Partnership HMO SNP 2016 Formulary. (List of Covered Drugs)

Transcription

1 Partnership HMO SNP 206 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID: 6373, Version Number: 39 This formulary was updated on 0/7/206. For more recent information or other questions, please contact us at or, for TTY users, Wisconsin Relay System 7, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit 3www.carewisc.org. 3 T U U 3 3 T H _CWHPFC 9-2-6_FINAL Populated Template 0/7/206 DHS Approved 8/4/205

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Care Wisconsin Health Plan, Inc. When it refers to plan or our plan, it means Partnership. This document includes a list of the drugs (formulary) for our plan which is current as of 9/27/206. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January, 206, and from time to time during the year. Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal. The formulary, pharmacy and/or provider network may change at any time. You will receive notice when necessary. To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin Customer Service at (TTY/TDD Wisconsin Relay System 7). 2

3 What is the Partnership Formulary? A formulary is a list of covered drugs selected by Partnership in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 206 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 9/27/206. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the 3

4 category name in the list that begins on page number 9. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 93. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Partnership covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Partnership may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Partnership will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 4

5 You can ask Partnership to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Partnership formulary? on page 6 for information about how to request an exception. What are over-the-counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Partnership pays for certain OTC drugs. Care Wisconsin covers the OTC formulations of the following drugs as part of its Part D Step Therapy program: omeprazole lansoprazole esomeprazole loratadine fexofenadine cetirizine nasal triamcinolone nasal fluticasone. In addition, the 206 Formulary Medicaid Supplement included with this formulary provides the list of OTC drugs covered by Partnership when they are ordered by a physician or nurse practitioner for a medical need. The drug must also have a valid National Drug Code (NDC) that is recognized by Wisconsin Medicaid. Partnership will provide these OTC drugs at no cost to you. The cost to Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap). What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Partnership does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership. You can ask Partnership to make an exception and cover your drug. See below for information about how to request an exception. 5

6 How do I request an exception to the Partnership Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Partnership limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Partnership will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day 6

7 emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Current members with a change in where they receive care Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include: You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital. You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary. Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of medications that are highly individualized. Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy. For more information For more detailed information about your Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Partnership, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Partnership s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 93. 7

8 The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the Requirements/Limits column tells you if Partnership has any special requirements for coverage of your drug. 8

9 Formulary: 6373, Version ID: 39 Date generated: 0/7/206 List of Abbreviations B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. CB: This prescription drug has a capped benefit limit. ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service at , 24-hours a day/7 days a week (office hours: Monday- Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 7. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at , 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 7. MO: Mail Order Drug. This prescription drug is available through a mail-order service. : Prior Authorization. Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. QL: Quantity Limit. For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. : Step Therapy. In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Partnership may not cover drug B unless you try Drug A first. If Drug A does not work for you, Partnership will then cover Drug B. 9

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11 LEGEND TIER NAME Covered SYMBOL NAME QL Quantity Limit Prior Authorization Step Therapy DESCRIPTION There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. LA Limited Access This prescription drug is limited to certain pharmacies.

12 Analgesics Nonsteroidal Anti-inflammatory Drugs celecoxib (50 mg capsule, 00 mg capsule, 200 mg capsule, 400 mg capsule) etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h) ibuprofen (00 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen/oxycodone hcl 400mg-5mg tablet ketoprofen (50 mg capsule, 75 mg capsule) nabumetone (500 mg tablet, 750 mg tablet) naproxen (25 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet) sulindac (50 mg tablet, 200 mg tablet) Opioid Analgesics, Long-acting fentanyl (2 mcg/hr, 25 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 00 mcg/hr) methadone hcl (5 mg/5 ml solution, 5 mg tablet, 0 mg/5 ml solution, 0 mg tablet) morphine sulfate (5 mg tablet er, 30 mg tablet er, 60 mg tablet er, 00 mg tablet er, 200 mg tablet er) oxycodone hcl (0 mg tab er, 5 mg tab er, 20 mg tab er, 30 mg tab er, 40 mg tab er, 60 mg tab er, 80 mg tab er) tramadol hcl (00 mg tbmp 24hr, 00 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr) Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (20-2mg/5 solution, 300mg/2.5 solution, 300mg- 30mg tablet, 300mg-60mg tablet, 300mg-5mg tablet) codeine sulfate (5 mg tablet, 30 mg tablet, 60 mg tablet), QL (0 PER 30 DAYS) on this table mean by going to page. 2

13 DURAMORPH (5 MG/0 ML, 0 MG/0 ML) ENDOCET (5-325 TABLET, MG TABLET, MG TABLET) fentanyl citrate (200 mcg, 400 mcg, 600 mcg, 800 mcg, 200 mcg, 600 mcg) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-325mg tablet, hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen 0mg- 325mg tablet) hydrocodone/ibuprofen (hydrocodone/ibuprofen 5mg-200mg tablet, hydrocodone/ibuprofen mg tablet, hydrocodone/ibuprofen 0mg- 200mg tablet) hydromorphone hcl ( mg/ml liquid, 2 mg/ml syringe, 2 mg tablet, 4 mg tablet, 8 mg tablet) hydromorphone hcl/pf (hcl/pf 0 mg/ml ampul, hcl/pf 0 mg/ml vial) morphine sulfate (0 mg/5 ml solution, 5 mg tablet, 20 mg/5 ml solution, 30 mg tablet, 00 mg/5ml solution) oxycodone hcl (5 mg tablet, 0 mg tablet, 5 mg tablet, 20 mg tablet, 30 mg tablet) oxycodone hcl/acetaminophen (hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen mg tablet, hcl/acetaminophen 0mg-325mg tablet) oxycodone hcl/acetaminophen 5-325/5 ml solution tramadol hcl 50 mg tablet tramadol hcl/acetaminophen mg tablet Anesthetics, QL (860 ML PER 30 DAYS) Local Anesthetics lidocaine 5 % adh. patch lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 5 mg/ml vial, 20 mg/ml vial, 40 mg/ml solution), QL (93 PER 3 DAYS) on this table mean by going to page. 3

