AETNA BETTER HEALTH SM PREMIER PLAN

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1 AETNA BETTER HEALTH SM PREMIER PLAN 2017 List of Covered Drugs/Formulary Aetna Better Health SM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. H8026_17_004_DRG_LST_FINAL ACCEPTED Updated 09/2016

2 Helpful information Member Services (TTY: 711) Representatives available 24 hours a day, 7 days a week Address Aetna Better Health SM Premier Plan 1333 Gratiot Avenue, Suite 400 Detroit, MI Personal information My primary care provider s (PCP) name and phone number My care manager s name and phone number

3 AETNA BETTER HEALTH SM PREMIER PLAN 2017 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Aetna Better Health Premier Plan. Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send a notice before we make a change that affects. Benefits may change on January 1 of each year. You can always check Aetna Better Health Premier Plan s up to date List of Covered Drugs online at Limitations, and patient pay amounts may apply. This means that may have to pay for some services and that need to follow certain rules to have Aetna Better Health Premier Plan pay for r services. For more information, call Aetna Better Health Premier Plan Member Services or read the Aetna Better Health Premier Plan Member Handbook. You can get this information for free in other languages. Call (TTY: 711), 24 hours a day, 7 days a week. The call is free. Puede obtener esta información en otros idiomas de manera gratuita. Llame al (TTY: 711), las 24 horas del día, los 7 días de la semana. Esta llamada es gratuita. يمكنك الحصول على هذه المعلومات مجانا بلغات أخرى برجاء االتصال برقم )هاتف ضعاف السمع: 711( متاح.24 ساعة / 7 أيام أسبوعيا. المكالمات تكون مجانية You can also get this information for free in other formats, such as large print, braille, or audio. Call (TTY: 711), 24 hours a day, 7 days a week. The call is free. If wish to make a standing request to receive all materials in a language other than English, or in an alternate format, can call Aetna Better Health Premier Plan Member Services at (TTY: 711), 24 hours a day, 7 days a week. If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI I

4 II If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI

5 Frequently Asked Questions (FAQ) Find answers here to questions have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are s covered by Aetna Better Health Premier Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide services. We refer to these pharmacies as network pharmacies. Aetna Better Health Premier Plan will cover all medically necessary drugs on the Drug List if: r doctor or other prescriber says need them to get better or stay healthy, and fill the prescription at an Aetna Better Health Premier Plan network pharmacy. Aetna Better Health Premier Plan may have additional steps to access certain drugs (see question #5 below). You can also see an up to date list of drugs that we cover on our website at or call Member Services toll-free at (TTY: 711), 24 hours a day, 7 days a week. 2. Does the Drug List ever change? Yes. Aetna Better Health Premier Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health Premier Plan before can get a drug.) Add or change the amount of a drug can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means must try one drug before we will cover another drug.) (For more information on these drug rules, see V.) We will tell when a drug are taking is removed from the Drug List. We will also tell when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Aetna Better Health Premier Plan s up to date Drug List online at You can also call Member Services to check the current Drug List at (TTY: 711), 24 hours a day, 7 days a week. If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI III

6 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell. We will tell at least 60 days before we remove it from the Drug List or when ask for a refill. Then can get a 60 day supply of before the change to the Drug List is made. You will be notified by mail if a drug list change will affect. You can also search for r drug with the online searchable formulary tool as it is updated to reflect current coverage. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug are taking is not safe, we will take it off the Drug List right away. We will also send a letter telling that. Please contact r doctor if a drug are taking is removed from list. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount can get. In some cases must do something before can get. For example: Prior approval (or prior authorization): For some drugs, or r doctor or other prescriber must get approval from Aetna Better Health Premier Plan before fill r prescription. If don t get approval, Aetna Better Health Premier Plan may not cover. Quantity limits: Sometimes Aetna Better Health Premier Plan limits the amount of a drug can get. Step therapy: Sometimes Aetna Better Health Premier Plan requires to do step therapy. This means will have to try drugs in a certain order for r medical condition. You might have to try one drug before we will cover another drug. If r prescriber thinks the first drug doesn t work for, then we will cover the second. You can find out if r drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send a copy. You can also ask for an exception from these limits. Please see question 11 for more information on exceptions. If are in a nursing home or other long term care facility and need a drug that is not on the Drug List, or if cannot easily get need, we can help. We will cover a 31 day emergency supply of need (unless have a prescription for fewer days), whether or not are a new Aetna Better Health Premier Plan member. This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. Please see question 11 for more information about exceptions. IV If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI

7 6. How will know if want has limitations or if there are required actions to take to get? The List of Covered Drugs on page 1 has a column labeled. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/ or step therapy restrictions on a drug. We will tell if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell at least 60 days before the restriction is added or when next ask for a refill. Then, can get a 60 day supply of before the change to the Drug List is made. This gives time to talk to r doctor or other prescriber about what to do next. 8. How can find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if know how to spell ), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it beginning on page 90. Then look for the name of r drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if have a heart condition, should look in the category, Cardiovascular Agents. That is where will find drugs that treat heart conditions. 9. What if want to take is not on the Drug List? If don t see r drug on the Drug List, call Member Services at (TTY: 711), 24 hours a day, 7 days a week and ask about it. If learn that Aetna Better Health Premier Plan will not cover the drug, can do one of these things: Ask Member Services for a list of drugs like the one want to take. Then show the list to r doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one want to take. Or You can ask the health plan to make an exception to cover r drug. Please see question 11 for more information about exceptions. If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI V

8 10. What if are a new Aetna Better Health Premier Plan member and can t find r drug on the Drug List or have a problem getting r drug? We can help. We may cover a temporary 30 day supply of r drug during the first 90 days are a member of Aetna Better Health Premier Plan. This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. We will cover a 30 day supply of r drug if: are taking a drug that is not on our Drug List, or health plan rules do not let get the amount ordered by r prescriber, or requires prior approval by Aetna Better Health Premier Plan, or are taking a drug that is part of a step therapy restriction. If live in a nursing home or other long term care facility, may refill r prescription for as long as at least 91 days and up to 98 days. You may refill multiple times during r first 90 days in the plan. This gives r prescriber time to change r drugs to ones on the Drug List or ask for an exception. If are a current member with change in level of care, we will cover a one-time temporary 30-day supply if move from the hospital to a home setting and: need a drug that is not on our drug list, and r ability to get is limited We will cover a one time temporary 31-day supply (see the note below for exceptions) if move into or out of a long-term care setting and: need a drug that is not on our drug list, and r ability to get is limited Note: Oral brand name solid dosage form such as tablets or capsules are limited to 14 day fills with exceptions as required by Medicare Part D rules. If r prescription is written for fewer than 31 days, we will pay for the smaller amount. During the time when are getting a temporary supply of a drug, should talk with r provider to decide what to do when r temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for and cover r current drug. VI If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI

9 11. Can ask for an exception to cover r drug? Yes. You can ask Aetna Better Health Premier Plan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on r drug. For example, Aetna Better Health Premier Plan may limit the amount of a drug we will cover. If r drug has a limit, can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must get a statement from r prescriber supporting r request for an exception. After we get the statement, we will give a decision on r exception request within 72 hours. If or r prescriber think r health may be harmed if have to wait 72 hours for a decision, can ask for an expedited exception. This is a faster decision. If r prescriber supports r request, we will give a decision within 24 hours of receiving r prescriber s supporting statement. 13. How can ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with and r provider to help ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well known names. Generic drugs are approved by the Food and Drug Administration (FDA). Aetna Better Health Premier Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over the counter. Aetna Better Health Premier Plan covers some OTC drugs when they are written as prescriptions by r provider. You can read the Aetna Better Health Premier Plan Drug List to see what OTC drugs are covered. 16. Does Aetna Better Health Premier Plan cover OTC non drug products? Aetna Better Health Premier Plan covers some OTC non drug products when they are written as prescriptions by r provider. You can read the Aetna Better Health Premier Plan Drug List to see what OTC non drug products are covered. If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI VII

10 17. What is r copay? As an Aetna Better Health Premier Plan member, have no copays for prescription and OTC drugs as long as follow Aetna Better Health Premier Plan s rules. 18. What are drug tiers? Tiers are groups of drugs. Tier 1: Part D prescription generic drug Tier 2: Part D prescription brand name drugs Tier 3: Non-Part D prescription and over-the-counter drugs All tiers have no copay. VIII If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI

11 List of Covered Drugs The list of covered drugs on the next page gives information about s covered by Aetna Better Health Premier Plan. If have trouble finding r drug in the list, turn to the Index that begins on page 90. The first column of the chart lists the name of. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower case italics (e.g., amoxicillin). The information in the necessary actions, column tells if Aetna Better Health Premier Plan has any rules for covering r drug. Note: The asterisk (*) next to a drug means is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if think we made a mistake. For example, we might decide that a drug that want is not covered or is no longer covered by Medicare or Michigan Medicaid. If or r prescriber disagrees with our decision, can appeal. To ask for instructions on how to appeal, call Member Services at (TTY: 711), 24 hours a day, 7 days a week. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision. Here are the meanings of the codes used in the Necessary action, column: (* ) = Non Medicare Part D drugs, or OTC items that B/D = Covered under Medicare B or D PA = Prior Authorization QL = Quantity Limits ST = Step Therapy MO = Available by mail order LA = Limited Access If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI IX

12 X If have questions, please call Aetna Better Health Premier Plan at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit MI

13 MI MMP effective 01/01/2017 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if have a heart condition, should look in the category, Cardiovascular Agents. That is where will find drugs that treat heart conditions. What Name of drug ANALGESICS-DRUGS USED TO TREAT PAIN AND INFLAMMATION Analgesics 8 hour pain relief $0 (3) * acetaminophen supp 650mg $0 (3) * arthritis pain $0 (3) * arthritis pain relief $0 (3) * ascomp/codeine $0 (1) QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine/codeine caps $0 (1) QL (180 EA per 30 days) PA 325mg; 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine/codeine caps $0 (1) QL (180 EA per 30 days) PA MO 300mg; 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine caps $0 (1) QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine tabs 325mg; $0 (1) QL (180 EA per 30 days) PA 50mg; 40mg butalbital/aspirin/caffeine $0 (1) QL (180 EA per 30 days) PA MO butalbital/aspirin/caffeine/codeine $0 (1) QL (180 EA per 30 days) PA capacet $0 (1) QL (180 EA per 30 days) PA esgic caps $0 (1) QL (180 EA per 30 days) PA MO gnp 8 hour pain reliever $0 (3) * gnp arthritis pain relief $0 (3) * hm arthritis pain relief $0 (3) * margesic $0 (1) QL (180 EA per 30 days) PA MO qc arthritis pain relief $0 (3) * sm 8 hour pain relief $0 (3) * sm arthritis pain relief $0 (3) * zebutal caps 325mg; 50mg; 40mg $0 (1) QL (180 EA per 30 days) PA MO Nonsteroidal Anti-inflammatory Drugs all day pain relief $0 (3) * celecoxib caps 400mg $0 (1) QL (30 EA per 30 days) 1

14 Name of drug What celecoxib caps 100mg, 200mg, 50mg $0 (1) QL (60 EA per 30 days) childrens ibuprofen susp 100mg/5ml $0 (3) * childs ibuprofen $0 (3) * diclofenac potassium $0 (1) diclofenac sodium dr $0 (1) diclofenac sodium er $0 (1) diflunisal tabs $0 (1) etodolac er tb24 600mg $0 (1) etodolac er tb24 400mg, 500mg $0 (1) MO etodolac tabs $0 (1) etodolac caps $0 (1) MO flurbiprofen tabs 100mg $0 (1) flurbiprofen tabs 50mg $0 (1) MO gnp all day pain relief $0 (3) * gnp childrens ibuprofen $0 (3) * gnp ibuprofen $0 (3) * hm ibuprofen infants $0 (3) * ibu-200 $0 (3) * ibuprofen childrens $0 (3) * ibuprofen junior strength $0 (3) * ibuprofen caps $0 (3) * ibuprofen susp 100mg/5ml $0 (1) MO ibuprofen susp 100mg/5ml $0 (3) * ibuprofen tabs 400mg, 600mg, 800mg $0 (1) ibuprofen tabs 200mg $0 (3) * infants ibuprofen $0 (3) * ketoprofen er $0 (1) MO ketoprofen caps $0 (1) meclofenamate sodium caps $0 (1) MO meloxicam tabs $0 (1) meloxicam susp $0 (1) MO nabumetone $0 (1) naproxen dr tbec 375mg $0 (1) naproxen dr tbec 500mg $0 (1) MO 2

15 Name of drug What naproxen sodium tabs 275mg, 550mg $0 (1) naproxen tabs $0 (1) naproxen susp $0 (1) MO oxaprozin $0 (1) piroxicam caps 20mg $0 (1) piroxicam caps 10mg $0 (1) MO qc childrens ibuprofen $0 (3) * sb ibuprofen $0 (3) * sm ibuprofen caps $0 (3) * sm infants ibuprofen $0 (3) * sm naproxen sodium tabs $0 (3) * sulindac tabs 150mg $0 (1) sulindac tabs 200mg $0 (1) MO tolmetin sodium caps $0 (1) MO tolmetin sodium tabs 200mg $0 (1) tolmetin sodium tabs 600mg $0 (1) MO VOLTAREN $0 (2) QL (1000 GM per 30 days) MO Opioid Analgesics, Long-acting fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr $0 (1) QL (15 EA per 30 days) fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/hr, $0 (1) QL (15 EA per 30 days) MO 62.5mcg/hr, 87.5mcg/hr methadone hcl inj $0 (1) PA methadone hcl tabs $0 (1) QL (180 EA per 30 days) PA methadone hcl oral soln $0 (1) QL (3000 ML per 30 days) PA methadone hcl conc $0 (1) QL (360 ML per 30 days) PA methadone hcl tbso $0 (1) QL (90 EA per 30 days) PA methadose tbso $0 (1) QL (90 EA per 30 days) PA morphine sulfate er cp24 120mg, 45mg, 75mg, 90mg $0 (1) QL (30 EA per 30 days) MO morphine sulfate er cp24 100mg, 20mg, 30mg, $0 (1) QL (60 EA per 30 days) 50mg, 60mg, 80mg morphine sulfate er cp24 10mg, 30mg, 60mg $0 (1) QL (60 EA per 30 days) MO morphine sulfate er tbcr 100mg, 200mg, 30mg, $0 (1) QL (60 EA per 30 days) 60mg morphine sulfate er tbcr 15mg $0 (1) QL (90 EA per 30 days) Opioid Analgesics, Short-acting 3

16 What Name of drug acetaminophen/codeine #3 $0 (1) QL (180 EA per 30 days) acetaminophen/codeine soln $0 (1) QL (4500 ML per 30 days) acetaminophen/codeine tabs 300mg; 15mg, 300mg; $0 (1) QL (180 EA per 30 days) 60mg butalbital compound/codeine $0 (1) QL (180 EA per 30 days) PA codeine sulfate tabs $0 (1) QL (180 EA per 30 days) MO duramorph $0 (1) B/D endocet tabs 325mg; 2.5mg, 325mg; 5mg $0 (1) QL (180 EA per 30 days) endocet tabs 325mg; 10mg, 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MO endodan $0 (1) QL (180 EA per 30 days) fentanyl citrate oral transmucosal $0 (1) QL (120 EA per 30 days) PA hydrocodone bitartrate/acetaminophen soln $0 (1) QL (5550 ML per 30 days) 325mg/15ml; 7.5mg/15ml hydrocodone bitartrate/acetaminophen tabs 325mg; $0 (1) QL (180 EA per 30 days) 2.5mg hydrocodone bitartrate/acetaminophen tabs 300mg; $0 (1) QL (180 EA per 30 days) MO 10mg, 300mg; 5mg, 300mg; 7.5mg hydrocodone/acetaminophen tabs 325mg; 10mg $0 (1) QL (180 EA per 30 days) hydrocodone/acetaminophen tabs 325mg; 5mg, $0 (1) QL (180 EA per 30 days) MO 325mg; 7.5mg hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; $0 (1) QL (150 EA per 30 days) 200mg hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg; $0 (1) QL (150 EA per 30 days) MO 200mg hydromorphone hcl tabs $0 (1) QL (180 EA per 30 days) hydromorphone hcl liqd $0 (1) QL (2400 ML per 30 days) MO hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, $0 (1) B/D 50mg/5ml hydromorphone hcl inj 4mg/ml $0 (1) B/D MO ibudone tabs 5mg; 200mg $0 (1) QL (150 EA per 30 days) MO lorcet $0 (1) QL (180 EA per 30 days) lorcet hd $0 (1) QL (180 EA per 30 days) lorcet plus tabs 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) lortab tabs 325mg; 5mg $0 (1) QL (180 EA per 30 days) lortab tabs 325mg; 10mg, 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MO 4

17 What Name of drug morphine sulfate inj 0.5mg/ml, 10mg/ml, $0 (1) B/D 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml morphine sulfate inj 10mg/ml, 1mg/ml $0 (1) B/D MO morphine sulfate oral soln 20mg/5ml $0 (1) QL (1020 ML per 30 days) morphine sulfate oral soln 100mg/5ml $0 (1) QL (180 ML per 30 days) morphine sulfate oral soln 10mg/5ml $0 (1) QL (1800 ML per 30 days) morphine sulfate tabs 30mg $0 (1) QL (180 EA per 30 days) MO morphine sulfate tabs 15mg $0 (1) QL (60 EA per 30 days) MO nalbuphine hcl inj $0 (1) MO oxycodone hcl caps $0 (1) QL (180 EA per 30 days) oxycodone hcl conc $0 (1) QL (180 ML per 30 days) oxycodone hcl soln $0 (1) QL (5400 ML per 30 days) oxycodone hcl tabs 30mg $0 (1) QL (120 EA per 30 days) oxycodone hcl tabs 10mg, 15mg, 20mg $0 (1) QL (120 EA per 30 days) MO oxycodone hcl tabs 5mg $0 (1) QL (180 EA per 30 days) oxycodone/acetaminophen soln $0 (1) QL (1800 ML per 30 days) oxycodone/acetaminophen tabs 325mg; 10mg, $0 (1) QL (180 EA per 30 days) 325mg; 2.5mg, 325mg; 5mg oxycodone/acetaminophen tabs 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MO oxycodone/aspirin $0 (1) QL (180 EA per 30 days) oxycodone/ibuprofen $0 (1) QL (120 EA per 30 days) MO reprexain tabs 10mg; 200mg $0 (1) QL (150 EA per 30 days) MO ROXICET SOLN $0 (2) QL (1800 ML per 30 days) roxicet tabs $0 (1) QL (180 EA per 30 days) tramadol hcl tabs $0 (1) QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen $0 (1) QL (240 EA per 30 days) vicodin es tabs 300mg; 7.5mg $0 (1) QL (180 EA per 30 days) vicodin tabs 300mg; 5mg $0 (1) QL (180 EA per 30 days) xylon $0 (1) QL (150 EA per 30 days) zamicet $0 (1) QL (5550 ML per 30 days) MO ANESTHETICS-DRUGS USED FOR NUMBING Local Anesthetics glydo $0 (1) MO lidocaine hcl jelly gel 2% $0 (1) 5

18 What Name of drug lidocaine hcl gel 2% $0 (1) MO lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% $0 (1) lidocaine hcl external soln 4% $0 (1) lidocaine hcl mouth/throat soln 4% $0 (1) lidocaine viscous $0 (1) lidocaine/prilocaine kit $0 (1) lidocaine/prilocaine crea $0 (1) MO lidocaine oint $0 (1) lidocaine ptch $0 (1) QL (90 EA per 30 days) PA relador pak plus $0 (1) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acamprosate calcium dr $0 (1) MO disulfiram tabs $0 (1) naltrexone hcl tabs $0 (1) Opioid Dependence Treatments buprenorphine hcl/naloxone hcl $0 (1) QL (90 EA per 30 days) PA MO buprenorphine hcl subl $0 (1) QL (90 EA per 30 days) PA MO SUBOXONE FILM 12MG; 3MG $0 (2) QL (60 EA per 30 days) PA MO SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; $0 (2) QL (90 EA per 30 days) PA MO 2MG Opioid Reversal Agents EVZIO $0 (2) MO naloxone hcl inj 0.4mg/ml $0 (1) naloxone hcl inj 1mg/ml $0 (1) MO NARCAN $0 (2) MO Smoking Cessation Agents buproban $0 (1) QL (60 EA per 30 days) bupropion hcl sr tb12 150mg $0 (1) QL (60 EA per 30 days) MO CHANTIX CONTINUING MONTH PAK $0 (2) QL (336 EA per 365 days) CHANTIX STARTING MONTH PAK $0 (2) QL (106 EA per 365 days) MO CHANTIX TABS 0.5MG, 1MG $0 (2) QL (336 EA per 365 days) MO gnp nicotine polacrilex gum 2mg $0 (3) * hm nicotine polacrilex lozg $0 (3) * hm nicotine polacrilex gum 2mg $0 (3) * 6

19 What Name of drug nicotine polacrilex gum, lozg $0 (3) * nicotine transdermal system pt24 21mg/24hr $0 (3) * NICOTROL NS $0 (2) QL (40 ML per 30 days) MO sm nicotine polacrilex $0 (3) * sm nicotine gum, lozg $0 (3) * ANTIBACTERIALS-DRUGS USED TO TREAT INFECTIONS Aminoglycosides amikacin sulfate inj 500mg/2ml $0 (1) amikacin sulfate inj 1gm/4ml $0 (1) MO gentamicin sulfate pediatric $0 (1) MO gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ $0 (1) ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9% gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ $0 (1) MO ml; 0.9% gentamicin sulfate inj 10mg/ml $0 (1) gentamicin sulfate inj 40mg/ml $0 (1) MO isotonic gentamicin inj 0.8mg/ml; 0.9% $0 (1) neomycin sulfate $0 (1) MO paromomycin sulfate $0 (1) MO streptomycin sulfate inj $0 (1) MO tobramycin sulfate inj 1.2gm/30ml, 1.2gm, 10mg/ml, $0 (1) 40mg/ml, 80mg/2ml Antibacterials, Other baciim $0 (1) bacitracin inj 50000unit $0 (1) MO chloramphenicol sodium succinate $0 (1) clindamycin hcl caps 150mg, 300mg $0 (1) clindamycin hcl caps 75mg $0 (1) MO clindamycin palmitate hcl $0 (1) clindamycin phosphate add-vantage inj 900mg/6ml $0 (1) clindamycin phosphate in d5w $0 (1) clindamycin phosphate crea 2% $0 (1) clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml, 900mg/6ml $0 (1) 7

20 Name of drug What colistimethate sodium $0 (1) PA CUBICIN $0 (2) DALVANCE $0 (2) ISOPROPYL ALCOHOL WIPES $0 (2) linezolid inj $0 (1) PA linezolid susr $0 (1) QL (1800 ML per 28 days) PA MO linezolid tabs $0 (1) QL (56 EA per 28 days) PA methenamine hippurate $0 (1) METRO IV $0 (2) metronidazole in nacl 0.79% $0 (1) metronidazole vaginal $0 (1) metronidazole caps 375mg $0 (1) MO metronidazole tabs 250mg, 500mg $0 (1) nitrofurantoin macrocrystals $0 (1) PA nitrofurantoin monohydrate $0 (1) PA nitrofurantoin monohydrate/macrocrystals $0 (1) PA nitrofurantoin susp $0 (1) PA SIVEXTRO INJ $0 (2) SIVEXTRO TABS $0 (2) MO SYNERCID $0 (2) tinidazole $0 (1) trimethoprim tabs $0 (1) MO TYGACIL $0 (2) vancomycin hcl in dextrose $0 (1) vancomycin hcl caps $0 (1) PA vancomycin hcl inj 1000mg, 10gm, 5000mg, 500mg, $0 (1) 750mg vandazole $0 (1) MO ZYVOX SUSR $0 (2) QL (1800 ML per 28 days) PA MO ZYVOX TABS $0 (2) QL (56 EA per 28 days) PA MO ZYVOX INJ 600MG/300ML $0 (2) PA Beta-lactam, Cephalosporins cefaclor er $0 (1) MO 8

21 Name of drug What cefaclor caps $0 (1) MO cefaclor susr 250mg/5ml, 375mg/5ml $0 (1) cefaclor susr 125mg/5ml $0 (1) MO cefadroxil caps, tabs $0 (1) cefadroxil susr 250mg/5ml $0 (1) cefadroxil susr 500mg/5ml $0 (1) MO cefazolin $0 (1) cefazolin sodium/dextrose $0 (1) cefazolin sodium inj 100gm, 10gm, 1gm, 1gm; 5%, $0 (1) 300gm, 500mg cefdinir $0 (1) cefditoren pivoxil tabs 400mg $0 (1) cefepime $0 (1) cefepime/dextrose $0 (1) cefixime $0 (1) MO cefotaxime sodium inj 10gm, 2gm, 500mg $0 (1) cefotaxime sodium inj 1gm $0 (1) MO cefotetan $0 (1) cefotetan/dextrose $0 (1) cefoxitin sodium $0 (1) cefpodoxime proxetil susr $0 (1) MO cefpodoxime proxetil tabs 200mg $0 (1) cefpodoxime proxetil tabs 100mg $0 (1) MO cefprozil $0 (1) ceftazidime $0 (1) ceftazidime/dextrose $0 (1) ceftriaxone in iso-osmotic dextrose $0 (1) ceftriaxone sodium inj 100gm, 10gm, 1gm, 250mg, $0 (1) 2gm, 500mg ceftriaxone sodium inj 2gm $0 (1) MO ceftriaxone/dextrose $0 (1) cefuroxime axetil $0 (1) cefuroxime sodium inj 1.5gm, 225gm, 7.5gm, 75gm $0 (1) cefuroxime sodium inj 750mg $0 (1) MO cephalexin caps 250mg, 500mg $0 (1) 9

22 Name of drug What cephalexin caps 750mg $0 (1) MO cephalexin susr $0 (1) cephalexin tabs $0 (1) MO SUPRAX CAPS $0 (2) SUPRAX CHEW 100MG $0 (2) SUPRAX CHEW 200MG $0 (2) MO SUPRAX SUSR 500MG/5ML $0 (2) tazicef inj 1gm, 2gm, 6gm $0 (1) TEFLARO $0 (2) Beta-lactam, Other aztreonam $0 (1) MO imipenem/cilastatin $0 (1) MO INVANZ INJ 1GM $0 (2) meropenem $0 (1) MO meropenem/sodium chloride $0 (1) Beta-lactam, Penicillins amoxicillin/clavulanate potassium er $0 (1) amoxicillin/clavulanate potassium chew $0 (1) MO amoxicillin/clavulanate potassium susr 200mg/5ml; $0 (1) 28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium susr 250mg/5ml; $0 (1) MO 62.5mg/5ml amoxicillin/clavulanate potassium tabs 500mg; $0 (1) 125mg, 875mg; 125mg amoxicillin/clavulanate potassium tabs 250mg; $0 (1) MO 125mg amoxicillin caps, susr $0 (1) amoxicillin chew $0 (1) MO amoxicillin tabs 875mg $0 (1) amoxicillin tabs 500mg $0 (1) MO ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, $0 (1) 2gm, 500mg ampicillin sodium inj 1gm $0 (1) MO ampicillin-sulbactam $0 (1) 10

23 Name of drug What ampicillin caps $0 (1) ampicillin susr 125mg/5ml $0 (1) ampicillin susr 250mg/5ml $0 (1) MO BICILLIN L-A $0 (2) MO dicloxacillin sodium $0 (1) nafcillin $0 (1) oxacillin sodium inj 10gm, 1gm $0 (1) oxacillin sodium inj 2gm $0 (1) MO penicillin g potassium inj unit $0 (1) penicillin g potassium inj unit $0 (1) MO penicillin g procaine $0 (1) MO penicillin g sodium $0 (1) penicillin v potassium tabs $0 (1) penicillin v potassium solr 125mg/5ml $0 (1) penicillin v potassium solr 250mg/5ml $0 (1) MO piperacillin sodium/ tazobactam sodium $0 (1) piperacillin sodium/tazobactam sodium $0 (1) piperacillin/tazobactam inj 36gm; 4.5gm, 4gm; 0.5gm $0 (1) Macrolides azithromycin inj, tabs $0 (1) azithromycin pack, susr $0 (1) MO clarithromycin tabs $0 (1) clarithromycin susr $0 (1) MO DIFICID $0 (2) MO ERYTHROCIN LACTOBIONATE $0 (2) erythromycin base $0 (1) MO erythromycin ethylsuccinate tabs $0 (1) MO erythromycin stearate tabs $0 (1) erythromycin cpep 250mg $0 (1) MO Quinolones ciprofloxacin er $0 (1) MO ciprofloxacin hcl tabs 250mg, 500mg $0 (1) ciprofloxacin hcl tabs 100mg, 750mg $0 (1) MO ciprofloxacin i.v.-in d5w $0 (1) 11

24 What Name of drug ciprofloxacin inj, otic soln, susr $0 (1) MO levofloxacin in d5w $0 (1) levofloxacin inj 25mg/ml $0 (1) levofloxacin oral soln 25mg/ml $0 (1) levofloxacin tabs 250mg, 500mg, 750mg $0 (1) ofloxacin tabs 400mg $0 (1) Sulfonamides sulfadiazine tabs $0 (1) MO sulfamethoxazole/trimethoprim ds $0 (1) sulfamethoxazole/trimethoprim inj, tabs $0 (1) sulfamethoxazole/trimethoprim susp $0 (1) MO sulfatrim pediatric $0 (1) Tetracyclines doxy 100 $0 (1) doxycycline hyclate dr $0 (1) doxycycline hyclate caps 100mg $0 (1) doxycycline hyclate caps 50mg $0 (1) MO doxycycline hyclate inj $0 (1) doxycycline hyclate tabs 100mg $0 (1) doxycycline hyclate tabs 20mg $0 (1) MO doxycycline monohydrate caps 100mg $0 (1) doxycycline monohydrate caps 50mg $0 (1) MO doxycycline monohydrate tabs 50mg, 75mg $0 (1) doxycycline monohydrate tabs 100mg, 150mg $0 (1) MO doxycycline caps 150mg $0 (1) doxycycline caps 75mg $0 (1) MO doxycycline susr $0 (1) MO minocycline hcl caps $0 (1) morgidox 1x100mg caps $0 (1) morgidox 2x100mg caps $0 (1) tetracycline hcl caps $0 (1) MO ANTICONVULSANTS-DRUGS USED TO TREAT SEIZURES Anticonvulsants, Other APTIOM TABS 200MG, 400MG, 800MG $0 (2) QL (30 EA per 30 days) PA MO 12

25 Name of drug What APTIOM TABS 600MG $0 (2) QL (60 EA per 30 days) PA MO BRIVIACT TABS $0 (2) QL (60 EA per 30 days) PA BRIVIACT INJ, ORAL SOLN $0 (2) QL (600 ML per 30 days) PA FYCOMPA SUSP $0 (2) QL (1020 ML per 30 days) PA FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG $0 (2) QL (30 EA per 30 days) PA MO FYCOMPA TABS 2MG $0 (2) QL (60 EA per 30 days) PA MO levetiracetam $0 (1) POTIGA TABS 50MG $0 (2) QL (270 EA per 30 days) MO POTIGA TABS 200MG, 300MG, 400MG $0 (2) QL (90 EA per 30 days) MO SPRITAM TB3D 250MG, 500MG, 750MG $0 (2) SPRITAM TB3D 1000MG $0 (2) MO Calcium Channel Modifying Agents CELONTIN $0 (2) MO ethosuximide $0 (1) LYRICA SOLN $0 (2) QL (900 ML per 30 days) PA MO LYRICA CAPS 225MG, 300MG $0 (2) QL (60 EA per 30 days) PA MO LYRICA CAPS 100MG, 150MG, 200MG, 25MG, $0 (2) QL (90 EA per 30 days) PA MO 50MG, 75MG zonisamide $0 (1) Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 1mg $0 (1) QL (120 EA per 30 days) clonazepam odt tbdp 2mg $0 (1) QL (300 EA per 30 days) clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg $0 (1) QL (90 EA per 30 days) clonazepam tabs 1mg $0 (1) QL (120 EA per 30 days) clonazepam tabs 2mg $0 (1) QL (300 EA per 30 days) clonazepam tabs 0.5mg $0 (1) QL (90 EA per 30 days) diazepam gel 10mg, 2.5mg, 20mg $0 (1) MO divalproex sodium $0 (1) divalproex sodium dr $0 (1) divalproex sodium er $0 (1) gabapentin caps, soln, tabs $0 (1) GABITRIL TABS 12MG, 16MG $0 (2) MO ONFI SUSP $0 (2) MO ONFI TABS 10MG, 20MG $0 (2) MO 13

