v potassium tab 500 mg $0 (1) PIPER/TAZOBA INJ GM $0 (2) piperacillin sod-tazobactam na for inj $0 (1) gm ( gm) piperacillin sod-tazobactam sod for inj $0 (1) 2.25 gm ( gm) piperacillin sod-tazobactam sod for inj $0 (1) 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj $0 (1) 40.5 gm ( gm) TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 inj 100mg $0 (1) doxycycline hyclate cap 50 mg $0 (1) doxycycline hyclate cap 100 mg $0 (1) doxycycline hyclate for inj 100 mg $0 (1) doxycycline hyclate tab 20 mg $0 (1) doxycycline hyclate tab 100 mg $0 (1) doxycycline monohydrate cap 50 mg $0 (1) doxycycline monohydrate cap 100 mg $0 (1) doxycycline monohydrate tab 50 mg $0 (1) doxycycline monohydrate tab 75 mg $0 (1) doxycycline monohydrate tab 100 mg $0 (1) doxycycline monohydrate tab 150 mg $0 (1) minocycline hcl cap 50 mg $0 (1) minocycline hcl cap 75 mg $0 (1) minocycline hcl cap 100 mg $0 (1) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA INJ 100/4ML $0 (2) NDS, B/D busulfan inj 6 mg/ml $0 (2) NDS, B/D CYCLOPHOSPH CAP 25MG $0 (2) B/D CYCLOPHOSPH CAP 50MG $0 (2) B/D cyclophosphamide cap 25 mg $0 (1) B/D cyclophosphamide cap 50 mg $0 (1) B/D cyclophosphamide for inj 1 gm $0 (2) NDS, B/D cyclophosphamide for inj 2 gm $0 (2) NDS, B/D cyclophosphamide for inj 500 mg $0 (2) NDS, B/D 21

38 Drug Name (By Medical Condition) WHAT THE dacarbazine for inj 100 mg $0 (1) B/D dacarbazine for inj 200 mg $0 (1) B/D EMCYT CAP 140MG $0 (2) GLEOSTINE CAP 5MG $0 (2) GLEOSTINE CAP 10MG $0 (2) GLEOSTINE CAP 40MG $0 (2) GLEOSTINE CAP 100MG $0 (2) HEXALEN CAP 50MG $0 (2) NDS IFEX INJ 3GM $0 (2) B/D ifosfamide for inj 1 gm $0 (1) B/D IFOSFAMIDE INJ 3GM $0 (2) B/D ifosfamide iv inj 1 gm/20ml (50 mg/ml) $0 (1) B/D ifosfamide iv inj 3 gm/60ml (50 mg/ml) $0 (1) B/D LEUKERAN TAB 2MG $0 (2) melphalan hcl for inj 50 mg (base equiv) $0 (2) NDS, B/D MUSTARGEN INJ 10MG $0 (2) NDS, B/D ANTHRACYCLINES adriamycin inj 20mg $0 (1) B/D doxorubicin hcl for inj 10 mg $0 (1) B/D doxorubicin hcl for inj 50 mg $0 (1) B/D doxorubicin hcl inj 2 mg/ml $0 (1) B/D doxorubicin hcl liposomal inj (for iv $0 (2) NDS, B/D infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (2 $0 (1) B/D mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 $0 (1) B/D mg/ml) ANTIBIOTICS bleomycin sulfate for inj 15 unit $0 (1) B/D bleomycin sulfate for inj 30 unit $0 (1) B/D mitomycin for iv soln 5 mg $0 (2) NDS, B/D mitomycin for iv soln 20 mg $0 (2) NDS, B/D mitomycin for iv soln 40 mg $0 (2) NDS, B/D ANTIMETABOLITES adrucil inj 2.5g/50m $0 (1) B/D adrucil inj 5gm/100m $0 (1) B/D adrucil inj 500/10ml $0 (1) B/D ALIMTA INJ 100MG $0 (2) NDS, B/D ALIMTA INJ 500MG $0 (2) NDS, B/D azacitidine for inj 100 mg $0 (2) NDS, B/D, NM cladribine iv soln 10 mg/10ml (1 mg/ml) $0 (2) NDS, B/D cytarabine inj 20 mg/ml $0 (1) B/D 22

39 Drug Name (By Medical Condition) WHAT THE fludarabine phosphate for inj 50 mg $0 (1) B/D fludarabine phosphate inj 25 mg/ml $0 (1) B/D fluorouracil iv soln 1 gm/20ml (50 $0 (1) B/D mg/ml) fluorouracil iv soln 2.5 gm/50ml (50 $0 (1) B/D mg/ml) fluorouracil iv soln 5 gm/100ml (50 $0 (1) B/D mg/ml) fluorouracil iv soln 500 mg/10ml (50 $0 (1) B/D mg/ml) gemcitabine hcl for inj 1 gm $0 (2) NDS, B/D gemcitabine hcl for inj 2 gm $0 (2) NDS, B/D gemcitabine hcl for inj 200 mg $0 (2) NDS, B/D gemcitabine hcl inj 1 gm/26.3ml (38 $0 (1) B/D mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 $0 (1) B/D mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 $0 (1) B/D mg/ml) (base equiv) mercaptopurine tab 50 mg $0 (1) methotrexate sodium for inj 1 gm $0 (1) B/D methotrexate sodium inj 50 mg/2ml (25 $0 (1) B/D mg/ml) methotrexate sodium inj 250 mg/10ml $0 (1) B/D (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml $0 (1) B/D (25 mg/ml) methotrexate sodium inj pf 250 $0 (1) B/D mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 $0 (1) B/D mg/40ml (25 mg/ml) NIPENT INJ 10MG $0 (2) NDS, B/D PURIXAN SUS 20MG/ML $0 (2) NDS TABLOID TAB 40MG $0 (2) ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG $0 (2) NDS, B/D docetaxel for inj conc 20 mg/ml $0 (2) NDS, B/D docetaxel for inj conc 80 mg/4ml (20 $0 (2) NDS, B/D mg/ml) DOCETAXEL INJ 20MG/2ML $0 (2) NDS, B/D DOCETAXEL INJ 80MG/4ML $0 (2) NDS, B/D DOCETAXEL INJ 80MG/8ML $0 (2) NDS, B/D DOCETAXEL INJ 160/8ML $0 (2) NDS, B/D 23

40 Drug Name (By Medical Condition) WHAT THE DOCETAXEL INJ 160/16ML $0 (2) NDS, B/D DOCETAXEL INJ 200/10 $0 (2) NDS, B/D docetaxel soln for iv infusion 20 mg/2ml $0 (2) NDS, B/D docetaxel soln for iv infusion 80 mg/8ml $0 (2) NDS, B/D docetaxel soln for iv infusion 160 mg/16ml $0 (2) NDS, B/D paclitaxel iv conc 30 mg/5ml (6 mg/ml) $0 (1) B/D paclitaxel iv conc 100 mg/16.7ml (6 $0 (1) B/D mg/ml) paclitaxel iv conc 150 mg/25ml (6 $0 (1) B/D mg/ml) paclitaxel iv conc 300 mg/50ml (6 $0 (1) B/D mg/ml) TAXOTERE INJ 80MG/4ML $0 (2) NDS, B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 mg/ml $0 (1) B/D vincasar pfs inj 1mg/ml $0 (1) B/D vincristine sulfate iv soln 1 mg/ml $0 (1) B/D vinorelbine tartrate inj 10 mg/ml (base $0 (1) B/D equiv) vinorelbine tartrate inj 50 mg/5ml (10 $0 (1) B/D mg/ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ $0 (2) NDS, NM, LA, PA AVASTIN INJ 400/16ML $0 (2) NDS, NM, LA, PA BELEODAQ INJ 500MG $0 (2) NDS, NM, PA BORTEZOMIB INJ 3.5MG $0 (2) NDS, PA ERIVEDGE CAP 150MG $0 (2) NDS, NM, LA, PA FARYDAK CAP 10MG $0 (2) NDS, LA, PA FARYDAK CAP 15MG $0 (2) NDS, LA, PA FARYDAK CAP 20MG $0 (2) NDS, LA, PA HERCEPTIN INJ 150MG $0 (2) NDS, PA HERCEPTIN INJ 440MG $0 (2) NDS, NM, PA IBRANCE CAP 75MG $0 (2) NDS, LA, PA IBRANCE CAP 100MG $0 (2) NDS, LA, PA IBRANCE CAP 125MG $0 (2) NDS, LA, PA IDHIFA TAB 50MG $0 (2) NDS, LA, PA IDHIFA TAB 100MG $0 (2) NDS, LA, PA KADCYLA INJ 100MG $0 (2) NDS, B/D, NM KADCYLA INJ 160MG $0 (2) NDS, B/D, NM KEYTRUDA INJ 100MG/4M $0 (2) NDS, PA KEYTRUDA SOL 50MG $0 (2) NDS, PA 24

41 Drug Name (By Medical Condition) WHAT THE KISQALI 200 PAK FEMARA $0 (2) NDS, PA KISQALI 400 PAK FEMARA $0 (2) NDS, PA KISQALI 600 PAK FEMARA $0 (2) NDS, PA KISQALI TAB 200DOSE $0 (2) NDS, PA KISQALI TAB 400DOSE $0 (2) NDS, PA KISQALI TAB 600DOSE $0 (2) NDS, PA LYNPARZA CAP 50MG $0 (2) NDS, LA, PA LYNPARZA TAB 100MG $0 (2) NDS, LA, PA LYNPARZA TAB 150MG $0 (2) NDS, LA, PA MYLOTARG INJ 4.5MG $0 (2) NDS, LA, PA NINLARO CAP 2.3MG $0 (2) NDS, PA NINLARO CAP 3MG $0 (2) NDS, PA NINLARO CAP 4MG $0 (2) NDS, PA ODOMZO CAP 200MG $0 (2) NDS, LA, PA RITUXAN INJ 100MG $0 (2) NDS, NM, LA, PA RITUXAN INJ 500MG $0 (2) NDS, NM, LA, PA RITUXAN INJ HYCELA $0 (2) NDS, LA, PA RUBRACA TAB 200MG $0 (2) NDS, LA, PA RUBRACA TAB 250MG $0 (2) NDS, LA, PA RUBRACA TAB 300MG $0 (2) NDS, LA, PA TECENTRIQ INJ 1200/20 $0 (2) NDS, LA, PA VELCADE INJ 3.5MG $0 (2) NDS, NM, PA VENCLEXTA TAB 10MG $0 (2) LA, PA VENCLEXTA TAB 50MG $0 (2) LA, PA VENCLEXTA TAB 100MG $0 (2) NDS, LA, PA VENCLEXTA TAB START PK $0 (2) NDS, LA, PA VERZENIO TAB 50MG $0 (2) NDS, LA, PA VERZENIO TAB 100MG $0 (2) NDS, LA, PA VERZENIO TAB 150MG $0 (2) NDS, LA, PA VERZENIO TAB 200MG $0 (2) NDS, LA, PA YERVOY INJ 50MG $0 (2) NDS, NM, PA YERVOY INJ 200MG $0 (2) NDS, NM, PA ZEJULA CAP 100MG $0 (2) NDS, LA, PA ZOLINZA CAP 100MG $0 (2) NDS, NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg $0 (1) bicalutamide tab 50 mg $0 (1) DEPO-PROVERA INJ 400/ML $0 (2) B/D ERLEADA TAB 60MG $0 (2) NDS, LA, PA exemestane tab 25 mg $0 (1) FARESTON TAB 60MG $0 (2) NDS FASLODEX INJ 250/5ML $0 (2) NDS, B/D 25

42 Drug Name (By Medical Condition) WHAT THE flutamide cap 125 mg $0 (1) hydroxyprogesterone caproate im in oil 1.25 gm/5ml $0 (2) NDS, B/D letrozole tab 2.5 mg $0 (1) leuprolide acetate inj kit 5 mg/ml $0 (1) NM, PA LUPRON DEPOT INJ 3.75MG $0 (2) NDS, NM, PA LUPRON DEPOT INJ 11.25MG $0 (2) NDS, NM, PA LYSODREN TAB 500MG $0 (2) megestrol acetate susp 40 mg/ml $0 (2) PA; PA if 65 years and megestrol acetate susp 625 mg/5ml $0 (2) PA megestrol acetate tab 20 mg $0 (2) PA; PA if 65 years and megestrol acetate tab 40 mg $0 (2) PA; PA if 65 years and nilutamide tab 150 mg $0 (2) NDS SOLTAMOX SOL 10MG/5ML $0 (2) tamoxifen citrate tab 10 mg (base $0 (1) equivalent) tamoxifen citrate tab 20 mg (base $0 (1) equivalent) TRELSTAR MIX INJ 3.75MG $0 (2) NDS, NM, PA TRELSTAR MIX INJ 11.25MG $0 (2) NDS, NM, PA XTANDI CAP 40MG $0 (2) NDS, NM, LA, PA ZYTIGA TAB 250MG $0 (2) NDS, NM, LA, PA ZYTIGA TAB 500MG $0 (2) NDS, LA, PA IMMUNOMODULATORS POMALYST CAP 1MG $0 (2) NDS, NM, LA, PA POMALYST CAP 2MG $0 (2) NDS, NM, LA, PA POMALYST CAP 3MG $0 (2) NDS, NM, LA, PA POMALYST CAP 4MG $0 (2) NDS, NM, LA, PA REVLIMID CAP 2.5MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA REVLIMID CAP 5MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA REVLIMID CAP 10MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA REVLIMID CAP 15MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA REVLIMID CAP 20MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA REVLIMID CAP 25MG $0 (2) NDS, QL (28 caps / 28 days), NM, LA, PA 26

43 Drug Name (By Medical Condition) WHAT THE THALOMID CAP 50MG $0 (2) NDS, QL (30 caps / 30 days), NM, PA THALOMID CAP 100MG $0 (2) NDS, QL (30 caps / 30 days), NM, PA THALOMID CAP 150MG $0 (2) NDS, QL (60 caps / 30 days), NM, PA THALOMID CAP 200MG $0 (2) NDS, QL (60 caps / 30 days), NM, PA KINASE INHIBITORS AFINITOR DIS TAB 2MG $0 (2) NDS, QL (150 tabs / 30 days), NM, PA AFINITOR DIS TAB 3MG $0 (2) NDS, QL (90 tabs / 30 days), NM, PA AFINITOR DIS TAB 5MG $0 (2) NDS, QL (60 tabs / 30 days), NM, PA AFINITOR TAB 2.5MG $0 (2) NDS, QL (30 tabs / 30 days), NM, PA AFINITOR TAB 5MG $0 (2) NDS, QL (30 tabs / 30 days), NM, PA AFINITOR TAB 7.5MG $0 (2) NDS, QL (30 tabs / 30 days), NM, PA AFINITOR TAB 10MG $0 (2) NDS, QL (30 tabs / 30 days), NM, PA ALECENSA CAP 150MG $0 (2) NDS, LA, PA ALUNBRIG PAK $0 (2) NDS, LA, PA ALUNBRIG TAB 30MG $0 (2) NDS, LA, PA ALUNBRIG TAB 90MG $0 (2) NDS, LA, PA ALUNBRIG TAB 180MG $0 (2) NDS, LA, PA BOSULIF TAB 100MG $0 (2) NDS, NM, PA BOSULIF TAB 400MG $0 (2) NDS, PA BOSULIF TAB 500MG $0 (2) NDS, NM, PA CABOMETYX TAB 20MG $0 (2) NDS, QL (30 tabs / 30 days), LA, PA CABOMETYX TAB 40MG $0 (2) NDS, QL (30 tabs / 30 days), LA, PA CABOMETYX TAB 60MG $0 (2) NDS, QL (30 tabs / 30 days), LA, PA CALQUENCE CAP 100MG $0 (2) NDS, LA, PA CAPRELSA TAB 100MG $0 (2) NDS, LA, PA CAPRELSA TAB 300MG $0 (2) NDS, LA, PA COMETRIQ KIT 60MG $0 (2) NDS, LA, PA COMETRIQ KIT 100MG $0 (2) NDS, LA, PA COMETRIQ KIT 140MG $0 (2) NDS, LA, PA 27

44 Drug Name (By Medical Condition) WHAT THE COTELLIC TAB 20MG $0 (2) NDS, LA, PA GILOTRIF TAB 20MG $0 (2) NDS, LA, PA GILOTRIF TAB 30MG $0 (2) NDS, LA, PA GILOTRIF TAB 40MG $0 (2) NDS, LA, PA ICLUSIG TAB 15MG $0 (2) NDS, LA, PA ICLUSIG TAB 45MG $0 (2) NDS, LA, PA imatinib mesylate tab 100 mg (base equivalent) $0 (2) NDS, QL (90 tabs / 30 days), NM, PA imatinib mesylate tab 400 mg (base equivalent) $0 (2) NDS, QL (60 tabs / 30 days), NM, PA IMBRUVICA CAP 70MG $0 (2) NDS, LA, PA IMBRUVICA CAP 140MG $0 (2) NDS, LA, PA IMBRUVICA TAB 140MG $0 (2) NDS, LA, PA IMBRUVICA TAB 280MG $0 (2) NDS, LA, PA IMBRUVICA TAB 420MG $0 (2) NDS, LA, PA IMBRUVICA TAB 560MG $0 (2) NDS, LA, PA INLYTA TAB 1MG $0 (2) NDS, QL (180 tabs / 30 days), NM, LA, PA INLYTA TAB 5MG $0 (2) NDS, QL (120 tabs / 30 days), NM, LA, PA IRESSA TAB 250MG $0 (2) NDS, LA, PA JAKAFI TAB 5MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA JAKAFI TAB 10MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA JAKAFI TAB 15MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA JAKAFI TAB 20MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA JAKAFI TAB 25MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA LENVIMA CAP 8 MG $0 (2) NDS, LA, PA LENVIMA CAP 10 MG $0 (2) NDS, LA, PA LENVIMA CAP 14 MG $0 (2) NDS, LA, PA LENVIMA CAP 18 MG $0 (2) NDS, LA, PA LENVIMA CAP 20 MG $0 (2) NDS, LA, PA LENVIMA CAP 24 MG $0 (2) NDS, LA, PA MEKINIST TAB 0.5MG $0 (2) NDS, NM, LA, PA MEKINIST TAB 2MG $0 (2) NDS, NM, LA, PA NERLYNX TAB 40MG $0 (2) NDS, LA, PA NEXAVAR TAB 200MG $0 (2) NDS, NM, LA, PA RYDAPT CAP 25MG $0 (2) NDS, PA SPRYCEL TAB 20MG $0 (2) NDS, NM, PA 28

45 Drug Name (By Medical Condition) WHAT THE SPRYCEL TAB 50MG $0 (2) NDS, NM, PA SPRYCEL TAB 70MG $0 (2) NDS, NM, PA SPRYCEL TAB 80MG $0 (2) NDS, NM, PA SPRYCEL TAB 100MG $0 (2) NDS, NM, PA SPRYCEL TAB 140MG $0 (2) NDS, NM, PA STIVARGA TAB 40MG $0 (2) NDS, NM, LA, PA SUTENT CAP 12.5MG $0 (2) NDS, NM, PA SUTENT CAP 25MG $0 (2) NDS, NM, PA SUTENT CAP 37.5MG $0 (2) NDS, NM, PA SUTENT CAP 50MG $0 (2) NDS, NM, PA TAFINLAR CAP 50MG $0 (2) NDS, NM, LA, PA TAFINLAR CAP 75MG $0 (2) NDS, NM, LA, PA TAGRISSO TAB 40MG $0 (2) NDS, LA, PA TAGRISSO TAB 80MG $0 (2) NDS, LA, PA TARCEVA TAB 25MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA TARCEVA TAB 100MG $0 (2) NDS, QL (30 tabs / 30 days), NM, LA, PA TARCEVA TAB 150MG $0 (2) NDS, QL (30 tabs / 30 days), NM, LA, PA TASIGNA CAP 50MG $0 (2) NDS, PA TASIGNA CAP 150MG $0 (2) NDS, NM, PA TASIGNA CAP 200MG $0 (2) NDS, NM, PA TYKERB TAB 250MG $0 (2) NDS, NM, LA, PA VOTRIENT TAB 200MG $0 (2) NDS, NM, LA, PA XALKORI CAP 200MG $0 (2) NDS, NM, LA, PA XALKORI CAP 250MG $0 (2) NDS, NM, LA, PA ZELBORAF TAB 240MG $0 (2) NDS, NM, LA, PA ZYDELIG TAB 100MG $0 (2) NDS, LA, PA ZYDELIG TAB 150MG $0 (2) NDS, LA, PA ZYKADIA CAP 150MG $0 (2) NDS, NM, LA, PA MISCELLANEOUS bexarotene cap 75 mg $0 (2) NDS, NM, PA DROXIA CAP 200MG $0 (2) DROXIA CAP 300MG $0 (2) DROXIA CAP 400MG $0 (2) hydroxyurea cap 500 mg $0 (1) LONSURF TAB $0 (2) NDS, PA LONSURF TAB $0 (2) NDS, PA MATULANE CAP 50MG $0 (2) NDS, LA mitoxantrone hcl inj conc 20 mg/10ml (2 $0 (1) B/D, NM mg/ml) 29

46 Drug Name (By Medical Condition) WHAT THE mitoxantrone hcl inj conc 25 mg/12.5ml $0 (1) B/D, NM (2 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 $0 (1) B/D, NM mg/ml) SYLATRON KIT 200MCG $0 (2) NDS, NM, PA SYLATRON KIT 300MCG $0 (2) NDS, NM, PA SYLATRON KIT 600MCG $0 (2) NDS, NM, PA SYNRIBO INJ 3.5MG $0 (2) NDS, NM, PA tretinoin cap 10 mg $0 (2) NDS TRISENOX INJ 12MG/6ML $0 (2) NDS, B/D PLATINUM-BASED AGENTS carboplatin iv soln 50 mg/5ml $0 (1) B/D carboplatin iv soln 150 mg/15ml $0 (1) B/D carboplatin iv soln 450 mg/45ml $0 (1) B/D carboplatin iv soln 600 mg/60ml $0 (1) B/D cisplatin inj 50 mg/50ml (1 mg/ml) $0 (1) B/D cisplatin inj 100 mg/100ml (1 mg/ml) $0 (1) B/D cisplatin inj 200 mg/200ml (1 mg/ml) $0 (1) B/D oxaliplatin for iv inj 50 mg $0 (2) NDS, B/D oxaliplatin for iv inj 100 mg $0 (2) NDS, B/D oxaliplatin iv soln 50 mg/10ml $0 (1) B/D oxaliplatin iv soln 100 mg/20ml $0 (1) B/D PROTECTIVE AGENTS dexrazoxane for inj 250 mg $0 (2) NDS, B/D dexrazoxane for inj 500 mg $0 (2) NDS, B/D ELITEK INJ 1.5MG $0 (2) NDS, B/D ELITEK INJ 7.5MG $0 (2) NDS, B/D leucovorin calcium for inj 50 mg $0 (1) B/D leucovorin calcium for inj 100 mg $0 (1) B/D leucovorin calcium for inj 200 mg $0 (1) B/D leucovorin calcium for inj 350 mg $0 (1) B/D leucovorin calcium for inj 500 mg $0 (1) B/D leucovorin calcium tab 5 mg $0 (1) leucovorin calcium tab 10 mg $0 (1) leucovorin calcium tab 15 mg $0 (1) leucovorin calcium tab 25 mg $0 (1) LEVOLEUCOVOR INJ 175MG $0 (2) NDS, B/D LEVOLEUCOVOR SOL 250MG/25 $0 (2) NDS, B/D levoleucovorin calcium for iv inj 50 mg $0 (2) NDS, B/D, NM (base equiv) levoleucovorin calcium inj 175 mg/17.5ml (base equiv) $0 (2) NDS, B/D 30

47 Drug Name (By Medical Condition) WHAT THE mesna inj 100 mg/ml $0 (1) B/D MESNEX TAB 400MG $0 (2) NDS TOPOISOMERASE INHIBITORS etoposide inj 100 mg/5ml (20 mg/ml) $0 (1) B/D etoposide inj 500 mg/25ml (20 mg/ml) $0 (1) B/D irinotecan hcl inj 40 mg/2ml (20 mg/ml) $0 (1) B/D irinotecan hcl inj 100 mg/5ml (20 $0 (1) B/D mg/ml) irinotecan hcl inj 500 mg/25ml (20 $0 (1) B/D mg/ml) toposar inj 1gm/50ml $0 (1) B/D toposar inj 100/5ml $0 (1) B/D topotecan hcl for inj 4 mg $0 (2) NDS, B/D, NM topotecan hcl inj 4 mg/4ml (base equiv) $0 (2) NDS, B/D (for infusion) TOPOTECAN INJ 4MG/4ML $0 (2) NDS, B/D CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-benazepril hcl cap $0 (1) mg amlodipine besylate-benazepril hcl cap $0 (1) 5-10 mg amlodipine besylate-benazepril hcl cap $0 (1) 5-20 mg amlodipine besylate-benazepril hcl cap $0 (1) 5-40 mg amlodipine besylate-benazepril hcl cap $0 (1) mg amlodipine besylate-benazepril hcl cap $0 (1) mg benazepril & hydrochlorothiazide tab 5- $0 (1) 6.25 mg benazepril & hydrochlorothiazide tab 10- $0 (1) 12.5 mg benazepril & hydrochlorothiazide tab 20- $0 (1) 12.5 mg benazepril & hydrochlorothiazide tab 20- $0 (1) 25 mg captopril & hydrochlorothiazide tab 25- $0 (1) 15 mg 31

48 Drug Name (By Medical Condition) WHAT THE captopril & hydrochlorothiazide tab 25- $0 (1) 25 mg captopril & hydrochlorothiazide tab 50- $0 (1) 15 mg captopril & hydrochlorothiazide tab mg $0 (1) enalapril maleate & hydrochlorothiazide $0 (1) tab mg enalapril maleate & hydrochlorothiazide $0 (1) tab mg fosinopril sodium & hydrochlorothiazide $0 (1) tab mg fosinopril sodium & hydrochlorothiazide $0 (1) tab mg lisinopril & hydrochlorothiazide tab 10- $0 (1) 12.5 mg lisinopril & hydrochlorothiazide tab 20- $0 (1) 12.5 mg lisinopril & hydrochlorothiazide tab $0 (1) mg moexipril-hydrochlorothiazide tab 7.5- $0 (1) 12.5 mg moexipril-hydrochlorothiazide tab 15- $0 (1) 12.5 mg moexipril-hydrochlorothiazide tab $0 (1) mg quinapril-hydrochlorothiazide tab 10- $0 (1) 12.5 mg quinapril-hydrochlorothiazide tab 20- $0 (1) 12.5 mg quinapril-hydrochlorothiazide tab $0 (1) mg ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl tab 5 mg $0 (1) benazepril hcl tab 10 mg $0 (1) benazepril hcl tab 20 mg $0 (1) benazepril hcl tab 40 mg $0 (1) captopril tab 12.5 mg $0 (1) captopril tab 25 mg $0 (1) captopril tab 50 mg $0 (1) captopril tab 100 mg $0 (1) enalapril maleate tab 2.5 mg $0 (1) enalapril maleate tab 5 mg $0 (1) 32

49 Drug Name (By Medical Condition) WHAT THE enalapril maleate tab 10 mg $0 (1) enalapril maleate tab 20 mg $0 (1) fosinopril sodium tab 10 mg $0 (1) fosinopril sodium tab 20 mg $0 (1) fosinopril sodium tab 40 mg $0 (1) lisinopril tab 2.5 mg $0 (1) lisinopril tab 5 mg $0 (1) lisinopril tab 10 mg $0 (1) lisinopril tab 20 mg $0 (1) lisinopril tab 30 mg $0 (1) lisinopril tab 40 mg $0 (1) moexipril hcl tab 7.5 mg $0 (1) moexipril hcl tab 15 mg $0 (1) perindopril erbumine tab 2 mg $0 (1) perindopril erbumine tab 4 mg $0 (1) perindopril erbumine tab 8 mg $0 (1) quinapril hcl tab 5 mg $0 (1) quinapril hcl tab 10 mg $0 (1) quinapril hcl tab 20 mg $0 (1) quinapril hcl tab 40 mg $0 (1) ramipril cap 1.25 mg $0 (1) ramipril cap 2.5 mg $0 (1) ramipril cap 5 mg $0 (1) ramipril cap 10 mg $0 (1) trandolapril tab 1 mg $0 (1) trandolapril tab 2 mg $0 (1) trandolapril tab 4 mg $0 (1) ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone tab 25 mg $0 (1) eplerenone tab 50 mg $0 (1) spironolactone tab 25 mg $0 (1) spironolactone tab 50 mg $0 (1) spironolactone tab 100 mg $0 (1) ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate tab 1 mg $0 (1) QL (30 tabs / 30 days) doxazosin mesylate tab 2 mg $0 (1) QL (30 tabs / 30 days) doxazosin mesylate tab 4 mg $0 (1) QL (30 tabs / 30 days) doxazosin mesylate tab 8 mg $0 (1) prazosin hcl cap 1 mg $0 (1) prazosin hcl cap 2 mg $0 (1) 33

50 Drug Name (By Medical Condition) WHAT THE prazosin hcl cap 5 mg $0 (1) terazosin hcl cap 1 mg (base equivalent) $0 (1) terazosin hcl cap 2 mg (base equivalent) $0 (1) terazosin hcl cap 5 mg (base equivalent) $0 (1) terazosin hcl cap 10 mg (base $0 (1) equivalent) ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan $0 (1) medoxomil tab 5-20 mg amlodipine besylate-olmesartan $0 (1) medoxomil tab 5-40 mg amlodipine besylate-olmesartan $0 (1) medoxomil tab mg amlodipine besylate-olmesartan $0 (1) medoxomil tab mg amlodipine besylate-valsartan tab $0 (1) mg amlodipine besylate-valsartan tab $0 (1) mg amlodipine besylate-valsartan tab 10- $0 (1) 160 mg amlodipine besylate-valsartan tab 10- $0 (1) 320 mg amlodipine-valsartanhydrochlorothiazide tab mg $0 (1) amlodipine-valsartanhydrochlorothiazide tab mg $0 (1) amlodipine-valsartanhydrochlorothiazide tab mg $0 (1) amlodipine-valsartanhydrochlorothiazide tab mg $0 (1) amlodipine-valsartanhydrochlorothiazide tab mg $0 (1) candesartan cilexetil-hydrochlorothiazide $0 (1) tab mg candesartan cilexetil-hydrochlorothiazide $0 (1) tab mg candesartan cilexetil-hydrochlorothiazide $0 (1) tab mg ENTRESTO TAB 24-26MG $0 (2) ENTRESTO TAB 49-51MG $0 (2) ENTRESTO TAB MG $0 (2) 34

51 Drug Name (By Medical Condition) irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg WHAT THE $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) 35

52 Drug Name (By Medical Condition) WHAT THE ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil tab 4 mg $0 (1) candesartan cilexetil tab 8 mg $0 (1) candesartan cilexetil tab 16 mg $0 (1) candesartan cilexetil tab 32 mg $0 (1) irbesartan tab 75 mg $0 (1) irbesartan tab 150 mg $0 (1) irbesartan tab 300 mg $0 (1) losartan potassium tab 25 mg $0 (1) losartan potassium tab 50 mg $0 (1) losartan potassium tab 100 mg $0 (1) olmesartan medoxomil tab 5 mg $0 (1) olmesartan medoxomil tab 20 mg $0 (1) olmesartan medoxomil tab 40 mg $0 (1) telmisartan tab 20 mg $0 (1) telmisartan tab 40 mg $0 (1) telmisartan tab 80 mg $0 (1) valsartan tab 40 mg $0 (1) valsartan tab 80 mg $0 (1) valsartan tab 160 mg $0 (1) valsartan tab 320 mg $0 (1) ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl inj 150 mg/3ml (50 $0 (1) mg/ml) amiodarone hcl inj 450 mg/9ml (50 $0 (1) mg/ml) amiodarone hcl inj 900 mg/18ml (50 $0 (1) mg/ml) amiodarone hcl tab 100 mg $0 (1) amiodarone hcl tab 200 mg $0 (1) amiodarone hcl tab 400 mg $0 (1) disopyramide phosphate cap 100 mg $0 (2) PA; PA if 65 years and disopyramide phosphate cap 150 mg $0 (2) PA; PA if 65 years and dofetilide cap 125 mcg (0.125 mg) $0 (1) NM dofetilide cap 250 mcg (0.25 mg) $0 (1) NM dofetilide cap 500 mcg (0.5 mg) $0 (1) NM flecainide acetate tab 50 mg $0 (1) flecainide acetate tab 100 mg $0 (1) 36

53 Drug Name (By Medical Condition) WHAT THE flecainide acetate tab 150 mg $0 (1) mexiletine hcl cap 150 mg $0 (1) mexiletine hcl cap 200 mg $0 (1) mexiletine hcl cap 250 mg $0 (1) MULTAQ TAB 400MG $0 (2) NORPACE CAP 100MG CR $0 (2) PA; PA if 65 years and NORPACE CAP 150MG CR $0 (2) PA; PA if 65 years and pacerone tab 100mg $0 (1) pacerone tab 200mg $0 (1) pacerone tab 400mg $0 (1) propafenone hcl cap er 12hr 225 mg $0 (1) propafenone hcl cap er 12hr 325 mg $0 (1) propafenone hcl cap er 12hr 425 mg $0 (1) propafenone hcl tab 150 mg $0 (1) propafenone hcl tab 225 mg $0 (1) propafenone hcl tab 300 mg $0 (1) quinidine gluconate tab er 324 mg $0 (1) quinidine sulfate tab 200 mg $0 (1) quinidine sulfate tab 300 mg $0 (1) sorine tab 80mg $0 (1) sorine tab 120mg $0 (1) sorine tab 160mg $0 (1) sorine tab 240mg $0 (1) sotalol hcl (afib/afl) tab 80 mg $0 (1) sotalol hcl (afib/afl) tab 120 mg $0 (1) sotalol hcl (afib/afl) tab 160 mg $0 (1) sotalol hcl tab 80 mg $0 (1) sotalol hcl tab 120 mg $0 (1) sotalol hcl tab 160 mg $0 (1) sotalol hcl tab 240 mg $0 (1) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium tab 10 mg (base $0 (1) equivalent) atorvastatin calcium tab 20 mg (base $0 (1) equivalent) atorvastatin calcium tab 40 mg (base $0 (1) equivalent) 37

54 Drug Name (By Medical Condition) WHAT THE $0 (1) atorvastatin calcium tab 80 mg (base equivalent) lovastatin tab 10 mg $0 (1) lovastatin tab 20 mg $0 (1) lovastatin tab 40 mg $0 (1) pravastatin sodium tab 10 mg $0 (1) pravastatin sodium tab 20 mg $0 (1) pravastatin sodium tab 40 mg $0 (1) pravastatin sodium tab 80 mg $0 (1) rosuvastatin calcium tab 5 mg $0 (1) QL (30 tabs / 30 days) rosuvastatin calcium tab 10 mg $0 (1) QL (30 tabs / 30 days) rosuvastatin calcium tab 20 mg $0 (1) QL (30 tabs / 30 days) rosuvastatin calcium tab 40 mg $0 (1) QL (30 tabs / 30 days) simvastatin tab 5 mg $0 (1) simvastatin tab 10 mg $0 (1) simvastatin tab 20 mg $0 (1) simvastatin tab 40 mg $0 (1) simvastatin tab 80 mg $0 (1) QL (30 tabs / 30 days) ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine light powder 4 gm/dose $0 (1) cholestyramine light powder packets 4 $0 (1) gm cholestyramine powder 4 gm/dose $0 (1) cholestyramine powder packets 4 gm $0 (1) colesevelam hcl tab 625 mg $0 (1) colestipol hcl granule packets 5 gm $0 (1) colestipol hcl granules 5 gm $0 (1) colestipol hcl tab 1 gm $0 (1) ezetimibe tab 10 mg $0 (1) fenofibrate micronized cap 67 mg $0 (1) fenofibrate micronized cap 134 mg $0 (1) fenofibrate micronized cap 200 mg $0 (1) fenofibrate tab 48 mg $0 (1) fenofibrate tab 54 mg $0 (1) fenofibrate tab 145 mg $0 (1) fenofibrate tab 160 mg $0 (1) gemfibrozil tab 600 mg $0 (1) JUXTAPID CAP 5MG $0 (2) NDS, LA, PA JUXTAPID CAP 10MG $0 (2) NDS, LA, PA JUXTAPID CAP 20MG $0 (2) NDS, LA, PA 38

55 Drug Name (By Medical Condition) WHAT THE JUXTAPID CAP 30MG $0 (2) NDS, LA, PA JUXTAPID CAP 40MG $0 (2) NDS, LA, PA JUXTAPID CAP 60MG $0 (2) NDS, LA, PA KYNAMRO INJ 200MG/ML $0 (2) NDS, NM, PA niacin tab er 500 mg $0 (1) QL (90 tabs / 30 days) (antihyperlipidemic) niacin tab er 750 mg $0 (1) (antihyperlipidemic) niacin tab er 1000 mg $0 (1) (antihyperlipidemic) niacor tab 500mg $0 (1) omega-3-acid ethyl esters cap 1 gm $0 (1) PRALUENT INJ 75MG/ML $0 (2) NDS, PA PRALUENT INJ 150MG/ML $0 (2) NDS, PA prevalite pow 4gm $0 (1) prevalite pow 4gm pk $0 (1) VASCEPA CAP 0.5GM $0 (2) VASCEPA CAP 1GM $0 (2) WELCHOL PAK 3.75GM $0 (2) WELCHOL TAB 625MG $0 (2) BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone tab mg $0 (1) atenolol & chlorthalidone tab mg $0 (1) bisoprolol & hydrochlorothiazide tab 2.5- $0 (1) 6.25 mg bisoprolol & hydrochlorothiazide tab 5- $0 (1) 6.25 mg bisoprolol & hydrochlorothiazide tab 10- $0 (1) 6.25 mg metoprolol & hydrochlorothiazide tab 50- $0 (1) 25 mg metoprolol & hydrochlorothiazide tab $0 (1) mg metoprolol & hydrochlorothiazide tab $0 (1) mg propranolol & hydrochlorothiazide tab $0 (1) mg propranolol & hydrochlorothiazide tab $0 (1) mg BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS 39