14 lidocaine hcl/pf (hcl/pf 5 mg/ml vial, hcl/pf 20 mg/ml ampul luer, hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial, hcl/pf 00 mg/5ml syringe) lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5 kit) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium 333 mg tablet dr disulfiram (250 mg tablet, 500 mg tablet) Opioid Dependence Treatments buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe) buprenorphine hcl (2 mg tab, 8 mg tab) buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab, /naloxone 8 mg-2 mg tab) naltrexone hcl 50 mg tablet Opioid Reversal Agents naloxone hcl mg/ml syringe Smoking Cessation Agents bupropion hcl 50 mg tablet er CHANTIX (0.5 MG TABLET, MG TABLET, ARTING MONTH BOX) NICOTROL CARTRIDGE INHALER NICOTROL NS 0 MG/ML SPRAY,, QL (336 PER 2 DAYS), QL (68 ML PER 30 DAYS) Anti-inflammatory Agents Glucocorticoids dexamethasone sod phosphate (4 mg/ml vial, 4 mg/ml syringe) methylprednisolone sod succ 40 mg vial Nonsteroidal Anti-inflammatory Drugs diclofenac sodium 3 % gel (gram) on this table mean by going to page. 4

15 naproxen sodium (275 mg tablet, 550 mg tablet) oxaprozin 600 mg tablet Antibacterials Aminoglycosides GENTAK 0.3 % EYE OINTMENT gentamicin sulfate (0. % oint. (g), 0. % cream (g), 0.3 % oint. (g), 0.3 % drops, 40 mg/ml vial) gentamicin sulfate in sodium chloride, isoosmotic (gentamic60 mg/50ml, gentamic80 mg/50ml, gentamic80mg/00ml, gentamic00mg/0.l, gentamic20mg/0.l) gentamicin sulfate/pf (sulfate/pf 20 mg/2 ml vial, sulfate/pf 60 mg/6 ml vial port, sulfate/pf 80 mg/8 ml vial port, sulfate/pf 00mg/0ml vial port) neomycin sulfate 500 mg tablet neomycin sulfate/polymyxin b sulfate (su/polymyx k/ml ampul, su/polymyx k/ml vial) paromomycin sulfate 250 mg capsule streptomycin sulfate g vial tobramycin 0.3 % drops tobramycin sulfate (.2 g vial, 0 mg/ml vial, 40 mg/ml vial) ZYLET EYE DROPS Antibacterials, Other BACIIM 50,000 UNITS VIAL bacitracin 500 unit/g oint. (g) bacitracin/polymyxin b sulfate 500-0k/g oint. (g) chloramphenicol sod succ g vial clindamycin hcl (75 mg capsule, 50 mg capsule, 300 mg capsule) clindamycin phosphate (2 % cream/appl, 50 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) on this table mean by going to page. 5

16 colistin (colistimethate na) 50 mg vial CUBICIN 500 MG VIAL linezolid (600mg/300 iv soln, 600 mg tablet) linezolid-0.9% sodium chloride 600mg/300 iv soln methenamine hippurate g tablet metronidazole (0.75 % gel w/appl, 250 mg tablet, 500 mg tablet) metronidazole 0.75 % gel (gram) metronidazole/sodium chloride 500mg/0.l piggyback MONUROL 3 GM SACHET mupirocin 2 % oint. (g) neomycin su/baci zn/poly/hc 3.5-0k- oint. (g) neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g) neomycin/polymyxn b/gramicidin.75mg-0k drops nitrofurantoin macrocrystal 50 mg capsule nitrofurantoin monohyd/m-cryst 00 mg capsule polymyxin b sulf/trimethoprim 0000-/ml drops polymyxin b sulfate 500k unit vial silver sulfadiazine % cream (g) SSD % CREAM SYNERCID 500 MG VIAL trimethoprim 00 mg tablet TYGACIL 50 MG VIAL vancomycin hcl ( g vial, g vial port, 5 g vial, 0 g vial, 25 mg capsule, 250 mg capsule, 500 mg vial, 500 mg vial port, 750 mg vial port, 750 mg vial) VANDAZOLE VAGINAL 0.75% GEL XIFAXAN (200 MG TABLET, 550 MG TABLET) ZYVOX 00 MG/5 ML SUSPENSION on this table mean by going to page. 6