26 What Name of drug phenobarbital elix $0 (1) QL (1500 ML per 30 days) PA MO phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, $0 (1) QL (120 EA per 30 days) PA 97.2mg phenobarbital tabs 100mg, 15mg, 30mg, 60mg $0 (1) QL (120 EA per 30 days) PA MO primidone tabs $0 (1) SABRIL $0 (2) PA tiagabine hydrochloride $0 (1) valproate sodium inj $0 (1) valproic acid caps $0 (1) valproic acid syrp $0 (1) MO Glutamate Reducing Agents felbamate $0 (1) lamotrigine titration $0 (1) MO lamotrigine chew, tabs $0 (1) topiramate cpsp 15mg $0 (1) topiramate cpsp 25mg $0 (1) MO topiramate tabs $0 (1) MO Sodium Channel Agents BANZEL $0 (2) PA MO carbamazepine er cp12 $0 (1) carbamazepine er tb12 $0 (1) MO carbamazepine chew, susp, tabs $0 (1) DILANTIN CAPS 30MG $0 (2) MO epitol $0 (1) MO fosphenytoin sodium $0 (1) oxcarbazepine tabs $0 (1) oxcarbazepine susp $0 (1) MO PEGANONE $0 (2) MO phenytoin sodium extended $0 (1) phenytoin sodium inj $0 (1) phenytoin susp $0 (1) phenytoin chew $0 (1) MO VIMPAT INJ $0 (2) VIMPAT ORAL SOLN $0 (2) MO 14

27 What Name of drug VIMPAT TABS 50MG $0 (2) QL (180 EA per 30 days) MO VIMPAT TABS 100MG, 150MG, 200MG $0 (2) QL (60 EA per 30 days) MO ANTIDEMENTIA AGENTS-DRUGS USED TO TREAT DEMENTIA AND MEMORY LOSS Antidementia Agents, Other ergoloid mesylates tabs $0 (1) PA MO Cholinesterase Inhibitors donepezil hcl tbdp $0 (1) QL (30 EA per 30 days) donepezil hcl tabs 23mg, 5mg $0 (1) QL (30 EA per 30 days) donepezil hcl tabs 10mg $0 (1) QL (60 EA per 30 days) galantamine hydrobromide soln $0 (1) QL (200 ML per 30 days) MO galantamine hydrobromide cp24 $0 (1) QL (30 EA per 30 days) galantamine hydrobromide tabs $0 (1) QL (60 EA per 30 days) NAMZARIC $0 (2) QL (30 EA per 30 days) PA MO rivastigmine tartrate $0 (1) QL (60 EA per 30 days) rivastigmine transdermal system $0 (1) QL (30 EA per 30 days) MO N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl $0 (1) QL (60 EA per 30 days) PA memantine hcl titration pak $0 (1) QL (98 EA per 365 days) PA MO memantine hydrochloride soln $0 (1) QL (360 ML per 30 days) PA NAMENDA TITRATION PAK $0 (2) QL (98 EA per 365 days) PA MO NAMENDA XR TITRATION PACK $0 (2) QL (56 EA per 365 days) PA MO NAMENDA XR CP24 14MG $0 (2) QL (30 EA per 30 days) PA NAMENDA XR CP24 21MG, 28MG, 7MG $0 (2) QL (30 EA per 30 days) PA MO NAMENDA SOLN $0 (2) QL (360 ML per 30 days) PA MO NAMENDA TABS $0 (2) QL (60 EA per 30 days) PA MO ANTIDEPRESSANTS-DRUGS USED TO TREAT DEPRESSION Antidepressants, Other bupropion hcl er $0 (1) QL (60 EA per 30 days) bupropion hcl sr tb12 100mg, 150mg, 200mg $0 (1) QL (60 EA per 30 days) bupropion hcl xl tb24 300mg $0 (1) QL (30 EA per 30 days) bupropion hcl xl tb24 150mg $0 (1) QL (30 EA per 30 days) MO bupropion hcl tabs $0 (1) QL (180 EA per 30 days) mirtazapine $0 (1) mirtazapine odt $0 (1) QL (30 EA per 30 days) MO TRINTELLIX $0 (2) QL (30 EA per 30 days) PA 15

28 Name of drug What Monoamine Oxidase Inhibitors EMSAM $0 (2) QL (30 EA per 30 days) PA MO MARPLAN $0 (2) MO phenelzine sulfate $0 (1) tranylcypromine sulfate $0 (1) MO SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitor BRINTELLIX TABS 20MG $0 (2) QL (30 EA per 30 days) PA BRINTELLIX TABS 10MG, 5MG $0 (2) QL (30 EA per 30 days) PA MO citalopram hydrobromide soln $0 (1) QL (600 ML per 30 days) citalopram hydrobromide tabs 10mg $0 (1) QL (120 EA per 30 days) citalopram hydrobromide tabs 40mg $0 (1) QL (30 EA per 30 days) citalopram hydrobromide tabs 20mg $0 (1) QL (60 EA per 30 days) desvenlafaxine er tb24 100mg, 50mg $0 (1) QL (30 EA per 30 days) PA desvenlafaxine er tb24 50mg $0 (1) QL (30 EA per 30 days) PA MO duloxetine hcl cpep 20mg, 60mg $0 (1) QL (60 EA per 30 days) duloxetine hcl cpep 40mg $0 (1) QL (60 EA per 30 days) MO duloxetine hcl cpep 30mg $0 (1) QL (90 EA per 30 days) MO escitalopram oxalate soln $0 (1) QL (600 ML per 30 days) escitalopram oxalate tabs 20mg $0 (1) QL (30 EA per 30 days) escitalopram oxalate tabs 10mg, 5mg $0 (1) QL (45 EA per 30 days) FETZIMA $0 (2) QL (30 EA per 30 days) PA MO FETZIMA TITRATION PACK $0 (2) QL (56 EA per 365 days) PA MO fluoxetine $0 (1) MO fluoxetine dr $0 (1) QL (4 EA per 28 days) MO fluoxetine hcl caps, soln $0 (1) fluoxetine hcl tabs 10mg, 20mg $0 (1) fluoxetine hcl tabs 60mg $0 (1) MO fluvoxamine maleate tabs 100mg, 50mg $0 (1) fluvoxamine maleate tabs 25mg $0 (1) MO maprotiline hcl $0 (1) MO nefazodone hcl $0 (1) MO olanzapine/fluoxetine caps 25mg; 12mg, 25mg; 6mg, $0 (1) QL (30 EA per 30 days) 50mg; 12mg, 50mg; 6mg olanzapine/fluoxetine caps 25mg; 3mg $0 (1) QL (30 EA per 30 days) MO 16

29 Name of drug What paroxetine hcl $0 (1) PAXIL SUSP $0 (2) MO PRISTIQ TB24 25MG $0 (2) QL (120 EA per 30 days) PA MO sertraline hcl conc, tabs $0 (1) trazodone hcl $0 (1) venlafaxine hcl $0 (1) MO venlafaxine hcl er cp mg, 75mg $0 (1) QL (30 EA per 30 days) venlafaxine hcl er cp24 150mg $0 (1) QL (60 EA per 30 days) venlafaxine hcl er tb mg, 75mg $0 (1) QL (30 EA per 30 days) venlafaxine hcl er tb24 225mg $0 (1) QL (30 EA per 30 days) MO venlafaxine hcl er tb24 150mg $0 (1) QL (60 EA per 30 days) VIIBRYD STARTER PACK $0 (2) QL (60 EA per 365 days) MO VIIBRYD TABS $0 (2) QL (30 EA per 30 days) MO VIIBRYD KIT $0 (2) QL (60 EA per 365 days) Tricyclics amitriptyline hcl tabs 100mg, 25mg, 50mg, 75mg $0 (1) PA amitriptyline hcl tabs 10mg, 150mg $0 (1) PA MO amoxapine $0 (1) MO clomipramine hcl caps $0 (1) PA desipramine hcl tabs 100mg, 150mg, 25mg, 50mg $0 (1) desipramine hcl tabs 10mg, 75mg $0 (1) MO doxepin hcl caps 100mg, 10mg, 25mg, 50mg, 75mg $0 (1) PA doxepin hcl caps 150mg $0 (1) PA MO doxepin hcl conc $0 (1) PA MO imipramine hcl tabs $0 (1) PA nortriptyline hcl caps 10mg, 25mg, 75mg $0 (1) nortriptyline hcl caps 50mg $0 (1) MO nortriptyline hcl soln $0 (1) MO perphenazine/amitriptyline tabs 25mg; 4mg $0 (1) perphenazine/amitriptyline tabs 10mg; 2mg, 10mg; $0 (1) MO 4mg, 25mg; 2mg, 50mg; 4mg protriptyline hcl $0 (1) trimipramine maleate caps $0 (1) PA ANTIEMETICS-DRUGS FOR NAUSEA AND VOMITING Antiemetics, Other 17

30 What Name of drug meclizine hcl tabs $0 (1) phenadoz supp 25mg $0 (1) PA phenadoz supp 12.5mg $0 (1) PA MO phenergan supp $0 (1) PA promethazine hcl supp 12.5mg, 50mg $0 (1) PA promethazine hcl supp 25mg $0 (1) PA MO promethegan supp 12.5mg, 25mg $0 (1) PA promethegan supp 50mg $0 (1) PA MO TRANSDERM-SCOP $0 (2) MO Emetogenic Therapy Adjuncts dronabinol $0 (1) QL (60 EA per 30 days) PA EMEND CAPS 40MG $0 (2) QL (1 EA per 30 days) B/D EMEND CAPS 0, 125MG, 80MG $0 (2) QL (6 EA per 30 days) B/D MO granisetron hcl tabs $0 (1) QL (60 EA per 30 days) B/D ondansetron hcl oral soln $0 (1) QL (900 ML per 30 days) B/D MO ondansetron hcl inj 40mg/20ml, 4mg/2ml $0 (1) ondansetron hcl inj 4mg/2ml $0 (1) MO ondansetron hcl tabs 4mg, 8mg $0 (1) B/D ondansetron hcl tabs 24mg $0 (1) B/D MO ondansetron odt tbdp 8mg $0 (1) B/D ondansetron odt tbdp 4mg $0 (1) B/D MO ANTIFUNGALS-DRUGS USED TO TREAT FUNGAL INFECTIONS Antifungals ABELCET $0 (2) B/D AMBISOME $0 (2) B/D amphotericin b $0 (1) B/D MO CANCIDAS INJ 50MG $0 (2) CANCIDAS INJ 70MG $0 (2) MO ciclodan $0 (1) ciclopirox nail lacquer $0 (1) ciclopirox olamine crea $0 (1) ciclopirox gel, susp $0 (1) ciclopirox sham $0 (1) MO clotrimazole/betamethasone dipropionate $0 (1) 18

31 Name of drug What clotrimazole vaginal crea 1% $0 (3) * clotrimazole soln $0 (1) clotrimazole external crea, troc $0 (1) MO econazole nitrate crea $0 (1) MO ERAXIS $0 (2) PA fluconazole in dextrose $0 (1) fluconazole in nacl inj 100mg/50ml; 0.9%, $0 (1) 400mg/200ml; 0.9% fluconazole susr, tabs $0 (1) flucytosine $0 (1) MO gnp miconazole 3 $0 (3) * gnp terbinafine hydrochloride $0 (3) * griseofulvin microsize susp $0 (1) griseofulvin microsize tabs $0 (1) MO griseofulvin ultramicrosize $0 (1) itraconazole caps $0 (1) PA ketoconazole tabs $0 (1) ketoconazole crea, sham $0 (1) MO LAMISIL AT $0 (3) * miconazole 3 combo pack $0 (3) * miconazole 7 $0 (3) * NOXAFIL INJ $0 (2) PA NOXAFIL SUSP, TBEC $0 (2) PA MO nyamyc $0 (1) MO nystatin crea, oint, powd, susp, tabs $0 (1) nystop $0 (1) MO qc 3 day vaginal cream $0 (3) * sm athletes foot crea $0 (3) * sm miconazole 3 $0 (3) * sm miconazole 7 crea $0 (3) * SPORANOX SOLN $0 (2) PA MO terbinafine hcl tabs $0 (1) terbinafine hcl crea $0 (3) * terconazole $0 (1) MO tioconazole-1 $0 (3) * 19

32 What Name of drug voriconazole inj, tabs $0 (1) voriconazole susr $0 (1) MO zazole $0 (1) ANTIGOUT AGENTS- DRUGS USED TO TREAT GOUT Antigout Agents allopurinol tabs 300mg $0 (1) allopurinol tabs 100mg $0 (1) MO colchicine caps, tabs $0 (1) MO probenecid/colchicine $0 (1) probenecid tabs $0 (1) MO ULORIC $0 (2) ST MO ANTIMIGRAINE AGENTS- DRUGS USED TO TREAT SEVERE HEADACHES Ergot Alkaloids dihydroergotamine mesylate inj $0 (1) MO MIGERGOT $0 (2) QL (20 EA per 28 days) MO Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl $0 (1) QL (9 EA per 30 days) rizatriptan benzoate odt $0 (1) QL (12 EA per 30 days) rizatriptan benzoate tabs 5mg $0 (1) QL (12 EA per 30 days) rizatriptan benzoate tabs 10mg $0 (1) QL (12 EA per 30 days) MO sumatriptan succinate refill inj 6mg/0.5ml $0 (1) QL (4 ML per 30 days) sumatriptan succinate refill inj 4mg/0.5ml $0 (1) QL (4 ML per 30 days) MO sumatriptan succinate inj 6mg/0.5ml $0 (1) QL (4 ML per 30 days) sumatriptan succinate inj 4mg/0.5ml $0 (1) QL (4 ML per 30 days) MO sumatriptan succinate tabs 100mg, 50mg $0 (1) QL (9 EA per 30 days) sumatriptan succinate tabs 25mg $0 (1) QL (9 EA per 30 days) MO sumatriptan soln $0 (1) QL (12 EA per 30 days) MO zolmitriptan odt $0 (1) QL (6 EA per 30 days) zolmitriptan tabs $0 (1) QL (6 EA per 30 days) ANTIMYASTHENIC AGENTS- DRUGS USED TO TREAT MYASTHENIA GRAVIS Parasympathomimetics guanidine hcl $0 (1) MESTINON TIMESPAN $0 (2) MO MESTINON SYRP $0 (2) MO 20

33 What Name of drug pyridostigmine bromide tabs, tbcr $0 (1) ANTIMYCOBACTERIALS- DRUGS USED TO TREAT TUBERCULOSIS Antimycobacterials, Other dapsone tabs $0 (1) MO rifabutin $0 (1) MO Antituberculars CAPASTAT SULFATE $0 (2) cycloserine $0 (1) MO ethambutol hcl $0 (1) MO isoniazid inj $0 (1) isoniazid syrp $0 (1) MO isoniazid tabs 300mg $0 (1) isoniazid tabs 100mg $0 (1) MO PASER $0 (2) MO PRIFTIN $0 (2) pyrazinamide tabs $0 (1) MO rifampin caps, inj $0 (1) RIFATER $0 (2) MO SIRTURO $0 (2) QL (188 EA per 365 days) PA TRECATOR $0 (2) MO ANTINEOPLASTICS- DRUGS USED TO TREAT CANCER Alkylating Agents ALKERAN TABS $0 (2) B/D MO BENDEKA $0 (2) BUSULFEX $0 (2) cyclophosphamide inj $0 (1) cyclophosphamide caps $0 (1) B/D MO GLEOSTINE CAPS 5MG $0 (2) HEXALEN $0 (2) MO LEUKERAN $0 (2) MO lomustine $0 (1) MATULANE $0 (2) melphalan hydrochloride $0 (1) MUSTARGEN $0 (2) 21

34 Name of drug What TEMODAR INJ $0 (2) B/D thiotepa $0 (1) TREANDA $0 (2) VALCHLOR $0 (2) PA LA YONDELIS $0 (2) PA Antiandrogens bicalutamide $0 (1) flutamide $0 (1) NILANDRON $0 (2) MO XTANDI $0 (2) QL (120 EA per 30 days) PA ZYTIGA $0 (2) QL (120 EA per 30 days) PA Antiangiogenic Agents POMALYST $0 (2) QL (21 EA per 28 days) PA REVLIMID $0 (2) QL (30 EA per 30 days) PA THALOMID CAPS 100MG, 150MG, 50MG $0 (2) QL (28 EA per 28 days) PA THALOMID CAPS 200MG $0 (2) QL (56 EA per 28 days) PA Antiestrogens/Modifiers EMCYT $0 (2) MO FARESTON $0 (2) MO SOLTAMOX $0 (2) PA MO tamoxifen citrate tabs 20mg $0 (1) tamoxifen citrate tabs 10mg $0 (1) MO Antimetabolites DEPOCYT $0 (2) DROXIA $0 (2) MO hydroxyurea caps $0 (1) LONSURF TABS 6.14MG; 15MG $0 (2) QL (100 EA per 28 days) PA LONSURF TABS 8.19MG; 20MG $0 (2) QL (80 EA per 28 days) PA mercaptopurine tabs $0 (1) PURIXAN $0 (2) PA TABLOID $0 (2) MO Antineoplastics, Other ABRAXANE $0 (2) adrucil $0 (1) B/D 22

35 Name of drug What ALIMTA $0 (2) PA amifostine $0 (1) ARRANON $0 (2) AVASTIN $0 (2) PA azacitidine $0 (1) PA BELEODAQ $0 (2) PA BICNU $0 (2) bleomycin sulfate $0 (1) B/D carboplatin $0 (1) cisplatin $0 (1) cladribine $0 (1) B/D CLOLAR $0 (2) COSMEGEN $0 (2) COTELLIC $0 (2) QL (63 EA per 28 days) PA cytarabine aqueous $0 (1) B/D dacarbazine $0 (1) daunorubicin hcl $0 (1) decitabine $0 (1) dexrazoxane $0 (1) DOCEFREZ INJ 20MG $0 (2) docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml, $0 (1) 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml doxorubicin hcl $0 (1) B/D doxorubicin hcl liposome $0 (1) ELITEK $0 (2) PA epirubicin hcl inj 200mg/100ml, 50mg/25ml $0 (1) ERBITUX $0 (2) PA ERWINAZE $0 (2) PA FARYDAK $0 (2) QL (6 EA per 21 days) PA FASLODEX $0 (2) PA MO fludarabine phosphate $0 (1) fluorouracil inj 2.5gm/50ml $0 (1) B/D FOLOTYN $0 (2) FUSILEV $0 (2) 23

36 Name of drug What gemcitabine $0 (1) gemcitabine hcl $0 (1) HALAVEN $0 (2) PA HERCEPTIN $0 (2) PA IBRANCE $0 (2) QL (21 EA per 28 days) PA idarubicin hcl $0 (1) ifosfamide $0 (1) INTRON A W/DILUENT $0 (2) PA INTRON A INJ 10MU/ML, 18MU, 50MU, $0 (2) PA UNIT/ML irinotecan $0 (1) ISTODAX $0 (2) PA IXEMPRA KIT $0 (2) PA JEVTANA $0 (2) PA KADCYLA $0 (2) PA leucovorin calcium inj $0 (1) leucovorin calcium tabs 5mg $0 (1) leucovorin calcium tabs 10mg, 15mg, 25mg $0 (1) MO levoleucovorin calcium $0 (1) levoleucovorin inj 250mg/25ml $0 (1) LYNPARZA $0 (2) QL (448 EA per 28 days) PA LA MARQIBO $0 (2) PA LA mesna $0 (1) MESNEX TABS $0 (2) MO mitomycin $0 (1) mitoxantrone hcl $0 (1) NINLARO $0 (2) QL (3 EA per 28 days) PA NIPENT $0 (2) ODOMZO $0 (2) QL (30 EA per 30 days) PA ONCASPAR $0 (2) oxaliplatin $0 (1) paclitaxel $0 (1) PERJETA $0 (2) PA PORTRAZZA $0 (2) PA LA PROLEUKIN $0 (2) 24

37 Name of drug What SYLATRON $0 (2) PA SYNRIBO $0 (2) PA TAGRISSO $0 (2) QL (30 EA per 30 days) PA LA THERACYS $0 (2) TICE BCG $0 (2) TRISENOX $0 (2) PA UVADEX $0 (2) VALSTAR $0 (2) VECTIBIX $0 (2) PA VELCADE $0 (2) PA VENCLEXTA $0 (2) QL (120 EA per 30 days) PA LA VENCLEXTA STARTING PACK $0 (2) QL (84 EA per 365 days) PA LA vinblastine sulfate inj 1mg/ml $0 (1) B/D vincasar pfs $0 (1) B/D vincristine sulfate $0 (1) B/D vinorelbine tartrate $0 (1) YERVOY $0 (2) PA ZALTRAP $0 (2) PA ZANOSAR $0 (2) ZOLINZA $0 (2) QL (120 EA per 30 days) PA Aromatase Inhibitors, 3rd Generation anastrozole tabs $0 (1) exemestane $0 (1) MO letrozole $0 (1) Enzyme Inhibitors etoposide inj $0 (1) toposar $0 (1) topotecan hcl $0 (1) ZYDELIG $0 (2) QL (60 EA per 30 days) PA LA Molecular Target Inhibitors AFINITOR $0 (2) QL (30 EA per 30 days) PA AFINITOR DISPERZ $0 (2) QL (60 EA per 30 days) PA ALECENSA $0 (2) QL (240 EA per 30 days) PA BOSULIF $0 (2) PA 25

38 Name of drug What CABOMETYX $0 (2) QL (30 EA per 30 days) PA CAPRELSA TABS 300MG $0 (2) QL (30 EA per 30 days) PA LA CAPRELSA TABS 100MG $0 (2) QL (60 EA per 30 days) PA LA COMETRIQ $0 (2) PA LA ERIVEDGE $0 (2) QL (30 EA per 30 days) PA GILOTRIF $0 (2) QL (30 EA per 30 days) PA LA GLEEVEC TABS 400MG $0 (2) QL (60 EA per 30 days) PA GLEEVEC TABS 100MG $0 (2) QL (90 EA per 30 days) PA ICLUSIG TABS 45MG $0 (2) QL (30 EA per 30 days) PA LA ICLUSIG TABS 15MG $0 (2) QL (60 EA per 30 days) PA LA imatinib mesylate tabs 400mg $0 (1) QL (60 EA per 30 days) PA imatinib mesylate tabs 100mg $0 (1) QL (90 EA per 30 days) PA IMBRUVICA $0 (2) QL (120 EA per 30 days) PA LA INLYTA TABS 5MG $0 (2) QL (120 EA per 30 days) PA INLYTA TABS 1MG $0 (2) QL (240 EA per 30 days) PA IRESSA $0 (2) QL (30 EA per 30 days) PA LA JAKAFI $0 (2) QL (60 EA per 30 days) PA LENVIMA 10 MG DAILY DOSE $0 (2) PA LA LENVIMA 14 MG DAILY DOSE $0 (2) PA LA LENVIMA 18 MG DAILY DOSE $0 (2) PA LENVIMA 20 MG DAILY DOSE $0 (2) PA LA LENVIMA 24 MG DAILY DOSE $0 (2) PA LA LENVIMA 8 MG DAILY DOSE $0 (2) PA MEKINIST TABS 0.5MG $0 (2) QL (120 EA per 30 days) PA MEKINIST TABS 2MG $0 (2) QL (30 EA per 30 days) PA NEXAVAR $0 (2) QL (120 EA per 30 days) PA SPRYCEL TABS 100MG, 140MG $0 (2) QL (30 EA per 30 days) PA SPRYCEL TABS 20MG, 50MG, 70MG, 80MG $0 (2) QL (60 EA per 30 days) PA STIVARGA $0 (2) QL (120 EA per 30 days) PA SUTENT CAPS 25MG, 37.5MG, 50MG $0 (2) QL (30 EA per 30 days) PA SUTENT CAPS 12.5MG $0 (2) QL (90 EA per 30 days) PA TAFINLAR CAPS 75MG $0 (2) QL (120 EA per 30 days) PA TAFINLAR CAPS 50MG $0 (2) QL (180 EA per 30 days) PA TARCEVA TABS 25MG $0 (2) QL (60 EA per 30 days) PA TARCEVA TABS 100MG, 150MG $0 (2) QL (90 EA per 30 days) PA 26

39 What Name of drug TASIGNA $0 (2) QL (120 EA per 30 days) PA TORISEL $0 (2) TYKERB $0 (2) QL (180 EA per 30 days) PA VOTRIENT $0 (2) QL (120 EA per 30 days) PA XALKORI $0 (2) QL (60 EA per 30 days) PA ZELBORAF $0 (2) QL (240 EA per 30 days) PA ZYKADIA $0 (2) QL (150 EA per 30 days) PA Monoclonal Antibodies ARZERRA $0 (2) PA BLINCYTO $0 (2) PA CYRAMZA $0 (2) PA LA DARZALEX $0 (2) PA EMPLICITI $0 (2) PA GAZYVA $0 (2) PA KEYTRUDA $0 (2) PA OPDIVO $0 (2) PA RITUXAN $0 (2) PA TECENTRIQ $0 (2) PA Retinoids bexarotene $0 (1) PA PANRETIN $0 (2) MO TARGRETIN $0 (2) PA tretinoin caps 10mg $0 (1) ANTIPARASITICS-DRUGS USED TO TREAT MALARIA AND LICE Anthelmintics ALBENZA $0 (2) MO ivermectin tabs $0 (1) MO Antiprotozoals ALINIA SUSR $0 (2) ALINIA TABS $0 (2) MO atovaquone $0 (1) PA MO atovaquone/proguanil hcl $0 (1) chloroquine phosphate tabs $0 (1) COARTEM $0 (2) MO DARAPRIM $0 (2) 27

40 What Name of drug hydroxychloroquine sulfate tabs $0 (1) mefloquine hcl $0 (1) MO MEPRON $0 (2) PA MO NEBUPENT $0 (2) B/D MO PENTAM 300 $0 (2) MO primaquine phosphate tabs $0 (1) MO quinine sulfate $0 (1) PA MO Pediculicides/Scabicides gnp lice treatment liqd $0 (3) * lindane sham $0 (1) lindane lotn $0 (1) MO malathion $0 (1) MO permethrin crea $0 (1) MO ANTIPARKINSON AGENTS- DRUGS USED TO TREAT PARKINSONS DISEASE Anticholinergics benztropine mesylate inj $0 (1) PA MO benztropine mesylate tabs 2mg $0 (1) PA benztropine mesylate tabs 0.5mg, 1mg $0 (1) PA MO trihexyphenidyl hcl $0 (1) PA Antiparkinson Agents, Other amantadine hcl caps, syrp $0 (1) amantadine hcl tabs $0 (1) MO entacapone $0 (1) Dopamine Agonists APOKYN $0 (2) PA bromocriptine mesylate caps, tabs $0 (1) NEUPRO $0 (2) QL (30 EA per 30 days) MO pramipexole dihydrochloride $0 (1) ropinirole hcl $0 (1) Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa $0 (1) carbidopa/levodopa er $0 (1) carbidopa/levodopa odt $0 (1) MO 28

41 What $0 (1) Name of drug carbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg, 25mg; 200mg; 100mg, 31.25mg; 200mg; 125mg, 37.5mg; 200mg; 150mg, 50mg; 200mg; 200mg carbidopa/levodopa/entacapone tabs 12.5mg; $0 (1) MO 200mg; 50mg carbidopa tabs $0 (1) Monoamine Oxidase B (MAO-B) Inhibitors AZILECT $0 (2) QL (30 EA per 30 days) MO selegiline hcl tabs $0 (1) selegiline hcl caps $0 (1) MO ANTIPSYCHOTICS- DRUGS USED TO TREAT PSYCHOSES AND SCHIZOPHRENIA 1st Generation/Typical chlorpromazine hcl inj $0 (1) chlorpromazine hcl tabs 100mg, 200mg, 25mg, $0 (1) 50mg chlorpromazine hcl tabs 10mg $0 (1) MO compro $0 (1) MO fluphenazine decanoate inj $0 (1) MO fluphenazine hcl elix $0 (1) fluphenazine hcl conc, inj $0 (1) MO fluphenazine hcl tabs 10mg, 1mg, 5mg $0 (1) fluphenazine hcl tabs 2.5mg $0 (1) MO haloperidol decanoate $0 (1) haloperidol lactate $0 (1) haloperidol conc $0 (1) MO haloperidol tabs 0.5mg, 1mg, 20mg, 5mg $0 (1) haloperidol tabs 10mg, 2mg $0 (1) MO loxapine succinate caps 10mg, 50mg, 5mg $0 (1) loxapine succinate caps 25mg $0 (1) MO perphenazine tabs 4mg $0 (1) perphenazine tabs 16mg, 2mg, 8mg $0 (1) MO pimozide $0 (1) MO prochlorperazine $0 (1) prochlorperazine edisylate inj $0 (1) MO 29

42 Name of drug What prochlorperazine maleate tabs $0 (1) thioridazine hcl tabs 10mg, 25mg, 50mg $0 (1) PA thioridazine hcl tabs 100mg $0 (1) PA MO thiothixene caps 1mg $0 (1) thiothixene caps 10mg, 2mg, 5mg $0 (1) MO trifluoperazine hcl tabs 1mg $0 (1) trifluoperazine hcl tabs 10mg, 2mg, 5mg $0 (1) MO 2nd Generation/Atypical ABILIFY DISCMELT $0 (2) QL (60 EA per 30 days) ABILIFY MAINTENA $0 (2) MO ABILIFY INJ $0 (2) MO ABILIFY ORAL SOLN $0 (2) QL (900 ML per 30 days) aripiprazole odt tbdp 15mg $0 (1) QL (60 EA per 30 days) aripiprazole odt tbdp 10mg $0 (1) QL (60 EA per 30 days) MO aripiprazole tabs $0 (1) QL (30 EA per 30 days) aripiprazole soln $0 (1) QL (900 ML per 30 days) ARISTADA $0 (2) FANAPT TITRATION PACK $0 (2) QL (16 EA per 365 days) PA FANAPT TABS 10MG $0 (2) QL (60 EA per 30 days) PA FANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG, 8MG $0 (2) QL (60 EA per 30 days) PA MO GEODON INJ $0 (2) MO INVEGA SUSTENNA $0 (2) INVEGA TRINZA $0 (2) LATUDA TABS 40MG, 80MG $0 (2) QL (30 EA per 30 days) PA LATUDA TABS 120MG, 20MG, 60MG $0 (2) QL (30 EA per 30 days) PA MO NUPLAZID $0 (2) QL (60 EA per 30 days) PA olanzapine odt $0 (1) QL (30 EA per 30 days) olanzapine inj $0 (1) MO olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg $0 (1) QL (30 EA per 30 days) olanzapine tabs 2.5mg $0 (1) QL (60 EA per 30 days) paliperidone er tb24 1.5mg, 3mg, 9mg $0 (1) QL (30 EA per 30 days) paliperidone er tb24 6mg $0 (1) QL (60 EA per 30 days) quetiapine fumarate tabs 200mg $0 (1) QL (120 EA per 30 days) quetiapine fumarate tabs 25mg $0 (1) QL (180 EA per 30 days) quetiapine fumarate tabs 300mg, 400mg $0 (1) QL (60 EA per 30 days) 30