56 Drug Name (By Medical Condition) WHAT THE acebutolol hcl cap 200 mg $0 (1) acebutolol hcl cap 400 mg $0 (1) atenolol tab 25 mg $0 (1) atenolol tab 50 mg $0 (1) atenolol tab 100 mg $0 (1) bisoprolol fumarate tab 5 mg $0 (1) bisoprolol fumarate tab 10 mg $0 (1) BYSTOLIC TAB 2.5MG $0 (2) QL (30 tabs / 30 days) BYSTOLIC TAB 5MG $0 (2) QL (30 tabs / 30 days) BYSTOLIC TAB 10MG $0 (2) QL (30 tabs / 30 days) BYSTOLIC TAB 20MG $0 (2) QL (60 tabs / 30 days) carvedilol tab mg $0 (1) carvedilol tab 6.25 mg $0 (1) carvedilol tab 12.5 mg $0 (1) carvedilol tab 25 mg $0 (1) labetalol hcl tab 100 mg $0 (1) labetalol hcl tab 200 mg $0 (1) labetalol hcl tab 300 mg $0 (1) metoprolol succinate tab er 24hr 25 mg $0 (1) (tartrate equiv) metoprolol succinate tab er 24hr 50 mg $0 (1) (tartrate equiv) metoprolol succinate tab er 24hr 100 mg $0 (1) (tartrate equiv) metoprolol succinate tab er 24hr 200 mg $0 (1) (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml $0 (1) metoprolol tartrate iv soln cart inj 5 $0 (1) mg/5ml (1 mg/ml) metoprolol tartrate tab 25 mg $0 (1) metoprolol tartrate tab 50 mg $0 (1) metoprolol tartrate tab 100 mg $0 (1) nadolol tab 20 mg $0 (1) nadolol tab 40 mg $0 (1) nadolol tab 80 mg $0 (1) pindolol tab 5 mg $0 (1) pindolol tab 10 mg $0 (1) propranolol hcl cap er 24hr 60 mg $0 (1) propranolol hcl cap er 24hr 80 mg $0 (1) propranolol hcl cap er 24hr 120 mg $0 (1) propranolol hcl cap er 24hr 160 mg $0 (1) propranolol hcl inj 1 mg/ml $0 (1) 40

57 Drug Name (By Medical Condition) WHAT THE propranolol hcl oral soln 20 mg/5ml $0 (1) propranolol hcl oral soln 40 mg/5ml $0 (1) propranolol hcl tab 10 mg $0 (1) propranolol hcl tab 20 mg $0 (1) propranolol hcl tab 40 mg $0 (1) propranolol hcl tab 60 mg $0 (1) propranolol hcl tab 80 mg $0 (1) timolol maleate tab 5 mg $0 (1) timolol maleate tab 10 mg $0 (1) timolol maleate tab 20 mg $0 (1) CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab tab 30mg cr $0 (1) afeditab tab 60mg cr $0 (1) amlodipine besylate tab 2.5 mg (base $0 (1) equivalent) amlodipine besylate tab 5 mg (base $0 (1) equivalent) amlodipine besylate tab 10 mg (base $0 (1) equivalent) diltiazem hcl cap er 12hr 60 mg $0 (1) diltiazem hcl cap er 12hr 90 mg $0 (1) diltiazem hcl cap er 12hr 120 mg $0 (1) diltiazem hcl cap er 24hr 120 mg $0 (1) diltiazem hcl cap er 24hr 180 mg $0 (1) diltiazem hcl cap er 24hr 240 mg $0 (1) diltiazem hcl coated beads cap er 24hr $0 (1) 120 mg diltiazem hcl coated beads cap er 24hr $0 (1) 180 mg diltiazem hcl coated beads cap er 24hr $0 (1) 240 mg diltiazem hcl coated beads cap er 24hr $0 (1) 300 mg diltiazem hcl coated beads cap er 24hr $0 (1) 360 mg diltiazem hcl extended release beads cap $0 (1) er 24hr 120 mg diltiazem hcl extended release beads cap $0 (1) er 24hr 180 mg diltiazem hcl extended release beads cap $0 (1) er 24hr 240 mg 41

58 Drug Name (By Medical Condition) WHAT THE diltiazem hcl extended release beads cap $0 (1) er 24hr 300 mg diltiazem hcl extended release beads cap $0 (1) er 24hr 360 mg diltiazem hcl extended release beads cap $0 (1) er 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 $0 (1) mg/ml) diltiazem hcl iv soln 50 mg/10ml (5 $0 (1) mg/ml) diltiazem hcl iv soln 125 mg/25ml (5 $0 (1) mg/ml) diltiazem hcl tab 30 mg $0 (1) diltiazem hcl tab 60 mg $0 (1) diltiazem hcl tab 90 mg $0 (1) diltiazem hcl tab 120 mg $0 (1) felodipine tab er 24hr 2.5 mg $0 (1) felodipine tab er 24hr 5 mg $0 (1) felodipine tab er 24hr 10 mg $0 (1) isradipine cap 2.5 mg $0 (1) isradipine cap 5 mg $0 (1) nicardipine hcl cap 20 mg $0 (1) nicardipine hcl cap 30 mg $0 (1) nifedipine tab er 24hr 30 mg $0 (1) nifedipine tab er 24hr 60 mg $0 (1) nifedipine tab er 24hr 90 mg $0 (1) nifedipine tab er 24hr osmotic release 30 $0 (1) mg nifedipine tab er 24hr osmotic release 60 $0 (1) mg nifedipine tab er 24hr osmotic release 90 $0 (1) mg nimodipine cap 30 mg $0 (2) NDS NYMALIZE SOL 30/10ML $0 (2) NDS taztia xt cap 120mg/24 $0 (1) taztia xt cap 180mg/24 $0 (1) taztia xt cap 240mg/24 $0 (1) taztia xt cap 300mg/24 $0 (1) taztia xt cap 360mg/24 $0 (1) verapamil hcl cap er 24hr 100 mg $0 (1) verapamil hcl cap er 24hr 120 mg $0 (1) verapamil hcl cap er 24hr 180 mg $0 (1) 42

59 Drug Name (By Medical Condition) WHAT THE verapamil hcl cap er 24hr 200 mg $0 (1) verapamil hcl cap er 24hr 240 mg $0 (1) verapamil hcl cap er 24hr 300 mg $0 (1) verapamil hcl cap er 24hr 360 mg $0 (1) verapamil hcl iv soln 2.5 mg/ml $0 (1) verapamil hcl tab 40 mg $0 (1) verapamil hcl tab 80 mg $0 (1) verapamil hcl tab 120 mg $0 (1) verapamil hcl tab er 120 mg $0 (1) verapamil hcl tab er 180 mg $0 (1) verapamil hcl tab er 240 mg $0 (1) DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek tab 0.25mg $0 (1) PA; PA if 65 years and digitek tab 0.125mg $0 (1) QL (30 tabs / 30 days) digoxin inj 0.25 mg/ml $0 (1) digoxin oral soln 0.05 mg/ml $0 (1) PA; PA if 65 years and digoxin tab 125 mcg (0.125 mg) $0 (1) QL (30 tabs / 30 days) digoxin tab 250 mcg (0.25 mg) $0 (1) PA; PA if 65 years and DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS TEKTURNA HCT TAB $0 (2) TEKTURNA HCT TAB MG $0 (2) TEKTURNA HCT TAB $0 (2) TEKTURNA HCT TAB MG $0 (2) TEKTURNA TAB 150MG $0 (2) TEKTURNA TAB 300MG $0 (2) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide cap er 12hr 500 mg $0 (1) acetazolamide tab 125 mg $0 (1) acetazolamide tab 250 mg $0 (1) amiloride & hydrochlorothiazide tab 5-50 $0 (1) mg amiloride hcl tab 5 mg $0 (1) bumetanide inj 0.25 mg/ml $0 (1) bumetanide tab 0.5 mg $0 (1) bumetanide tab 1 mg $0 (1) bumetanide tab 2 mg $0 (1) chlorothiazide tab 250 mg $0 (1) 43

60 Drug Name (By Medical Condition) WHAT THE chlorothiazide tab 500 mg $0 (1) chlorthalidone tab 25 mg $0 (1) chlorthalidone tab 50 mg $0 (1) furosemide inj 10 mg/ml $0 (1) furosemide oral soln 8 mg/ml $0 (1) furosemide oral soln 10 mg/ml $0 (1) furosemide tab 20 mg $0 (1) furosemide tab 40 mg $0 (1) furosemide tab 80 mg $0 (1) hydrochlorothiazide cap 12.5 mg $0 (1) hydrochlorothiazide tab 12.5 mg $0 (1) hydrochlorothiazide tab 25 mg $0 (1) hydrochlorothiazide tab 50 mg $0 (1) indapamide tab 1.25 mg $0 (1) indapamide tab 2.5 mg $0 (1) methazolamide tab 25 mg $0 (1) methazolamide tab 50 mg $0 (1) methyclothiazide tab 5 mg $0 (1) metolazone tab 2.5 mg $0 (1) metolazone tab 5 mg $0 (1) metolazone tab 10 mg $0 (1) spironolactone & hydrochlorothiazide tab $0 (1) mg torsemide tab 5 mg $0 (1) torsemide tab 10 mg $0 (1) torsemide tab 20 mg $0 (1) torsemide tab 100 mg $0 (1) triamterene & hydrochlorothiazide cap $0 (1) mg triamterene & hydrochlorothiazide tab $0 (1) mg triamterene & hydrochlorothiazide tab $0 (1) mg MISCELLANEOUS clonidine hcl tab 0.1 mg $0 (1) clonidine hcl tab 0.2 mg $0 (1) clonidine hcl tab 0.3 mg $0 (1) clonidine hcl td patch weekly 0.1 $0 (1) mg/24hr clonidine hcl td patch weekly 0.2 $0 (1) mg/24hr 44

61 Drug Name (By Medical Condition) WHAT THE $0 (1) clonidine hcl td patch weekly 0.3 mg/24hr CORLANOR TAB 5MG $0 (2) CORLANOR TAB 7.5MG $0 (2) DEMSER CAP 250MG $0 (2) NDS hydralazine hcl inj 20 mg/ml $0 (1) hydralazine hcl tab 10 mg $0 (1) hydralazine hcl tab 25 mg $0 (1) hydralazine hcl tab 50 mg $0 (1) hydralazine hcl tab 100 mg $0 (1) midodrine hcl tab 2.5 mg $0 (1) midodrine hcl tab 5 mg $0 (1) midodrine hcl tab 10 mg $0 (1) minoxidil tab 2.5 mg $0 (1) minoxidil tab 10 mg $0 (1) NORTHERA CAP 100MG $0 (2) NDS, LA, PA NORTHERA CAP 200MG $0 (2) NDS, LA, PA NORTHERA CAP 300MG $0 (2) NDS, LA, PA RANEXA TAB 500MG $0 (2) RANEXA TAB 1000MG $0 (2) NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorbide dinitrate tab 5 mg $0 (1) isosorbide dinitrate tab 10 mg $0 (1) isosorbide dinitrate tab 20 mg $0 (1) isosorbide dinitrate tab 30 mg $0 (1) isosorbide dinitrate tab er 40 mg $0 (1) isosorbide mononitrate tab 10 mg $0 (1) isosorbide mononitrate tab 20 mg $0 (1) isosorbide mononitrate tab er 24hr 30 $0 (1) mg isosorbide mononitrate tab er 24hr 60 $0 (1) mg isosorbide mononitrate tab er 24hr 120 $0 (1) mg minitran dis 0.1mg/hr $0 (1) minitran dis 0.2mg/hr $0 (1) minitran dis 0.4mg/hr $0 (1) minitran dis 0.6mg/hr $0 (1) NITRO-BID OIN 2% $0 (2) NITRO-DUR DIS 0.3MG/HR $0 (2) NITRO-DUR DIS 0.8MG/HR $0 (2) 45

62 Drug Name (By Medical Condition) WHAT THE nitroglycerin sl tab 0.3 mg $0 (1) nitroglycerin sl tab 0.4 mg $0 (1) nitroglycerin sl tab 0.6 mg $0 (1) nitroglycerin td patch 24hr 0.1 mg/hr $0 (1) nitroglycerin td patch 24hr 0.2 mg/hr $0 (1) nitroglycerin td patch 24hr 0.4 mg/hr $0 (1) nitroglycerin td patch 24hr 0.6 mg/hr $0 (1) PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA TAB 20MG $0 (2) NDS, QL (60 tabs / 30 days), NM, PA ADEMPAS TAB 0.5MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA ADEMPAS TAB 1.5MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA ADEMPAS TAB 1MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA ADEMPAS TAB 2.5MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA ADEMPAS TAB 2MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA LETAIRIS TAB 5MG $0 (2) NDS, QL (30 tabs / 30 days), NM, LA, PA LETAIRIS TAB 10MG $0 (2) NDS, QL (30 tabs / 30 days), NM, LA, PA OPSUMIT TAB 10MG $0 (2) NDS, QL (30 tabs / 30 days), NM, LA, PA REMODULIN INJ 1MG/ML $0 (2) NDS, NM, LA, PA REMODULIN INJ 2.5MG/ML $0 (2) NDS, NM, LA, PA REMODULIN INJ 5MG/ML $0 (2) NDS, NM, LA, PA REMODULIN INJ 10MG/ML $0 (2) NDS, NM, LA, PA sildenafil citrate tab 20 mg $0 (1) QL (90 tabs / 30 days), NM, PA TRACLEER TAB 62.5MG $0 (2) NDS, QL (120 tabs / 30 days), NM, LA, PA TRACLEER TAB 125MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA VENTAVIS SOL 10MCG/ML $0 (2) NDS, NM, PA VENTAVIS SOL 20MCG/ML $0 (2) NDS, NM, PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY 46

63 Drug Name (By Medical Condition) WHAT THE alprazolam tab 0.5 mg $0 (1) QL (240 tabs / 30 days) alprazolam tab 0.25 mg $0 (1) QL (480 tabs / 30 days) alprazolam tab 1 mg $0 (1) QL (120 tabs / 30 days) alprazolam tab 2 mg $0 (1) QL (150 tabs / 30 days) buspirone hcl tab 5 mg $0 (1) buspirone hcl tab 7.5 mg $0 (1) buspirone hcl tab 10 mg $0 (1) buspirone hcl tab 15 mg $0 (1) buspirone hcl tab 30 mg $0 (1) fluvoxamine maleate tab 25 mg $0 (1) QL (45 tabs / 30 days) fluvoxamine maleate tab 50 mg $0 (1) QL (45 tabs / 30 days) fluvoxamine maleate tab 100 mg $0 (1) lorazepam conc 2 mg/ml $0 (1) QL (150 ml / 30 days) lorazepam inj 2 mg/ml $0 (1) lorazepam inj 4 mg/ml $0 (1) lorazepam tab 0.5 mg $0 (1) QL (150 tabs / 30 days) lorazepam tab 1 mg $0 (1) QL (150 tabs / 30 days) lorazepam tab 2 mg $0 (1) QL (150 tabs / 30 days) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM TAB 200MG $0 (2) NDS, QL (180 tabs / 30 days) APTIOM TAB 400MG $0 (2) NDS, QL (90 tabs / 30 days) APTIOM TAB 600MG $0 (2) NDS, QL (60 tabs / 30 days) APTIOM TAB 800MG $0 (2) NDS, QL (60 tabs / 30 days) BANZEL SUS 40MG/ML $0 (2) NDS, PA BANZEL TAB 200MG $0 (2) NDS, PA BANZEL TAB 400MG $0 (2) NDS, PA BRIVIACT INJ 50MG/5ML $0 (2) PA BRIVIACT SOL 10MG/ML $0 (2) NDS, PA BRIVIACT TAB 10MG $0 (2) NDS, PA BRIVIACT TAB 25MG $0 (2) NDS, PA BRIVIACT TAB 50MG $0 (2) NDS, PA BRIVIACT TAB 75MG $0 (2) NDS, PA BRIVIACT TAB 100MG $0 (2) NDS, PA carbamazepine cap er 12hr 100 mg $0 (1) carbamazepine cap er 12hr 200 mg $0 (1) carbamazepine cap er 12hr 300 mg $0 (1) carbamazepine chew tab 100 mg $0 (1) carbamazepine susp 100 mg/5ml $0 (1) 47

64 Drug Name (By Medical Condition) WHAT THE carbamazepine tab 200 mg $0 (1) carbamazepine tab er 12hr 100 mg $0 (1) carbamazepine tab er 12hr 200 mg $0 (1) carbamazepine tab er 12hr 400 mg $0 (1) CELONTIN CAP 300MG $0 (2) clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg $0 (1) QL (240 tabs / 30 days) $0 (1) QL (480 tabs / 30 days) $0 (1) QL (960 tabs / 30 days) $0 (1) QL (120 tabs / 30 days) $0 (1) QL (300 tabs / 30 days) clonazepam tab 0.5 mg $0 (1) QL (240 tabs / 30 days) clonazepam tab 1 mg $0 (1) QL (120 tabs / 30 days) clonazepam tab 2 mg $0 (1) QL (300 tabs / 30 days) clorazepate dipotassium tab 3.75 mg $0 (1) QL (120 tabs / 30 days), PA; PA if 65 years and clorazepate dipotassium tab 7.5 mg $0 (1) QL (120 tabs / 30 days), PA; PA if 65 years and clorazepate dipotassium tab 15 mg $0 (1) QL (180 tabs / 30 days), PA; PA if 65 years and DIASTAT ACDL GEL 5-10MG $0 (2) DIASTAT ACDL GEL $0 (2) DIASTAT PED GEL 2.5M GEL $0 (2) diazepam con 5mg/ml $0 (1) QL (240 ml / 30 days), PA; PA if 65 years and diazepam inj 5 mg/ml $0 (1) diazepam oral soln 1 mg/ml $0 (1) QL (1200 ml / 30 days), PA; PA if 65 years and diazepam rectal gel delivery system 2.5 $0 (1) mg diazepam rectal gel delivery system 10 $0 (1) mg diazepam rectal gel delivery system 20 $0 (1) mg 48

65 Drug Name (By Medical Condition) WHAT THE diazepam tab 2 mg $0 (1) QL (120 tabs / 30 days), PA; PA if 65 years and diazepam tab 5 mg $0 (1) QL (120 tabs / 30 days), PA; PA if 65 years and diazepam tab 10 mg $0 (1) QL (120 tabs / 30 days), PA; PA if 65 years and DILANTIN CAP 30MG $0 (2) DILANTIN CAP 100MG $0 (2) DILANTIN CHW 50MG $0 (2) DILANTIN-125 SUS 125/5ML $0 (2) divalproex sodium cap delayed release $0 (1) sprinkle 125 mg divalproex sodium tab delayed release $0 (1) 125 mg divalproex sodium tab delayed release $0 (1) 250 mg divalproex sodium tab delayed release 500 mg $0 (1) divalproex sodium tab er 24 hr 250 mg $0 (1) divalproex sodium tab er 24 hr 500 mg $0 (1) epitol tab 200mg $0 (1) ethosuximide cap 250 mg $0 (1) ethosuximide soln 250 mg/5ml $0 (1) felbamate susp 600 mg/5ml $0 (2) NDS felbamate tab 400 mg $0 (1) felbamate tab 600 mg $0 (1) FYCOMPA SUS 0.5MG/ML $0 (2) NDS, QL (720 ml / 30 days), PA FYCOMPA TAB 2MG $0 (2) QL (180 tabs / 30 days), PA FYCOMPA TAB 4MG $0 (2) NDS, QL (90 tabs / 30 days), PA FYCOMPA TAB 6MG $0 (2) NDS, QL (60 tabs / 30 days), PA FYCOMPA TAB 8MG $0 (2) NDS, QL (30 tabs / 30 days), PA FYCOMPA TAB 10MG $0 (2) NDS, QL (30 tabs / 30 days), PA FYCOMPA TAB 12MG $0 (2) NDS, QL (30 tabs / 30 days), PA 49

66 Drug Name (By Medical Condition) WHAT THE gabapentin cap 100 mg $0 (1) QL (1080 caps / 30 days) gabapentin cap 300 mg $0 (1) QL (360 caps / 30 days) gabapentin cap 400 mg $0 (1) QL (270 caps / 30 days) gabapentin oral soln 250 mg/5ml $0 (1) QL (2160 ml / 30 days) gabapentin tab 600 mg $0 (1) QL (180 tabs / 30 days) gabapentin tab 800 mg $0 (1) QL (120 tabs / 30 days) GABITRIL TAB 12MG $0 (2) GABITRIL TAB 16MG $0 (2) lamotrigine tab 25 mg $0 (1) lamotrigine tab 100 mg $0 (1) lamotrigine tab 150 mg $0 (1) lamotrigine tab 200 mg $0 (1) lamotrigine tab chewable dispersible 5 $0 (1) mg lamotrigine tab chewable dispersible 25 $0 (1) mg lamotrigine tab er 24hr 25 mg $0 (1) lamotrigine tab er 24hr 50 mg $0 (1) lamotrigine tab er 24hr 100 mg $0 (1) lamotrigine tab er 24hr 200 mg $0 (1) lamotrigine tab er 24hr 250 mg $0 (1) lamotrigine tab er 24hr 300 mg $0 (1) levetiracetam in sodium chloride iv soln $0 (1) 500 mg/100ml levetiracetam in sodium chloride iv soln $0 (1) 1000 mg/100ml levetiracetam in sodium chloride iv soln $0 (1) 1500 mg/100ml levetiracetam inj 500 mg/5ml (100 $0 (1) mg/ml) levetiracetam oral soln 100 mg/ml $0 (1) levetiracetam tab 250 mg $0 (1) levetiracetam tab 500 mg $0 (1) levetiracetam tab 750 mg $0 (1) levetiracetam tab 1000 mg $0 (1) levetiracetam tab er 24hr 500 mg $0 (1) levetiracetam tab er 24hr 750 mg $0 (1) LYRICA CAP 25MG $0 (2) QL (120 caps / 30 days) LYRICA CAP 50MG $0 (2) QL (120 caps / 30 days) LYRICA CAP 75MG $0 (2) QL (120 caps / 30 days) LYRICA CAP 100MG $0 (2) QL (120 caps / 30 days) 50

67 Drug Name (By Medical Condition) WHAT THE LYRICA CAP 150MG $0 (2) QL (120 caps / 30 days) LYRICA CAP 200MG $0 (2) QL (90 caps / 30 days) LYRICA CAP 225MG $0 (2) QL (60 caps / 30 days) LYRICA CAP 300MG $0 (2) QL (60 caps / 30 days) LYRICA SOL 20MG/ML $0 (2) QL (946 ml / 30 days) ONFI SUS 2.5MG/ML $0 (2) NDS, PA ONFI TAB 10MG $0 (2) NDS, PA ONFI TAB 20MG $0 (2) NDS, PA oxcarbazepine susp 300 mg/5ml (60 $0 (1) mg/ml) oxcarbazepine tab 150 mg $0 (1) oxcarbazepine tab 300 mg $0 (1) oxcarbazepine tab 600 mg $0 (1) PEGANONE TAB 250MG $0 (2) PHENOBARB INJ 65MG/ML $0 (2) PA; PA if 65 years and phenobarbital elixir 20 mg/5ml $0 (2) PA; PA if 65 years and phenobarbital sodium inj 130 mg/ml $0 (2) PA; PA if 65 years and phenobarbital tab 15 mg $0 (2) PA; PA if 65 years and phenobarbital tab 16.2 mg $0 (2) PA; PA if 65 years and phenobarbital tab 30 mg $0 (2) PA; PA if 65 years and phenobarbital tab 32.4 mg $0 (2) PA; PA if 65 years and phenobarbital tab 60 mg $0 (2) PA; PA if 65 years and phenobarbital tab 64.8 mg $0 (2) PA; PA if 65 years and phenobarbital tab 97.2 mg $0 (2) PA; PA if 65 years and phenobarbital tab 100 mg $0 (2) PA; PA if 65 years and PHENYTEK CAP 200MG $0 (2) PHENYTEK CAP 300MG $0 (2) phenytoin chew tab 50 mg $0 (1) phenytoin sodium extended cap 100 mg $0 (1) phenytoin sodium extended cap 200 mg $0 (1) phenytoin sodium extended cap 300 mg $0 (1) phenytoin sodium inj 50 mg/ml $0 (1) 51

68 Drug Name (By Medical Condition) WHAT THE phenytoin susp 125 mg/5ml $0 (1) primidone tab 50 mg $0 (1) primidone tab 250 mg $0 (1) roweepra tab 500mg $0 (1) roweepra tab 750mg $0 (1) roweepra tab 1000mg $0 (1) roweepra xr tab 500mg xr $0 (1) roweepra xr tab 750mg xr $0 (1) SABRIL TAB 500MG $0 (2) NDS, QL (180 tabs / 30 days), NM, LA, PA SPRITAM TAB 250MG $0 (2) SPRITAM TAB 500MG $0 (2) SPRITAM TAB 750MG $0 (2) SPRITAM TAB 1000MG $0 (2) TEGRETOL SUS 100/5ML $0 (2) TEGRETOL TAB 200MG $0 (2) TEGRETOL-XR TAB 100MG $0 (2) TEGRETOL-XR TAB 200MG $0 (2) TEGRETOL-XR TAB 400MG $0 (2) tiagabine hcl tab 2 mg $0 (1) tiagabine hcl tab 4 mg $0 (1) tiagabine hcl tab 12 mg $0 (1) tiagabine hcl tab 16 mg $0 (1) topiramate sprinkle cap 15 mg $0 (1) topiramate sprinkle cap 25 mg $0 (1) topiramate tab 25 mg $0 (1) topiramate tab 50 mg $0 (1) topiramate tab 100 mg $0 (1) topiramate tab 200 mg $0 (1) valproate sodium inj 100 mg/ml $0 (1) valproate sodium oral soln 250 mg/5ml $0 (1) (base equiv) valproic acid cap 250 mg $0 (1) vigabatrin powd pack 500 mg $0 (2) NDS, QL (180 packets / 30 days), NM, LA, PA VIMPAT INJ 200MG/20 $0 (2) NDS VIMPAT SOL 10MG/ML $0 (2) NDS, QL (1200 ml / 30 days) VIMPAT TAB 50MG $0 (2) QL (180 tabs / 30 days) VIMPAT TAB 100MG $0 (2) NDS, QL (60 tabs / 30 days) 52

69 Drug Name (By Medical Condition) WHAT THE VIMPAT TAB 150MG $0 (2) NDS, QL (60 tabs / 30 days) VIMPAT TAB 200MG $0 (2) NDS, QL (60 tabs / 30 days) zonisamide cap 25 mg $0 (1) zonisamide cap 50 mg $0 (1) zonisamide cap 100 mg $0 (1) ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride orally $0 (1) QL (60 tabs / 30 days) disintegrating tab 5 mg donepezil hydrochloride orally $0 (1) disintegrating tab 10 mg donepezil hydrochloride tab 5 mg $0 (1) QL (60 tabs / 30 days) donepezil hydrochloride tab 10 mg $0 (1) donepezil hydrochloride tab 23 mg $0 (1) galantamine hydrobromide cap er 24hr 8 $0 (1) QL (30 caps / 30 days) mg galantamine hydrobromide cap er 24hr $0 (1) QL (30 caps / 30 days) 16 mg galantamine hydrobromide cap er 24hr $0 (1) 24 mg galantamine hydrobromide oral soln 4 $0 (1) mg/ml galantamine hydrobromide tab 4 mg $0 (1) QL (180 tabs / 30 days) galantamine hydrobromide tab 8 mg $0 (1) QL (90 tabs / 30 days) galantamine hydrobromide tab 12 mg $0 (1) memantine hcl cap er 24hr 7 mg $0 (1) PA; PA if < 30 yrs memantine hcl cap er 24hr 14 mg $0 (1) PA; PA if < 30 yrs memantine hcl cap er 24hr 21 mg $0 (1) PA; PA if < 30 yrs memantine hcl cap er 24hr 28 mg $0 (1) PA; PA if < 30 yrs memantine hcl oral solution 2 mg/ml $0 (1) PA; PA if < 30 yrs memantine hcl tab 5 mg $0 (1) PA; PA if < 30 yrs memantine hcl tab 10 mg $0 (1) PA; PA if < 30 yrs NAMENDA XR CAP 7MG $0 (2) PA; PA if < 30 yrs NAMENDA XR CAP 14MG $0 (2) PA; PA if < 30 yrs NAMENDA XR CAP 21MG $0 (2) PA; PA if < 30 yrs NAMENDA XR CAP 28MG $0 (2) PA; PA if < 30 yrs NAMENDA XR CAP TITRATIO $0 (2) PA; PA if < 30 yrs NAMZARIC CAP $0 (2) NAMZARIC CAP 7-10MG $0 (2) NAMZARIC CAP 14-10MG $0 (2) NAMZARIC CAP 21-10MG $0 (2) 53

70 Drug Name (By Medical Condition) WHAT THE NAMZARIC CAP 28-10MG $0 (2) rivastigmine tartrate cap 1.5 mg $0 (1) rivastigmine tartrate cap 3 mg $0 (1) rivastigmine tartrate cap 4.5 mg $0 (1) rivastigmine tartrate cap 6 mg $0 (1) rivastigmine td patch 24hr 4.6 mg/24hr $0 (1) QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr $0 (1) QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr $0 (1) QL (30 patches / 30 days) ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl tab 10 mg $0 (2) PA; PA if 65 years and amitriptyline hcl tab 25 mg $0 (2) PA; PA if 65 years and amitriptyline hcl tab 50 mg $0 (2) PA; PA if 65 years and amitriptyline hcl tab 75 mg $0 (2) PA; PA if 65 years and amitriptyline hcl tab 100 mg $0 (2) PA; PA if 65 years and amitriptyline hcl tab 150 mg $0 (2) PA; PA if 65 years and amoxapine tab 25 mg $0 (1) amoxapine tab 50 mg $0 (1) amoxapine tab 100 mg $0 (1) amoxapine tab 150 mg $0 (1) bupropion hcl tab 75 mg $0 (1) bupropion hcl tab 100 mg $0 (1) bupropion hcl tab er 12hr 100 mg $0 (1) bupropion hcl tab er 12hr 150 mg $0 (1) bupropion hcl tab er 12hr 200 mg $0 (1) bupropion hcl tab er 24hr 150 mg $0 (1) QL (90 tabs / 30 days) bupropion hcl tab er 24hr 300 mg $0 (1) QL (30 tabs / 30 days) citalopram hydrobromide oral soln 10 $0 (1) mg/5ml citalopram hydrobromide tab 10 mg $0 (1) QL (45 tabs / 30 days) (base equiv) citalopram hydrobromide tab 20 mg (base equiv) $0 (1) QL (45 tabs / 30 days) 54

71 Drug Name (By Medical Condition) WHAT THE citalopram hydrobromide tab 40 mg $0 (1) QL (30 tabs / 30 days) (base equiv) clomipramine hcl cap 25 mg $0 (2) PA; PA if 65 years and clomipramine hcl cap 50 mg $0 (2) PA; PA if 65 years and clomipramine hcl cap 75 mg $0 (2) PA; PA if 65 years and desipramine hcl tab 10 mg $0 (1) desipramine hcl tab 25 mg $0 (1) desipramine hcl tab 50 mg $0 (1) desipramine hcl tab 75 mg $0 (1) desipramine hcl tab 100 mg $0 (1) desipramine hcl tab 150 mg $0 (1) desvenlafaxine succinate tab er 24hr 25 $0 (1) QL (30 tabs / 30 days) mg (base equiv) desvenlafaxine succinate tab er 24hr 50 $0 (1) QL (30 tabs / 30 days) mg (base equiv) desvenlafaxine succinate tab er 24hr 100 $0 (1) QL (30 tabs / 30 days) mg (base equiv) doxepin hcl cap 10 mg $0 (2) PA; PA if 65 years and doxepin hcl cap 25 mg $0 (2) PA; PA if 65 years and doxepin hcl cap 50 mg $0 (2) PA; PA if 65 years and doxepin hcl cap 75 mg $0 (2) PA; PA if 65 years and doxepin hcl cap 100 mg $0 (2) PA; PA if 65 years and doxepin hcl cap 150 mg $0 (2) PA; PA if 65 years and doxepin hcl conc 10 mg/ml $0 (2) PA; PA if 65 years and duloxetine hcl enteric coated pellets cap $0 (1) QL (180 caps / 30 days) 20 mg (base eq) duloxetine hcl enteric coated pellets cap $0 (1) QL (120 caps / 30 days) 30 mg (base eq) duloxetine hcl enteric coated pellets cap $0 (1) QL (60 caps / 30 days) 60 mg (base eq) EMSAM DIS 6MG/24HR $0 (2) NDS, QL (30 patches / 30 days), PA 55

72 Drug Name (By Medical Condition) WHAT THE EMSAM DIS 9MG/24HR $0 (2) NDS, QL (30 patches / 30 days), PA EMSAM DIS 12MG/24H $0 (2) NDS, QL (30 patches / 30 days), PA escitalopram oxalate soln 5 mg/5ml $0 (1) QL (600 ml / 30 days) (base equiv) escitalopram oxalate tab 5 mg (base $0 (1) QL (45 tabs / 30 days) equiv) escitalopram oxalate tab 10 mg (base $0 (1) QL (45 tabs / 30 days) equiv) escitalopram oxalate tab 20 mg (base $0 (1) QL (60 tabs / 30 days) equiv) FETZIMA CAP 20MG $0 (2) QL (180 caps / 30 days) FETZIMA CAP 40MG $0 (2) QL (90 caps / 30 days) FETZIMA CAP 80MG $0 (2) QL (30 caps / 30 days) FETZIMA CAP 120MG $0 (2) QL (30 caps / 30 days) FETZIMA CAP TITRATIO $0 (2) fluoxetine hcl cap 10 mg $0 (1) QL (30 caps / 30 days) fluoxetine hcl cap 20 mg $0 (1) QL (120 caps / 30 days) fluoxetine hcl cap 40 mg $0 (1) fluoxetine hcl solution 20 mg/5ml $0 (1) imipramine hcl tab 10 mg $0 (2) PA; PA if 65 years and imipramine hcl tab 25 mg $0 (2) PA; PA if 65 years and imipramine hcl tab 50 mg $0 (2) PA; PA if 65 years and maprotiline hcl tab 25 mg $0 (1) maprotiline hcl tab 50 mg $0 (1) maprotiline hcl tab 75 mg $0 (1) MARPLAN TAB 10MG $0 (2) QL (180 tabs / 30 days) mirtazapine orally disintegrating tab 15 $0 (1) QL (30 tabs / 30 days) mg mirtazapine orally disintegrating tab 30 $0 (1) mg mirtazapine orally disintegrating tab 45 $0 (1) mg mirtazapine tab 7.5 mg $0 (1) QL (45 tabs / 30 days) mirtazapine tab 15 mg $0 (1) QL (45 tabs / 30 days) mirtazapine tab 30 mg $0 (1) mirtazapine tab 45 mg $0 (1) nefazodone hcl tab 50 mg $0 (1) nefazodone hcl tab 100 mg $0 (1) 56

73 Drug Name (By Medical Condition) WHAT THE nefazodone hcl tab 150 mg $0 (1) nefazodone hcl tab 200 mg $0 (1) nefazodone hcl tab 250 mg $0 (1) nortriptyline hcl cap 10 mg $0 (1) nortriptyline hcl cap 25 mg $0 (1) nortriptyline hcl cap 50 mg $0 (1) nortriptyline hcl cap 75 mg $0 (1) nortriptyline hcl soln 10 mg/5ml $0 (1) paroxetine hcl tab 10 mg $0 (1) QL (45 tabs / 30 days) paroxetine hcl tab 20 mg $0 (1) QL (45 tabs / 30 days) paroxetine hcl tab 30 mg $0 (1) QL (60 tabs / 30 days) paroxetine hcl tab 40 mg $0 (1) QL (45 tabs / 30 days) PAXIL SUS 10MG/5ML $0 (2) QL (900 ml / 30 days) phenelzine sulfate tab 15 mg $0 (1) protriptyline hcl tab 5 mg $0 (1) protriptyline hcl tab 10 mg $0 (1) sertraline hcl oral concentrate for $0 (1) solution 20 mg/ml sertraline hcl tab 25 mg $0 (1) QL (45 tabs / 30 days) sertraline hcl tab 50 mg $0 (1) QL (45 tabs / 30 days) sertraline hcl tab 100 mg $0 (1) tranylcypromine sulfate tab 10 mg $0 (1) trazodone hcl tab 50 mg $0 (1) trazodone hcl tab 100 mg $0 (1) trazodone hcl tab 150 mg $0 (1) trimipramine maleate cap 25 mg $0 (2) QL (240 caps / 30 days), PA; PA if 65 years and trimipramine maleate cap 50 mg $0 (2) QL (120 caps / 30 days), PA; PA if 65 years and trimipramine maleate cap 100 mg $0 (2) QL (60 caps / 30 days), PA; PA if 65 years and TRINTELLIX TAB 5MG $0 (2) QL (120 tabs / 30 days) TRINTELLIX TAB 10MG $0 (2) QL (60 tabs / 30 days) TRINTELLIX TAB 20MG $0 (2) QL (30 tabs / 30 days) venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) $0 (1) QL (30 caps / 30 days) venlafaxine hcl cap er 24hr 75 mg (base $0 (1) QL (30 caps / 30 days) equivalent) 57

74 Drug Name (By Medical Condition) WHAT THE venlafaxine hcl cap er 24hr 150 mg $0 (1) QL (60 caps / 30 days) (base equivalent) venlafaxine hcl tab 25 mg $0 (1) venlafaxine hcl tab 37.5 mg $0 (1) venlafaxine hcl tab 50 mg $0 (1) venlafaxine hcl tab 75 mg $0 (1) venlafaxine hcl tab 100 mg $0 (1) VIIBRYD KIT STARTER $0 (2) VIIBRYD TAB 10MG $0 (2) QL (30 tabs / 30 days) VIIBRYD TAB 20MG $0 (2) QL (30 tabs / 30 days) VIIBRYD TAB 40MG $0 (2) QL (30 tabs / 30 days) ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl cap 100 mg $0 (1) QL (120 caps / 30 days) amantadine hcl syrup 50 mg/5ml $0 (1) amantadine hcl tab 100 mg $0 (1) APOKYN INJ 10MG/ML $0 (2) NDS, NM, LA, PA benztropine mesylate inj 1 mg/ml $0 (1) benztropine mesylate tab 0.5 mg $0 (2) PA; PA if 65 years and benztropine mesylate tab 1 mg $0 (2) PA; PA if 65 years and benztropine mesylate tab 2 mg $0 (2) PA; PA if 65 years and bromocriptine mesylate cap 5 mg (base $0 (1) equivalent) bromocriptine mesylate tab 2.5 mg $0 (1) (base equivalent) carbidopa & levodopa orally $0 (1) disintegrating tab mg carbidopa & levodopa orally $0 (1) disintegrating tab mg carbidopa & levodopa orally $0 (1) disintegrating tab mg carbidopa & levodopa tab mg $0 (1) carbidopa & levodopa tab mg $0 (1) carbidopa & levodopa tab mg $0 (1) carbidopa & levodopa tab er mg $0 (1) carbidopa & levodopa tab er mg $0 (1) carbidopa-levodopa-entacapone tabs $0 (1) mg 58

