PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 TexanPlus HMO 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/08/2014. For more recent information or other questions, please contact TexanPlus HMO at or, for TTY users, 711, 8:00 a.m. to 8:00 p.m. in your local time zone, 7 days a week, or visit , Version 6 Y0067_POST_COMPFRM_0614 CMS Accepted 06/23/ E1-TXPS-F-CM

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means TexanPlus HMO. When it refers to plan or our plan, it means TexanPlus HMO. This document includes list of the drugs (formulary) for our plan which is current as of 08/08/2014. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. i

3 What is the TexanPlus Formulary? A formulary is a list of covered drugs selected by TexanPlus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. TexanPlus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a TexanPlus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 08/08/2014. To get updated information about the drugs covered by TexanPlus, please contact us. Our contact information appears on the front and back cover pages. A monthly supplemental addendum to the formulary is available at or call Member Services at the number listed on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 63. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. ii

4 What are generic drugs? TexanPlus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: TexanPlus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from TexanPlus before you fill your prescriptions. If you don t get approval, TexanPlus may not cover the drug. Quantity Limits: For certain drugs, TexanPlus limits the amount of the drug that TexanPlus will cover. For example, TexanPlus provides 30 tablets per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, TexanPlus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, TexanPlus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, TexanPlus will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask TexanPlus to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the TexanPlus s formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that TexanPlus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by TexanPlus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by TexanPlus. You can ask TexanPlus to make an exception and cover your drug. See below for information about how to request an exception. iii

5 How do I request an exception to the TexanPlus Formulary? You can ask TexanPlus to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, TexanPlus limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, TexanPlus will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. iv

6 If you are a current member in our plan, we will also cover a temporary transition supply if you have a change in your medications because of a level-of-care change. This may include unplanned changes in treatment settings, such as being discharged from an acute care (hospital) setting or being admitted to, or discharged from, a long-term care facility. For each drug that is not in our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (up to a 34-day supply if you are a resident of a long-term care facility) when you go to a network pharmacy. For more information For more detailed information about your TexanPlus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about TexanPlus, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit v

7 TexanPlus Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by TexanPlus. If you have trouble finding your drug in the list, turn to the Index that begins on page 63. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if TexanPlus has any special requirements for coverage of your drug. Prior Authorization drugs are designated with the abbreviation PA. Quantity Limit drugs are designated with the abbreviation QL. Step Therapy drugs are designated with the abbreviation ST. Drugs that require a coverage determination for Medicare Part B or Part D are designated with the abbreviation B/D. Limited Access drugs are designated with the abbreviation LA. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 8:00 a.m. to 8:00 p.m. in your local time zone, 7 days a week. (TTY/TDD users should call 711). Not available at mail-order is designated with the abbreviation NM. Gap coverage drugs are designated with the abbreviation GC. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Tier Indications The amount you pay for your prescriptions depends on the medication s tier. The TexanPlus formulary has 5 tiers. TexanPlus Benefit Design TexanPlus Classic (HMO) Copays Retail Mail Order Tier 30-day supply 90-day supply* 90-day supply Tier 1: Preferred Generic Drugs $0 $0 $0 Tier 2: Non-Preferred Generic Drugs $0 $0 $0 Tier 3: Preferred Brand Drugs $40 $100 $40 Tier 4: Non-Preferred Brand Drugs $80 $200 $80 Tier 5: Specialty Tier Drugs 33% Not Available Not Available *Available through select retail pharmacies. vi

8 ANALGESICS GOUT allopurinol tab 1 GC colchicine w/ probenecid 2 GC COLCRYS 3 QL (120 tabs / 30 probenecid 2 GC ULORIC 3 ST NSAIDS CELEBREX CAP 50MG 4 QL (60 caps / 30 CELEBREX CAP 100MG 4 QL (60 caps / 30 CELEBREX CAP 200MG 4 QL (60 caps / 30 CELEBREX CAP 400MG 4 QL (60 caps / 30 diclofenac potassium 2 GC diclofenac sodium TB24; TBEC 2 GC diflunisal 2 GC etodolac 2 GC etodolac er 2 GC flurbiprofen TABS 2 GC ibuprofen SUSP 2 GC ibuprofen TABS 400mg, 600mg 1 GC ibuprofen tab 800 mg 1 GC ketoprofen CAPS 2 GC MELOXICAM SUSP 2 GC meloxicam TABS 1 GC nabumetone TABS 2 GC naproxen SUSP 2 GC naproxen TABS; TBEC 1 GC naproxen sodium TABS 275mg, 550mg 1 GC piroxicam CAPS 2 GC sulindac TABS 1 GC OPIOID ANALGESICS acetaminophen w/ codeine SOLN 2 GC, QL (5000 ml / 30 acetaminophen w/ codeine TABS 2 GC, QL (400 tabs / 30 butorphanol tartrate SOLN 1mg/ml, 2 GC 2mg/ml hydroco/apap tab 5-325mg 2 GC, QL (360 tabs / 30 hydroco/apap tab GC, QL (360 tabs / 30 7

9 hydroco/apap tab mg 2 GC, QL (360 tabs / 30 hydrocodone-acetaminophen mg/15ml 2 GC, QL (5400 ml / 30 hydrocodone-ibuprofen tab mg 2 GC, QL (150 tabs / 30 tramadol hcl TABS 2 GC, QL (240 tabs / 30 tramadol-acetaminophen 2 GC, QL (240 tabs / 30 OPIOID ANALGESICS, CII DURAMORPH 2 GC, B/D endocet 2 GC, QL (360 tabs / 30 fentanyl 12mcg/hr, 25mcg/hr 2 GC, QL (10 patches / 30 fentanyl 50mcg/hr, 75mcg/hr, 100mcg/hr 2 GC, QL (10 patches / 30, PA fentanyl citrate LPOP 5 QL (120 lozenges / 30, PA hydromorphon inj 10mg/ml 2 GC, B/D hydromorphone hcl LIQD 2 GC hydromorphone hcl TABS 2 GC, QL (270 tabs / 30 LAZANDA SPR 100MCG 5 QL (30 bottles / 30, PA LAZANDA SPR 400MCG 5 QL (30 bottles / 30, PA methadone hcl CONC 2 GC, QL (120 ml / 30 methadone hcl SOLN 5mg/5ml, 10mg/5ml 2 GC, QL (600 ml / 30 methadone hcl TABS 2 GC, QL (240 tabs / 30 morphine ext-rel tab 15mg, 30mg, 60mg, 2 GC, QL (90 tabs / mg morphine ext-rel tab 200mg 2 GC, QL (60 tabs / 30 MORPHINE SUL INJ 1mg/ml, 4mg/ml, 2 GC, B/D 10mg/ml, 15mg/ml morphine sul inj.5mg/ml, 1mg/ml 2 GC, B/D morphine sulfate CP24 10mg, 20mg, 30mg, 50mg, 60mg 2 GC, QL (60 caps / 30 morphine sulfate CP24 80mg 5 QL (60 caps / 30 8

10 MORPHINE SULFATE SOLN 2mg/ml, 2 GC, B/D 8mg/ml MORPHINE SULFATE TABS 2 GC, QL (180 tabs / 30 morphine sulfate beads 2 GC, QL (60 caps / 30 morphine sulfate cap 100mg er 5 QL (60 caps / 30 MORPHINE SULFATE ORAL SOL 2 GC oxycodone hcl CAPS 2 GC, QL (180 caps / 30 OXYCODONE HCL CONC 2 GC oxycodone hcl SOLN 2 GC oxycodone hcl TABS 2 GC, QL (180 tabs / 30 oxycodone hcl tab 5 mg 2 GC, QL (180 tabs / 30 oxycodone w/ acetaminophen mg 2 GC, QL (360 tabs / 30 oxycodone w/ acetaminophen 5-325mg 2 GC, QL (360 tabs / 30 oxycodone w/ acetaminophen mg 2 GC, QL (360 tabs / 30 oxycodone w/ acetaminophen mg 2 GC, QL (360 tabs / 30 roxicet soln 3 QL (1800 ml / 30 days soln) roxicet tab 5-325mg 2 GC, QL (360 tabs / 30 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 GC, B/D lidocaine inj 0.5% 2 GC, B/D lidocaine inj 1% 2 GC, B/D lidocaine inj 1.5% 2 GC, B/D lidocaine inj 2% 2 GC, B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 GC gentamicin in saline 2 GC gentamicin sulfate SOLN 2 GC neomycin sulfate TABS 2 GC paromomycin sulfate CAPS 2 GC streptomycin sulfate SOLR 2 GC 9

11 sulfadiazine TABS 4 tobramycin NEBU 5 B/D, NM tobramycin sulfate SOLN; SOLR 2 GC tobramycin sulfate in saline 3 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 4 ALINIA 4 atovaquone SUSP 5 AZACTAM 4 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 5 aztreonam 2 GC BILTRICIDE 3 CAYSTON 5 NM, LA, PA clindamycin cap 75mg 1 GC clindamycin cap 300mg 1 GC clindamycin hcl cap 150 mg 1 GC clindamycin phosphate inj 2 GC clindamycin sol 75mg/5ml 2 GC colistimethate sodium SOLR 2 GC CUBICIN 5 B/D dapsone TABS 2 GC DARAPRIM 4 e.s.p. 2 GC ees/sulfisox sus GC imipenem-cilastatin 2 GC INVANZ 4 meropenem 2 GC methenamine hippurate 2 GC metronidazole TABS 1 GC metronidazole in nacl 2 GC NEBUPENT 4 B/D nitrofurantoin macrocrystal 4 PA; 90 day limit if >64 yr nitrofurantoin monohyd macro 4 PA; 90 day limit if >64 yr PENTAM sulfamethoxazole-trimethoprim 1 GC sulfamethoxazole-trimethoprim inj 2 GC SYNERCID 5 trimethoprim TABS 1 GC TYGACIL 5 10

12 vancomycin hcl CAPS 5 vancomycin hcl SOLR 2 GC, B/D ZYVOX 5 ANTIFUNGALS ABELCET 5 B/D AMBISOME 5 B/D amphotericin b SOLR 2 GC, B/D CANCIDAS 5 ERAXIS 5 fluconazole SUSR; TABS 2 GC fluconazole in dextrose 2 GC fluconazole in nacl 2 GC flucytosine CAPS 5 griseofulvin microsize 2 GC griseofulvin ultramicrosize 2 GC itraconazole CAPS 2 GC, PA ketoconazole TABS 2 GC, PA MYCAMINE 5 NOXAFIL SUSP; TBEC 5 nystatin TABS 2 GC terbinafine hcl TABS 1 GC, QL (90 tabs / 365 voriconazole SOLR 2 GC voriconazole SUSR; TABS 5 ANTIMALARIALS atovaquone-proguanil hcl 2 GC chloroquine phosphate TABS 2 GC COARTEM 3 mefloquine hcl 2 GC PRIMAQUINE PHOSPHATE 3 quinine sulfate CAPS 2 GC, PA ANTIRETROVIRAL AGENTS abacavir sulfate 2 GC APTIVUS 5 CRIXIVAN 4 didanosine 2 GC EDURANT 5 EMTRIVA 3 EPIVIR SOLN 3 FUZEON 5 NM INTELENCE 25mg 4 INTELENCE 100mg, 200mg 5 11

13 INVIRASE CAPS 4 INVIRASE TABS 5 ISENTRESS CHEW 25mg 3 ISENTRESS CHEW 100mg 5 ISENTRESS PACK 3 ISENTRESS TABS 5 lamivudine 150mg, 300mg 2 GC LEXIVA SUSP 4 LEXIVA TABS 5 NEVIRAPINE SUSP 2 GC nevirapine TABS; TB24 2 GC NORVIR 3 PREZISTA SUSP 5 PREZISTA TABS 75mg, 150mg 3 PREZISTA TABS 600mg, 800mg 5 RESCRIPTOR 4 RETROVIR IV INFUSION 3 REYATAZ 5 SELZENTRY 5 stavudine 2 GC SUSTIVA CAPS 3 SUSTIVA TABS 5 TIVICAY 5 VIDEX PEDIATRIC 4 VIRACEPT 5 VIRAMUNE XR 100mg 4 VIREAD 5 ZIAGEN SOLN 4 zidovudine 2 GC ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine 5 ATRIPLA 5 COMPLERA 5 EPZICOM 5 KALETRA SOL 5 KALETRA TAB MG 3 KALETRA TAB MG 5 lamivudine-zidovudine 5 STRIBILD 5 TRUVADA 5 QL (30 tabs / 30 ANTITUBERCULAR AGENTS CAPASTAT SULFATE 5 12

14 ethambutol hcl TABS 2 GC isoniazid TABS 1 GC isoniazid inj 100 mg/ml 2 GC isoniazid syp 50mg/5ml 2 GC paser d/r 3 PRIFTIN 4 pyrazinamide 2 GC rifabutin 2 GC rifampin CAPS; SOLR 2 GC RIFATER 4 SIRTURO 5 LA, PA TRECATOR 4 ANTIVIRALS acyclovir CAPS; TABS 1 GC acyclovir SUSP 2 GC acyclovir sodium SOLN 2 GC, B/D acyclovir sodium SOLR 1000mg 2 GC, B/D adefovir dipivoxil 5 BARACLUDE SOLN 3 BARACLUDE TABS 5 EPIVIR HBV SOLN 4 famciclovir TABS 2 GC foscarnet sodium 2 GC ganciclovir inj 500mg 2 GC, B/D lamivudine 100mg 2 GC moderiba 800 dose pack 5 NM, PA moderiba pak 600/day 5 NM, PA moderiba pak 1000/day 5 NM, PA moderiba pak 1200/day 5 NM, PA moderiba tab 200mg 2 GC, NM, PA OLYSIO 5 NM, PA REBETOL SOLN 5 NM, PA RELENZA DISKHALER 3 ribapak mis 600/day 5 NM, PA ribasphere CAPS 2 GC, NM, PA ribasphere TABS 200mg, 400mg 2 GC, NM, PA ribasphere TABS 600mg 5 NM, PA ribasphere ribapak NM, PA ribasphere ribapak NM, PA ribasphere ribapak NM, PA ribavirin 200mg 2 GC, NM, PA rimantadine hydrochloride 2 GC 13

15 SOVALDI 5 NM, PA TAMIFLU 3 TYZEKA 5 valacyclovir hcl TABS 2 GC VALCYTE 5 VICTRELIS 5 NM, PA CEPHALOSPORINS cefaclor 2 GC cefaclor monohydrate er 3 cefadroxil 2 GC cefazolin in d5w 3 cefazolin inj 2 GC cefazolin sodium 1gm, 20gm 2 GC cefdinir 2 GC cefepime hcl 2 GC cefotaxime sodium 2 GC cefoxitin sodium 2 GC cefpodoxime proxetil 2 GC cefprozil 2 GC ceftazidime 1gm, 2gm, 6gm 2 GC CEFTAZIDIME/DEXTROSE 4 ceftriaxone sodium SOLR 2 GC cefuroxime axetil TABS 1 GC cefuroxime sodium 1.5gm, 7.5gm, 750mg 2 GC cephalexin CAPS 250mg, 500mg 1 GC cephalexin SUSR 2 GC SUPRAX CAPS 3 suprax CHEW 4 suprax SUSR 100mg/5ml, 200mg/5ml 3 SUPRAX SUSR 500mg/5ml 3 suprax TABS 3 tazicef SOLR 2 GC tazicef vial 2 GC TEFLARO 4 ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 2 GC azithromycin SOLR 500mg 2 GC azithromycin SUSR 2 GC azithromycin TABS 250mg 1 GC azithromycin TABS 500mg, 600mg 2 GC clarithromycin TABS 2 GC clarithromycin er 2 GC 14