17 Beta-lactam, Cephalosporins cefaclor (250 mg capsule, 500 mg capsule) cefadroxil ( g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium ( g vial, g vial port, 0 g vial, 20 g vial, 00 g bulkbaginj, 300g bulkbaginj, 500 mg vial) cefazolin sodium/dextrose, iso-osmotic (sodium/dextrose,iso g/50 ml froz.piggy, sodium/dextrose,iso g/50 ml piggyback) cefdinir (25 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl ( vial, 2 vial) cefixime (00 mg/5ml, 200 mg/5ml) cefoxitin sodium ( vial, 2 vial, 0 vial) cefpodoxime proxetil (50 mg/5 ml susp recon, 00 mg tablet, 00 mg/5ml susp recon, 200 mg tablet) cefprozil (25 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftriaxone sodium ( g vial, g vial port, 2 g vial port, 2 g vial, 0 g vial, 00 g bulkbaginj, 250 mg vial, 500 mg vial) cefuroxime axetil (250 mg tablet, 500 mg tablet) cefuroxime sodium (.5 g vial, 7.5g vial, 7.5 g vial, 75 g bulkbaginj, 750 mg vial) cephalexin (25 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) SUPRAX 400 MG CAPSULE TEFLARO (400 MG VIAL, 600 MG VIAL) Beta-lactam, Other aztreonam ( vial, 2 vial) cefotetan disodium ( vial, 2 vial, 0 vial) imipenem/cilastatin sodium (imipenem/cilastatin 250 mg vial, imipenem/cilastatin 500 mg vial) on this table mean by going to page. 7

18 INVANZ GM VIAL meropenem ( g vial, 500 mg vial) Beta-lactam, Penicillins amoxicillin (25 mg tab chew, 25 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate (amoxicillin/potassium mg tab chew, amoxicillin/potassium /5 susp recon, amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium mg tab chew, amoxicillin/potassium mg/5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium tab er 2h) ampicillin sodium ( g vial, g vial port, 2 g vial, 0 g vial, 250 mg vial, 500 mg vial) ampicillin sodium/sulbactam sodium (sodium/sulbactam.5 vial, sodium/sulbactam 3 vial, sodium/sulbactam 5 vial) ampicillin trihydrate (250 mg capsule, 500 mg capsule) BICILLIN L-A (600,000 UNIT/ML,,200,000 UNITS, 2,400,000 UNITS) dicloxacillin sodium (250 mg capsule, 500 mg capsule) nafcillin in dextrose, iso-osmotic ( g/50 ml, 2 g/00 ml) nafcillin sodium ( vial, 2 vial, 0 vial) oxacillin sodium ( vial, 2 vial port, 2 vial, 0 vial) penicillin g potassium (5mm vial, 20mm vial) penicillin v potassium (25 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) on this table mean by going to page. 8

19 piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 vial port, sodium/tazobactam 2.25 vial, sodium/tazobactam vial, sodium/tazobactam vial port, sodium/tazobactam 4.5 vial, sodium/tazobactam 4.5 vial port, sodium/tazobactam 40.5 vial) ZOSYN (2.25 GM/50 ML BAG, GM/50 ML, 4.5 GM/00 ML BAG) Macrolides azithromycin (00 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg vial port, 500 mg tablet, 500 mg vial, 600 mg tablet) clarithromycin (25 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet) DIFICID 200 MG TABLET E.E.S. 200 MG/5 ML GRANULES E.E.S. 400 FILMTAB ERY-TAB (EC 250 MG TABLET, 333 MG TABLET EC, EC 333 MG TABLET, EC 500 MG TABLET) ERYPED 200 MG/5 ML SUSPENSION ERYPED 400 MG/5 ML SUSPENSION ERYTHROCIN 250 MG FILMTAB ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) erythromycin base (5 mg/g oint. (g), 250 mg tablet, 500 mg tablet) erythromycin base/ethyl alcohol (base/ethanol 2 % solution, base/ethanol 2 % gel (gram)) erythromycin ethylsuccinate 400 mg tablet KETEK (300 MG TABLET, 400 MG TABLET) Quinolones AVELOX IV 400 MG/250 ML CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION, on this table mean by going to page. 9

20 ciprofloxacin (250 mg/5ml, 500 mg/5ml) ciprofloxacin hcl (0.3 % drops, 00 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial) ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa 500 mg, ciprofloxacin/ciprofloxa 000 mg) gatifloxacin 0.5 % drops levofloxacin (0.5 % drops, 25 mg/ml vial, 250mg/0ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water (levofloxacin/d5w 750mg/.5l, levofloxacin/d5w 250mg/50ml, levofloxacin/d5w 500mg/0.l) MOXEZA 0.5% EYE DROPS ofloxacin 0.3 % drops VIGAMOX 0.5% EYE DROPS Sulfonamides sulfacetamide sodium 0 % drops sulfacetamide/prednisolone sp 0 %-0.23% drops sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 80-6mg/ml vial, sulfamethoxazole/trimethoprim mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, sulfamethoxazole/trimethoprim /20 oral susp, sulfamethoxazole/trimethoprim mg tablet) Tetracyclines demeclocycline hcl (50 mg tablet, 300 mg tablet) DOXY 00 VIAL doxycycline hyclate (20 mg tablet, 50 mg capsule, 00 mg capsule, 00 mg tablet) on this table mean by going to page. 20

21 doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 00 mg tablet, 00 mg capsule, 50 mg tablet) minocycline hcl (50 mg capsule, 75 mg capsule, 00 mg capsule) Anticonvulsants Anticonvulsants, Other APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) BRIVIACT (0 MG/ML ORAL SOLN, 0 MG TABLET, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET, 00 MG TABLET) FYCOM (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 0 MG TABLET, 2 MG TABLET) levetiracetam (00 mg/ml solution, 250 mg tablet, 500 mg/5ml solution, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml vial, 750 mg tablet, 750 mg tab er 24h, 000 mg tablet) phenobarbital (5 mg tablet, 30 mg tablet, 60 mg tablet, 64.8 mg tablet) phenobarbital (6.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet, 97.2mg tablet, 00 mg tablet) POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET) ROWEEPRA 500 MG TABLET SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET,,000 MG TABLET), - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY Calcium Channel Modifying Agents CELONTIN 300 MG KAPSEAL ethosuximide (250 mg/5ml solution, 250 mg capsule) LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE) zonisamide (25 mg capsule, 50 mg capsule, 00 mg capsule) QL (93 PER 3 DAYS) on this table mean by going to page. 2