75 Drug Name (By Medical Condition) WHAT THE carbidopa-levodopa-entacapone tabs mg $0 (1) carbidopa-levodopa-entacapone tabs 25- $0 (1) mg carbidopa-levodopa-entacapone tabs $0 (1) mg carbidopa-levodopa-entacapone tabs $0 (1) mg carbidopa-levodopa-entacapone tabs 50- $0 (1) mg entacapone tab 200 mg $0 (1) NEUPRO DIS 1MG/24HR $0 (2) NEUPRO DIS 2MG/24HR $0 (2) NEUPRO DIS 3MG/24HR $0 (2) NEUPRO DIS 4MG/24HR $0 (2) NEUPRO DIS 6MG/24HR $0 (2) NEUPRO DIS 8MG/24HR $0 (2) pramipexole dihydrochloride tab 0.5 mg $0 (1) pramipexole dihydrochloride tab 0.25 mg $0 (1) pramipexole dihydrochloride tab 0.75 mg $0 (1) pramipexole dihydrochloride tab $0 (1) mg pramipexole dihydrochloride tab 1 mg $0 (1) pramipexole dihydrochloride tab 1.5 mg $0 (1) rasagiline mesylate tab 0.5 mg (base $0 (1) equiv) rasagiline mesylate tab 1 mg (base $0 (1) equiv) ropinirole hydrochloride tab 0.5 mg $0 (1) ropinirole hydrochloride tab 0.25 mg $0 (1) ropinirole hydrochloride tab 1 mg $0 (1) ropinirole hydrochloride tab 2 mg $0 (1) ropinirole hydrochloride tab 3 mg $0 (1) ropinirole hydrochloride tab 4 mg $0 (1) ropinirole hydrochloride tab 5 mg $0 (1) selegiline hcl cap 5 mg $0 (1) selegiline hcl tab 5 mg $0 (1) trihexyphenidyl hcl elixir 0.4 mg/ml $0 (2) PA; PA if 65 years and trihexyphenidyl hcl tab 2 mg $0 (2) PA; PA if 65 years and 59

76 Drug Name (By Medical Condition) WHAT THE trihexyphenidyl hcl tab 5 mg $0 (2) PA; PA if 65 years and ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAIN INJ 300MG $0 (2) NDS, QL (1 injection / 28 days) ABILIFY MAIN INJ 400MG $0 (2) NDS, QL (1 injection / 28 days) aripiprazole oral solution 1 mg/ml $0 (2) NDS, QL (900 ml / 30 days) aripiprazole orally disintegrating tab 10 mg $0 (2) NDS, QL (60 tabs / 30 days) aripiprazole orally disintegrating tab 15 mg $0 (2) NDS, QL (60 tabs / 30 days) aripiprazole tab 2 mg $0 (1) QL (30 tabs / 30 days) aripiprazole tab 5 mg $0 (1) QL (30 tabs / 30 days) aripiprazole tab 10 mg $0 (1) QL (30 tabs / 30 days) aripiprazole tab 15 mg $0 (1) QL (30 tabs / 30 days) aripiprazole tab 20 mg $0 (2) NDS, QL (30 tabs / 30 days) aripiprazole tab 30 mg $0 (2) NDS, QL (30 tabs / 30 days) ARISTADA INJ 441MG/1. $0 (2) NDS, QL (1 injection / 28 days) ARISTADA INJ 662MG/2 $0 (2) NDS, QL (1 injection / 28 days) ARISTADA INJ 882MG/3 $0 (2) NDS, QL (1 injection / 28 days) ARISTADA INJ 1064MG $0 (2) NDS, QL (1 injection / 56 days) CHLORPROMAZ INJ 25MG/ML $0 (2) CHLORPROMAZ INJ 50MG/2ML $0 (2) chlorpromazine hcl tab 10 mg $0 (1) chlorpromazine hcl tab 25 mg $0 (1) chlorpromazine hcl tab 50 mg $0 (1) chlorpromazine hcl tab 100 mg $0 (1) chlorpromazine hcl tab 200 mg $0 (1) clozapine orally disintegrating tab 12.5 mg $0 (1) PA clozapine orally disintegrating tab 25 mg $0 (1) PA clozapine orally disintegrating tab 100 mg $0 (1) QL (270 tabs / 30 days), PA clozapine orally disintegrating tab 150 mg $0 (1) QL (180 tabs / 30 days), PA 60

77 Drug Name (By Medical Condition) WHAT THE clozapine orally disintegrating tab 200 mg $0 (2) NDS, QL (135 tabs / 30 days), PA clozapine tab 25 mg $0 (1) clozapine tab 50 mg $0 (1) clozapine tab 100 mg $0 (1) QL (270 tabs / 30 days) clozapine tab 200 mg $0 (1) QL (135 tabs / 30 days) FANAPT PAK $0 (2) FANAPT TAB 1MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 2MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 4MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 6MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 8MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 10MG $0 (2) QL (60 tabs / 30 days) FANAPT TAB 12MG $0 (2) QL (60 tabs / 30 days) fluphenazine decanoate inj 25 mg/ml $0 (1) fluphenazine hcl elixir 2.5 mg/5ml $0 (1) fluphenazine hcl inj 2.5 mg/ml $0 (1) fluphenazine hcl oral conc 5 mg/ml $0 (1) fluphenazine hcl tab 1 mg $0 (1) fluphenazine hcl tab 2.5 mg $0 (1) fluphenazine hcl tab 5 mg $0 (1) fluphenazine hcl tab 10 mg $0 (1) GEODON INJ 20MG $0 (2) QL (6 ml / 3 days) haloperidol decanoate im soln 50 mg/ml $0 (1) haloperidol decanoate im soln 100 $0 (1) mg/ml haloperidol lactate inj 5 mg/ml $0 (1) haloperidol lactate oral conc 2 mg/ml $0 (1) haloperidol tab 0.5 mg $0 (1) haloperidol tab 1 mg $0 (1) haloperidol tab 2 mg $0 (1) haloperidol tab 5 mg $0 (1) haloperidol tab 10 mg $0 (1) haloperidol tab 20 mg $0 (1) INVEGA SUST INJ 39/0.25 $0 (2) QL (1 injection / 28 days) INVEGA SUST INJ 78/0.5ML $0 (2) NDS, QL (1 injection / 28 days) INVEGA SUST INJ 117/0.75 $0 (2) NDS, QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML $0 (2) NDS, QL (1 injection / 28 days) 61

78 Drug Name (By Medical Condition) WHAT THE INVEGA SUST INJ 234/1.5 $0 (2) NDS, QL (1 injection / 28 days) INVEGA TRINZ INJ 273MG $0 (2) NDS, QL (1 injection / 90 days) INVEGA TRINZ INJ 410MG $0 (2) NDS, QL (1 injection / 90 days) INVEGA TRINZ INJ 546MG $0 (2) NDS, QL (1 injection / 90 days) INVEGA TRINZ INJ 819MG $0 (2) NDS, QL (1 injection / 90 days) LATUDA TAB 20MG $0 (2) QL (240 tabs / 30 days) LATUDA TAB 40MG $0 (2) QL (30 tabs / 30 days) LATUDA TAB 60MG $0 (2) QL (60 tabs / 30 days) LATUDA TAB 80MG $0 (2) QL (60 tabs / 30 days) LATUDA TAB 120MG $0 (2) QL (30 tabs / 30 days) loxapine succinate cap 5 mg $0 (1) loxapine succinate cap 10 mg $0 (1) loxapine succinate cap 25 mg $0 (1) loxapine succinate cap 50 mg $0 (1) NUPLAZID TAB 17MG $0 (2) NDS, QL (60 tabs / 30 days), LA, PA olanzapine for im inj 10 mg $0 (1) QL (3 vials / 1 day) olanzapine orally disintegrating tab 5 mg $0 (1) QL (30 tabs / 30 days) olanzapine orally disintegrating tab 10 $0 (1) QL (60 tabs / 30 days) mg olanzapine orally disintegrating tab 15 $0 (1) QL (60 tabs / 30 days) mg olanzapine orally disintegrating tab 20 $0 (1) QL (60 tabs / 30 days) mg olanzapine tab 2.5 mg $0 (1) QL (240 tabs / 30 days) olanzapine tab 5 mg $0 (1) QL (120 tabs / 30 days) olanzapine tab 7.5 mg $0 (1) QL (30 tabs / 30 days) olanzapine tab 10 mg $0 (1) QL (60 tabs / 30 days) olanzapine tab 15 mg $0 (1) QL (60 tabs / 30 days) olanzapine tab 20 mg $0 (1) QL (60 tabs / 30 days) paliperidone tab er 24hr 1.5 mg $0 (2) NDS, QL (30 tabs / 30 days) paliperidone tab er 24hr 3 mg $0 (2) NDS, QL (30 tabs / 30 days) paliperidone tab er 24hr 6 mg $0 (2) NDS, QL (60 tabs / 30 days) paliperidone tab er 24hr 9 mg $0 (2) NDS, QL (30 tabs / 30 days) 62

79 Drug Name (By Medical Condition) WHAT THE perphenazine tab 2 mg $0 (1) perphenazine tab 4 mg $0 (1) perphenazine tab 8 mg $0 (1) perphenazine tab 16 mg $0 (1) pimozide tab 1 mg $0 (1) pimozide tab 2 mg $0 (1) quetiapine fumarate tab 25 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab 50 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab 100 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab 200 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab 300 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab 400 mg $0 (1) QL (90 tabs / 30 days) quetiapine fumarate tab er 24hr 50 mg $0 (1) QL (120 tabs / 30 days) quetiapine fumarate tab er 24hr 150 mg $0 (1) QL (30 tabs / 30 days) quetiapine fumarate tab er 24hr 200 mg $0 (1) QL (30 tabs / 30 days) quetiapine fumarate tab er 24hr 300 mg $0 (1) QL (60 tabs / 30 days) quetiapine fumarate tab er 24hr 400 mg $0 (1) QL (60 tabs / 30 days) REXULTI TAB 0.5MG $0 (2) NDS, QL (180 tabs / 30 days) REXULTI TAB 0.25MG $0 (2) NDS, QL (360 tabs / 30 days) REXULTI TAB 1MG $0 (2) NDS, QL (90 tabs / 30 days) REXULTI TAB 2MG $0 (2) NDS, QL (60 tabs / 30 days) REXULTI TAB 3MG $0 (2) NDS, QL (30 tabs / 30 days) REXULTI TAB 4MG $0 (2) NDS, QL (30 tabs / 30 days) RISPERDAL INJ 12.5MG $0 (2) QL (2 injections / 28 days) RISPERDAL INJ 25MG $0 (2) QL (2 injections / 28 days) RISPERDAL INJ 37.5MG $0 (2) NDS, QL (2 injections / 28 days) RISPERDAL INJ 50MG $0 (2) NDS, QL (2 injections / 28 days) risperidone orally disintegrating tab 0.5 mg $0 (1) QL (90 tabs / 30 days) risperidone orally disintegrating tab 0.25 $0 (1) QL (90 tabs / 30 days) mg risperidone orally disintegrating tab 1 mg $0 (1) QL (60 tabs / 30 days) 63

80 Drug Name (By Medical Condition) WHAT THE risperidone orally disintegrating tab 2 $0 (1) QL (60 tabs / 30 days) mg risperidone orally disintegrating tab 3 $0 (1) QL (60 tabs / 30 days) mg risperidone orally disintegrating tab 4 $0 (1) QL (120 tabs / 30 days) mg risperidone soln 1 mg/ml $0 (1) QL (240 ml / 30 days) risperidone tab 0.5 mg $0 (1) QL (90 tabs / 30 days) risperidone tab 0.25 mg $0 (1) QL (90 tabs / 30 days) risperidone tab 1 mg $0 (1) QL (60 tabs / 30 days) risperidone tab 2 mg $0 (1) QL (60 tabs / 30 days) risperidone tab 3 mg $0 (1) QL (60 tabs / 30 days) risperidone tab 4 mg $0 (1) QL (120 tabs / 30 days) SAPHRIS SUB 2.5MG $0 (2) QL (240 tabs / 30 days) SAPHRIS SUB 5MG $0 (2) QL (120 tabs / 30 days) SAPHRIS SUB 10MG $0 (2) QL (60 tabs / 30 days) thioridazine hcl tab 10 mg $0 (2) PA; PA if 65 years and thioridazine hcl tab 25 mg $0 (2) PA; PA if 65 years and thioridazine hcl tab 50 mg $0 (2) PA; PA if 65 years and thioridazine hcl tab 100 mg $0 (2) PA; PA if 65 years and thiothixene cap 1 mg $0 (1) thiothixene cap 2 mg $0 (1) thiothixene cap 5 mg $0 (1) thiothixene cap 10 mg $0 (1) trifluoperazine hcl tab 1 mg (base $0 (1) equivalent) trifluoperazine hcl tab 2 mg (base $0 (1) equivalent) trifluoperazine hcl tab 5 mg (base $0 (1) equivalent) trifluoperazine hcl tab 10 mg (base $0 (1) equivalent) VERSACLOZ SUS 50MG/ML $0 (2) NDS, QL (600 ml / 30 days), PA VRAYLAR CAP 1.5-3MG $0 (2) PA VRAYLAR CAP 1.5MG $0 (2) NDS, QL (120 caps / 30 days), PA VRAYLAR CAP 3MG $0 (2) NDS, QL (60 caps / 30 days), PA 64

81 Drug Name (By Medical Condition) WHAT THE VRAYLAR CAP 4.5MG $0 (2) NDS, QL (30 caps / 30 days), PA VRAYLAR CAP 6MG $0 (2) NDS, QL (30 caps / 30 days), PA ziprasidone hcl cap 20 mg $0 (1) QL (60 caps / 30 days) ziprasidone hcl cap 40 mg $0 (1) QL (60 caps / 30 days) ziprasidone hcl cap 60 mg $0 (1) QL (60 caps / 30 days) ziprasidone hcl cap 80 mg $0 (1) QL (60 caps / 30 days) ZYPREXA RELP INJ 210MG $0 (2) QL (2 vials / 28 days), PA ZYPREXA RELP INJ 300MG $0 (2) NDS, QL (2 vials / 28 days), PA ZYPREXA RELP INJ 405MG $0 (2) NDS, QL (1 vial / 28 days), PA ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap $0 (1) QL (90 caps / 30 days) er 24hr 5 mg amphetamine-dextroamphetamine cap $0 (1) QL (90 caps / 30 days) er 24hr 10 mg amphetamine-dextroamphetamine cap $0 (1) QL (30 caps / 30 days) er 24hr 15 mg amphetamine-dextroamphetamine cap $0 (1) QL (30 caps / 30 days) er 24hr 20 mg amphetamine-dextroamphetamine cap $0 (1) QL (30 caps / 30 days) er 24hr 25 mg amphetamine-dextroamphetamine cap er 24hr 30 mg $0 (1) QL (30 caps / 30 days) amphetamine-dextroamphetamine tab 5 $0 (1) QL (360 tabs / 30 days) mg amphetamine-dextroamphetamine tab $0 (1) QL (240 tabs / 30 days) 7.5 mg amphetamine-dextroamphetamine tab $0 (1) QL (180 tabs / 30 days) 10 mg amphetamine-dextroamphetamine tab $0 (1) QL (144 tabs / 30 days) 12.5 mg amphetamine-dextroamphetamine tab $0 (1) QL (120 tabs / 30 days) 15 mg amphetamine-dextroamphetamine tab $0 (1) QL (90 tabs / 30 days) 20 mg amphetamine-dextroamphetamine tab 30 mg $0 (1) QL (60 tabs / 30 days) atomoxetine hcl cap 10 mg (base equiv) $0 (1) QL (120 caps / 30 days) 65

82 Drug Name (By Medical Condition) WHAT THE atomoxetine hcl cap 18 mg (base equiv) $0 (1) atomoxetine hcl cap 25 mg (base equiv) $0 (1) atomoxetine hcl cap 40 mg (base equiv) $0 (1) atomoxetine hcl cap 60 mg (base equiv) $0 (1) atomoxetine hcl cap 80 mg (base equiv) $0 (1) atomoxetine hcl cap 100 mg (base equiv) guanfacine hcl tab er 24hr 1 mg (base equiv) guanfacine hcl tab er 24hr 2 mg (base equiv) guanfacine hcl tab er 24hr 3 mg (base equiv) QL (120 caps / 30 days) QL (120 caps / 30 days) QL (60 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) $0 (1) QL (30 caps / 30 days) $0 (2) PA; PA if 65 years and $0 (2) PA; PA if 65 years and $0 (2) PA; PA if 65 years and $0 (2) PA; PA if 65 years and guanfacine hcl tab er 24hr 4 mg (base equiv) methylphenidate hcl soln 5 mg/5ml $0 (1) QL (1800 ml / 30 days) methylphenidate hcl soln 10 mg/5ml $0 (1) QL (900 ml / 30 days) methylphenidate hcl tab 5 mg $0 (1) QL (180 tabs / 30 days) methylphenidate hcl tab 10 mg $0 (1) QL (180 tabs / 30 days) methylphenidate hcl tab 20 mg $0 (1) QL (90 tabs / 30 days) methylphenidate hcl tab er 10 mg $0 (1) QL (90 tabs / 30 days) methylphenidate hcl tab er 20 mg $0 (1) QL (90 tabs / 30 days) HYPNOTICS - DRUGS TO TREAT INSOMNIA eszopiclone tab 1 mg $0 (2) QL (30 tabs / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year eszopiclone tab 2 mg $0 (2) QL (30 tabs / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year eszopiclone tab 3 mg $0 (2) QL (30 tabs / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year HETLIOZ CAP 20MG $0 (2) NDS, LA, PA SILENOR TAB 3MG $0 (2) QL (60 tabs / 30 days) SILENOR TAB 6MG $0 (2) QL (30 tabs / 30 days) 66

83 Drug Name (By Medical Condition) WHAT THE temazepam cap 7.5 mg $0 (1) QL (30 caps / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year temazepam cap 15 mg $0 (1) QL (60 caps / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year zolpidem tartrate tab 5 mg $0 (2) QL (30 tabs / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year zolpidem tartrate tab 10 mg $0 (2) QL (30 tabs / 30 days), PA; PA applies if 65 years and after a 90 day supply in a calendar year MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES dihydroergotamine mesylate inj 1 mg/ml $0 (2) NDS dihydroergotamine mesylate nasal spray $0 (2) NDS, QL (8 ml / 30 4 mg/ml days) eletriptan hydrobromide tab 20 mg $0 (1) QL (12 tabs / 30 days) (base equivalent) eletriptan hydrobromide tab 40 mg $0 (1) QL (12 tabs / 30 days) (base equivalent) ergotamine w/ caffeine tab mg $0 (1) migergot sup 2/100 $0 (2) NDS naratriptan hcl tab 1 mg (base equiv) $0 (1) QL (12 tabs / 30 days) naratriptan hcl tab 2.5 mg (base equiv) $0 (1) QL (12 tabs / 30 days) rizatriptan benzoate oral disintegrating $0 (1) QL (18 tabs / 30 days) tab 5 mg (base eq) rizatriptan benzoate oral disintegrating $0 (1) QL (18 tabs / 30 days) tab 10 mg (base eq) rizatriptan benzoate tab 5 mg (base $0 (1) QL (18 tabs / 30 days) equivalent) rizatriptan benzoate tab 10 mg (base $0 (1) QL (18 tabs / 30 days) equivalent) sumatriptan nasal spray 5 mg/act $0 (1) QL (24 inhalers / 30 days) 67

84 Drug Name (By Medical Condition) WHAT THE sumatriptan nasal spray 20 mg/act $0 (1) QL (12 inhalers / 30 days) sumatriptan succinate inj 6 mg/0.5ml $0 (1) QL (12 injections / 30 days) sumatriptan succinate solution autoinjector 4 mg/0.5ml $0 (1) QL (18 injections / 30 days) sumatriptan succinate solution autoinjector 6 mg/0.5ml $0 (1) QL (12 injections / 30 days) sumatriptan succinate solution cartridge $0 (1) QL (18 injections / 30 4 mg/0.5ml days) sumatriptan succinate solution cartridge $0 (1) QL (12 injections / 30 6 mg/0.5ml days) sumatriptan succinate solution prefilled syringe 6 mg/0.5ml $0 (1) QL (12 injections / 30 days) sumatriptan succinate tab 25 mg $0 (1) QL (12 tabs / 30 days) sumatriptan succinate tab 50 mg $0 (1) QL (12 tabs / 30 days) sumatriptan succinate tab 100 mg $0 (1) QL (12 tabs / 30 days) zolmitriptan orally disintegrating tab 2.5 $0 (1) QL (12 tabs / 30 days) mg zolmitriptan orally disintegrating tab 5 $0 (1) QL (12 tabs / 30 days) mg zolmitriptan tab 2.5 mg $0 (1) QL (12 tabs / 30 days) zolmitriptan tab 5 mg $0 (1) QL (12 tabs / 30 days) MISCELLANEOUS AUSTEDO TAB 6MG $0 (2) NDS, QL (60 tabs / 30 days), LA, PA AUSTEDO TAB 9MG $0 (2) NDS, QL (120 tabs / 30 days), LA, PA AUSTEDO TAB 12MG $0 (2) NDS, QL (120 tabs / 30 days), LA, PA lithium carbonate cap 150 mg $0 (1) lithium carbonate cap 300 mg $0 (1) lithium carbonate cap 600 mg $0 (1) lithium carbonate tab 300 mg $0 (1) lithium carbonate tab er 300 mg $0 (1) lithium carbonate tab er 450 mg $0 (1) LITHIUM SOL 8MEQ/5ML $0 (2) NUEDEXTA CAP 20-10MG $0 (2) PA pyridostigmine bromide tab 60 mg $0 (1) riluzole tab 50 mg $0 (1) tetrabenazine tab 12.5 mg $0 (2) NDS, QL (240 tabs / 30 days), NM, PA 68

85 Drug Name (By Medical Condition) WHAT THE tetrabenazine tab 25 mg $0 (2) NDS, QL (120 tabs / 30 days), NM, PA MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA TAB 10MG $0 (2) NDS, NM, LA, PA BETASERON INJ 0.3MG $0 (2) NDS, QL (14 syringes / 28 days), NM, PA GILENYA CAP 0.5MG $0 (2) NDS, QL (28 caps / 28 days), NM, PA glatiramer acetate soln prefilled syringe $0 (2) NDS, QL (30 syringes / 20 mg/ml 30 days), NM, PA glatiramer acetate soln prefilled syringe $0 (2) NDS, QL (12 syringes / 40 mg/ml 28 days), NM, PA glatopa inj 20mg/ml $0 (2) NDS, QL (30 syringes / 30 days), NM, PA glatopa inj 40mg/ml $0 (2) NDS, QL (12 syringes / 28 days), NM, PA TYSABRI INJ 300/15ML $0 (2) NDS, NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen tab 10 mg $0 (1) baclofen tab 20 mg $0 (1) carisoprodol tab 350 mg $0 (2) QL (120 tabs / 30 days), PA; PA if 65 years and cyclobenzaprine hcl tab 5 mg $0 (2) PA; PA if 65 years and cyclobenzaprine hcl tab 10 mg $0 (2) PA; PA if 65 years and dantrolene sodium cap 25 mg $0 (1) dantrolene sodium cap 50 mg $0 (1) dantrolene sodium cap 100 mg $0 (1) methocarbamol tab 500 mg $0 (2) PA; PA if 65 years and methocarbamol tab 750 mg $0 (2) PA; PA if 65 years and tizanidine hcl tab 2 mg (base equivalent) $0 (1) tizanidine hcl tab 4 mg (base equivalent) $0 (1) NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil tab 50 mg $0 (1) QL (150 tabs / 30 days), PA 69

86 Drug Name (By Medical Condition) WHAT THE armodafinil tab 150 mg $0 (1) QL (60 tabs / 30 days), PA armodafinil tab 200 mg $0 (1) QL (30 tabs / 30 days), PA armodafinil tab 250 mg $0 (1) QL (30 tabs / 30 days), PA XYREM SOL 500MG/ML $0 (2) NDS, QL (540 ml / 30 days), LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium tab delayed release $0 (1) 333 mg buprenorphine hcl sl tab 2 mg (base $0 (1) PA equiv) buprenorphine hcl sl tab 8 mg (base equiv) $0 (1) PA buprenorphine hcl-naloxone hcl sl tab 2- $0 (1) QL (120 tabs / 30 days), 0.5 mg (base equiv) PA buprenorphine hcl-naloxone hcl sl tab 8- $0 (1) QL (120 tabs / 30 days), 2 mg (base equiv) PA bupropion hcl (smoking deterrent) tab er $0 (1) 12hr 150 mg CHANTIX PAK 0.5& 1MG $0 (2) PA CHANTIX PAK 1MG $0 (2) PA CHANTIX TAB 0.5MG $0 (2) PA CHANTIX TAB 1MG $0 (2) PA disulfiram tab 250 mg $0 (1) disulfiram tab 500 mg $0 (1) naloxone hcl inj 0.4 mg/ml $0 (1) naloxone hcl inj 4 mg/10ml $0 (1) naloxone hcl soln cartridge 0.4 mg/ml $0 (1) naloxone hcl soln prefilled syringe 2 $0 (1) mg/2ml naltrexone hcl tab 50 mg $0 (1) NARCAN SPR $0 (2) nicorelief gum 2mg mint $0 (3) NM; * nicorelief gum 2mg orig $0 (3) NM; * nicorelief gum 4mg mint $0 (3) NM; * nicorelief gum 4mg orig $0 (3) NM; * nicotine polacrilex gum 2 mg $0 (3) NM; * nicotine polacrilex gum 4 mg $0 (3) NM; * nicotine polacrilex lozenge 2 mg $0 (3) NM; * nicotine polacrilex lozenge 4 mg $0 (3) NM; * 70

87 Drug Name (By Medical Condition) WHAT THE NICOTINE SYS KIT TRANSDER $0 (3) NM; * nicotine td dis 7mg/24hr $0 (3) NM; * nicotine td dis 14mg/24h $0 (3) NM; * nicotine td dis 21mg/24h $0 (3) NM; * nicotine td patch 24hr 7 mg/24hr $0 (3) NM; * nicotine td patch 24hr 14 mg/24hr $0 (3) NM; * nicotine td patch 24hr 21 mg/24hr $0 (3) NM; * NICOTROL INH $0 (2) NICOTROL NS SPR 10MG/ML $0 (2) night time tab 25mg $0 (3) NM; * sleep aid tab 25mg $0 (3) NM; * SUBOXONE MIS 2-0.5MG $0 (2) QL (120 SL films / 30 days), PA SUBOXONE MIS 4-1MG $0 (2) QL (120 SL films / 30 days), PA SUBOXONE MIS 8-2MG $0 (2) QL (120 SL films / 30 days), PA SUBOXONE MIS 12-3MG $0 (2) QL (60 SL films / 30 days), PA VIVITROL INJ 380MG $0 (2) NDS, NM ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 TAB 50MG $0 (2) NDS, PA ANDRODERM DIS 2MG/24HR $0 (2) QL (30 patches / 30 days), PA ANDRODERM DIS 4MG/24HR $0 (2) QL (30 patches / 30 days), PA ANDROGEL GEL 1.62% $0 (2) QL (150 grams / 30 days), PA oxandrolone tab 2.5 mg $0 (1) PA oxandrolone tab 10 mg $0 (1) PA testosterone cypionate im inj in oil 100 $0 (1) PA mg/ml testosterone cypionate im inj in oil 200 $0 (1) PA mg/ml testosterone enanthate im inj in oil 200 $0 (1) PA mg/ml testosterone td gel 12.5 mg/act (1%) $0 (1) QL (300 gm / 30 days), PA testosterone td gel 25 mg/2.5gm (1%) $0 (1) QL (300 gm / 30 days), PA 71

88 Drug Name (By Medical Condition) WHAT THE testosterone td gel 50 mg/5gm (1%) $0 (1) QL (300 gm / 30 days), PA ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS $0 (2) BASAGLAR INJ 100UNIT $0 (2) BYDUREON INJ 2MG $0 (2) QL (4 vials / 28 days) BYDUREON INJ BCISE $0 (2) QL (4 pens / 28 days) BYDUREON PEN INJ 2MG $0 (2) QL (4 pens / 28 days) BYETTA INJ 5MCG $0 (2) QL (1 pen / 30 days) BYETTA INJ 10MCG $0 (2) QL (1 pen / 30 days) FIASP FLEX INJ TOUCH $0 (2) FIASP INJ 100/ML $0 (2) GAUZE PADS 2" X 2" $0 (2) HUMULIN R INJ U-500 $0 (2) NDS; KwikPen HUMULIN R INJ U-500 $0 (2) NDS, B/D; Vial (Concentrate) INSULIN PEN NEEDLE $0 (2) INSULIN SAFETY NEEDLES $0 (2) INSULIN SYRINGE $0 (2) LEVEMIR INJ $0 (2) LEVEMIR INJ FLEXTOUC $0 (2) NOVOLIN INJ 70/30 $0 (2) (brand RELION not covered) NOVOLIN N INJ U-100 $0 (2) (brand RELION not covered) NOVOLIN R INJ U-100 $0 (2) (brand RELION not covered) NOVOLOG INJ 100/ML $0 (2) NOVOLOG INJ FLEXPEN $0 (2) NOVOLOG INJ PENFILL $0 (2) NOVOLOG MIX INJ 70/30 $0 (2) NOVOLOG MIX INJ FLEXPEN $0 (2) OZEMPIC INJ 2/1.5ML $0 (2) QL (1 pen / 28 days) OZEMPIC INJ 2/1.5ML $0 (2) QL (2 pens / 28 days) SOLIQUA INJ 100/33 $0 (2) QL (10 pens / 30 days) TRESIBA FLEX INJ 100UNIT $0 (2) TRESIBA FLEX INJ 200UNIT $0 (2) TRULICITY INJ 0.75/0.5 $0 (2) QL (4 pens / 28 days) TRULICITY INJ 1.5/0.5 $0 (2) QL (4 pens / 28 days) VICTOZA INJ 18MG/3ML $0 (2) QL (3 pens / 30 days) XULTOPHY INJ 100/3.6 $0 (2) QL (5 pens / 30 days) ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES 72

89 Drug Name (By Medical Condition) WHAT THE acarbose tab 25 mg $0 (1) acarbose tab 50 mg $0 (1) acarbose tab 100 mg $0 (1) FARXIGA TAB 5MG $0 (2) QL (60 tabs / 30 days) FARXIGA TAB 10MG $0 (2) QL (30 tabs / 30 days) glimepiride tab 1 mg $0 (1) QL (240 tabs / 30 days) glimepiride tab 2 mg $0 (1) QL (120 tabs / 30 days) glimepiride tab 4 mg $0 (1) QL (60 tabs / 30 days) glipizide tab 5 mg $0 (1) QL (240 tabs / 30 days) glipizide tab 10 mg $0 (1) QL (120 tabs / 30 days) glipizide tab er 24hr 2.5 mg $0 (1) QL (240 tabs / 30 days) glipizide tab er 24hr 5 mg $0 (1) QL (120 tabs / 30 days) glipizide tab er 24hr 10 mg $0 (1) QL (60 tabs / 30 days) glipizide xl tab 2.5mg $0 (1) QL (240 tabs / 30 days) glipizide xl tab 5mg $0 (1) QL (120 tabs / 30 days) glipizide xl tab 10mg $0 (1) QL (60 tabs / 30 days) glipizide-metformin hcl tab mg $0 (1) QL (240 tabs / 30 days) glipizide-metformin hcl tab mg $0 (1) QL (120 tabs / 30 days) glipizide-metformin hcl tab mg $0 (1) QL (120 tabs / 30 days) glyburide micronized tab 1.5 mg $0 (2) QL (240 tabs / 30 days), PA; PA if 65 years and glyburide micronized tab 3 mg $0 (2) QL (120 tabs / 30 days), PA; PA if 65 years and glyburide micronized tab 6 mg $0 (2) QL (60 tabs / 30 days), PA; PA if 65 years and glyburide tab 1.25 mg $0 (2) QL (480 tabs / 30 days), PA; PA if 65 years and glyburide tab 2.5 mg $0 (2) QL (240 tabs / 30 days), PA; PA if 65 years and glyburide tab 5 mg $0 (2) QL (120 tabs / 30 days), PA; PA if 65 years and INVOKAMET TAB MG $0 (2) QL (120 tabs / 30 days) INVOKAMET TAB $0 (2) QL (60 tabs / 30 days) INVOKAMET TAB $0 (2) QL (60 tabs / 30 days) INVOKAMET TAB $0 (2) QL (60 tabs / 30 days) INVOKAMET XR TAB MG $0 (2) QL (120 tabs / 30 days) INVOKAMET XR TAB $0 (2) QL (60 tabs / 30 days) 73

90 Drug Name (By Medical Condition) WHAT THE INVOKAMET XR TAB $0 (2) QL (60 tabs / 30 days) INVOKAMET XR TAB $0 (2) QL (60 tabs / 30 days) INVOKANA TAB 100MG $0 (2) QL (90 tabs / 30 days) INVOKANA TAB 300MG $0 (2) QL (30 tabs / 30 days) JANUMET TAB MG $0 (2) QL (60 tabs / 30 days) JANUMET TAB $0 (2) QL (60 tabs / 30 days) JANUMET XR TAB MG $0 (2) QL (60 tabs / 30 days) JANUMET XR TAB $0 (2) QL (60 tabs / 30 days) JANUMET XR TAB $0 (2) QL (30 tabs / 30 days) JANUVIA TAB 25MG $0 (2) QL (30 tabs / 30 days) JANUVIA TAB 50MG $0 (2) QL (30 tabs / 30 days) JANUVIA TAB 100MG $0 (2) QL (30 tabs / 30 days) JENTADUETO TAB $0 (2) QL (60 tabs / 30 days) JENTADUETO TAB $0 (2) QL (60 tabs / 30 days) JENTADUETO TAB $0 (2) QL (60 tabs / 30 days) JENTADUETO TAB XR $0 (2) QL (30 tabs / 30 days) JENTADUETO TAB XR $0 (2) QL (60 tabs / 30 days) metformin hcl tab 500 mg $0 (1) QL (150 tabs / 30 days) metformin hcl tab 850 mg $0 (1) QL (90 tabs / 30 days) metformin hcl tab 1000 mg $0 (1) QL (75 tabs / 30 days) metformin hcl tab er 24hr 500 mg $0 (1) QL (120 tabs / 30 days); (generic of GLUCOPHAGE XR) metformin hcl tab er 24hr 750 mg $0 (1) QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR) nateglinide tab 60 mg $0 (1) QL (90 tabs / 30 days) nateglinide tab 120 mg $0 (1) QL (90 tabs / 30 days) pioglitazone hcl tab 15 mg (base equiv) $0 (1) QL (30 tabs / 30 days) pioglitazone hcl tab 30 mg (base equiv) $0 (1) QL (30 tabs / 30 days) pioglitazone hcl tab 45 mg (base equiv) $0 (1) QL (30 tabs / 30 days) repaglinide tab 0.5 mg $0 (1) QL (120 tabs / 30 days) repaglinide tab 1 mg $0 (1) QL (120 tabs / 30 days) repaglinide tab 2 mg $0 (1) QL (240 tabs / 30 days) TRADJENTA TAB 5MG $0 (2) QL (30 tabs / 30 days) XIGDUO XR TAB $0 (2) QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG $0 (2) QL (60 tabs / 30 days) XIGDUO XR TAB MG $0 (2) QL (60 tabs / 30 days) XIGDUO XR TAB MG $0 (2) QL (30 tabs / 30 days) XIGDUO XR TAB $0 (2) QL (30 tabs / 30 days) BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium tab 5 mg $0 (1) 74

91 Drug Name (By Medical Condition) WHAT THE alendronate sodium tab 10 mg $0 (1) alendronate sodium tab 35 mg $0 (1) QL (4 tabs / 28 days) alendronate sodium tab 40 mg $0 (1) alendronate sodium tab 70 mg $0 (1) QL (4 tabs / 28 days) ibandronate sodium tab 150 mg (base $0 (1) B/D equivalent) pamidronate disodium for inj 30 mg $0 (1) B/D pamidronate disodium for inj 90 mg $0 (1) B/D pamidronate disodium iv soln 3 mg/ml $0 (1) B/D pamidronate disodium iv soln 9 mg/ml $0 (1) B/D PAMIDRONATE INJ 6MG/ML $0 (2) B/D zoledronic acid inj conc for iv infusion 4 $0 (1) B/D, NM mg/5ml zoledronic acid iv soln 5 mg/100ml $0 (1) B/D, NM CALCIUM RECEPTOR AGONISTS SENSIPAR TAB 30MG $0 (2) NDS, B/D, QL (120 tabs / 30 days), NM SENSIPAR TAB 60MG $0 (2) NDS, B/D, QL (60 tabs / 30 days), NM SENSIPAR TAB 90MG $0 (2) NDS, B/D, QL (120 tabs / 30 days), NM CHELATING AGENTS CHEMET CAP 100MG $0 (2) DEPEN TITRA TAB 250MG $0 (2) NDS JADENU SPRKL GRA 90MG $0 (2) NDS, LA, PA JADENU SPRKL GRA 180MG $0 (2) NDS, LA, PA JADENU SPRKL GRA 360MG $0 (2) NDS, LA, PA JADENU TAB 90MG $0 (2) NDS, LA, PA JADENU TAB 180MG $0 (2) NDS, LA, PA JADENU TAB 360MG $0 (2) NDS, LA, PA sodium polystyrene sulfonate oral susp $0 (1) 15 gm/60ml sodium polystyrene sulfonate powder $0 (1) SYPRINE CAP 250MG $0 (2) NDS trientine hcl cap 250 mg $0 (2) NDS CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL alyacen tab 1/35 $0 (1) apri tab $0 (1) aranelle tab $0 (1) aubra tab $0 (1) aviane tab $0 (1) balziva tab $0 (1) 75