43 What Name of drug quetiapine fumarate tabs 100mg, 50mg $0 (1) QL (90 EA per 30 days) REXULTI $0 (2) QL (30 EA per 30 days) PA MO RISPERDAL CONSTA $0 (2) MO risperidone odt tbdp 4mg $0 (1) QL (120 EA per 30 days) MO risperidone odt tbdp 1mg, 2mg $0 (1) QL (60 EA per 30 days) risperidone odt tbdp 0.5mg $0 (1) QL (90 EA per 30 days) risperidone odt tbdp 0.25mg, 3mg $0 (1) QL (90 EA per 30 days) MO risperidone soln $0 (1) risperidone tabs 4mg $0 (1) QL (120 EA per 30 days) risperidone tabs 1mg, 2mg $0 (1) QL (60 EA per 30 days) risperidone tabs 0.25mg, 0.5mg, 3mg $0 (1) QL (90 EA per 30 days) SAPHRIS SUBL 10MG $0 (2) QL (60 EA per 30 days) PA SAPHRIS SUBL 2.5MG, 5MG $0 (2) QL (60 EA per 30 days) PA MO VRAYLAR CPPK $0 (2) QL (14 EA per 365 days) PA MO VRAYLAR CAPS $0 (2) QL (30 EA per 30 days) PA MO ziprasidone hcl caps 60mg, 80mg $0 (1) QL (60 EA per 30 days) ziprasidone hcl caps 20mg, 40mg $0 (1) QL (60 EA per 30 days) MO ZYPREXA RELPREVV INJ 405MG $0 (2) QL (1 EA per 28 days) ZYPREXA RELPREVV INJ 210MG, 300MG $0 (2) QL (2 EA per 28 days) Antipsychotics molindone hydrochloride tabs 25mg $0 (1) QL (270 EA per 30 days) MO molindone hydrochloride tabs 10mg $0 (1) QL (60 EA per 30 days) MO molindone hydrochloride tabs 5mg $0 (1) QL (90 EA per 30 days) MO Treatment-Resistant clozapine $0 (1) clozapine odt $0 (1) FAZACLO TBDP 12.5MG, 150MG, 200MG $0 (2) PA VERSACLOZ $0 (2) PA ANTISPASTICITY AGENTS - DRUGS USED TO TREAT MUSCLE SPASMS Antispasticity Agents baclofen tabs $0 (1) dantrolene sodium caps $0 (1) MO tizanidine hcl tabs $0 (1) 31

44 Name of drug What ANTIVIRALS- DRUGS USED TO TREAT VIRAL INFECTIONS, HEPATITIS AND HIV/AIDS INFECTIONS Anti-cytomegalovirus (CMV) Agents ganciclovir inj $0 (1) B/D VALCYTE SOLR $0 (2) MO valganciclovir $0 (1) Anti-hepatitis B (HBV) Agents adefovir dipivoxil $0 (1) QL (30 EA per 30 days) MO BARACLUDE SOLN $0 (2) QL (630 ML per 30 days) MO entecavir $0 (1) QL (30 EA per 30 days) EPIVIR HBV SOLN $0 (2) MO lamivudine tabs 100mg $0 (1) TYZEKA $0 (2) QL (30 EA per 30 days) MO Anti-hepatitis C (HCV) Agents HARVONI $0 (2) QL (30 EA per 30 days) PA moderiba tabs $0 (1) PEG-INTRON REDIPEN $0 (2) PA PEGINTRON $0 (2) PA ribasphere caps $0 (1) ribasphere tabs 200mg $0 (1) ribavirin $0 (1) SOVALDI $0 (2) QL (28 EA per 28 days) PA Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA $0 (2) QL (30 EA per 30 days) MO GENVOYA $0 (2) QL (30 EA per 30 days) MO ISENTRESS TABS $0 (2) QL (120 EA per 30 days) MO ISENTRESS CHEW $0 (2) QL (180 EA per 30 days) MO ISENTRESS PACK $0 (2) QL (300 EA per 30 days) TIVICAY TABS 10MG, 25MG $0 (2) QL (60 EA per 30 days) TIVICAY TABS 50MG $0 (2) QL (60 EA per 30 days) MO VITEKTA $0 (2) QL (30 EA per 30 days) Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA $0 (2) QL (30 EA per 30 days) MO EDURANT $0 (2) QL (30 EA per 30 days) MO INTELENCE TABS 25MG $0 (2) QL (180 EA per 30 days) 32

45 Name of drug What INTELENCE TABS 100MG, 200MG $0 (2) QL (60 EA per 30 days) MO nevirapine er tb24 400mg $0 (1) nevirapine er tb24 100mg $0 (1) MO nevirapine tabs $0 (1) nevirapine susp $0 (1) MO ODEFSEY $0 (2) QL (30 EA per 30 days) MO RESCRIPTOR $0 (2) MO STRIBILD $0 (2) QL (30 EA per 30 days) MO SUSTIVA $0 (2) MO VIRAMUNE SUSP $0 (2) MO Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir $0 (1) abacavir sulfate/lamivudine/zidovudine $0 (1) MO DESCOVY $0 (2) QL (30 EA per 30 days) MO didanosine cpdr 200mg, 250mg, 400mg $0 (1) didanosine cpdr 125mg $0 (1) MO EMTRIVA $0 (2) MO EPZICOM $0 (2) MO lamivudine/zidovudine $0 (1) lamivudine soln 10mg/ml $0 (1) lamivudine tabs 150mg, 300mg $0 (1) RETROVIR IV INFUSION $0 (2) stavudine caps 15mg, 20mg $0 (1) stavudine caps 30mg, 40mg $0 (1) MO stavudine solr $0 (1) TRIUMEQ $0 (2) QL (30 EA per 30 days) MO TRUVADA TABS 100MG; 150MG, 133MG; 200MG, $0 (2) QL (30 EA per 30 days) 167MG; 250MG TRUVADA TABS 200MG; 300MG $0 (2) QL (30 EA per 30 days) MO VIDEX PEDIATRIC SOLR 2GM $0 (2) VIDEX PEDIATRIC SOLR 4GM $0 (2) MO VIREAD $0 (2) MO ZIAGEN SOLN $0 (2) MO zidovudine $0 (1) MO 33

46 Name of drug What Anti-HIV Agents, Other FUZEON $0 (2) QL (60 EA per 30 days) SELZENTRY TABS 300MG $0 (2) QL (120 EA per 30 days) MO SELZENTRY TABS 150MG $0 (2) QL (60 EA per 30 days) MO TYBOST $0 (2) QL (30 EA per 30 days) MO Anti-HIV Agents, Protease Inhibitors APTIVUS SOLN $0 (2) APTIVUS CAPS $0 (2) MO CRIXIVAN $0 (2) MO EVOTAZ $0 (2) QL (30 EA per 30 days) MO INVIRASE $0 (2) MO KALETRA SOLN $0 (2) QL (390 ML per 30 days) MO KALETRA TABS 200MG; 50MG $0 (2) QL (120 EA per 30 days) MO KALETRA TABS 100MG; 25MG $0 (2) QL (240 EA per 30 days) MO LEXIVA $0 (2) MO NORVIR $0 (2) MO PREZCOBIX $0 (2) QL (30 EA per 30 days) MO PREZISTA SUSP $0 (2) MO PREZISTA TABS 75MG $0 (2) PREZISTA TABS 150MG, 600MG, 800MG $0 (2) MO REYATAZ $0 (2) MO VIRACEPT $0 (2) MO Anti-influenza Agents RELENZA DISKHALER $0 (2) QL (120 EA per 365 days) MO rimantadine hcl $0 (1) MO TAMIFLU SUSR $0 (2) QL (1080 ML per 365 days) MO TAMIFLU CAPS 30MG $0 (2) QL (168 EA per 365 days) MO TAMIFLU CAPS 45MG, 75MG $0 (2) QL (84 EA per 365 days) MO Antiherpetic Agents acyclovir sodium inj 50mg/ml $0 (1) B/D acyclovir sodium inj 500mg $0 (1) B/D MO acyclovir caps, susp, tabs $0 (1) acyclovir oint $0 (1) MO DENAVIR $0 (2) MO famciclovir tabs 125mg, 250mg $0 (1) QL (60 EA per 30 days) MO 34

47 What Name of drug famciclovir tabs 500mg $0 (1) QL (90 EA per 30 days) MO valacyclovir hcl $0 (1) Antivirals VIRAZOLE $0 (2) ZEPATIER $0 (2) QL (30 EA per 30 days) PA ANXIOLYTICS- DRUGS USED TO TREAT ANXIETY Anxiolytics, Other buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg $0 (1) buspirone hcl tabs 30mg $0 (1) MO Benzodiazepines alprazolam tabs 0.25mg, 0.5mg $0 (1) QL (120 EA per 30 days) alprazolam tabs 1mg, 2mg $0 (1) QL (150 EA per 30 days) clorazepate dipotassium tabs 15mg $0 (1) QL (180 EA per 30 days) clorazepate dipotassium tabs 3.75mg, 7.5mg $0 (1) QL (90 EA per 30 days) MO diazepam intensol $0 (1) MO diazepam inj 5mg/ml $0 (1) QL (240 ML per 30 days) diazepam oral soln 1mg/ml $0 (1) QL (1200 ML per 30 days) MO diazepam tabs 10mg, 2mg, 5mg $0 (1) QL (120 EA per 30 days) lorazepam intensol $0 (1) QL (150 ML per 30 days) lorazepam inj 2mg/ml, 4mg/ml $0 (1) QL (120 ML per 30 days) lorazepam tabs 0.5mg $0 (1) QL (120 EA per 30 days) lorazepam tabs 2mg $0 (1) QL (150 EA per 30 days) lorazepam tabs 1mg $0 (1) QL (180 EA per 30 days) BIPOLAR AGENTS- DRUGS USED TO TREAT BIPOLAR DISORDER Mood Stabilizers EQUETRO $0 (2) MO lithium $0 (1) MO lithium carbonate er $0 (1) lithium carbonate caps, tabs $0 (1) BLOOD GLUCOSE REGULATORS- DRUGS USED TO TREAT DIABETES Antidiabetic Agents acarbose $0 (1) alogliptin $0 (1) QL (30 EA per 30 days) MO alogliptin/metformin hcl $0 (1) QL (60 EA per 30 days) MO 35

48 Name of drug What alogliptin/pioglitazone $0 (1) QL (30 EA per 30 days) MO glimepiride $0 (1) glipizide er $0 (1) glipizide xl tb24 10mg $0 (1) glipizide xl tb24 2.5mg, 5mg $0 (1) MO glipizide/metformin hcl tabs 2.5mg; 250mg $0 (1) glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; $0 (1) MO 500mg glipizide tabs $0 (1) glyburide micronized tabs 3mg, 6mg $0 (1) PA glyburide micronized tabs 1.5mg $0 (1) PA MO glyburide/metformin hcl $0 (1) PA glyburide tabs 2.5mg, 5mg $0 (1) PA glyburide tabs 1.25mg $0 (1) PA MO INVOKAMET $0 (2) QL (60 EA per 30 days) MO INVOKANA TABS 300MG $0 (2) QL (30 EA per 30 days) INVOKANA TABS 100MG $0 (2) QL (60 EA per 30 days) JANUMET $0 (2) QL (60 EA per 30 days) MO JANUMET XR TB MG; 100MG, 500MG; $0 (2) QL (30 EA per 30 days) 50MG JANUMET XR TB MG; 50MG $0 (2) QL (60 EA per 30 days) JANUVIA TABS 100MG, 25MG $0 (2) QL (30 EA per 30 days) JANUVIA TABS 50MG $0 (2) QL (30 EA per 30 days) MO JENTADUETO $0 (2) JENTADUETO XR $0 (2) KORLYM $0 (2) QL (120 EA per 30 days) PA LA metformin hcl er tb24 500mg, 750mg $0 (1) metformin hcl er tb mg, 500mg $0 (1) MO metformin hcl tabs $0 (1) miglitol $0 (1) QL (90 EA per 30 days) nateglinide $0 (1) pioglitazone hcl $0 (1) QL (30 EA per 30 days) pioglitazone hcl-glimepiride $0 (1) QL (30 EA per 30 days) MO pioglitazone hcl/metformin hcl $0 (1) QL (90 EA per 30 days) repaglinide/metformin hydrochloride $0 (1) QL (150 EA per 30 days) MO 36

49 Name of drug What repaglinide tabs 0.5mg, 1mg $0 (1) QL (120 EA per 30 days) repaglinide tabs 2mg $0 (1) QL (240 EA per 30 days) SYMLINPEN 120 $0 (2) QL (10.8 ML per 30 days) MO SYMLINPEN 60 $0 (2) QL (6 ML per 30 days) MO tolazamide $0 (1) MO tolbutamide $0 (1) TRADJENTA $0 (2) TRULICITY $0 (2) QL (2 ML per 28 days) MO VICTOZA $0 (2) QL (9 ML per 30 days) MO Glycemic Agents GLUCAGEN HYPOKIT $0 (2) QL (4 EA per 30 days) MO GLUCAGON EMERGENCY KIT $0 (2) QL (4 EA per 30 days) MO PROGLYCEM $0 (2) MO Insulins HUMALOG $0 (2) MO HUMALOG KWIKPEN $0 (2) MO HUMALOG MIX 50/50 $0 (2) MO HUMALOG MIX 50/50 KWIKPEN $0 (2) MO HUMALOG MIX 75/25 $0 (2) MO HUMALOG MIX 75/25 KWIKPEN $0 (2) MO HUMULIN 70/30 $0 (2) MO HUMULIN 70/30 KWIKPEN $0 (2) HUMULIN N $0 (2) MO HUMULIN N KWIKPEN $0 (2) HUMULIN R $0 (2) MO HUMULIN R U-500 (CONCENTRATED) $0 (2) MO HUMULIN R U-500 KWIKPEN $0 (2) MO LANTUS $0 (2) MO LANTUS SOLOSTAR $0 (2) MO LEVEMIR $0 (2) MO LEVEMIR FLEXTOUCH $0 (2) MO NOVOLIN 70/30 $0 (2) MO NOVOLIN 70/30 RELION $0 (2) NOVOLIN N $0 (2) MO NOVOLIN N RELION $0 (2) 37

50 What Name of drug NOVOLIN R $0 (2) MO NOVOLIN R RELION $0 (2) NOVOLOG $0 (2) MO NOVOLOG FLEXPEN $0 (2) MO NOVOLOG MIX 70/30 $0 (2) MO NOVOLOG MIX 70/30 PREFILLED FLEXPEN $0 (2) MO NOVOLOG PENFILL $0 (2) MO TRESIBA FLEXTOUCH $0 (2) MO BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS- DRUGS USED TO TREAT BLOOD DISORDERS; ANTICOAGULANTS/BLOOD THINNERS Anticoagulants enoxaparin sodium $0 (1) fondaparinux sodium $0 (1) heparin sodium/d5w $0 (1) heparin sodium/nacl 0.45% $0 (1) heparin sodium/nacl 0.9% $0 (1) heparin sodium/sodium chloride 0.9% $0 (1) heparin sodium/sodium chloride 0.9% premix $0 (1) heparin sodium inj 10000unit/ml, 1000unit/ml, $0 (1) 20000unit/ml, 5000unit/0.5ml, 5000unit/ml jantoven tabs 10mg, 2.5mg, 5mg $0 (1) jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg $0 (1) MO PRADAXA $0 (2) QL (60 EA per 30 days) MO warfarin sodium tabs $0 (1) XARELTO STARTER PACK $0 (2) QL (102 EA per 365 days) MO XARELTO TABS 10MG, 20MG $0 (2) QL (30 EA per 30 days) XARELTO TABS 15MG $0 (2) QL (60 EA per 30 days) Blood Formation Modifiers anagrelide hydrochloride $0 (1) MO ARANESP ALBUMIN FREE INJ 500MCG/ML $0 (2) QL (1 ML per 21 days) PA ARANESP ALBUMIN FREE INJ 150MCG/0.3ML, $0 (2) QL (1.2 ML per 28 days) PA 60MCG/0.3ML ARANESP ALBUMIN FREE INJ 200MCG/0.4ML, $0 (2) QL (1.6 ML per 28 days) PA 40MCG/0.4ML ARANESP ALBUMIN FREE INJ 25MCG/0.42ML $0 (2) QL (1.68 ML per 28 days) PA 38

51 Name of drug What ARANESP ALBUMIN FREE INJ 100MCG/0.5ML $0 (2) QL (2 ML per 28 days) PA ARANESP ALBUMIN FREE INJ 300MCG/0.6ML $0 (2) QL (2.4 ML per 28 days) PA ARANESP ALBUMIN FREE INJ 150MCG/0.75ML $0 (2) QL (3 ML per 28 days) PA ARANESP ALBUMIN FREE INJ 10MCG/0.4ML $0 (2) QL (3.2 ML per 28 days) PA ARANESP ALBUMIN FREE INJ 100MCG/ML, $0 (2) QL (4 ML per 28 days) PA 200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/ ML, 60MCG/ML LEUKINE INJ 250MCG $0 (2) PA MOZOBIL $0 (2) PA NEUMEGA $0 (2) PA NEUPOGEN $0 (2) PA PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, $0 (2) QL (12 ML per 28 days) PA 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML PROCRIT INJ 40000UNIT/ML $0 (2) QL (8 ML per 28 days) PA PROMACTA $0 (2) QL (30 EA per 30 days) PA Coagulants tranexamic acid inj $0 (1) tranexamic acid tabs $0 (1) QL (30 EA per 5 days) Platelet Modifying Agents aspirin/dipyridamole $0 (1) QL (60 EA per 30 days) BRILINTA $0 (2) QL (60 EA per 30 days) MO cilostazol $0 (1) clopidogrel tabs 300mg $0 (1) QL (2 EA per 365 days) clopidogrel tabs 75mg $0 (1) QL (30 EA per 30 days) EFFIENT $0 (2) QL (30 EA per 30 days) ticlopidine hcl $0 (1) PA CARDIOVASCULAR AGENTS - DRUGS USED TO TREAT HEART AND CIRCULATION CONDITIONS, HIGH BLOOD PRESSURE, HEART RHYTHM, HIGH CHOLESTEROL Alpha-adrenergic Agonists clonidine hcl tabs $0 (1) clonidine hcl ptwk $0 (1) QL (8 EA per 28 days) midodrine hcl $0 (1) Alpha-adrenergic Blocking Agents doxazosin $0 (1) MO doxazosin mesylate tabs 8mg $0 (1) 39

52 Name of drug What doxazosin mesylate tabs 1mg, 2mg $0 (1) MO prazosin hcl $0 (1) terazosin hcl $0 (1) Angiotensin II Receptor Antagonists candesartan cilexetil/hydrochlorothiazide tabs 32mg; $0 (1) QL (30 EA per 30 days) 12.5mg, 32mg; 25mg candesartan cilexetil/hydrochlorothiazide tabs 16mg; $0 (1) QL (60 EA per 30 days) 12.5mg candesartan cilexetil tabs 16mg, 32mg $0 (1) QL (30 EA per 30 days) candesartan cilexetil tabs 4mg, 8mg $0 (1) QL (30 EA per 30 days) MO EDARBI $0 (2) QL (30 EA per 30 days) MO EDARBYCLOR $0 (2) QL (30 EA per 30 days) MO ENTRESTO $0 (2) QL (60 EA per 30 days) PA MO eprosartan mesylate $0 (1) QL (30 EA per 30 days) MO irbesartan $0 (1) QL (30 EA per 30 days) irbesartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days) losartan potassium/hydrochlorothiazide $0 (1) QL (30 EA per 30 days) losartan potassium tabs 100mg $0 (1) QL (30 EA per 30 days) losartan potassium tabs 25mg, 50mg $0 (1) QL (60 EA per 30 days) telmisartan $0 (1) QL (30 EA per 30 days) telmisartan/amlodipine $0 (1) QL (30 EA per 30 days) MO telmisartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days) valsartan $0 (1) valsartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide $0 (1) MO benazepril hcl tabs $0 (1) captopril/hydrochlorothiazide $0 (1) MO captopril tabs 12.5mg, 25mg, 50mg $0 (1) captopril tabs 100mg $0 (1) MO enalapril maleate/hydrochlorothiazide $0 (1) enalapril maleate tabs $0 (1) fosinopril sodium/hydrochlorothiazide $0 (1) fosinopril sodium tabs 20mg, 40mg $0 (1) fosinopril sodium tabs 10mg $0 (1) MO 40

53 Name of drug What lisinopril $0 (1) lisinopril/hydrochlorothiazide $0 (1) moexipril hcl tabs 15mg $0 (1) moexipril hcl tabs 7.5mg $0 (1) MO moexipril/hydrochlorothiazide $0 (1) MO perindopril erbumine $0 (1) quinapril hcl tabs 10mg, 40mg $0 (1) quinapril hcl tabs 20mg, 5mg $0 (1) MO quinapril/hydrochlorothiazide $0 (1) ramipril caps 10mg, 2.5mg, 5mg $0 (1) ramipril caps 1.25mg $0 (1) MO trandolapril $0 (1) trandolapril/verapamil hcl $0 (1) MO trandolapril/verapamil hcl er $0 (1) Antiarrhythmics amiodarone hcl tabs 200mg $0 (1) amiodarone hcl tabs 100mg, 400mg $0 (1) MO disopyramide phosphate caps 150mg $0 (1) PA disopyramide phosphate caps 100mg $0 (1) PA MO dofetilide $0 (1) flecainide acetate tabs 50mg $0 (1) flecainide acetate tabs 100mg, 150mg $0 (1) MO lidocaine hcl inj 10mg/ml, 20mg/ml $0 (1) mexiletine hcl $0 (1) MO MULTAQ $0 (2) MO pacerone tabs 100mg $0 (1) pacerone tabs 200mg, 400mg $0 (1) MO propafenone hcl $0 (1) propafenone hcl er $0 (1) quinidine gluconate cr $0 (1) MO quinidine gluconate er $0 (1) quinidine sulfate tabs 300mg $0 (1) quinidine sulfate tabs 200mg $0 (1) MO sorine $0 (1) 41

54 Name of drug What sotalol hcl (af) tabs 160mg, 80mg $0 (1) sotalol hcl (af) tabs 120mg $0 (1) MO sotalol hcl tabs 120mg, 160mg, 80mg $0 (1) sotalol hcl tabs 240mg $0 (1) MO TIKOSYN $0 (2) Beta-adrenergic Blocking Agents acebutolol hcl caps $0 (1) atenolol/chlorthalidone tabs 50mg; 25mg $0 (1) atenolol/chlorthalidone tabs 100mg; 25mg $0 (1) MO atenolol tabs $0 (1) betaxolol hcl tabs 10mg, 20mg $0 (1) MO bisoprolol fumarate $0 (1) bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; $0 (1) 6.25mg, 5mg; 6.25mg bisoprolol fumarate/hydrochlorothiazide tabs 10mg; $0 (1) MO 6.25mg carvedilol $0 (1) labetalol hcl inj, tabs $0 (1) metoprolol succinate er tb24 100mg, 25mg, 50mg $0 (1) metoprolol succinate er tb24 200mg $0 (1) MO metoprolol tartrate inj $0 (1) metoprolol tartrate tabs 100mg, 25mg, 50mg $0 (1) metoprolol tartrate tabs 37.5mg, 75mg $0 (1) MO metoprolol/hydrochlorothiazide $0 (1) MO nadolol/bendroflumethiazide $0 (1) MO nadolol tabs 40mg, 80mg $0 (1) nadolol tabs 20mg $0 (1) MO pindolol $0 (1) MO propranolol hcl er $0 (1) propranolol hcl inj $0 (1) propranolol hcl oral soln $0 (1) MO propranolol hcl tabs 80mg $0 (1) propranolol hcl tabs 10mg, 20mg, 40mg, 60mg $0 (1) MO propranolol/hydrochlorothiazide $0 (1) MO timolol maleate tabs 10mg, 20mg, 5mg $0 (1) MO 42

55 What Name of drug Calcium Channel Blocking Agents amlodipine besylate/atorvastatin calcium tabs 10mg; $0 (1) 20mg, 10mg; 40mg amlodipine besylate/atorvastatin calcium tabs 10mg; $0 (1) MO 10mg, 10mg; 80mg, 2.5mg; 10mg, 2.5mg; 20mg, 2.5mg; 40mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg, 5mg; 80mg amlodipine besylate/benazepril hydrochloride $0 (1) QL (30 EA per 30 days) amlodipine besylate/valsartan $0 (1) QL (30 EA per 30 days) MO amlodipine besylate tabs $0 (1) amlodipine/valsartan/hctz $0 (1) QL (30 EA per 30 days) cartia xt $0 (1) dilt-xr $0 (1) diltiazem cd $0 (1) diltiazem hcl cd $0 (1) diltiazem hcl er cp24 120mg, 180mg, 240mg, $0 (1) 300mg, 360mg, 420mg diltiazem hcl er cp24 180mg, 360mg $0 (1) MO diltiazem hcl er tb24 $0 (1) diltiazem hcl er cp12 $0 (1) MO diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, $0 (1) 50mg/10ml diltiazem hcl tabs 30mg, 60mg $0 (1) diltiazem hcl tabs 120mg, 90mg $0 (1) MO felodipine er tb24 10mg $0 (1) felodipine er tb24 2.5mg, 5mg $0 (1) MO isradipine $0 (1) MO matzim la $0 (1) MO nicardipine hcl caps 30mg $0 (1) nicardipine hcl caps 20mg $0 (1) MO nifedipine er tb24 30mg, 60mg, 90mg $0 (1) nifedipine er tb24 90mg $0 (1) MO nisoldipine $0 (1) MO nisoldipine er $0 (1) MO taztia xt $0 (1) 43

56 What Name of drug verapamil hcl er cp24 200mg $0 (1) verapamil hcl er cp24 100mg, 120mg, 180mg, $0 (1) MO 240mg, 300mg verapamil hcl er tbcr 120mg $0 (1) verapamil hcl er tbcr 180mg, 240mg $0 (1) MO verapamil hcl sr cp24 120mg, 180mg, 240mg $0 (1) verapamil hcl sr cp24 360mg $0 (1) MO verapamil hcl sr tbcr 240mg $0 (1) verapamil hcl inj, tabs $0 (1) Cardiovascular Agents, Other CORLANOR $0 (2) PA MO digitek $0 (1) digoxin inj, oral soln $0 (1) PA MO digoxin tabs 125mcg $0 (1) digoxin tabs 250mcg $0 (1) PA digox tabs 125mcg $0 (1) digox tabs 250mcg $0 (1) PA NORTHERA $0 (2) PA pentoxifylline cr $0 (1) pentoxifylline er $0 (1) PRALUENT $0 (2) QL (2 ML per 28 days) PA RANEXA $0 (2) QL (60 EA per 30 days) MO REPATHA $0 (2) QL (3 ML per 28 days) PA REPATHA SURECLICK $0 (2) QL (3 ML per 28 days) PA Diuretics, Carbonic Anhydrase Inhibitors acetazolamide er $0 (1) acetazolamide tabs 250mg $0 (1) acetazolamide tabs 125mg $0 (1) MO methazolamide $0 (1) MO Diuretics, Loop bumetanide tabs $0 (1) bumetanide inj $0 (1) MO furosemide tabs $0 (1) furosemide oral soln $0 (1) MO furosemide inj 10mg/ml $0 (1) 44

57 Name of drug What torsemide tabs 10mg, 20mg, 5mg $0 (1) torsemide tabs 100mg $0 (1) MO Diuretics, Potassium-sparing amiloride hcl tabs $0 (1) amiloride/hydrochlorothiazide $0 (1) eplerenone $0 (1) spironolactone/hydrochlorothiazide $0 (1) spironolactone tabs $0 (1) triamterene/hydrochlorothiazide caps 25mg; 37.5mg $0 (1) triamterene/hydrochlorothiazide caps 25mg; 50mg $0 (1) MO triamterene/hydrochlorothiazide tabs $0 (1) Diuretics, Thiazide chlorothiazide $0 (1) MO chlorthalidone tabs 25mg $0 (1) chlorthalidone tabs 50mg $0 (1) MO hydrochlorothiazide caps $0 (1) hydrochlorothiazide tabs 25mg, 50mg $0 (1) hydrochlorothiazide tabs 12.5mg $0 (1) MO indapamide $0 (1) methyclothiazide tabs $0 (1) MO metolazone $0 (1) MO Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized $0 (1) MO fenofibrate caps 130mg, 43mg $0 (1) fenofibrate caps 150mg, 50mg $0 (1) MO fenofibrate tabs 145mg, 160mg, 48mg, 54mg $0 (1) fenofibrate tabs 120mg, 40mg $0 (1) MO fenofibric acid $0 (1) MO fenofibric acid dr $0 (1) gemfibrozil tabs $0 (1) Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium $0 (1) fluvastatin sodium er $0 (1) QL (30 EA per 30 days) MO fluvastatin caps 40mg $0 (1) 45

58 Name of drug What fluvastatin caps 20mg $0 (1) MO lovastatin $0 (1) pravastatin sodium tabs 10mg, 80mg $0 (1) pravastatin sodium tabs 20mg, 40mg $0 (1) MO rosuvastatin calcium tabs 10mg, 20mg, 5mg $0 (1) QL (30 EA per 30 days) rosuvastatin calcium tabs 40mg $0 (1) QL (30 EA per 30 days) MO simvastatin tabs 10mg, 20mg, 40mg, 5mg $0 (1) simvastatin tabs 80mg $0 (1) QL (30 EA per 30 days) Dyslipidemics, Other cholestyramine light $0 (1) cholestyramine pack $0 (1) cholestyramine powd $0 (1) MO colestipol hcl tabs $0 (1) colestipol hcl gran, pack $0 (1) MO KYNAMRO $0 (2) PA LOVAZA $0 (2) QL (120 EA per 30 days) ST MO niacin er $0 (1) omega-3-acid ethyl esters $0 (1) QL (120 EA per 30 days) prevalite $0 (1) MO VASCEPA $0 (2) MO ZETIA $0 (2) QL (30 EA per 30 days) MO Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate er $0 (1) MO isosorbide dinitrate tabs $0 (1) isosorbide mononitrate er $0 (1) isosorbide mononitrate tabs 20mg $0 (1) isosorbide mononitrate tabs 10mg $0 (1) MO minitran $0 (1) nitroglycerin lingual $0 (1) nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/hr, $0 (1) 0.6mg/hr nitroglycerin transdermal pt24 0.2mg/hr $0 (1) MO nitroglycerin inj $0 (1) NITROSTAT $0 (2) MO Vasodilators, Direct-acting Arterial 46