22 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam (0.25 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, mg tab rapdis, 2 mg tab rapdis) clonazepam (0.5 mg tablet, mg tablet, 2 mg tablet) diazepam (2.5 mg, mg, ) divalproex sodium (25 mg tablet dr, 25 mg cap sprink, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tablet dr) gabapentin (00 mg capsule, 250 mg/5ml solution, 300 mg/6ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (2 MG TABLET, 6 MG TABLET) ONFI (2.5 MG/ML SUSPENSION, 0 MG TABLET, 20 MG TABLET) primidone (50 mg tablet, 250 mg tablet) SABRIL (500 MG TABLET, 500 MG POWDER CKET) tiagabine hcl (2 mg tablet, 4 mg tablet) valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500 mg/5ml vial, salt) 500mg/0ml solution) valproic acid 250 mg capsule - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) lamotrigine (25 mg tablet, 25 mg tab er 24, 25 mg tb chw dsp, 50 mg tab er 24, 00 mg tab er 24, 00 mg tablet, 50 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 200 MG CAPSULE) topiramate (5 mg cap, 25 mg cap) topiramate (25 mg cap 24, 50 mg cap 24, 00 mg cap 24, 50 mg cap 24, 200 mg cap 24) topiramate (25 mg tablet, 00 mg tablet, 200 mg tablet) - FOR NEW ARTS ONLY on this table mean by going to page. 22

23 TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE, 200 MG CAPSULE) Sodium Channel Agents BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) carbamazepine (00 mg tab er 2h, 00 mg cpmp 2hr, 00 mg/5ml oral susp, 00 mg tab chew, 200 mg tablet, 200 mg tab er 2h, 200 mg cpmp 2hr, 300 mg cpmp 2hr, 400 mg tab er 2h) DILANTIN (30 MG KAPSEAL, 30 MG CAPSULE) EPITOL 200 MG TABLET fosphenytoin sodium (00mg pe/2 vial, 500 pe/0 vial) oxcarbazepine (50 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) OXTELLAR XR (50 MG TABLET, 300 MG TABLET, 600 MG TABLET) PEGANONE 250 MG TABLET phenytoin (50 mg tab chew, 00 mg/4ml oral susp, 25 mg/5ml oral susp) phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul) phenytoin sodium extended (00 mg capsule, 200 mg capsule, 300 mg capsule) VIMT (0 MG/ML SOLUTION, 50 MG TABLET, 00 MG TABLET, 50 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET) Antidementia Agents Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 0 mg tablet, 0 mg tab rapdis) galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 2 mg tablet, 6 mg cap24h pel, 24 mg cap24h pel) rivastigmine tartrate (.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) on this table mean by going to page. 23

24 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (2 mg/ml solution, 5 mg-0 mg tab ds pk, 5 mg tablet, 0 mg tablet) NAMENDA (2 MG/ML SOLUTION, 5-0 MG TITRATION PK, 5 MG TABLET, 0 MG TABLET) Antidepressants Antidepressants, Other bupropion hcl (75 mg tablet, 00 mg tablet er, 00 mg tablet, 50 mg tab er 24h, 50 mg tablet er, 200 mg tablet er, 300 mg tab er 24h) maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet) mirtazapine (5 mg tablet, 5 mg tab rapdis, 30 mg tablet, 45 mg tablet, 45 mg tab rapdis) mirtazapine (7.5 mg tablet, 30 mg tab rapdis) nefazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 200 mg tablet, 250 mg tablet) trazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 300 mg tablet) TRINTELLIX (0 MG TABLET, 20 MG TABLET) TRINTELLIX 5 MG TABLET Monoamine Oxidase Inhibitors EMSAM (6 MG/24, 9 MG/24, 2 MG/24) MARPLAN 0 MG TABLET phenelzine sulfate 5 mg tablet tranylcypromine sulfate 0 mg tablet, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide (0 mg tablet, 0 mg/5 ml solution, 20 mg tablet, 40 mg tablet) desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 00 mg tab er 24h, 00 mg tab er 24) duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 40 mg capsule dr, 60 mg capsule dr) QL (62 PER 3 DAYS) on this table mean by going to page. 24

25 escitalopram oxalate (5 mg tablet, 0 mg tablet, 20 mg tablet) FETZIMA (20-40 MG TITRATION K, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 20 MG CAPSULE) fluoxetine hcl (0 mg tablet, 0 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluvoxamine maleate (25 mg tablet, 50 mg tablet, 00 mg tablet) paroxetine hcl (0 mg tablet, 20 mg tablet, 30 mg tablet, 37.5 mg tab er 24h, 40 mg tablet) paroxetine hcl (2.5 mg tab er, 25 mg tab er) sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 00 mg tablet) venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg tab er 24, 75 mg cap er 24h, 75 mg tablet, 00 mg tablet, 50 mg cap er 24h, 50 mg tab er 24) VIIBRYD (0-20 MG ARTER CK, 0 MG TABLET, 20 MG TABLET, 40 MG TABLET), - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY Tricyclics amitriptyline hcl (0 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) amoxapine (25 mg tablet, 50 mg tablet, 00 mg tablet, 50 mg tablet) clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (0 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) doxepin hcl (0 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 00 mg capsule, 50 mg capsule) imipramine hcl (0 mg tablet, 25 mg tablet, 50 mg tablet) nortriptyline hcl (0 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY,, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY,, - FOR NEW ARTS ONLY on this table mean by going to page. 25