92 Drug Name (By Medical Condition) WHAT THE bekyree tab $0 (1) blisovi fe tab 1.5/30 $0 (1) blisovi fe tab 1/20 $0 (1) briellyn tab $0 (1) camila tab 0.35mg $0 (1) cryselle-28 tab 28 tabs $0 (1) cyclafem tab 1/35 $0 (1) cyclafem tab 7/7/7 $0 (1) dasetta tab 1/35 $0 (1) dasetta tab 7/7/7 $0 (1) deblitane tab 0.35mg $0 (1) delyla tab $0 (1) desogest-eth estrad & eth estrad tab $0 (1) /0.01 mg(21/5) desogest-ethin est tab / $0 (1) 0.025/ mg-mg desogestrel & ethinyl estradiol tab 0.15 $0 (1) mg-30 mcg drospirenone-ethinyl estradiol tab $0 (1) mg drospirenone-ethinyl estradiol tab $0 (1) mg econtra ez tab 1.5mg $0 (3) NM; * ELLA TAB 30MG $0 (2) emoquette tab $0 (1) enpresse-28 tab $0 (1) enskyce tab $0 (1) errin tab 0.35mg $0 (1) ethynodiol diacetate & ethinyl estradiol $0 (1) tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol $0 (1) tab 1 mg-50 mcg fallback tab 1.5mg $0 (3) NM; * falmina tab $0 (1) femynor tab $0 (1) gildagia tab $0 (1) heather tab 0.35mg $0 (1) introvale tab $0 (1) isibloom tab $0 (1) jolivette tab 0.35mg $0 (1) juleber tab $0 (1) junel 1.5/30 tab $0 (1) 76

93 Drug Name (By Medical Condition) WHAT THE junel 1/20 tab $0 (1) junel fe tab 1.5/30 $0 (1) junel fe tab 1/20 $0 (1) kariva tab 28 day $0 (1) kelnor 1/50 tab $0 (1) kelnor tab 1/35 $0 (1) kimidess tab $0 (1) kurvelo tab 0.15/30 $0 (1) larin fe tab 1.5/30 $0 (1) larin fe tab 1/20 $0 (1) larin tab 1.5/30 $0 (1) larin tab 1/20 $0 (1) lessina tab $0 (1) levonest tab $0 (1) levonorgestrel & ethinyl estradiol (91- $0 (1) day) tab mg levonorgestrel & ethinyl estradiol tab 0.1 $0 (1) mg-20 mcg levonorgestrel & ethinyl estradiol tab $0 (1) 0.15 mg-30 mcg levonorgestrel tab 1.5 mg $0 (3) NM; * levonorgestrel-eth estra tab $0 (1) 30/ / mg-mcg levora-28 tab 0.15/30 $0 (1) loryna tab mg $0 (1) lutera tab $0 (1) lyza tab 0.35mg $0 (1) marlissa tab 0.15/30 $0 (1) medroxyprogesterone acetate im susp $0 (1) 150 mg/ml medroxyprogesterone acetate im susp $0 (1) prefilled syr 150 mg/ml mononessa tab $0 (1) my way tab 1.5mg $0 (3) NM; * myzilra tab $0 (1) necon tab 0.5/35 $0 (1) necon tab 7/7/7 $0 (1) next choice tab 1.5mg $0 (3) NM; * nikki tab mg $0 (1) norelgestromin-ethinyl estradiol td ptwk $0 (1) mcg/24hr 77

94 Drug Name (By Medical Condition) WHAT THE norethindrone & mestranol tab 1 mg-50 $0 (1) mcg norethindrone ac-ethinyl estrad-fe tab 1-$0 (1) 20/1-30/1-35 mg-mcg norethindrone ace & ethinyl estradiol tab $0 (1) 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab $0 (1) 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe $0 (1) tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe $0 (1) tab 1.5 mg-30 mcg norethindrone tab 0.35 mg $0 (1) norethindrone-eth estradiol tab 0.5- $0 (1) 35/1-35/ mg-mcg norgestimate & ethinyl estradiol tab 0.25 $0 (1) mg-35 mcg norgestimate-eth estrad tab $0 (1) 25/ / mg-mcg norgestimate-eth estrad tab $0 (1) 35/ / mg-mcg norgestrel & ethinyl estradiol tab 0.3 $0 (1) mg-30 mcg norlyroc tab 0.35mg $0 (1) nortrel tab 0.5/35 $0 (1) nortrel tab 1/35 $0 (1) nortrel tab 7/7/7 $0 (1) NUVARING MIS $0 (2) opcicon tab 1.5mg $0 (3) NM; * orsythia tab $0 (1) philith tab $0 (1) pimtrea tab $0 (1) pirmella tab 1/35 $0 (1) portia-28 tab $0 (1) previfem tab $0 (1) quasense tab $0 (1) reclipsen tab $0 (1) sharobel tab 0.35mg $0 (1) sprintec 28 tab 28 day $0 (1) tarina fe tab 1/20 $0 (1) tri-legest tab fe $0 (1) tri-lo- tab sprintec $0 (1) 78

95 Drug Name (By Medical Condition) WHAT THE tri-previfem tab $0 (1) tri-sprintec tab $0 (1) tri-vylibra tab $0 (1) trinessa lo tab $0 (1) trinessa tab $0 (1) trivora-28 tab $0 (1) velivet pak $0 (1) vienva tab $0 (1) viorele tab $0 (1) vyfemla tab $0 (1) vylibra tab $0 (1) zarah tab mg $0 (1) zenchent tab $0 (1) zovia 1/35e tab $0 (1) zovia 1/50e tab $0 (1) ENDOMETRIOSIS danazol cap 50 mg $0 (1) danazol cap 100 mg $0 (1) danazol cap 200 mg $0 (1) SYNAREL SOL 2MG/ML $0 (2) NDS, NM ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN INJ 250/ML $0 (2) NDS, LA, PA ALDURAZYME INJ 2.9MG/5M $0 (2) NDS, NM, LA, PA CARBAGLU TAB 200MG $0 (2) NDS, LA, PA CERDELGA CAP 84MG $0 (2) NDS, NM, PA CEREZYME INJ 400UNIT $0 (2) NDS, NM, LA, PA CYSTADANE POW $0 (2) NDS, LA CYSTAGON CAP 50MG $0 (2) NM, LA, PA CYSTAGON CAP 150MG $0 (2) NM, LA, PA FABRAZYME INJ 5MG $0 (2) NDS, NM, LA, PA FABRAZYME INJ 35MG $0 (2) NDS, NM, LA, PA KUVAN POW 100MG $0 (2) NDS, NM, LA, PA KUVAN POW 500MG $0 (2) NDS, NM, LA, PA KUVAN TAB 100MG $0 (2) NDS, NM, LA, PA levocarnitine inj 200 mg/ml $0 (1) B/D levocarnitine oral soln 1 gm/10ml (10%) $0 (1) B/D levocarnitine tab 330 mg $0 (1) B/D LUMIZYME INJ 50MG $0 (2) NDS, NM, LA, PA miglustat cap 100 mg $0 (2) NDS, PA NAGLAZYME INJ 1MG/ML $0 (2) NDS, NM, LA, PA ORFADIN CAP 2MG $0 (2) NDS, LA, PA 79

96 Drug Name (By Medical Condition) WHAT THE ORFADIN CAP 5MG $0 (2) NDS, LA, PA ORFADIN CAP 10MG $0 (2) NDS, LA, PA ORFADIN CAP 20MG $0 (2) NDS, LA, PA ORFADIN SUS 4MG/ML $0 (2) NDS, LA, PA sodium phenylbutyrate oral powder 3 $0 (2) NDS, NM, PA gm/teaspoonful sodium phenylbutyrate tab 500 mg $0 (2) NDS, NM, PA ZAVESCA CAP 100MG $0 (2) NDS, LA, PA ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN INJ 10MG/ML $0 (2) estradiol tab 0.5 mg $0 (2) PA; PA if 65 years and estradiol tab 1 mg $0 (2) PA; PA if 65 years and estradiol tab 2 mg $0 (2) PA; PA if 65 years and estradiol td patch weekly 0.1 mg/24hr $0 (2) PA; PA if 65 years and estradiol td patch weekly 0.05 mg/24hr $0 (2) PA; PA if 65 years and estradiol td patch weekly 0.06 mg/24hr $0 (2) PA; PA if 65 years and estradiol td patch weekly mg/24hr $0 (2) PA; PA if 65 years and estradiol td patch weekly mg/24hr $0 (2) PA; PA if 65 years and estradiol td patch weekly mg/24hr (37.5 mcg/24hr) $0 (2) PA; PA if 65 years and estradiol vaginal cream 0.1 mg/gm $0 (1) estradiol vaginal tab 10 mcg $0 (1) estradiol valerate im in oil 20 mg/ml $0 (1) estradiol valerate im in oil 40 mg/ml $0 (1) jinteli tab 1mg-5mcg $0 (2) PA; PA if 65 years and norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg $0 (2) PA; PA if 65 years and GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate tab 25 mg $0 (1) DEXAMETHASON CON 1MG/ML $0 (2) dexamethasone elixir 0.5 mg/5ml $0 (1) dexamethasone sod phosphate $0 (1) preservative free inj 10 mg/ml 80

97 Drug Name (By Medical Condition) WHAT THE dexamethasone sodium phosphate inj 4 $0 (1) mg/ml dexamethasone sodium phosphate inj 10 $0 (1) mg/ml dexamethasone sodium phosphate inj 20 $0 (1) mg/5ml dexamethasone sodium phosphate inj $0 (1) 100 mg/10ml dexamethasone sodium phosphate inj $0 (1) 120 mg/30ml dexamethasone soln 0.5 mg/5ml $0 (1) dexamethasone tab 0.5 mg $0 (1) dexamethasone tab 0.75 mg $0 (1) dexamethasone tab 1 mg $0 (1) dexamethasone tab 1.5 mg $0 (1) dexamethasone tab 2 mg $0 (1) dexamethasone tab 4 mg $0 (1) dexamethasone tab 6 mg $0 (1) fludrocortisone acetate tab 0.1 mg $0 (1) hydrocortisone tab 5 mg $0 (1) hydrocortisone tab 10 mg $0 (1) hydrocortisone tab 20 mg $0 (1) methylprednisolone acetate inj susp 40 $0 (1) B/D mg/ml methylprednisolone acetate inj susp 80 $0 (1) B/D mg/ml methylprednisolone sod succ for inj 40 mg (base equiv) $0 (1) B/D methylprednisolone sod succ for inj 125 $0 (1) B/D mg (base equiv) methylprednisolone sod succ for inj 1000 $0 (1) B/D mg (base equiv) methylprednisolone tab 4 mg $0 (1) B/D methylprednisolone tab 8 mg $0 (1) B/D methylprednisolone tab 16 mg $0 (1) B/D methylprednisolone tab 32 mg $0 (1) B/D methylprednisolone tab therapy pack 4 $0 (1) mg (21) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) $0 (1) B/D prednisolone sod phosphate oral soln 15 $0 (1) B/D mg/5ml (base equiv) 81

98 Drug Name (By Medical Condition) WHAT THE prednisolone sodium phosphate oral soln $0 (1) B/D 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp $0 (1) B/D solution equivalent) PREDNISONE CON 5MG/ML $0 (2) B/D prednisone oral soln 5 mg/5ml $0 (1) B/D prednisone tab 1 mg $0 (1) B/D prednisone tab 2.5 mg $0 (1) B/D prednisone tab 5 mg $0 (1) B/D prednisone tab 10 mg $0 (1) B/D prednisone tab 20 mg $0 (1) B/D prednisone tab 50 mg $0 (1) B/D prednisone tab therapy pack 5 mg (21) $0 (1) prednisone tab therapy pack 5 mg (48) $0 (1) prednisone tab therapy pack 10 mg (21) $0 (1) prednisone tab therapy pack 10 mg (48) $0 (1) SOLU-CORTEF INJ 250MG $0 (2) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN INJ HYPOKIT $0 (2) GLUCAGON KIT 1MG $0 (2) PROGLYCEM SUS 50MG/ML $0 (2) HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES NORDITROPIN INJ 5/1.5ML $0 (2) NDS, NM, PA NORDITROPIN INJ 10/1.5ML $0 (2) NDS, NM, PA NORDITROPIN INJ 15/1.5ML $0 (2) NDS, NM, PA NORDITROPIN INJ 30/3ML $0 (2) NDS, NM, PA MISCELLANEOUS cabergoline tab 0.5 mg $0 (1) calcitonin (salmon) nasal soln 200 $0 (1) B/D unit/act FORTEO SOL 600/2.4 $0 (2) NDS, NM, PA INCRELEX INJ 40MG/4ML $0 (2) NDS, NM, LA, PA KORLYM TAB 300MG $0 (2) NDS, LA, PA LUPR DEP-PED INJ 3M 30MG $0 (2) NDS, NM, PA LUPR DEP-PED INJ 7.5MG $0 (2) NDS, NM, PA LUPR DEP-PED INJ 11.25MG $0 (2) NDS, NM, PA LUPR DEP-PED INJ 15MG $0 (2) NDS, NM, PA MIACALCIN INJ 200/ML $0 (2) NDS, B/D NATPARA INJ 25MCG $0 (2) NDS, PA 82

99 Drug Name (By Medical Condition) WHAT THE NATPARA INJ 50MCG $0 (2) NDS, PA NATPARA INJ 75MCG $0 (2) NDS, PA NATPARA INJ 100MCG $0 (2) NDS, PA octreotide acetate inj 50 mcg/ml (0.05 $0 (1) NM, PA mg/ml) octreotide acetate inj 100 mcg/ml (0.1 $0 (1) NM, PA mg/ml) octreotide acetate inj 200 mcg/ml (0.2 $0 (1) NM, PA mg/ml) octreotide acetate inj 500 mcg/ml (0.5 $0 (2) NDS, NM, PA mg/ml) octreotide acetate inj 1000 mcg/ml (1 $0 (2) NDS, NM, PA mg/ml) PROLIA SOL 60MG/ML $0 (2) QL (1 injection / 180 days), NM raloxifene hcl tab 60 mg $0 (1) SANDOSTATIN KIT LAR 10MG $0 (2) NDS, NM, PA SANDOSTATIN KIT LAR 20MG $0 (2) NDS, NM, PA SANDOSTATIN KIT LAR 30MG $0 (2) NDS, NM, PA SIGNIFOR INJ 0.3MG/ML $0 (2) NDS, LA, PA SIGNIFOR INJ 0.6MG/ML $0 (2) NDS, LA, PA SIGNIFOR INJ 0.9MG/ML $0 (2) NDS, LA, PA SOMATULINE INJ 60/0.2ML $0 (2) NDS, PA SOMATULINE INJ 90/0.3ML $0 (2) NDS, PA SOMATULINE INJ 120/.5ML $0 (2) NDS, NM, PA SOMAVERT INJ 10MG $0 (2) NDS, NM, LA, PA SOMAVERT INJ 15MG $0 (2) NDS, NM, LA, PA SOMAVERT INJ 20MG $0 (2) NDS, NM, LA, PA SOMAVERT INJ 25MG $0 (2) NDS, NM, LA, PA SOMAVERT INJ 30MG $0 (2) NDS, NM, LA, PA XGEVA INJ $0 (2) NDS, NM, PA PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA TAB 210MG $0 (2) NDS, QL (360 tabs / 30 days) calcium acetate (phosphate binder) cap $0 (1) QL (360 caps / 30 days) 667 mg (169 mg ca) calcium acetate (phosphate binder) tab $0 (1) QL (360 tabs / 30 days) 667 mg sevelamer carbonate packet 0.8 gm $0 (1) QL (540 packs / 30 days) 83

100 Drug Name (By Medical Condition) WHAT THE sevelamer carbonate packet 2.4 gm $0 (1) QL (180 packs / 30 days) sevelamer carbonate tab 800 mg $0 (1) QL (540 tabs / 30 days) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab 2.5 $0 (1) mg medroxyprogesterone acetate tab 5 mg $0 (1) medroxyprogesterone acetate tab 10 mg $0 (1) norethindrone acetate tab 5 mg $0 (1) THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levo-t tab 25mcg $0 (1) levo-t tab 50mcg $0 (1) levo-t tab 75mcg $0 (1) levo-t tab 88mcg $0 (1) levo-t tab 100mcg $0 (1) levo-t tab 112mcg $0 (1) levo-t tab 125mcg $0 (1) levo-t tab 137mcg $0 (1) levo-t tab 150mcg $0 (1) levo-t tab 175mcg $0 (1) levo-t tab 200 mcg $0 (1) levo-t tab 300 mcg $0 (1) levothyroxine sodium tab 25 mcg $0 (1) levothyroxine sodium tab 50 mcg $0 (1) levothyroxine sodium tab 75 mcg $0 (1) levothyroxine sodium tab 88 mcg $0 (1) levothyroxine sodium tab 100 mcg $0 (1) levothyroxine sodium tab 112 mcg $0 (1) levothyroxine sodium tab 125 mcg $0 (1) levothyroxine sodium tab 137 mcg $0 (1) levothyroxine sodium tab 150 mcg $0 (1) levothyroxine sodium tab 175 mcg $0 (1) levothyroxine sodium tab 200 mcg $0 (1) levothyroxine sodium tab 300 mcg $0 (1) levoxyl tab 25mcg $0 (1) levoxyl tab 50mcg $0 (1) levoxyl tab 75mcg $0 (1) levoxyl tab 88mcg $0 (1) levoxyl tab 100mcg $0 (1) levoxyl tab 112mcg $0 (1) levoxyl tab 125mcg $0 (1) 84

101 Drug Name (By Medical Condition) WHAT THE levoxyl tab 137mcg $0 (1) levoxyl tab 150mcg $0 (1) levoxyl tab 175mcg $0 (1) levoxyl tab 200mcg $0 (1) liothyronine sodium tab 5 mcg $0 (1) liothyronine sodium tab 25 mcg $0 (1) liothyronine sodium tab 50 mcg $0 (1) methimazole tab 5 mg $0 (1) methimazole tab 10 mg $0 (1) propylthiouracil tab 50 mg $0 (1) SYNTHROID TAB 25MCG $0 (2) SYNTHROID TAB 50MCG $0 (2) SYNTHROID TAB 75MCG $0 (2) SYNTHROID TAB 88MCG $0 (2) SYNTHROID TAB 100MCG $0 (2) SYNTHROID TAB 112MCG $0 (2) SYNTHROID TAB 125MCG $0 (2) SYNTHROID TAB 137MCG $0 (2) SYNTHROID TAB 150MCG $0 (2) SYNTHROID TAB 175MCG $0 (2) SYNTHROID TAB 200MCG $0 (2) SYNTHROID TAB 300MCG $0 (2) unithroid tab 25mcg $0 (1) unithroid tab 50mcg $0 (1) unithroid tab 75mcg $0 (1) unithroid tab 88mcg $0 (1) unithroid tab 100mcg $0 (1) unithroid tab 112mcg $0 (1) unithroid tab 125mcg $0 (1) unithroid tab 150mcg $0 (1) unithroid tab 175mcg $0 (1) unithroid tab 200mcg $0 (1) unithroid tab 300mcg $0 (1) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate inj 4 mcg/ml $0 (1) NM desmopressin acetate nasal soln 0.01% $0 (1) NM (refrigerated) desmopressin acetate nasal spray soln $0 (1) NM 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) $0 (1) NM 85

102 Drug Name (By Medical Condition) WHAT THE desmopressin acetate tab 0.1 mg $0 (1) NM desmopressin acetate tab 0.2 mg $0 (1) NM STIMATE SOL 1.5MG/ML $0 (2) NDS, NM GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTACIDS acid gone sus $0 (3) NM; * almacone chw $0 (3) NM; * almacone dbl sus strength $0 (3) NM; * almacone sus $0 (3) NM; * ALUM HYDROX SUS 320/5ML $0 (3) NM; * antacid chw 500mg $0 (3) NM; * antacid chw 750mg $0 (3) NM; * antacid plus sus gas rel $0 (3) NM; * antacid sus max st $0 (3) NM; * cal-gest chw 500mg $0 (3) NM; * calc antacid chw 500mg $0 (3) NM; * calc antacid chw 750mg $0 (3) NM; * gnp antacid sus anti-gas $0 (3) NM; * gnp masanti sus max st $0 (3) NM; * gnp masanti sus reg st $0 (3) NM; * magnesium oxide tab 400 mg $0 (3) NM; * mi-acid sus $0 (3) NM; * mi-acid sus max st $0 (3) NM; * mintox sus max st $0 (3) NM; * rulox sus $0 (3) NM; * sm antacid sus anti-gas $0 (3) NM; * sm antacid/ sus antigas $0 (3) NM; * sodium bicarbonate tab 325 mg $0 (3) NM; * sodium bicarbonate tab 650 mg $0 (3) NM; * ANTI-DIARRHEAL anti-diarrhe tab 2mg $0 (3) NM; * bismatrol chw 262mg $0 (3) NM; * bismatrol sus 262/15ml $0 (3) NM; * bismatrol sus 525/15ml $0 (3) NM; * kao-tin sus 262/15ml $0 (3) NM; * loperamide hcl liq 1 mg/5ml (0.2 mg/ml) $0 (3) NM; * loperamide hcl liq 1 mg/7.5ml $0 (3) NM; * peptic relf chw 262mg $0 (3) NM; * pink bismuth chw 262mg $0 (3) NM; * sm anti-diar tab 2mg $0 (3) NM; * 86

103 Drug Name (By Medical Condition) WHAT THE ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant capsule 40 mg $0 (1) B/D aprepitant capsule 80 mg $0 (1) B/D aprepitant capsule 125 mg $0 (1) B/D aprepitant capsule therapy pack 80 & $0 (1) B/D 125 mg compro sup 25mg $0 (1) dronabinol cap 2.5 mg $0 (1) B/D, QL (60 caps / 30 days) dronabinol cap 5 mg $0 (1) B/D, QL (60 caps / 30 days) dronabinol cap 10 mg $0 (1) B/D, QL (60 caps / 30 days) EMEND SUS 125MG $0 (2) B/D granisetron hcl inj 0.1 mg/ml $0 (1) granisetron hcl inj 1 mg/ml $0 (1) granisetron hcl inj 4 mg/4ml (1 mg/ml) $0 (1) granisetron hcl tab 1 mg $0 (1) B/D meclizine hcl tab 12.5 mg $0 (1) meclizine hcl tab 12.5 mg $0 (3) NM; * meclizine hcl tab 25 mg $0 (1) metoclopramide hcl inj 5 mg/ml (base $0 (1) equivalent) metoclopramide hcl soln 5 mg/5ml (10 $0 (1) mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base $0 (1) equivalent) metoclopramide hcl tab 10 mg (base equivalent) $0 (1) ondansetron hcl inj 4 mg/2ml (2 mg/ml) $0 (1) ondansetron hcl inj 40 mg/20ml (2 $0 (1) mg/ml) ondansetron hcl oral soln 4 mg/5ml $0 (1) B/D ondansetron hcl tab 4 mg $0 (1) B/D ondansetron hcl tab 8 mg $0 (1) B/D ondansetron hcl tab 24 mg $0 (1) B/D ondansetron orally disintegrating tab 4 $0 (1) B/D mg ondansetron orally disintegrating tab 8 $0 (1) B/D mg prochlorperazine edisylate inj 5 mg/ml $0 (1) 87

104 Drug Name (By Medical Condition) WHAT THE prochlorperazine maleate tab 5 mg (base $0 (1) equivalent) prochlorperazine maleate tab 10 mg $0 (1) (base equivalent) prochlorperazine suppos 25 mg $0 (1) promethazine hcl inj 25 mg/ml $0 (2) PA; PA if 65 years and promethazine hcl inj 50 mg/ml $0 (2) PA; PA if 65 years and promethazine hcl syrup 6.25 mg/5ml $0 (2) PA; PA if 65 years and promethazine hcl tab 12.5 mg $0 (2) PA; PA if 65 years and promethazine hcl tab 25 mg $0 (2) PA; PA if 65 years and promethazine hcl tab 50 mg $0 (2) PA; PA if 65 years and scopolamine td patch 72hr 1 mg/3days $0 (2) QL (10 patches / 30 days), PA; PA if 65 years and travel sick chw 25mg $0 (3) NM; * travel sick tab 50mg $0 (3) NM; * ANTISPASMODICS - DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10 mg $0 (1) dicyclomine hcl oral soln 10 mg/5ml $0 (1) dicyclomine hcl tab 20 mg $0 (1) glycopyrrolate inj 4 mg/20ml (0.2 $0 (1) mg/ml) glycopyrrolate tab 1 mg $0 (1) glycopyrrolate tab 2 mg $0 (1) H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID acid reducer tab 20mg $0 (3) NM; * famotidine for susp 40 mg/5ml $0 (1) famotidine in nacl 0.9% iv soln 20 $0 (1) mg/50ml famotidine inj 20 mg/2ml $0 (1) famotidine inj 40 mg/4ml $0 (1) famotidine inj 200 mg/20ml $0 (1) famotidine tab 10 mg $0 (3) NM; * famotidine tab 20 mg $0 (1) famotidine tab 40 mg $0 (1) 88

105 Drug Name (By Medical Condition) WHAT THE ranitidine hcl inj 50 mg/2ml (25 mg/ml) $0 (1) ranitidine hcl inj 150 mg/6ml (25 $0 (1) mg/ml) ranitidine hcl syrup 15 mg/ml (75 $0 (1) mg/5ml) ranitidine hcl tab 75 mg $0 (3) NM; * ranitidine hcl tab 150 mg $0 (1) ranitidine hcl tab 150 mg $0 (3) NM; * ranitidine hcl tab 300 mg $0 (1) INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM $0 (2) balsalazide disodium cap 750 mg $0 (1) budesonide delayed release particles cap $0 (2) NDS 3 mg CANASA SUP 1000MG $0 (2) DELZICOL CAP 400MG $0 (2) hydrocortisone enema 100 mg/60ml $0 (1) mesalamine enema 4 gm $0 (1) mesalamine rectal enema 4 gm & $0 (1) cleanser wipe kit mesalamine tab delayed release 800 mg $0 (1) sulfasalazine tab 500 mg $0 (1) sulfasalazine tab delayed release 500 mg $0 (1) LAXATIVES bisac-evac sup 10mg $0 (3) NM; * bisacodyl tab 5mg ec $0 (3) NM; * biscolax sup 10mg $0 (3) NM; * calcium polycarbophil tab 625 mg $0 (3) NM; * constulose sol 10gm/15 $0 (1) diocto liq 50mg/5ml $0 (3) NM; * diocto syp 60/15ml $0 (3) NM; * doc-q-lax tab mg $0 (3) NM; * docqlace cap 100mg $0 (3) NM; * DOCUSOL PLUS ENE $0 (3) NM; * dok cap 100mg $0 (3) NM; * dok plus tab mg $0 (3) NM; * dok tab 100mg $0 (3) NM; * ENEMEEZ MINI ENE $0 (3) NM; * ENEMEEZ PLUS ENE $0 (3) NM; * enulose sol 10gm/15 $0 (1) fiber laxtiv cap 0.52gm $0 (3) NM; * fiber-lax tab 625mg $0 (3) NM; * 89

106 Drug Name (By Medical Condition) WHAT THE gavilyte-c sol $0 (1) gavilyte-g sol $0 (1) gavilyte-n sol flav pk $0 (1) generlac sol 10gm/15 $0 (1) GOLYTELY SOL $0 (2) lactulose (encephalopathy) solution 10 $0 (1) gm/15ml lactulose solution 10 gm/15ml $0 (1) laxative sup 10mg $0 (3) NM; * milk of magn sus $0 (3) NM; * milk of magn sus 400/5ml $0 (3) NM; * milk of magn sus 1200/15 $0 (3) NM; * MILK OF MAGN SUS 2400MG $0 (3) NM; * MOVIPREP SOL $0 (2) nat fiber pow therapy $0 (3) NM; * naturl fiber pow 28.3% $0 (3) NM; * NULYTELY SOL FLAV PKS $0 (2) peg 3350-kcl-na bicarb-nacl-na sulfate $0 (1) for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate $0 (1) for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln $0 (1) 420 gm polyethylene glycol 3350 oral packet $0 (1) polyethylene glycol 3350 oral packet $0 (3) NM; * polyethylene glycol 3350 oral powder $0 (1) polyethylene glycol 3350 oral powder $0 (3) NM; * reguloid cap 0.52gm $0 (3) NM; * sani-supp sup adult $0 (3) NM; * sani-supp sup pediatri $0 (3) NM; * senexon liq 8.8mg/5 $0 (3) NM; * senexon tab 8.6mg $0 (3) NM; * senna lax tab 8.6mg $0 (3) NM; * senna plus tab mg $0 (3) NM; * senna-lax tab 8.6mg $0 (3) NM; * sennalax-s tab mg $0 (3) NM; * sennosides syrup 8.8 mg/5ml $0 (3) NM; * sennosides tab 8.6 mg $0 (3) NM; * sennosides-docusate sodium tab $0 (3) NM; * mg sodium phosphates - enema $0 (3) NM; * stim laxat tab 5mg ec $0 (3) NM; * 90

107 Drug Name (By Medical Condition) WHAT THE stool softnr cap 100mg $0 (3) NM; * stool softnr cap 240mg $0 (3) NM; * SUPREP BOWEL SOL PREP KIT $0 (2) trilyte sol $0 (1) MISCELLANEOUS actidose/sor liq 50/240ml $0 (3) NM; * alosetron hcl tab 0.5 mg (base equiv) $0 (2) NDS, PA alosetron hcl tab 1 mg (base equiv) $0 (2) NDS, PA AMITIZA CAP 8MCG $0 (2) QL (180 caps / 30 days) AMITIZA CAP 24MCG $0 (2) QL (60 caps / 30 days) cromolyn sodium oral conc 100 mg/5ml $0 (2) NDS diphenoxylate w/ atropine liq $0 (1) mg/5ml diphenoxylate w/ atropine tab $0 (1) mg formula em sol $0 (3) NM; * gas relief cap 125mg $0 (3) NM; * gas relief cap 180mg $0 (3) NM; * gas relief chw 80mg $0 (3) NM; * gas relief chw 125mg $0 (3) NM; * gas relief dro 20/0.3ml $0 (3) NM; * GATTEX KIT 5MG $0 (2) NDS, NM, LA, PA LINZESS CAP 72MCG $0 (2) QL (30 caps / 30 days) LINZESS CAP 145MCG $0 (2) QL (60 caps / 30 days) LINZESS CAP 290MCG $0 (2) QL (30 caps / 30 days) loperamide hcl cap 2 mg $0 (1) mi-acid gas chw 80mg $0 (3) NM; * misoprostol tab 100 mcg $0 (1) misoprostol tab 200 mcg $0 (1) MOVANTIK TAB 12.5MG $0 (2) QL (60 tabs / 30 days) MOVANTIK TAB 25MG $0 (2) QL (30 tabs / 30 days) mytab gas chw 80mg $0 (3) NM; * mytab gas chw 125mg $0 (3) NM; * RELISTOR INJ 8/0.4ML $0 (2) NDS, PA RELISTOR INJ 12/0.6ML $0 (2) NDS, PA simethicone cap 180 mg $0 (3) NM; * simethicone dro 20/0.3ml $0 (3) NM; * sucralfate tab 1 gm $0 (1) ursodiol cap 300 mg $0 (1) ursodiol tab 250 mg $0 (1) ursodiol tab 500 mg $0 (1) XIFAXAN TAB 550MG $0 (2) NDS, PA 91

108 Drug Name (By Medical Condition) WHAT THE PANCREATIC ENZYMES CREON CAP 3000UNIT $0 (2) CREON CAP 6000UNIT $0 (2) CREON CAP 12000UNT $0 (2) CREON CAP 24000UNT $0 (2) CREON CAP 36000UNT $0 (2) ZENPEP CAP $0 (2) ZENPEP CAP 3000UNIT $0 (2) ZENPEP CAP 5000UNIT $0 (2) ZENPEP CAP 10000UNT $0 (2) ZENPEP CAP 15000UNT $0 (2) ZENPEP CAP 20000UNT $0 (2) ZENPEP CAP 25000UNT $0 (2) ZENPEP CAP 40000UNT $0 (2) PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT CAP 30MG DR $0 (2) QL (30 caps / 30 days) DEXILANT CAP 60MG DR $0 (2) QL (30 caps / 30 days) esomeprazole magnesium cap delayed $0 (1) QL (30 caps / 30 days) release 20 mg (base eq) esomeprazole magnesium cap delayed $0 (1) QL (30 caps / 30 days) release 40 mg (base eq) esomeprazole sodium for intravenous $0 (1) soln 20 mg (base equiv) esomeprazole sodium for intravenous $0 (1) soln 40 mg (base equiv) heartburn tr cap 15mg $0 (3) NM; * lansoprazole cap delayed release 15 mg $0 (1) QL (30 caps / 30 days) lansoprazole cap delayed release 15 mg $0 (3) NM; * lansoprazole cap delayed release 30 mg $0 (1) QL (30 caps / 30 days) omeprazole cap delayed release 10 mg $0 (1) QL (30 caps / 30 days) omeprazole cap delayed release 20 mg $0 (1) QL (60 caps / 30 days) omeprazole cap delayed release 40 mg $0 (1) QL (30 caps / 30 days) omeprazole magnesium cap dr 20.6 mg $0 (3) NM; * (20 mg base equiv) OMEPRAZOLE TAB 20MG $0 (3) NM; * pantoprazole sodium ec tab 20 mg (base $0 (1) QL (30 tabs / 30 days) equiv) pantoprazole sodium ec tab 40 mg (base $0 (1) QL (30 tabs / 30 days) equiv) rabeprazole sodium ec tab 20 mg $0 (1) QL (30 tabs / 30 days) 92

109 Drug Name (By Medical Condition) WHAT THE GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl tab er 24hr 10 mg $0 (1) QL (30 tabs / 30 days) dutasteride cap 0.5 mg $0 (1) QL (30 caps / 30 days) dutasteride-tamsulosin hcl cap $0 (1) QL (30 caps / 30 days) mg finasteride tab 5 mg $0 (1) tamsulosin hcl cap 0.4 mg $0 (1) MISCELLANEOUS bethanechol chloride tab 5 mg $0 (1) bethanechol chloride tab 10 mg $0 (1) bethanechol chloride tab 25 mg $0 (1) bethanechol chloride tab 50 mg $0 (1) potassium citrate tab er 5 meq (540 mg) $0 (1) potassium citrate tab er 10 meq (1080 $0 (1) mg) potassium citrate tab er 15 meq (1620 $0 (1) mg) URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ TAB 25MG $0 (2) QL (60 tabs / 30 days) MYRBETRIQ TAB 50MG $0 (2) QL (30 tabs / 30 days) oxybutynin chloride syrup 5 mg/5ml $0 (1) oxybutynin chloride tab 5 mg $0 (1) oxybutynin chloride tab er 24hr 5 mg $0 (1) QL (30 tabs / 30 days) oxybutynin chloride tab er 24hr 10 mg $0 (1) QL (60 tabs / 30 days) oxybutynin chloride tab er 24hr 15 mg $0 (1) QL (60 tabs / 30 days) tolterodine tartrate cap er 24hr 2 mg $0 (1) QL (30 caps / 30 days) tolterodine tartrate cap er 24hr 4 mg $0 (1) QL (30 caps / 30 days) tolterodine tartrate tab 1 mg $0 (1) tolterodine tartrate tab 2 mg $0 (1) TOVIAZ TAB 4MG $0 (2) QL (30 tabs / 30 days) TOVIAZ TAB 8MG $0 (2) QL (30 tabs / 30 days) trospium chloride tab 20 mg $0 (1) QL (60 tabs / 30 days) VESICARE TAB 5MG $0 (2) QL (30 tabs / 30 days) VESICARE TAB 10MG $0 (2) QL (30 tabs / 30 days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% $0 (1) 93

110 Drug Name (By Medical Condition) WHAT THE clotrimazole vaginal cream 1% $0 (3) NM; * metronidazole vaginal gel 0.75% $0 (1) miconazole 7 cre 2% $0 (3) NM; * miconazole 7 sup 100mg $0 (3) NM; * miconazole nitrate vaginal cream 2% $0 (3) NM; * miconazole nitrate vaginal suppos 100 $0 (3) NM; * mg terconazole vaginal cream 0.4% $0 (1) terconazole vaginal cream 0.8% $0 (1) terconazole vaginal suppos 80 mg $0 (1) tioconazole oin 6.5% vag $0 (3) NM; * vandazole gel 0.75% $0 (1) HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN TAB 1MG $0 (2) COUMADIN TAB 2.5MG $0 (2) COUMADIN TAB 2MG $0 (2) COUMADIN TAB 3MG $0 (2) COUMADIN TAB 4MG $0 (2) COUMADIN TAB 5MG $0 (2) COUMADIN TAB 6MG $0 (2) COUMADIN TAB 7.5MG $0 (2) COUMADIN TAB 10MG $0 (2) ELIQUIS ST P TAB 5MG $0 (2) ELIQUIS TAB 2.5MG $0 (2) ELIQUIS TAB 5MG $0 (2) enoxaparin sodium inj 30 mg/0.3ml $0 (1) NM enoxaparin sodium inj 40 mg/0.4ml $0 (1) NM enoxaparin sodium inj 60 mg/0.6ml $0 (1) NM enoxaparin sodium inj 80 mg/0.8ml $0 (1) NM enoxaparin sodium inj 100 mg/ml $0 (1) NM enoxaparin sodium inj 120 mg/0.8ml $0 (1) NM enoxaparin sodium inj 150 mg/ml $0 (1) NM enoxaparin sodium inj 300 mg/3ml $0 (1) NM fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml $0 (1) NM fondaparinux sodium subcutaneous inj 5 $0 (2) NDS, NM mg/0.4ml fondaparinux sodium subcutaneous inj $0 (2) NDS, NM 7.5 mg/0.6ml fondaparinux sodium subcutaneous inj 10 mg/0.8ml $0 (2) NDS, NM 94

111 Drug Name (By Medical Condition) WHAT THE HEP SOD/NACL INJ 25000UNT $0 (2) heparin sodium (porcine) 40 unit/ml in $0 (2) d5w heparin sodium (porcine) 50 unit/ml in $0 (2) d5w heparin sodium (porcine) 100 unit/ml in $0 (2) d5w heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml $0 (1) B/D $0 (1) B/D $0 (1) B/D $0 (1) B/D jantoven tab 1mg $0 (1) jantoven tab 2.5mg $0 (1) jantoven tab 2mg $0 (1) jantoven tab 3mg $0 (1) jantoven tab 4mg $0 (1) jantoven tab 5mg $0 (1) jantoven tab 6mg $0 (1) jantoven tab 7.5mg $0 (1) jantoven tab 10mg $0 (1) PRADAXA CAP 75MG $0 (2) PRADAXA CAP 110MG $0 (2) PRADAXA CAP 150MG $0 (2) warfarin sodium tab 1 mg $0 (1) warfarin sodium tab 2 mg $0 (1) warfarin sodium tab 2.5 mg $0 (1) warfarin sodium tab 3 mg $0 (1) warfarin sodium tab 4 mg $0 (1) warfarin sodium tab 5 mg $0 (1) warfarin sodium tab 6 mg $0 (1) warfarin sodium tab 7.5 mg $0 (1) warfarin sodium tab 10 mg $0 (1) XARELTO STAR TAB 15/20MG $0 (2) XARELTO TAB 10MG $0 (2) XARELTO TAB 15MG $0 (2) XARELTO TAB 20MG $0 (2) HEMATOPOIETIC GROWTH FACTORS GRANIX INJ 300/0.5 $0 (2) NDS, NM, PA 95