59 What Name of drug hydralazine hcl inj, tabs $0 (1) minoxidil tabs $0 (1) CENTRAL NERVOUS SYSTEM AGENTS- DRUGS USED TO TREAT ADHD, MULTIPLE SCLEROSIS, CHOREA ASSOCIATED WITH HUNTINGTON DISEASE Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg $0 (1) QL (60 EA per 30 days) PA amphetamine/dextroamphetamine tabs 1.875mg; $0 (1) QL (60 EA per 30 days) PA MO 1.875mg; 1.875mg; 1.875mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg amphetamine/dextroamphetamine tabs 5mg; 5mg; $0 (1) QL (90 EA per 30 days) PA 5mg; 5mg dextroamphetamine sulfate tabs $0 (1) QL (180 EA per 30 days) PA MO dextroamphetamine sulfate soln $0 (1) QL (1800 ML per 30 days) PA Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate hcl $0 (1) QL (60 EA per 30 days) PA MO guanfacine er $0 (1) QL (30 EA per 30 days) metadate er $0 (1) QL (90 EA per 30 days) PA methylphenidate hcl er cp24 30mg $0 (1) QL (60 EA per 30 days) PA MO methylphenidate hcl er tbcr 10mg, 20mg $0 (1) QL (90 EA per 30 days) PA methylphenidate hcl sr $0 (1) QL (90 EA per 30 days) PA methylphenidate hcl tabs $0 (1) PA STRATTERA CAPS 100MG, 80MG $0 (2) QL (30 EA per 30 days) PA MO STRATTERA CAPS 10MG, 18MG, 25MG, 40MG, $0 (2) QL (60 EA per 30 days) PA MO 60MG Central Nervous System, Other NUEDEXTA $0 (2) QL (60 EA per 30 days) MO riluzole $0 (1) tetrabenazine tabs 25mg $0 (1) QL (120 EA per 30 days) PA tetrabenazine tabs 12.5mg $0 (1) QL (90 EA per 30 days) PA Multiple Sclerosis Agents AMPYRA $0 (2) QL (60 EA per 30 days) PA 47

60 What Name of drug COPAXONE INJ 40MG/ML $0 (2) QL (12 ML per 28 days) PA COPAXONE INJ 20MG/ML $0 (2) QL (30 ML per 30 days) PA GILENYA $0 (2) QL (30 EA per 30 days) PA glatopa $0 (1) QL (30 ML per 30 days) PA REBIF $0 (2) QL (6 ML per 28 days) PA REBIF REBIDOSE $0 (2) QL (6 ML per 28 days) PA REBIF REBIDOSE TITRATION PACK $0 (2) QL (4.2 ML per 365 days) PA REBIF TITRATION PACK $0 (2) QL (8.4 ML per 365 days) PA TYSABRI $0 (2) QL (15 ML per 28 days) PA DENTAL AND ORAL AGENTS Dental and Oral Agents chlorhexidine gluconate oral rinse $0 (1) clinpro 5000 $0 (1) MO dentagel $0 (1) MO fluoridex daily defense $0 (1) oralone $0 (1) paroex $0 (1) periogard $0 (1) MO phos-flur $0 (1) pilocarpine hcl tabs 7.5mg $0 (1) pilocarpine hydrochloride $0 (1) sf $0 (1) MO triamcinolone acetonide pste 0.1% $0 (1) triamcinolone in orabase $0 (1) MO DERMATOLOGICAL AGENTS- ANTIPSORIATICS, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE, ACNE, WOUND CARE AGENTS, ANTIBIOTICS Dermatological Agents 8-MOP $0 (2) acitretin caps 10mg, 25mg $0 (1) PA acitretin caps 17.5mg $0 (1) PA MO ALTABAX $0 (2) ammonium lactate crea, lotn $0 (1) amnesteem $0 (1) avita $0 (1) PA MO calcipotriene $0 (1) 48

61 Name of drug What calcitrene $0 (1) MO claravis $0 (1) clindacin etz pledgets $0 (1) MO clindacin-p $0 (1) MO clindamax $0 (1) clindamycin phosphate foam 1% $0 (1) MO clindamycin phosphate gel 1% $0 (1) clindamycin phosphate lotn 1% $0 (1) clindamycin phosphate external soln 1% $0 (1) clindamycin phosphate swab 1% $0 (1) MO clindamycin/benzoyl peroxide gel 5%; 1.2% $0 (1) clindamycin/benzoyl peroxide gel 5%; 1% $0 (1) MO diclofenac sodium gel $0 (1) QL (1020 GM per 30 days) MO doxepin hydrochloride $0 (1) MO ELIDEL $0 (2) QL (60 GM per 30 days) ST MO ery $0 (1) MO erythromycin/benzoyl peroxide $0 (1) MO erythromycin gel 2% $0 (1) MO erythromycin pads 2% $0 (1) erythromycin soln 2% $0 (1) fluocinolone acetonide body $0 (1) MO fluocinolone acetonide scalp $0 (1) MO fluorouracil crea 5% $0 (1) fluorouracil crea 0.5% $0 (1) MO fluorouracil external soln 2%, 5% $0 (1) MO gentamicin sulfate crea 0.1% $0 (1) MO gentamicin sulfate external oint 0.1% $0 (1) MO imiquimod crea $0 (1) MO methoxsalen caps $0 (1) metronidazole crea 0.75% $0 (1) metronidazole gel 0.75% $0 (1) metronidazole gel 1% $0 (1) MO metronidazole lotn 0.75% $0 (1) mupirocin calcium $0 (1) 49

62 What Name of drug mupirocin oint $0 (1) mupirocin crea $0 (1) MO myorisan $0 (1) neuac $0 (1) MO podofilox soln $0 (1) MO REGRANEX $0 (2) QL (15 GM per 30 days) PA MO rosadan crea $0 (1) rosadan gel $0 (1) MO SANTYL $0 (2) selenium sulfide lotn $0 (1) MO silver sulfadiazine $0 (1) sodium sulfacetamide lotn 10% $0 (1) ssd $0 (1) sulfacetamide sodium susp 10% $0 (1) SULFAMYLON $0 (2) MO TAZORAC $0 (2) MO tretinoin crea 0.025%, 0.05%, 0.1% $0 (1) PA MO tretinoin gel 0.01% $0 (1) PA tretinoin gel 0.025%, 0.05% $0 (1) PA MO zenatane $0 (1) ZONALON $0 (2) MO ENZYME REPLACEMENT/MODIFIERS- DRUGS USED TO TREAT ENZYME DEFICIENCIES, PANCREATIC ENZYMES Enzyme Replacement/Modifiers ADAGEN $0 (2) PA LA ALDURAZYME $0 (2) PA BUPHENYL TABS $0 (2) PA CARBAGLU $0 (2) LA CEREZYME $0 (2) PA CREON CPEP UNIT; 24000UNIT; $0 (2) 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT, $0 (2) MO UNIT; 36000UNIT; UNIT CYSTADANE $0 (2) LA 50

63 What Name of drug CYSTAGON $0 (2) PA FABRAZYME $0 (2) PA KUVAN $0 (2) PA LUMIZYME $0 (2) NAGLAZYME $0 (2) PA ORFADIN CAPS 10MG, 2MG, 5MG $0 (2) PA LA pancrelipase $0 (1) RAVICTI $0 (2) PA sodium phenylbutyrate powd $0 (1) PA VPRIV $0 (2) PA ZAVESCA $0 (2) PA LA ZENPEP $0 (2) MO GASTROINTESTINAL- DRUGS USED TO TREAT STOMACH AND INTESTINAL DISORDERS, ANTI- DIARRHEAL, LAXATIVES, ULCERS AND STOMACH ACID Antispasmodics, Gastrointestinal dicyclomine hcl caps, soln, tabs $0 (1) PA MO glycopyrrolate tabs $0 (1) MO glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml $0 (1) glycopyrrolate inj 4mg/20ml $0 (1) MO methscopolamine bromide $0 (1) Gastrointestinal Agents, Other anti-diarrheal tabs $0 (3) * cromolyn sodium conc 100mg/5ml $0 (1) diphenatol $0 (1) diphenoxylate/atropine tabs $0 (1) diphenoxylate/atropine liqd $0 (1) MO GATTEX $0 (2) PA gavilyte-h $0 (1) MO gnp loperamide hcl $0 (3) * loperamide hcl caps $0 (1) loperamide hcl liqd, susp $0 (3) * metoclopramide hcl oral soln, tabs $0 (1) metoclopramide hcl inj $0 (1) MO MOVANTIK $0 (2) QL (30 EA per 30 days) PA MO qc anti-diarrheal $0 (3) * 51

64 Name of drug What RELISTOR $0 (2) PA MO sb anti-diarrhea $0 (3) * sm anti-diarrheal tabs $0 (3) * ursodiol caps, tabs $0 (1) MO Histamine2 (H2) Receptor Antagonists acid reducer maximum strength tabs 20mg $0 (3) * acid reducer tabs 10mg, 75mg $0 (3) * cimetidine hcl $0 (1) MO cimetidine tabs 400mg $0 (1) cimetidine tabs 200mg, 300mg, 800mg $0 (1) MO dual action complete $0 (3) * famotidine premixed $0 (1) famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml $0 (1) famotidine susr 40mg/5ml $0 (1) MO famotidine tabs 20mg, 40mg $0 (1) gnp acid control 150 maximum strength $0 (3) * gnp acid reducer maximum strength $0 (3) * gnp acid reducer tabs 10mg $0 (3) * heartburn relief 150 maximum strength $0 (3) * heartburn relief maximum strength $0 (3) * heartburn relief tabs 10mg, 200mg $0 (3) * hm complete dual action $0 (3) * qc acid controller $0 (3) * qc acid controller maximum strength $0 (3) * ranitidine 150 maximum strength $0 (3) * ranitidine 75 $0 (3) * ranitidine hcl caps 150mg, 300mg $0 (1) MO ranitidine hcl inj 150mg/6ml $0 (1) ranitidine hcl inj 50mg/2ml $0 (1) MO ranitidine hcl syrp 15mg/ml $0 (1) ranitidine hcl tabs 150mg, 300mg $0 (1) sm acid reducer tabs 200mg, 75mg $0 (3) * Irritable Bowel Syndrome Agents alosetron hydrochloride $0 (1) QL (60 EA per 30 days) MO 52

65 Name of drug What AMITIZA $0 (2) QL (60 EA per 30 days) MO LINZESS $0 (2) QL (30 EA per 30 days) MO Laxatives clearlax powd $0 (3) * constulose $0 (1) enulose $0 (1) gavilax powd $0 (3) * gavilyte-c $0 (1) MO gavilyte-g $0 (1) MO gavilyte-n/flavor pack $0 (1) MO generlac $0 (1) gnp clearlax $0 (3) * healthylax $0 (3) * lactulose soln 10gm/15ml $0 (1) MOVIPREP $0 (2) MO peg 3350/electrolytes $0 (1) peg 3350 powd $0 (3) * peg-3350/electrolytes $0 (1) MO peg-3350/nacl/na bicarbonate/kcl $0 (1) polyethylene glycol 3350 pack 0 $0 (1) MO polyethylene glycol 3350 pack 0 $0 (3) * polyethylene glycol 3350 powd 0 $0 (1) MO polyethylene glycol 3350 powd 0 $0 (3) * PREPOPIK $0 (2) MO sm clearlax $0 (3) * SUPREP BOWEL PREP $0 (2) MO trilyte $0 (1) MO Protectants CARAFATE SUSP $0 (2) MO misoprostol $0 (1) sucralfate susp, tabs $0 (1) Proton Pump Inhibitors esomeprazole magnesium $0 (1) QL (30 EA per 30 days) esomeprazole sodium $0 (1) 53

66 What Name of drug omeprazole magnesium $0 (3) * omeprazole cpdr 20mg $0 (1) omeprazole cpdr 10mg $0 (1) QL (30 EA per 30 days) omeprazole cpdr 40mg $0 (1) QL (60 EA per 30 days) pantoprazole sodium tbec 20mg $0 (1) QL (30 EA per 30 days) pantoprazole sodium tbec 40mg $0 (1) QL (60 EA per 30 days) PRILOSEC OTC $0 (3) * qc omeprazole magnesium $0 (3) * GENITOURINARY- VAGINAL ANTI-INFECTIVES Antispasmodics, Urinary darifenacin hydrobromide er $0 (1) QL (30 EA per 30 days) MYRBETRIQ $0 (2) QL (30 EA per 30 days) oxybutynin chloride er tb24 5mg $0 (1) QL (30 EA per 30 days) oxybutynin chloride er tb24 10mg $0 (1) QL (60 EA per 30 days) oxybutynin chloride er tb24 15mg $0 (1) QL (60 EA per 30 days) MO oxybutynin chloride tabs $0 (1) QL (120 EA per 30 days) oxybutynin chloride syrp $0 (1) QL (600 ML per 30 days) tolterodine tartrate $0 (1) QL (60 EA per 30 days) VESICARE $0 (2) QL (30 EA per 30 days) MO Benign Prostatic Hypertrophy Agents alfuzosin hcl er $0 (1) dutasteride $0 (1) QL (30 EA per 30 days) dutasteride/tamsulosin hydrochloride $0 (1) QL (30 EA per 30 days) MO finasteride tabs 5mg $0 (1) tamsulosin hcl $0 (1) Genitourinary Agents, Other bethanechol chloride $0 (1) methylergonovine maleate $0 (1) MO RENACIDIN SOLN 6.602GM/100ML; $0 (2) MO 0.198GM/100ML; 3.177GM/100ML sodium chloride 0.9% $0 (1) THIOLA $0 (2) Phosphate Binders calcium acetate caps $0 (1) calcium acetate tabs 667mg $0 (1) MO 54

67 What Name of drug FOSRENOL CHEW $0 (2) ST MO FOSRENOL PACK 750MG $0 (2) ST FOSRENOL PACK 1000MG $0 (2) ST MO RENVELA $0 (2) MO VELPHORO $0 (2) MO HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)- CORTICOSTEROID DRUGS THAT CAN BE USED FOR A VARIETY OF CONDITIONS SUCH AS INFLAMMATION Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort $0 (1) MO ala cort $0 (1) alclometasone dipropionate $0 (1) amcinonide $0 (1) MO augmented betamethasone dipropionate crea, lotn $0 (1) augmented betamethasone dipropionate gel, oint $0 (1) MO baycadron $0 (1) betamethasone dipropionate lotn $0 (1) betamethasone dipropionate crea, oint $0 (1) MO betamethasone valerate lotn $0 (1) betamethasone valerate crea, foam, oint $0 (1) MO budesonide cpep 3mg $0 (1) clobetasol propionate e $0 (1) MO clobetasol propionate emollient foam $0 (1) MO clobetasol propionate foam 0.05% $0 (1) clobetasol propionate crea, gel, lotn, oint, sham $0 (1) clobetasol propionate liqd, soln $0 (1) MO clodan $0 (1) MO colocort $0 (1) MO cormax scalp application $0 (1) cortisone acetate tabs $0 (1) MO deltasone $0 (1) desonide crea, lotn $0 (1) desonide oint $0 (1) MO desoximetasone crea 0.25% $0 (1) desoximetasone crea 0.05% $0 (1) MO 55

68 Name of drug What desoximetasone oint $0 (1) desoximetasone gel $0 (1) MO DEXAMETHASONE INTENSOL $0 (2) MO dexamethasone sodium phosphate inj 10mg/ml, $0 (1) 20mg/5ml, 4mg/ml dexamethasone sodium phosphate inj 10mg/ml, $0 (1) MO 120mg/30ml dexamethasone elix $0 (1) dexamethasone soln, tabs $0 (1) MO diflorasone diacetate $0 (1) MO fludrocortisone acetate tabs $0 (1) fluocinolone acetonide crea 0.01%, 0.025% $0 (1) fluocinolone acetonide oint 0.025% $0 (1) fluocinolone acetonide soln 0.01% $0 (1) fluocinonide-e $0 (1) fluocinonide crea 0.1% $0 (1) fluocinonide crea 0.05% $0 (1) MO fluocinonide oint, soln $0 (1) fluocinonide gel $0 (1) MO fluticasone propionate crea 0.05% $0 (1) fluticasone propionate lotn 0.05% $0 (1) MO fluticasone propionate oint 0.005% $0 (1) MO halobetasol propionate crea $0 (1) halobetasol propionate oint $0 (1) MO hydrocortisone butyrate (lipophilic) $0 (1) MO hydrocortisone butyrate crea, oint, soln $0 (1) MO hydrocortisone in absorbase $0 (1) hydrocortisone valerate crea $0 (1) hydrocortisone valerate oint $0 (1) MO hydrocortisone crea 1%, 2.5% $0 (1) hydrocortisone enem, tabs $0 (1) hydrocortisone lotn 2.5% $0 (1) hydrocortisone oint 2.5% $0 (1) hydrocortisone oint 1% $0 (1) MO lokara $0 (1) 56

69 Name of drug What methylprednisolone acetate inj $0 (1) methylprednisolone dose pack $0 (1) methylprednisolone sodiumsuccinate $0 (1) MO methylprednisolone tabs $0 (1) MILLIPRED $0 (2) MILLIPRED DP $0 (2) MO mometasone furoate oint, soln $0 (1) mometasone furoate crea $0 (1) MO prednicarbate crea $0 (1) prednicarbate oint $0 (1) MO prednisolone sodium phosphate oral soln 15mg/5ml, $0 (1) MO 25mg/5ml, 5mg/5ml prednisolone soln, syrp $0 (1) PREDNISONE INTENSOL $0 (2) MO prednisone soln $0 (1) MO prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg $0 (1) prednisone tabs 50mg $0 (1) MO prednisone tbpk 10mg, 5mg $0 (1) procto-med hc $0 (1) procto-pak $0 (1) MO proctosol hc $0 (1) MO proctozone-hc $0 (1) MO triamcinolone acetonide aers 0.147mg/gm $0 (1) MO triamcinolone acetonide crea 0.1% $0 (1) triamcinolone acetonide crea 0.025%, 0.5% $0 (1) MO triamcinolone acetonide lotn 0.025%, 0.1% $0 (1) MO triamcinolone acetonide oint 0.025% $0 (1) triamcinolone acetonide oint 0.1%, 0.5% $0 (1) MO triderm $0 (1) MO HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)- DRUGS USED TO REGULATE PITUITARY HORMONES, GROWTH HORMONES Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate inj, tabs $0 (1) desmopressin acetate nasal soln 0.01% $0 (1) 57

70 What Name of drug EGRIFTA INJ 2MG $0 (2) QL (30 EA per 30 days) PA EGRIFTA INJ 1MG $0 (2) QL (60 EA per 30 days) PA H.P. ACTHAR $0 (2) PA INCRELEX $0 (2) PA NORDITROPIN FLEXPRO $0 (2) PA OMNITROPE $0 (2) PA VASOSTRICT $0 (2) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)- BIRTH CONTROL, ENDOMETRIOSIS, ESTROGENS, MALE HORMONES Anabolic Steroids ANADROL-50 $0 (2) MO oxandrolone tabs 2.5mg $0 (1) QL (120 EA per 30 days) PA MO oxandrolone tabs 10mg $0 (1) QL (60 EA per 30 days) PA MO Androgens ANDROGEL PUMP GEL 1.62% $0 (2) PA MO ANDROGEL PUMP GEL 1% $0 (2) QL (300 GM per 30 days) PA ANDROGEL GEL 20.25MG/1.25GM, $0 (2) PA MO 40.5MG/2.5GM ANDROGEL GEL 25MG/2.5GM, 50MG/5GM $0 (2) QL (300 GM per 30 days) PA MO danazol caps $0 (1) MO testosterone cypionate inj $0 (1) MO testosterone enanthate inj $0 (1) testosterone gel 1%, 25mg/2.5gm $0 (1) QL (300 GM per 30 days) PA MO Estrogens altavera $0 (1) alyacen 1/35 $0 (1) alyacen 7/7/7 tabs $0 (1) amethia $0 (1) amethia lo $0 (1) amethyst $0 (1) apri $0 (1) aranelle $0 (1) ashlyna $0 (1) aubra $0 (1) aviane $0 (1) 58

71 Name of drug What azurette $0 (1) balziva $0 (1) MO bekyree $0 (1) blisovi 24 fe $0 (1) blisovi fe 1.5/30 $0 (1) blisovi fe 1/20 $0 (1) briellyn $0 (1) camrese $0 (1) camrese lo $0 (1) MO caziant $0 (1) MO chateal $0 (1) cryselle-28 $0 (1) MO cyclafem 1/35 $0 (1) cyclafem 7/7/7 $0 (1) MO cyred $0 (1) dasetta 1/35 $0 (1) dasetta 7/7/7 $0 (1) daysee $0 (1) delyla $0 (1) DEPO-ESTRADIOL $0 (2) MO desogestrel/ethinyl estradiol $0 (1) drospirenone/ethinyl estradiol tabs 3mg; 0.02mg $0 (1) drospirenone/ethinyl estradiol tabs 3mg; 0.03mg $0 (1) MO elinest $0 (1) emoquette $0 (1) enpresse-28 $0 (1) enskyce $0 (1) estarylla $0 (1) ESTRACE CREA $0 (2) MO estradiol/norethindrone acetate $0 (1) PA estradiol ptwk $0 (1) QL (4 EA per 28 days) PA estradiol pttw $0 (1) QL (8 EA per 28 days) PA estradiol tabs 2mg $0 (1) PA estradiol tabs 0.5mg, 1mg $0 (1) PA MO 59

72 Name of drug What falmina $0 (1) fyavolv $0 (1) PA gianvi $0 (1) gildagia $0 (1) gildess 1.5/30 $0 (1) gildess 1/20 $0 (1) gildess 24 fe $0 (1) gildess fe 1.5/30 $0 (1) gildess fe 1/20 $0 (1) introvale $0 (1) jinteli $0 (1) PA MO jolessa $0 (1) juleber $0 (1) junel 1.5/30 $0 (1) junel 1/20 $0 (1) junel fe 1.5/30 $0 (1) MO junel fe 1/20 $0 (1) MO junel fe 24 $0 (1) kaitlib fe $0 (1) kariva $0 (1) kelnor 1/35 $0 (1) MO kimidess $0 (1) kurvelo $0 (1) larin 1.5/30 $0 (1) larin 1/20 $0 (1) larin 24 fe $0 (1) larin fe 1.5/30 $0 (1) larin fe 1/20 $0 (1) layolis fe $0 (1) MO leena $0 (1) MO lessina $0 (1) levonest $0 (1) levonorgestrel and ethinyl estradiol tabs 0; 0 $0 (1) 60

73 What Name of drug levonorgestrel and ethinyl estradiol tabs 20mcg; $0 (1) MO 90mcg levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, $0 (1) 0; 0, 20mcg; 0.1mg levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg $0 (1) MO levora 0.15/30-28 $0 (1) lomedia 24 fe $0 (1) lopreeza $0 (1) PA loryna $0 (1) MO low-ogestrel $0 (1) lutera $0 (1) marlissa $0 (1) MO MENEST $0 (2) PA MO microgestin 1.5/30 $0 (1) microgestin 1/20 $0 (1) microgestin 24 fe $0 (1) microgestin fe $0 (1) microgestin fe 1.5/30 $0 (1) mimvey $0 (1) PA mimvey lo $0 (1) PA mono-linyah $0 (1) mononessa $0 (1) myzilra $0 (1) MO necon 0.5/35-28 $0 (1) necon 1/35 $0 (1) NECON 1/50-28 $0 (2) MO NECON 10/11-28 $0 (2) MO necon 7/7/7 $0 (1) nikki $0 (1) norethindrone & ethinyl estradiol ferrous fumarate $0 (1) MO norethindrone acetate/ethinyl estradiol/ferrous fumarate norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg $0 (1) $0 (1) 61

74 What Name of drug norethindrone acetate/ethinyl estradiol tabs 5mcg; $0 (1) PA 1mg norgestimate/ethinyl estradiol $0 (1) NORINYL 1+50 $0 (2) MO nortrel 0.5/35 (28) $0 (1) MO nortrel 1/35 $0 (1) nortrel 7/7/7 $0 (1) ocella $0 (1) OGESTREL $0 (2) MO orsythia $0 (1) philith $0 (1) pimtrea $0 (1) pirmella 1/35 $0 (1) pirmella 7/7/7 $0 (1) portia-28 $0 (1) previfem $0 (1) MO quasense $0 (1) reclipsen $0 (1) setlakin $0 (1) sprintec 28 $0 (1) sronyx $0 (1) MO syeda $0 (1) tarina fe 1/20 $0 (1) tilia fe $0 (1) tri-estarylla $0 (1) tri-legest fe $0 (1) MO tri-linyah $0 (1) tri-lo-estarylla $0 (1) tri-lo-marzia $0 (1) tri-lo-sprintec $0 (1) tri-previfem $0 (1) tri-sprintec $0 (1) MO trinessa $0 (1) trinessa lo $0 (1) MO 62

75 Name of drug What trivora-28 $0 (1) VAGIFEM $0 (2) MO velivet $0 (1) MO vestura $0 (1) vienva $0 (1) viorele $0 (1) MO vyfemla $0 (1) MO wera $0 (1) wymzya fe $0 (1) MO zarah $0 (1) zenchent $0 (1) zenchent fe $0 (1) zovia 1/35e $0 (1) zovia 1/50e $0 (1) MO Progesterone Agonists/Antagonists ELLA $0 (2) Progestins camila $0 (1) MO deblitane $0 (1) DEPO-PROVERA $0 (2) MO errin $0 (1) MO heather $0 (1) MO hydroxyprogesterone caproate inj $0 (1) PA jencycla $0 (1) jolivette $0 (1) levonorgestrel $0 (1) lyza $0 (1) medroxyprogesterone acetate inj $0 (1) medroxyprogesterone acetate tabs 5mg $0 (1) medroxyprogesterone acetate tabs 10mg, 2.5mg $0 (1) MO megestrol acetate tabs $0 (1) PA megestrol acetate susp 40mg/ml $0 (1) PA nora-be $0 (1) norethindrone acetate tabs $0 (1) 63

76 What Name of drug norethindrone tabs $0 (1) norlyroc $0 (1) progesterone inj $0 (1) progesterone caps $0 (1) MO sharobel $0 (1) Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride $0 (1) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) - DRUGS USED TO REGULATE THYROID LEVELS Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium inj $0 (1) MO levothyroxine sodium tabs 100mcg, 112mcg, $0 (1) 125mcg, 150mcg, 25mcg, 50mcg, 75mcg, 88mcg levothyroxine sodium tabs 137mcg, 175mcg, $0 (1) MO 200mcg, 300mcg levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg, $0 (1) 75mcg, 88mcg levoxyl tabs 125mcg, 137mcg, 175mcg, 200mcg, $0 (1) MO 25mcg liothyronine sodium tabs $0 (1) SYNTHROID TABS 112MCG $0 (2) SYNTHROID TABS 100MCG, 125MCG, 137MCG, $0 (2) MO 150MCG, 175MCG, 200MCG, 25MCG, 300MCG, 50MCG, 75MCG, 88MCG THYROLAR-1 $0 (2) MO THYROLAR-1/2 $0 (2) MO THYROLAR-1/4 $0 (2) MO THYROLAR-2 $0 (2) MO THYROLAR-3 $0 (2) unithroid tabs 200mcg $0 (1) unithroid tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg $0 (1) MO 64

77 Name of drug What HORMONAL AGENTS, SUPPRESSANT (ADRENAL) - DRUG(S) USED TO TREAT ADRENAL CORTICAL CANCER Hormonal Agents, Suppressant (Adrenal) LYSODREN $0 (2) MO HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) - DRUGS USED TO TREAT HIGH CALCIUM LEVELS IN PEOPLE WITH CHRONIC KIDNEY DISEASE Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABS 90MG $0 (2) QL (120 EA per 30 days) SENSIPAR TABS 30MG, 60MG $0 (2) QL (60 EA per 30 days) HORMONAL AGENTS, SUPPRESSANT (PITUITARY)- DRUGS USED TO TREAT PROSTATE CANCER AND OTHER CONDITIONS ASSOCIATED WITH AN OVERACTIVE PITUITARY GLAND Hormonal Agents, Suppressant (Pituitary) cabergoline $0 (1) FIRMAGON $0 (2) PA leuprolide acetate inj $0 (1) PA LUPRON DEPOT $0 (2) PA LUPRON DEPOT-PED $0 (2) PA octreotide acetate $0 (1) PA SIGNIFOR $0 (2) QL (60 ML per 30 days) PA LA SOMATULINE DEPOT INJ 60MG/0.2ML $0 (2) QL (0.2 ML per 28 days) PA SOMATULINE DEPOT INJ 90MG/0.3ML $0 (2) QL (0.3 ML per 28 days) PA SOMATULINE DEPOT INJ 120MG/0.5ML $0 (2) QL (0.5 ML per 28 days) PA SOMAVERT $0 (2) PA SYNAREL $0 (2) MO TRELSTAR MIXJECT $0 (2) PA VANTAS $0 (2) ZOLADEX $0 (2) HORMONAL AGENTS, SUPPRESSANT (THYROID) - DRUGS USED TO LOWER THYROID LEVELS Antithyroid Agents methimazole tabs $0 (1) propylthiouracil tabs $0 (1) MO IMMUNOLOGICAL AGENTS- VACCINES, RHEUMATOID ARTHRITIS, IMMUNOGLOBULINS, IMMUNOMODULATORS, IMMUNOSUPPRESSANTS Angioedema (HAE) Agents CINRYZE $0 (2) PA 65

78 Name of drug What FIRAZYR $0 (2) QL (270 ML per 30 days) PA Immune Suppressants azathioprine inj, tabs $0 (1) B/D CELLCEPT INTRAVENOUS $0 (2) B/D cyclosporine modified caps 100mg, 25mg $0 (1) PA cyclosporine modified caps 50mg $0 (1) PA MO cyclosporine modified soln $0 (1) PA cyclosporine inj $0 (1) PA cyclosporine caps $0 (1) PA MO ENBREL SURECLICK $0 (2) QL (7.84 ML per 28 days) PA ENBREL INJ 25MG/0.5ML $0 (2) QL (4.08 ML per 28 days) PA ENBREL INJ 50MG/ML $0 (2) QL (7.84 ML per 28 days) PA ENBREL INJ 25MG $0 (2) QL (8 EA per 28 days) PA ENVARSUS XR $0 (2) B/D gengraf caps 100mg, 25mg $0 (1) PA gengraf soln $0 (1) PA MO hecoria $0 (1) B/D HUMIRA PEDIATRIC CROHNS DISEASE STARTER $0 (2) QL (6 EA per 28 days) PA PACK HUMIRA PEN $0 (2) QL (6 EA per 28 days) PA HUMIRA PEN-CROHNS DISEASESTARTER $0 (2) QL (6 EA per 28 days) PA HUMIRA PEN-PSORIASIS STARTER $0 (2) QL (6 EA per 28 days) PA HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML $0 (2) QL (2 EA per 28 days) PA HUMIRA INJ 40MG/0.8ML $0 (2) QL (6 EA per 28 days) PA methotrexate sodium inj 1gm/40ml, 1gm, $0 (1) 250mg/10ml, 50mg/2ml methotrexate tabs $0 (1) mycophenolate mofetil caps, tabs $0 (1) B/D mycophenolate mofetil susr $0 (1) B/D MO NULOJIX $0 (2) PA OTREXUP INJ 10MG/0.4ML, 15MG/0.4ML, $0 (2) ST 17.5MG/0.4ML, 20MG/0.4ML, 22.5MG/0.4ML, 25MG/0.4ML, 7.5MG/0.4ML PROGRAF INJ $0 (2) B/D RAPAMUNE SOLN $0 (2) B/D MO 66

79 Name of drug What RASUVO $0 (2) ST REMICADE $0 (2) PA SANDIMMUNE SOLN $0 (2) PA MO SIMULECT $0 (2) B/D sirolimus tabs 0.5mg, 2mg $0 (1) B/D sirolimus tabs 1mg $0 (1) B/D MO tacrolimus caps $0 (1) B/D XELJANZ $0 (2) QL (60 EA per 30 days) PA ZORTRESS $0 (2) PA MO Immunizing Agents, Passive ATGAM $0 (2) B/D FLEBOGAMMA DIF $0 (2) PA GAMASTAN S/D $0 (2) PA GAMMAGARD LIQUID $0 (2) PA GAMMAGARD S/D IGA LESS THAN 1MCG/ML $0 (2) PA GAMMAKED $0 (2) PA GAMMAPLEX $0 (2) PA GAMUNEX-C $0 (2) PA OCTAGAM $0 (2) PA THYMOGLOBULIN $0 (2) B/D Immunomodulators ACTIMMUNE $0 (2) PA ARCALYST $0 (2) PA BENLYSTA $0 (2) PA ILARIS $0 (2) QL (2 EA per 28 days) PA leflunomide $0 (1) OTEZLA TBPK $0 (2) QL (110 EA per 365 days) PA OTEZLA TABS $0 (2) QL (60 EA per 30 days) PA SYNAGIS $0 (2) PA XELJANZ XR $0 (2) QL (30 EA per 30 days) PA Vaccines ACTHIB $0 (2) ADACEL $0 (2) bcg vaccine $0 (1) BEXSERO $0 (2) 67