16 clarithromycin for susp 2 GC DIFICID 5 e.e.s. 2 GC e.e.s GC E.E.S. GRANULES 4 ery-tab 4 ERYPED ERYPED erythrocin lactobionate 500mg 4 erythrocin stearate 2 GC erythromycin base 2 GC erythromycin cap 250mg ec 2 GC ZMAX 3 FLUOROQUINOLONES ciprofloxacin SUSR 2 GC ciprofloxacin er 2 GC ciprofloxacin hcl tab 1 GC ciprofloxacin in d5w 2 GC ciprofloxacin inj 2 GC levofloxacin TABS 2 GC levofloxacin in d5w 2 GC levofloxacin inj 25mg/ml 2 GC levofloxacin oral soln 25 mg/ml 2 GC PENICILLINS amoxicillin 1 GC amoxicillin & pot clavulanate 2 GC ampicillin & sulbactam sodium 2 GC ampicillin cap 250 mg 1 GC ampicillin cap 500 mg 1 GC ampicillin for susp 125 mg/5ml 1 GC ampicillin for susp 250 mg/5ml 1 GC ampicillin inj 2 GC ampicillin sodium 2 GC BICILLIN L-A 4 dicloxacillin sodium 2 GC nafcillin sodium 1gm 2 GC nafcillin sodium 2gm, 10gm 5 oxacillin sodium 1gm, 2gm 2 GC oxacillin sodium 10gm 5 PENICILLIN G POT IN DEXTROSE 4 penicillin g potassium 2 GC penicillin g procaine 3 15

17 penicillin g sodium 2 GC penicillin v potassium 1 GC penicilln gk inj 5mu 2 GC piperacillin sodium-tazobactam sodium 2 GC TIMENTIN SOLR 4 TIMENTIN INJ 3.1GM 4 TETRACYCLINES doxycycline (monohydrate) CAPS 50mg, 2 GC 100mg doxycycline (monohydrate) TABS 2 GC doxycycline hyclate CAPS; SOLR; TABS 2 GC minocycline hcl CAPS 2 GC VIBRAMYCIN SYRP 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 4 B/D BUSULFEX 4 B/D cyclophosphamide SOLR; TABS 2 GC, B/D dacarbazine 200mg 2 GC, B/D EMCYT 4 HEXALEN 5 IFEX 3gm 4 B/D ifosfamide inj 1gm 2 GC, B/D ifosfamide inj 1gm/20ml 2 GC, B/D IFOSFAMIDE INJ 3GM 4 B/D ifosfamide inj 3gm/60ml 2 GC, B/D LEUKERAN 4 LOMUSTINE 2 GC melphalan hcl 5 B/D MUSTARGEN 4 B/D TREANDA 5 B/D, NM ANTHRACYCLINES adriamycin 50mg 2 GC, B/D adriamycin inj 20mg 2 GC, B/D daunorubicin hcl 2 GC, B/D daunorubicin hcl for inj 20 mg 2 GC, B/D doxorubicin hcl for inj 50 mg 2 GC, B/D doxorubicin hcl liposomal inj 2mg/ml 5 B/D doxorubicin inj 50mg 2 GC, B/D epirubicin hcl SOLN 2 GC, B/D idarubicin hcl 5 B/D ANTIBIOTICS 16

18 bleomycin sulfate 2 GC, B/D mitomycin SOLR 2 GC, B/D ANTIMETABOLITES adrucil 2 GC, B/D ALIMTA 5 B/D azacitidine 5 B/D, NM cladribine 5 B/D cytarabine SOLN 20mg/ml 2 GC, B/D cytarabine SOLR 100mg 2 GC, B/D fludarabine phosphate 2 GC, B/D fluorouracil SOLN 2 GC, B/D GEMCITABINE HCL SOLN 5 B/D gemcitabine hcl SOLR 5 B/D mercaptopurine TABS 2 GC methotrexate sodium inj 2 GC, B/D TABLOID 4 ANTIMITOTIC, TAXOIDS DOCETAXEL CONC 20mg/0.5ml, 20mg/ml, 5 B/D 80mg/4ml docetaxel CONC 140mg/7ml 5 B/D DOCETAXEL SOLN 80mg/8ml 5 B/D paclitaxel 2 GC, B/D TAXOTERE 80mg/2ml 5 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 3 B/D vincasar 2 GC, B/D vincristine sulfate 2 GC, B/D vinorelbine tartrate 2 GC, B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 B/D, NM ERIVEDGE 5 NM, LA, PA HERCEPTIN 5 B/D, NM ISTODAX 5 B/D, NM KADCYLA 5 B/D, NM PROLEUKIN 5 B/D, NM RITUXAN 5 NM, PA VELCADE 5 B/D, NM ZOLINZA 5 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 2 GC bicalutamide 2 GC DEPO-PROVERA INJ 400/ML 4 B/D 17

19 exemestane 2 GC FARESTON 5 FASLODEX 5 B/D flutamide 2 GC letrozole TABS 2 GC leuprolide acetate KIT 2 GC, NM, PA LUPR DEP-PED INJ 30MG (3-MONTH) 5 NM, PA LUPRON DEPOT 3.75mg 5 NM, PA LUPRON DEPOT INJ MG 5 NM, PA LUPRON DEPOT-PED 5 NM, PA LYSODREN 3 MEGACE ES 5 PA megestrol acetate SUSP; TABS 4 PA NILANDRON 5 SOLTAMOX 4 tamoxifen citrate TABS 1 GC TRELSTAR DEP INJ 3.75MG 5 NM, PA TRELSTAR LA INJ 11.25MG 5 NM, PA XTANDI 5 NM, LA, PA ZYTIGA 5 NM, PA KINASE INHIBITORS AFINITOR 5 NM, PA AFINITOR DISPERZ 5 NM, PA BOSULIF 5 NM, PA CAPRELSA 5 NM, LA, PA COMETRIQ 5 NM, PA GILOTRIF TAB 20MG 5 NM, LA, PA GILOTRIF TAB 30MG 5 NM, LA, PA GILOTRIF TAB 40MG 5 NM, LA, PA GLEEVEC 5 NM, PA ICLUSIG 5 NM, LA, PA IMBRUVICA CAP 140MG 5 NM, LA, PA INLYTA 5 NM, LA, PA JAKAFI 5 NM, LA, PA MEKINIST 5 NM, PA NEXAVAR 5 NM, LA, PA SPRYCEL 5 NM, PA STIVARGA 5 NM, LA, PA SUTENT 12.5mg, 25mg, 50mg 5 NM, PA SUTENT 37.5mg 5 PA TAFINLAR 5 NM, PA TARCEVA 5 NM, PA 18

20 TASIGNA 5 NM, PA TYKERB 5 NM, LA, PA VOTRIENT 5 NM, PA XALKORI 5 NM, LA, PA ZELBORAF 5 NM, LA, PA ZYKADIA 5 NM, LA, PA MISCELLANEOUS DROXIA 3 hydroxyurea CAPS 2 GC MATULANE 5 mitoxantrone hcl 2 GC, B/D, NM POMALYST CAP 1MG 5 NM, LA, PA POMALYST CAP 2MG 5 NM, LA, PA POMALYST CAP 3MG 5 NM, LA, PA POMALYST CAP 4MG 5 NM, LA, PA SYLATRON KIT 296MCG 5 NM, PA SYLATRON KIT 444MCG 5 NM, PA SYLATRON KIT 888MCG 5 NM, PA TARGRETIN CAPS 5 NM, PA tretinoin (chemotherapy) 5 TRISENOX 5 B/D PLATINUM-BASED AGENTS carboplatin SOLN 2 GC, B/D cisplatin 2 GC, B/D oxaliplatin 5 B/D PROTECTIVE AGENTS amifostine crystalline 5 B/D dexrazoxane 250mg 5 B/D ELITEK 5 B/D leucovorin calcium SOLR 2 GC, B/D leucovorin calcium TABS 2 GC leucovorin calcium for inj 500 mg 2 GC, B/D leucovorin calcium inj 10 mg/ml 2 GC, B/D mesna 2 GC, B/D MESNEX TABS 5 TOPOISOMERASE INHIBITORS etoposide SOLN 500mg/25ml 2 GC, B/D irinotecan hcl 5 B/D toposar 1gm/50ml 2 GC, B/D topotecan hcl SOLR 5 B/D CARDIOVASCULAR 19

21 ACE INHIBITOR COMBINATIONS amlodipine--benazepril hcl cap mg 1 GC, QL (30 caps / 30 amlodipine-benazepril hcl cap mg 1 GC, QL (30 caps / 30 amlodipine-benazepril hcl cap 5-10 mg 1 GC, QL (30 caps / 30 amlodipine-benazepril hcl cap 5-20 mg 1 GC, QL (30 caps / 30 amlodipine-benazepril hcl cap 5-40 mg 1 GC, QL (30 caps / 30 amlodipine-benazepril hcl cap 10-40mg 1 GC benazepril & hydrochlorothiazide 1 GC captopril & hydrochlorothiazide 1 GC enalapril maleate & hydrochlorothiazide 1 GC fosinopril sodium & hydrochlorothiazide 1 GC lisinopril & hydrochlorothiazide 1 GC moexipril-hydrochlorothiazide 1 GC quinapril-hydrochlorothiazide 1 GC ACE INHIBITORS benazepril hcl TABS 1 GC captopril TABS 1 GC enalapril maleate TABS 1 GC fosinopril sodium 1 GC lisinopril TABS 1 GC moexipril hcl 1 GC perindopril erbumine 1 GC quinapril hcl 1 GC ramipril 1 GC trandolapril 1 GC ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 2 GC spironolactone TABS 1 GC ALPHA BLOCKERS doxazosin mesylate 1mg, 2mg, 4mg 2 GC, QL (30 tabs / 30 doxazosin mesylate 8mg 2 GC prazosin hcl 1 GC terazosin hcl 1 GC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS AZOR 10-40MG 3 AZOR TAB 5-20MG 3 QL (30 tabs / 30 20

22 AZOR TAB 5-40MG 3 QL (30 tabs / 30 AZOR TAB 10-20MG 3 QL (30 tabs / 30 BENICAR HCT 40-25MG 3 BENICAR HCT TAB MG 3 QL (30 tabs / 30 BENICAR HCT TAB MG 3 QL (30 tabs / 30 EXFORGE HCT/5- TAB QL (30 tabs / 30 EXFORGE HCT/5- TAB QL (60 tabs / 30 EXFORGE HCT/10- TAB QL (30 tabs / 30 EXFORGE HCT/10- TAB QL (30 tabs / 30 EXFORGE HCT/10- TAB EXFORGE TAB 5-160MG 3 QL (30 tabs / 30 EXFORGE TAB 5-320MG 3 QL (30 tabs / 30 EXFORGE TAB MG 3 QL (30 tabs / 30 EXFORGE TAB MG 3 losartan-hctz mg 1 GC, QL (30 tabs / 30 losartan-hctz mg 1 GC, QL (30 tabs / 30 losartan-hctz mg 1 GC TRIBENZOR40- TAB 10-25MG 3 TRIBENZOR TAB MG 3 QL (30 tabs / 30 TRIBENZOR TAB MG 3 QL (30 tabs / 30 TRIBENZOR TAB MG 3 QL (30 tabs / 30 TRIBENZOR TAB QL (30 tabs / 30 valsartan & hctz tab mg 1 GC, QL (30 tabs / 30 valsartan & hctz tab mg 1 GC, QL (30 tabs / 30 valsartan & hctz tab mg 1 GC, QL (30 tabs / 30 valsartan & hctz tab mg 1 GC valsartan & hctz tab mg 1 GC ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg 3 QL (60 tabs / 30 BENICAR 20mg 3 QL (30 tabs / 30 BENICAR 40mg 3 DIOVAN 40mg, 80mg, 160mg 4 QL (60 tabs / 30 DIOVAN 320mg 4 losartan potassium 25mg, 50mg 1 GC, QL (60 tabs / 30 losartan potassium 100mg 1 GC valsartan 40mg, 80mg, 160mg 1 GC, QL (60 tabs / 30 21

23 valsartan 320mg 1 GC ANTIARRHYTHMICS amiodarone hcl SOLN 2 GC amiodarone hcl TABS 100mg, 400mg 2 GC amiodarone hcl TABS 200mg 1 GC disopyramide phosphate 4 PA flecainide acetate 2 GC mexiletine hcl 2 GC MULTAQ 4 NORPACE CR 4 PA pacerone 100mg, 400mg 2 GC pacerone 200mg 1 GC propafenone hcl 2 GC quinidine gluconate TBCR 2 GC quinidine sulfate TABS 1 GC sorine 2 GC sotalol hcl 2 GC sotalol hcl (afib/afl) 2 GC TIKOSYN 4 NM ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium 1 GC, QL (30 tabs / 30 CRESTOR 3 QL (30 tabs / 30 lovastatin 10mg 1 GC, QL (30 tabs / 30 lovastatin 20mg 1 GC, QL (120 tabs / 30 lovastatin 40mg 1 GC, QL (60 tabs / 30 pravastatin sodium 1 GC, QL (30 tabs / 30 simvastatin TABS 1 GC, QL (30 tabs / 30 ANTILIPEMICS, MISCELLANEOUS cholestyramine 2 GC cholestyramine light 2 GC choline fenofibrate 2 GC colestipol hcl 2 GC fenofibrate TABS 2 GC fenofibrate micronized 2 GC fenofibrate micronized cap 2 GC gemfibrozil TABS 2 GC 22

24 niacin (antihyperlipidemic) 500mg 2 GC, QL (90 tabs / 30 niacin (antihyperlipidemic) 750mg, 2 GC 1000mg niacor 2 GC omega-3-acid ethyl esters 2 GC prevalite 2 GC VASCEPA 4 WELCHOL 3 ZETIA TAB 10MG 3 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1 GC bisoprolol & hydrochlorothiazide 1 GC metoprolol & hctz tab 50-25mg 2 GC metoprolol & hctz tab mg 2 GC metoprolol & hctz tab mg 2 GC propranolol & hydrochlorothiazide 2 GC BETA-BLOCKERS acebutolol hcl CAPS 1 GC atenolol TABS 1 GC bisoprolol fumarate 2 GC BYSTOLIC 4 carvedilol 1 GC labetalol hcl TABS 2 GC metoprolol succinate 25mg, 50mg 2 GC, QL (60 tabs / 30 metoprolol succinate 100mg 2 GC, QL (45 tabs / 30 metoprolol succinate 200mg 2 GC metoprolol tartrate SOLN 2 GC metoprolol tartrate TABS 1 GC nadolol TABS 2 GC pindolol 2 GC propranolol cap er 2 GC propranolol hcl SOLN 2 GC propranolol hcl TABS 1 GC timolol maleate TABS 2 GC CALCIUM CHANNEL BLOCKERS afeditab cr 30mg 2 GC, QL (60 tabs / 30 afeditab cr 60mg 2 GC 23

25 amlodipine besylate TABS 2.5mg, 5mg 1 GC, QL (45 tabs / 30 amlodipine besylate TABS 10mg 1 GC cartia xt cap 120/24hr 2 GC cartia xt cap 180/24hr 2 GC cartia xt cap 240/24hr 2 GC cartia xt cap 300/24hr 2 GC dilt-cd cap 2 GC dilt-xr cap 2 GC diltiazem cap 2 GC diltiazem cap 120mg/24hr 2 GC diltiazem cap er/12hr 2 GC diltiazem hcl SOLN 2 GC diltiazem hcl TABS 1 GC diltiazem hcl coated beads CP24 2 GC diltzac 2 GC felodipine 2.5mg 2 GC, QL (30 tabs / 30 felodipine 5mg 2 GC, QL (60 tabs / 30 felodipine 10mg 2 GC isradipine 2 GC nicardipine hcl CAPS 2 GC nifedical 30mg 2 GC, QL (30 tabs / 30 nifedical 60mg 2 GC nifedipine TB24 30mg 2 GC, QL (60 tabs / 30 nifedipine TB24 60mg, 90mg 2 GC nifedipine er 30mg 2 GC, QL (30 tabs / 30 nifedipine er 60mg, 90mg 2 GC nimodipine CAPS 2 GC NYMALIZE 5 taztia 2 GC verapamil cap er 100mg, 120mg, 180mg, 2 GC 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg 2 GC verapamil hcl SOLN 2 GC verapamil hcl TABS 1 GC verapamil tab er 2 GC DIGITALIS GLYCOSIDES digoxin SOLN 2 GC 24