26 nortriptyline hcl 0 mg/5 ml solution - FOR NEW ARTS ONLY protriptyline hcl (5 mg tablet, 0 mg tablet) SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE) trimipramine maleate (25 mg capsule, 50 mg capsule, 00 mg capsule) Antiemetics - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY, Antiemetics, Other meclizine hcl (2.5 mg tablet, 25 mg tablet) promethazine hcl (2.5 mg supp.rect, 2.5 mg tablet, 25 mg/ml vial, 25 mg tablet, 25 mg/ml ampul, 25 mg supp.rect, 25 mg/ml syringe, 50 mg/ml ampul, 50 mg/ml vial) PROMETHEGAN 25 MG SUPPOSITORY TRANSDERM-SCOP.5 MG/3 DAY Emetogenic Therapy Adjuncts ANZEMET (50 MG TABLET, 00 MG TABLET) - TO CONFIRM RT D COVERAGE,, QL (9 PER 30 DAYS) ANZEMET 20 MG/ML VIAL dronabinol 0 mg capsule dronabinol 2.5 mg capsule dronabinol 5 mg capsule EMEND (40 MG CAPSULE, 80 MG CAPSULE, 25 MG CAPSULE), QL (62 PER 3 DAYS), QL (248 PER 3 DAYS), QL (24 PER 3 DAYS) - TO CONFIRM RT D COVERAGE,, QL (9 PER 30 DAYS) EMEND TRICK - TO CONFIRM RT D COVERAGE,, QL (6 PER 30 DAYS) granisetron hcl ( mg/ml() vial, mg/ml vial) granisetron hcl mg tablet granisetron hcl/pf (hcl/pf mg/ml() vial, hcl/pf 00 mcg/ml vial) ondansetron (4 mg tab rapdis, 8 mg tab rapdis) ondansetron hcl (4 mg tablet, 8 mg tablet) - TO CONFIRM RT D COVERAGE, - TO CONFIRM RT D COVERAGE, QL (62 PER 3 DAYS) - TO CONFIRM RT D COVERAGE, QL (62 PER 3 DAYS) on this table mean by going to page. 26

27 ondansetron hcl 24 mg tablet - TO CONFIRM RT D COVERAGE,, QL (3 PER 3 DAYS) ondansetron hcl 4 mg/5 ml solution ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 ml vial) Antifungals ABELCET 00 MG/20 ML VIAL AMBISOME 50 MG VIAL amphotericin b 50 mg vial CANCIDAS (50 MG VIAL, 70 MG VIAL) ciclopirox ( % shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clotrimazole ( % cream (g), % solution, 0 mg troche) econazole nitrate % cream (g) fluconazole (0 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 00 mg tablet, 50 mg tablet, 200 mg tablet) fluconazole in dextrose, iso-osmotic (200mg/0.l, 400mg/0.2l) flucytosine (250 mg capsule, 500 mg capsule) griseofulvin, microsize (25 mg/5ml oral susp, 500 mg tablet) itraconazole 00 mg capsule ketoconazole (2 % cream (g), 2 % shampoo, 200 mg tablet) miconazole nitrate 200 mg supp.vag MYCAMINE (50 MG VIAL, 00 MG VIAL) NOXAFIL 40 MG/ML SUSPENSION NYAMYC 00,000 UNITS/GM POWDER nystatin (50mm unit powder(ea), 50mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 00000/ml oral susp, 00000/g powder, 00000/g cream (g), 00000/g oint. (g)) - TO CONFIRM RT D COVERAGE,, QL (950 ML PER 3 DAYS) on this table mean by going to page. 27

28 nystatin/triamcinolone acetonide (nystatin/triamcin cream (g), nystatin/triamcin oint. (g)) NYOP 00,000 UNITS/GM POWDER SPORANOX 0 MG/ML SOLUTION terbinafine hcl 250 mg tablet terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (50 mg tablet, 200 mg tablet, 200 mg vial, 200 mg/5ml susp recon) Antigout Agents allopurinol (00 mg tablet, 300 mg tablet) colchicine (0.6 mg capsule, 0.6 mg tablet) colchicine/probenecid mg tablet COLCRYS 0.6 MG TABLET MITIGARE 0.6 MG CAPSULE probenecid 500 mg tablet Antimigraine Agents Ergot Alkaloids CAFERGOT TABLET dihydroergotamine mesylate ( mg/ml ampul, mg/ml vial) ERGOMAR 2 MG TABLET SL Prophylactic divalproex sodium 500 mg tab er 24h topiramate 50 mg tablet Serotonin (5-HT) b/d Receptor Agonists naratriptan hcl ( mg tablet, 2.5 mg tablet) rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 0 mg tablet, 0 mg tab rapdis) sumatriptan succinate (25 mg tablet, 50 mg tablet, 00 mg tablet) QL (9 PER 30 DAYS) QL (8 PER 30 DAYS) QL (9 PER 30 DAYS) on this table mean by going to page. 28