80 Name of drug What BOOSTRIX $0 (2) CERVARIX $0 (2) COMVAX $0 (2) DAPTACEL $0 (2) diphtheria/tetanus toxoids adsorbed pediatric $0 (1) ENGERIX-B $0 (2) B/D GARDASIL $0 (2) GARDASIL 9 $0 (2) HAVRIX $0 (2) HIBERIX $0 (2) IMOVAX RABIES (H.D.C.V.) $0 (2) B/D INFANRIX $0 (2) IPOL INACTIVATED IPV $0 (2) IXIARO $0 (2) KINRIX $0 (2) M-M-R II $0 (2) MENACTRA $0 (2) MENHIBRIX $0 (2) MENOMUNE-A/C/Y/W-135 $0 (2) MENVEO $0 (2) PEDIARIX $0 (2) PEDVAX HIB $0 (2) PENTACEL $0 (2) PROQUAD $0 (2) QUADRACEL $0 (2) RABAVERT $0 (2) B/D RECOMBIVAX HB $0 (2) B/D ROTARIX $0 (2) ROTATEQ $0 (2) TENIVAC $0 (2) tetanus/diphtheria toxoids-adsorbed $0 (1) TRUMENBA $0 (2) TWINRIX $0 (2) TYPHIM VI $0 (2) 68

81 What Name of drug VAQTA $0 (2) VARIVAX $0 (2) YF-VAX $0 (2) ZOSTAVAX $0 (2) QL (1 EA per 365 days) INFLAMMATORY BOWEL DISEASE AGENTS DRUGS USED TO MANAGE DISORDERS IN THE COLON AND/OR INTESTINES Aminosalicylates APRISO $0 (2) MO ASACOL HD $0 (2) ST MO balsalazide disodium $0 (1) MO DELZICOL $0 (2) ST MO LIALDA $0 (2) ST MO mesalamine enem, kit $0 (1) PENTASA $0 (2) ST MO Sulfonamides sulfasalazine tabs, tbec $0 (1) METABOLIC BONE DISEASE AGENTS- DRUGS USED TO TREAT BONE LOSS Metabolic Bone Disease Agents alendronate sodium soln $0 (1) MO alendronate sodium tabs 10mg, 5mg $0 (1) QL (30 EA per 30 days) alendronate sodium tabs 40mg $0 (1) QL (30 EA per 30 days) MO alendronate sodium tabs 35mg, 70mg $0 (1) QL (4 EA per 28 days) calcitonin-salmon $0 (1) MO calcitriol caps, inj $0 (1) calcitriol oral soln $0 (1) MO doxercalciferol caps $0 (1) etidronate disodium $0 (1) MO FORTEO $0 (2) QL (2.4 ML per 28 days) PA MIACALCIN INJ $0 (2) MO pamidronate disodium $0 (1) paricalcitol $0 (1) PROLIA $0 (2) QL (1 ML per 180 days) risedronate sodium dr $0 (1) QL (4 EA per 28 days) MO risedronate sodium tabs 150mg $0 (1) QL (1 EA per 28 days) risedronate sodium tabs 35mg $0 (1) QL (12 EA per 84 days) 69

82 What Name of drug risedronate sodium tabs 30mg, 5mg $0 (1) QL (30 EA per 30 days) MO XGEVA $0 (2) PA zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml $0 (1) MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents ALCOHOL PREP PADS $0 (2) FERRIPROX SOLN 100MG/ML $0 (2) PA LA GAUZE PADS 2 X2 $0 (2) INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2 $0 (2) MO INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16 $0 (2) INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2 $0 (2) MO INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16 $0 (2) MO INSUPEN 33GX4MM $0 (2) MO NATPARA $0 (2) QL (2 EA per 28 days) PA ORFADIN SUSP 4MG/ML $0 (2) PA PEN NEEDLE/ULTRAFINE/29G X 12.7MM $0 (2) SYLVANT $0 (2) PA V-GO 20 $0 (2) MO V-GO 30 $0 (2) MO V-GO 40 $0 (2) MO OPHTHALMIC AGENTS- DRUGS USED TO TREAT EYE ALLERGIES, INFECTIONS, INFLAMMATION, AND GLAUCOMA Ophthalmic Prostaglandin and Prostamide Analogs COMBIGAN $0 (2) MO latanoprost $0 (1) LUMIGAN $0 (2) MO TRAVATAN Z $0 (2) ST MO travoprost $0 (1) MO Ophthalmic Agents, Other ak-poly-bac $0 (1) MO atropine sulfate soln $0 (1) MO AZASITE $0 (2) MO bacitracin/neomycin/polymyxin $0 (1) bacitracin/polymyxin b $0 (1) MO bacitracin oint 500unit/gm $0 (1) MO 70

83 Name of drug What BESIVANCE $0 (2) MO ciprofloxacin hcl soln 0.3% $0 (1) MO CYSTARAN $0 (2) QL (60 ML per 28 days) LA erythromycin oint 5mg/gm $0 (1) gatifloxacin $0 (1) gentak $0 (1) MO gentamicin sulfate ophthalmic oint 0.3% $0 (1) gentamicin sulfate ophthalmic soln 0.3% $0 (1) MO ilotycin $0 (1) levofloxacin ophthalmic soln 0.5% $0 (1) MO MOXEZA $0 (2) MO naphazoline hcl $0 (1) MO neo-polycin $0 (1) neomycin/bacitracin/polymyxin $0 (1) MO neomycin/polymyxin/bacitracin/hydrocortisone $0 (1) MO neomycin/polymyxin/dexamethasone oint $0 (1) neomycin/polymyxin/dexamethasone susp $0 (1) MO neomycin/polymyxin/gramicidin $0 (1) MO neomycin/polymyxin/hydrocortisone ophthalmic susp $0 (1) MO 1%; 3.5mg/ml; 10000unit/ml ofloxacin ophthalmic soln 0.3% $0 (1) polycin $0 (1) polymyxin b sulfate/trimethoprim sulfate $0 (1) MO proparacaine hcl $0 (1) RESTASIS $0 (2) MO sodium sulfacetamide soln 10% $0 (1) MO sulfacetamide sodium/prednisolone sodium phosphate $0 (1) sulfacetamide sodium oint 10% $0 (1) MO sulfacetamide sodium soln 10% $0 (1) TOBRADEX $0 (2) MO TOBRADEX ST $0 (2) MO tobramycin sulfate ophthalmic soln 0.3% $0 (1) MO tobramycin/dexamethasone $0 (1) MO TOBREX $0 (2) MO trifluridine $0 (1) 71

84 Name of drug What trimethoprim sulfate/polymyxin b sulfate $0 (1) triple antibiotic $0 (1) VIGAMOX $0 (2) MO ZIRGAN $0 (2) MO Ophthalmic Anti-allergy Agents azelastine hcl ophthalmic soln 0.05% $0 (1) cromolyn sodium soln 4% $0 (1) MO epinastine hcl $0 (1) MO olopatadine hcl ophthalmic soln 0.1% $0 (1) PATADAY $0 (2) MO PAZEO $0 (2) MO Ophthalmic Anti-inflammatories ACUVAIL $0 (2) MO dexamethasone sodium phosphate ophthalmic soln $0 (1) MO 0.1% DUREZOL $0 (2) MO fluorometholone $0 (1) MO flurbiprofen sodium $0 (1) MO ILEVRO $0 (2) MO ketorolac tromethamine $0 (1) LOTEMAX $0 (2) MO NEVANAC $0 (2) MO prednisolone acetate $0 (1) prednisolone sodium phosphate ophthalmic soln 1% $0 (1) MO PROLENSA $0 (2) MO ZADITOR $0 (3) * Ophthalmic Antiglaucoma Agents ALPHAGAN P SOLN 0.1% $0 (2) MO apraclonidine $0 (1) MO AZOPT $0 (2) MO betaxolol hcl soln 0.5% $0 (1) MO BETIMOL $0 (2) MO BETOPTIC-S $0 (2) MO brimonidine tartrate $0 (1) MO carteolol hcl $0 (1) 72

85 What Name of drug dorzolamide hcl $0 (1) MO dorzolamide hcl/timolol maleate $0 (1) MO levobunolol hcl $0 (1) MO metipranolol $0 (1) PHOSPHOLINE IODIDE $0 (2) pilocarpine hcl soln 1%, 2%, 4% $0 (1) MO SIMBRINZA $0 (2) MO timolol maleate ophthalmic gel forming $0 (1) MO timolol maleate soln 0.25%, 0.5% $0 (1) OTIC AGENTS- DRUGS USED TO TREAT CONDITIONS OF THE EAR Otic Agents acetasol hc $0 (1) acetic acid $0 (1) acetic acid/aluminum acetate $0 (1) MO antibiotic ear $0 (1) CIPRODEX $0 (2) MO fluocinolone acetonide oil 0.01% $0 (1) MO hydrocortisone/acetic acid $0 (1) neomycin/polymyxin/hc $0 (1) MO neomycin/polymyxin/hydrocortisone otic susp 1%; $0 (1) MO 3.5mg/ml; 10000unit/ml ofloxacin otic soln 0.3% $0 (1) RESPIRATORY TRACT/PULMONARY AGENTS- DRUGS USED TO TREAT ALLERGIES, ASTHMA, COPD, PULMONARY HYPERTENSION Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS $0 (2) QL (60 EA per 30 days) MO ADVAIR HFA $0 (2) QL (12 GM per 30 days) MO ASMANEX HFA $0 (2) QL (13 GM per 30 days) MO ASMANEX TWISTHALER 120 METERED DOSES $0 (2) QL (1 EA per 30 days) MO ASMANEX TWISTHALER 14 METERED DOSES $0 (2) QL (2 EA per 28 days) ASMANEX TWISTHALER 30 METERED DOSES $0 (2) QL (1 EA per 30 days) MO ASMANEX TWISTHALER 60 METERED DOSES $0 (2) QL (1 EA per 30 days) MO ASMANEX TWISTHALER 7 METERED DOSES $0 (2) QL (4 EA per 28 days) BREO ELLIPTA $0 (2) QL (60 EA per 30 days) MO 73

86 What Name of drug budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, $0 (1) B/D MO 1mg/2ml budesonide nasal susp 32mcg/act $0 (1) QL (17.2 GM per 30 days) FLOVENT DISKUS AEPB 250MCG/BLIST $0 (2) QL (240 EA per 30 days) MO FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/ $0 (2) QL (60 EA per 30 days) MO BLIST FLOVENT HFA AERO 44MCG/ACT $0 (2) QL (21.2 GM per 30 days) MO FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT $0 (2) QL (24 GM per 30 days) MO flunisolide $0 (1) MO fluticasone propionate susp 50mcg/act $0 (1) QL (16 GM per 30 days) MO NASONEX $0 (2) QL (34 GM per 30 days) MO QVAR $0 (2) QL (17.4 GM per 30 days) MO triamcinolone acetonide aero 55mcg/act $0 (1) Antihistamines all day allergy childrens soln $0 (3) * all day allergy tabs $0 (3) * allergy relief tbdp $0 (3) * allergy relief tabs 10mg $0 (3) * allergy tbdp $0 (3) * allergy tabs 10mg $0 (3) * allerhist-1 $0 (3) * azelastine hcl nasal soln 0.15% $0 (1) MO azelastine hcl nasal soln 0.1% $0 (1) QL (30 ML per 25 days) cetirizine hcl allergy childrens $0 (3) * cetirizine hcl childrens soln 5mg/5ml $0 (3) * cetirizine hcl hives relief childrens $0 (3) * cetirizine hcl chew, tabs $0 (3) * childrens loratadine $0 (3) * chlorpheniramine maleate tbcr $0 (3) * clemastine fumarate tabs 2.68mg $0 (1) PA cyproheptadine hcl tabs $0 (1) PA dayhist allergy 12 hour relief $0 (3) * diphenhydramine hcl inj $0 (1) PA gnp all day allergy childrens syrp $0 (3) * gnp all day allergy childrens soln 5mg/5ml $0 (3) * 74

87 Name of drug What gnp allergy relief for kids tbdp $0 (3) * gnp allergy relief tbdp $0 (3) * gnp dayhist allergy $0 (3) * gnp loratadine childrens $0 (3) * gnp loratadine tabs $0 (3) * goodsense all day allergy $0 (3) * hm all day allergy $0 (3) * hm allergy relief tbdp $0 (3) * hydroxyzine hcl tabs $0 (1) PA hydroxyzine hcl inj, syrp $0 (1) PA MO hydroxyzine pamoate caps 25mg, 50mg $0 (1) PA hydroxyzine pamoate caps 100mg $0 (1) PA MO levocetirizine dihydrochloride tabs $0 (1) QL (30 EA per 30 days) levocetirizine dihydrochloride soln $0 (1) QL (300 ML per 30 days) MO loratadine childrens $0 (3) * loratadine hives relief $0 (3) * loratadine tabs $0 (3) * olopatadine hcl nasal soln 0.6% $0 (1) QL (30.5 GM per 30 days) promethazine hcl tabs 25mg $0 (1) PA promethazine hcl tabs 12.5mg, 50mg $0 (1) PA MO qc all day allergy $0 (3) * qc allergy relief $0 (3) * qc loratadine allergy relief $0 (3) * sb allergy tabs $0 (3) * sb loratadine tabs $0 (3) * sm all day allergy $0 (3) * sm all day allergy childrens soln 5mg/5ml $0 (3) * sm allergy relief loratadine $0 (3) * sm allergy relief tabs 1.34mg $0 (3) * sm loratadine allergy relief $0 (3) * sm loratadine syrp $0 (3) * Antileukotrienes montelukast sodium $0 (1) QL (30 EA per 30 days) zafirlukast $0 (1) QL (60 EA per 30 days) MO 75

88 Name of drug What Bronchodilators, Anticholinergic ANORO ELLIPTA $0 (2) QL (60 EA per 30 days) MO COMBIVENT RESPIMAT $0 (2) QL (8 GM per 30 days) MO INCRUSE ELLIPTA $0 (2) QL (30 EA per 30 days) MO ipratropium bromide/albuterol sulfate $0 (1) B/D ipratropium bromide nasal soln $0 (1) ipratropium bromide inhalation soln $0 (1) B/D SPIRIVA HANDIHALER $0 (2) QL (30 EA per 30 days) MO SPIRIVA RESPIMAT $0 (2) QL (4 GM per 30 days) MO Bronchodilators, Sympathomimetic albuterol sulfate er $0 (1) MO albuterol sulfate syrp $0 (1) albuterol sulfate nebu 0.083%, 0.63mg/3ml, $0 (1) B/D 1.25mg/3ml albuterol sulfate nebu 0.5% $0 (1) B/D MO albuterol sulfate tabs 4mg $0 (1) albuterol sulfate tabs 2mg $0 (1) MO ARCAPTA NEOHALER $0 (2) QL (30 EA per 30 days) ST MO EPIPEN 2-PAK $0 (2) QL (2 EA per 30 days) MO EPIPEN-JR 2-PAK $0 (2) QL (2 EA per 30 days) MO FORADIL AEROLIZER $0 (2) QL (60 EA per 30 days) MO levalbuterol hcl nebu $0 (1) B/D levalbuterol nebu $0 (1) B/D MO metaproterenol sulfate syrp, tabs $0 (1) MO PROAIR HFA $0 (2) QL (17 GM per 30 days) MO PROAIR RESPICLICK $0 (2) QL (2 EA per 30 days) MO SEREVENT DISKUS $0 (2) QL (60 EA per 30 days) ST MO STRIVERDI RESPIMAT $0 (2) QL (4 GM per 30 days) MO terbutaline sulfate tabs $0 (1) VENTOLIN HFA $0 (2) QL (36 GM per 30 days) MO Cystic Fibrosis Agents CAYSTON $0 (2) QL (84 ML per 56 days) LA KALYDECO PACK $0 (2) QL (56 EA per 28 days) PA KALYDECO TABS $0 (2) QL (60 EA per 30 days) PA ORKAMBI $0 (2) QL (112 EA per 28 days) PA 76

89 Name of drug What PULMOZYME $0 (2) B/D TOBI PODHALER $0 (2) QL (224 EA per 56 days) tobramycin $0 (1) QL (280 ML per 56 days) B/D Mast Cell Stabilizers cromolyn sodium aers 5.2mg/act $0 (3) * cromolyn sodium nebu 20mg/2ml $0 (1) B/D MO Phosphodiesterase Inhibitors, Airways Disease aminophylline $0 (1) DALIRESP $0 (2) QL (30 EA per 30 days) MO theophylline $0 (1) theophylline cr tb12 200mg $0 (1) theophylline cr tb12 100mg $0 (1) MO theophylline er tb24 $0 (1) theophylline er tb12 100mg, 200mg, 300mg $0 (1) theophylline er tb12 450mg $0 (1) MO Pulmonary Antihypertensives ADEMPAS $0 (2) QL (90 EA per 30 days) PA epoprostenol sodium $0 (1) PA LA LETAIRIS $0 (2) QL (30 EA per 30 days) PA OPSUMIT $0 (2) QL (30 EA per 30 days) PA REMODULIN $0 (2) PA sildenafil tabs $0 (1) QL (90 EA per 30 days) PA TRACLEER $0 (2) QL (60 EA per 30 days) PA VENTAVIS $0 (2) PA Respiratory Tract Agents, Other acetylcysteine inj $0 (1) acetylcysteine inhalation soln 10% $0 (1) B/D acetylcysteine inhalation soln 20% $0 (1) B/D MO ESBRIET $0 (2) QL (270 EA per 30 days) PA OFEV $0 (2) QL (60 EA per 30 days) PA PROLASTIN-C $0 (2) PA LA STIOLTO RESPIMAT $0 (2) QL (4 GM per 30 days) MO TYZINE PEDIATRIC NASAL DROPS $0 (2) XOLAIR $0 (2) QL (6 EA per 28 days) PA 77

90 What Name of drug ZEMAIRA $0 (2) PA LA SKELETAL MUSCLE RELAXANTS- DRUGS USED TO TREAT MUSCLE SPASMS Skeletal Muscle Relaxants chlorzoxazone $0 (1) QL (180 EA per 30 days) PA MO cyclobenzaprine hcl tabs $0 (1) QL (90 EA per 30 days) PA SLEEP DISORDER AGENTS- DRUGS USED TO TREAT INSOMNIA OR SLEEP DISORDERS GABA Receptor Modulators zaleplon caps 5mg $0 (1) QL (30 EA per 30 days) PA zaleplon caps 10mg $0 (1) QL (60 EA per 30 days) PA zolpidem tartrate er $0 (1) QL (30 EA per 30 days) PA zolpidem tartrate tabs 10mg $0 (1) QL (30 EA per 30 days) PA zolpidem tartrate tabs 5mg $0 (1) QL (30 EA per 30 days) PA MO Sleep Disorders, Other armodafinil $0 (1) QL (30 EA per 30 days) PA HETLIOZ $0 (2) QL (30 EA per 30 days) PA LA modafinil tabs 100mg $0 (1) QL (30 EA per 30 days) PA modafinil tabs 200mg $0 (1) QL (60 EA per 30 days) PA ROZEREM $0 (2) QL (30 EA per 30 days) XYREM $0 (2) QL (540 ML per 30 days) PA THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES, VITAMINS AND IV NUTRITION Electrolyte/Mineral Modifiers CUPRIMINE $0 (2) MO DEPEN TITRATABS $0 (2) MO EXJADE $0 (2) PA FERRIPROX TABS 500MG $0 (2) PA LA fomepizole $0 (1) kionex $0 (1) MO levocarnitine $0 (1) SAMSCA TABS 15MG $0 (2) QL (30 EA per 30 days) PA SAMSCA TABS 30MG $0 (2) QL (60 EA per 30 days) PA sodium bicarbonate partial fill $0 (1) MO sodium bicarbonate inj 8.4% $0 (1) MO sodium polystyrene sulfonate $0 (1) sps $0 (1) 78

91 Name of drug What SYPRINE $0 (2) MO Electrolyte/Mineral Replacement AMINOSYN $0 (2) B/D AMINOSYN 7%/ELECTROLYTES $0 (2) B/D aminosyn 8.5%/electrolytes $0 (1) B/D aminosyn ii 8.5%/electrolytes $0 (1) B/D AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; $0 (2) B/D 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 44.4MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN M $0 (2) B/D AMINOSYN-HBC $0 (2) B/D AMINOSYN-PF $0 (2) B/D AMINOSYN-PF 7% $0 (2) B/D AMINOSYN-RF $0 (2) B/D calcium chloride $0 (1) calcium gluconate inj $0 (1) citric acid/sodium citrate $0 (1) clinisol sf 15% $0 (1) B/D dextrose 10%/nacl 0.45% $0 (1) dextrose 5% /electrolyte #48 viaflex $0 (1) 79

92 Name of drug What dextrose 10% $0 (1) B/D dextrose 10% flex container $0 (1) B/D dextrose 10%/nacl 0.2% $0 (1) dextrose 2.5%/sodium chloride 0.45% $0 (1) dextrose 20% $0 (1) B/D dextrose 25% $0 (1) B/D dextrose 30% $0 (1) B/D dextrose 40% $0 (1) B/D dextrose 5% $0 (1) MO dextrose 5%/lactated ringers $0 (1) dextrose 5%/nacl 0.2% $0 (1) dextrose 5%/nacl 0.225% $0 (1) dextrose 5%/nacl 0.3% $0 (1) dextrose 5%/nacl 0.33% $0 (1) dextrose 5%/nacl 0.45% $0 (1) dextrose 5%/nacl 0.9% $0 (1) dextrose 5%/potassium chloride 0.15% $0 (1) dextrose 50% $0 (1) B/D dextrose 70% $0 (1) B/D FLORIVA LIQD 0.25MG/ML; 400UNIT/ML $0 (2) MO fluor-a-day soln $0 (1) fluoride chew 1.1mg, 2.2mg $0 (1) fluoride chew 0.25mg $0 (1) MO fluoritab chew 0.5mg, 1mg $0 (1) fluoritab soln $0 (1) FLURA-DROPS SOLN 0.25MG/DROP $0 (2) MO FREAMINE III INJ 89MEQ/L; 710MG/100ML; $0 (2) B/D 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML hepatamine $0 (1) B/D 80

93 Name of drug What INTRALIPID INJ 30GM/100ML $0 (2) B/D intralipid inj 20gm/100ml $0 (1) B/D k-sol $0 (1) KABIVEN $0 (2) B/D kcl 0.075%/d5w/nacl 0.45% $0 (1) kcl 0.15%/d5w/lr $0 (1) kcl 0.15%/d5w/nacl 0.2% $0 (1) kcl 0.15%/d5w/nacl 0.225% $0 (1) kcl 0.15%/d5w/nacl 0.45% $0 (1) kcl 0.15%/d5w/nacl 0.9% $0 (1) kcl 0.3%/d5w/lr iv lac ring $0 (1) kcl 0.3%/d5w/nacl 0.45% $0 (1) kcl 0.3%/d5w/nacl 0.9% $0 (1) klor-con $0 (1) klor-con 10 $0 (1) KLOR-CON 25 $0 (2) klor-con 8 $0 (1) klor-con m10 $0 (1) KLOR-CON M15 $0 (2) MO klor-con m20 $0 (1) klor-con sprinkle $0 (1) klor-con/ef $0 (1) MO lactated ringers dextrose 5% viaflex $0 (1) lactated ringers viaflex $0 (1) ludent $0 (1) MO magnesium sulfate inj $0 (1) NEPHRAMINE $0 (2) B/D nutrilipid $0 (1) B/D PERIKABIVEN $0 (2) B/D plenamine $0 (1) B/D potassium chloride 0.15% /nacl 0.45% viaflex $0 (1) potassium chloride 0.15% d5w/nacl 0.33% $0 (1) potassium chloride 0.15% d5w/nacl 0.45% $0 (1) potassium chloride 0.15% d5w/nacl 0.45% viaflex $0 (1) 81

94 Name of drug What potassium chloride 0.15% nacl 0.9% $0 (1) potassium chloride 0.15%/nacl 0.9% $0 (1) potassium chloride 0.22% d5w/nacl 0.45% $0 (1) potassium chloride 0.224%d5w/nacl 0.45% viaflex $0 (1) potassium chloride 0.3%/ nacl 0.9% $0 (1) potassium chloride 0.3%/d5w $0 (1) potassium chloride cr tbcr 10meq, 20meq $0 (1) potassium chloride er cpcr $0 (1) potassium chloride er tbcr 10meq, 20meq, 8meq $0 (1) potassium chloride er tbcr 20meq $0 (1) MO potassium chloride sr $0 (1) potassium chloride oral soln $0 (1) potassium chloride inj 10meq/100ml, 10meq/50ml, $0 (1) 20meq/100ml, 2meq/ml, 40meq/100ml potassium chloride inj 0.4meq/ml $0 (1) MO potassium citrate er tbcr 15meq $0 (1) potassium citrate er tbcr 1080mg, 540mg $0 (1) MO PREMASOL INJ 52MEQ/L; 1760MG/100ML; $0 (2) B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; $0 (1) B/D 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml ringers injection $0 (1) sodium chloride 0.45% viaflex $0 (1) sodium chloride inj 0.9%, 5% $0 (1) sodium chloride inj 2.5meq/ml, 3% $0 (1) MO sodium fluoride chew 0.5mg, 1.1mg $0 (1) 82

95 Name of drug What sodium fluoride soln $0 (1) sodium phosphate $0 (1) sterile water irrigation $0 (1) tpn electrolytes $0 (1) B/D TRAVASOL $0 (2) B/D TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; $0 (2) B/D 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML vitamins a/d/c/fluoride $0 (1) Vitamins ACTIVE OB $0 (2) BAL-CARE DHA $0 (2) CALCIUM PNV $0 (2) CITRANATAL 90 DHA $0 (2) MO CITRANATAL ASSURE $0 (2) MO CITRANATAL B-CALM $0 (2) MO CITRANATAL DHA $0 (2) MO CITRANATAL RX TABS 120MG; 125MG; 400UNIT; $0 (2) 2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG completenate $0 (1) MO CONCEPT DHA $0 (2) MO CONCEPT OB $0 (2) MO DUET DHA 400 $0 (2) MO DUET DHA BALANCED MISC 120MG; 2800UNIT; $0 (2) MO 215MG; 640UNIT; 55MG; 1.8MG; 12MCG; 0; 0; 0; 1MG; 25MG; 0; 25MG; 20MG; 267MG; 0; 210MCG; 50MG; 2MG; 0; 65MCG; 1.5MG; 15MG; 25MG elite-ob $0 (1) MO ENBRACE HR $0 (2) MO 83

96 What Name of drug ESCAVITE D $0 (2) ESCAVITE LQ $0 (2) EXTRA-VIRT PLUS DHA $0 (2) floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg; $0 (1) 262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg; 20unit; 2000unit; 5mg FOCALGIN 90 DHA $0 (2) FOCALGIN CA $0 (2) MO FOLCAL DHA $0 (2) FOLCAPS OMEGA 3 $0 (2) FOLET ONE $0 (2) MO FOLIVANE-OB $0 (2) FOLIVANE-PRX DHA NF $0 (2) HEMENATAL OB $0 (2) MO HEMENATAL OB + DHA $0 (2) MO inatal advance $0 (1) inatal ultra $0 (1) MARNATAL-F $0 (2) MO mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; $0 (1) MO 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; $0 (1) 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit; 2500unit multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ $0 (1) ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ ml; 5unit/ml; 1500unit/ml multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; $0 (1) 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ $0 (1) ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml $0 (1) 84

97 What Name of drug multivitamin with fluoride chew 60mg; 4.5mcg; $0 (1) 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit mvc-fluoride $0 (1) MO $0 (2) NATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT NATALVIRT 90 DHA $0 (2) NATALVIRT CA $0 (2) NATELLE ONE $0 (2) MO NESTABS $0 (2) MO NESTABS ABC $0 (2) MO NESTABS DHA $0 (2) MO NEXA PLUS $0 (2) MO NIVA-PLUS $0 (2) O-CAL PRENATAL $0 (2) MO OB COMPLETE GOLD $0 (2) MO OB COMPLETE ONE $0 (2) MO OB COMPLETE PETITE $0 (2) MO OB COMPLETE PREMIER $0 (2) MO OB COMPLETE/DHA $0 (2) MO OB COMPLETE TABS $0 (2) MO PAIRE OB $0 (2) MO PNV FERROUS FUMARATE/DOCUSATE/FOLIC $0 (2) ACID PNV FOLIC ACID + IRON MULTIVITAMIN $0 (2) PNV OB+DHA $0 (2) pnv prenatal plus multivitamin $0 (1) MO pnv tabs 29-1 $0 (1) pnv-dha $0 (1) MO pnv-select $0 (1) MO PNV-VP-U $0 (2) poly-vitamin/fluoride chew $0 (1) 85

98 What Name of drug poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ $0 (1) ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml pr natal 400 $0 (1) PREFERA OB $0 (2) PREFERA OB + DHA MISC 30MCG; 10MG; $0 (2) 400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG PREFERAOB +DHA $0 (2) MO PREFERAOB ONE $0 (2) PRENAISSANCE $0 (2) MO PRENAISSANCE PLUS $0 (2) MO PRENATA $0 (2) MO prenatabs fa $0 (1) MO prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; $0 (1) 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg; $0 (1) 400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg PRENATAL PLUS $0 (2) prenatal plus iron tabs 120mg; 0; 200mg; 400unit; $0 (1) 2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg PRENATE AM $0 (2) MO PRENATE DHA CAPS 90MG; 145MG; 220UNIT; $0 (2) 13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG; $0 (2) 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT; 15MG PRENATE ELITE TABS 600MCG; 75MG; 2600UNIT; 330MCG; 155MG; 600UNIT; 1.5MG; 13MCG; 20MG; 400MCG; 25MG; 21MG; 150MCG; 21MG; 3.5MG; 3MG; 40UNIT; 15MG $0 (2) MO 86

99 What Name of drug PRENATE ENHANCE $0 (2) MO $0 (2) PRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT PRENATE ESSENTIAL CAPS 600MCG; 90MG; $0 (2) MO 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG; 10UNIT PRENATE MINI CAPS 60MG; 280MCG; 100MG; $0 (2) 220UNIT; 13MCG; 350MG; 400MCG; 29MG; 600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG PRENATE MINI CAPS 600MCG; 60MG; 280MCG; $0 (2) MO 80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG; 18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG PRENATE PIXIE $0 (2) MO PRENATE RESTORE $0 (2) MO PRENATE STAR $0 (2) MO PREPLUS TABS 120MG; 0; 200MG; 400UNIT; $0 (2) 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG PREQUE 10 $0 (2) MO PRETAB $0 (2) PROVIDA DHA $0 (2) PROVIDA OB $0 (2) MO PUREFE OB PLUS $0 (2) QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/ $0 (2) ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ ML; 12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/ $0 (2) MO ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML RELNATE DHA $0 (2) MO se-natal 19 $0 (1) MO SELECT-OB+DHA $0 (2) MO 87