26 digoxin TABS 125mcg 2 GC, QL (30 tabs / 30 digoxin TABS 250mcg 2 GC, PA DIGOXIN SOL 50MCG/ML 2 GC, PA LANOXIN TABS 125mcg 3 QL (30 tabs / 30 LANOXIN TABS 250mcg 3 PA DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE TAB QL (30 tabs / 30 AMTURNIDE TAB QL (30 tabs / 30 AMTURNIDE TAB MG 3 QL (30 tabs / 30 AMTURNIDE TAB QL (30 tabs / 30 AMTURNIDE TAB MG 3 TEKAMLO MG 3 TEKAMLO TAB 150-5MG 3 QL (30 tabs / 30 TEKAMLO TAB MG 3 QL (30 tabs / 30 TEKAMLO TAB 300-5MG 3 QL (30 tabs / 30 TEKTURNA 150mg 3 QL (30 tabs / 30 TEKTURNA 300mg 3 TEKTURNA HCT TAB MG 3 QL (30 tabs / 30 TEKTURNA HCT TAB MG 3 QL (60 tabs / 30 TEKTURNA HCT TAB MG 3 QL (30 tabs / 30 TEKTURNA HCT TAB MG 3 DIURETICS acetazolamide CP12; TABS 2 GC amiloride & hydrochlorothiazide 1 GC amiloride hcl 2 GC bumetanide SOLN 2 GC bumetanide TABS 1 GC chlorothiazide 1 GC chlorthalidone 25mg, 50mg 1 GC DIURIL SUS 250/5ML 3 DYRENIUM 4 EDECRIN 4 furosemide SOLN 8mg/ml 2 GC furosemide SOLN 10mg/ml 1 GC furosemide TABS 1 GC furosemide inj 2 GC hydrochlorothiazide CAPS; TABS 1 GC indapamide 1 GC methazolamide TABS 2 GC methyclothiazide 2 GC metolazone 2 GC 25

27 spironolactone & hydrochlorothiazide 1 GC torsemide inj 2 GC torsemide tabs 1 GC triamterene & hydrochlorothiazide TABS 1 GC triamterene & hydrochlorothiazide cap 1 GC mg MISCELLANEOUS clonidine hcl PTWK 2 GC clonidine hcl TABS 1 GC DEMSER 5 hydralazine hcl 2 GC midodrine hcl 2 GC minoxidil TABS 2 GC RANEXA 3 NITRATES isosorb mononitrate tab 1 GC isosorbide dinitrate 2 GC isosorbide mononitrate er tab 1 GC minitran 2 GC nitro-bid 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin PT24 2 GC NITROLINGUAL PUMPSPRAY 3 NITROSTAT 3 PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 QL (60 tabs / 30, NM, PA ADEMPAS 5 QL (90 tabs / 30, NM, PA LETAIRIS 5 QL (30 tabs / 30, NM, LA, PA REMODULIN 5 B/D, NM, LA sildenafil citrate (pulmonary hypertension) 5 QL (90 tabs / 30, NM, PA TRACLEER 62.5mg 5 QL (120 tabs / 30, NM, LA, PA TRACLEER 125mg 5 QL (60 tabs / 30, NM, LA, PA CENTRAL NERVOUS SYSTEM ANTIANXIETY 26

28 alprazolam CONC 2 GC, QL (300 ml / 30 alprazolam tab 0.5mg 1 GC, QL (240 tabs / 30 alprazolam tab 0.25mg 1 GC, QL (480 tabs / 30 alprazolam tab 1mg 1 GC, QL (120 tabs / 30 alprazolam tab 2mg 1 GC, QL (150 tabs / 30 buspirone hcl TABS 2 GC fluvoxamine maleate TABS 25mg, 50mg 2 GC, QL (45 tabs / 30 fluvoxamine maleate TABS 100mg 2 GC lorazepam CONC 2 GC, QL (150 ml / 30 lorazepam SOLN 2 GC lorazepam TABS 1 GC, QL (150 tabs / 30 ANTICONVULSANTS APTIOM 200mg 4 QL (180 tabs / 30 APTIOM 400mg 4 QL (90 tabs / 30 APTIOM 600mg 4 QL (60 tabs / 30 APTIOM 800mg 4 QL (30 tabs / 30 BANZEL SUS 40MG/ML 5 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 5 PA carbamazepine CHEW; TABS 1 GC carbamazepine CP12; SUSP; TB12 2 GC CELONTIN 4 clonazepam TABS 1mg 1 GC, QL (600 tabs / 30 clonazepam TABS 2mg 1 GC, QL (300 tabs / 30 clonazepam TABS.5mg 1 GC, QL (1200 tabs / 30 clonazepam TBDP 1mg 2 GC, QL (600 tabs / 30 clonazepam TBDP 2mg 2 GC, QL (300 tabs / 30 clonazepam TBDP.5mg 2 GC, QL (1200 tabs / 30 clonazepam TBDP.25mg 2 GC, QL (2400 tabs / 30 27

29 clonazepam TBDP.125mg 2 GC, QL (4800 tabs / 30 clorazepate dipotassium 3.75mg, 7.5mg 2 GC, QL (120 tabs / 30, PA clorazepate dipotassium 15mg 2 GC, QL (180 tabs / 30, PA diazepam CONC 2 GC, QL (240 ml / 30, PA diazepam SOLN 2 GC, QL (1200 ml / 30, PA diazepam TABS 1 GC, QL (120 tabs / 30, PA DIAZEPAM GEL 2 GC diazepam inj 2 GC dilantin 3 DILANTIN-125 SUS 125/5ML 3 divalproex sodium 2 GC epitol 1 GC ethosuximide CAPS; SOLN 2 GC felbamate SUSP 5 felbamate TABS 400mg 2 GC felbamate TABS 600mg 5 FYCOMPA 2mg 4 QL (180 tabs / 30, PA FYCOMPA 4mg 4 QL (90 tabs / 30, PA FYCOMPA 6mg 4 QL (60 tabs / 30, PA FYCOMPA 8mg, 10mg, 12mg 4 QL (30 tabs / 30, PA gabapentin CAPS 100mg 1 GC, QL (1080 caps / 30 gabapentin CAPS 300mg 1 GC, QL (360 caps / 30 gabapentin CAPS 400mg 1 GC, QL (270 caps / 30 gabapentin SOLN 2 GC, QL (2160 ml / 30 gabapentin TABS 600mg 2 GC, QL (180 tabs / 30 gabapentin TABS 800mg 2 GC, QL (120 tabs / 30 GABITRIL 12mg, 16mg 4 lamotrigine CHEW; TB24 2 GC 28

30 lamotrigine TABS 1 GC levetiracetam SOLN; TABS; TB24 2 GC LYRICA CAPS 25mg, 50mg, 75mg, 3 QL (120 caps / mg, 150mg LYRICA CAPS 200mg 3 QL (90 caps / 30 LYRICA CAPS 225mg, 300mg 3 QL (60 caps / 30 LYRICA SOLN 3 QL (946 ml / 30 ONFI 4 PA oxcarbazepine 2 GC PEGANONE 4 phenobarbital ELIX; TABS 4 PA PHENOBARBITAL SODIUM 65mg/ml 4 PA phenobarbital sodium 130mg/ml 4 PA phenytek 3 phenytoin CHEW; SUSP 2 GC phenytoin sodium SOLN 2 GC phenytoin sodium extended 2 GC POTIGA 50mg 4 POTIGA 200mg 4 QL (180 tabs / 30 POTIGA 300mg, 400mg 4 QL (90 tabs / 30 primidone TABS 2 GC SABRIL PACK 5 QL (180 packets / 30, NM, LA, PA SABRIL TABS 5 QL (180 tabs / 30, NM, LA, PA TEGRETOL 4 TEGRETOL-XR 4 tiagabine hcl 2 GC topiramate CPSP; TABS 2 GC valproate sodium SOLN; SYRP 2 GC valproic acid CAPS 2 GC VIMPAT SOLN 10mg/ml 4 QL (1200 ml / 30 VIMPAT SOLN 200mg/20ml 4 VIMPAT TABS 50mg 4 QL (180 tabs / 30 VIMPAT TABS 100mg, 150mg, 200mg 4 QL (60 tabs / 30 zonisamide 2 GC ANTIDEMENTIA donepezil hydrochloride TABS 5mg 2 GC, QL (30 tabs / 30 donepezil hydrochloride TABS 10mg, 2 GC 23mg donepezil hydrochloride TBDP 5mg 2 GC, QL (30 tabs / 30 29

31 donepezil hydrochloride TBDP 10mg 2 GC EXELON PATCHES 4 QL (30 patches / 30 galantamine hydrobromide CP24 8mg, 16mg 2 GC, QL (30 caps / 30 galantamine hydrobromide CP24 24mg 2 GC galantamine hydrobromide SOLN 2 GC galantamine hydrobromide TABS 4mg 2 GC, QL (180 tabs / 30 galantamine hydrobromide TABS 8mg 2 GC, QL (90 tabs / 30 galantamine hydrobromide TABS 12mg 2 GC NAMENDA SOL 10MG/5ML 3 PA; PA if <30 yr NAMENDA XR 7mg, 14mg 4 QL (30 caps / 30, PA; PA if <30 yr NAMENDA XR 21mg, 28mg 4 PA; PA if <30 yr NAMENDA XR TITRATION PACK 4 PA; PA if <30 yr rivastigmine tartrate 2 GC ANTIDEPRESSANTS amitriptyline hcl TABS 4 PA amoxapine tab 25mg 2 GC amoxapine tab 50mg 2 GC amoxapine tab 100mg 2 GC amoxapine tab 150mg 2 GC BRINTELLIX 5mg 4 QL (120 tabs / 30 BRINTELLIX 10mg 4 QL (60 tabs / 30 BRINTELLIX 20mg 4 QL (30 tabs / 30 bupropion hcl TABS 2 GC bupropion hcl TB12 2 GC bupropion hcl TB24 150mg 2 GC, QL (90 tabs / 30 bupropion hcl TB24 300mg 2 GC, QL (30 tabs / 30 citalopram hydrobromide SOLN 2 GC citalopram hydrobromide TABS 10mg, 20mg 1 GC, QL (45 tabs / 30 citalopram hydrobromide TABS 40mg 1 GC, QL (30 tabs / 30 clomipramine hcl CAPS 4 PA desipramine hcl TABS 2 GC doxepin hcl CAPS; CONC 4 PA duloxetine hcl CPEP 2 GC, QL (60 caps / 30 30

32 EMSAM 5 QL (30 patches / 30, PA escitalopram oxalate SOLN 2 GC, QL (600 ml / 30 escitalopram oxalate TABS 5mg, 10mg 2 GC, QL (45 tabs / 30 escitalopram oxalate TABS 20mg 2 GC, QL (60 tabs / 30 FETZIMA 20mg 4 QL (180 caps / 30 FETZIMA 40mg 4 QL (90 caps / 30 FETZIMA 80mg, 120mg 4 QL (30 caps / 30 FETZIMA TITRATION PACK 4 fluoxetine hcl CAPS 10mg 1 GC, QL (30 caps / 30 fluoxetine hcl CAPS 20mg 1 GC, QL (120 caps / 30 fluoxetine hcl CAPS 40mg 1 GC fluoxetine hcl SOLN 2 GC fluoxetine hcl TABS 10mg 1 GC, QL (45 tabs / 30 fluoxetine hcl TABS 20mg 1 GC imipramine hcl TABS 4 PA maprotiline hcl 2 GC MARPLAN TAB 10MG 4 QL (180 tabs / 30 mirtazapine TABS 7.5mg 2 GC, QL (45 tabs / 30 mirtazapine TABS 15mg 1 GC, QL (45 tabs / 30 mirtazapine TABS 30mg, 45mg 1 GC mirtazapine TBDP 15mg 2 GC, QL (30 tabs / 30 mirtazapine TBDP 30mg, 45mg 2 GC nefazodone hcl 2 GC nortriptyline hcl CAPS 1 GC nortriptyline hcl SOLN 2 GC paroxetine hcl TABS 10mg, 20mg, 40mg 1 GC, QL (45 tabs / 30 paroxetine hcl TABS 30mg 1 GC, QL (60 tabs / 30 PAXIL SUSP 4 QL (900 ml / 30 phenelzine sulfate TABS 2 GC PRISTIQ 3 QL (30 tabs / 30 protriptyline hcl 2 GC sertraline hcl CONC 2 GC 31

33 sertraline hcl TABS 25mg, 50mg 1 GC, QL (45 tabs / 30 sertraline hcl TABS 100mg 1 GC SURMONTIL CAP 25MG 4 QL (240 caps / 30, PA SURMONTIL CAP 50MG 4 QL (120 caps / 30, PA SURMONTIL CAP 100MG 4 QL (60 caps / 30, PA tranylcypromine sulfate 2 GC trazodone hcl TABS 50mg, 100mg, 150mg 1 GC venlafaxine hcl CP mg, 75mg 2 GC, QL (30 caps / 30 venlafaxine hcl CP24 150mg 2 GC, QL (60 caps / 30 venlafaxine hcl TABS 2 GC VIIBRYD KIT 4 VIIBRYD TABS 4 QL (30 tabs / 30 ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS 2 GC APOKYN 5 NM, LA, PA AZILECT 3 benztropine mesylate SOLN 2 GC benztropine mesylate TABS 4 PA bromocriptine mesylate CAPS; TABS 2 GC carbidopa-levodopa 2 GC CARBIDOPA/LEVODOPA/ENTACAPONE 2 GC entacapone 2 GC NEUPRO 4 pramipexole dihydrochloride 2 GC ropinirole hydrochloride TABS 2 GC selegiline hcl CAPS; TABS 2 GC ANTIPSYCHOTICS ABILIFY SOLN 1mg/ml 5 QL (900 ml / 30 ABILIFY SOLN 9.75mg/1.3ml 4 QL (4 ml / 1 day) ABILIFY TABS 5 QL (30 tabs / 30 ABILIFY DISCMELT 5 QL (60 tabs / 30 ABILIFY MAIN INJ 300MG 5 QL (1 vial / 28 ABILIFY MAIN INJ 400MG 5 QL (1 vial / 28 chlorpromazine hcl SOLN 4 chlorpromazine hcl TABS 2 GC clozapine TABS 25mg, 50mg 2 GC 32