29 sumatriptan succinate (4 mg/0.5ml pen injctr, 4 mg/0.5ml cartridge, 6 mg/0.5ml cartridge, 6 mg/0.5ml vial) zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis) zolmitriptan (2.5 mg tablet, 5 mg tablet) ZOMIG (2.5 MG, 5 MG), QL (6 ML PER 30 DAYS), QL (6 PER 30 DAYS), QL (9 PER 30 DAYS), QL (6 PER 30 DAYS) Antimyasthenic Agents Parasympathomimetics guanidine hcl 25 mg tablet pyridostigmine bromide 60 mg tablet Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 00 mg tablet) rifabutin 50 mg capsule Antituberculars CAAT SULFATE GM VIAL ethambutol hcl (00 mg tablet, 400 mg tablet) isoniazid (00 mg/ml vial, 00 mg tablet, 300 mg tablet) SER GRANULES 4 GM CKET pyrazinamide 500 mg tablet rifampin (50 mg capsule, 300 mg capsule, 600 mg vial) SIRTURO 00 MG TABLET TRECATOR 250 MG TABLET Antineoplastics Alkylating Agents cyclophosphamide (25 mg capsule, 50 mg capsule) GLEOINE 5 MG CAPSULE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 29

30 HEXALEN 50 MG CAPSULE LEUKERAN 2 MG TABLET MATULANE 50 MG CAPSULE thiotepa 5 mg vial VALCHLOR 0.06% GEL Antiandrogens bicalutamide 50 mg tablet flutamide 25 mg capsule NILANDRON 50 MG TABLET nilutamide 50 mg tablet XTANDI 40 MG CAPSULE ZYTIGA 250 MG TABLET Antiangiogenic Agents CAPRELSA (00 MG TABLET, 300 MG TABLET) REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 0 MG CAPSULE, 5 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE) THALOMID (50 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 200 MG CAPSULE) LA Antiestrogens/Modifiers EMCYT 40 MG CAPSULE FAREON 60 MG TABLET SOLTAMOX 0 MG/5 ML SOLN tamoxifen citrate (0 mg tablet, 20 mg tablet) Antimetabolites ADRUCIL (5 GRAM/00 ML VIAL, 500 MG/0 ML VIAL, 2,500 MG/50 ML VIAL) ALIMTA (00 MG VIAL, 500 MG VIAL) DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400 MG CAPSULE) hydroxyurea 500 mg capsule LONSURF (5 MG-6.4 MG TABLET, 20 MG-8.9 MG TABLET) on this table mean by going to page. 30

31 mercaptopurine 50 mg tablet PURIXAN 20 MG/ML ORAL SUSP TABLOID 40 MG TABLET FARYDAK (0 MG CAPSULE, 5 MG CAPSULE, 20 MG CAPSULE) VENCLEXTA (0 MG TABLET, 50 MG TABLET, 00 MG TABLET) VENCLEXTA ARTING CK ZALTRAP (00 MG/4 ML VIAL, 200 MG/8 ML VIAL) ZYKADIA 50 MG CAPSULE - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY Antineoplastics, Other ALECENSA 50 MG CAPSULE amifostine crystalline 500 mg vial azacitidine 00 mg vial BELEODAQ 500 MG VIAL bleomycin sulfate (5 vial, 30 vial) CABOMETYX (20 MG TABLET, 40 MG TABLET, 60 MG TABLET) cisplatin mg/ml vial COMETRIQ (60 MG CK, 00 MG PK, 40 MG PK) COTELLIC 20 MG TABLET CYRAMZA (00 MG/0 ML VIAL, 500 MG/50 ML VIAL) daunorubicin hcl (5 mg/ml vial, 20 mg vial) decitabine 50 mg vial DOCEFREZ 20 MG VIAL docetaxel (20 mg/2 ml vial, 20mg/ml() vial, 80 mg/8 ml vial, 80 mg/4 ml vial, 40 mg/7ml vial, 60 mg/8ml vial, 60mg/6ml vial, 200mg/20ml vial) doxorubicin hcl (2 mg/ml vial, 0 mg vial, 0 mg/5 ml vial, 20 mg/0ml vial, 50 mg vial, 50 mg/25ml vial) doxorubicin hcl peg-liposomal 2 mg/ml vial, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY LA on this table mean by going to page. 3

32 ERIVEDGE 50 MG CAPSULE ERWINAZE 0,000 UNITS VIAL GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET) HALAVEN MG/2 ML VIAL IBRANCE (75 MG CAPSULE, 00 MG CAPSULE, 25 MG CAPSULE) IRESSA 250 MG TABLET JAKAFI (5 MG TABLET, 0 MG TABLET, 5 MG TABLET, 20 MG TABLET, 25 MG TABLET) JEVTANA 60 MG/.5 ML KIT leucovorin calcium (5 mg tablet, 0 mg/ml vial, 0 mg tablet, 5 mg tablet, 25 mg tablet, 50 mg vial, 00 mg vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg vial) levoleucovorin calcium 0 mg/ml vial LYNRZA 50 MG CAPSULE MEKINI (0.5 MG TABLET, 2 MG TABLET) MENE (0.3 MG TABLET, MG TABLET,.25 MG TABLET, 2.5 MG TABLET) mesna 00 mg/ml vial MESNEX 400 MG TABLET mitoxantrone hcl 2 mg/ml vial NINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) ODOMZO 200 MG CAPSULE ONCASR (750 UNIT/ML VIAL, 3,750 UNIT/5 ML VIAL) oxaliplatin (50 mg vial, 50 mg/0ml vial, 00 mg vial, 00mg/20ml vial) paclitaxel 6 mg/ml vial POMALY ( MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) PROLEUKIN 22 MILLION UNIT VIAL SYLATRON (200 MCG, 300 MCG, 600 MCG) SYLATRON 4-CK (200 MCG, 300 MCG) - FOR NEW ARTS ONLY LA on this table mean by going to page. 32