100 What $0 (2) Name of drug SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; 1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 1.6MG; 30UNIT; 1700UNIT; 15MG SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; $0 (2) MO 0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG TARON-BC $0 (2) TARON-PREX $0 (2) MO thrivite rx $0 (1) TL FOLATE $0 (2) TL-CARE DHA $0 (2) TL-SELECT $0 (2) tri-vit/fluoride $0 (1) MO tri-vit/fluoride/iron $0 (1) MO tri-vitamin/fluoride $0 (1) triadvance $0 (1) tricare $0 (1) MO TRICARE PRENATAL COMPLEAT $0 (2) MO TRICARE PRENATAL DHA ONE $0 (2) TRINATAL GT $0 (2) MO trinatal rx 1 $0 (1) MO triple-vitamin/fluoride $0 (1) TRISTART DHA $0 (2) MO TRIVEEN-DUO DHA $0 (2) MO TRIVEEN-PRX RNF $0 (2) ultimatecare one nf $0 (1) MO VEMAVITE-PRX 2 $0 (2) MO VENA-BAL DHA $0 (2) MO VIRT-ADVANCE $0 (2) MO VIRT-C DHA $0 (2) VIRT-CARE ONE $0 (2) VIRT-PN $0 (2) MO VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT; 12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG; 25MG; 10UNIT $0 (2) 88

101 Name of drug What VIRT-PN PLUS $0 (2) MO VIRT-SELECT $0 (2) VITAFOL FE+ $0 (2) MO VITAFOL GUMMIES $0 (2) VITAFOL ULTRA $0 (2) MO VITAFOL-NANO $0 (2) MO VITAFOL-OB $0 (2) MO VITAFOL-OB+DHA $0 (2) MO VITAFOL-ONE $0 (2) MO VITAMEDMD ONE RX/QUATREFOLIC $0 (2) MO VITAMEDMD PLUS RX/QUATRE FOLIC $0 (2) MO vitamins a/c/d/fluoride $0 (1) MO VOL-NATE $0 (2) MO VOL-PLUS $0 (2) MO VP CH ULTRA $0 (2) VP-CH PLUS $0 (2) VP-CH-PNV $0 (2) VP-GGR-B6 PRENATAL $0 (2) MO VP-HEME OB $0 (2) VP-HEME ONE $0 (2) VP-PNV-DHA $0 (2) MO ZATEAN-CH $0 (2) MO ZATEAN-PN $0 (2) ZATEAN-PN DHA $0 (2) MO ZATEAN-PN PLUS $0 (2) MO 89

102 Drug Name Page # Drug Name Page # 8 hour pain relief MOP...48 abacavir...33 abacavir sulfate/lamivudine/zidovudine...33 ABELCET...18 ABILIFY DISCMELT...30 ABILIFY INJ...30 ABILIFY MAINTENA...30 ABILIFY ORAL SOLN...30 ABRAXANE...22 acamprosate calcium dr... 6 acarbose...35 acebutolol hcl caps...42 acetaminophen/codeine # acetaminophen/codeine soln... 4 acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg... 4 acetaminophen supp 650mg... 1 acetasol hc...73 acetazolamide er...44 acetazolamide tabs 125mg...44 acetazolamide tabs 250mg...44 acetic acid...73 acetic acid/aluminum acetate...73 acetylcysteine inhalation soln 10%...77 acetylcysteine inhalation soln 20%...77 acetylcysteine inj...77 acid reducer maximum strength tabs 20mg...52 acid reducer tabs 10mg, 75mg...52 acitretin caps 10mg, 25mg...48 acitretin caps 17.5mg...48 ACTHIB...67 ACTIMMUNE...67 ACTIVE OB...83 ACUVAIL...72 acyclovir caps, susp, tabs...34 acyclovir oint...34 acyclovir sodium inj 50mg/ml...34 acyclovir sodium inj 500mg...34 ADACEL...67 ADAGEN...50 adefovir dipivoxil...32 ADEMPAS...77 adrucil...22 ADVAIR DISKUS Index of Drugs ADVAIR HFA...73 AFINITOR...25 AFINITOR DISPERZ...25 a-hydrocort...55 ak-poly-bac...70 ala cort...55 ALBENZA...27 albuterol sulfate er...76 albuterol sulfate nebu 0.5%...76 albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml...76 albuterol sulfate syrp...76 albuterol sulfate tabs 2mg...76 albuterol sulfate tabs 4mg...76 alclometasone dipropionate...55 ALCOHOL PREP PADS...70 ALDURAZYME...50 ALECENSA...25 alendronate sodium soln...69 alendronate sodium tabs 10mg, 5mg...69 alendronate sodium tabs 35mg, 70mg...69 alendronate sodium tabs 40mg...69 alfuzosin hcl er...54 ALIMTA...23 ALINIA SUSR...27 ALINIA TABS...27 ALKERAN TABS...21 all day allergy childrens soln...74 all day allergy tabs...74 all day pain relief... 1 allergy relief tabs 10mg...74 allergy relief tbdp...74 allergy tabs 10mg...74 allergy tbdp...74 allerhist allopurinol tabs 100mg...20 allopurinol tabs 300mg...20 alogliptin...35 alogliptin/metformin hcl...35 alogliptin/pioglitazone...36 alosetron hydrochloride...52 ALPHAGAN P SOLN 0.1%...72 alprazolam tabs 0.25mg, 0.5mg...35 alprazolam tabs 1mg, 2mg...35 ALTABAX...48

103 Drug Name Page # Drug Name Page # altavera...58 alyacen 1/ alyacen 7/7/7 tabs...58 amantadine hcl caps, syrp...28 amantadine hcl tabs...28 AMBISOME...18 amcinonide...55 amethia...58 amethia lo...58 amethyst...58 amifostine...23 amikacin sulfate inj 1gm/4ml... 7 amikacin sulfate inj 500mg/2ml... 7 amiloride hcl tabs...45 amiloride/hydrochlorothiazide...45 aminophylline...77 AMINOSYN...79 AMINOSYN 7%/ELECTROLYTES...79 aminosyn 8.5%/electrolytes...79 AMINOSYN-HBC...79 aminosyn ii 8.5%/electrolytes...79 AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 44.4MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML...79 AMINOSYN M...79 AMINOSYN-PF...79 AMINOSYN-PF 7%...79 AMINOSYN-RF...79 amiodarone hcl tabs 100mg, 400mg...41 amiodarone hcl tabs 200mg...41 AMITIZA...53 amitriptyline hcl tabs 10mg, 150mg...17 amitriptyline hcl tabs 100mg, 25mg, 50mg, 75mg...17 amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg, 10mg; 80mg, 2.5mg; 10mg, 2.5mg; 20mg, 2.5mg; 40mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg, 5mg; 80mg...43 amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg, 10mg; 40mg...43 amlodipine besylate/benazepril hydrochloride...43 amlodipine besylate tabs...43 amlodipine besylate/valsartan...43 amlodipine/valsartan/hctz...43 ammonium lactate crea, lotn...48 amnesteem...48 amoxapine...17 amoxicillin caps, susr...10 amoxicillin chew...10 amoxicillin/clavulanate potassium chew...10 amoxicillin/clavulanate potassium er...10 amoxicillin/clavulanate potassium susr 200mg/5ml; 28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml...10 amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml...10 amoxicillin/clavulanate potassium tabs 250mg; 125mg.. 10 amoxicillin/clavulanate potassium tabs 500mg; 125mg, 875mg; 125mg...10 amoxicillin tabs 500mg...10 amoxicillin tabs 875mg...10 amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg...47 amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg; 1.875mg; 1.875mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg...47 amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg...47 amphotericin b...18 ampicillin caps...11 ampicillin sodium inj 1gm...10 ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm, 500mg...10 ampicillin-sulbactam...10 ampicillin susr 125mg/5ml

104 Drug Name Page # Drug Name Page # ampicillin susr 250mg/5ml...11 AMPYRA...47 ANADROL anagrelide hydrochloride...38 anastrozole tabs...25 ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM 58 ANDROGEL GEL 25MG/2.5GM, 50MG/5GM...58 ANDROGEL PUMP GEL 1%...58 ANDROGEL PUMP GEL 1.62%...58 ANORO ELLIPTA...76 antibiotic ear...73 anti-diarrheal tabs...51 APOKYN...28 apraclonidine...72 apri...58 APRISO...69 APTIOM TABS 200MG, 400MG, 800MG...12 APTIOM TABS 600MG...13 APTIVUS CAPS...34 APTIVUS SOLN...34 aranelle...58 ARANESP ALBUMIN FREE INJ 10MCG/0.4ML...39 ARANESP ALBUMIN FREE INJ 25MCG/0.42ML...38 ARANESP ALBUMIN FREE INJ 100MCG/0.5ML...39 ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/ ML, 60MCG/ML...39 ARANESP ALBUMIN FREE INJ 150MCG/0.3ML, 60MCG/0.3ML...38 ARANESP ALBUMIN FREE INJ 150MCG/0.75ML...39 ARANESP ALBUMIN FREE INJ 200MCG/0.4ML, 40MCG/0.4ML...38 ARANESP ALBUMIN FREE INJ 300MCG/0.6ML...39 ARANESP ALBUMIN FREE INJ 500MCG/ML...38 ARCALYST...67 ARCAPTA NEOHALER...76 aripiprazole odt tbdp 10mg...30 aripiprazole odt tbdp 15mg...30 aripiprazole soln...30 aripiprazole tabs...30 ARISTADA...30 armodafinil...78 ARRANON...23 arthritis pain... 1 arthritis pain relief... 1 ARZERRA...27 ASACOL HD...69 ascomp/codeine... 1 ashlyna...58 ASMANEX HFA...73 ASMANEX TWISTHALER 7 METERED DOSES...73 ASMANEX TWISTHALER 14 METERED DOSES...73 ASMANEX TWISTHALER 30 METERED DOSES...73 ASMANEX TWISTHALER 60 METERED DOSES...73 ASMANEX TWISTHALER 120 METERED DOSES...73 aspirin/dipyridamole...39 atenolol/chlorthalidone tabs 50mg; 25mg...42 atenolol/chlorthalidone tabs 100mg; 25mg...42 atenolol tabs...42 ATGAM...67 atorvastatin calcium...45 atovaquone...27 atovaquone/proguanil hcl...27 ATRIPLA...32 atropine sulfate soln...70 aubra...58 augmented betamethasone dipropionate crea, lotn...55 augmented betamethasone dipropionate gel, oint...55 AVASTIN...23 aviane...58 avita...48 azacitidine...23 AZASITE...70 azathioprine inj, tabs...66 azelastine hcl nasal soln 0.1%...74 azelastine hcl nasal soln 0.15%...74 azelastine hcl ophthalmic soln 0.05%...72 AZILECT...29 azithromycin inj, tabs...11 azithromycin pack, susr...11 AZOPT...72 aztreonam...10 azurette...59 baciim... 7 bacitracin inj 50000unit... 7 bacitracin/neomycin/polymyxin...70 bacitracin oint 500unit/gm...70 bacitracin/polymyxin b...70 baclofen tabs...31 BAL-CARE DHA...83 balsalazide disodium...69 balziva...59 BANZEL

105 Drug Name Page # Drug Name Page # BARACLUDE SOLN...32 baycadron...55 bcg vaccine...67 bekyree...59 BELEODAQ...23 benazepril hcl/hydrochlorothiazide...40 benazepril hcl tabs...40 BENDEKA...21 BENLYSTA...67 benztropine mesylate inj...28 benztropine mesylate tabs 0.5mg, 1mg...28 benztropine mesylate tabs 2mg...28 BESIVANCE...71 betamethasone dipropionate crea, oint...55 betamethasone dipropionate lotn...55 betamethasone valerate crea, foam, oint...55 betamethasone valerate lotn...55 betaxolol hcl soln 0.5%...72 betaxolol hcl tabs 10mg, 20mg...42 bethanechol chloride...54 BETIMOL...72 BETOPTIC-S...72 bexarotene...27 BEXSERO...67 bicalutamide...22 BICILLIN L-A...11 BICNU...23 bisoprolol fumarate...42 bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg, 5mg; 6.25mg...42 bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg...42 bleomycin sulfate...23 BLINCYTO...27 blisovi 24 fe...59 blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX...68 BOSULIF...25 BREO ELLIPTA...73 briellyn...59 BRILINTA...39 brimonidine tartrate...72 BRINTELLIX TABS 10MG, 5MG...16 BRINTELLIX TABS 20MG...16 BRIVIACT INJ, ORAL SOLN...13 BRIVIACT TABS...13 bromocriptine mesylate caps, tabs...28 budesonide cpep 3mg...55 budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml...74 budesonide nasal susp 32mcg/act...74 bumetanide inj...44 bumetanide tabs...44 BUPHENYL TABS...50 buprenorphine hcl/naloxone hcl... 6 buprenorphine hcl subl... 6 buproban... 6 bupropion hcl er...15 bupropion hcl sr tb12 100mg, 150mg, 200mg...15 bupropion hcl sr tb12 150mg... 6 bupropion hcl tabs...15 bupropion hcl xl tb24 150mg...15 bupropion hcl xl tb24 300mg...15 buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg...35 buspirone hcl tabs 30mg...35 BUSULFEX...21 butalbital/acetaminophen/caffeine caps... 1 butalbital/acetaminophen/caffeine/codeine caps 300mg; 50mg; 40mg; 30mg... 1 butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg... 1 butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg... 1 butalbital/aspirin/caffeine... 1 butalbital/aspirin/caffeine/codeine... 1 butalbital compound/codeine... 4 cabergoline...65 CABOMETYX...26 calcipotriene...48 calcitonin-salmon...69 calcitrene...49 calcitriol caps, inj...69 calcitriol oral soln...69 calcium acetate caps...54 calcium acetate tabs 667mg...54 calcium chloride...79 calcium gluconate inj...79 CALCIUM PNV...83 camila...63 camrese...59 camrese lo...59 CANCIDAS INJ 50MG...18 CANCIDAS INJ 70MG

106 Drug Name Page # Drug Name Page # candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg...40 candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg...40 candesartan cilexetil tabs 4mg, 8mg...40 candesartan cilexetil tabs 16mg, 32mg...40 capacet... 1 CAPASTAT SULFATE...21 CAPRELSA TABS 100MG...26 CAPRELSA TABS 300MG...26 captopril/hydrochlorothiazide...40 captopril tabs 12.5mg, 25mg, 50mg...40 captopril tabs 100mg...40 CARAFATE SUSP...53 CARBAGLU...50 carbamazepine chew, susp, tabs...14 carbamazepine er cp carbamazepine er tb carbidopa/levodopa...28 carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg...29 carbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg, 25mg; 200mg; 100mg, 31.25mg; 200mg; 125mg, 37.5mg; 200mg; 150mg, 50mg; 200mg; 200mg...29 carbidopa/levodopa er...28 carbidopa/levodopa odt...28 carbidopa tabs...29 carboplatin...23 carteolol hcl...72 cartia xt...43 carvedilol...42 CAYSTON...76 caziant...59 cefaclor caps... 9 cefaclor er... 8 cefaclor susr 125mg/5ml... 9 cefaclor susr 250mg/5ml, 375mg/5ml... 9 cefadroxil caps, tabs... 9 cefadroxil susr 250mg/5ml... 9 cefadroxil susr 500mg/5ml... 9 cefazolin... 9 cefazolin sodium/dextrose... 9 cefazolin sodium inj 100gm, 10gm, 1gm, 1gm; 5%, 300gm, 500mg... 9 cefdinir... 9 cefditoren pivoxil tabs 400mg... 9 cefepime... 9 cefepime/dextrose... 9 cefixime... 9 cefotaxime sodium inj 1gm... 9 cefotaxime sodium inj 10gm, 2gm, 500mg... 9 cefotetan... 9 cefotetan/dextrose... 9 cefoxitin sodium... 9 cefpodoxime proxetil susr... 9 cefpodoxime proxetil tabs 100mg... 9 cefpodoxime proxetil tabs 200mg... 9 cefprozil... 9 ceftazidime... 9 ceftazidime/dextrose... 9 ceftriaxone/dextrose... 9 ceftriaxone in iso-osmotic dextrose... 9 ceftriaxone sodium inj 2gm... 9 ceftriaxone sodium inj 100gm, 10gm, 1gm, 250mg, 2gm, 500mg... 9 cefuroxime axetil... 9 cefuroxime sodium inj 1.5gm, 225gm, 7.5gm, 75gm... 9 cefuroxime sodium inj 750mg... 9 celecoxib caps 100mg, 200mg, 50mg... 2 celecoxib caps 400mg... 1 CELLCEPT INTRAVENOUS...66 CELONTIN...13 cephalexin caps 250mg, 500mg... 9 cephalexin caps 750mg...10 cephalexin susr...10 cephalexin tabs...10 CEREZYME...50 CERVARIX...68 cetirizine hcl allergy childrens...74 cetirizine hcl chew, tabs...74 cetirizine hcl childrens soln 5mg/5ml...74 cetirizine hcl hives relief childrens...74 CHANTIX CONTINUING MONTH PAK... 6 CHANTIX STARTING MONTH PAK... 6 CHANTIX TABS 0.5MG, 1MG... 6 chateal...59 childrens ibuprofen susp 100mg/5ml... 2 childrens loratadine...74 childs ibuprofen... 2 chloramphenicol sodium succinate... 7 chlorhexidine gluconate oral rinse...48 chloroquine phosphate tabs...27 chlorothiazide

107 Drug Name Page # Drug Name Page # chlorpheniramine maleate tbcr...74 chlorpromazine hcl inj...29 chlorpromazine hcl tabs 10mg...29 chlorpromazine hcl tabs 100mg, 200mg, 25mg, 50mg.. 29 chlorthalidone tabs 25mg...45 chlorthalidone tabs 50mg...45 chlorzoxazone...78 cholestyramine light...46 cholestyramine pack...46 cholestyramine powd...46 ciclodan...18 ciclopirox gel, susp...18 ciclopirox nail lacquer...18 ciclopirox olamine crea...18 ciclopirox sham...18 cilostazol...39 cimetidine hcl...52 cimetidine tabs 200mg, 300mg, 800mg...52 cimetidine tabs 400mg...52 CINRYZE...65 CIPRODEX...73 ciprofloxacin er...11 ciprofloxacin hcl soln 0.3%...71 ciprofloxacin hcl tabs 100mg, 750mg...11 ciprofloxacin hcl tabs 250mg, 500mg...11 ciprofloxacin inj, otic soln, susr...12 ciprofloxacin i.v.-in d5w...11 cisplatin...23 citalopram hydrobromide soln...16 citalopram hydrobromide tabs 10mg...16 citalopram hydrobromide tabs 20mg...16 citalopram hydrobromide tabs 40mg...16 CITRANATAL 90 DHA...83 CITRANATAL ASSURE...83 CITRANATAL B-CALM...83 CITRANATAL DHA...83 CITRANATAL RX TABS 120MG; 125MG; 400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG...83 citric acid/sodium citrate...79 cladribine...23 claravis...49 clarithromycin susr...11 clarithromycin tabs...11 clearlax powd...53 clemastine fumarate tabs 2.68mg...74 clindacin etz pledgets...49 clindacin-p...49 clindamax...49 clindamycin/benzoyl peroxide gel 5%; 1%...49 clindamycin/benzoyl peroxide gel 5%; 1.2%...49 clindamycin hcl caps 75mg... 7 clindamycin hcl caps 150mg, 300mg... 7 clindamycin palmitate hcl... 7 clindamycin phosphate add-vantage inj 900mg/6ml... 7 clindamycin phosphate crea 2%... 7 clindamycin phosphate external soln 1%...49 clindamycin phosphate foam 1%...49 clindamycin phosphate gel 1%...49 clindamycin phosphate in d5w... 7 clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml, 900mg/6ml... 7 clindamycin phosphate lotn 1%...49 clindamycin phosphate swab 1%...49 clinisol sf 15%...79 clinpro clobetasol propionate crea, gel, lotn, oint, sham...55 clobetasol propionate e...55 clobetasol propionate emollient foam...55 clobetasol propionate foam 0.05%...55 clobetasol propionate liqd, soln...55 clodan...55 CLOLAR...23 clomipramine hcl caps...17 clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg...13 clonazepam odt tbdp 1mg...13 clonazepam odt tbdp 2mg...13 clonazepam tabs 0.5mg...13 clonazepam tabs 1mg...13 clonazepam tabs 2mg...13 clonidine hcl ptwk...39 clonidine hcl tabs...39 clopidogrel tabs 75mg...39 clopidogrel tabs 300mg...39 clorazepate dipotassium tabs 3.75mg, 7.5mg...35 clorazepate dipotassium tabs 15mg...35 clotrimazole/betamethasone dipropionate...18 clotrimazole external crea, troc...19 clotrimazole soln...19 clotrimazole vaginal crea 1%...19 clozapine...31 clozapine odt...31 COARTEM

108 Drug Name Page # Drug Name Page # codeine sulfate tabs... 4 colchicine caps, tabs...20 colestipol hcl gran, pack...46 colestipol hcl tabs...46 colistimethate sodium... 8 colocort...55 COMBIGAN...70 COMBIVENT RESPIMAT...76 COMETRIQ...26 COMPLERA...32 completenate...83 compro...29 COMVAX...68 CONCEPT DHA...83 CONCEPT OB...83 constulose...53 COPAXONE INJ 20MG/ML...48 COPAXONE INJ 40MG/ML...48 CORLANOR...44 cormax scalp application...55 cortisone acetate tabs...55 COSMEGEN...23 COTELLIC...23 CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT, UNIT; 36000UNIT; UNIT...50 CREON CPEP UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT...50 CRIXIVAN...34 cromolyn sodium aers 5.2mg/act...77 cromolyn sodium conc 100mg/5ml...51 cromolyn sodium nebu 20mg/2ml...77 cromolyn sodium soln 4%...72 cryselle CUBICIN... 8 CUPRIMINE...78 cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl tabs...78 cyclophosphamide caps...21 cyclophosphamide inj...21 cycloserine...21 cyclosporine caps...66 cyclosporine inj...66 cyclosporine modified caps 50mg...66 cyclosporine modified caps 100mg, 25mg...66 cyclosporine modified soln...66 cyproheptadine hcl tabs...74 CYRAMZA...27 cyred...59 CYSTADANE...50 CYSTAGON...51 CYSTARAN...71 cytarabine aqueous...23 dacarbazine...23 DALIRESP...77 DALVANCE... 8 danazol caps...58 dantrolene sodium caps...31 dapsone tabs...21 DAPTACEL...68 DARAPRIM...27 darifenacin hydrobromide er...54 DARZALEX...27 dasetta 1/ dasetta 7/7/ daunorubicin hcl...23 dayhist allergy 12 hour relief...74 daysee...59 deblitane...63 decitabine...23 deltasone...55 delyla...59 DELZICOL...69 DENAVIR...34 dentagel...48 DEPEN TITRATABS...78 DEPOCYT...22 DEPO-ESTRADIOL...59 DEPO-PROVERA...63 DESCOVY...33 desipramine hcl tabs 10mg, 75mg...17 desipramine hcl tabs 100mg, 150mg, 25mg, 50mg...17 desmopressin acetate inj, tabs...57 desmopressin acetate nasal soln 0.01%...57 desogestrel/ethinyl estradiol...59 desonide crea, lotn...55 desonide oint...55 desoximetasone crea 0.05%...55 desoximetasone crea 0.25%...55 desoximetasone gel...56 desoximetasone oint...56 desvenlafaxine er tb24 50mg...16 desvenlafaxine er tb24 100mg, 50mg

109 Drug Name Page # Drug Name Page # dexamethasone elix...56 DEXAMETHASONE INTENSOL...56 dexamethasone sodium phosphate inj 10mg/ml, 20mg/5ml, 4mg/ml...56 dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml...56 dexamethasone sodium phosphate ophthalmic soln 0.1%...72 dexamethasone soln, tabs...56 dexmethylphenidate hcl...47 dexrazoxane...23 dextroamphetamine sulfate soln...47 dextroamphetamine sulfate tabs...47 dextrose 2.5%/sodium chloride 0.45%...80 dextrose 5%...80 dextrose 5% /electrolyte #48 viaflex...79 dextrose 5%/lactated ringers...80 dextrose 5%/nacl 0.2%...80 dextrose 5%/nacl 0.3%...80 dextrose 5%/nacl 0.9%...80 dextrose 5%/nacl 0.33%...80 dextrose 5%/nacl 0.45%...80 dextrose 5%/nacl 0.225%...80 dextrose 5%/potassium chloride 0.15%...80 dextrose 10%...80 dextrose 10% flex container...80 dextrose 10%/nacl 0.2%...80 dextrose 10%/nacl 0.45%...79 dextrose 20%...80 dextrose 25%...80 dextrose 30%...80 dextrose 40%...80 dextrose 50%...80 dextrose 70%...80 diazepam gel 10mg, 2.5mg, 20mg...13 diazepam inj 5mg/ml...35 diazepam intensol...35 diazepam oral soln 1mg/ml...35 diazepam tabs 10mg, 2mg, 5mg...35 diclofenac potassium... 2 diclofenac sodium dr... 2 diclofenac sodium er... 2 diclofenac sodium gel...49 dicloxacillin sodium...11 dicyclomine hcl caps, soln, tabs...51 didanosine cpdr 125mg...33 didanosine cpdr 200mg, 250mg, 400mg...33 DIFICID...11 diflorasone diacetate...56 diflunisal tabs... 2 digitek...44 digoxin inj, oral soln...44 digoxin tabs 125mcg...44 digoxin tabs 250mcg...44 digox tabs 125mcg...44 digox tabs 250mcg...44 dihydroergotamine mesylate inj...20 DILANTIN CAPS 30MG...14 diltiazem cd...43 diltiazem hcl cd...43 diltiazem hcl er cp diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg...43 diltiazem hcl er cp24 180mg, 360mg...43 diltiazem hcl er tb diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml...43 diltiazem hcl tabs 30mg, 60mg...43 diltiazem hcl tabs 120mg, 90mg...43 dilt-xr...43 diphenatol...51 diphenhydramine hcl inj...74 diphenoxylate/atropine liqd...51 diphenoxylate/atropine tabs...51 diphtheria/tetanus toxoids adsorbed pediatric...68 disopyramide phosphate caps 100mg...41 disopyramide phosphate caps 150mg...41 disulfiram tabs... 6 divalproex sodium...13 divalproex sodium dr...13 divalproex sodium er...13 DOCEFREZ INJ 20MG...23 docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml, 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml...23 dofetilide...41 donepezil hcl tabs 10mg...15 donepezil hcl tabs 23mg, 5mg...15 donepezil hcl tbdp...15 dorzolamide hcl...73 dorzolamide hcl/timolol maleate...73 doxazosin...39 doxazosin mesylate tabs 1mg, 2mg...40 doxazosin mesylate tabs 8mg

110 Drug Name Page # Drug Name Page # doxepin hcl caps 100mg, 10mg, 25mg, 50mg, 75mg.17 doxepin hcl caps 150mg...17 doxepin hcl conc...17 doxepin hydrochloride...49 doxercalciferol caps...69 doxorubicin hcl...23 doxorubicin hcl liposome...23 doxy doxycycline caps 75mg...12 doxycycline caps 150mg...12 doxycycline hyclate caps 50mg...12 doxycycline hyclate caps 100mg...12 doxycycline hyclate dr...12 doxycycline hyclate inj...12 doxycycline hyclate tabs 20mg...12 doxycycline hyclate tabs 100mg...12 doxycycline monohydrate caps 50mg...12 doxycycline monohydrate caps 100mg...12 doxycycline monohydrate tabs 50mg, 75mg...12 doxycycline monohydrate tabs 100mg, 150mg...12 doxycycline susr...12 dronabinol...18 drospirenone/ethinyl estradiol tabs 3mg; 0.02mg...59 drospirenone/ethinyl estradiol tabs 3mg; 0.03mg...59 DROXIA...22 dual action complete...52 DUET DHA DUET DHA BALANCED MISC 120MG; 2800UNIT; 215MG; 640UNIT; 55MG; 1.8MG; 12MCG; 0; 0; 0; 1MG; 25MG; 0; 25MG; 20MG; 267MG; 0; 210MCG; 50MG; 2MG; 0; 65MCG; 1.5MG; 15MG; 25MG...83 duloxetine hcl cpep 20mg, 60mg...16 duloxetine hcl cpep 30mg...16 duloxetine hcl cpep 40mg...16 duramorph... 4 DUREZOL...72 dutasteride...54 dutasteride/tamsulosin hydrochloride...54 econazole nitrate crea...19 EDARBI...40 EDARBYCLOR...40 EDURANT...32 EFFIENT...39 EGRIFTA INJ 1MG...58 EGRIFTA INJ 2MG...58 ELIDEL...49 elinest...59 ELITEK...23 elite-ob...83 ELLA...63 EMCYT...22 EMEND CAPS 0, 125MG, 80MG...18 EMEND CAPS 40MG...18 emoquette...59 EMPLICITI...27 EMSAM...16 EMTRIVA...33 enalapril maleate/hydrochlorothiazide...40 enalapril maleate tabs...40 ENBRACE HR...83 ENBREL INJ 25MG...66 ENBREL INJ 25MG/0.5ML...66 ENBREL INJ 50MG/ML...66 ENBREL SURECLICK...66 endocet tabs 325mg; 2.5mg, 325mg; 5mg... 4 endocet tabs 325mg; 10mg, 325mg; 7.5mg... 4 endodan... 4 ENGERIX-B...68 enoxaparin sodium...38 enpresse enskyce...59 entacapone...28 entecavir...32 ENTRESTO...40 enulose...53 ENVARSUS XR...66 epinastine hcl...72 EPIPEN 2-PAK...76 EPIPEN-JR 2-PAK...76 epirubicin hcl inj 200mg/100ml, 50mg/25ml...23 epitol...14 EPIVIR HBV SOLN...32 eplerenone...45 epoprostenol sodium...77 eprosartan mesylate...40 EPZICOM...33 EQUETRO...35 ERAXIS...19 ERBITUX...23 ergoloid mesylates tabs...15 ERIVEDGE...26 errin...63 ERWINAZE...23 ery

111 Drug Name Page # Drug Name Page # ERYTHROCIN LACTOBIONATE...11 erythromycin base...11 erythromycin/benzoyl peroxide...49 erythromycin cpep 250mg...11 erythromycin ethylsuccinate tabs...11 erythromycin gel 2%...49 erythromycin oint 5mg/gm...71 erythromycin pads 2%...49 erythromycin soln 2%...49 erythromycin stearate tabs...11 ESBRIET...77 ESCAVITE D...84 ESCAVITE LQ...84 escitalopram oxalate soln...16 escitalopram oxalate tabs 10mg, 5mg...16 escitalopram oxalate tabs 20mg...16 esgic caps... 1 esomeprazole magnesium...53 esomeprazole sodium...53 estarylla...59 ESTRACE CREA...59 estradiol/norethindrone acetate...59 estradiol pttw...59 estradiol ptwk...59 estradiol tabs 0.5mg, 1mg...59 estradiol tabs 2mg...59 ethambutol hcl...21 ethosuximide...13 etidronate disodium...69 etodolac caps... 2 etodolac er tb24 400mg, 500mg... 2 etodolac er tb24 600mg... 2 etodolac tabs... 2 etoposide inj...25 EVOTAZ...34 EVZIO... 6 exemestane...25 EXJADE...78 EXTRA-VIRT PLUS DHA...84 FABRAZYME...51 falmina...60 famciclovir tabs 125mg, 250mg...34 famciclovir tabs 500mg...35 famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml..52 famotidine premixed...52 famotidine susr 40mg/5ml...52 famotidine tabs 20mg, 40mg...52 FANAPT TABS 10MG...30 FANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG, 8MG FANAPT TITRATION PACK...30 FARESTON...22 FARYDAK...23 FASLODEX...23 FAZACLO TBDP 12.5MG, 150MG, 200MG...31 felbamate...14 felodipine er tb24 2.5mg, 5mg...43 felodipine er tb24 10mg...43 fenofibrate caps 130mg, 43mg...45 fenofibrate caps 150mg, 50mg...45 fenofibrate micronized...45 fenofibrate tabs 120mg, 40mg...45 fenofibrate tabs 145mg, 160mg, 48mg, 54mg...45 fenofibric acid...45 fenofibric acid dr...45 fentanyl citrate oral transmucosal... 4 fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr... 3 fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr... 3 FERRIPROX SOLN 100MG/ML...70 FERRIPROX TABS 500MG...78 FETZIMA...16 FETZIMA TITRATION PACK...16 finasteride tabs 5mg...54 FIRAZYR...66 FIRMAGON...65 FLEBOGAMMA DIF...67 flecainide acetate tabs 50mg...41 flecainide acetate tabs 100mg, 150mg...41 floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg; 262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg; 20unit; 2000unit; 5mg...84 FLORIVA LIQD 0.25MG/ML; 400UNIT/ML...80 FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/ BLIST...74 FLOVENT DISKUS AEPB 250MCG/BLIST...74 FLOVENT HFA AERO 44MCG/ACT...74 FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT.74 fluconazole in dextrose...19 fluconazole in nacl inj 100mg/50ml; 0.9%, 400mg/200ml; 0.9%...19 fluconazole susr, tabs...19 flucytosine...19 fludarabine phosphate