34 clozapine TABS 100mg 2 GC, QL (270 tabs / 30 clozapine TABS 200mg 2 GC, QL (135 tabs / 30 CLOZAPINE TBDP 12.5mg, 25mg 2 GC, PA CLOZAPINE TBDP 100mg 2 GC, QL (270 tabs / 30, PA FANAPT 4 QL (60 tabs / 30, ST FANAPT TITRATION PACK 4 ST FAZACLO TAB 12.5/ODT 4 PA FAZACLO TAB 25MG ODT 4 PA FAZACLO TAB 100/ODT 4 QL (270 tabs / 30, PA FAZACLO TAB 150MG 4 QL (180 tabs / 30, PA FAZACLO TAB 200MG 4 QL (135 tabs / 30, PA fluphenazine decanoate SOLN 2 GC fluphenazine hcl 2 GC GEODON SOLR 4 QL (6 ml / 3 haloperidol TABS 2 GC haloperidol decanoate SOLN 2 GC haloperidol lactate 2 GC haloperidol lactate oral conc 2 mg/ml 2 GC INVEGA 1.5mg, 3mg, 9mg 5 QL (30 tabs / 30 INVEGA 6mg 5 QL (60 tabs / 30 INVEGA SUST INJ 39 MG/0.25 ML 4 QL (1 injection / 28 INVEGA SUST INJ 78 MG/0.5 ML 5 QL (1 injection / 28 INVEGA SUST INJ 117 MG/0.75 ML 5 QL (1 injection / 28 INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 28 INVEGA SUST INJ 234 MG/1.5 ML 5 QL (1 injection / 28 LATUDA 20mg 5 QL (240 tabs / 30 LATUDA 40mg, 120mg 5 QL (30 tabs / 30 LATUDA 60mg, 80mg 5 QL (60 tabs / 30 loxapine succinate 2 GC olanzapine SOLR 2 GC, QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 7.5mg 2 GC, QL (30 tabs / 30 33

35 olanzapine TABS 10mg, 15mg, 20mg 2 GC, QL (60 tabs / 30 olanzapine TBDP 5mg 2 GC, QL (30 tabs / 30 olanzapine TBDP 10mg, 15mg 2 GC, QL (60 tabs / 30 olanzapine TBDP 20mg 5 QL (60 tabs / 30 ORAP 4 perphenazine TABS 2 GC quetiapine fumarate 2 GC, QL (90 tabs / 30 RISPERDAL INJ 12.5MG 4 QL (2 injections / 28 RISPERDAL INJ 25MG 4 QL (2 injections / 28 RISPERDAL INJ 37.5MG 5 QL (2 injections / 28 RISPERDAL INJ 50MG 5 QL (2 injections / 28 risperidone SOLN 2 GC, QL (240 ml / 30 risperidone TABS 1mg, 2mg, 3mg 2 GC, QL (60 tabs / 30 risperidone TABS 4mg 2 GC, QL (120 tabs / 30 risperidone TABS.25mg,.5mg 2 GC, QL (90 tabs / 30 risperidone TBDP 1mg, 2mg, 3mg 2 GC, QL (60 tabs / 30 risperidone TBDP 4mg 2 GC, QL (120 tabs / 30 risperidone TBDP.25mg,.5mg 2 GC, QL (90 tabs / 30 SAPHRIS 5mg 4 QL (120 tabs / 30 SAPHRIS 10mg 4 QL (60 tabs / 30 SEROQUEL XR 50mg 4 QL (120 tabs / 30 SEROQUEL XR 150mg, 200mg 4 QL (30 tabs / 30 SEROQUEL XR 300mg, 400mg 4 QL (60 tabs / 30 thioridazine hcl TABS 4 PA thiothixene 2 GC trifluoperazine hcl 2 GC VERSACLOZ 5 QL (600 ml / 30, PA 34

36 ziprasidone hcl 20mg, 40mg 2 GC, QL (60 caps / 30 ziprasidone hcl 60mg, 80mg 2 GC, QL (90 caps / 30 ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg 2 GC, QL (90 caps / 30 amphetamine-dextroamphetamine cap sr 24hr 10 mg 2 GC, QL (90 caps / 30 amphetamine-dextroamphetamine cap sr 24hr 15 mg 2 GC, QL (30 caps / 30 amphetamine-dextroamphetamine cap sr 24hr 20 mg 2 GC, QL (30 caps / 30 amphetamine-dextroamphetamine cap sr 24hr 25 mg 2 GC, QL (30 caps / 30 amphetamine-dextroamphetamine cap sr 24hr 30 mg 2 GC, QL (30 caps / 30 amphetamine-dextroamphetamine tab 5 mg 2 GC, QL (360 tabs / 30 amphetamine-dextroamphetamine tab GC, QL (240 tabs / 30 mg amphetamine-dextroamphetamine tab 10 mg 2 GC, QL (180 tabs / 30 amphetamine-dextroamphetamine tab 12.5 mg 2 GC, QL (144 tabs / 30 amphetamine-dextroamphetamine tab 15 mg 2 GC, QL (120 tabs / 30 amphetamine-dextroamphetamine tab 20 mg 2 GC, QL (90 tabs / 30 amphetamine-dextroamphetamine tab 30 mg 2 GC, QL (60 tabs / 30 INTUNIV 4 metadate tab 20mg er 2 GC, QL (90 tabs / 30 methylphenidate hcl TABS 5mg, 10mg 2 GC, QL (180 tabs / 30 methylphenidate hcl TABS 20mg 2 GC, QL (90 tabs / 30 methylphenidate hcl TBCR 10mg, 20mg 2 GC, QL (90 tabs / 30 methylphenidate hcl oral soln 5mg/5ml 2 GC, QL (1800 ml / 30 methylphenidate hcl oral soln 10mg/5ml 2 GC, QL (900 ml / 30 35

37 STRATTERA 10mg, 18mg, 25mg 4 QL (120 caps / 30 STRATTERA 40mg 4 QL (60 caps / 30 STRATTERA 60mg, 80mg, 100mg 4 QL (30 caps / 30 HYPNOTICS ROZEREM 4 QL (30 tabs / 30 SILENOR 3mg 3 QL (60 tabs / 30 SILENOR 6mg 3 QL (30 tabs / 30 temazepam 7.5mg 2 GC, QL (30 caps / 30, PA; 90 day limit if >64 yr temazepam 15mg 2 GC, QL (60 caps / 30, PA; 90 day limit if >64 yr zolpidem tartrate TABS 4 QL (30 tabs / 30, PA; 90 day limit if >64 yr MIGRAINE cafergot 4 dihydroergotamine mesylate 2 GC naratriptan hcl 2 GC, QL (9 tabs / 30 RELPAX 3 QL (12 tabs / 30 rizatriptan benzoate 2 GC, QL (18 tabs / 30 SUMATRIPTAN SOLN 5mg/act 2 GC, QL (24 inhalers / 30 SUMATRIPTAN SOLN 20mg/act 2 GC, QL (12 inhalers / 30 SUMATRIPTAN SUCCINATE SOCT 2 GC, QL (6 ml / 30 sumatriptan succinate SOSY 2 GC, QL (6 ml / 30 sumatriptan succinate TABS 2 GC, QL (9 tabs / 30 SUMATRIPTAN SUCCINATE INJ SOAJ 4mg/0.5ml 2 GC, QL (6 ml / 30 sumatriptan succinate inj SOAJ 6mg/0.5ml 2 GC, QL (6 ml / 30 SUMATRIPTAN SUCCINATE INJ SOCT 2 GC, QL (6 ml / 30 sumatriptan succinate inj SOLN 2 GC, QL (6 ml / 30 zolmitriptan TABS 2 GC, QL (12 tabs / 30 zolmitriptan odt 2 GC, QL (12 tabs / 30 MISCELLANEOUS lithium carbonate CAPS; TABS 1 GC 36

38 lithium carbonate er 2 GC LITHIUM CITRATE 3 NUEDEXTA 3 PA pyridostigmine bromide TABS 2 GC riluzole 2 GC XENAZINE 12.5mg 5 QL (240 tabs / 30, NM, LA, PA XENAZINE 25mg 5 QL (120 tabs / 30, NM, LA, PA MULTIPLE SCLEROSIS AGENTS BETASERON 5 QL (14 syringes / 28, NM, PA COPAXONE INJ 40MG/ML 5 QL (12 syringes / 28, NM, PA COPAXONE KIT 20MG/ML 5 QL (1 kit / 30, NM, PA GILENYA CAP 0.5MG 5 QL (28 caps / 28, NM, PA TYSABRI 5 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1 GC cyclobenzaprine hcl TABS 5mg, 10mg 4 PA dantrolene sodium CAPS 2 GC tizanidine hcl TABS 2 GC NARCOLEPSY/CATAPLEXY NUVIGIL 50mg 4 QL (150 tabs / 30, PA NUVIGIL 150mg 4 QL (60 tabs / 30, PA NUVIGIL 200mg, 250mg 4 QL (30 tabs / 30, PA XYREM 5 QL (540 ml / 30, LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 GC buprenorphine hcl SUBL 2 GC, PA buprenorphine hcl-naloxone hcl sl 2 GC, QL (120 tabs / 30, PA buproban 2 GC CHANTIX 4 PA CHANTIX STARTER PACK 4 PA disulfiram TABS 2 GC naloxone hcl SOLN 2 GC 37

39 naltrexone hcl TABS 2 GC NICOTROL INHALER 4 NICOTROL NS 4 SUBOXONE MIS 2-0.5MG 4 QL (4 boxes / 30, PA SUBOXONE MIS 4-1MG 4 QL (4 boxes / 30, PA SUBOXONE MIS 8-2MG 4 QL (4 boxes / 30, PA SUBOXONE MIS 12-3MG 4 QL (2 boxes / 30, PA ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 4 QL (30 patches / 30, PA androxy 4 PA oxandrolone TABS 2 GC, PA TESTIM 3 QL (300 grams / 30, PA testosterone cypionate OIL 2 GC testosterone enanthate OIL 2 GC ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 3 GAUZE PADS 2" X 2" 3 HUMULIN R INJ U B/D INSULIN PEN NEEDLE 2 INSULIN SAFETY NEEDLES 2 INSULIN SYRINGE 2 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXPEN 3 NOVOLIN 70/30 3 RELION not covered NOVOLIN N 3 RELION not covered NOVOLIN R 3 RELION not covered NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG MIX 70/30 PREFILL 3 NOVOLOG PENFILL 3 SYMLINPEN 60 4 QL (8 pens / 30, PA 38

40 SYMLINPEN QL (4 pens / 30, PA VICTOZA 3 QL (3 pens / 30 ANTIDIABETICS, ORAL acarbose 2 GC glimepiride 1mg 1 GC, QL (240 tabs / 30 glimepiride 2mg 1 GC, QL (120 tabs / 30 glimepiride 4mg 1 GC, QL (60 tabs / 30 glip/metform tab 5-500mg 1 GC, QL (120 tabs / 30 glipizide TABS 5mg 1 GC, QL (240 tabs / 30 glipizide TABS 10mg 1 GC, QL (120 tabs / 30 glipizide TB24 2.5mg 1 GC, QL (240 tabs / 30 glipizide TB24 5mg 1 GC, QL (120 tabs / 30 glipizide TB24 10mg 1 GC, QL (60 tabs / 30 glipizide-metformin hcl tab mg 1 GC, QL (240 tabs / 30 glipizide-metformin hcl tab mg 1 GC, QL (120 tabs / 30 INVOKANA 100mg 3 QL (90 tabs / 30 INVOKANA 300mg 3 QL (30 tabs / 30 JANUMET 3 QL (60 tabs / 30 JANUMET XR TAB MG 3 QL (60 tabs / 30 JANUMET XR TAB QL (60 tabs / 30 JANUMET XR TAB QL (30 tabs / 30 JANUVIA 3 QL (30 tabs / 30 JENTADUETO 3 QL (60 tabs / 30 metformin hcl TABS 500mg 1 GC, QL (150 tabs / 30 metformin hcl TABS 850mg 1 GC, QL (90 tabs / 30 metformin hcl TABS 1000mg 1 GC, QL (75 tabs / 30 metformin hcl TB24 500mg 1 GC, QL (120 tabs / 30 39

41 metformin hcl TB24 750mg 1 GC, QL (60 tabs / 30 nateglinide 1 GC, QL (90 tabs / 30 pioglitazone hcl 1 GC, QL (30 tabs / 30 repaglinide 2mg 1 GC, QL (240 tabs / 30 repaglinide.5mg, 1mg 1 GC, QL (120 tabs / 30 RIOMET 4 QL (946 ml / 30 TRADJENTA 3 QL (30 tabs / 30 BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg 1 GC alendronate sodium TABS 35mg, 70mg 1 GC, QL (4 tabs / 28 alendronate sodium TABS 40mg 2 GC ibandronate sodium TABS 2 GC, B/D, QL (1 tab / 30 pamidronate disodium SOLN 2 GC, B/D zoledronic inj 4mg/5ml 5 B/D, NM ZOMETA SOLN 5 B/D, NM CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 3 QL (120 tabs / 30, NM SENSIPAR 60mg 5 QL (60 tabs / 30, NM SENSIPAR 90mg 5 QL (120 tabs / 30, NM CHELATING AGENTS CHEMET 4 DEPEN TITRATABS 5 EXJADE 5 NM, LA, PA kionex 2 GC sodium polystyrene sulfonate 2 GC sps susp 15gm/60ml 2 GC SYPRINE 5 CONTRACEPTIVES altavera 2 GC apri 28 day 2 GC aranelle 28 2 GC aviane 28 2 GC balziva 28 day 2 GC 40

42 briellyn 28 day 2 GC camila 28 day 2 GC cryselle 28 2 GC cyclafem 1/35 28 day 2 GC cyclafem 7/7/7 28 day 2 GC drospirenone-ethinyl estradiol 2 GC ELLA 3 emoquette 2 GC enpresse 28 day 2 GC errin 28 day 2 GC GIANVI 2 GC gildagia 2 GC heather 2 GC introvale 91 day 2 GC JOLIVETTE 2 GC junel 1.5/30 21 day 2 GC junel 1/20 21 day 2 GC junel fe 1.5/30 28 day 2 GC junel fe 1/20 28 day 2 GC kariva 28 day 2 GC larin 1/20 2 GC larin fe 1.5/30 2 GC larin fe 1/20 2 GC LEENA 2 GC lessina 28 day 2 GC levonest 28 day 2 GC levonorgestrel (emergency oc) 2 GC levonorgestrel-ethinyl estradiol (91-day) 2 GC levora 0.15/30 28 day 2 GC loryna 28 day 2 GC low-ogestrel 28 day 2 GC lutera 28 day 2 GC lyza 2 GC marlissa 28 day 2 GC medroxyprogesterone acetate 150 mg/ml 2 GC microgestin 1.5/30 21 day 2 GC microgestin 1/20 21 day 2 GC microgestin fe 1.5/30 28 day 2 GC microgestin fe 1/20 28 day 2 GC MONONESSA 2 GC my way 2 GC myzilra 2 GC 41

43 necon 0.5/35 28 day 2 GC necon 1/35 28 day 2 GC NECON 7/7/7 2 GC necon 10/11 28 day 3 NECON TAB 1/ GC next choice one dose 2 GC NORA-BE TAB 2 GC norethindrone (contraceptive) 2 GC norgestimate-ethinyl estradiol (triphasic) 2 GC nortrel 0.5/35 28 day 2 GC nortrel 1/35 21 day 2 GC nortrel 1/35 28 day 2 GC nortrel 7/7/7 28 day 2 GC NUVARING 4 OCELLA TAB MG 2 GC orsythia 28 day 2 GC philith 2 GC pimtrea pack 2 GC pirmella 1/35 28 day 2 GC portia 28 day 2 GC previfem 28 day 2 GC quasense 91 day 2 GC reclipsen 28 day 2 GC SOLIA 2 GC sprintec 28 day 2 GC sronyx 2 GC tri-legest 28 day 2 GC tri-previfem 28 day 2 GC tri-sprintec 28 day 2 GC TRINESSA 2 GC trivora 28 day 2 GC velivet 28 day 2 GC vestura 2 GC viorele 2 GC vyfemia 28 day 2 GC xulane 2 GC zarah 2 GC zenchent 28 day 2 GC ENDOMETRIOSIS danazol CAPS 2 GC SYNAREL 5 ENZYME REPLACEMENTS 42