33 SYNRIBO 3.5 MG/ML VIAL - FOR NEW ARTS ONLY TAGRISSO (40 MG TABLET, 80 MG TABLET) TAXOTERE (20 MG/ML VIAL, 80 MG/4 ML VIAL) TRISENOX 0 MG/0 ML AMPULE VELCADE 3.5 MG VIAL ZOLINZA 00 MG CAPSULE Aromatase Inhibitors, 3rd Generation anastrozole mg tablet exemestane 25 mg tablet letrozole 2.5 mg tablet Enzyme Inhibitors etoposide 20 mg/ml vial topotecan hcl (4 mg/4 ml vial, 4 mg vial) ZYDELIG (00 MG TABLET, 50 MG TABLET) Molecular Target Inhibitors AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 0 MG TABLET) AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET) BOSULIF (00 MG TABLET, 500 MG TABLET) GLEEVEC (00 MG TABLET, 400 MG TABLET) ICLUSIG (5 MG TABLET, 45 MG TABLET) imatinib mesylate (00 mg tablet, 400 mg tablet) IMBRUVICA 40 MG CAPSULE INLYTA ( MG TABLET, 5 MG TABLET) LENVIMA (8 MG, 0 MG, 4 MG, 8 MG, 20 MG, 24 MG) NEXAVAR 200 MG TABLET SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MG TABLET, 00 MG TABLET, 40 MG TABLET) IVARGA 40 MG TABLET LA on this table mean by going to page. 33

34 SUTENT (2.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MG CAPSULE) TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) TARCEVA (25 MG TABLET, 00 MG TABLET, 50 MG TABLET) TASIGNA (50 MG CAPSULE, 200 MG CAPSULE) TYKERB 250 MG TABLET VOTRIENT 200 MG TABLET XALKORI (200 MG CAPSULE, 250 MG CAPSULE) ZELBORAF 240 MG TABLET - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY Monoclonal Antibodies ARZERRA,000 MG/50 ML VIAL AVAIN (00 MG/4 ML VIAL, 400 MG/6 ML VIAL) DARZALEX (00 MG/5 ML VIAL, 400 MG/20 ML VIAL) EMPLICITI (300 MG VIAL, 400 MG VIAL) HERCEPTIN 440 MG VIAL KADCYLA (00 MG VIAL, 60 MG VIAL) KEYTRUDA (50 MG VIAL, 00 MG/4 ML VIAL) OPDIVO (40 MG/4 ML VIAL, 00 MG/0 ML VIAL) PERJETA 420 MG/4 ML VIAL RITUXAN 0 MG/ML VIAL TECENTRIQ,200 MG/20 ML VIAL YERVOY (50 MG/0 ML VIAL, 200 MG/40 ML VIAL) Retinoids bexarotene 75 mg capsule NRETIN 0.% GEL TARGRETIN (% GEL, 75 MG SOFTGEL, 75 MG CAPSULE) tretinoin 0 mg capsule LA on this table mean by going to page. 34

35 DRUG NAME Antiparasitics TIER REQUIREMENTS/LIMITS Anthelmintics ALBENZA 200 MG TABLET BILTRICIDE 600 MG TABLET ivermectin 3 mg tablet Antiprotozoals ALINIA (00 MG/5 ML SUSPENSION, 500 MG TABLET) atovaquone 750 mg/5ml oral susp atovaquone/proguanil hcl (atovaquone/proguanil mg tablet, atovaquone/proguanil mg tablet) chloroquine phosphate (250 mg tablet, 500 mg tablet) COARTEM TABLETS DARAPRIM 25 MG TABLET hydroxychloroquine sulfate 200 mg tablet mefloquine hcl 250 mg tablet NEBUPENT 300 MG INHAL POWDER PENTAM 300 VIAL primaquine phosphate 26.3 mg tablet quinine sulfate 324 mg capsule tinidazole (250 mg tablet, 500 mg tablet) Pediculicides/Scabicides EURAX 0% LOTION lindane % shampoo permethrin 5 % cream (g) Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, mg tablet, 2 mg tablet) on this table mean by going to page. 35

36 trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet) Antiparkinson Agents, Other entacapone 200 mg tablet tolcapone 00 mg tablet Dopamine Agonists APOKYN 30 MG/3 ML CARTRIDGE bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) NEUPRO ( MG/24 HR, 2 MG/24 HR, 3 MG/24 HR, 4 MG/24 HR, 6 MG/24 HR, 8 MG/24 HR) pramipexole di-hcl (0.25 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, mg tablet,.5 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa (carbidopa/levodopa 0mg- 00mg tablet, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 25mg-00mg tablet er, carbidopa/levodopa 25mg-00mg tablet, carbidopa/levodopa 50mg-200mg tablet er) carbidopa/levodopa/entacapone (carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone tablet, carbidopa/levodopa/entacapone tablet, carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone tablet) Monoamine Oxidase B (MAO-B) Inhibitors AZILECT (0.5 MG TABLET, MG TABLET) selegiline hcl (5 mg tablet, 5 mg capsule) on this table mean by going to page. 36