112 Drug Name Page # Drug Name Page # fludrocortisone acetate tabs...56 flunisolide...74 fluocinolone acetonide body...49 fluocinolone acetonide crea 0.01%, 0.025%...56 fluocinolone acetonide oil 0.01%...73 fluocinolone acetonide oint 0.025%...56 fluocinolone acetonide scalp...49 fluocinolone acetonide soln 0.01%...56 fluocinonide crea 0.1%...56 fluocinonide crea 0.05%...56 fluocinonide-e...56 fluocinonide gel...56 fluocinonide oint, soln...56 fluor-a-day soln...80 fluoride chew 0.25mg...80 fluoride chew 1.1mg, 2.2mg...80 fluoridex daily defense...48 fluoritab chew 0.5mg, 1mg...80 fluoritab soln...80 fluorometholone...72 fluorouracil crea 0.5%...49 fluorouracil crea 5%...49 fluorouracil external soln 2%, 5%...49 fluorouracil inj 2.5gm/50ml...23 fluoxetine...16 fluoxetine dr...16 fluoxetine hcl caps, soln...16 fluoxetine hcl tabs 10mg, 20mg...16 fluoxetine hcl tabs 60mg...16 fluphenazine decanoate inj...29 fluphenazine hcl conc, inj...29 fluphenazine hcl elix...29 fluphenazine hcl tabs 2.5mg...29 fluphenazine hcl tabs 10mg, 1mg, 5mg...29 FLURA-DROPS SOLN 0.25MG/DROP...80 flurbiprofen sodium...72 flurbiprofen tabs 50mg... 2 flurbiprofen tabs 100mg... 2 flutamide...22 fluticasone propionate crea 0.05%...56 fluticasone propionate lotn 0.05%...56 fluticasone propionate oint 0.005%...56 fluticasone propionate susp 50mcg/act...74 fluvastatin caps 20mg...46 fluvastatin caps 40mg...45 fluvastatin sodium er...45 fluvoxamine maleate tabs 25mg...16 fluvoxamine maleate tabs 100mg, 50mg...16 FOCALGIN 90 DHA...84 FOCALGIN CA...84 FOLCAL DHA...84 FOLCAPS OMEGA FOLET ONE...84 FOLIVANE-OB...84 FOLIVANE-PRX DHA NF...84 FOLOTYN...23 fomepizole...78 fondaparinux sodium...38 FORADIL AEROLIZER...76 FORTEO...69 fosinopril sodium/hydrochlorothiazide...40 fosinopril sodium tabs 10mg...40 fosinopril sodium tabs 20mg, 40mg...40 fosphenytoin sodium...14 FOSRENOL CHEW...55 FOSRENOL PACK 750MG...55 FOSRENOL PACK 1000MG...55 FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML.80 furosemide inj 10mg/ml...44 furosemide oral soln...44 furosemide tabs...44 FUSILEV...23 FUZEON...34 fyavolv...60 FYCOMPA SUSP...13 FYCOMPA TABS 2MG...13 FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG...13 gabapentin caps, soln, tabs...13 GABITRIL TABS 12MG, 16MG...13 galantamine hydrobromide cp galantamine hydrobromide soln...15 galantamine hydrobromide tabs...15 GAMASTAN S/D...67 GAMMAGARD LIQUID...67 GAMMAGARD S/D IGA LESS THAN 1MCG/ML...67 GAMMAKED...67 GAMMAPLEX...67 GAMUNEX-C

113 Drug Name Page # Drug Name Page # ganciclovir inj...32 GARDASIL...68 GARDASIL gatifloxacin...71 GATTEX...51 GAUZE PADS 2 X gavilax powd...53 gavilyte-c...53 gavilyte-g...53 gavilyte-h...51 gavilyte-n/flavor pack...53 GAZYVA...27 gemcitabine...24 gemcitabine hcl...24 gemfibrozil tabs...45 generlac...53 gengraf caps 100mg, 25mg...66 gengraf soln...66 gentak...71 gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9%... 7 gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%... 7 gentamicin sulfate crea 0.1%...49 gentamicin sulfate external oint 0.1%...49 gentamicin sulfate inj 10mg/ml... 7 gentamicin sulfate inj 40mg/ml... 7 gentamicin sulfate ophthalmic oint 0.3%...71 gentamicin sulfate ophthalmic soln 0.3%...71 gentamicin sulfate pediatric... 7 GENVOYA...32 GEODON INJ...30 gianvi...60 gildagia...60 gildess 1.5/ gildess 1/ gildess 24 fe...60 gildess fe 1.5/ gildess fe 1/ GILENYA...48 GILOTRIF...26 glatopa...48 GLEEVEC TABS 100MG...26 GLEEVEC TABS 400MG...26 GLEOSTINE CAPS 5MG...21 glimepiride...36 glipizide er...36 glipizide/metformin hcl tabs 2.5mg; 250mg...36 glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg...36 glipizide tabs...36 glipizide xl tb24 2.5mg, 5mg...36 glipizide xl tb24 10mg...36 GLUCAGEN HYPOKIT...37 GLUCAGON EMERGENCY KIT...37 glyburide/metformin hcl...36 glyburide micronized tabs 1.5mg...36 glyburide micronized tabs 3mg, 6mg...36 glyburide tabs 1.25mg...36 glyburide tabs 2.5mg, 5mg...36 glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml...51 glycopyrrolate inj 4mg/20ml...51 glycopyrrolate tabs...51 glydo... 5 gnp 8 hour pain reliever... 1 gnp acid control 150 maximum strength...52 gnp acid reducer maximum strength...52 gnp acid reducer tabs 10mg...52 gnp all day allergy childrens soln 5mg/5ml...74 gnp all day allergy childrens syrp...74 gnp all day pain relief... 2 gnp allergy relief for kids tbdp...75 gnp allergy relief tbdp...75 gnp arthritis pain relief... 1 gnp childrens ibuprofen... 2 gnp clearlax...53 gnp dayhist allergy...75 gnp ibuprofen... 2 gnp lice treatment liqd...28 gnp loperamide hcl...51 gnp loratadine childrens...75 gnp loratadine tabs...75 gnp miconazole gnp nicotine polacrilex gum 2mg... 6 gnp terbinafine hydrochloride...19 goodsense all day allergy...75 granisetron hcl tabs...18 griseofulvin microsize susp...19 griseofulvin microsize tabs...19 griseofulvin ultramicrosize...19 guanfacine er...47 guanidine hcl...20 HALAVEN

114 Drug Name Page # Drug Name Page # halobetasol propionate crea...56 halobetasol propionate oint...56 haloperidol conc...29 haloperidol decanoate...29 haloperidol lactate...29 haloperidol tabs 0.5mg, 1mg, 20mg, 5mg...29 haloperidol tabs 10mg, 2mg...29 HARVONI...32 HAVRIX...68 healthylax...53 heartburn relief 150 maximum strength...52 heartburn relief maximum strength...52 heartburn relief tabs 10mg, 200mg...52 heather...63 hecoria...66 HEMENATAL OB...84 HEMENATAL OB + DHA...84 heparin sodium/d5w...38 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml...38 heparin sodium/nacl 0.9%...38 heparin sodium/nacl 0.45%...38 heparin sodium/sodium chloride 0.9%...38 heparin sodium/sodium chloride 0.9% premix...38 hepatamine...80 HERCEPTIN...24 HETLIOZ...78 HEXALEN...21 HIBERIX...68 hm all day allergy...75 hm allergy relief tbdp...75 hm arthritis pain relief... 1 hm complete dual action...52 hm ibuprofen infants... 2 hm nicotine polacrilex gum 2mg... 6 hm nicotine polacrilex lozg... 6 H.P. ACTHAR...58 HUMALOG...37 HUMALOG KWIKPEN...37 HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN...37 HUMALOG MIX 75/ HUMALOG MIX 75/25 KWIKPEN...37 HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML...66 HUMIRA INJ 40MG/0.8ML...66 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK...66 HUMIRA PEN...66 HUMIRA PEN-CROHNS DISEASESTARTER...66 HUMIRA PEN-PSORIASIS STARTER...66 HUMULIN 70/ HUMULIN 70/30 KWIKPEN...37 HUMULIN N...37 HUMULIN N KWIKPEN...37 HUMULIN R...37 HUMULIN R U-500 (CONCENTRATED)...37 HUMULIN R U-500 KWIKPEN...37 hydralazine hcl inj, tabs...47 hydrochlorothiazide caps...45 hydrochlorothiazide tabs 12.5mg...45 hydrochlorothiazide tabs 25mg, 50mg...45 hydrocodone/acetaminophen tabs 325mg; 5mg, 325mg; 7.5mg... 4 hydrocodone/acetaminophen tabs 325mg; 10mg... 4 hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml... 4 hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg... 4 hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg... 4 hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg; 200mg... 4 hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg... 4 hydrocortisone/acetic acid...73 hydrocortisone butyrate crea, oint, soln...56 hydrocortisone butyrate (lipophilic)...56 hydrocortisone crea 1%, 2.5%...56 hydrocortisone enem, tabs...56 hydrocortisone in absorbase...56 hydrocortisone lotn 2.5%...56 hydrocortisone oint 1%...56 hydrocortisone oint 2.5%...56 hydrocortisone valerate crea...56 hydrocortisone valerate oint...56 hydromorphone hcl inj 4mg/ml... 4 hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, 50mg/5ml... 4 hydromorphone hcl liqd... 4 hydromorphone hcl tabs... 4 hydroxychloroquine sulfate tabs...28 hydroxyprogesterone caproate inj...63 hydroxyurea caps...22 hydroxyzine hcl inj, syrp

115 Drug Name Page # Drug Name Page # hydroxyzine hcl tabs...75 hydroxyzine pamoate caps 25mg, 50mg...75 hydroxyzine pamoate caps 100mg...75 IBRANCE...24 ibu ibudone tabs 5mg; 200mg... 4 ibuprofen caps... 2 ibuprofen childrens... 2 ibuprofen junior strength... 2 ibuprofen susp 100mg/5ml... 2 ibuprofen susp 100mg/5ml... 2 ibuprofen tabs 200mg... 2 ibuprofen tabs 400mg, 600mg, 800mg... 2 ICLUSIG TABS 15MG...26 ICLUSIG TABS 45MG...26 idarubicin hcl...24 ifosfamide...24 ILARIS...67 ILEVRO...72 ilotycin...71 imatinib mesylate tabs 100mg...26 imatinib mesylate tabs 400mg...26 IMBRUVICA...26 imipenem/cilastatin...10 imipramine hcl tabs...17 imiquimod crea...49 IMOVAX RABIES (H.D.C.V.)...68 inatal advance...84 inatal ultra...84 INCRELEX...58 INCRUSE ELLIPTA...76 indapamide...45 INFANRIX...68 infants ibuprofen... 2 INLYTA TABS 1MG...26 INLYTA TABS 5MG...26 INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2.70 INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16.70 INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2..70 INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/ INSUPEN 33GX4MM...70 INTELENCE TABS 25MG...32 INTELENCE TABS 100MG, 200MG...33 intralipid inj 20gm/100ml...81 INTRALIPID INJ 30GM/100ML...81 INTRON A INJ 10MU/ML, 18MU, 50MU, UNIT/ML...24 INTRON A W/DILUENT...24 introvale...60 INVANZ INJ 1GM...10 INVEGA SUSTENNA...30 INVEGA TRINZA...30 INVIRASE...34 INVOKAMET...36 INVOKANA TABS 100MG...36 INVOKANA TABS 300MG...36 IPOL INACTIVATED IPV...68 ipratropium bromide/albuterol sulfate...76 ipratropium bromide inhalation soln...76 ipratropium bromide nasal soln...76 irbesartan...40 irbesartan/hydrochlorothiazide...40 IRESSA...26 irinotecan...24 ISENTRESS CHEW...32 ISENTRESS PACK...32 ISENTRESS TABS...32 isoniazid inj...21 isoniazid syrp...21 isoniazid tabs 100mg...21 isoniazid tabs 300mg...21 ISOPROPYL ALCOHOL WIPES... 8 isosorbide dinitrate er...46 isosorbide dinitrate tabs...46 isosorbide mononitrate er...46 isosorbide mononitrate tabs 10mg...46 isosorbide mononitrate tabs 20mg...46 isotonic gentamicin inj 0.8mg/ml; 0.9%... 7 isradipine...43 ISTODAX...24 itraconazole caps...19 ivermectin tabs...27 IXEMPRA KIT...24 IXIARO...68 JAKAFI...26 jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg...38 jantoven tabs 10mg, 2.5mg, 5mg...38 JANUMET...36 JANUMET XR TB MG; 50MG...36 JANUMET XR TB MG; 100MG, 500MG; 50MG 36 JANUVIA TABS 50MG...36 JANUVIA TABS 100MG, 25MG...36 jencycla

116 Drug Name Page # Drug Name Page # JENTADUETO...36 JENTADUETO XR...36 JEVTANA...24 jinteli...60 jolessa...60 jolivette...63 juleber...60 junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ junel fe KABIVEN...81 KADCYLA...24 kaitlib fe...60 KALETRA SOLN...34 KALETRA TABS 100MG; 25MG...34 KALETRA TABS 200MG; 50MG...34 KALYDECO PACK...76 KALYDECO TABS...76 kariva...60 kcl 0.3%/d5w/lr iv lac ring...81 kcl 0.3%/d5w/nacl 0.9%...81 kcl 0.3%/d5w/nacl 0.45%...81 kcl 0.15%/d5w/lr...81 kcl 0.15%/d5w/nacl 0.2%...81 kcl 0.15%/d5w/nacl 0.9%...81 kcl 0.15%/d5w/nacl 0.45%...81 kcl 0.15%/d5w/nacl 0.225%...81 kcl 0.075%/d5w/nacl 0.45%...81 kelnor 1/ ketoconazole crea, sham...19 ketoconazole tabs...19 ketoprofen caps... 2 ketoprofen er... 2 ketorolac tromethamine...72 KEYTRUDA...27 kimidess...60 KINRIX...68 kionex...78 klor-con...81 klor-con klor-con KLOR-CON klor-con/ef...81 klor-con m KLOR-CON M klor-con m klor-con sprinkle...81 KORLYM...36 k-sol...81 kurvelo...60 KUVAN...51 KYNAMRO...46 labetalol hcl inj, tabs...42 lactated ringers dextrose 5% viaflex...81 lactated ringers viaflex...81 lactulose soln 10gm/15ml...53 LAMISIL AT...19 lamivudine soln 10mg/ml...33 lamivudine tabs 100mg...32 lamivudine tabs 150mg, 300mg...33 lamivudine/zidovudine...33 lamotrigine chew, tabs...14 lamotrigine titration...14 LANTUS...37 LANTUS SOLOSTAR...37 larin 1.5/ larin 1/ larin 24 fe...60 larin fe 1.5/ larin fe 1/ latanoprost...70 LATUDA TABS 40MG, 80MG...30 LATUDA TABS 120MG, 20MG, 60MG...30 layolis fe...60 leena...60 leflunomide...67 LENVIMA 8 MG DAILY DOSE...26 LENVIMA 10 MG DAILY DOSE...26 LENVIMA 14 MG DAILY DOSE...26 LENVIMA 18 MG DAILY DOSE...26 LENVIMA 20 MG DAILY DOSE...26 LENVIMA 24 MG DAILY DOSE...26 lessina...60 LETAIRIS...77 letrozole...25 leucovorin calcium inj...24 leucovorin calcium tabs 5mg...24 leucovorin calcium tabs 10mg, 15mg, 25mg...24 LEUKERAN...21 LEUKINE INJ 250MCG...39 leuprolide acetate inj...65 levalbuterol hcl nebu

117 Drug Name Page # Drug Name Page # levalbuterol nebu...76 LEVEMIR...37 LEVEMIR FLEXTOUCH...37 levetiracetam...13 levobunolol hcl...73 levocarnitine...78 levocetirizine dihydrochloride soln...75 levocetirizine dihydrochloride tabs...75 levofloxacin in d5w...12 levofloxacin inj 25mg/ml...12 levofloxacin ophthalmic soln 0.5%...71 levofloxacin oral soln 25mg/ml...12 levofloxacin tabs 250mg, 500mg, 750mg...12 levoleucovorin calcium...24 levoleucovorin inj 250mg/25ml...24 levonest...60 levonorgestrel...63 levonorgestrel and ethinyl estradiol tabs 0; levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg. 61 levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg.61 levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg...61 levora 0.15/ levothyroxine sodium inj...64 levothyroxine sodium tabs 100mcg, 112mcg, 125mcg, 150mcg, 25mcg, 50mcg, 75mcg, 88mcg...64 levothyroxine sodium tabs 137mcg, 175mcg, 200mcg, 300mcg...64 levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg, 75mcg, 88mcg...64 levoxyl tabs 125mcg, 137mcg, 175mcg, 200mcg, 25mcg...64 LEXIVA...34 LIALDA...69 lidocaine hcl external soln 4%... 6 lidocaine hcl gel 2%... 6 lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%... 6 lidocaine hcl inj 10mg/ml, 20mg/ml...41 lidocaine hcl jelly gel 2%... 5 lidocaine hcl mouth/throat soln 4%... 6 lidocaine oint... 6 lidocaine/prilocaine crea... 6 lidocaine/prilocaine kit... 6 lidocaine ptch... 6 lidocaine viscous... 6 lindane lotn...28 lindane sham...28 linezolid inj... 8 linezolid susr... 8 linezolid tabs... 8 LINZESS...53 liothyronine sodium tabs...64 lisinopril...41 lisinopril/hydrochlorothiazide...41 lithium...35 lithium carbonate caps, tabs...35 lithium carbonate er...35 lokara...56 lomedia 24 fe...61 lomustine...21 LONSURF TABS 6.14MG; 15MG...22 LONSURF TABS 8.19MG; 20MG...22 loperamide hcl caps...51 loperamide hcl liqd, susp...51 lopreeza...61 loratadine childrens...75 loratadine hives relief...75 loratadine tabs...75 lorazepam inj 2mg/ml, 4mg/ml...35 lorazepam intensol...35 lorazepam tabs 0.5mg...35 lorazepam tabs 1mg...35 lorazepam tabs 2mg...35 lorcet... 4 lorcet hd... 4 lorcet plus tabs 325mg; 7.5mg... 4 lortab tabs 325mg; 5mg... 4 lortab tabs 325mg; 10mg, 325mg; 7.5mg... 4 loryna...61 losartan potassium/hydrochlorothiazide...40 losartan potassium tabs 25mg, 50mg...40 losartan potassium tabs 100mg...40 LOTEMAX...72 lovastatin...46 LOVAZA...46 low-ogestrel...61 loxapine succinate caps 10mg, 50mg, 5mg...29 loxapine succinate caps 25mg...29 ludent...81 LUMIGAN...70 LUMIZYME...51 LUPRON DEPOT...65 LUPRON DEPOT-PED

118 Drug Name Page # Drug Name Page # lutera...61 LYNPARZA...24 LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG...13 LYRICA CAPS 225MG, 300MG...13 LYRICA SOLN...13 LYSODREN...65 lyza...63 magnesium sulfate inj...81 malathion...28 maprotiline hcl...16 margesic... 1 marlissa...61 MARNATAL-F...84 MARPLAN...16 MARQIBO...24 MATULANE...21 matzim la...43 meclizine hcl tabs...18 meclofenamate sodium caps... 2 medroxyprogesterone acetate inj...63 medroxyprogesterone acetate tabs 5mg...63 medroxyprogesterone acetate tabs 10mg, 2.5mg...63 mefloquine hcl...28 megestrol acetate susp 40mg/ml...63 megestrol acetate tabs...63 MEKINIST TABS 0.5MG...26 MEKINIST TABS 2MG...26 meloxicam susp... 2 meloxicam tabs... 2 melphalan hydrochloride...21 memantine hcl...15 memantine hcl titration pak...15 memantine hydrochloride soln...15 MENACTRA...68 MENEST...61 MENHIBRIX...68 MENOMUNE-A/C/Y/W MENVEO...68 MEPRON...28 mercaptopurine tabs...22 meropenem...10 meropenem/sodium chloride...10 mesalamine enem, kit...69 mesna...24 MESNEX TABS...24 MESTINON SYRP...20 MESTINON TIMESPAN...20 metadate er...47 metaproterenol sulfate syrp, tabs...76 metformin hcl er tb24 500mg, 750mg...36 metformin hcl er tb mg, 500mg...36 metformin hcl tabs...36 methadone hcl conc... 3 methadone hcl inj... 3 methadone hcl oral soln... 3 methadone hcl tabs... 3 methadone hcl tbso... 3 methadose tbso... 3 methazolamide...44 methenamine hippurate... 8 methimazole tabs...65 methotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml, 50mg/2ml...66 methotrexate tabs...66 methoxsalen caps...49 methscopolamine bromide...51 methyclothiazide tabs...45 methylergonovine maleate...54 methylphenidate hcl er cp24 30mg...47 methylphenidate hcl er tbcr 10mg, 20mg...47 methylphenidate hcl sr...47 methylphenidate hcl tabs...47 methylprednisolone acetate inj...57 methylprednisolone dose pack...57 methylprednisolone sodiumsuccinate...57 methylprednisolone tabs...57 metipranolol...73 metoclopramide hcl inj...51 metoclopramide hcl oral soln, tabs...51 metolazone...45 metoprolol/hydrochlorothiazide...42 metoprolol succinate er tb24 100mg, 25mg, 50mg...42 metoprolol succinate er tb24 200mg...42 metoprolol tartrate inj...42 metoprolol tartrate tabs 37.5mg, 75mg...42 metoprolol tartrate tabs 100mg, 25mg, 50mg...42 METRO IV... 8 metronidazole caps 375mg... 8 metronidazole crea 0.75%...49 metronidazole gel 0.75%...49 metronidazole gel 1%...49 metronidazole in nacl 0.79%... 8 metronidazole lotn 0.75%

119 Drug Name Page # Drug Name Page # metronidazole tabs 250mg, 500mg... 8 metronidazole vaginal... 8 mexiletine hcl...41 MIACALCIN INJ...69 miconazole 3 combo pack...19 miconazole microgestin 1.5/ microgestin 1/ microgestin 24 fe...61 microgestin fe...61 microgestin fe 1.5/ midodrine hcl...39 MIGERGOT...20 miglitol...36 MILLIPRED...57 MILLIPRED DP...57 mimvey...61 mimvey lo...61 minitran...46 minocycline hcl caps...12 minoxidil tabs...47 mirtazapine...15 mirtazapine odt...15 misoprostol...53 mitomycin...24 mitoxantrone hcl...24 M-M-R II...68 modafinil tabs 100mg...78 modafinil tabs 200mg...78 moderiba tabs...32 moexipril hcl tabs 7.5mg...41 moexipril hcl tabs 15mg...41 moexipril/hydrochlorothiazide...41 molindone hydrochloride tabs 5mg...31 molindone hydrochloride tabs 10mg...31 molindone hydrochloride tabs 25mg...31 mometasone furoate crea...57 mometasone furoate oint, soln...57 mono-linyah...61 mononessa...61 montelukast sodium...75 morgidox 1x100mg caps...12 morgidox 2x100mg caps...12 morphine sulfate er cp24 10mg, 30mg, 60mg... 3 morphine sulfate er cp24 100mg, 20mg, 30mg, 50mg, 60mg, 80mg... 3 morphine sulfate er cp24 120mg, 45mg, 75mg, 90mg.3 morphine sulfate er tbcr 15mg... 3 morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg.3 morphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ ml, 5mg/ml, 8mg/ml... 5 morphine sulfate inj 10mg/ml, 1mg/ml... 5 morphine sulfate oral soln 10mg/5ml... 5 morphine sulfate oral soln 20mg/5ml... 5 morphine sulfate oral soln 100mg/5ml... 5 morphine sulfate tabs 15mg... 5 morphine sulfate tabs 30mg... 5 MOVANTIK...51 MOVIPREP...53 MOXEZA...71 MOZOBIL...39 MULTAQ...41 multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit; 2500unit...84 multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml...84 multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml...84 multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit...85 multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml...84 multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml...84 mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit...84 mupirocin calcium...49 mupirocin crea...50 mupirocin oint...50 MUSTARGEN...21 mvc-fluoride...85 mycophenolate mofetil caps, tabs...66 mycophenolate mofetil susr...66 myorisan

120 Drug Name Page # Drug Name Page # MYRBETRIQ...54 myzilra...61 nabumetone... 2 nadolol/bendroflumethiazide...42 nadolol tabs 20mg...42 nadolol tabs 40mg, 80mg...42 nafcillin...11 NAGLAZYME...51 nalbuphine hcl inj... 5 naloxone hcl inj 0.4mg/ml... 6 naloxone hcl inj 1mg/ml... 6 naltrexone hcl tabs... 6 NAMENDA SOLN...15 NAMENDA TABS...15 NAMENDA TITRATION PAK...15 NAMENDA XR CP24 14MG...15 NAMENDA XR CP24 21MG, 28MG, 7MG...15 NAMENDA XR TITRATION PACK...15 NAMZARIC...15 naphazoline hcl...71 naproxen dr tbec 375mg... 2 naproxen dr tbec 500mg... 2 naproxen sodium tabs 275mg, 550mg... 3 naproxen susp... 3 naproxen tabs... 3 naratriptan hcl...20 NARCAN... 6 NASONEX...74 NATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT...85 NATALVIRT 90 DHA...85 NATALVIRT CA...85 nateglinide...36 NATELLE ONE...85 NATPARA...70 NEBUPENT...28 necon 0.5/ necon 1/ NECON 1/ necon 7/7/ NECON 10/ nefazodone hcl...16 neomycin/bacitracin/polymyxin...71 neomycin/polymyxin/bacitracin/hydrocortisone...71 neomycin/polymyxin/dexamethasone oint...71 neomycin/polymyxin/dexamethasone susp...71 neomycin/polymyxin/gramicidin...71 neomycin/polymyxin/hc...73 neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml...71 neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml...73 neomycin sulfate... 7 neo-polycin...71 NEPHRAMINE...81 NESTABS...85 NESTABS ABC...85 NESTABS DHA...85 neuac...50 NEUMEGA...39 NEUPOGEN...39 NEUPRO...28 NEVANAC...72 nevirapine er tb24 100mg...33 nevirapine er tb24 400mg...33 nevirapine susp...33 nevirapine tabs...33 NEXA PLUS...85 NEXAVAR...26 niacin er...46 nicardipine hcl caps 20mg...43 nicardipine hcl caps 30mg...43 nicotine polacrilex gum, lozg... 7 nicotine transdermal system pt24 21mg/24hr... 7 NICOTROL NS... 7 nifedipine er tb24 30mg, 60mg, 90mg...43 nifedipine er tb24 90mg...43 nikki...61 NILANDRON...22 NINLARO...24 NIPENT...24 nisoldipine...43 nisoldipine er...43 nitrofurantoin macrocrystals... 8 nitrofurantoin monohydrate... 8 nitrofurantoin monohydrate/macrocrystals... 8 nitrofurantoin susp... 8 nitroglycerin inj...46 nitroglycerin lingual...46 nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/hr, 0.6mg/hr...46 nitroglycerin transdermal pt24 0.2mg/hr...46 NITROSTAT

121 Drug Name Page # Drug Name Page # NIVA-PLUS...85 nora-be...63 NORDITROPIN FLEXPRO...58 norethindrone acetate/ethinyl estradiol/ferrous fumarate 61 norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg. 62 norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg...61 norethindrone acetate tabs...63 norethindrone & ethinyl estradiol ferrous fumarate...61 norethindrone tabs...64 norgestimate/ethinyl estradiol...62 NORINYL norlyroc...64 NORTHERA...44 nortrel 0.5/35 (28)...62 nortrel 1/ nortrel 7/7/ nortriptyline hcl caps 10mg, 25mg, 75mg...17 nortriptyline hcl caps 50mg...17 nortriptyline hcl soln...17 NORVIR...34 NOVOLIN 70/ NOVOLIN 70/30 RELION...37 NOVOLIN N...37 NOVOLIN N RELION...37 NOVOLIN R...38 NOVOLIN R RELION...38 NOVOLOG...38 NOVOLOG FLEXPEN...38 NOVOLOG MIX 70/ NOVOLOG MIX 70/30 PREFILLED FLEXPEN...38 NOVOLOG PENFILL...38 NOXAFIL INJ...19 NOXAFIL SUSP, TBEC...19 NUEDEXTA...47 NULOJIX...66 NUPLAZID...30 nutrilipid...81 nyamyc...19 nystatin crea, oint, powd, susp, tabs...19 nystop...19 OB COMPLETE/DHA...85 OB COMPLETE GOLD...85 OB COMPLETE ONE...85 OB COMPLETE PETITE...85 OB COMPLETE PREMIER...85 OB COMPLETE TABS...85 O-CAL PRENATAL...85 ocella...62 OCTAGAM...67 octreotide acetate...65 ODEFSEY...33 ODOMZO...24 OFEV...77 ofloxacin ophthalmic soln 0.3%...71 ofloxacin otic soln 0.3%...73 ofloxacin tabs 400mg...12 OGESTREL...62 olanzapine/fluoxetine caps 25mg; 3mg...16 olanzapine/fluoxetine caps 25mg; 12mg, 25mg; 6mg, 50mg; 12mg, 50mg; 6mg...16 olanzapine inj...30 olanzapine odt...30 olanzapine tabs 2.5mg...30 olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg...30 olopatadine hcl nasal soln 0.6%...75 olopatadine hcl ophthalmic soln 0.1%...72 omega-3-acid ethyl esters...46 omeprazole cpdr 10mg...54 omeprazole cpdr 20mg...54 omeprazole cpdr 40mg...54 omeprazole magnesium...54 OMNITROPE...58 ONCASPAR...24 ondansetron hcl inj 4mg/2ml...18 ondansetron hcl inj 40mg/20ml, 4mg/2ml...18 ondansetron hcl oral soln...18 ondansetron hcl tabs 4mg, 8mg...18 ondansetron hcl tabs 24mg...18 ondansetron odt tbdp 4mg...18 ondansetron odt tbdp 8mg...18 ONFI SUSP...13 ONFI TABS 10MG, 20MG...13 OPDIVO...27 OPSUMIT...77 oralone...48 ORFADIN CAPS 10MG, 2MG, 5MG...51 ORFADIN SUSP 4MG/ML...70 ORKAMBI...76 orsythia...62 OTEZLA TABS...67 OTEZLA TBPK