44 ADAGEN 5 NM, LA, PA ALDURAZYME 5 NM, LA, PA CARBAGLU 5 NM, LA, PA CEREZYME 5 NM, PA CYSTADANE 5 NM CYSTAGON 4 NM, PA FABRAZYME 5 NM, PA KUVAN 5 NM, PA levocarnitine (metabolic modifiers) 2 GC, B/D LUMIZYME 5 NM, PA MYOZYME 5 NM, PA NAGLAZYME 5 NM, LA, PA ORFADIN 5 NM, PA sodium phenylbutyrate 5 NM ZAVESCA 5 NM, LA, PA ESTROGENS COMBIPATCH 4 PA estradiol PTWK; TABS 4 PA ESTRADIOL VALERATE OIL 10mg/ml, 2 GC 40mg/ml estradiol valerate OIL 20mg/ml 2 GC PREMARIN CREAM 4 VAGIFEM 4 GLUCOCORTICOIDS a-hydrocort 2 GC cortisone acetate TABS 2 GC dexamethasone CONC; ELIX; SOLN 2 GC dexamethasone TABS 1 GC dexamethasone sodium phosphate 2 GC fludrocortisone acetate TABS 2 GC hydrocortisone TABS 2 GC methylpr ace inj 40mg/ml 2 GC, B/D methylpr ace inj 80mg/ml 2 GC, B/D methylpr ss inj 1gm 2 GC, B/D methylpr ss inj 40mg 2 GC, B/D methylpr ss inj 125mg 2 GC, B/D methylpr ss inj 500mg 2 GC, B/D methylpred pak 4mg 2 GC, B/D methylpred tab 4mg 2 GC, B/D methylpred tab 8mg 2 GC, B/D methylpred tab 16mg 2 GC, B/D methylpred tab 32mg 2 GC, B/D 43

45 pred sod pho sol 5mg/5ml 2 GC, B/D prednisolone sol 15mg/5ml 2 GC, B/D prednisolone sol 25mg/5ml 1 GC, B/D prednisolone syp 15mg/5ml 1 GC, B/D prednisone con 5mg/ml 3 B/D prednisone pak 5mg 1 GC, B/D prednisone pak 10mg 1 GC, B/D prednisone sol 5mg/5ml 2 GC, B/D prednisone tab 1mg 1 GC, B/D prednisone tab 2.5mg 1 GC, B/D prednisone tab 5mg 1 GC, B/D prednisone tab 10mg 1 GC, B/D prednisone tab 20mg 1 GC, B/D prednisone tab 50mg 1 GC, B/D SOLU-CORTEF 250mg 3 GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 3 PROGLYCEM SUS 50MG/ML 4 HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO 5 NM, PA NORDITROPIN NORDIFLEX PEN 5 NM, PA TEV-TROPIN 5 NM, PA MISCELLANEOUS cabergoline 2 GC calcitonin (salmon) 2 GC FORTICAL 3 INCRELEX 5 NM, LA, PA methylergonovine maleate TABS 2 GC MIACALCIN 200unit/ml 4 B/D octreotide acetate 50mcg/ml, 100mcg/ml, 2 GC, NM, PA 200mcg/ml octreotide acetate 500mcg/ml, 5 NM, PA 1000mcg/ml PROLIA 4 QL (1 syringe / 180, NM raloxifene hcl 2 GC SANDOSTATIN LAR DEPOT 5 NM, PA SOMATULINE DEPOT 5 NM, PA SOMAVERT 5 NM, LA, PA XGEVA 5 NM, PA PARATHYROID HORMONES 44

46 FORTEO 5 QL (1 pen / 28, NM, PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) 2 GC FOSRENOL 5 PHOSLYRA 3 RENVELA PAK 0.8GM 5 RENVELA PAK 2.4GM 5 RENVELA TAB 800MG 3 PROGESTINS medroxyprogesterone acetate tab 1 GC norethindrone acetate TABS 2 GC THYROID AGENTS levothyroxine sodium TABS 1 GC LEVOXYL 1 GC liothyronine sodium TABS 2 GC methimazole TABS 1 GC propylthiouracil TABS 2 GC SYNTHROID 4 UNITHROID 1 GC VASOPRESSINS desmopressin acetate spray 2 GC desmopressin acetate spray refrigerated 2 GC desmopressin acetate tabs 2 GC desmopressin inj 4mcg/ml 2 GC DESMOPRESSIN SOL 0.01% 2 GC GASTROINTESTINAL ANTIEMETICS compro 2 GC dronabinol 2.5mg, 5mg 2 GC, B/D, QL (60 caps / 30 dronabinol 10mg 5 B/D, QL (60 caps / 30 EMEND CAP 40MG 4 PA EMEND CAP 80MG 4 B/D EMEND CAP 125MG 4 B/D EMEND PAK 80 & B/D granisetron hcl SOLN 2 GC granisetron hcl TABS 2 GC, B/D meclizine hcl TABS 2 GC metoclopramide hcl SOLN; TABS 1 GC metoclopramide inj 2 GC 45

47 ondansetron hcl SOLN 2 GC ondansetron hcl TABS 2 GC, B/D ondansetron hcl inj 2 GC ondansetron hcl oral soln 2 GC, B/D ondansetron odt 2 GC, B/D prochlorperazine inj 2 GC prochlorperazine maleate TABS 1 GC prochlorperazine supp 2 GC promethazine hcl SOLN 25mg/ml, 4 PA 50mg/ml TRANSDERM-SCOP 4 QL (10 patches / 30, PA ANTISPASMODICS CUVPOSA 4 dicyclomine hcl CAPS; TABS 1 GC dicyclomine hcl SOLN 2 GC glycopyrrolate TABS 2 GC glycopyrrolate inj 2 GC H2-RECEPTOR ANTAGONISTS famotidine SOLN 40mg/4ml, 200mg/20ml 2 GC famotidine SUSR 2 GC famotidine TABS 20mg, 40mg 1 GC famotidine inj 2 GC ranitidine hcl SOLN 2 GC ranitidine hcl TABS 150mg, 300mg 1 GC ranitidine hcl inj 2 GC ranitidine syrup 2 GC INFLAMMATORY BOWEL DISEASE APRISO 3 ASACOL HD 4 balsalazide disodium 2 GC budesonide ec 5 CANASA 4 colocort enema 100mg 2 GC DELZICOL 4 DIPENTUM 5 HYDROCORTISONE (INTRARECTAL) 2 GC LIALDA 4 mesalamine enema 2 GC mesalamine w/ cleanser 2 GC PENTASA 4 sulfasalazine TABS 2 GC 46

48 sulfasalazine ec 2 GC UCERIS 5 LAXATIVES constulose 2 GC enulose 2 GC gaviltye-g 1 GC gavilyte-c 1 GC gavilyte-n 2 GC generlac 2 GC GOLYTELY 3 lactulose 2 GC lactulose (encephalopathy) 2 GC MOVIPREP 4 NULYTELY/FLAVOR PACKS 3 peg 3350-kcl-sod bicarb-sod chloride-sod 1 GC sulfate peg 3350-potassium chloride-sod 2 GC bicarbonate-sod chloride PEG 3350/ELECTROLYTES 1 GC polyethylene glycol 3350 PACK; POWD 2 GC RELISTOR 4 PA SUPREP BOWEL PREP 4 trilyte 2 GC MISCELLANEOUS AMITIZA CAP 8MCG 3 QL (60 caps / 30 AMITIZA CAP 24MCG 3 QL (60 caps / 30 cromolyn sodium (mastocytosis) 5 diphenoxylate w/ atropine LIQD 2 GC diphenoxylate w/ atropine TABS 1 GC LINZESS CAP 145MCG 3 QL (60 caps / 30 LINZESS CAP 290MCG 3 QL (30 caps / 30 loperamide hcl CAPS 1 GC LOTRONEX 5 PA misoprostol TABS 2 GC SUCRAID 5 sucralfate TABS 2 GC ursodiol CAPS; TABS 2 GC XIFAXAN 550mg 5 PA PANCREATIC ENZYMES CREON 3 ZENPEP 4 PROTON PUMP INHIBITORS 47

49 DEXILANT 3 QL (30 caps / 30 esomeprazole sodium 2 GC NEXIUM CAP 4 QL (30 caps / 30 NEXIUM GRA 2.5MG DR 4 NEXIUM GRA 5MG DR 4 NEXIUM GRA 10MG DR 4 QL (30 packets / 30 NEXIUM GRA 20MG DR 4 QL (30 packets / 30 NEXIUM GRA 40MG DR 4 QL (30 packets / 30 omeprazole CPDR 10mg, 40mg 1 GC, QL (30 caps / 30 omeprazole CPDR 20mg 1 GC, QL (60 caps / 30 pantoprazole sodium TBEC 2 GC, QL (30 tabs / 30 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 2 GC, QL (30 tabs / 30 AVODART 3 QL (30 caps / 30 finasteride TABS 5mg 2 GC JALYN 3 QL (30 caps / 30 tamsulosin hcl 2 GC, QL (60 caps / 30 MISCELLANEOUS bethanechol chloride TABS 2 GC ELMIRON 4 POTASSIUM CITRATE (ALKALINIZER) 2 GC URINARY ANTISPASMODICS MYRBETRIQ 25mg 4 QL (60 tabs / 30 MYRBETRIQ 50mg 4 QL (30 tabs / 30 oxybutynin chloride SYRP 1 GC oxybutynin chloride TABS 2 GC oxybutynin chloride TB24 5mg 2 GC, QL (30 tabs / 30 oxybutynin chloride TB24 10mg, 15mg 2 GC, QL (60 tabs / 30 TOLTERODINE TARTRATE CAP ER 2 GC, QL (30 caps / 30 tolterodine tartrate tabs 2 GC TOVIAZ 3 QL (30 tabs / 30 48

50 trospium chloride TABS 2 GC, QL (60 tabs / 30 VESICARE 4 QL (30 tabs / 30 VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal 2 GC metronidazole vaginal 2 GC terconazole vaginal 2 GC VANDAZOLE 2 GC zazole.4% 2 GC ZAZOLE.8% 2 GC HEMATOLOGIC ANTICOAGULANTS COUMADIN 4 ELIQUIS 3 enoxaparin sodium 30mg/0.3ml, 2 GC 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 5 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml 2 GC fondaparinux sodium 5mg/0.4ml, 5 7.5mg/0.6ml, 10mg/0.8ml heparin sod inj 1000/ml 2 GC, B/D HEPARIN SOD INJ 2000/ML 3 B/D HEPARIN SOD INJ 2500/ML 3 B/D heparin sod inj 5000/ml 2 GC, B/D heparin sod inj 10000/ml 2 GC, B/D heparin sod inj 20000/ml 2 GC, B/D HEPARIN SODIUM/D5W 3 HEPARIN SODIUM/NACL 0.45% 3 HEPARIN SODIUM/SODIUM CHL 3 jantoven 1 GC PRADAXA 3 warfarin sodium 1 GC XARELTO 3 HEMATOPOIETIC GROWTH FACTORS GRANIX 5 NM, PA LEUKINE 5 NM, PA MOZOBIL 5 NM, PA NEUMEGA 5 NM NEUPOGEN 5 NM, PA 49

51 PROCRIT 2000unit/ml, 3000unit/ml, 3 NM, PA 4000unit/ml, 10000unit/ml PROCRIT 20000unit/ml, 40000unit/ml 5 NM, PA MISCELLANEOUS anagrelide hcl 2 GC cilostazol 2 GC CINRYZE 5 NM, LA, PA FIRAZYR 5 NM, PA pentoxifylline TBCR 2 GC PROMACTA 12.5mg 5 QL (240 tabs / 30, NM, LA, PA PROMACTA 25mg 5 QL (120 tabs / 30, NM, LA, PA PROMACTA 50mg 5 QL (60 tabs / 30, NM, LA, PA PROMACTA 75mg 5 QL (30 tabs / 30, NM, LA, PA tranexamic acid SOLN; TABS 2 GC PLATELET AGGREGATION INHIBITORS AGGRENOX 4 BRILINTA 4 clopidogrel bisulfate 75mg 2 GC, QL (30 tabs / 30 EFFIENT 4 IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA 5 NM, PA CIMZIA STARTER KIT 5 NM, PA HUMIRA 5 NM, PA HUMIRA KIT 40MG/0.8 5 NM, PA HUMIRA PEN 5 NM, PA HUMIRA PEN-CROHNS DISEASE 5 NM, PA HUMIRA PEN-PSORIASIS STAR 5 NM, PA hydroxychloroquine sulfate 1 GC leflunomide TABS 2 GC methotrexate sodium tabs 2 GC REMICADE 5 NM, PA IMMUNOGLOBULINS BIVIGAM 10gm/100ml 5 NM, PA CARIMUNE NANOFILTERED 5 NM, PA FLEBOGAMMA 5 NM, PA FLEBOGAMMA DIF 5 NM, PA 50

52 GAMASTAN S/D 3 B/D, NM GAMMAGARD LIQUID 5 NM, PA GAMMAGARD S/D 5 NM, PA GAMMAKED 5 NM, PA GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 5 NM, PA 10gm/200ml GAMUNEX-C 5 NM, PA GAMUNEX-C 1GM/10ML 5 NM, PA OCTAGAM 5 NM, PA PRIVIGEN 5 NM, PA IMMUNOMODULATORS ACTIMMUNE 5 NM, LA, PA ARCALYST 5 NM, PA INTRON-A INJ 10MU 5 B/D, NM INTRON-A INJ 18MU 5 B/D, NM INTRON-A INJ 25MU 5 B/D, NM INTRON-A INJ 50MU 5 B/D, NM PEG-INTRON 5 NM, PA PEG-INTRON REDIPEN 5 NM, PA REVLIMID 5 NM, LA, PA THALOMID 5 NM, PA IMMUNOSUPPRESSANTS azathioprine TABS 2 GC, B/D CELLCEPT SUSR 5 B/D cyclosporine CAPS; SOLN 2 GC, B/D cyclosporine modified (for microemulsion) 2 GC, B/D gengraf 2 GC, B/D mycophenolate mofetil 2 GC, B/D mycophenolate sodium 180mg 2 GC, B/D mycophenolate sodium 360mg 5 B/D NEORAL 3 B/D NULOJIX 5 B/D PROGRAF CAPS 5mg 5 B/D PROGRAF CAPS.5mg, 1mg 4 B/D RAPAMUNE SOLN 5 B/D RAPAMUNE TABS 1mg, 2mg 5 B/D SANDIMMUNE CAPS 3 B/D SANDIMMUNE SOLN 100mg/ml 3 B/D sirolimus TABS 2 GC, B/D tacrolimus CAPS 5mg 5 B/D tacrolimus CAPS.5mg, 1mg 2 GC, B/D ZORTRESS TAB 0.5MG 5 B/D 51

53 ZORTRESS TAB 0.25MG 4 B/D ZORTRESS TAB 0.75MG 5 B/D VACCINES ACTHIB 3 ADACEL 3 BCG VACCINE 3 BOOSTRIX 3 CERVARIX 3 COMVAX 3 DAPTACEL 3 DIPHTHERIA/TETANUS TOXOID 3 B/D ENGERIX-B SUSP 3 B/D GARDASIL 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II W/DILUENT 10 DOS 3 MENACTRA 3 MENOMUNE-A/C/Y/W MENVEO 3 PEDVAX HIB 3 PROQUAD 3 RABAVERT 3 RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ 3 SYNAGIS 5 TENIVAC 3 B/D TETANUS TOXOID ADSORBED 3 B/D TETANUS/DIPHTHERIA TOXOID 3 B/D TWINRIX INJ 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3 QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON 8 2 GC 52