112 Drug Name (By Medical Condition) WHAT THE GRANIX INJ 480/0.8 $0 (2) NDS, NM, PA MOZOBIL INJ $0 (2) NDS, NM, PA NEUPOGEN INJ 300/0.5 $0 (2) NDS, NM, PA NEUPOGEN INJ 300MCG $0 (2) NDS, NM, PA NEUPOGEN INJ 480/0.8 $0 (2) NDS, NM, PA NEUPOGEN INJ 480MCG $0 (2) NDS, NM, PA PROCRIT INJ 2000/ML $0 (2) NM, PA PROCRIT INJ 3000/ML $0 (2) NM, PA PROCRIT INJ 4000/ML $0 (2) NM, PA PROCRIT INJ 10000/ML $0 (2) NM, PA PROCRIT INJ 20000/ML $0 (2) NDS, NM, PA PROCRIT INJ 40000/ML $0 (2) NDS, NM, PA IRON FUSION CAP $0 (3) NM; * INFED INJ 50MG/ML $0 (3) NM; * TANDEM CAP $0 (3) NM; * MISCELLANEOUS anagrelide hcl cap 0.5 mg $0 (1) anagrelide hcl cap 1 mg $0 (1) cilostazol tab 50 mg $0 (1) cilostazol tab 100 mg $0 (1) CINRYZE SOL 500 UNIT $0 (2) NDS, QL (20 vials / 30 days), NM, LA, PA ENDARI POW 5GM $0 (2) NDS, LA, PA FIRAZYR INJ 30MG/3ML $0 (2) NDS, QL (9 syringes / 30 days), NM, PA HAEGARDA INJ 2000UNIT $0 (2) NDS, QL (30 vials / 30 days), LA, PA HAEGARDA INJ 3000UNIT $0 (2) NDS, QL (20 vials / 30 days), LA, PA pentoxifylline tab er 400 mg $0 (1) PROMACTA TAB 12.5MG $0 (2) NDS, QL (360 tabs / 30 days), NM, LA, PA PROMACTA TAB 25MG $0 (2) NDS, QL (180 tabs / 30 days), NM, LA, PA PROMACTA TAB 50MG $0 (2) NDS, QL (90 tabs / 30 days), NM, LA, PA PROMACTA TAB 75MG $0 (2) NDS, QL (60 tabs / 30 days), NM, LA, PA tranexamic acid iv soln 1000 mg/10ml $0 (1) (100 mg/ml) tranexamic acid tab 650 mg $0 (1) 96

113 Drug Name (By Medical Condition) WHAT THE PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr $0 (1) mg BRILINTA TAB 60MG $0 (2) BRILINTA TAB 90MG $0 (2) clopidogrel bisulfate tab 75 mg (base $0 (1) equiv) prasugrel hcl tab 5 mg (base equiv) $0 (1) prasugrel hcl tab 10 mg (base equiv) $0 (1) ZONTIVITY TAB 2.08MG $0 (2) IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS HUMIRA INJ 10/0.1ML $0 (2) NDS, QL (2 syringes / 28 days), PA HUMIRA INJ 10MG/0.2 $0 (2) NDS, QL (2 syringes / 28 days), NM, PA HUMIRA INJ 20/0.2ML $0 (2) NDS, QL (2 syringes / 28 days), PA HUMIRA INJ 40/0.4ML $0 (2) NDS, QL (6 syringes / 28 days), PA HUMIRA KIT 20MG/0.4 $0 (2) NDS, QL (2 syringes / 28 days), NM, PA HUMIRA KIT 40MG/0.8 $0 (2) NDS, QL (6 syringes / 28 days), NM, PA HUMIRA PEDIA INJ CROHNS $0 (2) NDS, PA HUMIRA PEDIA INJ CROHNS $0 (2) NDS, NM, PA HUMIRA PEN INJ 40/0.4ML $0 (2) NDS, QL (6 pens / 28 days), PA HUMIRA PEN INJ 40MG/0.8 $0 (2) NDS, QL (6 pens / 28 days), NM, PA HUMIRA PEN INJ CROHNS $0 (2) NDS, NM, PA HUMIRA PEN INJ PSORIASI $0 (2) NDS, NM, PA hydroxychloroquine sulfate tab 200 mg $0 (1) leflunomide tab 10 mg $0 (1) leflunomide tab 20 mg $0 (1) methotrexate sodium tab 2.5 mg (base $0 (1) equiv) REMICADE INJ 100MG $0 (2) NDS, NM, PA XATMEP SOL 2.5MG/ML $0 (2) B/D 97

114 Drug Name (By Medical Condition) WHAT THE XELJANZ TAB 5MG $0 (2) NDS, QL (60 tabs / 30 days), NM, PA XELJANZ XR TAB 11MG $0 (2) NDS, QL (30 tabs / 30 days), PA IMMUNOGLOBULINS BIVIGAM INJ 10% $0 (2) NDS, NM, PA CARIMUNE NF INJ 6GM $0 (2) NDS, NM, PA CARIMUNE NF INJ 12GM $0 (2) NDS, NM, PA FLEBOGAMMA INJ 5GM/50ML $0 (2) NDS, NM, PA FLEBOGAMMA INJ 10/100ML $0 (2) NDS, NM, PA FLEBOGAMMA INJ 10/200ML $0 (2) NDS, NM, PA FLEBOGAMMA INJ 20/200ML $0 (2) NDS, NM, PA FLEBOGAMMA INJ 20/400ML $0 (2) NDS, NM, PA FLEBOGAMMA INJ DIF 5% $0 (2) NDS, NM, PA GAMASTAN S/D INJ $0 (2) B/D, NM GAMMAGARD INJ 1GM/10ML $0 (2) NDS, NM, PA GAMMAGARD INJ 2.5GM/25 $0 (2) NDS, NM, PA GAMMAGARD INJ 5GM/50ML $0 (2) NDS, NM, PA GAMMAGARD INJ 10GM/100 $0 (2) NDS, NM, PA GAMMAGARD INJ 20GM/200 $0 (2) NDS, NM, PA GAMMAGARD INJ 30GM/300 $0 (2) NDS, NM, PA GAMMAGARD SD INJ 5GM HU $0 (2) NDS, NM, PA GAMMAGARD SD INJ 10GM HU $0 (2) NDS, NM, PA GAMMAKED INJ 1GM/10ML $0 (2) NDS, NM, PA GAMMAKED INJ 2.5GM/25 $0 (2) NDS, NM, PA GAMMAKED INJ 5GM/50ML $0 (2) NDS, NM, PA GAMMAKED INJ 10GM/100 $0 (2) NDS, NM, PA GAMMAKED INJ 20GM/200 $0 (2) NDS, NM, PA GAMMAPLEX INJ 5% $0 (2) NDS, NM, PA GAMMAPLEX INJ 10% $0 (2) NDS, NM, PA GAMUNEX-C INJ 1GM/10ML $0 (2) NDS, NM, PA GAMUNEX-C INJ 2.5GM/25 $0 (2) NDS, NM, PA GAMUNEX-C INJ 5GM/50ML $0 (2) NDS, NM, PA GAMUNEX-C INJ 10GM/100 $0 (2) NDS, NM, PA GAMUNEX-C INJ 20GM/200 $0 (2) NDS, NM, PA GAMUNEX-C INJ 40/400ML $0 (2) NDS, NM, PA OCTAGAM INJ 1GM $0 (2) NDS, NM, PA OCTAGAM INJ 2.5GM $0 (2) NDS, NM, PA OCTAGAM INJ 2GM/20ML $0 (2) NDS, NM, PA OCTAGAM INJ 5GM $0 (2) NDS, NM, PA OCTAGAM INJ 5GM/50ML $0 (2) NDS, NM, PA OCTAGAM INJ 10/100ML $0 (2) NDS, NM, PA 98

115 Drug Name (By Medical Condition) WHAT THE OCTAGAM INJ 10GM $0 (2) NDS, NM, PA OCTAGAM INJ 20/200ML $0 (2) NDS, NM, PA OCTAGAM INJ 25GM $0 (2) NDS, NM, PA PRIVIGEN INJ 5 GRAMS $0 (2) NDS, NM, PA PRIVIGEN INJ 10GRAMS $0 (2) NDS, NM, PA PRIVIGEN INJ 20GRAMS $0 (2) NDS, NM, PA PRIVIGEN INJ 40GRAMS $0 (2) NDS, NM, PA IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 $0 (2) NDS, NM, LA, PA ARCALYST INJ 220MG $0 (2) NDS, NM, PA INTRON A INJ 10MU $0 (2) NDS, B/D, NM INTRON A INJ 18MU $0 (2) NDS, B/D, NM INTRON A INJ 25MU $0 (2) NDS, B/D, NM INTRON A INJ 50MU $0 (2) NDS, B/D, NM IMMUNOSUPPRESSANTS AZATHIOPRINE INJ 100MG $0 (2) B/D azathioprine tab 50 mg $0 (1) B/D BENLYSTA INJ 120MG $0 (2) NDS, NM, PA BENLYSTA INJ 200MG/ML $0 (2) NDS, PA BENLYSTA INJ 400MG $0 (2) NDS, NM, PA cyclosporine cap 25 mg $0 (1) B/D cyclosporine cap 100 mg $0 (1) B/D cyclosporine iv soln 50 mg/ml $0 (1) B/D cyclosporine modified cap 25 mg $0 (1) B/D cyclosporine modified cap 50 mg $0 (1) B/D cyclosporine modified cap 100 mg $0 (1) B/D cyclosporine modified oral soln 100 $0 (1) B/D mg/ml gengraf cap 25mg $0 (1) B/D gengraf cap 100mg $0 (1) B/D gengraf sol 100mg/ml $0 (1) B/D mycophenolate mofetil cap 250 mg $0 (1) B/D mycophenolate mofetil for oral susp 200 $0 (2) NDS, B/D mg/ml mycophenolate mofetil tab 500 mg $0 (1) B/D mycophenolate sodium tab dr 180 mg $0 (1) B/D (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg $0 (1) B/D (mycophenolic acid equiv) NULOJIX INJ 250MG $0 (2) NDS, B/D RAPAMUNE SOL 1MG/ML $0 (2) NDS, B/D SANDIMMUNE SOL 100MG/ML $0 (2) B/D 99

116 Drug Name (By Medical Condition) WHAT THE sirolimus tab 0.5 mg $0 (1) B/D sirolimus tab 1 mg $0 (1) B/D sirolimus tab 2 mg $0 (2) NDS, B/D tacrolimus cap 0.5 mg $0 (1) B/D tacrolimus cap 1 mg $0 (1) B/D tacrolimus cap 5 mg $0 (1) B/D ZORTRESS TAB 0.5MG $0 (2) NDS, B/D ZORTRESS TAB 0.25MG $0 (2) NDS, B/D ZORTRESS TAB 0.75MG $0 (2) NDS, B/D VACCINES ACTHIB INJ $0 (2) ADACEL INJ $0 (2) BCG VACCINE INJ $0 (2) BEXSERO INJ $0 (2) BOOSTRIX INJ $0 (2) DAPTACEL INJ $0 (2) DIP/TET PED INJ 25-5LFU $0 (2) B/D ENGERIX-B INJ 10/0.5ML $0 (2) B/D ENGERIX-B INJ 20MCG/ML $0 (2) B/D GARDASIL 9 INJ $0 (2) HAVRIX INJ 720UNIT $0 (2) HAVRIX INJ 1440UNIT $0 (2) HIBERIX SOL 10MCG $0 (2) IMOVAX RABIE INJ 2.5/ML $0 (2) INFANRIX INJ $0 (2) IPOL INJ INACTIVE $0 (2) IXIARO INJ $0 (2) KINRIX INJ $0 (2) M-M-R II INJ $0 (2) MENACTRA INJ $0 (2) MENVEO INJ $0 (2) PEDIARIX INJ 0.5ML $0 (2) PEDVAX HIB INJ $0 (2) PENTACEL INJ $0 (2) PROQUAD INJ $0 (2) QUADRACEL INJ $0 (2) RABAVERT INJ $0 (2) RECOMBIVA HB INJ 5MCG/0.5 $0 (2) B/D RECOMBIVA HB INJ 10MCG/ML $0 (2) B/D RECOMBIVA-HB INJ 40MCG/ML $0 (2) B/D ROTARIX SUS $0 (2) 100

117 Drug Name (By Medical Condition) WHAT THE ROTATEQ SOL $0 (2) SHINGRIX INJ 50MCG $0 (2) QL (2 vials per lifetime) SYNAGIS INJ 50MG $0 (2) NDS, NM SYNAGIS INJ 100MG/ML $0 (2) NDS, NM TENIVAC INJ 5-2LF $0 (2) B/D TET/DIP TOX INJ 2-2 LF $0 (2) B/D TRUMENBA INJ $0 (2) TWINRIX INJ $0 (2) TYPHIM VI INJ $0 (2) VAQTA INJ 25/0.5ML $0 (2) VAQTA INJ 50UNT/ML $0 (2) VARIVAX INJ $0 (2) YF-VAX INJ $0 (2) ZOSTAVAX INJ $0 (2) QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES klor-con 8 tab 8meq er $0 (1) klor-con 10 tab 10meq er $0 (1) KLOR-CON M15 TAB 15MEQ ER $0 (2) MAGNESIUM SU INJ 2GM/50ML $0 (2) MAGNESIUM SU INJ 4G/100ML $0 (2) MAGNESIUM SU INJ 20/500ML $0 (2) MAGNESIUM SU INJ 40G/1000 $0 (2) MAGNESIUM SU INJ 80MG/ML $0 (2) magnesium sulfate in dextrose 5% iv $0 (2) soln 1 gm/100ml magnesium sulfate inj 50% $0 (2) magnesium sulfate iv soln 2 gm/50ml $0 (2) (40 mg/ml) magnesium sulfate iv soln 4 gm/50ml $0 (2) (80 mg/ml) magnesium sulfate iv soln 4 gm/100ml $0 (2) (40 mg/ml) magnesium sulfate iv soln 20 gm/500ml $0 (2) (40 mg/ml) magnesium sulfate iv soln 40 $0 (2) gm/1000ml (40 mg/ml) MG SO4/D5W INJ 10MG/ML $0 (2) MG SO4/D5W INJ 20MG/ML $0 (2) potassium chloride cap er 8 meq $0 (1) potassium chloride cap er 10 meq $0 (1) 101

118 Drug Name (By Medical Condition) WHAT THE potassium chloride microencapsulated $0 (1) crys er tab 10 meq potassium chloride microencapsulated $0 (1) crys er tab 20 meq potassium chloride oral soln 10% (20 $0 (1) meq/15ml) potassium chloride oral soln 20% (40 $0 (1) meq/15ml) potassium chloride powder packet 20 $0 (1) meq potassium chloride tab er 8 meq (600 $0 (1) mg) potassium chloride tab er 10 meq $0 (1) potassium chloride tab er 20 meq (1500 $0 (1) mg) sodium chloride inj 2.5 meq/ml (14.6%) $0 (1) sodium fluoride chew; tab; 1.1 (0.5 f) $0 (1) mg/ml soln tpn electrol inj $0 (2) B/D IV NUTRITION amino acid infusion 6% $0 (1) B/D AMINOSYN 7% INJ /LYTES $0 (2) B/D AMINOSYN II INJ 8.5% $0 (2) B/D aminosyn ii inj 8.5/lyte $0 (2) B/D AMINOSYN II INJ 10% $0 (2) B/D AMINOSYN INJ 8.5% $0 (2) B/D aminosyn inj 8.5/lyte $0 (2) B/D AMINOSYN INJ 10% $0 (2) B/D AMINOSYN M INJ 3.5% $0 (2) B/D AMINOSYN-HBC INJ 7% $0 (2) B/D AMINOSYN-PF INJ 7% $0 (2) B/D AMINOSYN-PF INJ 10% $0 (2) B/D AMINOSYN-RF INJ 5.2% $0 (2) B/D CLINIMIX INJ 2.75/D5W $0 (2) B/D CLINIMIX INJ 4.25/D5W $0 (2) B/D CLINIMIX INJ 4.25/D10 $0 (2) B/D CLINIMIX INJ 4.25/D20 $0 (2) B/D CLINIMIX INJ 4.25/D25 $0 (2) B/D CLINIMIX INJ 5%/D15W $0 (2) B/D CLINIMIX INJ 5%/D20W $0 (2) B/D CLINIMIX INJ 5%/D25W $0 (2) B/D fat emulsion iv soln 20% $0 (2) B/D 102

119 Drug Name (By Medical Condition) WHAT THE FREAMINE HBC INJ 6.9% $0 (2) B/D FREAMINE III INJ 10% $0 (2) B/D hepatamine sol 8% $0 (2) B/D INTRALIPID INJ 30% $0 (2) B/D NEPHRAMINE INJ 5.4% $0 (2) B/D PREMASOL SOL 10% $0 (2) B/D PROCALAMINE INJ 3% $0 (2) B/D PROSOL INJ 20% $0 (2) B/D TRAVASOL INJ 10% $0 (2) B/D TROPHAMINE INJ 10% $0 (2) B/D IV REPLACEMENT SOLUTIONS D5W/LYTES INJ #48 $0 (2) D5W/NACL INJ 0.3% $0 (2) D10W/NACL INJ 0.2% $0 (2) dextrose 2.5% w/ sodium chloride $0 (1) 0.45% dextrose 5% in lactated ringers $0 (1) dextrose 5% w/ sodium chloride 0.2% $0 (1) dextrose 5% w/ sodium chloride 0.9% $0 (1) dextrose 5% w/ sodium chloride 0.33% $0 (1) dextrose 5% w/ sodium chloride 0.45% $0 (1) dextrose 5% w/ sodium chloride 0.225% $0 (1) dextrose 10% w/ sodium chloride 0.45% $0 (1) dextrose inj 5% $0 (1) dextrose inj 10% $0 (1) dextrose inj 50% $0 (1) dextrose inj 70% $0 (1) IONOSOL-MB INJ /D5W $0 (2) ISOLYTE-P INJ /D5W $0 (2) ISOLYTE-S INJ $0 (2) kcl 10 meq/l (0.075%) in dextrose 5% & $0 (1) nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & $0 (1) nacl 0.2% inj kcl 20 meq/l (0.15%) in dextrose 5% & $0 (1) nacl 0.9% inj kcl 20 meq/l (0.15%) in dextrose 5% & $0 (1) nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & $0 (1) nacl 0.45% inj kcl 20 meq/l (0.15%) in nacl 0.9% inj $0 (1) kcl 20 meq/l (0.15%) in nacl 0.45% inj $0 (1) 103

120 Drug Name (By Medical Condition) WHAT THE kcl 30 meq/l (0.224%) in dextrose 5% & $0 (1) nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & $0 (1) nacl 0.45% inj kcl 40 meq/l (0.3%) in nacl 0.9% inj $0 (1) KCL/D5W/NACL INJ 0.3/0.9% $0 (2) KCL/D5W/NACL INJ 0.15/0.2 $0 (2) lactated ringer's solution $0 (1) NORMOSOL -M INJ /D5W $0 (2) NORMOSOL -R INJ /D5W $0 (2) NORMOSOL-R INJ PH 7.4 $0 (2) PLASMA-LYTE INJ -148 $0 (2) PLASMA-LYTE INJ -A $0 (2) potassium chloride 20 meq/l (0.15%) in $0 (1) dextrose 5% inj potassium chloride 40 meq/l (0.3%) in $0 (1) dextrose 5% inj potassium chloride inj 2 meq/ml $0 (1) potassium chloride inj 10 meq/50ml $0 (1) potassium chloride inj 10 meq/100ml $0 (1) potassium chloride inj 20 meq/50ml $0 (1) potassium chloride inj 20 meq/100ml $0 (1) potassium chloride inj 40 meq/100ml $0 (1) ringer's solution $0 (1) sodium chloride inj 0.45% $0 (1) sodium chloride inj 3% $0 (1) sodium chloride inj 5% $0 (1) sodium chloride iv soln 0.9% $0 (1) MINERALS calcium carbonate (antacid) susp 1250 mg/5ml $0 (3) NM; * magnesium oxide tab 400 mg (241.3 mg $0 (3) NM; * elemental mg) MISCELLANEOUS SUSPENDOL-S LIQ $0 (3) NM; * VITAMINS calcitriol cap 0.5 mcg $0 (1) B/D calcitriol cap 0.25 mcg $0 (1) B/D calcitriol inj 1 mcg/ml $0 (1) B/D calcitriol oral soln 1 mcg/ml $0 (1) B/D ergocalciferol cap unit $0 (3) NM; * 104

121 Drug Name (By Medical Condition) WHAT THE folic acid inj 5 mg/ml $0 (3) NM; * folic acid tab 1 mg $0 (3) NM; * MEPHYTON TAB 5MG $0 (3) NM; * paricalcitol cap 1 mcg $0 (1) B/D paricalcitol cap 2 mcg $0 (1) B/D paricalcitol cap 4 mcg $0 (1) B/D phytonadione inj 10 mg/ml $0 (3) NM; * prenatal vitamin/folic acid > 0.8 mg $0 (1) (generic) RAYALDEE CAP 30MCG $0 (2) NDS vitamin d3 dro 400unit $0 (3) NM; * OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-polymyxin-neomycin-hc ophth $0 (1) oint 1% BLEPHAMIDE OIN S.O.P. $0 (2) neomycin-polymyxin-dexamethasone $0 (1) ophth oint 0.1% neomycin-polymyxin-dexamethasone $0 (1) ophth susp 0.1% neomycin-polymyxin-hc ophth susp $0 (1) sulfacetamide sodium-prednisolone $0 (1) ophth soln (0.25)% TOBRADEX OIN % $0 (2) TOBRADEX ST SUS $0 (2) tobramycin-dexamethasone ophth susp $0 (1) % ZYLET SUS % $0 (2) ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS bacitracin ophth oint 500 unit/gm $0 (1) bacitracin-polymyxin b ophth oint $0 (1) BESIVANCE SUS 0.6% $0 (2) CILOXAN OIN 0.3% OP $0 (2) ciprofloxacin hcl ophth soln 0.3% $0 (1) erythromycin ophth oint 5 mg/gm $0 (1) gatifloxacin ophth soln 0.5% $0 (1) gentak oin 0.3% op $0 (1) gentamicin sulfate ophth soln 0.3% $0 (1) MOXEZA SOL 0.5% $0 (2) moxifloxacin hcl ophth soln 0.5% (base $0 (1) equiv) 105

122 Drug Name (By Medical Condition) WHAT THE NATACYN SUS 5% OP $0 (2) neomycin-bacitrac zn-polymyx $0 (1) 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol $0 (1) mg-unt-mg/ml ofloxacin ophth soln 0.3% $0 (1) polymyxin b-trimethoprim ophth soln $0 (1) unit/ml-0.1% sulfacetamide sodium ophth oint 10% $0 (1) sulfacetamide sodium ophth soln 10% $0 (1) tobramycin ophth soln 0.3% $0 (1) trifluridine ophth soln 1% $0 (1) ZIRGAN GEL 0.15% $0 (2) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX SUS 0.2% $0 (2) bromfenac sodium ophth soln 0.09% $0 (1) (base equiv) (once-daily) BROMSITE DRO 0.075% $0 (2) dexamethasone sodium phosphate ophth $0 (1) soln 0.1% diclofenac sodium ophth soln 0.1% $0 (1) DUREZOL EMU 0.05% $0 (2) fluorometholone ophth susp 0.1% $0 (1) flurbiprofen sodium ophth soln 0.03% $0 (1) ILEVRO DRO 0.3% OP $0 (2) ketorolac tromethamine ophth soln 0.4% $0 (1) ketorolac tromethamine ophth soln 0.5% $0 (1) LOTEMAX GEL 0.5% $0 (2) LOTEMAX OIN 0.5% $0 (2) LOTEMAX SUS 0.5% $0 (2) PRED SOD PHO SOL 1% OP $0 (2) prednisolone acetate ophth susp 1% $0 (1) PROLENSA SOL 0.07% $0 (2) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine hcl ophth soln 0.05% $0 (1) BEPREVE DRO 1.5% $0 (2) cromolyn sodium ophth soln 4% $0 (1) eye drops sol 0.05% op $0 (3) NM; * eye itch sol relief $0 (3) NM; * LASTACAFT SOL 0.25% $0 (2) 106

123 Drug Name (By Medical Condition) WHAT THE $0 (1) olopatadine hcl ophth soln 0.2% (base equivalent) opti-clear sol 0.05% $0 (3) NM; * PAZEO DRO 0.7% $0 (2) ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% $0 (2) AZOPT SUS 1% OP $0 (2) betaxolol hcl ophth soln 0.5% $0 (1) BETOPTIC-S SUS 0.25% OP $0 (2) brimonidine tartrate ophth soln 0.2% $0 (1) brimonidine tartrate ophth soln 0.15% $0 (1) carteolol hcl ophth soln 1% $0 (1) COMBIGAN SOL 0.2/0.5% $0 (2) dorzolamide hcl ophth soln 2% $0 (1) dorzolamide hcl-timolol maleate ophth $0 (1) soln mg/ml latanoprost ophth soln 0.005% $0 (1) levobunolol hcl ophth soln 0.5% $0 (1) LUMIGAN SOL 0.01% $0 (2) metipranolol ophth soln 0.3% $0 (1) PHOSPHOLINE SOL 0.125%OP $0 (2) pilocarpine hcl ophth soln 1% $0 (1) pilocarpine hcl ophth soln 2% $0 (1) pilocarpine hcl ophth soln 4% $0 (1) SIMBRINZA SUS 1-0.2% $0 (2) timolol maleate ophth gel forming soln $0 (1) 0.5% timolol maleate ophth gel forming soln $0 (1) 0.25% timolol maleate ophth soln 0.5% $0 (1) timolol maleate ophth soln 0.5% (oncedaily) $0 (1) timolol maleate ophth soln 0.25% $0 (1) TRAVATAN Z DRO 0.004% $0 (2) MISCELLANEOUS akwa tears oin op $0 (3) NM; * artifi tears oin op $0 (3) NM; * artifi tears sol 1.4% op $0 (3) NM; * CYSTARAN SOL 0.44% $0 (2) NDS, LA, PA FRESHKOTE SOL 2.7-2% $0 (3) NM; * ISOPTO TEARS SOL 0.5% OP $0 (3) NM; * 107

124 Drug Name (By Medical Condition) WHAT THE liquitears sol $0 (3) NM; * lubricnt eye dro % $0 (3) NM; * lubricnt eye dro 0.5% op $0 (3) NM; * lubrifresh oin p.m. $0 (3) NM; * MURO 128 SOL 2% OP $0 (3) NM; * natural bal sol tears $0 (3) NM; * natures sol tears $0 (3) NM; * proparacaine hcl ophth soln 0.5% $0 (1) puralube oin $0 (3) NM; * REFRESH CELL GEL 1% OP $0 (3) NM; * refresh lacr oin op $0 (3) NM; * RESTASIS EMU 0.05% $0 (2) QL (64 single use vials / 30 days) RESTASIS MUL EMU 0.05% $0 (2) QL (1 bottle / 30 days) sodium chloride hypertonic ophth oint $0 (3) NM; * 5% sodium chloride hypertonic ophth soln 5% $0 (3) NM; * RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPT AER $0 (2) QL (60 blisters / 30 days) BEVESPI AER 9-4.8MCG $0 (2) QL (1 inhaler / 30 days) COMBIVENT AER $0 (2) QL (2 inhalers / 30 days) ipratropium-albuterol nebu soln 0.5- $0 (1) B/D 2.5(3) mg/3ml TRELEGY AER ELLIPTA $0 (2) QL (60 blisters / 30 days) ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA AER 17MCG $0 (2) QL (2 inhalers / 30 days) INCRUSE ELPT INH 62.5MCG $0 (2) QL (30 blisters / 30 days) ipratropium bromide inhal soln 0.02% $0 (1) B/D ipratropium bromide nasal soln 0.03% $0 (1) (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) $0 (1) ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALA-HIST IR TAB 2MG $0 (3) NM; * all day allg chw 10mg $0 (3) NM; * all day allg sol 1mg/ml $0 (3) NM; * 108

125 Drug Name (By Medical Condition) WHAT THE all day allg tab 10mg $0 (3) NM; * aller-chlor syp 2mg/5ml $0 (3) NM; * aller-chlor tab 4mg $0 (3) NM; * allergy relf liq 12.5/5ml $0 (3) NM; * allergy relf syp 5mg/5ml $0 (3) NM; * allergy relf tab 1.34mg $0 (3) NM; * allergy relf tab 10mg $0 (3) NM; * allergy tab 4mg $0 (3) NM; * allergy tab 10mg $0 (3) NM; * azelastine hcl nasal spray 0.1% (137 mcg/spray) $0 (1) azelastine hcl nasal spray 0.15% (205.5 $0 (1) mcg/spray) banophen cap 50mg $0 (3) NM; * banophen liq 12.5/5ml $0 (3) NM; * cetirizine hcl chew tab 5 mg $0 (3) NM; * cetirizine hcl chew tab 10 mg $0 (3) NM; * cetirizine hcl oral soln 1 mg/ml (5 $0 (1) mg/5ml) cetirizine hcl tab 5 mg $0 (3) NM; * cetirizine hcl tab 10 mg $0 (3) NM; * cetirizine sol 1mg/ml $0 (3) NM; * cetirizine sol 5mg/5ml $0 (3) NM; * chld allergy liq 12.5/5ml $0 (3) NM; * chlorphen sr tab 12mg $0 (3) NM; * comp allergy cap 25mg $0 (3) NM; * cyproheptadine hcl syrup 2 mg/5ml $0 (2) PA; PA if 65 years and cyproheptadine hcl tab 4 mg $0 (2) PA; PA if 65 years and diphenhist cap 25mg $0 (3) NM; * diphenhist liq 12.5/5ml $0 (3) NM; * diphenhydramine hcl cap 25 mg $0 (3) NM; * diphenhydramine hcl cap 50 mg $0 (3) NM; * diphenhydramine hcl inj 50 mg/ml $0 (1) ED CHLORPED LIQ 2MG/ML $0 (3) NM; * ed chlorped syp jr $0 (3) NM; * ed-chlortan tab 4mg $0 (3) NM; * fexofenadine hcl tab 60 mg $0 (3) NM; * fexofenadine hcl tab 180 mg $0 (3) NM; * fexofenadine sus 30mg/5ml $0 (3) NM; * gnp all day tab allergy $0 (3) NM; * 109

126 Drug Name (By Medical Condition) WHAT THE gnp allergy tab 4mg $0 (3) NM; * gnp dayhist tab 1.34mg $0 (3) NM; * HISTEX PD DRO 0.938MG $0 (3) NM; * HISTEX SYP 2.5MG/5 $0 (3) NM; * hydroxyzine hcl im soln 25 mg/ml $0 (2) PA; PA if 65 years and hydroxyzine hcl im soln 50 mg/ml $0 (2) PA; PA if 65 years and hydroxyzine hcl syrup 10 mg/5ml $0 (2) PA; PA if 65 years and hydroxyzine hcl tab 10 mg $0 (2) PA; PA if 65 years and hydroxyzine hcl tab 25 mg $0 (2) PA; PA if 65 years and hydroxyzine hcl tab 50 mg $0 (2) PA; PA if 65 years and hydroxyzine pamoate cap 25 mg $0 (2) PA; PA if 65 years and hydroxyzine pamoate cap 50 mg $0 (2) PA; PA if 65 years and levocetirizine dihydrochloride soln 2.5 $0 (1) mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg $0 (1) loratadine sol 5mg/5ml $0 (3) NM; * loratadine syp 5mg/5ml $0 (3) NM; * loratadine tab 10 mg $0 (3) NM; * loratadine tab 10mg $0 (3) NM; * m-hist pd liq 0.625/ml $0 (3) NM; * q-dryl cap 25mg $0 (3) NM; * q-dryl liq 12.5/5ml $0 (3) NM; * siladryl alr liq 12.5/5ml $0 (3) NM; * silphen coug syp 12.5/5ml $0 (3) NM; * sm allergy tab 4mg $0 (3) NM; * VANACLEAR PD LIQ 0.313MG $0 (3) NM; * VANAMINE PD LIQ 6.25/ML $0 (3) NM; * BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate soln nebu 0.5% (5 mg/ml) $0 (1) B/D albuterol sulfate soln nebu 0.63 mg/3ml $0 (1) B/D (base equiv) albuterol sulfate soln nebu 0.083% (2.5 $0 (1) B/D mg/3ml) 110

127 Drug Name (By Medical Condition) WHAT THE albuterol sulfate soln nebu 1.25 mg/3ml $0 (1) B/D (base equiv) albuterol sulfate syrup 2 mg/5ml $0 (1) albuterol sulfate tab 2 mg $0 (1) albuterol sulfate tab 4 mg $0 (1) albuterol sulfate tab er 12hr 4 mg $0 (1) albuterol sulfate tab er 12hr 8 mg $0 (1) levalbuterol hcl soln nebu 1.25 mg/3ml $0 (1) B/D (base equiv) levalbuterol hcl soln nebu conc 1.25 $0 (1) B/D mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 $0 (1) QL (2 inhalers / 30 days) mcg/act (base equiv) SEREVENT DIS AER 50MCG $0 (2) QL (60 inhalations / 30 days) terbutaline sulfate tab 2.5 mg $0 (1) terbutaline sulfate tab 5 mg $0 (1) VENTOLIN HFA AER $0 (2) QL (2 inhalers / 30 days) COUGH AND COLD aceta-gesic tab $0 (3) NM; * ALA-HIST PE TAB 2-10MG $0 (3) NM; * ALAHIST DM LIQ $0 (3) NM; * all-nite liq cold/flu $0 (3) NM; * allergy relf tab d-24 $0 (3) NM; * allergy-d tab 5-120mg $0 (3) NM; * ap-hist dm liq $0 (3) NM; * aprodine tab mg $0 (3) NM; * benzonatate cap 100 mg $0 (3) NM; * benzonatate cap 150 mg $0 (3) NM; * benzonatate cap 200 mg $0 (3) NM; * bromfed dm syp $0 (3) NM; * BROTAPP DM LIQ /5 $0 (3) NM; * brotapp liq $0 (3) NM; * budesonide nasal susp 32 mcg/act $0 (3) NM; * cetirizine-pseudoephedrine tab er 12hr $0 (3) NM; * mg cgh/cold day liq delsym $0 (3) NM; * cheratussin syp /5 $0 (3) NM; * chest conges tab 400mg $0 (3) NM; * chest congst tab rlf pe $0 (3) NM; * child silfed liq 15mg/5ml $0 (3) NM; * CHLO TUSS LIQ $0 (3) NM; * 111

128 Drug Name (By Medical Condition) WHAT THE cold/cough elx dm child $0 (3) NM; * cough dm sus 30mg/5ml $0 (3) NM; * cough syp $0 (3) NM; * cough syp 100/5ml $0 (3) NM; * cromolyn sodium nasal aerosol soln 5.2 $0 (3) NM; * mg/act (4%) DALLERGY DRO 1-2.5MG $0 (3) NM; * DALLERGY TAB 1-5MG $0 (3) NM; * DECONEX DMX TAB $0 (3) NM; * DECONEX IR TAB MG $0 (3) NM; * decongestant sol 1% $0 (3) NM; * decongestant tab 120mg er $0 (3) NM; * delsym cough liq congs dm $0 (3) NM; * delsym night liq cgh+cld $0 (3) NM; * dextromethorphan polistirex extended $0 (3) NM; * release susp 30 mg/5ml dextromethorphan-guaifenesin tab er $0 (3) NM; * 12hr mg dimaphen dm elx $0 (3) NM; * dimaphen elx children $0 (3) NM; * diphenhydramine-acetaminophen tab $0 (3) NM; * mg (sleep) ed a-hist dm liq $0 (3) NM; * ED A-HIST DM TAB $0 (3) NM; * ed a-hist tab mg $0 (3) NM; * ed a-hist tab 4-10mg $0 (3) NM; * ED BRON GP LIQ $0 (3) NM; * ED CHLORPED DRO D $0 (3) NM; * endacof-dm liq $0 (3) NM; * extra action syp /5 $0 (3) NM; * FLOWTUSS SOL $0 (3) NM; * gnp tussin liq dm $0 (3) NM; * gnp tussin syp 100/5ml $0 (3) NM; * guaifenesin syp /5 $0 (3) NM; * guaifenesin tab er 12hr 600 mg $0 (3) NM; * guaifenesin tab er 12hr 1200 mg $0 (3) NM; * guaifenesin-codeine soln mg/5ml $0 (3) NM; * HISTEX-DM SYP $0 (3) NM; * HISTEX-PE SYP /5 $0 (3) NM; * HYCOFENIX SOL $0 (3) NM; * hydrocod polst-chlorphen polst er susp 10-8 mg/5ml $0 (3) NM; * 112

129 Drug Name (By Medical Condition) WHAT THE hydrocodone w/ homatropine syrup 5- $0 (3) NM; * 1.5 mg/5ml hydrocodone w/ homatropine tab $0 (3) NM; * mg hydromet syp 5-1.5/5 $0 (3) NM; * kidkare liq cgh/cold $0 (3) NM; * LODRANE D CAP 4-60MG $0 (3) NM; * LOHIST-D LIQ $0 (3) NM; * LOHIST-DM SYP MG $0 (3) NM; * lorata-dine tab d 24hr $0 (3) NM; * loratadine-d tab 5-120mg $0 (3) NM; * loratadine-d tab mg $0 (3) NM; * LORTUSS EX LIQ $0 (3) NM; * LORTUSS LQ LIQ $0 (3) NM; * M-END DMX LIQ $0 (3) NM; * mapap cold tab $0 (3) NM; * mapap pm tab mg $0 (3) NM; * mapap sinus tab max st $0 (3) NM; * MUCINEX CGH GRA 5-100MG $0 (3) NM; * mucinex cgh liq 5-100mg $0 (3) NM; * mucinex chld liq 100/5ml $0 (3) NM; * MUCINEX CHLD MIS DAY/NITE $0 (3) NM; * mucinex cold tab flu&sore $0 (3) NM; * mucinex cold tab sinus $0 (3) NM; * mucinex dm liq $0 (3) NM; * mucinex fast liq cold flu $0 (3) NM; * MUCINEX FAST MIS MX DAY/N $0 (3) NM; * MUCINEX FAST TAB $0 (3) NM; * mucinex fast tab $0 (3) NM; * mucinex fast tab sev cold $0 (3) NM; * mucinex ff spr 0.05% $0 (3) NM; * mucinex ms liq cold ngh $0 (3) NM; * MUCINEX TAB 600MG ER $0 (3) NM; * mucinex tab sinus $0 (3) NM; * MUCINEX/KIDS GRA 100MG $0 (3) NM; * mucus relief tab 400mg $0 (3) NM; * mucusrelief tab sinus $0 (3) NM; * NASAL DECON SYP 30MG/5ML $0 (3) NM; * nasal decong spr 0.05% $0 (3) NM; * nasal decong tab 10mg $0 (3) NM; * NASOPEN PE LIQ $0 (3) NM; * night time cap cold/flu $0 (3) NM; * 113