122 Drug Name Page # Drug Name Page # OTREXUP INJ 10MG/0.4ML, 15MG/0.4ML, 17.5MG/0.4ML, 20MG/0.4ML, 22.5MG/0.4ML, 25MG/0.4ML, 7.5MG/0.4ML...66 oxacillin sodium inj 2gm...11 oxacillin sodium inj 10gm, 1gm...11 oxaliplatin...24 oxandrolone tabs 2.5mg...58 oxandrolone tabs 10mg...58 oxaprozin... 3 oxcarbazepine susp...14 oxcarbazepine tabs...14 oxybutynin chloride er tb24 5mg...54 oxybutynin chloride er tb24 10mg...54 oxybutynin chloride er tb24 15mg...54 oxybutynin chloride syrp...54 oxybutynin chloride tabs...54 oxycodone/acetaminophen soln... 5 oxycodone/acetaminophen tabs 325mg; 7.5mg... 5 oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg... 5 oxycodone/aspirin... 5 oxycodone hcl caps... 5 oxycodone hcl conc... 5 oxycodone hcl soln... 5 oxycodone hcl tabs 5mg... 5 oxycodone hcl tabs 10mg, 15mg, 20mg... 5 oxycodone hcl tabs 30mg... 5 oxycodone/ibuprofen... 5 pacerone tabs 100mg...41 pacerone tabs 200mg, 400mg...41 paclitaxel...24 PAIRE OB...85 paliperidone er tb24 1.5mg, 3mg, 9mg...30 paliperidone er tb24 6mg...30 pamidronate disodium...69 pancrelipase...51 PANRETIN...27 pantoprazole sodium tbec 20mg...54 pantoprazole sodium tbec 40mg...54 paricalcitol...69 paroex...48 paromomycin sulfate... 7 paroxetine hcl...17 PASER...21 PATADAY...72 PAXIL SUSP...17 PAZEO...72 PEDIARIX...68 PEDVAX HIB...68 peg 3350/electrolytes...53 peg-3350/electrolytes...53 peg-3350/nacl/na bicarbonate/kcl...53 peg 3350 powd...53 PEGANONE...14 PEGINTRON...32 PEG-INTRON REDIPEN...32 penicillin g potassium inj unit...11 penicillin g potassium inj unit...11 penicillin g procaine...11 penicillin g sodium...11 penicillin v potassium solr 125mg/5ml...11 penicillin v potassium solr 250mg/5ml...11 penicillin v potassium tabs...11 PEN NEEDLE/ULTRAFINE/29G X 12.7MM...70 PENTACEL...68 PENTAM PENTASA...69 pentoxifylline cr...44 pentoxifylline er...44 PERIKABIVEN...81 perindopril erbumine...41 periogard...48 PERJETA...24 permethrin crea...28 perphenazine/amitriptyline tabs 10mg; 2mg, 10mg; 4mg, 25mg; 2mg, 50mg; 4mg...17 perphenazine/amitriptyline tabs 25mg; 4mg...17 perphenazine tabs 4mg...29 perphenazine tabs 16mg, 2mg, 8mg...29 phenadoz supp 12.5mg...18 phenadoz supp 25mg...18 phenelzine sulfate...16 phenergan supp...18 phenobarbital elix...14 phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg.. 14 phenobarbital tabs 100mg, 15mg, 30mg, 60mg...14 phenytoin chew...14 phenytoin sodium extended...14 phenytoin sodium inj...14 phenytoin susp...14 philith...62 phos-flur...48 PHOSPHOLINE IODIDE

123 Drug Name Page # Drug Name Page # pilocarpine hcl soln 1%, 2%, 4%...73 pilocarpine hcl tabs 7.5mg...48 pilocarpine hydrochloride...48 pimozide...29 pimtrea...62 pindolol...42 pioglitazone hcl...36 pioglitazone hcl-glimepiride...36 pioglitazone hcl/metformin hcl...36 piperacillin sodium/ tazobactam sodium...11 piperacillin sodium/tazobactam sodium...11 piperacillin/tazobactam inj 36gm; 4.5gm, 4gm; 0.5gm pirmella 1/ pirmella 7/7/ piroxicam caps 10mg... 3 piroxicam caps 20mg... 3 plenamine...81 pnv-dha...85 PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID PNV FOLIC ACID + IRON MULTIVITAMIN...85 PNV OB+DHA...85 pnv prenatal plus multivitamin...85 pnv-select...85 pnv tabs PNV-VP-U...85 podofilox soln...50 polycin...71 polyethylene glycol 3350 pack polyethylene glycol 3350 pack polyethylene glycol 3350 powd polyethylene glycol 3350 powd polymyxin b sulfate/trimethoprim sulfate...71 poly-vitamin/fluoride chew...85 poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml...86 POMALYST...22 portia PORTRAZZA...24 potassium chloride 0.3%/d5w...82 potassium chloride 0.3%/ nacl 0.9%...82 potassium chloride 0.15% d5w/nacl 0.33%...81 potassium chloride 0.15% d5w/nacl 0.45%...81 potassium chloride 0.15% d5w/nacl 0.45% viaflex...81 potassium chloride 0.15% nacl 0.9%...82 potassium chloride 0.15%/nacl 0.9%...82 potassium chloride 0.15% /nacl 0.45% viaflex...81 potassium chloride 0.22% d5w/nacl 0.45%...82 potassium chloride 0.224%d5w/nacl 0.45% viaflex...82 potassium chloride cr tbcr 10meq, 20meq...82 potassium chloride er cpcr...82 potassium chloride er tbcr 10meq, 20meq, 8meq...82 potassium chloride er tbcr 20meq...82 potassium chloride inj 0.4meq/ml...82 potassium chloride inj 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml...82 potassium chloride oral soln...82 potassium chloride sr...82 potassium citrate er tbcr 15meq...82 potassium citrate er tbcr 1080mg, 540mg...82 POTIGA TABS 50MG...13 POTIGA TABS 200MG, 300MG, 400MG...13 PRADAXA...38 PRALUENT...44 pramipexole dihydrochloride...28 pravastatin sodium tabs 10mg, 80mg...46 pravastatin sodium tabs 20mg, 40mg...46 prazosin hcl...40 prednicarbate crea...57 prednicarbate oint...57 prednisolone acetate...72 prednisolone sodium phosphate ophthalmic soln 1%..72 prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml...57 prednisolone soln, syrp...57 PREDNISONE INTENSOL...57 prednisone soln...57 prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg...57 prednisone tabs 50mg...57 prednisone tbpk 10mg, 5mg...57 PREFERA OB...86 PREFERAOB +DHA...86 PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG...86 PREFERAOB ONE...86 PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 111

124 Drug Name Page # Drug Name Page # 34MG/100ML; 152MG/100ML...82 premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml...82 PRENAISSANCE...86 PRENAISSANCE PLUS...86 PRENATA...86 prenatabs fa...86 prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg...86 prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg...86 PRENATAL PLUS...86 prenatal plus iron tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg...86 PRENATE AM...86 PRENATE DHA CAPS 90MG; 145MG; 220UNIT; 13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT...86 PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG; 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT; 15MG...86 PRENATE ELITE TABS 600MCG; 75MG; 2600UNIT; 330MCG; 155MG; 600UNIT; 1.5MG; 13MCG; 20MG; 400MCG; 25MG; 21MG; 150MCG; 21MG; 3.5MG; 3MG; 40UNIT; 15MG...86 PRENATE ENHANCE...87 PRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT 87 PRENATE ESSENTIAL CAPS 600MCG; 90MG; 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG; 10UNIT...87 PRENATE MINI CAPS 60MG; 280MCG; 100MG; 220UNIT; 13MCG; 350MG; 400MCG; 29MG; 600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG.8 7 PRENATE MINI CAPS 600MCG; 60MG; 280MCG; 80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG; 18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG.8 7 PRENATE PIXIE...87 PRENATE RESTORE...87 PRENATE STAR...87 PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG...87 PREPOPIK...53 PREQUE PRETAB...87 prevalite...46 previfem...62 PREZCOBIX...34 PREZISTA SUSP...34 PREZISTA TABS 75MG...34 PREZISTA TABS 150MG, 600MG, 800MG...34 PRIFTIN...21 PRILOSEC OTC...54 primaquine phosphate tabs...28 primidone tabs...14 PRISTIQ TB24 25MG...17 pr natal PROAIR HFA...76 PROAIR RESPICLICK...76 probenecid/colchicine...20 probenecid tabs...20 prochlorperazine...29 prochlorperazine edisylate inj...29 prochlorperazine maleate tabs...30 PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML...39 PROCRIT INJ 40000UNIT/ML...39 procto-med hc...57 procto-pak...57 proctosol hc...57 proctozone-hc...57 progesterone caps...64 progesterone inj...64 PROGLYCEM...37 PROGRAF INJ...66 PROLASTIN-C...77 PROLENSA...72 PROLEUKIN...24 PROLIA...69 PROMACTA...39 promethazine hcl supp 12.5mg, 50mg

125 Drug Name Page # Drug Name Page # promethazine hcl supp 25mg...18 promethazine hcl tabs 12.5mg, 50mg...75 promethazine hcl tabs 25mg...75 promethegan supp 12.5mg, 25mg...18 promethegan supp 50mg...18 propafenone hcl...41 propafenone hcl er...41 proparacaine hcl...71 propranolol hcl er...42 propranolol hcl inj...42 propranolol hcl oral soln...42 propranolol hcl tabs 10mg, 20mg, 40mg, 60mg...42 propranolol hcl tabs 80mg...42 propranolol/hydrochlorothiazide...42 propylthiouracil tabs...65 PROQUAD...68 protriptyline hcl...17 PROVIDA DHA...87 PROVIDA OB...87 PULMOZYME...77 PUREFE OB PLUS...87 PURIXAN...22 pyrazinamide tabs...21 pyridostigmine bromide tabs, tbcr...21 qc 3 day vaginal cream...19 qc acid controller...52 qc acid controller maximum strength...52 qc all day allergy...75 qc allergy relief...75 qc anti-diarrheal...51 qc arthritis pain relief... 1 qc childrens ibuprofen... 3 qc loratadine allergy relief...75 qc omeprazole magnesium...54 QUADRACEL...68 quasense...62 quetiapine fumarate tabs 25mg...30 quetiapine fumarate tabs 100mg, 50mg...31 quetiapine fumarate tabs 200mg...30 quetiapine fumarate tabs 300mg, 400mg...30 QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/ ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/ ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/ ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ML; 12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/ ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML...87 quinapril hcl tabs 10mg, 40mg...41 quinapril hcl tabs 20mg, 5mg...41 quinapril/hydrochlorothiazide...41 quinidine gluconate cr...41 quinidine gluconate er...41 quinidine sulfate tabs 200mg...41 quinidine sulfate tabs 300mg...41 quinine sulfate...28 QVAR...74 RABAVERT...68 raloxifene hydrochloride...64 ramipril caps 1.25mg...41 ramipril caps 10mg, 2.5mg, 5mg...41 RANEXA...44 ranitidine ranitidine 150 maximum strength...52 ranitidine hcl caps 150mg, 300mg...52 ranitidine hcl inj 50mg/2ml...52 ranitidine hcl inj 150mg/6ml...52 ranitidine hcl syrp 15mg/ml...52 ranitidine hcl tabs 150mg, 300mg...52 RAPAMUNE SOLN...66 RASUVO...67 RAVICTI...51 REBIF...48 REBIF REBIDOSE...48 REBIF REBIDOSE TITRATION PACK...48 REBIF TITRATION PACK...48 reclipsen...62 RECOMBIVAX HB...68 REGRANEX...50 relador pak plus... 6 RELENZA DISKHALER...34 RELISTOR...52 RELNATE DHA...87 REMICADE...67 REMODULIN...77 RENACIDIN SOLN 6.602GM/100ML; 0.198GM/100ML; 3.177GM/100ML...54 RENVELA...55 repaglinide/metformin hydrochloride...36 repaglinide tabs 0.5mg, 1mg...37 repaglinide tabs 2mg...37 REPATHA...44 REPATHA SURECLICK

126 Drug Name Page # Drug Name Page # reprexain tabs 10mg; 200mg... 5 RESCRIPTOR...33 RESTASIS...71 RETROVIR IV INFUSION...33 REVLIMID...22 REXULTI...31 REYATAZ...34 ribasphere caps...32 ribasphere tabs 200mg...32 ribavirin...32 rifabutin...21 rifampin caps, inj...21 RIFATER...21 riluzole...47 rimantadine hcl...34 ringers injection...82 risedronate sodium dr...69 risedronate sodium tabs 30mg, 5mg...70 risedronate sodium tabs 35mg...69 risedronate sodium tabs 150mg...69 RISPERDAL CONSTA...31 risperidone odt tbdp 0.5mg...31 risperidone odt tbdp 0.25mg, 3mg...31 risperidone odt tbdp 1mg, 2mg...31 risperidone odt tbdp 4mg...31 risperidone soln...31 risperidone tabs 0.25mg, 0.5mg, 3mg...31 risperidone tabs 1mg, 2mg...31 risperidone tabs 4mg...31 RITUXAN...27 rivastigmine tartrate...15 rivastigmine transdermal system...15 rizatriptan benzoate odt...20 rizatriptan benzoate tabs 5mg...20 rizatriptan benzoate tabs 10mg...20 ropinirole hcl...28 rosadan crea...50 rosadan gel...50 rosuvastatin calcium tabs 10mg, 20mg, 5mg...46 rosuvastatin calcium tabs 40mg...46 ROTARIX...68 ROTATEQ...68 ROXICET SOLN... 5 roxicet tabs... 5 ROZEREM...78 SABRIL...14 SAMSCA TABS 15MG...78 SAMSCA TABS 30MG...78 SANDIMMUNE SOLN...67 SANTYL...50 SAPHRIS SUBL 2.5MG, 5MG...31 SAPHRIS SUBL 10MG...31 sb allergy tabs...75 sb anti-diarrhea...52 sb ibuprofen... 3 sb loratadine tabs...75 SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; 0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG...88 SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; 1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 1.6MG; 30UNIT; 1700UNIT; 15MG...88 SELECT-OB+DHA...87 selegiline hcl caps...29 selegiline hcl tabs...29 selenium sulfide lotn...50 SELZENTRY TABS 150MG...34 SELZENTRY TABS 300MG...34 se-natal SENSIPAR TABS 30MG, 60MG...65 SENSIPAR TABS 90MG...65 SEREVENT DISKUS...76 sertraline hcl conc, tabs...17 setlakin...62 sf...48 sharobel...64 SIGNIFOR...65 sildenafil tabs...77 silver sulfadiazine...50 SIMBRINZA...73 SIMULECT...67 simvastatin tabs 10mg, 20mg, 40mg, 5mg...46 simvastatin tabs 80mg...46 sirolimus tabs 0.5mg, 2mg...67 sirolimus tabs 1mg...67 SIRTURO...21 SIVEXTRO INJ... 8 SIVEXTRO TABS... 8 sm 8 hour pain relief... 1 sm acid reducer tabs 200mg, 75mg...52 sm all day allergy...75 sm all day allergy childrens soln 5mg/5ml...75 sm allergy relief loratadine...75 sm allergy relief tabs 1.34mg

127 Drug Name Page # Drug Name Page # sm anti-diarrheal tabs...52 sm arthritis pain relief... 1 sm athletes foot crea...19 sm clearlax...53 sm ibuprofen caps... 3 sm infants ibuprofen... 3 sm loratadine allergy relief...75 sm loratadine syrp...75 sm miconazole sm miconazole 7 crea...19 sm naproxen sodium tabs... 3 sm nicotine gum, lozg... 7 sm nicotine polacrilex... 7 sodium bicarbonate inj 8.4%...78 sodium bicarbonate partial fill...78 sodium chloride 0.9%...54 sodium chloride 0.45% viaflex...82 sodium chloride inj 0.9%, 5%...82 sodium chloride inj 2.5meq/ml, 3%...82 sodium fluoride chew 0.5mg, 1.1mg...82 sodium fluoride soln...83 sodium phenylbutyrate powd...51 sodium phosphate...83 sodium polystyrene sulfonate...78 sodium sulfacetamide lotn 10%...50 sodium sulfacetamide soln 10%...71 SOLTAMOX...22 SOMATULINE DEPOT INJ 60MG/0.2ML...65 SOMATULINE DEPOT INJ 90MG/0.3ML...65 SOMATULINE DEPOT INJ 120MG/0.5ML...65 SOMAVERT...65 sorine...41 sotalol hcl (af) tabs 120mg...42 sotalol hcl (af) tabs 160mg, 80mg...42 sotalol hcl tabs 120mg, 160mg, 80mg...42 sotalol hcl tabs 240mg...42 SOVALDI...32 SPIRIVA HANDIHALER...76 SPIRIVA RESPIMAT...76 spironolactone/hydrochlorothiazide...45 spironolactone tabs...45 SPORANOX SOLN...19 sprintec SPRITAM TB3D 250MG, 500MG, 750MG...13 SPRITAM TB3D 1000MG...13 SPRYCEL TABS 20MG, 50MG, 70MG, 80MG...26 SPRYCEL TABS 100MG, 140MG...26 sps...78 sronyx...62 ssd...50 stavudine caps 15mg, 20mg...33 stavudine caps 30mg, 40mg...33 stavudine solr...33 sterile water irrigation...83 STIOLTO RESPIMAT...77 STIVARGA...26 STRATTERA CAPS 10MG, 18MG, 25MG, 40MG, 60MG...47 STRATTERA CAPS 100MG, 80MG...47 streptomycin sulfate inj... 7 STRIBILD...33 STRIVERDI RESPIMAT...76 SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG... 6 SUBOXONE FILM 12MG; 3MG... 6 sucralfate susp, tabs...53 sulfacetamide sodium oint 10%...71 sulfacetamide sodium/prednisolone sodium phosphate sulfacetamide sodium soln 10%...71 sulfacetamide sodium susp 10%...50 sulfadiazine tabs...12 sulfamethoxazole/trimethoprim ds...12 sulfamethoxazole/trimethoprim inj, tabs...12 sulfamethoxazole/trimethoprim susp...12 SULFAMYLON...50 sulfasalazine tabs, tbec...69 sulfatrim pediatric...12 sulindac tabs 150mg... 3 sulindac tabs 200mg... 3 sumatriptan soln...20 sumatriptan succinate inj 4mg/0.5ml...20 sumatriptan succinate inj 6mg/0.5ml...20 sumatriptan succinate refill inj 4mg/0.5ml...20 sumatriptan succinate refill inj 6mg/0.5ml...20 sumatriptan succinate tabs 25mg...20 sumatriptan succinate tabs 100mg, 50mg...20 SUPRAX CAPS...10 SUPRAX CHEW 100MG...10 SUPRAX CHEW 200MG...10 SUPRAX SUSR 500MG/5ML...10 SUPREP BOWEL PREP...53 SUSTIVA...33 SUTENT CAPS 12.5MG

128 Drug Name Page # Drug Name Page # SUTENT CAPS 25MG, 37.5MG, 50MG...26 syeda...62 SYLATRON...25 SYLVANT...70 SYMLINPEN SYMLINPEN SYNAGIS...67 SYNAREL...65 SYNERCID... 8 SYNRIBO...25 SYNTHROID TABS 100MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 25MCG, 300MCG, 50MCG, 75MCG, 88MCG...64 SYNTHROID TABS 112MCG...64 SYPRINE...79 TABLOID...22 tacrolimus caps...67 TAFINLAR CAPS 50MG...26 TAFINLAR CAPS 75MG...26 TAGRISSO...25 TAMIFLU CAPS 30MG...34 TAMIFLU CAPS 45MG, 75MG...34 TAMIFLU SUSR...34 tamoxifen citrate tabs 10mg...22 tamoxifen citrate tabs 20mg...22 tamsulosin hcl...54 TARCEVA TABS 25MG...26 TARCEVA TABS 100MG, 150MG...26 TARGRETIN...27 tarina fe 1/ TARON-BC...88 TARON-PREX...88 TASIGNA...27 tazicef inj 1gm, 2gm, 6gm...10 TAZORAC...50 taztia xt...43 TECENTRIQ...27 TEFLARO...10 telmisartan...40 telmisartan/amlodipine...40 telmisartan/hydrochlorothiazide...40 TEMODAR INJ...22 TENIVAC...68 terazosin hcl...40 terbinafine hcl crea...19 terbinafine hcl tabs...19 terbutaline sulfate tabs...76 terconazole...19 testosterone cypionate inj...58 testosterone enanthate inj...58 testosterone gel 1%, 25mg/2.5gm...58 tetanus/diphtheria toxoids-adsorbed...68 tetrabenazine tabs 12.5mg...47 tetrabenazine tabs 25mg...47 tetracycline hcl caps...12 THALOMID CAPS 100MG, 150MG, 50MG...22 THALOMID CAPS 200MG...22 theophylline...77 theophylline cr tb12 100mg...77 theophylline cr tb12 200mg...77 theophylline er tb12 100mg, 200mg, 300mg...77 theophylline er tb12 450mg...77 theophylline er tb THERACYS...25 THIOLA...54 thioridazine hcl tabs 10mg, 25mg, 50mg...30 thioridazine hcl tabs 100mg...30 thiotepa...22 thiothixene caps 1mg...30 thiothixene caps 10mg, 2mg, 5mg...30 thrivite rx...88 THYMOGLOBULIN...67 THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine hydrochloride...14 TICE BCG...25 ticlopidine hcl...39 TIKOSYN...42 tilia fe...62 timolol maleate ophthalmic gel forming...73 timolol maleate soln 0.25%, 0.5%...73 timolol maleate tabs 10mg, 20mg, 5mg...42 tinidazole... 8 tioconazole TIVICAY TABS 10MG, 25MG...32 TIVICAY TABS 50MG...32 tizanidine hcl tabs...31 TL-CARE DHA...88 TL FOLATE...88 TL-SELECT...88 TOBI PODHALER

129 Drug Name Page # Drug Name Page # TOBRADEX...71 TOBRADEX ST...71 tobramycin...77 tobramycin/dexamethasone...71 tobramycin sulfate inj 1.2gm/30ml, 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml... 7 tobramycin sulfate ophthalmic soln 0.3%...71 TOBREX...71 tolazamide...37 tolbutamide...37 tolmetin sodium caps... 3 tolmetin sodium tabs 200mg... 3 tolmetin sodium tabs 600mg... 3 tolterodine tartrate...54 topiramate cpsp 15mg...14 topiramate cpsp 25mg...14 topiramate tabs...14 toposar...25 topotecan hcl...25 TORISEL...27 torsemide tabs 10mg, 20mg, 5mg...45 torsemide tabs 100mg...45 tpn electrolytes...83 TRACLEER...77 TRADJENTA...37 tramadol hcl tabs... 5 tramadol hydrochloride/acetaminophen... 5 trandolapril...41 trandolapril/verapamil hcl...41 trandolapril/verapamil hcl er...41 tranexamic acid inj...39 tranexamic acid tabs...39 TRANSDERM-SCOP...18 tranylcypromine sulfate...16 TRAVASOL...83 TRAVATAN Z...70 travoprost...70 trazodone hcl...17 TREANDA...22 TRECATOR...21 TRELSTAR MIXJECT...65 TRESIBA FLEXTOUCH...38 tretinoin caps 10mg...27 tretinoin crea 0.025%, 0.05%, 0.1%...50 tretinoin gel 0.01%...50 tretinoin gel 0.025%, 0.05%...50 triadvance...88 triamcinolone acetonide aero 55mcg/act...74 triamcinolone acetonide aers 0.147mg/gm...57 triamcinolone acetonide crea 0.1%...57 triamcinolone acetonide crea 0.025%, 0.5%...57 triamcinolone acetonide lotn 0.025%, 0.1%...57 triamcinolone acetonide oint 0.1%, 0.5%...57 triamcinolone acetonide oint 0.025%...57 triamcinolone acetonide pste 0.1%...48 triamcinolone in orabase...48 triamterene/hydrochlorothiazide caps 25mg; 37.5mg.45 triamterene/hydrochlorothiazide caps 25mg; 50mg...45 triamterene/hydrochlorothiazide tabs...45 tricare...88 TRICARE PRENATAL COMPLEAT...88 TRICARE PRENATAL DHA ONE...88 triderm...57 tri-estarylla...62 trifluoperazine hcl tabs 1mg...30 trifluoperazine hcl tabs 10mg, 2mg, 5mg...30 trifluridine...71 trihexyphenidyl hcl...28 tri-legest fe...62 tri-linyah...62 tri-lo-estarylla...62 tri-lo-marzia...62 tri-lo-sprintec...62 trilyte...53 trimethoprim sulfate/polymyxin b sulfate...72 trimethoprim tabs... 8 trimipramine maleate caps...17 TRINATAL GT...88 trinatal rx trinessa...62 trinessa lo...62 TRINTELLIX...15 triple antibiotic...72 triple-vitamin/fluoride...88 tri-previfem...62 TRISENOX...25 tri-sprintec...62 TRISTART DHA...88 TRIUMEQ...33 TRIVEEN-DUO DHA...88 TRIVEEN-PRX RNF...88 tri-vitamin/fluoride...88 tri-vit/fluoride...88 tri-vit/fluoride/iron

130 Drug Name Page # Drug Name Page # trivora TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML...83 TRULICITY...37 TRUMENBA...68 TRUVADA TABS 100MG; 150MG, 133MG; 200MG, 167MG; 250MG...33 TRUVADA TABS 200MG; 300MG...33 TWINRIX...68 TYBOST...34 TYGACIL... 8 TYKERB...27 TYPHIM VI...68 TYSABRI...48 TYZEKA...32 TYZINE PEDIATRIC NASAL DROPS...77 ULORIC...20 ultimatecare one nf...88 unithroid tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg...64 unithroid tabs 200mcg...64 ursodiol caps, tabs...52 UVADEX...25 VAGIFEM...63 valacyclovir hcl...35 VALCHLOR...22 VALCYTE SOLR...32 valganciclovir...32 valproate sodium inj...14 valproic acid caps...14 valproic acid syrp...14 valsartan...40 valsartan/hydrochlorothiazide...40 VALSTAR...25 vancomycin hcl caps... 8 vancomycin hcl in dextrose... 8 vancomycin hcl inj 1000mg, 10gm, 5000mg, 500mg, 750mg... 8 vandazole... 8 VANTAS...65 VAQTA...69 VARIVAX...69 VASCEPA...46 VASOSTRICT...58 VECTIBIX...25 VELCADE...25 velivet...63 VELPHORO...55 VEMAVITE-PRX VENA-BAL DHA...88 VENCLEXTA...25 VENCLEXTA STARTING PACK...25 venlafaxine hcl...17 venlafaxine hcl er cp mg, 75mg...17 venlafaxine hcl er cp24 150mg...17 venlafaxine hcl er tb mg, 75mg...17 venlafaxine hcl er tb24 150mg...17 venlafaxine hcl er tb24 225mg...17 VENTAVIS...77 VENTOLIN HFA...76 verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg...44 verapamil hcl er cp24 200mg...44 verapamil hcl er tbcr 120mg...44 verapamil hcl er tbcr 180mg, 240mg...44 verapamil hcl inj, tabs...44 verapamil hcl sr cp24 120mg, 180mg, 240mg...44 verapamil hcl sr cp24 360mg...44 verapamil hcl sr tbcr 240mg...44 VERSACLOZ...31 VESICARE...54 vestura...63 V-GO V-GO V-GO vicodin es tabs 300mg; 7.5mg... 5 vicodin tabs 300mg; 5mg... 5 VICTOZA...37 VIDEX PEDIATRIC SOLR 2GM...33 VIDEX PEDIATRIC SOLR 4GM...33 vienva...63 VIGAMOX...72 VIIBRYD KIT...17 VIIBRYD STARTER PACK...17 VIIBRYD TABS...17 VIMPAT INJ...14 VIMPAT ORAL SOLN

131 Drug Name Page # Drug Name Page # VIMPAT TABS 50MG...15 VIMPAT TABS 100MG, 150MG, 200MG...15 vinblastine sulfate inj 1mg/ml...25 vincasar pfs...25 vincristine sulfate...25 vinorelbine tartrate...25 viorele...63 VIRACEPT...34 VIRAMUNE SUSP...33 VIRAZOLE...35 VIREAD...33 VIRT-ADVANCE...88 VIRT-CARE ONE...88 VIRT-C DHA...88 VIRT-PN...88 VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT; 12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG; 25MG; 10UNIT...88 VIRT-PN PLUS...89 VIRT-SELECT...89 VITAFOL FE VITAFOL GUMMIES...89 VITAFOL-NANO...89 VITAFOL-OB...89 VITAFOL-OB+DHA...89 VITAFOL-ONE...89 VITAFOL ULTRA...89 VITAMEDMD ONE RX/QUATREFOLIC...89 VITAMEDMD PLUS RX/QUATRE FOLIC...89 vitamins a/c/d/fluoride...89 vitamins a/d/c/fluoride...83 VITEKTA...32 VOL-NATE...89 VOL-PLUS...89 VOLTAREN... 3 voriconazole inj, tabs...20 voriconazole susr...20 VOTRIENT...27 VP-CH PLUS...89 VP-CH-PNV...89 VP CH ULTRA...89 VP-GGR-B6 PRENATAL...89 VP-HEME OB...89 VP-HEME ONE...89 VP-PNV-DHA...89 VPRIV...51 VRAYLAR CAPS...31 VRAYLAR CPPK...31 vyfemla...63 warfarin sodium tabs...38 wera...63 wymzya fe...63 XALKORI...27 XARELTO STARTER PACK...38 XARELTO TABS 10MG, 20MG...38 XARELTO TABS 15MG...38 XELJANZ...67 XELJANZ XR...67 XGEVA...70 XOLAIR...77 XTANDI...22 xylon... 5 XYREM...78 YERVOY...25 YF-VAX...69 YONDELIS...22 ZADITOR...72 zafirlukast...75 zaleplon caps 5mg...78 zaleplon caps 10mg...78 ZALTRAP...25 zamicet... 5 ZANOSAR...25 zarah...63 ZATEAN-CH...89 ZATEAN-PN...89 ZATEAN-PN DHA...89 ZATEAN-PN PLUS...89 ZAVESCA...51 zazole...20 zebutal caps 325mg; 50mg; 40mg... 1 ZELBORAF...27 ZEMAIRA...78 zenatane...50 zenchent...63 zenchent fe...63 ZENPEP...51 ZEPATIER...35 ZETIA...46 ZIAGEN SOLN...33 zidovudine...33 ziprasidone hcl caps 20mg, 40mg...31 ziprasidone hcl caps 60mg, 80mg...31 ZIRGAN

132 Drug Name Page # Drug Name Page # ZOLADEX...65 zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml...70 ZOLINZA...25 zolmitriptan odt...20 zolmitriptan tabs...20 zolpidem tartrate er...78 zolpidem tartrate tabs 5mg...78 zolpidem tartrate tabs 10mg...78 ZONALON...50 zonisamide...13 ZORTRESS...67 ZOSTAVAX...69 zovia 1/35e...63 zovia 1/50e...63 ZYDELIG...25 ZYKADIA...27 ZYPREXA RELPREVV INJ 210MG, 300MG...31 ZYPREXA RELPREVV INJ 405MG...31 ZYTIGA...22 ZYVOX INJ 600MG/300ML... 8 ZYVOX SUSR... 8 ZYVOX TABS

133 AETNA BETTER HEALTH PREMIER PLAN 1333 Gratiot Avenue, Suite 400 Detroit, MI Aetna, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Aetna, Inc.: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o o Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If need these services, contact Aetna Medicaid Civil Rights Coordinator If believe that Aetna, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, can file a grievance with: Aetna Medicaid Civil Rights Coordinator, 4500 Cotton Center Blvd., Phoenix, AZ 85040, , TTY 711, , MedicaidCRCoordinator@aetna.com. You can file a grievance in person or by mail, fax, or . If need help filing a grievance, Aetna Medicaid Civil Rights Coordinator is available to help. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at 121

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