54 KLOR-CON 10 2 GC klor-con m15 2 GC klor-con m20 2 GC klor-con pow 20meq 2 GC MAGNESIUM SULFATE SOLN 3 MAGNESIUM SULFATE IN D5W 3 magnesium sulfate inj 50% 2 GC potassium chloride CPCR 2 GC potassium chloride LIQD 1 GC POTASSIUM CHLORIDE TBCR 2 GC POTASSIUM CHLORIDE ER 2 GC potassium chloride microencapsulated 2 GC crystals cr SODIUM CHLORIDE SOLN 2.5meq/ml 2 GC SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 2 GC F) MG/ML SOLN TPN ELECTROLYTES 4 B/D IV NUTRITION AMINOSYN 4 B/D AMINOSYN 7%/ELECTROLYTES 4 B/D AMINOSYN 8.5%/ELECTROLYTE 4 B/D AMINOSYN II 4 B/D AMINOSYN II 8.5%/ELECTROL 4 B/D AMINOSYN M 4 B/D AMINOSYN-HBC 4 B/D AMINOSYN-PF 4 B/D AMINOSYN-PF 7% 4 B/D AMINOSYN-RF 4 B/D CLINIMIX 2.75%/DEXTROSE 5% 4 B/D CLINIMIX 4.25%/DEXTROSE 5% 4 B/D CLINIMIX 4.25%/DEXTROSE 25% 4 B/D CLINIMIX 5%/DEXTROSE 15% 4 B/D CLINIMIX 5%/DEXTROSE 20% 4 B/D CLINIMIX 5%/DEXTROSE 25% 4 B/D CLINIMIX INJ 4.25/D10 4 B/D CLINIMIX INJ 4.25/D20 4 B/D FREAMINE HBC 6.9% 4 B/D FREAMINE III 4 B/D HEPATAMINE 4 B/D hepatasol 8 2 GC, B/D INTRALIPID INJ 20% 3 B/D INTRALIPID INJ 30% 3 B/D 53

55 NEPHRAMINE 4 B/D premasol sol 6% 2 GC, B/D premasol sol 10% 4 B/D PROCALAMINE 4 B/D PROSOL 4 B/D travasol 10 4 B/D TROPHAMINE INJ 10% 4 B/D IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45% 2 GC DEXTROSE 5% 2 GC DEXTROSE 5% /ELECTROLYTE 3 DEXTROSE 5%/LACTATED RING 2 GC DEXTROSE 5%/NACL 0.2% 2 GC DEXTROSE 5%/NACL 0.3% 2 GC DEXTROSE 5%/NACL 0.9% 2 GC DEXTROSE 5%/NACL 0.33% 2 GC DEXTROSE 5%/NACL 0.45% 2 GC DEXTROSE 5%/NACL 0.225% 2 GC DEXTROSE 5%/POTASSIUM CHL 2 GC DEXTROSE 10% FLEX CONTAIN 2 GC DEXTROSE 10%/NACL 0.2% 3 DEXTROSE 10%/NACL 0.45% 2 GC DEXTROSE 50% 2 GC dextrose inj 70% 2 GC IONOSOL-B/DEXTROSE 5% 4 IONOSOL-MB/DEXTROSE 5% 4 ISOLYTE P 4 isolyte s 4 KCL0.15%/D5W/NACL0.2% 2 GC KCL0.15%/D5W/NACL0.225% 3 KCL 0.3%/D5W/NACL 0.9% 2 GC KCL 0.3%/D5W/NACL 0.45% 2 GC KCL 0.15%/D5W/NACL 0.9% 2 GC KCL 0.075%/D5W/NACL 0.45% 2 GC KCL/D5W INJ 0.3% 2 GC KCL/NACL INJ GC LACTATED RINGER'S INJ 1 GC normosol-m 2 GC NORMOSOL-R 4 NORMOSOL-R IN D5W 4 PLASMA-LYTE A 4 PLASMA-LYTE-56/D5W 4 54

56 PLASMA-LYTE POTASSIUM CHLORIDE SOLN 2 GC 10meq/100ml, 20meq/100ml potassium chloride SOLN.4meq/ml, 2 GC 2meq/ml, 10meq/50ml, 40meq/100ml POTASSIUM CHLORIDE 0.15% 2 GC POTASSIUM CHLORIDE 0.22% 2 GC potassium chloride in nacl 2 GC RINGER'S 2 GC SODIUM CHLORIDE SOLN 3%, 5% 2 GC SODIUM CHLORIDE 0.45% VIA 2 GC SODIUM CHLORIDE INJ 0.9% 2 GC VITAMINS calcitriol CAPS 2 GC, B/D calcitriol inj 2 GC, B/D calcitriol oral soln 1 mcg/ml 2 GC, B/D paricalcitol 2 GC, B/D PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 2 GC (GENERIC) OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 GC blephamide OINT 4 neomycin-polymy-dexameth 2 GC neomycin-polymyxin-hc (ophth) 2 GC sulfacetamide sod-prednisolone 2 GC TOBRADEX OINT 3 TOBRADEX ST 3 tobramycin-dexamethasone 2 GC ZYLET 3 ANTI-INFECTIVES bacitracin (ophthalmic) 2 GC bacitracin-polymyxin b (ophth) 2 GC BESIVANCE 3 CILOXAN OINT 3 ciprofloxacin hcl (ophth) 2 GC erythromycin (ophth) 1 GC gatifloxacin (ophth) 2 GC gentak 2 GC gentamicin sulfate (ophth) OINT 2 GC gentamicin sulfate (ophth) SOLN 1 GC MOXEZA 3 55

57 NATACYN 4 neomycin-bacitracin zn-polymyxin 2 GC neomycin-polymy-gramicid 2 GC ofloxacin (ophth) 1 GC polymyxin b-trimethoprim 1 GC sulfacetamide sodium (ophth) OINT 2 GC sulfacetamide sodium (ophth) SOLN 1 GC tobramycin sulfate (ophth) 1 GC TOBREX OINT 4 trifluridine SOLN 2 GC VIGAMOX 3 ANTI-INFLAMMATORIES ALREX 3 BROMFENAC SODIUM (OPHTH)(ONCE- DAILY) 2 GC dexamethasone sodium phosphate (ophth) 2 GC diclofenac sodium (ophth) 2 GC DUREZOL 3 FLUOROMETHOLONE 2 GC flurbiprofen sodium 1 GC ILEVRO 3 ketorolac tromethamine (ophth) 2 GC LOTEMAX 3 MAXIDEX 3 NEVANAC 3 PREDNISOLONE ACETATE (OPHTH) 2 GC prednisolone sodium phosphate (ophth) 3 ANTIALLERGICS azelastine hcl (ophth) 2 GC BEPREVE 3 cromolyn sodium (ophth) 1 GC LASTACAFT 4 PATADAY 3 PATANOL 3 ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 AZOPT 3 betaxolol hcl (ophth) 2 GC BETOPTIC-S 3 brimonidine sol 0.2% 1 GC BRIMONIDINE SOL 0.15% 2 GC carteolol hcl (ophth) 1 GC 56

58 COMBIGAN 3 dorzolamide hcl 2 GC dorzolamide hcl-timolol maleate 2 GC ISTALOL 3 latanoprost 2 GC levobunolol hcl.5% 2 GC LEVOBUNOLOL HCL.25% 2 GC LUMIGAN 3 metipranolol 2 GC PHOSPHOLINE IODIDE 3 PILOCARPINE HCL SOLN 2 GC SIMBRINZA 3 timolol maleate (ophth) 1 GC TIMOLOL MALEATE GEL 2 GC TRAVATAN Z 3 MISCELLANEOUS naphazoline 0.1% 1 GC PROLENSA 3 proparacaine hcl SOLN 1 GC RESTASIS 3 QL (64 vials / 30 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA 3 QL (1 inhaler / 30 COMBIVENT RESPIMAT 4 QL (2 inhalers / 30 ipratropium-albuterol nebu 2 GC, B/D ANTICHOLINERGICS ATROVENT HFA 4 QL (2 inhalers / 30 ipratropium bromide SOLN 2 GC, B/D ipratropium bromide (nasal) 2 GC SPIRIVA HANDIHALER 3 QL (30 caps / 30 TUDORZA PRESSAIR 3 QL (1 inhaler / 30 ANTIHISTAMINES ASTEPRO 3 azelastine hcl SOLN 2 GC azelastine spr 0.1% 2 GC cetirizine syrup 2 GC diphenhydramine inj 2 GC hydroxyzine hcl SOLN 25mg/ml, 50mg/ml 4 PA levocetirizine dihydrochloride 2 GC PATANASE 3 57

59 BETA AGONISTS albuterol sulfate NEBU 2 GC, B/D albuterol sulfate SYRP 1 GC albuterol sulfate TABS; TB12 2 GC FORADIL AEROLIZER 3 QL (60 caps / 30 levalbuterol conc 1.25mg/0.5ml 2 GC, B/D PERFOROMIST 4 B/D PROAIR HFA 3 QL (2 inhalers / 30 SEREVENT DISKUS 3 QL (1 inhaler / 30 terbutaline sulfate SOLN; TABS 2 GC XOPENEX HFA 3 QL (2 inhalers / 30 LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; PACK; TABS 2 GC zafirlukast 2 GC MAST CELL STABILIZERS cromolyn sodium nebu 2 GC, B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% 2 GC, B/D ARALAST NP 5 NM, LA, PA AUVI-Q 3 DALIRESP 4 EPIPEN 2-PAK 3 EPIPEN-JR 2-PAK 3 PROLASTIN-C 5 NM, LA, PA PULMOZYME 5 B/D, NM XOLAIR 5 NM, LA, PA ZEMAIRA 5 NM, LA, PA NASAL STEROIDS flunisolide (nasal) 2 GC, QL (2 bottles / 30 fluticasone propionate (nasal) 2 GC, QL (1 bottle / 30 NASONEX 4 QL (2 bottles / 30 STEROID INHALANTS ASMANEX 14 METERED DOSES 3 QL (2 inhalers / 30 ASMANEX 30 METERED DOSES 3 QL (2 inhalers / 30 ASMANEX 60 METERED DOSES 3 QL (2 inhalers / 30 58

60 ASMANEX 120 METERED DOSES 3 QL (2 inhalers / 30 budesonide (inhalation) 2 GC, B/D FLOVENT DISKUS 50mcg/blist, 100mcg/blist 3 QL (2 inhalers / 30 FLOVENT DISKUS 250mcg/blist 3 QL (4 inhalers / 30 FLOVENT HFA 3 QL (2 inhalers / 30 QVAR 40mcg/act 3 QL (1 inhaler / 30 QVAR 80mcg/act 3 QL (2 inhalers / 30 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 3 QL (1 inhaler / 30 ADVAIR HFA 3 QL (1 inhaler / 30 BREO ELLIPTA 3 QL (1 inhaler / 30 DULERA 4 QL (1 inhaler / 30 SYMBICORT 3 QL (1 inhaler / 30 XANTHINES aminophylline inj 2 GC elixophyllin 4 theo-24 4 theophylline SOLN; TB24 2 GC theophylline TB12 1 GC TOPICAL DERMATOLOGY, ACNE adapalene CREA 2 GC adapalene GEL.1% 2 GC amnesteem 2 GC AVITA 2 GC benzoyl peroxide-erythromycin 2 GC claravis 2 GC clindamycin phosphate (topical) GEL; 2 GC LOTN; SOLN; SWAB ery pad 2% 2 GC erythromycin (acne aid) 2 GC myorisan 2 GC sulfacetamide sodium (acne) 2 GC tretinoin CREA; GEL 2 GC zenatane 2 GC DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) 1 GC 59

61 mafenide acetate PACK 2 GC mupirocin OINT 1 GC SILVER SULFADIAZINE CREA 2 GC SSD 2 GC SULFAMYLON CREA 4 DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; GEL; SUSP 2 GC ciclopirox shampoo 1% 2 GC clotrimazole (topical) CREA 2 GC clotrimazole (topical) SOLN 1 GC econazole nitrate CREA 2 GC ketoconazole cream 2 GC nyamyc 2 GC nystatin (topical) 2 GC nystop 2 GC pedi-dri 2 GC DERMATOLOGY, ANTIPRURITIC procto-pak 2 GC proctozone hc 1 GC PRUDOXIN CRE 5% 2 GC DERMATOLOGY, ANTIPSORIATICS acitretin 5 PA calcipotriene CREA; OINT; SOLN 2 GC calcitrene oin 0.005% 2 GC 8-MOP 4 TAZORAC CREA 4 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 GC selenium sulfide LOTN 1 GC DERMATOLOGY, ANTIVIRALS acyclovir topical 2 GC DENAVIR 4 DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 GC alclometasone dipropionate 2 GC amcinonide CREA; LOTN 2 GC amcinonide OINT 4 betamethasone dipropionate (topical) 2 GC betamethasone dipropionate augmented 2 GC betamethasone valerate CREA; LOTN; OINT 2 GC 60

62 clobetasol propionate CREA 2 GC clobetasol propionate GEL 2 GC clobetasol propionate OINT 2 GC clobetasol propionate SOLN 2 GC DESONIDE CREA 2 GC desonide LOTN; OINT 2 GC desoximetasone CREA 2 GC desoximetasone GEL 2 GC DESOXIMETASONE OINT.05% 2 GC desoximetasone OINT.25% 2 GC diflorasone diacetate 2 GC fluocinolone acetonide CREA; OIL; OINT; 2 GC SOLN fluocinonide CREA.05% 2 GC fluocinonide GEL 2 GC fluocinonide OINT 2 GC fluocinonide SOLN 2 GC fluocinonide emulsified base 2 GC fluticasone propionate CREA 2 GC fluticasone propionate OINT 2 GC halobetasol propionate 2 GC hydrocortisone (topical) CREA; OINT 1 GC hydrocortisone (topical) LOTN 2 GC hydrocortisone butyrate 2 GC hydrocortisone valerate 2 GC LOKARA LOTN 0.05% 2 GC mometasone furoate CREA; OINT; SOLN 2 GC texacort soln 2.5% 4 triamcinolone acetonide (topical) CREA; 1 GC OINT triamcinolone acetonide (topical) LOTN 2 GC triderm 1 GC DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH 2 GC, QL (3 patches / 1 day), PA lidocaine hcl GEL 2 GC lidocaine hcl SOLN 4% 1 GC lidocaine oint 5% 2 GC lidocaine-prilocaine 2 GC, B/D DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN 2 GC ELIDEL 4 PA 61

63 fluorouracil (topical) 2 GC imiquimod CREA 2 GC laclotion lotn 12% 2 GC metronidazole (topical) CREA; LOTN 2 GC metronidazole gel 0.75% 2 GC PANRETIN 5 podofilox SOLN 2 GC rosadan cre 0.75% 2 GC TARGRETIN GEL 5 NM, PA VALCHLOR 5 NM, LA, PA VOLTAREN 3 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 4 malathion 2 GC permethrin CREA 2 GC DERMATOLOGY, WOUND CARE AGENTS acetic acid.25% 1 GC REGRANEX 5 PA SANTYL 4 SODIUM CHLORIDE 0.9% 1 GC STERILE WATER IRRIGATION 2 GC MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 2 GC chlorhexidine gluconate (mouth-throat) 1 GC clotrimazole TROC 2 GC lidocaine hcl (mouth-throat) 1 GC nystatin (mouth-throat) 2 GC periogard 1 GC pilocarpine hcl (oral) 2 GC triamcinolone acetonide (mouth) 2 GC OTIC acetic acid (otic) 2 GC acetic acid-aluminum acetate 2 GC CIPRODEX 3 fluocinolone acetonide (otic) 2 GC neomycin-polymyxin-hc (otic) 2 GC ofloxacin (otic) 2 GC 62