130 Drug Name (By Medical Condition) WHAT THE NINJACOF LIQ $0 (3) NM; * NINJACOF-A LIQ $0 (3) NM; * NINJACOF-XG LIQ 200-8/5 $0 (3) NM; * nohist-dm liq $0 (3) NM; * nohist-lq liq 4-10/5ml $0 (3) NM; * nrs nasal spr 0.05% $0 (3) NM; * organ-i nr tab 200mg $0 (3) NM; * pain relieve tab mg $0 (3) NM; * pain rlf sin tab pe day $0 (3) NM; * pediatric liq cgh/cold $0 (3) NM; * PHENHIST DH LIQ $0 (3) NM; * POLY-HIST DM LIQ $0 (3) NM; * POLY-HIST PD LIQ $0 (3) NM; * POLY-VENT DM TAB $0 (3) NM; * POLY-VENT IR TAB MG $0 (3) NM; * prometh vc/ syp codeine $0 (3) NM; * promethazine w/ codeine syrup $0 (3) NM; * mg/5ml promethazine-dm syrup mg/5ml $0 (3) NM; * promethazine-phenylephrine-codeine $0 (3) NM; * syrup mg/5ml pseudoeph-chlorphen w/ hydrocodone soln mg/5ml $0 (3) NM; * pseudoephed-bromphen-dm syrup $0 (3) NM; * 10 mg/5ml pseudoephedrine hcl tab 30 mg $0 (3) NM; * pseudoephedrine-guaifenesin tab er 12hr $0 (3) NM; * mg pyrilamine-phenylephrine tab mg $0 (3) NM; * q-tussin dm syp /5 $0 (3) NM; * q-tussin sol 100/5ml $0 (3) NM; * qc cough liq sore thr $0 (3) NM; * RESCON TAB 2-60MG $0 (3) NM; * RESCON-DM SYP $0 (3) NM; * RESCON-GG LIQ $0 (3) NM; * RESPAIRE-30 CAP $0 (3) NM; * REZIRA SOL 60-5/5ML $0 (3) NM; * robafen cf liq $0 (3) NM; * robafen cgh cap 15mg $0 (3) NM; * robafen dm liq /5 $0 (3) NM; * robafen dm syp /5 $0 (3) NM; * robafen syp 100/5ml $0 (3) NM; * RU-HIST D TAB 4-10MG $0 (3) NM; * 114

131 Drug Name (By Medical Condition) WHAT THE RYMED TAB 2-10MG $0 (3) NM; * rynex dm liq $0 (3) NM; * rynex pe elx $0 (3) NM; * rynex pse liq $0 (3) NM; * siltussin dm liq das $0 (3) NM; * siltussin sa syp 100/5ml $0 (3) NM; * siltussin-dm syp alc free $0 (3) NM; * sinus-max mis day/nght $0 (3) NM; * sm nasal 12h spr 0.05% $0 (3) NM; * sm nasal dec tab 30mg $0 (3) NM; * sm tussin dm syp /5 $0 (3) NM; * sm tussin syp dm $0 (3) NM; * STAHIST AD LIQ $0 (3) NM; * STAHIST AD TAB 25-60MG $0 (3) NM; * sudogest pe tab 10mg $0 (3) NM; * sudogest tab 4-60mg $0 (3) NM; * sudogest tab 30mg $0 (3) NM; * sudogest tab 60mg $0 (3) NM; * sudogest tab 120mg er $0 (3) NM; * tussin dm liq $0 (3) NM; * tussin dm liq clear $0 (3) NM; * tussin dm syp /5 $0 (3) NM; * VANACOF DM LIQ $0 (3) NM; * VANACOF-8 LIQ 25-50/15 $0 (3) NM; * virtussin ac sol /5 $0 (3) NM; * virtussin sol dac $0 (3) NM; * LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg $0 (1) (base equiv) montelukast sodium chew tab 5 mg (base equiv) $0 (1) montelukast sodium oral granules packet $0 (1) 4 mg (base equiv) montelukast sodium tab 10 mg (base $0 (1) equiv) zafirlukast tab 10 mg $0 (1) zafirlukast tab 20 mg $0 (1) MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium soln nebu 20 mg/2ml $0 (1) B/D MISCELLANEOUS acetylcysteine inhal soln 10% $0 (1) B/D acetylcysteine inhal soln 20% $0 (1) B/D 115

132 Drug Name (By Medical Condition) WHAT THE ARALAST NP INJ 500MG $0 (2) NDS, NM, LA, PA ARALAST NP INJ 1000MG $0 (2) NDS, NM, LA, PA DALIRESP TAB 250MCG $0 (2) DALIRESP TAB 500MCG $0 (2) epinephrine solution auto-injector 0.3 $0 (1) (generic of Adrenaclick) mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 $0 (1) (generic of Adrenaclick) mg/0.15ml (1:1000) ESBRIET CAP 267MG $0 (2) NDS, PA ESBRIET TAB 267MG $0 (2) NDS, PA ESBRIET TAB 801MG $0 (2) NDS, PA KALYDECO PAK 50MG $0 (2) NDS, PA KALYDECO PAK 75MG $0 (2) NDS, PA KALYDECO TAB 150MG $0 (2) NDS, PA OFEV CAP 100MG $0 (2) NDS, PA OFEV CAP 150MG $0 (2) NDS, PA ORKAMBI TAB $0 (2) NDS, PA ORKAMBI TAB $0 (2) NDS, PA PROLASTIN-C INJ 1000MG $0 (2) NDS, LA, PA PROLASTIN-C INJ 1000MG $0 (2) NDS, NM, LA, PA PULMOZYME SOL 1MG/ML $0 (2) NDS, NM, PA SYMDEKO TAB $0 (2) NDS, LA, PA XOLAIR SOL 150MG $0 (2) NDS, NM, LA, PA ZEMAIRA INJ 1000MG $0 (2) NDS, NM, LA, PA NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide nasal soln 25 mcg/act $0 (1) QL (3 bottles / 30 days) (0.025%) fluticasone propionate nasal susp 50 $0 (1) QL (1 bottle / 30 days) mcg/act triamcinolone acetonide nasal aerosol suspension 55 mcg/act $0 (3) NM; * STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELPT INH 100MCG $0 (2) QL (30 inhalations / 30 days) ARNUITY ELPT INH 200MCG $0 (2) QL (30 inhalations / 30 days) budesonide inhalation susp 0.5 mg/2ml $0 (1) B/D budesonide inhalation susp 0.25 mg/2ml $0 (1) B/D FLOVENT DISK AER 50MCG $0 (2) QL (120 inhalations / 30 days) FLOVENT DISK AER 100MCG $0 (2) QL (120 inhalations / 30 days) 116

133 Drug Name (By Medical Condition) WHAT THE FLOVENT DISK AER 250MCG $0 (2) QL (240 inhalations / 30 days) FLOVENT HFA AER 44MCG $0 (2) QL (2 inhalers / 30 days) FLOVENT HFA AER 110MCG $0 (2) QL (2 inhalers / 30 days) FLOVENT HFA AER 220MCG $0 (2) QL (2 inhalers / 30 days) PULMICORT INH 90MCG $0 (2) QL (2 inhalers / 30 days) PULMICORT INH 180MCG $0 (2) QL (2 inhalers / 30 days) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKU AER 100/50 $0 (2) QL (60 inhalations / 30 days) ADVAIR DISKU AER 250/50 $0 (2) QL (60 inhalations / 30 days) ADVAIR DISKU AER 500/50 $0 (2) QL (60 inhalations / 30 days) ADVAIR HFA AER 45/21 $0 (2) QL (1 inhaler / 30 days) ADVAIR HFA AER 115/21 $0 (2) QL (1 inhaler / 30 days) ADVAIR HFA AER 230/21 $0 (2) QL (1 inhaler / 30 days) BREO ELLIPTA INH $0 (2) QL (60 blisters / 30 days) BREO ELLIPTA INH $0 (2) QL (60 blisters / 30 days) SYMBICORT AER $0 (2) QL (1 inhaler / 30 days) SYMBICORT AER $0 (2) QL (1 inhaler / 30 days) XANTHINES - DRUGS TO TREAT COPD aminophylline inj 25 mg/ml $0 (1) THEO-24 CAP 100MG CR $0 (2) THEO-24 CAP 200MG CR $0 (2) THEO-24 CAP 300MG CR $0 (2) THEO-24 CAP 400MG ER $0 (2) theophylline soln 80 mg/15ml $0 (1) theophylline tab er 12hr 100 mg $0 (1) theophylline tab er 12hr 200 mg $0 (1) theophylline tab er 12hr 300 mg $0 (1) theophylline tab er 12hr 450 mg $0 (1) theophylline tab er 24hr 400 mg $0 (1) theophylline tab er 24hr 600 mg $0 (1) TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE acne medicat gel 5% $0 (3) NM; * acne medicat gel 10% $0 (3) NM; * 117

134 Drug Name (By Medical Condition) WHAT THE ACNE MEDICAT LOT 5% $0 (3) NM; * ACNE MEDICAT LOT 10% $0 (3) NM; * amnesteem cap 10mg $0 (1) PA amnesteem cap 20mg $0 (1) PA amnesteem cap 40mg $0 (1) PA avita cre 0.025% $0 (1) PA avita gel 0.025% $0 (1) PA BENZOYL PER GEL 2.5% $0 (3) NM; * benzoyl peroxide foam 5.3% $0 (3) NM; * benzoyl peroxide foam 9.8% $0 (3) NM; * benzoyl peroxide gel 5% $0 (3) NM; * benzoyl peroxide gel 10% $0 (3) NM; * benzoyl peroxide-erythromycin gel 5-3% $0 (1) BENZYL PEROX LOT CLNSR9% $0 (3) NM; * BENZYL PEROX LOT CLNSR 3% $0 (3) NM; * benzyl perox lot clnsr 6% $0 (3) NM; * claravis cap 10mg $0 (1) PA claravis cap 20mg $0 (1) PA claravis cap 30mg $0 (1) PA claravis cap 40mg $0 (1) PA clindacin-p pad 1% $0 (1) clindamycin phosphate gel 1% $0 (1) clindamycin phosphate lotion 1% $0 (1) clindamycin phosphate soln 1% $0 (1) clindamycin phosphate swab 1% $0 (1) erythromycin gel 2% $0 (1) erythromycin pads 2% $0 (1) erythromycin soln 2% $0 (1) isotretinoin cap 10 mg $0 (1) PA isotretinoin cap 20 mg $0 (1) PA isotretinoin cap 30 mg $0 (1) PA isotretinoin cap 40 mg $0 (1) PA myorisan cap 10mg $0 (1) PA myorisan cap 20mg $0 (1) PA myorisan cap 30mg $0 (1) PA myorisan cap 40mg $0 (1) PA sulfacetamide sodium lotion 10% (acne) $0 (1) tretinoin cream 0.1% $0 (1) PA tretinoin cream 0.05% $0 (1) PA tretinoin cream 0.025% $0 (1) PA tretinoin gel 0.01% $0 (1) PA tretinoin gel 0.025% $0 (1) PA 118

135 Drug Name (By Medical Condition) WHAT THE zenatane cap 10mg $0 (1) PA zenatane cap 20mg $0 (1) PA zenatane cap 30mg $0 (1) PA zenatane cap 40mg $0 (1) PA DERMATOLOGY, ANTIBIOTICS bacitracin oint 500 unit/gm $0 (3) NM; * bacitracin zinc oint 500 unit/gm $0 (3) NM; * gentamicin sulfate cream 0.1% $0 (1) gentamicin sulfate oint 0.1% $0 (1) mafenide acetate packet for topical soln $0 (1) 5% (50 gm) mupirocin oint 2% $0 (1) neomycin-bacitracin-polymyxin oint $0 (3) NM; * silver sulfadiazine cream 1% $0 (1) ssd cre 1% $0 (1) SULFAMYLON CRE 85MG/GM $0 (2) SULFAMYLON PAK 5% $0 (2) NDS triple antib oin $0 (3) NM; * triple antib oin plus $0 (3) NM; * DERMATOLOGY, ANTIFUNGALS anti-fungal pow 1% $0 (3) NM; * antifungal aer 1% $0 (3) NM; * antifungal cre 1% $0 (3) NM; * antifungal cre 2% $0 (3) NM; * ciclopirox gel 0.77% $0 (1) ciclopirox olamine cream 0.77% (base $0 (1) equiv) ciclopirox olamine susp 0.77% (base $0 (1) equiv) ciclopirox shampoo 1% $0 (1) clotrimazole cre 1% $0 (3) NM; * clotrimazole cream 1% $0 (1) clotrimazole cream 1% $0 (3) NM; * clotrimazole soln 1% $0 (1) clotrimazole soln 1% $0 (3) NM; * FUNGOID TINC SOL 2% $0 (3) NM; * ketoconazole cream 2% $0 (1) miconazole nitrate cream 2% $0 (3) NM; * nyamyc pow $0 (1) nystatin cream unit/gm $0 (1) nystatin oint unit/gm $0 (1) nystatin topical powder unit/gm $0 (1) 119

136 Drug Name (By Medical Condition) WHAT THE nystop pow $0 (1) terbinafine hcl cream 1% $0 (3) NM; * tolnaftate cre 1% $0 (3) NM; * tolnaftate cream 1% $0 (3) NM; * tolnaftate powder 1% $0 (3) NM; * zeasorb-af pow 2% $0 (3) NM; * DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 mg $0 (2) NDS, PA acitretin cap 17.5 mg $0 (2) NDS, PA acitretin cap 25 mg $0 (2) NDS, PA calcipotriene cream 0.005% $0 (1) calcipotriene soln 0.005% (50 mcg/ml) $0 (1) tazarotene cream 0.1% $0 (1) PA TAZORAC CRE 0.05% $0 (2) PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% $0 (1) selenium sulfide lotion 2.5% $0 (1) DERMATOLOGY, CORTICOSTEROIDS ala-cort cre 1% $0 (1) ala-cort cre 2.5% $0 (1) alclometasone dipropionate cream $0 (1) 0.05% alclometasone dipropionate oint 0.05% $0 (1) betamethasone dipropionate augmented $0 (1) cream 0.05% betamethasone dipropionate augmented $0 (1) gel 0.05% betamethasone dipropionate augmented $0 (1) lotion 0.05% betamethasone dipropionate augmented $0 (1) oint 0.05% betamethasone dipropionate cream $0 (1) 0.05% betamethasone dipropionate lotion $0 (1) 0.05% betamethasone dipropionate oint 0.05% $0 (1) betamethasone valerate cream 0.1% $0 (1) (base equivalent) betamethasone valerate lotion 0.1% $0 (1) (base equivalent) betamethasone valerate oint 0.1% (base $0 (1) equivalent) 120

137 Drug Name (By Medical Condition) WHAT THE desoximetasone cream 0.05% $0 (1) desoximetasone cream 0.25% $0 (1) desoximetasone gel 0.05% $0 (1) desoximetasone oint 0.05% $0 (1) desoximetasone oint 0.25% $0 (1) fluocinolone acetonide cream 0.01% $0 (1) fluocinolone acetonide cream 0.025% $0 (1) fluocinolone acetonide oil 0.01% (body $0 (1) oil) fluocinolone acetonide oil 0.01% (scalp $0 (1) oil) fluocinolone acetonide oint 0.025% $0 (1) fluocinolone acetonide soln 0.01% $0 (1) fluocinonide cream 0.05% $0 (1) fluocinonide emulsified base cream $0 (1) 0.05% fluocinonide gel 0.05% $0 (1) fluocinonide soln 0.05% $0 (1) fluticasone propionate cream 0.05% $0 (1) fluticasone propionate oint 0.005% $0 (1) halobetasol propionate cream 0.05% $0 (1) halobetasol propionate oint 0.05% $0 (1) hydrocortisone butyrate cream 0.1% $0 (1) hydrocortisone butyrate oint 0.1% $0 (1) hydrocortisone butyrate soln 0.1% $0 (1) hydrocortisone cream 0.5% $0 (3) NM; * hydrocortisone cream 1% $0 (1) hydrocortisone cream 1% $0 (3) NM; * hydrocortisone cream 2.5% $0 (1) hydrocortisone lotion 2.5% $0 (1) hydrocortisone oint 0.5% $0 (3) NM; * hydrocortisone oint 1% $0 (1) hydrocortisone oint 1% $0 (3) NM; * hydrocortisone oint 2.5% $0 (1) hydrocortisone valerate cream 0.2% $0 (1) hydrocortisone valerate oint 0.2% $0 (1) hydrocortisone-aloe vera cream 1% $0 (3) NM; * mometasone furoate cream 0.1% $0 (1) mometasone furoate oint 0.1% $0 (1) mometasone furoate solution 0.1% $0 (1) (lotion) TEXACORT SOL 2.5% $0 (2) 121

138 Drug Name (By Medical Condition) WHAT THE triamcinolone acetonide cream 0.1% $0 (1) triamcinolone acetonide cream 0.5% $0 (1) triamcinolone acetonide cream 0.025% $0 (1) triamcinolone acetonide lotion 0.1% $0 (1) triamcinolone acetonide lotion 0.025% $0 (1) triamcinolone acetonide oint 0.1% $0 (1) triamcinolone acetonide oint 0.5% $0 (1) triamcinolone acetonide oint 0.025% $0 (1) DERMATOLOGY, LOCAL ANESTHETICS glydo gel 2% $0 (1) QL (30 ml / 30 days), PA lidocaine hcl gel 2% $0 (1) QL (30 ml / 30 days), PA lidocaine hcl soln 4% $0 (1) QL (50 ml / 30 days), PA lidocaine oint 5% $0 (1) QL (50 gm / 30 days), PA lidocaine patch 5% $0 (1) QL (3 patches / 1 day), PA lidocaine-prilocaine cream % $0 (1) QL (30 gm / 30 days), PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE anu-med sup $0 (3) NM; * blue gel 2% $0 (3) NM; * COATS ALOE CRE $0 (3) NM; * COATS ALOE GEL $0 (3) NM; * COATS ALOE LOT MOIST $0 (3) NM; * CUTTER BACKW AER 25% $0 (3) NM; * DIAPER RASH AER 10% $0 (3) NM; * dibucaine rectal ointment 1% $0 (3) NM; * diclofenac sodium gel 1% $0 (1) PA doxepin hcl cream 5% $0 (1) fluorouracil cream 5% $0 (1) fluorouracil soln 2% $0 (1) fluorouracil soln 5% $0 (1) hemorrhoidal sup $0 (3) NM; * hydrocortisone rectal cream 2.5% $0 (1) imiquimod cream 5% $0 (1) lactic acid (ammonium lactate) cream $0 (1) 12% lactic acid (ammonium lactate) lotion 12% $0 (1) 122

139 Drug Name (By Medical Condition) WHAT THE lidocaine anorectal cream 5% $0 (3) NM; * major-prep oin hemorrho $0 (3) NM; * metronidazole cream 0.75% $0 (1) metronidazole gel 0.75% $0 (1) metronidazole lotion 0.75% $0 (1) moisturel lot theraput $0 (3) NM; * NATRAPEL 12H SPR 20% $0 (3) NM; * OFF DEEP WDS AER 25% $0 (3) NM; * pain cre relievng $0 (3) NM; * PANRETIN GEL 0.1% $0 (2) NDS PICATO GEL 0.05% $0 (2) PICATO GEL 0.015% $0 (2) podofilox soln 0.5% $0 (1) povidone-iodine oint 10% $0 (3) NM; * povidone-iodine soln 10% $0 (3) NM; * procto-med cre hc 2.5% $0 (1) procto-pak cre 1% $0 (1) proctozone cre -hc 2.5% $0 (1) RASH + SKIN AER 10% $0 (3) NM; * REPEL HUNTER AER 25% $0 (3) NM; * REPEL SPORTS AER 25% $0 (3) NM; * REPEL SPORTS AER 40% $0 (3) NM; * rosadan cre 0.75% $0 (1) SAWYER REPEL SPR 20% $0 (3) NM; * tacrolimus oint 0.1% $0 (1) tacrolimus oint 0.03% $0 (1) TARGRETIN GEL 1% $0 (2) NDS, NM, PA VALCHLOR GEL 0.016% $0 (2) NDS, LA, PA vitamins a & d oint $0 (3) NM; * white petrolatum gel $0 (3) NM; * Z-BUM CRE 22.5% $0 (3) NM; * zinc oxide oint 20% $0 (3) NM; * DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion lotion 0.5% $0 (1) permethrin cream 5% $0 (1) DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation soln 0.25% $0 (1) REGRANEX GEL 0.01% $0 (2) NDS, PA SANTYL OIN 250/GM $0 (2) sodium chloride irrigation soln 0.9% $0 (1) water for irrigation, sterile irrigation soln $0 (1) 123

140 Drug Name (By Medical Condition) WHAT THE MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg $0 (1) chlorhexidine gluconate soln 0.12% $0 (1) clotrimazole troche 10 mg $0 (1) lidocaine hcl viscous soln 2% $0 (1) nystatin susp unit/ml $0 (1) periogard sol 0.12% $0 (1) pilocarpine hcl tab 5 mg $0 (1) pilocarpine hcl tab 7.5 mg $0 (1) triamcinolone acetonide dental paste $0 (1) 0.1% OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid otic soln 2% $0 (1) CIPRODEX SUS % $0 (2) fluocinolone acetonide (otic) oil 0.01% $0 (1) neomycin-polymyxin-hc otic soln 1% $0 (1) neomycin-polymyxin-hc otic susp 3.5 $0 (1) mg/ml unit/ml-1% ofloxacin otic soln 0.3% $0 (1) _PART B DIABETIC METERS AND TEST STRIPS TRUE METRIX KIT AIR $0 TRUE METRIX KIT METER $0 TRUE METRIX STRIPS $0 124

141 Index A abacavir sulfate soln 20 mg/ml (base equiv) abacavir sulfate tab 300 mg (base equiv) abacavir sulfate-lamivudine tab mg abacavir sulfate-lamivudine-zidovudine tab mg ABELCET INJ 5MG/ML ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABRAXANE INJ 100MG acamprosate calcium tab delayed release 333 mg acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg acephen sup 120mg... 1 acephen sup 325mg... 1 acephen sup 650mg... 1 aceta-gesic tab acetaminophen tab 325 mg... 1 acetaminophen w/ codeine soln mg/5ml... 3 acetaminophen w/ codeine tab mg... 3 acetaminophen w/ codeine tab mg... 3 acetaminophen w/ codeine tab mg... 3 acetazolamide cap er 12hr 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg acetic acid irrigation soln 0.25% acetic acid otic soln 2% acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% acid gone sus acid reducer tab 20mg acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg acne medicat gel 10% acne medicat gel 5% ACNE MEDICAT LOT 10% ACNE MEDICAT LOT 5% ACTHIB INJ actidose/sor liq 50/240ml ACTIMMUNE INJ 2MU/ acyclovir cap 200 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg ADACEL INJ ADAGEN INJ 250/ML ADCIRCA TAB 20MG adefovir dipivoxil tab 10 mg ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG adriamycin inj 20mg adrucil inj 2.5g/50m adrucil inj 500/10ml adrucil inj 5gm/100m ADVAIR DISKU AER 100/ ADVAIR DISKU AER 250/ ADVAIR DISKU AER 500/ ADVAIR HFA AER 115/ ADVAIR HFA AER 230/ ADVAIR HFA AER 45/ afeditab tab 30mg cr afeditab tab 60mg cr AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG akwa tears oin op ala-cort cre 1% ala-cort cre 2.5% ALAHIST DM LIQ ALA-HIST IR TAB 2MG ALA-HIST PE TAB 2-10MG ALBENZA TAB 200MG

142 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% ALCOHOL SWABS ALDURAZYME INJ 2.9MG/5M ALECENSA CAP 150MG alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg alfuzosin hcl tab er 24hr 10 mg ALIMTA INJ 100MG ALIMTA INJ 500MG ALINIA SUS 100/5ML... 7 ALINIA TAB 500MG... 7 all day allg chw 10mg all day allg sol 1mg/ml all day allg tab 10mg all day relf tab 220mg... 2 aller-chlor syp 2mg/5ml aller-chlor tab 4mg allergy relf liq 12.5/5ml allergy relf syp 5mg/5ml allergy relf tab 1.34mg allergy relf tab 10mg allergy relf tab d allergy tab 10mg allergy tab 4mg allergy-d tab 5-120mg all-nite liq cold/flu allopurinol tab 100 mg... 1 allopurinol tab 300 mg... 1 almacone chw almacone dbl sus strength almacone sus alosetron hcl tab 0.5 mg (base equiv). 91 alosetron hcl tab 1 mg (base equiv) ALPHAGAN P SOL 0.1% alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg ALREX SUS 0.2% ALUM HYDROX SUS 320/5ML ALUNBRIG PAK ALUNBRIG TAB 180MG ALUNBRIG TAB 30MG ALUNBRIG TAB 90MG alyacen tab 1/ amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg AMBISOME INJ 50MG amikacin sulfate inj 1 gm/4ml (250 mg/ml)... 7 amikacin sulfate inj 500 mg/2ml (250 mg/ml)... 7 amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg amino acid infusion 6% aminophylline inj 25 mg/ml AMINOSYN 7% INJ /LYTES AMINOSYN II INJ 10% AMINOSYN II INJ 8.5% aminosyn ii inj 8.5/lyte AMINOSYN INJ 10% AMINOSYN INJ 8.5% aminosyn inj 8.5/lyte AMINOSYN M INJ 3.5% AMINOSYN-HBC INJ 7% AMINOSYN-PF INJ 10% AMINOSYN-PF INJ 7% AMINOSYN-RF INJ 5.2% amiodarone hcl inj 150 mg/3ml (50 mg/ml) amiodarone hcl inj 450 mg/9ml (50 mg/ml) amiodarone hcl inj 900 mg/18ml (50 mg/ml) amiodarone hcl tab 100 mg

143 amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amlodipine besylate tab 10 mg (base equivalent) amlodipine besylate tab 2.5 mg (base equivalent) amlodipine besylate tab 5 mg (base equivalent) amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-olmesartan medoxomil tab mg amlodipine besylate-olmesartan medoxomil tab mg amlodipine besylate-olmesartan medoxomil tab 5-20 mg amlodipine besylate-olmesartan medoxomil tab 5-40 mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine-valsartan-hydrochlorothiazide tab mg amlodipine-valsartan-hydrochlorothiazide tab mg amlodipine-valsartan-hydrochlorothiazide tab mg amlodipine-valsartan-hydrochlorothiazide tab mg amlodipine-valsartan-hydrochlorothiazide tab mg amnesteem cap 10mg amnesteem cap 20mg amnesteem cap 40mg amoxapine tab 100 mg amoxapine tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab er 12hr mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg

144 amoxicillin (trihydrate) tab 875 mg amphetamine-dextroamphetamine cap er 24hr 10 mg amphetamine-dextroamphetamine cap er 24hr 15 mg amphetamine-dextroamphetamine cap er 24hr 20 mg amphetamine-dextroamphetamine cap er 24hr 25 mg amphetamine-dextroamphetamine cap er 24hr 30 mg amphetamine-dextroamphetamine cap er 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphotericin b for inj 50 mg ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for inj 3 (2-1) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 mg ampicillin sodium for inj 2 gm ampicillin sodium for inj 250 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 10 gm ampicillin sodium for iv soln 2 gm AMPYRA TAB 10MG ANADROL-50 TAB 50MG anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg anastrozole tab 1 mg ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR ANDROGEL GEL 1.62% ANORO ELLIPT AER antacid chw 500mg antacid chw 750mg antacid plus sus gas rel antacid sus max st anti-diarrhe tab 2mg antifungal aer 1% antifungal cre 1% antifungal cre 2% anti-fungal pow 1% anu-med sup ap-hist dm liq APOKYN INJ 10MG/ML aprepitant capsule 125 mg aprepitant capsule 40 mg aprepitant capsule 80 mg aprepitant capsule therapy pack 80 & 125 mg apri tab APRISO CAP 0.375GM aprodine tab mg APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG APTIVUS CAP 250MG APTIVUS SOL ARALAST NP INJ 1000MG ARALAST NP INJ 500MG aranelle tab ARCALYST INJ 220MG aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 2 mg

145 aripiprazole tab 20 mg aripiprazole tab 30 mg aripiprazole tab 5 mg ARISTADA INJ 1064MG ARISTADA INJ 441MG/ ARISTADA INJ 662MG/ ARISTADA INJ 882MG/ armodafinil tab 150 mg armodafinil tab 200 mg armodafinil tab 250 mg armodafinil tab 50 mg ARNUITY ELPT INH 100MCG ARNUITY ELPT INH 200MCG arthrts pain tab 650mg... 1 artifi tears oin op artifi tears sol 1.4% op aspirin chew tab 81 mg... 1 aspirin chw 81mg... 1 aspirin low chw 81mg... 1 aspirin low tab 81mg ec... 1 aspirin tab 325 mg... 1 aspirin tab delayed release 325 mg... 1 aspirin tab delayed release 81 mg... 1 aspirin-dipyridamole cap er 12hr mg aspir-low tab 81mg ec... 1 atazanavir sulfate cap 150 mg (base equiv) atazanavir sulfate cap 200 mg (base equiv) atazanavir sulfate cap 300 mg (base equiv) atenolol & chlorthalidone tab mg atenolol & chlorthalidone tab mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg atomoxetine hcl cap 10 mg (base equiv) atomoxetine hcl cap 100 mg (base equiv) atomoxetine hcl cap 18 mg (base equiv) atomoxetine hcl cap 25 mg (base equiv) atomoxetine hcl cap 40 mg (base equiv) atomoxetine hcl cap 60 mg (base equiv) atomoxetine hcl cap 80 mg (base equiv) atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) atovaquone susp 750 mg/5ml... 7 atovaquone-proguanil hcl tab mg atovaquone-proguanil hcl tab mg ATRIPLA TAB ATROVENT HFA AER 17MCG aubra tab AURYXIA TAB 210MG AUSTEDO TAB 12MG AUSTEDO TAB 6MG AUSTEDO TAB 9MG AVASTIN INJ AVASTIN INJ 400/16ML aviane tab avita cre 0.025% avita gel 0.025% azacitidine for inj 100 mg AZACTAM INJ 1GM... 7 AZACTAM INJ 2GM... 7 AZACTAM/DEX INJ 1GM... 7 AZACTAM/DEX INJ 2GM... 7 AZATHIOPRINE INJ 100MG azathioprine tab 50 mg azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) azelastine hcl ophth soln 0.05% azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp 1 gm 17 azithromycin tab 250 mg azithromycin tab 500 mg

146 azithromycin tab 600 mg AZOPT SUS 1% OP aztreonam for inj 1 gm... 7 aztreonam for inj 2 gm... 7 B bacitracin oint 500 unit/gm bacitracin ophth oint 500 unit/gm bacitracin zinc oint 500 unit/gm bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% baclofen tab 10 mg baclofen tab 20 mg balsalazide disodium cap 750 mg balziva tab banophen cap 50mg banophen liq 12.5/5ml BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE SOL.05MG/ML BASAGLAR INJ 100UNIT BCG VACCINE INJ bekyree tab BELEODAQ INJ 500MG benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg benazepril hcl tab 5 mg BENDEKA INJ 100/4ML BENLYSTA INJ 120MG BENLYSTA INJ 200MG/ML BENLYSTA INJ 400MG benzonatate cap 100 mg benzonatate cap 150 mg benzonatate cap 200 mg BENZOYL PER GEL 2.5% benzoyl peroxide foam 5.3% benzoyl peroxide foam 9.8% benzoyl peroxide gel 10% benzoyl peroxide gel 5% benzoyl peroxide-erythromycin gel 5-3% benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg BENZYL PEROX LOT CLNSR 3% benzyl perox lot clnsr 6% BENZYL PEROX LOT CLNSR9% BEPREVE DRO 1.5% BESIVANCE SUS 0.6% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate cream 0.1% (base equivalent) betamethasone valerate lotion 0.1% (base equivalent) betamethasone valerate oint 0.1% (base equivalent) BETASERON INJ 0.3MG betaxolol hcl ophth soln 0.5% bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg BETOPTIC-S SUS 0.25% OP BEVESPI AER 9-4.8MCG bexarotene cap 75 mg BEXSERO INJ bicalutamide tab 50 mg BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ BIKTARVY TAB BILTRICIDE TAB 600MG

147 bisac-evac sup 10mg bisacodyl tab 5mg ec biscolax sup 10mg bismatrol chw 262mg bismatrol sus 262/15ml bismatrol sus 525/15ml bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg BIVIGAM INJ 10% bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit BLEPHAMIDE OIN S.O.P blisovi fe tab 1.5/ blisovi fe tab 1/ blue gel 2% BOOSTRIX INJ BORTEZOMIB INJ 3.5MG BOSULIF TAB 100MG BOSULIF TAB 400MG BOSULIF TAB 500MG BREO ELLIPTA INH BREO ELLIPTA INH briellyn tab BRILINTA TAB 60MG BRILINTA TAB 90MG brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2% 107 BRIVIACT INJ 50MG/5ML BRIVIACT SOL 10MG/ML BRIVIACT TAB 100MG BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG bromfed dm syp bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) bromocriptine mesylate cap 5 mg (base equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) BROMSITE DRO 0.075% BROTAPP DM LIQ / brotapp liq budesonide delayed release particles cap 3 mg budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 0.5 mg/2ml budesonide nasal susp 32 mcg/act bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) bupropion hcl (smoking deterrent) tab er 12hr 150 mg bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg bupropion hcl tab er 24hr 150 mg bupropion hcl tab er 24hr 300 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg busulfan inj 6 mg/ml butorphanol tartrate inj 1 mg/ml... 3 butorphanol tartrate inj 2 mg/ml... 3 BUTRANS DIS 10MCG/HR... 3 BUTRANS DIS 15MCG/HR... 3 BUTRANS DIS 20MCG/HR... 3 BUTRANS DIS 5MCG/HR... 3 BUTRANS DIS 7.5/HR... 3 BYDUREON INJ 2MG BYDUREON INJ BCISE BYDUREON PEN INJ 2MG BYETTA INJ 10MCG

148 BYETTA INJ 5MCG BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG C cabergoline tab 0.5 mg CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG calc antacid chw 500mg calc antacid chw 750mg calcipotriene cream 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) cap 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 667 mg calcium carbonate (antacid) susp 1250 mg/5ml calcium polycarbophil tab 625 mg cal-gest chw 500mg CALQUENCE CAP 100MG camila tab 0.35mg CANASA SUP 1000MG CANCIDAS INJ 50MG CANCIDAS INJ 70MG candesartan cilexetil tab 16 mg candesartan cilexetil tab 32 mg candesartan cilexetil tab 4 mg candesartan cilexetil tab 8 mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg CAPASTAT SUL INJ 1GM CAPRELSA TAB 100MG CAPRELSA TAB 300MG captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril tab 100 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg CARBAGLU TAB 200MG carbamazepine cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa tab mg. 58 carbidopa & levodopa tab mg. 58 carbidopa & levodopa tab mg. 58 carbidopa & levodopa tab er mg carbidopa & levodopa tab er mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml

149 carboplatin iv soln 50 mg/5ml carboplatin iv soln 600 mg/60ml CARIMUNE NF INJ 12GM CARIMUNE NF INJ 6GM carisoprodol tab 350 mg carteolol hcl ophth soln 1% carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab mg carvedilol tab 6.25 mg caspofungin acetate for iv soln 50 mg. 10 caspofungin acetate for iv soln 70 mg. 10 CASPOFUNGIN INJ 50MG CASPOFUNGIN INJ 70MG CAYSTON INH 75MG... 7 cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm CEFAZOLIN INJ 1GM/50ML cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm CEFAZOLIN SOL cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 500 mg cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm CEFTAZIDIME/ SOL D5W 1GM CEFTAZIDIME/ SOL D5W 2GM ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm. 17 celecoxib cap 100 mg... 2 celecoxib cap 200 mg... 2 celecoxib cap 400 mg... 2 celecoxib cap 50 mg... 2 CELONTIN CAP 300MG cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml CERDELGA CAP 84MG CEREZYME INJ 400UNIT cetirizine hcl chew tab 10 mg cetirizine hcl chew tab 5 mg cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) cetirizine hcl tab 10 mg cetirizine hcl tab 5 mg cetirizine sol 1mg/ml cetirizine sol 5mg/5ml cetirizine-pseudoephedrine tab er 12hr mg cevimeline hcl cap 30 mg cgh/cold day liq delsym CHANTIX PAK 0.5& 1MG

150 CHANTIX PAK 1MG CHANTIX TAB 0.5MG CHANTIX TAB 1MG CHEMET CAP 100MG cheratussin syp / chest conges tab 400mg chest congst tab rlf pe child asa chw 81mg... 1 child silfed liq 15mg/5ml chld allergy liq 12.5/5ml chlds mapap tab 80mg rt... 1 CHLO TUSS LIQ chlorhexidine gluconate soln 0.12% chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorphen sr tab 12mg CHLORPROMAZ INJ 25MG/ML CHLORPROMAZ INJ 50MG/2ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm.. 38 ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% cilostazol tab 100 mg cilostazol tab 50 mg CILOXAN OIN 0.3% OP CINRYZE SOL 500 UNIT CIPRODEX SUS % ciprofloxacin 200 mg/100ml in d5w ciprofloxacin 400 mg/200ml in d5w ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 200 mg/20ml (1%) ciprofloxacin iv soln 400 mg/40ml (1%) cisplatin inj 100 mg/100ml (1 mg/ml). 30 cisplatin inj 200 mg/200ml (1 mg/ml). 30 cisplatin inj 50 mg/50ml (1 mg/ml) citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) cladribine iv soln 10 mg/10ml (1 mg/ml) claravis cap 10mg claravis cap 20mg claravis cap 30mg claravis cap 40mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab er 24hr 500 mg clindacin-p pad 1% clindamycin hcl cap 150 mg... 8 clindamycin hcl cap 300 mg... 8 clindamycin hcl cap 75 mg... 8 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)... 8 clindamycin phosphate gel 1% clindamycin phosphate in d5w iv soln 300 mg/50ml... 8 clindamycin phosphate in d5w iv soln 600 mg/50ml