64 Index 8 8-MOP A abacavir sulfate abacavir sulfate-lamivudine-zidovudine12 ABELCET ABILIFY ABILIFY DISCMELT ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG acamprosate calcium acarbose acebutolol hcl acetaminophen w/ codeine... 7 acetazolamide acetic acid acetic acid (otic) acetic acid-aluminum acetate acetylcysteine acitretin ACTHIB ACTIMMUNE acyclovir acyclovir sodium acyclovir topical ADACEL ADAGEN adapalene ADCIRCA adefovir dipivoxil ADEMPAS adriamycin adriamycin inj 20mg adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX a-hydrocort ala-cort ALBENZA albuterol sulfate alclometasone dipropionate ALCOHOL SWABS ALDURAZYME alendronate sodium alfuzosin hcl ALIMTA ALINIA allopurinol tab... 7 ALPHAGAN P SOL 0.1% alprazolam alprazolam tab 0.25mg alprazolam tab 0.5mg alprazolam tab 1mg alprazolam tab 2mg ALREX altavera amantadine hcl AMBISOME amcinonide amifostine crystalline amikacin sulfate... 9 amiloride & hydrochlorothiazide amiloride hcl aminophylline inj AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTE AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF amiodarone hcl AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl amlodipine besylate amlodipine--benazepril hcl cap mg amlodipine-benazepril hcl cap 10-40mg amlodipine-benazepril hcl cap mg 63

65 amlodipine-benazepril hcl cap 5-10 mg 20 amlodipine-benazepril hcl cap 5-20 mg 20 amlodipine-benazepril hcl cap 5-40 mg 20 ammonium lactate amnesteem amoxapine tab 100mg amoxapine tab 150mg amoxapine tab 25mg amoxapine tab 50mg amoxicillin amoxicillin & pot clavulanate amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg amphetamine-dextroamphetamine cap sr 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 ampicillin & sulbactam sodium ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin inj ampicillin sodium AMTURNIDE TAB AMTURNIDE TAB AMTURNIDE TAB MG AMTURNIDE TAB AMTURNIDE TAB MG anagrelide hcl anastrozole ANDRODERM androxy ANORO ELLIPTA APOKYN apri 28 day APRISO APTIOM APTIVUS ARALAST NP aranelle ARCALYST ASACOL HD ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASTEPRO atenolol atenolol & chlorthalidone atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA ATROVENT HFA AUVI-Q AVASTIN aviane AVITA AVODART azacitidine AZACTAM AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM azathioprine azelastine hcl azelastine hcl (ophth) azelastine spr 0.1% AZILECT azithromycin

66 AZITHROMYCIN AZOPT AZOR 10-40MG AZOR TAB 10-20MG AZOR TAB 5-20MG AZOR TAB 5-40MG aztreonam B bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) bacitracin-poly-neomycin-hc baclofen balsalazide disodium balziva 28 day BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE BCG VACCINE benazepril & hydrochlorothiazide benazepril hcl BENICAR BENICAR HCT 40-25MG BENICAR HCT TAB MG BENICAR HCT TAB MG benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate (topical). 60 betamethasone dipropionate augmented betamethasone valerate BETASERON betaxolol hcl (ophth) bethanechol chloride BETOPTIC-S bicalutamide BICILLIN L-A BICNU BILTRICIDE bisoprolol & hydrochlorothiazide bisoprolol fumarate BIVIGAM bleomycin sulfate blephamide BOOSTRIX BOSULIF BREO ELLIPTA briellyn 28 day BRILINTA BRIMONIDINE SOL 0.15% brimonidine sol 0.2% BRINTELLIX BROMFENAC SODIUM (OPHTH)(ONCE- DAILY) bromocriptine mesylate budesonide (inhalation) budesonide ec bumetanide buprenorphine hcl buprenorphine hcl-naloxone hcl sl buproban bupropion hcl buspirone hcl BUSULFEX butorphanol tartrate... 7 BYSTOLIC C cabergoline cafergot calcipotriene calcitonin (salmon) calcitrene oin 0.005% calcitriol calcitriol inj calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) camila 28 day CANASA CANCIDAS CAPASTAT SULFATE CAPRELSA captopril captopril & hydrochlorothiazide CARBAGLU carbamazepine CARBIDOPA/LEVODOPA/ENTACAPONE 32 carbidopa-levodopa carboplatin CARIMUNE NANOFILTERED carteolol hcl (ophth)

67 cartia xt cap 120/24hr cartia xt cap 180/24hr cartia xt cap 240/24hr cartia xt cap 300/24hr carvedilol CAYSTON cefaclor cefaclor monohydrate er cefadroxil cefazolin in d5w cefazolin inj cefazolin sodium cefdinir cefepime hcl cefotaxime sodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME/DEXTROSE ceftriaxone sodium cefuroxime axetil cefuroxime sodium CELEBREX CAP 100MG... 7 CELEBREX CAP 200MG... 7 CELEBREX CAP 400MG... 7 CELEBREX CAP 50MG... 7 CELLCEPT CELONTIN cephalexin CEREZYME CERVARIX cetirizine syrup cevimeline hcl CHANTIX CHANTIX STARTER PACK CHEMET chlorhexidine gluconate (mouth-throat) chloroquine phosphate chlorothiazide chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light choline fenofibrate ciclopirox ciclopirox shampoo 1% cilostazol CILOXAN CIMZIA CIMZIA STARTER KIT CINRYZE CIPRODEX ciprofloxacin ciprofloxacin er ciprofloxacin hcl (ophth) ciprofloxacin hcl tab ciprofloxacin in d5w ciprofloxacin inj cisplatin citalopram hydrobromide cladribine claravis clarithromycin clarithromycin er clarithromycin for susp clindamycin cap 300mg clindamycin cap 75mg clindamycin hcl cap 150 mg clindamycin phosphate (topical) clindamycin phosphate inj clindamycin phosphate vaginal clindamycin sol 75mg/5ml CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D clobetasol propionate clomipramine hcl clonazepam... 27, 28 clonidine hcl clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical) clozapine... 32, 33 CLOZAPINE

68 COARTEM colchicine w/ probenecid... 7 COLCRYS... 7 colestipol hcl colistimethate sodium colocort enema 100mg COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ COMPLERA compro COMVAX constulose COPAXONE INJ 40MG/ML COPAXONE KIT 20MG/ML cortisone acetate COUMADIN CREON CRESTOR CRIXIVAN cromolyn sodium (mastocytosis) cromolyn sodium (ophth) cromolyn sodium nebu cryselle CUBICIN CUVPOSA cyclafem 1/35 28 day cyclafem 7/7/7 28 day cyclobenzaprine hcl cyclophosphamide cyclosporine cyclosporine modified (for microemulsion) CYSTADANE CYSTAGON cytarabine D dacarbazine DALIRESP danazol dantrolene sodium dapsone DAPTACEL DARAPRIM daunorubicin hcl daunorubicin hcl for inj 20 mg DELZICOL DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA INJ 400/ML desipramine hcl desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml DESMOPRESSIN SOL 0.01% desonide DESONIDE desoximetasone DESOXIMETASONE dexamethasone dexamethasone sodium phosphate dexamethasone sodium phosphate (ophth) DEXILANT dexrazoxane DEXTROSE 10% FLEX CONTAIN DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.45% DEXTROSE 2.5%/NACL 0.45% DEXTROSE 5% DEXTROSE 5% /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 50% dextrose inj 70% diazepam DIAZEPAM GEL diazepam inj diclofenac potassium... 7 diclofenac sodium... 7 diclofenac sodium (ophth) dicloxacillin sodium

69 dicyclomine hcl didanosine DIFICID diflorasone diacetate diflunisal... 7 digoxin... 24, 25 DIGOXIN SOL 50MCG/ML dihydroergotamine mesylate dilantin DILANTIN-125 SUS 125/5ML dilt-cd cap diltiazem cap diltiazem cap 120mg/24hr diltiazem cap er/12hr diltiazem hcl diltiazem hcl coated beads dilt-xr cap diltzac DIOVAN DIPENTUM diphenhydramine inj diphenoxylate w/ atropine DIPHTHERIA/TETANUS TOXOID disopyramide phosphate disulfiram DIURIL SUS 250/5ML divalproex sodium docetaxel DOCETAXEL donepezil hydrochloride... 29, 30 dorzolamide hcl dorzolamide hcl-timolol maleate doxazosin mesylate doxepin hcl doxorubicin hcl for inj 50 mg doxorubicin hcl liposomal inj 2mg/ml.. 16 doxorubicin inj 50mg doxycycline (monohydrate) doxycycline hyclate dronabinol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine hcl DURAMORPH... 8 DUREZOL DYRENIUM E e.e.s e.e.s E.E.S. GRANULES e.s.p econazole nitrate EDECRIN EDURANT ees/sulfisox sus EFFIENT ELIDEL ELIQUIS ELITEK elixophyllin ELLA ELMIRON EMCYT EMEND CAP 125MG EMEND CAP 40MG EMEND CAP 80MG EMEND PAK 80 & emoquette EMSAM EMTRIVA enalapril maleate enalapril maleate & hydrochlorothiazide endocet... 8 ENGERIX-B enoxaparin sodium enpresse 28 day entacapone enulose EPIPEN 2-PAK EPIPEN-JR 2-PAK epirubicin hcl epitol EPIVIR EPIVIR HBV eplerenone EPZICOM ERAXIS ERIVEDGE errin 28 day ery pad 2%

70 ERYPED ERYPED ery-tab erythrocin lactobionate erythrocin stearate erythromycin (acne aid) erythromycin (ophth) erythromycin base erythromycin cap 250mg ec escitalopram oxalate esomeprazole sodium estradiol estradiol valerate ESTRADIOL VALERATE ethambutol hcl ethosuximide etodolac... 7 etodolac er... 7 etoposide EURAX EXELON PATCHES exemestane EXFORGE HCT/10- TAB EXFORGE HCT/10- TAB EXFORGE HCT/10- TAB EXFORGE HCT/5- TAB EXFORGE HCT/5- TAB EXFORGE TAB MG EXFORGE TAB MG EXFORGE TAB 5-160MG EXFORGE TAB 5-320MG EXJADE F FABRAZYME famciclovir famotidine famotidine inj FANAPT FANAPT TITRATION PACK FARESTON FASLODEX FAZACLO TAB 100/ODT FAZACLO TAB 12.5/ODT FAZACLO TAB 150MG FAZACLO TAB 200MG FAZACLO TAB 25MG ODT felbamate felodipine fenofibrate fenofibrate micronized fenofibrate micronized cap fentanyl... 8 fentanyl citrate... 8 FETZIMA FETZIMA TITRATION PACK finasteride FIRAZYR FLEBOGAMMA FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in dextrose fluconazole in nacl flucytosine fludarabine phosphate fludrocortisone acetate flunisolide (nasal) fluocinolone acetonide fluocinolone acetonide (otic) fluocinonide fluocinonide emulsified base FLUOROMETHOLONE fluorouracil fluorouracil (topical) fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurbiprofen... 7 flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate (nasal) fluvoxamine maleate fondaparinux sodium FORADIL AEROLIZER FORTEO FORTICAL foscarnet sodium fosinopril sodium fosinopril sodium & hydrochlorothiazide 69

71 FOSRENOL FREAMINE HBC 6.9% FREAMINE III furosemide furosemide inj FUZEON FYCOMPA G gabapentin GABITRIL galantamine hydrobromide GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX-C GAMUNEX-C 1GM/10ML ganciclovir inj 500mg GARDASIL gatifloxacin (ophth) GAUZE PADS 2" X 2" gaviltye-g gavilyte-c gavilyte-n gemcitabine hcl GEMCITABINE HCL gemfibrozil generlac gengraf gentak gentamicin in saline... 9 gentamicin sulfate... 9 gentamicin sulfate (ophth) gentamicin sulfate (topical) GEODON GIANVI gildagia GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC glimepiride glip/metform tab 5-500mg glipizide glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glycopyrrolate glycopyrrolate inj GOLYTELY granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate haloperidol lactate oral conc 2 mg/ml.. 33 HAVRIX heather heparin sod inj 1000/ml heparin sod inj 10000/ml HEPARIN SOD INJ 2000/ML heparin sod inj 20000/ml HEPARIN SOD INJ 2500/ML heparin sod inj 5000/ml HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% HEPARIN SODIUM/SODIUM CHL HEPATAMINE hepatasol HERCEPTIN HEXALEN HIBERIX HUMIRA HUMIRA KIT 40MG/ HUMIRA PEN HUMIRA PEN-CROHNS DISEASE HUMIRA PEN-PSORIASIS STAR HUMULIN R INJ U hydralazine hcl hydrochlorothiazide hydroco/apap tab mg... 8 hydroco/apap tab 5-325mg

72 hydroco/apap tab hydrocodone-acetaminophen mg/15ml... 8 hydrocodone-ibuprofen tab mg 8 hydrocortisone HYDROCORTISONE (INTRARECTAL) hydrocortisone (topical) hydrocortisone butyrate hydrocortisone valerate hydromorphon inj 10mg/ml... 8 hydromorphone hcl... 8 hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl I ibandronate sodium ibuprofen... 7 ibuprofen tab 800 mg... 7 ICLUSIG idarubicin hcl IFEX ifosfamide inj 1gm ifosfamide inj 1gm/20ml IFOSFAMIDE INJ 3GM ifosfamide inj 3gm/60ml ILEVRO IMBRUVICA CAP 140MG imipenem-cilastatin imipramine hcl imiquimod IMOVAX RABIES (H.D.C.V.) INCRELEX indapamide INFANRIX INLYTA INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE INTELENCE INTRALIPID INJ 20% INTRALIPID INJ 30% INTRON-A INJ 10MU INTRON-A INJ 18MU INTRON-A INJ 25MU INTRON-A INJ 50MU introvale 91 day INTUNIV INVANZ INVEGA INVEGA SUST INJ 117 MG/0.75 ML INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234 MG/1.5 ML INVEGA SUST INJ 39 MG/0.25 ML INVEGA SUST INJ 78 MG/0.5 ML INVIRASE INVOKANA IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% IPOL INACTIVATED IPV ipratropium bromide ipratropium bromide (nasal) ipratropium-albuterol nebu irinotecan hcl ISENTRESS ISOLYTE P isolyte s isoniazid isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml isosorb mononitrate tab isosorbide dinitrate isosorbide mononitrate er tab isradipine ISTALOL ISTODAX itraconazole IXIARO J JAKAFI JALYN jantoven JANUMET JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA JENTADUETO JOLIVETTE junel 1.5/30 21 day junel 1/20 21 day junel fe 1.5/30 28 day junel fe 1/20 28 day

73 K KADCYLA KALETRA SOL KALETRA TAB MG KALETRA TAB MG kariva 28 day KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% KCL/D5W INJ 0.3% KCL/NACL INJ KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225% ketoconazole ketoconazole cream ketoconazole shampoo ketoprofen... 7 ketorolac tromethamine (ophth) kionex KLOR-CON KLOR-CON klor-con m klor-con m klor-con pow 20meq KUVAN L labetalol hcl laclotion lotn 12% LACTATED RINGER'S INJ lactulose lactulose (encephalopathy) lamivudine... 12, 13 lamivudine-zidovudine lamotrigine... 28, 29 LANOXIN LANTUS LANTUS SOLOSTAR larin 1/ larin fe 1.5/ larin fe 1/ LASTACAFT latanoprost LATUDA LAZANDA SPR 100MCG... 8 LAZANDA SPR 400MCG... 8 LEENA leflunomide lessina 28 day LETAIRIS letrozole leucovorin calcium leucovorin calcium for inj 500 mg leucovorin calcium inj 10 mg/ml LEUKERAN LEUKINE leuprolide acetate levalbuterol conc 1.25mg/0.5ml LEVEMIR LEVEMIR FLEXPEN levetiracetam levobunolol hcl LEVOBUNOLOL HCL levocarnitine (metabolic modifiers) levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml levonest 28 day levonorgestrel (emergency oc) levonorgestrel-ethinyl estradiol (91-day) levora 0.15/30 28 day levothyroxine sodium LEVOXYL LEXIVA LIALDA lidocaine lidocaine hcl lidocaine hcl (local anesth.)... 9 lidocaine hcl (mouth-throat) lidocaine inj 0.5%... 9 lidocaine inj 1%... 9 lidocaine inj 1.5%... 9 lidocaine inj 2%... 9 lidocaine oint 5% lidocaine-prilocaine LINZESS CAP 145MCG LINZESS CAP 290MCG liothyronine sodium lisinopril

74 lisinopril & hydrochlorothiazide lithium carbonate lithium carbonate er LITHIUM CITRATE LOKARA LOTN 0.05% LOMUSTINE loperamide hcl lorazepam loryna 28 day losartan potassium losartan-hctz mg losartan-hctz mg losartan-hctz mg LOTEMAX LOTRONEX lovastatin low-ogestrel 28 day loxapine succinate LUMIGAN LUMIZYME LUPR DEP-PED INJ 30MG (3-MONTH).. 18 LUPRON DEPOT LUPRON DEPOT INJ MG LUPRON DEPOT-PED lutera 28 day LYRICA LYSODREN lyza M mafenide acetate MAGNESIUM SULFATE MAGNESIUM SULFATE IN D5W magnesium sulfate inj 50% malathion maprotiline hcl marlissa 28 day MARPLAN TAB 10MG MATULANE MAXIDEX meclizine hcl medroxyprogesterone acetate 150 mg/ml medroxyprogesterone acetate tab mefloquine hcl MEGACE ES megestrol acetate MEKINIST meloxicam... 7 MELOXICAM... 7 melphalan hcl MENACTRA MENOMUNE-A/C/Y/W MENVEO mercaptopurine meropenem mesalamine enema mesalamine w/ cleanser mesna MESNEX metadate tab 20mg er metformin hcl... 39, 40 methadone hcl... 8 methazolamide methenamine hippurate methimazole methotrexate sodium inj methotrexate sodium tabs methyclothiazide methylergonovine maleate methylphenidate hcl methylphenidate hcl oral soln methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 125mg methylpr ss inj 1gm methylpr ss inj 40mg methylpr ss inj 500mg methylpred pak 4mg methylpred tab 16mg methylpred tab 32mg methylpred tab 4mg methylpred tab 8mg metipranolol metoclopramide hcl metoclopramide inj metolazone metoprolol & hctz tab mg metoprolol & hctz tab mg metoprolol & hctz tab 50-25mg metoprolol succinate metoprolol tartrate metronidazole

75 metronidazole (topical) metronidazole gel 0.75% metronidazole in nacl metronidazole vaginal mexiletine hcl MIACALCIN microgestin 1.5/30 21 day microgestin 1/20 21 day microgestin fe 1.5/30 28 day microgestin fe 1/20 28 day midodrine hcl minitran minocycline hcl minoxidil mirtazapine misoprostol mitomycin mitoxantrone hcl M-M-R II W/DILUENT 10 DOS moderiba 800 dose pack moderiba pak 1000/day moderiba pak 1200/day moderiba pak 600/day moderiba tab 200mg moexipril hcl moexipril-hydrochlorothiazide mometasone furoate MONONESSA montelukast sodium morphine ext-rel tab... 8 morphine sul inj... 8 MORPHINE SUL INJ... 8 morphine sulfate... 8 MORPHINE SULFATE... 9 morphine sulfate beads... 9 morphine sulfate cap 100mg er... 9 MORPHINE SULFATE ORAL SOL... 9 MOVIPREP MOXEZA MOZOBIL MULTAQ mupirocin MUSTARGEN my way MYCAMINE mycophenolate mofetil mycophenolate sodium myorisan MYOZYME MYRBETRIQ myzilra N nabumetone... 7 nadolol nafcillin sodium NAGLAZYME naloxone hcl naltrexone hcl NAMENDA SOL 10MG/5ML NAMENDA XR NAMENDA XR TITRATION PACK naphazoline 0.1% naproxen... 7 naproxen sodium... 7 naratriptan hcl NASONEX NATACYN nateglinide NEBUPENT necon 0.5/35 28 day necon 1/35 28 day necon 10/11 28 day NECON 7/7/ NECON TAB 1/ nefazodone hcl neomycin sulfate... 9 neomycin-bacitracin zn-polymyxin neomycin-polymy-dexameth neomycin-polymy-gramicid neomycin-polymyxin-hc (ophth) neomycin-polymyxin-hc (otic) NEORAL NEPHRAMINE NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEVIRAPINE NEXAVAR NEXIUM CAP NEXIUM GRA 10MG DR

76 NEXIUM GRA 2.5MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR NEXIUM GRA 5MG DR next choice one dose niacin (antihyperlipidemic) niacor nicardipine hcl NICOTROL INHALER NICOTROL NS nifedical nifedipine nifedipine er NILANDRON nimodipine nitro-bid NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystal nitrofurantoin monohyd macro nitroglycerin NITROLINGUAL PUMPSPRAY NITROSTAT NORA-BE TAB NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol (triphasic) normosol-m NORMOSOL-R NORMOSOL-R IN D5W NORPACE CR nortrel 0.5/35 28 day nortrel 1/35 21 day nortrel 1/35 28 day nortrel 7/7/7 28 day nortriptyline hcl NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL NOXAFIL NUEDEXTA NULOJIX NULYTELY/FLAVOR PACKS NUVARING NUVIGIL nyamyc NYMALIZE nystatin nystatin (mouth-throat) nystatin (topical) nystop O OCELLA TAB MG OCTAGAM octreotide acetate ofloxacin (ophth) ofloxacin (otic) olanzapine... 33, 34 OLYSIO omega-3-acid ethyl esters omeprazole ondansetron hcl ondansetron hcl inj ondansetron hcl oral soln ondansetron odt ONFI ORAP ORFADIN orsythia 28 day oxacillin sodium oxaliplatin oxandrolone oxcarbazepine oxybutynin chloride oxycodone hcl... 9 OXYCODONE HCL... 9 oxycodone hcl tab 5 mg... 9 oxycodone w/ acetaminophen mg... 9 oxycodone w/ acetaminophen mg... 9 oxycodone w/ acetaminophen 5-325mg 9 oxycodone w/ acetaminophen mg 75

77 ... 9 P pacerone paclitaxel pamidronate disodium PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate... 9 paroxetine hcl paser d/r PATADAY PATANASE PATANOL PAXIL pedi-dri PEDVAX HIB PEG 3350/ELECTROLYTES peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350-potassium chloride-sod bicarbonate-sod chloride PEGANONE PEG-INTRON PEG-INTRON REDIPEN PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium penicilln gk inj 5mu PENTAM PENTASA pentoxifylline PERFOROMIST perindopril erbumine periogard permethrin perphenazine phenelzine sulfate phenobarbital phenobarbital sodium PHENOBARBITAL SODIUM phenytek phenytoin phenytoin sodium phenytoin sodium extended philith PHOSLYRA PHOSPHOLINE IODIDE PILOCARPINE HCL pilocarpine hcl (oral) pimtrea pack pindolol pioglitazone hcl piperacillin sodium-tazobactam sodium 16 pirmella 1/35 28 day piroxicam... 7 PLASMA-LYTE A PLASMA-LYTE PLASMA-LYTE-56/D5W podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG portia 28 day potassium chloride... 53, 55 POTASSIUM CHLORIDE... 53, 55 POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.22% POTASSIUM CHLORIDE ER potassium chloride in nacl potassium chloride microencapsulated crystals cr POTASSIUM CITRATE (ALKALINIZER).. 48 POTIGA PRADAXA pramipexole dihydrochloride pravastatin sodium prazosin hcl pred sod pho sol 5mg/5ml PREDNISOLONE ACETATE (OPHTH) prednisolone sodium phosphate (ophth) prednisolone sol 15mg/5ml prednisolone sol 25mg/5ml prednisolone syp 15mg/5ml prednisone con 5mg/ml prednisone pak 10mg

78 prednisone pak 5mg prednisone sol 5mg/5ml prednisone tab 10mg prednisone tab 1mg prednisone tab 2.5mg prednisone tab 20mg prednisone tab 50mg prednisone tab 5mg PREMARIN CREAM premasol sol 10% premasol sol 6% PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) prevalite previfem 28 day PREZISTA PRIFTIN PRIMAQUINE PHOSPHATE primidone PRISTIQ PRIVIGEN PROAIR HFA probenecid... 7 PROCALAMINE prochlorperazine inj prochlorperazine maleate prochlorperazine supp PROCRIT procto-pak proctozone hc PROGLYCEM SUS 50MG/ML PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl propafenone hcl proparacaine hcl propranolol & hydrochlorothiazide propranolol cap er propranolol hcl propylthiouracil PROQUAD PROSOL protriptyline hcl PRUDOXIN CRE 5% PULMOZYME pyrazinamide pyridostigmine bromide Q quasense 91 day quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl ranitidine hcl inj ranitidine syrup RAPAMUNE REBETOL SOLN reclipsen 28 day RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELISTOR RELPAX REMICADE REMODULIN RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENVELA TAB 800MG repaglinide RESCRIPTOR RESTASIS RETROVIR IV INFUSION REVLIMID REYATAZ ribapak mis 600/day ribasphere ribasphere ribapak ribasphere ribapak ribasphere ribapak

79 ribavirin 200mg rifabutin rifampin RIFATER riluzole rimantadine hydrochloride RINGER'S RIOMET RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone RITUXAN rivastigmine tartrate rizatriptan benzoate ropinirole hydrochloride rosadan cre 0.75% ROTARIX ROTATEQ roxicet soln... 9 roxicet tab 5-325mg... 9 ROZEREM S SABRIL SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR sertraline hcl... 31, 32 sildenafil citrate (pulmonary hypertension) SILENOR SILVER SULFADIAZINE SIMBRINZA simvastatin sirolimus SIRTURO SODIUM CHLORIDE... 53, 55 SODIUM CHLORIDE 0.45% VIA SODIUM CHLORIDE 0.9% SODIUM CHLORIDE INJ 0.9% SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN sodium phenylbutyrate sodium polystyrene sulfonate SOLIA SOLTAMOX SOLU-CORTEF SOMATULINE DEPOT SOMAVERT sorine sotalol hcl sotalol hcl (afib/afl) SOVALDI SPIRIVA HANDIHALER spironolactone spironolactone & hydrochlorothiazide.. 26 sprintec 28 day SPRYCEL sps susp 15gm/60ml sronyx SSD stavudine STERILE WATER IRRIGATION STIVARGA STRATTERA streptomycin sulfate... 9 STRIBILD SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUCRAID sucralfate sulfacetamide sodium (acne) sulfacetamide sodium (ophth) sulfacetamide sod-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfamethoxazole-trimethoprim inj SULFAMYLON sulfasalazine sulfasalazine ec sulindac... 7 SUMATRIPTAN

80 sumatriptan succinate SUMATRIPTAN SUCCINATE sumatriptan succinate inj SUMATRIPTAN SUCCINATE INJ suprax SUPRAX SUPREP BOWEL PREP SURMONTIL CAP 100MG SURMONTIL CAP 25MG SURMONTIL CAP 50MG SUSTIVA SUTENT SYLATRON KIT 296MCG SYLATRON KIT 444MCG SYLATRON KIT 888MCG SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNTHROID SYPRINE T TABLOID tacrolimus TAFINLAR TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN... 19, 62 TASIGNA TAXOTERE tazicef tazicef vial TAZORAC taztia TEFLARO TEGRETOL TEGRETOL-XR TEKAMLO MG TEKAMLO TAB MG TEKAMLO TAB 150-5MG TEKAMLO TAB 300-5MG TEKTURNA TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG temazepam TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole vaginal TESTIM testosterone cypionate testosterone enanthate TETANUS TOXOID ADSORBED TETANUS/DIPHTHERIA TOXOID TEV-TROPIN texacort soln 2.5% THALOMID theo theophylline thioridazine hcl thiothixene tiagabine hcl TIKOSYN TIMENTIN TIMENTIN INJ 3.1GM timolol maleate timolol maleate (ophth) TIMOLOL MALEATE GEL TIVICAY tizanidine hcl TOBRADEX TOBRADEX ST tobramycin tobramycin sulfate tobramycin sulfate (ophth) tobramycin sulfate in saline tobramycin-dexamethasone TOBREX TOLTERODINE TARTRATE CAP ER tolterodine tartrate tabs topiramate toposar topotecan hcl torsemide inj torsemide tabs

81 TOVIAZ TPN ELECTROLYTES TRACLEER TRADJENTA tramadol hcl... 8 tramadol-acetaminophen... 8 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate travasol TRAVATAN Z trazodone hcl TREANDA TRECATOR TRELSTAR DEP INJ 3.75MG TRELSTAR LA INJ 11.25MG tretinoin tretinoin (chemotherapy) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide triamterene & hydrochlorothiazide cap mg TRIBENZOR TAB MG TRIBENZOR TAB TRIBENZOR TAB MG TRIBENZOR TAB MG TRIBENZOR40- TAB 10-25MG triderm trifluoperazine hcl trifluridine tri-legest 28 day trilyte trimethoprim TRINESSA tri-previfem 28 day TRISENOX tri-sprintec 28 day trivora 28 day TROPHAMINE INJ 10% trospium chloride TRUVADA TUDORZA PRESSAIR TWINRIX INJ TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA U UCERIS ULORIC... 7 UNITHROID ursodiol V VAGIFEM valacyclovir hcl VALCHLOR VALCYTE valproate sodium valproic acid valsartan... 21, 22 valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg vancomycin hcl VANDAZOLE VAQTA VARIVAX VASCEPA VELCADE velivet 28 day venlafaxine hcl verapamil cap er VERAPAMIL CAP ER verapamil hcl verapamil tab er VERSACLOZ VESICARE vestura VIBRAMYCIN VICTOZA VICTRELIS VIDEX PEDIATRIC VIGAMOX VIIBRYD VIMPAT vinblastine sulfate vincasar

82 vincristine sulfate vinorelbine tartrate viorele VIRACEPT VIRAMUNE XR VIREAD VOLTAREN voriconazole VOTRIENT vyfemia 28 day W warfarin sodium WELCHOL X XALKORI XARELTO XENAZINE XGEVA XIFAXAN XOLAIR XOPENEX HFA XTANDI xulane XYREM Y YF-VAX Z zafirlukast zarah ZAVESCA zazole ZAZOLE ZELBORAF ZEMAIRA zenatane zenchent 28 day ZENPEP ZETIA TAB 10MG ZIAGEN zidovudine ziprasidone hcl ZMAX zoledronic inj 4mg/5ml ZOLINZA zolmitriptan zolmitriptan odt zolpidem tartrate ZOMETA zonisamide ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZOSTAVAX ZYKADIA ZYLET ZYTIGA ZYVOX

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84 Member Services This formulary was updated on 08/08/2014. For more recent information or other questions, please contact TexanPlus at or, for TTY users, 711, 8:00 a.m. to 8:00 p.m. in your local time zone, 7 days a week, or visit This information is available for free in other languages. Please call member service number at , 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711) 7 days a week. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al , de 8:00 a. m. a 8:00 p. m. en su zona horaria local (los usuarios de TTY deben llamar al 711) los 7 días de la semana. TexanPlus HMO is a Health plan with a Medicare contract. Enrollment in TexanPlus HMO depends on contract renewal.