151 clindamycin phosphate in d5w iv soln 900 mg/50ml... 8 clindamycin phosphate inj 300 mg/2ml. 8 clindamycin phosphate inj 600 mg/4ml. 8 clindamycin phosphate inj 9 gm/60ml.. 8 clindamycin phosphate inj 900 mg/6ml. 8 clindamycin phosphate iv soln 300 mg/2ml... 8 clindamycin phosphate iv soln 900 mg/6ml... 8 clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate vaginal cream 2% CLINDMYC/NAC INJ 300/50ML... 8 CLINDMYC/NAC INJ 600/50ML... 8 CLINDMYC/NAC INJ 900/50ML... 8 CLINIMIX INJ 2.75/D5W CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D5W CLINIMIX INJ 5%/D15W CLINIMIX INJ 5%/D20W CLINIMIX INJ 5%/D25W clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine hcl td patch weekly 0.1 mg/24hr clonidine hcl td patch weekly 0.2 mg/24hr clonidine hcl td patch weekly 0.3 mg/24hr clopidogrel bisulfate tab 75 mg (base equiv) clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg.. 48 clorazepate dipotassium tab 7.5 mg clotrimazole cre 1% clotrimazole cream 1% clotrimazole soln 1% clotrimazole troche 10 mg clotrimazole vaginal cream 1% clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine orally disintegrating tab 25 mg clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg COARTEM TAB MG COATS ALOE CRE COATS ALOE GEL COATS ALOE LOT MOIST colchicine w/ probenecid tab mg... 1 COLCRYS TAB 0.6MG... 1 cold/cough elx dm child colesevelam hcl tab 625 mg colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm colistimethate sod for inj 150 mg (colistin base activity)... 8 COMBIGAN SOL 0.2/0.5% COMBIVENT AER COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG comp allergy cap 25mg COMPLERA TAB

152 compro sup 25mg constulose sol 10gm/ CORLANOR TAB 5MG CORLANOR TAB 7.5MG cortisone acetate tab 25 mg COTELLIC TAB 20MG cough dm sus 30mg/5ml cough syp cough syp 100/5ml COUMADIN TAB 10MG COUMADIN TAB 1MG COUMADIN TAB 2.5MG COUMADIN TAB 2MG COUMADIN TAB 3MG COUMADIN TAB 4MG COUMADIN TAB 5MG COUMADIN TAB 6MG COUMADIN TAB 7.5MG CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) cromolyn sodium ophth soln 4% cromolyn sodium oral conc 100 mg/5ml cromolyn sodium soln nebu 20 mg/2ml cryselle-28 tab 28 tabs CUTTER BACKW AER 25% cyclafem tab 1/ cyclafem tab 7/7/ cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide cap 25 mg cyclophosphamide cap 50 mg cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 mg cycloserine cap 250 mg cyclosporine cap 100 mg cyclosporine cap 25 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 100 mg cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified oral soln 100 mg/ml cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg CYSTADANE POW CYSTAGON CAP 150MG CYSTAGON CAP 50MG CYSTARAN SOL 0.44% cytarabine inj 20 mg/ml D D10W/NACL INJ 0.2% D5W/LYTES INJ # D5W/NACL INJ 0.3% dacarbazine for inj 100 mg dacarbazine for inj 200 mg DAKLINZA TAB 30MG DAKLINZA TAB 60MG DAKLINZA TAB 90MG DALIRESP TAB 250MCG DALIRESP TAB 500MCG DALLERGY DRO 1-2.5MG DALLERGY TAB 1-5MG danazol cap 100 mg danazol cap 200 mg danazol cap 50 mg dantrolene sodium cap 100 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dapsone tab 100 mg... 8 dapsone tab 25 mg... 8 DAPTACEL INJ daptomycin for iv soln 500 mg... 8 dasetta tab 1/ dasetta tab 7/7/ deblitane tab 0.35mg DECONEX DMX TAB DECONEX IR TAB MG decongestant sol 1% decongestant tab 120mg er DELESTROGEN INJ 10MG/ML delsym cough liq congs dm delsym night liq cgh+cld delyla tab DELZICOL CAP 400MG

153 DEMSER CAP 250MG DEPEN TITRA TAB 250MG DEPO-PROVERA INJ 400/ML DESCOVY TAB 200/ desipramine hcl tab 10 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desmopressin acetate inj 4 mcg/ml desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg desogest-eth estrad & eth estrad tab /0.01 mg(21/5) desogest-ethin est tab / / mg-mg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05% desoximetasone oint 0.25% desvenlafaxine succinate tab er 24hr 100 mg (base equiv) desvenlafaxine succinate tab er 24hr 25 mg (base equiv) desvenlafaxine succinate tab er 24hr 50 mg (base equiv) DEXAMETHASON CON 1MG/ML dexamethasone elixir 0.5 mg/5ml dexamethasone sod phosphate preservative free inj 10 mg/ml dexamethasone sodium phosphate inj 10 mg/ml dexamethasone sodium phosphate inj 100 mg/10ml dexamethasone sodium phosphate inj 120 mg/30ml dexamethasone sodium phosphate inj 20 mg/5ml dexamethasone sodium phosphate inj 4 mg/ml dexamethasone sodium phosphate ophth soln 0.1% dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg dextromethorphan polistirex extended release susp 30 mg/5ml dextromethorphan-guaifenesin tab er 12hr mg dextrose 10% w/ sodium chloride 0.45% dextrose 2.5% w/ sodium chloride 0.45% dextrose 5% in lactated ringers dextrose 5% w/ sodium chloride 0.2% dextrose 5% w/ sodium chloride 0.225% dextrose 5% w/ sodium chloride 0.33% dextrose 5% w/ sodium chloride 0.45% dextrose 5% w/ sodium chloride 0.9% dextrose inj 10% dextrose inj 5% dextrose inj 50% dextrose inj 70% DIAPER RASH AER 10% DIASTAT ACDL GEL DIASTAT ACDL GEL 5-10MG DIASTAT PED GEL 2.5M GEL diazepam con 5mg/ml diazepam inj 5 mg/ml diazepam oral soln 1 mg/ml diazepam rectal gel delivery system 10 mg

154 diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 20 mg diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg dibucaine rectal ointment 1% diclofenac potassium tab 50 mg... 2 diclofenac sodium gel 1% diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release 25 mg... 2 diclofenac sodium tab delayed release 50 mg... 2 diclofenac sodium tab delayed release 75 mg... 2 diclofenac sodium tab er 24hr 100 mg.. 2 dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg DIFICID TAB 200MG diflunisal tab 500 mg... 2 digitek tab 0.125mg digitek tab 0.25mg digoxin inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml DILANTIN CAP 100MG DILANTIN CAP 30MG DILANTIN CHW 50MG DILANTIN-125 SUS 125/5ML diltiazem hcl cap er 12hr 120 mg diltiazem hcl cap er 12hr 60 mg diltiazem hcl cap er 12hr 90 mg diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 120 mg diltiazem hcl coated beads cap er 24hr 180 mg diltiazem hcl coated beads cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 300 mg diltiazem hcl coated beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) diltiazem hcl tab 120 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg dimaphen dm elx dimaphen elx children diocto liq 50mg/5ml diocto syp 60/15ml DIP/TET PED INJ 25-5LFU diphenhist cap 25mg diphenhist liq 12.5/5ml diphenhydramine hcl cap 25 mg diphenhydramine hcl cap 50 mg diphenhydramine hcl inj 50 mg/ml diphenhydramine-acetaminophen tab mg (sleep) diphenoxylate w/ atropine liq

155 mg/5ml diphenoxylate w/ atropine tab mg disopyramide phosphate cap 100 mg.. 36 disopyramide phosphate cap 150 mg.. 36 disulfiram tab 250 mg disulfiram tab 500 mg divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg docetaxel for inj conc 20 mg/ml docetaxel for inj conc 80 mg/4ml (20 mg/ml) DOCETAXEL INJ 160/16ML DOCETAXEL INJ 160/8ML DOCETAXEL INJ 200/ DOCETAXEL INJ 20MG/2ML DOCETAXEL INJ 80MG/4ML DOCETAXEL INJ 80MG/8ML docetaxel soln for iv infusion 160 mg/16ml docetaxel soln for iv infusion 20 mg/2ml docetaxel soln for iv infusion 80 mg/8ml docqlace cap 100mg doc-q-lax tab mg DOCUSOL PLUS ENE dofetilide cap 125 mcg (0.125 mg) dofetilide cap 250 mcg (0.25 mg) dofetilide cap 500 mcg (0.5 mg) dok cap 100mg dok plus tab mg dok tab 100mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg donepezil hydrochloride tab 5 mg dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln mg/ml doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl conc 10 mg/ml doxepin hcl cream 5% doxorubicin hcl for inj 10 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj 2 mg/ml doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml doxy 100 inj 100mg doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg doxycycline hyclate tab 20 mg doxycycline monohydrate cap 100 mg 21 doxycycline monohydrate cap 50 mg.. 21 doxycycline monohydrate tab 100 mg. 21 doxycycline monohydrate tab 150 mg. 21 doxycycline monohydrate tab 50 mg.. 21 doxycycline monohydrate tab 75 mg.. 21 dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg drospirenone-ethinyl estradiol tab mg drospirenone-ethinyl estradiol tab mg DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG duloxetine hcl enteric coated pellets cap 20 mg (base eq) duloxetine hcl enteric coated pellets cap 30 mg (base eq)

156 duloxetine hcl enteric coated pellets cap 60 mg (base eq) DUREZOL EMU 0.05% dutasteride cap 0.5 mg dutasteride-tamsulosin hcl cap mg E econtra ez tab 1.5mg ed a-hist dm liq ED A-HIST DM TAB ed a-hist tab mg ed a-hist tab 4-10mg ED BRON GP LIQ ED CHLORPED DRO D ED CHLORPED LIQ 2MG/ML ed chlorped syp jr ed-apap liq 80mg/ ed-chlortan tab 4mg EDURANT TAB 25MG efavirenz cap 200 mg efavirenz cap 50 mg efavirenz tab 600 mg eletriptan hydrobromide tab 20 mg (base equivalent) eletriptan hydrobromide tab 40 mg (base equivalent) ELIQUIS ST P TAB 5MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG ELITEK INJ 1.5MG ELITEK INJ 7.5MG ELLA TAB 30MG EMCYT CAP 140MG EMEND SUS 125MG emoquette tab EMSAM DIS 12MG/24H EMSAM DIS 6MG/24HR EMSAM DIS 9MG/24HR EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML EMVERM CHW 100MG... 8 enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate tab 10 mg enalapril maleate tab 2.5 mg enalapril maleate tab 20 mg enalapril maleate tab 5 mg endacof-dm liq ENDARI POW 5GM endocet tab mg... 4 endocet tab endocet tab 5-325mg... 4 endocet tab ENEMEEZ MINI ENE ENEMEEZ PLUS ENE ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml.. 94 enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 300 mg/3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml enpresse-28 tab enskyce tab entacapone tab 200 mg entecavir tab 0.5 mg entecavir tab 1 mg ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB MG enulose sol 10gm/ EPCLUSA TAB epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) epitol tab 200mg EPIVIR HBV SOL 5MG/ML eplerenone tab 25 mg eplerenone tab 50 mg ergocalciferol cap unit ergotamine w/ caffeine tab mg. 67 ERIVEDGE CAP 150MG ERLEADA TAB 60MG errin tab 0.35mg ery-tab tab 250mg ec ery-tab tab 333mg ec

157 ery-tab tab 500mg ec ERYTHROCIN INJ 500MG erythrocin tab 250mg erythromycin ethylsuccinate tab 400 mg erythromycin gel 2% erythromycin ophth oint 5 mg/gm erythromycin pads 2% erythromycin soln 2% erythromycin tab 250 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg ESBRIET CAP 267MG ESBRIET TAB 267MG ESBRIET TAB 801MG escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate tab 5 mg (base equiv) esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv) esomeprazole sodium for intravenous soln 40 mg (base equiv) estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch weekly mg/24hr estradiol td patch weekly mg/24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 mg/24hr estradiol td patch weekly 0.06 mg/24hr estradiol td patch weekly mg/24hr estradiol td patch weekly 0.1 mg/24hr 80 estradiol vaginal cream 0.1 mg/gm estradiol vaginal tab 10 mcg estradiol valerate im in oil 20 mg/ml.. 80 estradiol valerate im in oil 40 mg/ml.. 80 eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg etodolac cap 200 mg... 2 etodolac cap 300 mg... 2 etodolac tab 400 mg... 2 etodolac tab 500 mg... 2 etodolac tab er 24hr 400 mg... 2 etodolac tab er 24hr 500 mg... 2 etodolac tab er 24hr 600 mg... 2 etoposide inj 100 mg/5ml (20 mg/ml) 31 etoposide inj 500 mg/25ml (20 mg/ml) EVOTAZ TAB exemestane tab 25 mg extra action syp / eye drops sol 0.05% op eye itch sol relief ezetimibe tab 10 mg F FABRAZYME INJ 35MG FABRAZYME INJ 5MG fallback tab 1.5mg falmina tab famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg famotidine for susp 40 mg/5ml famotidine in nacl 0.9% iv soln 20 mg/50ml famotidine inj 20 mg/2ml famotidine inj 200 mg/20ml famotidine inj 40 mg/4ml famotidine tab 10 mg famotidine tab 20 mg famotidine tab 40 mg FANAPT PAK FANAPT TAB 10MG

158 FANAPT TAB 12MG FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG FANAPT TAB 8MG FARESTON TAB 60MG FARXIGA TAB 10MG FARXIGA TAB 5MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FASLODEX INJ 250/5ML fat emulsion iv soln 20% felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg felodipine tab er 24hr 10 mg felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg femynor tab fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 67 mg fenofibrate tab 145 mg fenofibrate tab 160 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fentanyl citrate lozenge on a handle 1200 mcg... 4 fentanyl citrate lozenge on a handle 1600 mcg... 4 fentanyl citrate lozenge on a handle 200 mcg... 4 fentanyl citrate lozenge on a handle 400 mcg... 4 fentanyl citrate lozenge on a handle 600 mcg... 4 fentanyl citrate lozenge on a handle 800 mcg... 4 fentanyl td patch 72hr 100 mcg/hr... 4 fentanyl td patch 72hr 12 mcg/hr... 4 fentanyl td patch 72hr 25 mcg/hr... 4 fentanyl td patch 72hr 50 mcg/hr... 4 fentanyl td patch 72hr 75 mcg/hr... 4 FENTORA TAB 100MCG... 4 FENTORA TAB 200MCG... 4 FENTORA TAB 400MCG... 4 FENTORA TAB 600MCG... 4 FENTORA TAB 800MCG... 4 FETZIMA CAP 120MG FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP TITRATIO fexofenadine hcl tab 180 mg fexofenadine hcl tab 60 mg fexofenadine sus 30mg/5ml FIASP FLEX INJ TOUCH FIASP INJ 100/ML fiber laxtiv cap 0.52gm fiber-lax tab 625mg finasteride tab 5 mg FIRAZYR INJ 30MG/3ML FLEBOGAMMA INJ 10/100ML FLEBOGAMMA INJ 10/200ML FLEBOGAMMA INJ 20/200ML FLEBOGAMMA INJ 20/400ML FLEBOGAMMA INJ 5GM/50ML FLEBOGAMMA INJ DIF 5% flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT DISK AER 50MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG FLOVENT HFA AER 44MCG FLOWTUSS SOL fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in dextrose inj 200 mg/100ml fluconazole in dextrose inj 400 mg/200ml fluconazole in nacl 0.9% inj 200 mg/100ml fluconazole in nacl 0.9% inj 400 mg/200ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg FLUCONAZOLE/ INJ NACL flucytosine cap 250 mg

159 flucytosine cap 500 mg fludarabine phosphate for inj 50 mg fludarabine phosphate inj 25 mg/ml fludrocortisone acetate tab 0.1 mg flunisolide nasal soln 25 mcg/act (0.025%) fluocinolone acetonide (otic) oil 0.01% fluocinolone acetonide cream 0.01%. 121 fluocinolone acetonide cream 0.025% 121 fluocinolone acetonide oil 0.01% (body oil) fluocinolone acetonide oil 0.01% (scalp oil) fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide soln 0.05% fluorometholone ophth susp 0.1% fluorouracil cream 5% fluorouracil iv soln 1 gm/20ml (50 mg/ml) fluorouracil iv soln 2.5 gm/50ml (50 mg/ml) fluorouracil iv soln 5 gm/100ml (50 mg/ml) fluorouracil iv soln 500 mg/10ml (50 mg/ml) fluorouracil soln 2% fluorouracil soln 5% fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluphenazine decanoate inj 25 mg/ml.. 61 fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg flurbiprofen sodium ophth soln 0.03% flurbiprofen tab 100 mg... 2 flurbiprofen tab 50 mg... 2 flutamide cap 125 mg fluticasone propionate cream 0.05%. 121 fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg folic acid inj 5 mg/ml folic acid tab 1 mg fondaparinux sodium subcutaneous inj 10 mg/0.8ml fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml formula em sol FORTEO SOL 600/ fosamprenavir calcium tab 700 mg (base equiv) fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg FREAMINE HBC INJ 6.9% FREAMINE III INJ 10% FRESHKOTE SOL 2.7-2% FUNGOID TINC SOL 2% furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide oral soln 8 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg FUSION CAP FUZEON INJ 90MG FYCOMPA SUS 0.5MG/ML FYCOMPA TAB 10MG FYCOMPA TAB 12MG FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG

160 FYCOMPA TAB 8MG G gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg GABITRIL TAB 12MG GABITRIL TAB 16MG galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 12 mg. 53 galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg GAMASTAN S/D INJ GAMMAGARD INJ 10GM/ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/ GAMMAGARD INJ 20GM/ GAMMAGARD INJ 30GM/ GAMMAGARD INJ 5GM/50ML GAMMAGARD SD INJ 10GM HU GAMMAGARD SD INJ 5GM HU GAMMAKED INJ 10GM/ GAMMAKED INJ 1GM/10ML GAMMAKED INJ 2.5GM/ GAMMAKED INJ 20GM/ GAMMAKED INJ 5GM/50ML GAMMAPLEX INJ 10% GAMMAPLEX INJ 5% GAMUNEX-C INJ 10GM/ GAMUNEX-C INJ 1GM/10ML GAMUNEX-C INJ 2.5GM/ GAMUNEX-C INJ 20GM/ GAMUNEX-C INJ 40/400ML GAMUNEX-C INJ 5GM/50ML GANCICLOVIR INJ 500MG ganciclovir sodium for inj 500 mg GARDASIL 9 INJ gas relief cap 125mg gas relief cap 180mg gas relief chw 125mg gas relief chw 80mg gas relief dro 20/0.3ml gatifloxacin ophth soln 0.5% GATTEX KIT 5MG GAUZE PADS gavilyte-c sol gavilyte-g sol gavilyte-n sol flav pk gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj 200 mg gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) gemfibrozil tab 600 mg generlac sol 10gm/ gengraf cap 100mg gengraf cap 25mg gengraf sol 100mg/ml gentak oin 0.3% op gentamicin in saline inj 0.8 mg/ml... 7 gentamicin in saline inj 1 mg/ml... 7 gentamicin in saline inj 1.2 mg/ml... 7 gentamicin in saline inj 1.6 mg/ml... 7 gentamicin in saline inj 2 mg/ml... 7 gentamicin sulfate cream 0.1% gentamicin sulfate inj 10 mg/ml... 7 gentamicin sulfate inj 40 mg/ml... 7 gentamicin sulfate oint 0.1% gentamicin sulfate ophth soln 0.3% GENVOYA TAB GEODON INJ 20MG gildagia tab GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG glatiramer acetate soln prefilled syringe 20 mg/ml glatiramer acetate soln prefilled syringe 40 mg/ml glatopa inj 20mg/ml glatopa inj 40mg/ml GLEOSTINE CAP 100MG

161 GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 5MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab er 24hr 10 mg glipizide tab er 24hr 2.5 mg glipizide tab er 24hr 5 mg glipizide xl tab 10mg glipizide xl tab 2.5mg glipizide xl tab 5mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg.. 73 GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg glydo gel 2% gnp all day tab allergy gnp allergy tab 4mg gnp antacid sus anti-gas gnp dayhist tab 1.34mg gnp masanti sus max st gnp masanti sus reg st gnp tussin liq dm gnp tussin syp 100/5ml GOLYTELY SOL granisetron hcl inj 0.1 mg/ml granisetron hcl inj 1 mg/ml granisetron hcl inj 4 mg/4ml (1 mg/ml) granisetron hcl tab 1 mg GRANIX INJ 300/ GRANIX INJ 480/ griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg 10 griseofulvin ultramicrosize tab 250 mg 10 guaifenesin syp / guaifenesin tab er 12hr 1200 mg guaifenesin tab er 12hr 600 mg guaifenesin-codeine soln mg/5ml guanfacine hcl tab er 24hr 1 mg (base equiv) guanfacine hcl tab er 24hr 2 mg (base equiv) guanfacine hcl tab er 24hr 3 mg (base equiv) guanfacine hcl tab er 24hr 4 mg (base equiv) H HAEGARDA INJ 2000UNIT HAEGARDA INJ 3000UNIT halobetasol propionate cream 0.05% 121 halobetasol propionate oint 0.05% haloperidol decanoate im soln 100 mg/ml haloperidol decanoate im soln 50 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml. 61 haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg HARVONI TAB MG HAVRIX INJ 1440UNIT HAVRIX INJ 720UNIT heartburn tr cap 15mg heather tab 0.35mg hemorrhoidal sup HEP SOD/NACL INJ 25000UNT heparin sodium (porcine) 100 unit/ml in d5w heparin sodium (porcine) 40 unit/ml in d5w heparin sodium (porcine) 50 unit/ml in d5w

162 heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml hepatamine sol 8% HERCEPTIN INJ 150MG HERCEPTIN INJ 440MG HETLIOZ CAP 20MG HEXALEN CAP 50MG HIBERIX SOL 10MCG HISTEX PD DRO 0.938MG HISTEX SYP 2.5MG/ HISTEX-DM SYP HISTEX-PE SYP / HUMIRA INJ 10/0.1ML HUMIRA INJ 10MG/ HUMIRA INJ 20/0.2ML HUMIRA INJ 40/0.4ML HUMIRA KIT 20MG/ HUMIRA KIT 40MG/ HUMIRA PEDIA INJ CROHNS HUMIRA PEN INJ 40/0.4ML HUMIRA PEN INJ 40MG/ HUMIRA PEN INJ CROHNS HUMIRA PEN INJ PSORIASI HUMULIN R INJ U HYCOFENIX SOL hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg hydrocod polst-chlorphen polst er susp 10-8 mg/5ml hydrocodone w/ homatropine syrup mg/5ml hydrocodone w/ homatropine tab mg hydrocodone-acetaminophen soln mg/15ml... 4 hydrocodone-acetaminophen tab mg... 5 hydrocodone-acetaminophen tab mg... 4 hydrocodone-acetaminophen tab mg... 5 hydrocodone-ibuprofen tab mg 5 hydrocortisone butyrate cream 0.1% 121 hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 0.5% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/60ml.. 89 hydrocortisone lotion 2.5% hydrocortisone oint 0.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone rectal cream 2.5% hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg hydrocortisone valerate cream 0.2% 121 hydrocortisone valerate oint 0.2% hydrocortisone-aloe vera cream 1%. 121 hydromet syp 5-1.5/ hydromorphone hcl liqd 1 mg/ml... 5 hydromorphone hcl preservative free (pf) inj 10 mg/ml... 5 hydromorphone hcl tab 2 mg... 5 hydromorphone hcl tab 4 mg... 5 hydromorphone hcl tab 8 mg... 5 hydroxychloroquine sulfate tab 200 mg hydroxyprogesterone caproate im in oil 1.25 gm/5ml hydroxyurea cap 500 mg hydroxyzine hcl im soln 25 mg/ml hydroxyzine hcl im soln 50 mg/ml hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg HYSINGLA ER TAB 100 MG... 5 HYSINGLA ER TAB 120 MG... 5 HYSINGLA ER TAB 20 MG

163 HYSINGLA ER TAB 30 MG... 5 HYSINGLA ER TAB 40 MG... 5 HYSINGLA ER TAB 60 MG... 5 HYSINGLA ER TAB 80 MG... 5 I ibandronate sodium tab 150 mg (base equivalent) IBRANCE CAP 100MG IBRANCE CAP 125MG IBRANCE CAP 75MG ibu-200 tab 200mg... 2 ibu-drops dro 40mg/ml... 2 ibu-drops dro 50/ ibuprofen cap 200 mg... 2 ibuprofen dro 50/ ibuprofen jr chw 100mg... 2 ibuprofen sus 100/5ml... 2 ibuprofen susp 100 mg/5ml... 2 ibuprofen tab 200 mg... 2 ibuprofen tab 200mg... 2 ibuprofen tab 400 mg... 2 ibuprofen tab 600 mg... 3 ibuprofen tab 800 mg... 3 ICLUSIG TAB 15MG ICLUSIG TAB 45MG IDHIFA TAB 100MG IDHIFA TAB 50MG IFEX INJ 3GM ifosfamide for inj 1 gm IFOSFAMIDE INJ 3GM ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) ILEVRO DRO 0.3% OP imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG IMBRUVICA CAP 70MG IMBRUVICA TAB 140MG IMBRUVICA TAB 280MG IMBRUVICA TAB 420MG IMBRUVICA TAB 560MG imipenem-cilastatin intravenous for soln 250 mg... 8 imipenem-cilastatin intravenous for soln 500 mg... 8 imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imiquimod cream 5% IMOVAX RABIE INJ 2.5/ML INCRELEX INJ 40MG/4ML INCRUSE ELPT INH 62.5MCG indapamide tab 1.25 mg indapamide tab 2.5 mg INFANRIX INJ INFED INJ 50MG/ML INLYTA TAB 1MG INLYTA TAB 5MG INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE INTELENCE TAB 100MG INTELENCE TAB 200MG INTELENCE TAB 25MG INTRALIPID INJ 30% INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU introvale tab INVANZ INJ 1GM... 8 INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/ INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG INVIRASE CAP 200MG INVIRASE TAB 500MG INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG INVOKANA TAB 100MG INVOKANA TAB 300MG

164 IONOSOL-MB INJ /D5W IPOL INJ INACTIVE ipratropium bromide inhal soln 0.02% ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) ipratropium-albuterol nebu soln (3) mg/3ml irbesartan tab 150 mg irbesartan tab 300 mg irbesartan tab 75 mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg IRESSA TAB 250MG irinotecan hcl inj 100 mg/5ml (20 mg/ml) irinotecan hcl inj 40 mg/2ml (20 mg/ml) irinotecan hcl inj 500 mg/25ml (20 mg/ml) ISENTRESS CHW 100MG ISENTRESS CHW 25MG ISENTRESS HD TAB 600MG ISENTRESS POW 100MG ISENTRESS TAB 400MG isibloom tab ISOLYTE-P INJ /D5W ISOLYTE-S INJ isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg ISOPTO TEARS SOL 0.5% OP isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab 5 mg isosorbide dinitrate tab er 40 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab er 24hr 120 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isotretinoin cap 10 mg isotretinoin cap 20 mg isotretinoin cap 30 mg isotretinoin cap 40 mg isradipine cap 2.5 mg isradipine cap 5 mg itraconazole cap 100 mg ivermectin tab 3 mg... 8 IXIARO INJ J JADENU SPRKL GRA 180MG JADENU SPRKL GRA 360MG JADENU SPRKL GRA 90MG JADENU TAB 180MG JADENU TAB 360MG JADENU TAB 90MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG jantoven tab 10mg jantoven tab 1mg jantoven tab 2.5mg jantoven tab 2mg jantoven tab 3mg jantoven tab 4mg jantoven tab 5mg jantoven tab 6mg jantoven tab 7.5mg JANUMET TAB JANUMET TAB MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA TAB 100MG JANUVIA TAB 25MG JANUVIA TAB 50MG JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR jinteli tab 1mg-5mcg jolivette tab 0.35mg juleber tab JULUCA TAB 50-25MG

165 junel 1.5/30 tab junel 1/20 tab junel fe tab 1.5/ junel fe tab 1/ junior mapap tab 160mg rt... 1 JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG JUXTAPID CAP 60MG K KADCYLA INJ 100MG KADCYLA INJ 160MG KALETRA TAB MG KALETRA TAB MG KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG kao-tin sus 262/15ml kariva tab 28 day kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj kcl 20 meq/l (0.15%) in nacl 0.45% inj kcl 20 meq/l (0.15%) in nacl 0.9% inj kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj kcl 40 meq/l (0.3%) in nacl 0.9% inj. 104 KCL/D5W/NACL INJ 0.15/ KCL/D5W/NACL INJ 0.3/0.9% kelnor 1/50 tab kelnor tab 1/ ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab 200 mg ketoprofen cap 50 mg... 3 ketoprofen cap 75 mg... 3 ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% KEYTRUDA INJ 100MG/4M KEYTRUDA SOL 50MG kidkare liq cgh/cold kimidess tab KINRIX INJ KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200DOSE KISQALI TAB 400DOSE KISQALI TAB 600DOSE klor-con 10 tab 10meq er klor-con 8 tab 8meq er KLOR-CON M15 TAB 15MEQ ER KORLYM TAB 300MG kurvelo tab 0.15/ KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG KYNAMRO INJ 200MG/ML L labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg lactated ringer's solution lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml lamivudine oral soln 10 mg/ml lamivudine tab 100 mg (hbv) lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible

166 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab er 24hr 100 mg lamotrigine tab er 24hr 200 mg lamotrigine tab er 24hr 25 mg lamotrigine tab er 24hr 250 mg lamotrigine tab er 24hr 300 mg lamotrigine tab er 24hr 50 mg lansoprazole cap delayed release 15 mg lansoprazole cap delayed release 30 mg larin fe tab 1.5/ larin fe tab 1/ larin tab 1.5/ larin tab 1/ LASTACAFT SOL 0.25% latanoprost ophth soln 0.005% LATUDA TAB 120MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG laxative sup 10mg leflunomide tab 10 mg leflunomide tab 20 mg LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 8 MG lessina tab LETAIRIS TAB 10MG LETAIRIS TAB 5MG letrozole tab 2.5 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg leucovorin calcium for inj 350 mg leucovorin calcium for inj 50 mg leucovorin calcium for inj 500 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg LEUKERAN TAB 2MG leuprolide acetate inj kit 5 mg/ml levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) LEVEMIR INJ LEVEMIR INJ FLEXTOUC levetiracetam in sodium chloride iv soln 1000 mg/100ml levetiracetam in sodium chloride iv soln 1500 mg/100ml levetiracetam in sodium chloride iv soln 500 mg/100ml levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 1000 mg levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg levobunolol hcl ophth soln 0.5% levocarnitine inj 200 mg/ml levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg levofloxacin in d5w iv soln 250 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 25 mg/ml levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg LEVOLEUCOVOR INJ 175MG LEVOLEUCOVOR SOL 250MG/ levoleucovorin calcium for iv inj 50 mg (base equiv) levoleucovorin calcium inj

167 mg/17.5ml (base equiv) levonest tab levonorgestrel & ethinyl estradiol (91- day) tab mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel tab 1.5 mg levonorgestrel-eth estra tab / / mg-mcg levora-28 tab 0.15/ levo-t tab 100mcg levo-t tab 112mcg levo-t tab 125mcg levo-t tab 137mcg levo-t tab 150mcg levo-t tab 175mcg levo-t tab 200 mcg levo-t tab 25mcg levo-t tab 300 mcg levo-t tab 50mcg levo-t tab 75mcg levo-t tab 88mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg levoxyl tab 100mcg levoxyl tab 112mcg levoxyl tab 125mcg levoxyl tab 137mcg levoxyl tab 150mcg levoxyl tab 175mcg levoxyl tab 200mcg levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg LEXIVA SUS 50MG/ML LEXIVA TAB 700MG lidocaine anorectal cream 5% lidocaine hcl gel 2% lidocaine hcl local inj 0.5%... 6 lidocaine hcl local inj 1%... 6 lidocaine hcl local inj 2%... 6 lidocaine hcl local preservative free (pf) inj 0.5%... 6 lidocaine hcl local preservative free (pf) inj 1%... 6 lidocaine hcl local preservative free (pf) inj 1.5%... 7 lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine oint 5% lidocaine patch 5% lidocaine-prilocaine cream %. 122 linezolid for susp 100 mg/5ml... 8 linezolid in sodium chloride iv soln 600 mg/300ml-0.9%... 8 linezolid iv soln 600 mg/300ml (2 mg/ml)... 8 linezolid tab 600 mg... 8 LINZESS CAP 145MCG LINZESS CAP 290MCG LINZESS CAP 72MCG liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg liquitears sol lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril tab 10 mg lisinopril tab 2.5 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg lisinopril tab 5 mg lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab er 300 mg lithium carbonate tab er 450 mg

168 LITHIUM SOL 8MEQ/5ML LODRANE D CAP 4-60MG LOHIST-D LIQ LOHIST-DM SYP MG LONSURF TAB LONSURF TAB loperamide hcl cap 2 mg loperamide hcl liq 1 mg/5ml (0.2 mg/ml) loperamide hcl liq 1 mg/7.5ml lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) loratadine sol 5mg/5ml loratadine syp 5mg/5ml loratadine tab 10 mg loratadine tab 10mg lorata-dine tab d 24hr loratadine-d tab mg loratadine-d tab 5-120mg lorazepam conc 2 mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg LORTUSS EX LIQ LORTUSS LQ LIQ loryna tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium tab 100 mg losartan potassium tab 25 mg losartan potassium tab 50 mg LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg lubricnt eye dro % lubricnt eye dro 0.5% op lubrifresh oin p.m LUMIGAN SOL 0.01% LUMIZYME INJ 50MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 3M 30MG LUPR DEP-PED INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 3.75MG lutera tab LYNPARZA CAP 50MG LYNPARZA TAB 100MG LYNPARZA TAB 150MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 25MG LYRICA CAP 300MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA SOL 20MG/ML LYSODREN TAB 500MG lyza tab 0.35mg M mafenide acetate packet for topical soln 5% (50 gm) magnesium oxide tab 400 mg magnesium oxide tab 400 mg (241.3 mg elemental mg) MAGNESIUM SU INJ 20/500ML MAGNESIUM SU INJ 2GM/50ML MAGNESIUM SU INJ 40G/ MAGNESIUM SU INJ 4G/100ML MAGNESIUM SU INJ 80MG/ML magnesium sulfate in dextrose 5% iv soln 1 gm/100ml magnesium sulfate inj 50% magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) magnesium sulfate iv soln 20 gm/500ml (40 mg/ml) magnesium sulfate iv soln 4 gm/100ml (40 mg/ml) magnesium sulfate iv soln 4 gm/50ml (80 mg/ml) magnesium sulfate iv soln 40 gm/1000ml 152

169 (40 mg/ml) major-prep oin hemorrho malathion lotion 0.5% mapap apap liq 500/15ml... 1 mapap cap 500mg... 1 mapap child tab 80mg rt... 1 mapap childr sus 160/5ml... 1 mapap chw 80mg... 1 mapap cold tab mapap liq 160/5ml... 1 mapap pm tab mg mapap sinus tab max st mapap tab 325mg... 1 mapap tab 500mg... 1 maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg marlissa tab 0.15/ MARPLAN TAB 10MG MATULANE CAP 50MG MAVYRET TAB MG meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg medroxyprogesterone acetate im susp 150 mg/ml medroxyprogesterone acetate im susp prefilled syr 150 mg/ml medroxyprogesterone acetate tab 10 mg medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg mefloquine hcl tab 250 mg megestrol acetate susp 40 mg/ml megestrol acetate susp 625 mg/5ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg MEKINIST TAB 0.5MG MEKINIST TAB 2MG meloxicam tab 15 mg... 3 meloxicam tab 7.5 mg... 3 melphalan hcl for inj 50 mg (base equiv) memantine hcl cap er 24hr 14 mg memantine hcl cap er 24hr 21 mg memantine hcl cap er 24hr 28 mg memantine hcl cap er 24hr 7 mg memantine hcl oral solution 2 mg/ml.. 53 memantine hcl tab 10 mg memantine hcl tab 5 mg MENACTRA INJ M-END DMX LIQ MENVEO INJ MEPHYTON TAB 5MG mercaptopurine tab 50 mg meropenem iv for soln 1 gm... 8 meropenem iv for soln 500 mg... 8 mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit mesalamine tab delayed release 800 mg mesna inj 100 mg/ml MESNEX TAB 400MG metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab er 24hr 500 mg metformin hcl tab er 24hr 750 mg methadone con 10mg/ml... 5 methadone hcl soln 10 mg/5ml... 5 methadone hcl soln 5 mg/5ml... 5 methadone hcl tab 10 mg... 5 methadone hcl tab 5 mg... 5 methazolamide tab 25 mg methazolamide tab 50 mg methenamine hippurate tab 1 gm... 9 methimazole tab 10 mg methimazole tab 5 mg methocarbamol tab 500 mg methocarbamol tab 750 mg methotrexate sodium for inj 1 gm methotrexate sodium inj 250 mg/10ml (25 mg/ml) methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) methyclothiazide tab 5 mg

170 methylphenidate hcl soln 10 mg/5ml methylphenidate hcl soln 5 mg/5ml methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab 5 mg methylphenidate hcl tab er 10 mg methylphenidate hcl tab er 20 mg methylprednisolone acetate inj susp 40 mg/ml methylprednisolone acetate inj susp 80 mg/ml methylprednisolone sod succ for inj 1000 mg (base equiv) methylprednisolone sod succ for inj 125 mg (base equiv) methylprednisolone sod succ for inj 40 mg (base equiv) methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab therapy pack 4 mg (21) metipranolol ophth soln 0.3% metoclopramide hcl inj 5 mg/ml (base equivalent) metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) metoclopramide hcl tab 10 mg (base equivalent) metoclopramide hcl tab 5 mg (base equivalent) metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol succinate tab er 24hr 100 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol succinate tab er 24hr 25 mg (tartrate equiv) metoprolol succinate tab er 24hr 50 mg (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml.. 40 metoprolol tartrate iv soln cart inj 5 mg/5ml (1 mg/ml) metoprolol tartrate tab 100 mg metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg metronidazole cream 0.75% metronidazole gel 0.75% metronidazole in nacl 0.79% iv soln 500 mg/100ml... 9 metronidazole lotion 0.75% metronidazole tab 250 mg... 9 metronidazole tab 500 mg... 9 metronidazole vaginal gel 0.75% mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg MG SO4/D5W INJ 10MG/ML MG SO4/D5W INJ 20MG/ML m-hist pd liq 0.625/ml MIACALCIN INJ 200/ML mi-acid gas chw 80mg mi-acid sus mi-acid sus max st miconazole 7 cre 2% miconazole 7 sup 100mg miconazole nitrate cream 2% miconazole nitrate vaginal cream 2%. 94 miconazole nitrate vaginal suppos 100 mg midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg migergot sup 2/ miglustat cap 100 mg migraine tab formula... 1 milk of magn sus milk of magn sus 1200/ MILK OF MAGN SUS 2400MG milk of magn sus 400/5ml minitran dis 0.1mg/hr minitran dis 0.2mg/hr minitran dis 0.4mg/hr minitran dis 0.6mg/hr minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg

171 minoxidil tab 10 mg minoxidil tab 2.5 mg mintox sus max st mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg mirtazapine tab 7.5 mg misoprostol tab 100 mcg misoprostol tab 200 mcg MITIGARE CAP 0.6MG... 1 mitomycin for iv soln 20 mg mitomycin for iv soln 40 mg mitomycin for iv soln 5 mg mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) M-M-R II INJ moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moisturel lot theraput mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) mononessa tab montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) MORPHINE SUL INJ 10MG/ML... 5 MORPHINE SUL INJ 150/30ML... 5 MORPHINE SUL INJ 2MG/ML... 5 MORPHINE SUL INJ 4MG/ML... 5 MORPHINE SUL INJ 5MG/ML... 5 MORPHINE SUL INJ 8MG/ML... 5 morphine sulfate inj 10 mg/ml... 5 morphine sulfate inj 8 mg/ml... 5 morphine sulfate iv soln 1 mg/ml... 5 morphine sulfate iv soln pf 10 mg/ml... 5 morphine sulfate iv soln pf 4 mg/ml... 5 morphine sulfate iv soln pf 8 mg/ml... 5 morphine sulfate oral soln 10 mg/5ml... 5 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)... 5 morphine sulfate oral soln 20 mg/5ml... 5 morphine sulfate tab 15 mg... 5 morphine sulfate tab 30 mg... 5 morphine sulfate tab er 100 mg... 6 morphine sulfate tab er 15 mg... 5 morphine sulfate tab er 200 mg... 6 morphine sulfate tab er 30 mg... 6 morphine sulfate tab er 60 mg... 6 MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG MOVIPREP SOL MOXEZA SOL 0.5% moxifloxacin hcl ophth soln 0.5% (base equiv) moxifloxacin hcl tab 400 mg (base equiv) MOZOBIL INJ MUCINEX CGH GRA 5-100MG mucinex cgh liq 5-100mg mucinex chld liq 100/5ml MUCINEX CHLD MIS DAY/NITE mucinex cold tab flu&sore mucinex cold tab sinus mucinex dm liq mucinex fast liq cold flu MUCINEX FAST MIS MX DAY/N mucinex fast tab MUCINEX FAST TAB mucinex fast tab sev cold mucinex ff spr 0.05% mucinex ms liq cold ngh MUCINEX TAB 600MG ER mucinex tab sinus

172 MUCINEX/KIDS GRA 100MG mucus relief tab 400mg mucusrelief tab sinus MULTAQ TAB 400MG mupirocin oint 2% MURO 128 SOL 2% OP MUSTARGEN INJ 10MG my way tab 1.5mg MYCAMINE INJ 100MG MYCAMINE INJ 50MG mycophenolate mofetil cap 250 mg mycophenolate mofetil for oral susp 200 mg/ml mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) MYLOTARG INJ 4.5MG myorisan cap 10mg myorisan cap 20mg myorisan cap 30mg myorisan cap 40mg MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG mytab gas chw 125mg mytab gas chw 80mg myzilra tab N nabumetone tab 500 mg... 3 nabumetone tab 750 mg... 3 nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 10 gm nafcillin sodium for iv soln 2 gm NAGLAZYME INJ 1MG/ML nalbuphine hcl inj 10 mg/ml... 3 nalbuphine hcl inj 20 mg/ml... 3 naloxone hcl inj 0.4 mg/ml naloxone hcl inj 4 mg/10ml naloxone hcl soln cartridge 0.4 mg/ml. 70 naloxone hcl soln prefilled syringe 2 mg/2ml naltrexone hcl tab 50 mg NAMENDA XR CAP 14MG NAMENDA XR CAP 21MG NAMENDA XR CAP 28MG NAMENDA XR CAP 7MG NAMENDA XR CAP TITRATIO NAMZARIC CAP NAMZARIC CAP 14-10MG NAMZARIC CAP 21-10MG NAMZARIC CAP 28-10MG NAMZARIC CAP 7-10MG naproxen dr tab 375mg... 3 naproxen dr tab 500mg... 3 naproxen sod tab 220mg... 3 naproxen sodium tab 275 mg... 3 naproxen sodium tab 550 mg... 3 naproxen susp 125 mg/5ml... 3 naproxen tab 250 mg... 3 naproxen tab 375 mg... 3 naproxen tab 500 mg... 3 naratriptan hcl tab 1 mg (base equiv). 67 naratriptan hcl tab 2.5 mg (base equiv) NARCAN SPR NASAL DECON SYP 30MG/5ML nasal decong spr 0.05% nasal decong tab 10mg NASOPEN PE LIQ nat fiber pow therapy NATACYN SUS 5% OP nateglinide tab 120 mg nateglinide tab 60 mg NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG NATRAPEL 12H SPR 20% natural bal sol tears natures sol tears naturl fiber pow 28.3% NEBUPENT INH 300MG... 9 necon tab 0.5/ necon tab 7/7/ nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg nefazodone hcl tab 50 mg neomycin sulfate tab 500 mg

173 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-bacitracin-polymyxin oint neomycin-polymy-gramicid op sol mg-unt-mg/ml neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp neomycin-polymyxin-hc otic soln 1% 124 neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% NEPHRAMINE INJ 5.4% NERLYNX TAB 40MG NEUPOGEN INJ 300/ NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/ NEUPOGEN INJ 480MCG NEUPRO DIS 1MG/24HR NEUPRO DIS 2MG/24HR NEUPRO DIS 3MG/24HR NEUPRO DIS 4MG/24HR NEUPRO DIS 6MG/24HR NEUPRO DIS 8MG/24HR nevirapine tab 200 mg nevirapine tab er 24hr 100 mg nevirapine tab er 24hr 400 mg NEXAVAR TAB 200MG next choice tab 1.5mg niacin tab er 1000 mg (antihyperlipidemic) niacin tab er 500 mg (antihyperlipidemic) niacin tab er 750 mg (antihyperlipidemic) niacor tab 500mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nicorelief gum 2mg mint nicorelief gum 2mg orig nicorelief gum 4mg mint nicorelief gum 4mg orig nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg NICOTINE SYS KIT TRANSDER nicotine td dis 14mg/24h nicotine td dis 21mg/24h nicotine td dis 7mg/24hr nicotine td patch 24hr 14 mg/24hr nicotine td patch 24hr 21 mg/24hr nicotine td patch 24hr 7 mg/24hr NICOTROL INH NICOTROL NS SPR 10MG/ML nifedipine tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 30 mg nifedipine tab er 24hr osmotic release 60 mg nifedipine tab er 24hr osmotic release 90 mg night time cap cold/flu night time tab 25mg nikki tab mg nilutamide tab 150 mg nimodipine cap 30 mg NINJACOF LIQ NINJACOF-A LIQ NINJACOF-XG LIQ 200-8/ NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG NIPENT INJ 10MG NITRO-BID OIN 2% NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystalline cap 100 mg... 9 nitrofurantoin macrocrystalline cap 50 mg... 9 nitrofurantoin monohydrate macrocrystalline cap 100 mg... 9 nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr. 46 nitroglycerin td patch 24hr 0.2 mg/hr. 46 nitroglycerin td patch 24hr 0.4 mg/hr. 46 nitroglycerin td patch 24hr 0.6 mg/hr. 46 nohist-dm liq nohist-lq liq 4-10/5ml NORDITROPIN INJ 10/1.5ML

174 NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML NORDITROPIN INJ 5/1.5ML norelgestromin-ethinyl estradiol td ptwk mcg/24hr norethindrone & mestranol tab 1 mg-50 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone acetate tab 5 mg norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg norethindrone tab 0.35 mg norethindrone-eth estradiol tab /1-35/ mg-mcg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab / / mg-mcg norgestimate-eth estrad tab / / mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg- 30 mcg norlyroc tab 0.35mg NORMOSOL -M INJ /D5W NORMOSOL -R INJ /D5W NORMOSOL-R INJ PH NORPACE CAP 100MG CR NORPACE CAP 150MG CR NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG nortrel tab 0.5/ nortrel tab 1/ nortrel tab 7/7/ nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG NOVOLIN INJ 70/ NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/ NOVOLOG MIX INJ FLEXPEN NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG nrs nasal spr 0.05% NUCYNTA ER TAB 100MG... 6 NUCYNTA ER TAB 150MG... 6 NUCYNTA ER TAB 200MG... 6 NUCYNTA ER TAB 250MG... 6 NUCYNTA ER TAB 50MG... 6 NUEDEXTA CAP 20-10MG NULOJIX INJ 250MG NULYTELY SOL FLAV PKS NUPLAZID TAB 17MG NUVARING MIS nyamyc pow NYMALIZE SOL 30/10ML nystatin cream unit/gm nystatin oint unit/gm nystatin susp unit/ml nystatin tab unit nystatin topical powder unit/gm nystop pow O OCTAGAM INJ 10/100ML OCTAGAM INJ 10GM OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 20/200ML OCTAGAM INJ 25GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM OCTAGAM INJ 5GM/50ML octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) octreotide acetate inj 200 mcg/ml (

175 mg/ml) octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ODEFSEY TAB ODOMZO CAP 200MG OFEV CAP 100MG OFEV CAP 150MG OFF DEEP WDS AER 25% ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% olanzapine for im inj 10 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine orally disintegrating tab 5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 2.5 mg olanzapine tab 20 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olmesartan medoxomil tab 20 mg olmesartan medoxomil tab 40 mg olmesartan medoxomil tab 5 mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan medoxomilhydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg. 35 olmesartan-amlodipinehydrochlorothiazide tab mg olmesartan-amlodipinehydrochlorothiazide tab mg.. 35 olmesartan-amlodipinehydrochlorothiazide tab mg. 35 olmesartan-amlodipinehydrochlorothiazide tab mg olopatadine hcl ophth soln 0.2% (base equivalent) omega-3-acid ethyl esters cap 1 gm omeprazole cap delayed release 10 mg92 omeprazole cap delayed release 20 mg92 omeprazole cap delayed release 40 mg92 omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) OMEPRAZOLE TAB 20MG ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl inj 40 mg/20ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml ondansetron hcl tab 24 mg ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG opcicon tab 1.5mg OPSUMIT TAB 10MG opti-clear sol 0.05% ORFADIN CAP 10MG ORFADIN CAP 20MG ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN SUS 4MG/ML organ-i nr tab 200mg ORKAMBI TAB ORKAMBI TAB orsythia tab oseltamivir phosphate cap 30 mg (base equiv) oseltamivir phosphate cap 45 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) oseltamivir phosphate for susp 6 mg/ml (base equiv) oxacillin sodium for inj 1 gm (base equivalent) oxacillin sodium for inj 10 gm (base equivalent) oxacillin sodium for inj 2 gm (base 159

176 equivalent) oxaliplatin for iv inj 100 mg oxaliplatin for iv inj 50 mg oxaliplatin iv soln 100 mg/20ml oxaliplatin iv soln 50 mg/10ml oxandrolone tab 10 mg oxandrolone tab 2.5 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab er 24hr 10 mg 93 oxybutynin chloride tab er 24hr 15 mg 93 oxybutynin chloride tab er 24hr 5 mg.. 93 oxycodone hcl cap 5 mg... 6 oxycodone hcl conc 100 mg/5ml (20 mg/ml)... 6 oxycodone hcl soln 5 mg/5ml... 6 oxycodone hcl tab 10 mg... 6 oxycodone hcl tab 15 mg... 6 oxycodone hcl tab 20 mg... 6 oxycodone hcl tab 30 mg... 6 oxycodone hcl tab 5 mg... 6 oxycodone w/ acetaminophen tab mg... 6 oxycodone w/ acetaminophen tab mg... 6 oxycodone w/ acetaminophen tab mg... 6 oxycodone w/ acetaminophen tab mg... 6 OXYCONTIN TAB 10MG CR... 6 OXYCONTIN TAB 15MG CR... 6 OXYCONTIN TAB 20MG CR... 6 OXYCONTIN TAB 30MG CR... 6 OXYCONTIN TAB 40MG CR... 6 OXYCONTIN TAB 60MG CR... 6 OXYCONTIN TAB 80MG CR... 6 OZEMPIC INJ 2/1.5ML P pacerone tab 100mg pacerone tab 200mg pacerone tab 400mg paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml) paclitaxel iv conc 30 mg/5ml (6 mg/ml) paclitaxel iv conc 300 mg/50ml (6 mg/ml) pain & fever chw 80mg... 1 pain & fever sol 160/5ml... 1 pain & fever sus 160/5ml... 2 pain & fever tab 325mg... 2 pain & fever tab 500mg... 2 pain cre relievng pain relieve tab mg pain rlf sin tab pe day paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg pamidronate disodium for inj 30 mg pamidronate disodium for inj 90 mg pamidronate disodium iv soln 3 mg/ml 75 pamidronate disodium iv soln 9 mg/ml 75 PAMIDRONATE INJ 6MG/ML PANRETIN GEL 0.1% pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paromomycin sulfate cap 250 mg... 7 paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg PASER GRA 4GM PAXIL SUS 10MG/5ML PAZEO DRO 0.7% PEDIARIX INJ 0.5ML pediatric liq cgh/cold PEDVAX HIB INJ peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm

177 PEGANONE TAB 250MG PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEN G PROC INJ PENICILL GK/ INJ DEX 2MU PENICILL GK/ INJ DEX 3MU penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PENTACEL INJ PENTAM 300 INJ 300MG... 9 pentoxifylline tab er 400 mg peptic relf chw 262mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg periogard sol 0.12% permethrin cream 5% perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg phenelzine sulfate tab 15 mg PHENHIST DH LIQ PHENOBARB INJ 65MG/ML phenobarbital elixir 20 mg/5ml phenobarbital sodium inj 130 mg/ml phenobarbital tab 100 mg phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg PHENYTEK CAP 200MG PHENYTEK CAP 300MG phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml philith tab PHOSPHOLINE SOL 0.125%OP phytonadione inj 10 mg/ml PICATO GEL 0.015% PICATO GEL 0.05% pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4% pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg pimozide tab 1 mg pimozide tab 2 mg pimtrea tab pindolol tab 10 mg pindolol tab 5 mg pink bismuth chw 262mg pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) PIPER/TAZOBA INJ GM piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) pirmella tab 1/ piroxicam cap 10 mg... 3 piroxicam cap 20 mg... 3 PLASMA-LYTE INJ PLASMA-LYTE INJ -A podofilox soln 0.5% polyethylene glycol 3350 oral packet.. 90 polyethylene glycol 3350 oral powder. 90 POLY-HIST DM LIQ

178 POLY-HIST PD LIQ polymyxin b-trimethoprim ophth soln unit/ml-0.1% POLY-VENT DM TAB POLY-VENT IR TAB MG POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG portia-28 tab potassium chloride 20 meq/l (0.15%) in dextrose 5% inj potassium chloride 40 meq/l (0.3%) in dextrose 5% inj potassium chloride cap er 10 meq potassium chloride cap er 8 meq potassium chloride inj 10 meq/100ml 104 potassium chloride inj 10 meq/50ml potassium chloride inj 2 meq/ml potassium chloride inj 20 meq/100ml 104 potassium chloride inj 20 meq/50ml potassium chloride inj 40 meq/100ml 104 potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 mg) potassium chloride tab er 8 meq (600 mg) potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) potassium citrate tab er 5 meq (540 mg) povidone-iodine oint 10% povidone-iodine soln 10% PRADAXA CAP 110MG PRADAXA CAP 150MG PRADAXA CAP 75MG PRALUENT INJ 150MG/ML PRALUENT INJ 75MG/ML pramipexole dihydrochloride tab mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg 59 pramipexole dihydrochloride tab 1.5 mg prasugrel hcl tab 10 mg (base equiv).. 97 prasugrel hcl tab 5 mg (base equiv) pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg praziquantel tab 600 mg... 9 prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg PRED SOD PHO SOL 1% OP prednisolone acetate ophth susp 1% 106 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE CON 5MG/ML prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 50 mg prednisone tab therapy pack 10 mg (21) prednisone tab therapy pack 10 mg (48) prednisone tab therapy pack 5 mg (21) prednisone tab therapy pack 5 mg (48) 162

179 PREMASOL SOL 10% prenatal vitamin/folic acid > 0.8 mg (generic) prevalite pow 4gm prevalite pow 4gm pk previfem tab PREZCOBIX TAB PREZISTA SUS 100MG/ML PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 75MG PREZISTA TAB 800MG PRIFTIN TAB 150MG PRIMAQUINE TAB 26.3MG primidone tab 250 mg primidone tab 50 mg PRIVIGEN INJ 10GRAMS PRIVIGEN INJ 20GRAMS PRIVIGEN INJ 40GRAMS PRIVIGEN INJ 5 GRAMS probenecid tab 500 mg... 1 PROCALAMINE INJ 3% prochlorperazine edisylate inj 5 mg/ml 87 prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine suppos 25 mg PROCRIT INJ 10000/ML PROCRIT INJ 2000/ML PROCRIT INJ 20000/ML PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 40000/ML procto-med cre hc 2.5% procto-pak cre 1% proctozone cre -hc 2.5% PROGLYCEM SUS 50MG/ML PROLASTIN-C INJ 1000MG PROLENSA SOL 0.07% PROLIA SOL 60MG/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG prometh vc/ syp codeine promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl syrup 6.25 mg/5ml.. 88 promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg promethazine w/ codeine syrup mg/5ml promethazine-dm syrup mg/5ml promethazine-phenylephrine-codeine syrup mg/5ml propafenone hcl cap er 12hr 225 mg.. 37 propafenone hcl cap er 12hr 325 mg.. 37 propafenone hcl cap er 12hr 425 mg.. 37 propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg proparacaine hcl ophth soln 0.5% propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg propranolol hcl cap er 24hr 120 mg propranolol hcl cap er 24hr 160 mg propranolol hcl cap er 24hr 60 mg propranolol hcl cap er 24hr 80 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg propylthiouracil tab 50 mg PROQUAD INJ PROSOL INJ 20% protriptyline hcl tab 10 mg protriptyline hcl tab 5 mg pseudoeph-chlorphen w/ hydrocodone soln mg/5ml pseudoephed-bromphen-dm syrup mg/5ml pseudoephedrine hcl tab 30 mg pseudoephedrine-guaifenesin tab er 12hr mg PULMICORT INH 180MCG PULMICORT INH 90MCG

180 PULMOZYME SOL 1MG/ML puralube oin PURIXAN SUS 20MG/ML pyrazinamide tab 500 mg pyridostigmine bromide tab 60 mg pyrilamine-phenylephrine tab mg Q qc cough liq sore thr q-dryl cap 25mg q-dryl liq 12.5/5ml q-pap child sus 160/5ml... 2 q-pap tab 325mg... 2 q-pap tab 500mg... 2 q-tussin dm syp / q-tussin sol 100/5ml QUADRACEL INJ quasense tab quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab er 24hr 150 mg quetiapine fumarate tab er 24hr 200 mg quetiapine fumarate tab er 24hr 300 mg quetiapine fumarate tab er 24hr 400 mg quetiapine fumarate tab er 24hr 50 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg quinapril hcl tab 5 mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinidine gluconate tab er 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg quinine sulfate cap 324 mg R RABAVERT INJ rabeprazole sodium ec tab 20 mg raloxifene hcl tab 60 mg ramipril cap 1.25 mg ramipril cap 10 mg ramipril cap 2.5 mg ramipril cap 5 mg RANEXA TAB 1000MG RANEXA TAB 500MG ranitidine hcl inj 150 mg/6ml (25 mg/ml) ranitidine hcl inj 50 mg/2ml (25 mg/ml) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg ranitidine hcl tab 300 mg ranitidine hcl tab 75 mg RAPAMUNE SOL 1MG/ML rasagiline mesylate tab 0.5 mg (base equiv) rasagiline mesylate tab 1 mg (base equiv) RASH + SKIN AER 10% RAYALDEE CAP 30MCG REBETOL SOL 40MG/ML reclipsen tab RECOMBIVA HB INJ 10MCG/ML RECOMBIVA HB INJ 5MCG/ RECOMBIVA-HB INJ 40MCG/ML REFRESH CELL GEL 1% OP refresh lacr oin op REGRANEX GEL 0.01% reguloid cap 0.52gm RELENZA MIS DISKHALE RELISTOR INJ 12/0.6ML RELISTOR INJ 8/0.4ML REMICADE INJ 100MG REMODULIN INJ 10MG/ML REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML repaglinide tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg REPEL HUNTER AER 25% REPEL SPORTS AER 25%

181 REPEL SPORTS AER 40% RESCON TAB 2-60MG RESCON-DM SYP RESCON-GG LIQ RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RESPAIRE-30 CAP RESTASIS EMU 0.05% RESTASIS MUL EMU 0.05% RETROVIR INJ 10MG/ML REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG REXULTI TAB 0.25MG REXULTI TAB 0.5MG REXULTI TAB 1MG REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG REYATAZ POW 50MG REZIRA SOL 60-5/5ML ribasphere cap 200mg ribasphere tab 200mg ribasphere tab 400mg ribasphere tab 600mg ribavirin cap 200 mg ribavirin tab 200 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB riluzole tab 50 mg rimantadine hydrochloride tab 100 mg 15 ringer's solution RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab 2 mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab 4 mg risperidone soln 1 mg/ml risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg ritonavir tab 100 mg RITUXAN INJ 100MG RITUXAN INJ 500MG RITUXAN INJ HYCELA rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap 4.5 mg rivastigmine tartrate cap 6 mg rivastigmine td patch 24hr 13.3 mg/24hr rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rizatriptan benzoate oral disintegrating tab 10 mg (base eq) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) rizatriptan benzoate tab 10 mg (base equivalent) rizatriptan benzoate tab 5 mg (base equivalent) robafen cf liq robafen cgh cap 15mg robafen dm liq / robafen dm syp / robafen syp 100/5ml ropinirole hydrochloride tab 0.25 mg.. 59 ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg rosadan cre 0.75%

182 rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg rosuvastatin calcium tab 5 mg ROTARIX SUS ROTATEQ SOL roweepra tab 1000mg roweepra tab 500mg roweepra tab 750mg roweepra xr tab 500mg xr roweepra xr tab 750mg xr RUBRACA TAB 200MG RUBRACA TAB 250MG RUBRACA TAB 300MG RU-HIST D TAB 4-10MG rulox sus RYDAPT CAP 25MG RYMED TAB 2-10MG rynex dm liq rynex pe elx rynex pse liq S SABRIL TAB 500MG SANDIMMUNE SOL 100MG/ML SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG sani-supp sup adult sani-supp sup pediatri SANTYL OIN 250/GM SAPHRIS SUB 10MG SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAWYER REPEL SPR 20% scopolamine td patch 72hr 1 mg/3days selegiline hcl cap 5 mg selegiline hcl tab 5 mg selenium sulfide lotion 2.5% SELZENTRY SOL 20MG/ML SELZENTRY TAB 150MG SELZENTRY TAB 25MG SELZENTRY TAB 300MG SELZENTRY TAB 75MG senexon liq 8.8mg/ senexon tab 8.6mg senna lax tab 8.6mg senna plus tab mg senna-lax tab 8.6mg sennalax-s tab mg sennosides syrup 8.8 mg/5ml sennosides tab 8.6 mg sennosides-docusate sodium tab mg SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG SEREVENT DIS AER 50MCG sertraline hcl oral concentrate for solution 20 mg/ml sertraline hcl tab 100 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg sevelamer carbonate packet 0.8 gm sevelamer carbonate packet 2.4 gm sevelamer carbonate tab 800 mg sharobel tab 0.35mg SHINGRIX INJ 50MCG SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML siladryl alr liq 12.5/5ml sildenafil citrate tab 20 mg SILENOR TAB 3MG SILENOR TAB 6MG silphen coug syp 12.5/5ml siltussin dm liq das siltussin sa syp 100/5ml siltussin-dm syp alc free silver sulfadiazine cream 1% SIMBRINZA SUS 1-0.2% simethicone cap 180 mg simethicone dro 20/0.3ml simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg simvastatin tab 80 mg sinus-max mis day/nght sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg SIRTURO TAB 100MG SIVEXTRO INJ 200MG... 9 SIVEXTRO TAB 200MG... 9 sleep aid tab 25mg

183 sm allergy tab 4mg sm antacid sus anti-gas sm antacid/ sus antigas sm anti-diar tab 2mg sm nasal 12h spr 0.05% sm nasal dec tab 30mg sm tussin dm syp / sm tussin syp dm sodium bicarbonate tab 325 mg sodium bicarbonate tab 650 mg sodium chloride hypertonic ophth oint 5% sodium chloride hypertonic ophth soln 5% sodium chloride inj 0.45% sodium chloride inj 2.5 meq/ml (14.6%) sodium chloride inj 3% sodium chloride inj 5% sodium chloride irrigation soln 0.9%. 123 sodium chloride iv soln 0.9% sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln sodium phenylbutyrate oral powder 3 gm/teaspoonful sodium phenylbutyrate tab 500 mg sodium phosphates - enema sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder.. 75 SOLIQUA INJ 100/ SOLTAMOX SOL 10MG/5ML SOLU-CORTEF INJ 250MG SOMATULINE INJ 120/.5ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG sorine tab 120mg sorine tab 160mg sorine tab 240mg sorine tab 80mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg SOVALDI TAB 400MG spironolactone & hydrochlorothiazide tab mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg sprintec 28 tab 28 day SPRITAM TAB 1000MG SPRITAM TAB 250MG SPRITAM TAB 500MG SPRITAM TAB 750MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG ssd cre 1% STAHIST AD LIQ STAHIST AD TAB 25-60MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stim laxat tab 5mg ec STIMATE SOL 1.5MG/ML STIVARGA TAB 40MG stool softnr cap 100mg stool softnr cap 240mg streptomycin sulfate for inj 1 gm... 7 STRIBILD TAB SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG sucralfate tab 1 gm sudogest pe tab 10mg sudogest tab 120mg er sudogest tab 30mg sudogest tab 4-60mg sudogest tab 60mg sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium ophth oint 10% 167

184 sulfacetamide sodium ophth soln 10% sulfacetamide sodium-prednisolone ophth soln (0.25)% SULFADIAZINE TAB 500MG... 7 sulfamethoxazole-trimethoprim iv soln mg/5ml... 9 sulfamethoxazole-trimethoprim susp mg/5ml... 9 sulfamethoxazole-trimethoprim tab mg... 9 sulfamethoxazole-trimethoprim tab mg... 9 SULFAMYLON CRE 85MG/GM SULFAMYLON PAK 5% sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg sulindac tab 150 mg... 3 sulindac tab 200 mg... 3 sumatriptan nasal spray 20 mg/act sumatriptan nasal spray 5 mg/act sumatriptan succinate inj 6 mg/0.5ml. 68 sumatriptan succinate solution autoinjector 4 mg/0.5ml sumatriptan succinate solution autoinjector 6 mg/0.5ml sumatriptan succinate solution cartridge 4 mg/0.5ml sumatriptan succinate solution cartridge 6 mg/0.5ml sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate tab 100 mg sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG SUPRAX SUS 500/5ML SUPREP BOWEL SOL PREP KIT SUSPENDOL-S LIQ SUSTIVA TAB 600MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYMBICORT AER SYMBICORT AER SYMDEKO TAB SYMFI LO TAB SYNAGIS INJ 100MG/ML SYNAGIS INJ 50MG SYNAREL SOL 2MG/ML SYNERCID INJ 500MG... 9 SYNRIBO INJ 3.5MG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 25MCG SYNTHROID TAB 300MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG SYPRINE CAP 250MG T TABLOID TAB 40MG tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg tacrolimus oint 0.03% tacrolimus oint 0.1% TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) tamsulosin hcl cap 0.4 mg TANDEM CAP TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TARGRETIN GEL 1% tarina fe tab 1/ TASIGNA CAP 150MG

185 TASIGNA CAP 200MG TASIGNA CAP 50MG TAXOTERE INJ 80MG/4ML tazarotene cream 0.1% tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TAZORAC CRE 0.05% taztia xt cap 120mg/ taztia xt cap 180mg/ taztia xt cap 240mg/ taztia xt cap 300mg/ taztia xt cap 360mg/ TECENTRIQ INJ 1200/ TEFLARO INJ 400MG TEFLARO INJ 600MG TEGRETOL SUS 100/5ML TEGRETOL TAB 200MG TEGRETOL-XR TAB 100MG TEGRETOL-XR TAB 200MG TEGRETOL-XR TAB 400MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA TAB 150MG TEKTURNA TAB 300MG telmisartan tab 20 mg telmisartan tab 40 mg telmisartan tab 80 mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg temazepam cap 15 mg temazepam cap 7.5 mg TENIVAC INJ 5-2LF tenofovir disoproxil fumarate tab 300 mg terazosin hcl cap 1 mg (base equivalent) terazosin hcl cap 10 mg (base equivalent) terazosin hcl cap 2 mg (base equivalent) terazosin hcl cap 5 mg (base equivalent) terbinafine hcl cream 1% terbinafine hcl tab 250 mg terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 12.5 mg/act (1%). 71 testosterone td gel 25 mg/2.5gm (1%)71 testosterone td gel 50 mg/5gm (1%).. 72 TET/DIP TOX INJ 2-2 LF tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg TEXACORT SOL 2.5% THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THALOMID CAP 50MG THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg thioridazine hcl tab 10 mg thioridazine hcl tab 100 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg thiothixene cap 5 mg tiagabine hcl tab 12 mg tiagabine hcl tab 16 mg tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg

186 tigecycline for iv soln 50 mg... 9 TIGECYCLINE INJ 50MG... 9 timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate ophth soln 0.5% (oncedaily) timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg tioconazole oin 6.5% vag TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) TOBRADEX OIN % TOBRADEX ST SUS tobramycin nebu soln 300 mg/5ml... 7 tobramycin ophth soln 0.3% tobramycin sulfate for inj 1.2 gm... 7 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)... 7 tobramycin sulfate inj 10 mg/ml (base equivalent)... 7 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv)... 7 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)... 7 tobramycin-dexamethasone ophth susp % tolnaftate cre 1% tolnaftate cream 1% tolnaftate powder 1% tolterodine tartrate cap er 24hr 2 mg.. 93 tolterodine tartrate cap er 24hr 4 mg.. 93 tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 100 mg topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg toposar inj 100/5ml toposar inj 1gm/50ml topotecan hcl for inj 4 mg topotecan hcl inj 4 mg/4ml (base equiv) (for infusion) TOPOTECAN INJ 4MG/4ML torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg TOVIAZ TAB 4MG TOVIAZ TAB 8MG tpn electrol inj TRACLEER TAB 125MG TRACLEER TAB 62.5MG TRADJENTA TAB 5MG tramadol hcl tab 50 mg... 3 tramadol-acetaminophen tab mg... 4 trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) tranexamic acid tab 650 mg tranylcypromine sulfate tab 10 mg TRAVASOL INJ 10% TRAVATAN Z DRO 0.004% travel sick chw 25mg travel sick tab 50mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 50 mg TRECATOR TAB 250MG TRELEGY AER ELLIPTA TRELSTAR MIX INJ 11.25MG TRELSTAR MIX INJ 3.75MG TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT tretinoin cap 10 mg tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% triamcinolone acetonide cream 0.025%

187 triamcinolone acetonide cream 0.1%. 121 triamcinolone acetonide cream 0.5%. 121 triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide nasal aerosol suspension 55 mcg/act triamcinolone acetonide oint 0.025%. 122 triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg trientine hcl cap 250 mg trifluoperazine hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluridine ophth soln 1% trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg tri-legest tab fe tri-lo- tab sprintec trilyte sol trimethoprim tab 100 mg... 9 trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg trinessa lo tab trinessa tab TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG TRINTELLIX TAB 5MG triple antib oin triple antib oin plus tri-previfem tab TRISENOX INJ 12MG/6ML tri-sprintec tab TRIUMEQ TAB trivora-28 tab tri-vylibra tab TROGARZO INJ 150MG/ML TROPHAMINE INJ 10% trospium chloride tab 20 mg TRUE METRIX KIT AIR TRUE METRIX KIT METER TRUE METRIX STRIPS TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUMENBA INJ TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB tussin dm liq tussin dm liq clear tussin dm syp / TWINRIX INJ TYBOST TAB 150MG TYKERB TAB 250MG TYPHIM VI INJ TYSABRI INJ 300/15ML U ULORIC TAB 40MG... 1 ULORIC TAB 80MG... 1 unithroid tab 100mcg unithroid tab 112mcg unithroid tab 125mcg unithroid tab 150mcg unithroid tab 175mcg unithroid tab 200mcg unithroid tab 25mcg unithroid tab 300mcg unithroid tab 50mcg unithroid tab 75mcg unithroid tab 88mcg ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg V valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCHLOR GEL 0.016% valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 450 mg (base 171

188 equivalent) valproate sodium inj 100 mg/ml valproate sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg valsartan tab 160 mg valsartan tab 320 mg valsartan tab 40 mg valsartan tab 80 mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg VANACLEAR PD LIQ 0.313MG VANACOF DM LIQ VANACOF-8 LIQ 25-50/ VANAMINE PD LIQ 6.25/ML vancomycin hcl cap 125 mg... 9 vancomycin hcl cap 250 mg... 9 vancomycin hcl for inj 10 gm... 9 vancomycin hcl for inj 1000 mg... 9 vancomycin hcl for inj 500 mg... 9 vancomycin hcl for inj 5000 mg... 9 vancomycin hcl for inj 750 mg... 9 VANCOMYCIN INJ 1 GM... 9 VANCOMYCIN INJ 500MG... 9 VANCOMYCIN INJ 750MG vandazole gel 0.75% VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ VASCEPA CAP 0.5GM VASCEPA CAP 1GM VELCADE INJ 3.5MG velivet pak VEMLIDY TAB 25MG VENCLEXTA TAB 100MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG VENCLEXTA TAB START PK venlafaxine hcl cap er 24hr 150 mg (base equivalent) venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base equivalent) venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VENTOLIN HFA AER verapamil hcl cap er 24hr 100 mg verapamil hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 180 mg verapamil hcl cap er 24hr 200 mg verapamil hcl cap er 24hr 240 mg verapamil hcl cap er 24hr 300 mg verapamil hcl cap er 24hr 360 mg verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 120 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg VERSACLOZ SUS 50MG/ML VERZENIO TAB 100MG VERZENIO TAB 150MG VERZENIO TAB 200MG VERZENIO TAB 50MG VESICARE TAB 10MG VESICARE TAB 5MG VICTOZA INJ 18MG/3ML VIDEX EC CAP 125MG VIDEX SOL 2GM VIDEX SOL 4GM vienva tab vigabatrin powd pack 500 mg VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG VIMPAT INJ 200MG/ VIMPAT SOL 10MG/ML VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG

189 VIMPAT TAB 50MG vinblastine sulfate inj 1 mg/ml vincasar pfs inj 1mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) viorele tab VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIRAMUNE SUS 50MG/5ML VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG virtussin ac sol / virtussin sol dac vitamin d3 dro 400unit vitamins a & d oint VIVITROL INJ 380MG voriconazole for inj 200 mg voriconazole for susp 40 mg/ml voriconazole tab 200 mg voriconazole tab 50 mg VOSEVI TAB VOTRIENT TAB 200MG VRAYLAR CAP 1.5-3MG VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG vyfemla tab vylibra tab W warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg water for irrigation, sterile irrigation soln WELCHOL PAK 3.75GM WELCHOL TAB 625MG white petrolatum gel X XALKORI CAP 200MG XALKORI CAP 250MG XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XATMEP SOL 2.5MG/ML XELJANZ TAB 5MG XELJANZ XR TAB 11MG XGEVA INJ XIFAXAN TAB 550MG XIGDUO XR TAB XIGDUO XR TAB MG XIGDUO XR TAB XIGDUO XR TAB MG XIGDUO XR TAB 5-500MG XOLAIR SOL 150MG XTANDI CAP 40MG XULTOPHY INJ 100/ XYREM SOL 500MG/ML Y YERVOY INJ 200MG YERVOY INJ 50MG YF-VAX INJ Z zafirlukast tab 10 mg zafirlukast tab 20 mg zarah tab mg ZAVESCA CAP 100MG Z-BUM CRE 22.5% zeasorb-af pow 2% ZEJULA CAP 100MG ZELBORAF TAB 240MG ZEMAIRA INJ 1000MG zenatane cap 10mg zenatane cap 20mg zenatane cap 30mg zenatane cap 40mg zenchent tab ZENPEP CAP ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 3000UNIT

190 ZENPEP CAP 40000UNT ZENPEP CAP 5000UNIT ZEPATIER TAB MG ZERIT SOL 1MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg zinc oxide oint 20% ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZIRGAN GEL 0.15% zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml ZOLINZA CAP 100MG zolmitriptan orally disintegrating tab 2.5 mg zolmitriptan orally disintegrating tab 5 mg zolmitriptan tab 2.5 mg zolmitriptan tab 5 mg zolpidem tartrate tab 10 mg zolpidem tartrate tab 5 mg zonisamide cap 100 mg zonisamide cap 25 mg zonisamide cap 50 mg ZONTIVITY TAB 2.08MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZOSTAVAX INJ zovia 1/35e tab zovia 1/50e tab ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG ZYLET SUS % ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ZYTIGA TAB 250MG ZYTIGA TAB 500MG

191

192 Versión 11 FECHA DE PUBLICACIÓN: 07/2018 Departamento de Servicios para Miembros: (866) , TTY / TDD al 711 De lunes a viernes, de 8:00 a. m. a 8:00 p. m., localtime