37 Antipsychotics st Generation/Typical chlorpromazine hcl (0 mg tablet, 25 mg/ml ampul) chlorpromazine hcl (25 mg tablet, 50 mg tablet, 00 mg tablet, 200 mg tablet) COMPRO 25 MG SUPPOSITORY fluphenazine decanoate 25 mg/ml vial fluphenazine hcl ( mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc) fluphenazine hcl 0 mg tablet haloperidol (0.5 mg tablet, mg tablet, 2 mg tablet, 5 mg tablet, 0 mg tablet, 20 mg tablet) haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul, 00 mg/ml ampul, 00 mg/ml vial) haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5 mg/ml ampul) loxapine succinate (5 mg capsule, 0 mg capsule, 25 mg capsule, 50 mg capsule) molindone hcl (5 mg tablet, 0 mg tablet, 25 mg tablet) ORAP MG TABLET ORAP 2 MG TABLET perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet) perphenazine 6 mg tablet pimozide ( mg tablet, 2 mg tablet) prochlorperazine 25 mg supp.rect prochlorperazine edisylate (5 mg/ml vial, 0 mg/2 ml vial) prochlorperazine maleate (5 mg tablet, 0 mg tablet) thioridazine hcl (0 mg tablet, 25 mg tablet, 50 mg tablet, 00 mg tablet) thiothixene ( mg capsule, 2 mg capsule, 5 mg capsule, 0 mg capsule) - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY on this table mean by going to page. 37

38 trifluoperazine hcl ( mg tablet, 2 mg tablet, 5 mg tablet, 0 mg tablet) 2nd Generation/Atypical ABILIFY MAINTENA (ER 300 MG, ER 400 MG) aripiprazole (0 mg tab rapdis, 5 mg tab rapdis) aripiprazole (2 mg tablet, 5 mg tablet, 0 mg tablet, 5 mg tablet, 20 mg tablet, 30 mg tablet) ARIADA (ER 44 MG/.6 ML, ER 662 MG/2.4 ML, ER 882 MG/3.2 ML) FANAPT ( MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 0 MG TABLET, 2 MG TABLET, TITRATION CK) GEODON 20 MG/ML VIAL INVEGA (ER.5 MG TABLET, ER 3 MG TABLET, ER 6 MG TABLET, ER 9 MG TABLET) - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY INVEGA SUENNA (39 MG/0.25 ML, 78 MG/0.5 ML, 7 MG/0.75 ML, 56 MG/ML SYRG, 234 MG/.5 ML) INVEGA TRINZA (273 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/2.625 ML) LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET, 20 MG TABLET) NUPLAZID 7 MG TABLET - FOR NEW ARTS ONLY, QL (62 PER 3 DAYS) olanzapine (2.5 mg tablet, 5 mg tablet, 0 mg, - FOR NEW ARTS ONLY tablet, 0 mg vial, 5 mg tablet, 20 mg tablet) olanzapine (5 mg tab rapdis, 7.5 mg tablet, 0 mg tab rapdis, 5 mg tab rapdis, 20 mg tab rapdis) - FOR NEW ARTS ONLY paliperidone (.5 mg tab er 24, 3 mg tab er 24, 6 mg tab er 24, 9 mg tab er 24) quetiapine fumarate (25 mg tablet, 50 mg tablet, 00 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet) REXULTI (0.25 MG TABLET, 0.5 MG TABLET, MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) RISPERDAL CONA (2.5 MG, 37.5 MG, 50 MG) on this table mean by going to page. 38

39 risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, mg tab rapdis, mg/ml solution, mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet) SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL BLK CHERRY, 5 MG TABLET SUBLINGUAL, 0 MG TAB SUBLINGUAL, 0 MG TAB SL BLK CHERY) SEROQUEL XR (50 MG TABLET, 50 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET) VRAYLAR (.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule) ZYPREXA RELPREVV (20 MG VIAL, 20 MG VL KIT, 300 MG VL KIT, 300 MG VIAL, 405 MG VL KIT, 405 MG VIAL) - FOR NEW ARTS ONLY, QL (3 PER 3 DAYS) - FOR NEW ARTS ONLY Treatment-Resistant clozapine (2.5 mg tab rapdis, 25 mg tab rapdis, 00 mg tab rapdis, 50 mg tab rapdis, 200 mg tab rapdis) clozapine (25 mg tablet, 50 mg tablet, 00 mg tablet, 200 mg tablet) FAZACLO (2.5 MG TABLET, 2.5 MG ODT, 25 MG TABLET, 25 MG ODT, 00 MG ODT, 00 MG TABLET) - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY VERSACLOZ 50 MG/ML SUSPENSION - FOR NEW ARTS ONLY Antispasticity Agents baclofen (0 mg tablet, 20 mg tablet) dantrolene sodium (25 mg capsule, 50 mg capsule, 00 mg capsule) tizanidine hcl (2 mg tablet, 4 mg tablet) Antivirals Anti-HIV Agents, Integrase Inhibitors (INI) ATRIPLA TABLET on this table mean by going to page. 39

40 TIVICAY (0 MG TABLET, 25 MG TABLET, 50 MG TABLET) VITEKTA (85 MG TABLET, 50 MG TABLET) Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA TABLET EDURANT 25 MG TABLET INTELENCE (25 MG TABLET, 00 MG TABLET, 200 MG TABLET) nevirapine (50 mg/5 ml oral susp, 00 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) ODEFSEY TABLET RESCRIPTOR (00 MG TABLET, 200 MG TABLET) RIBILD TABLET SUIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) VIRAMUNE XR 00 MG TABLET Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate 300 mg tablet abacavir/lamivudine/zidovudine mg tablet DESCOVY MG TABLET didanosine (25 mg capsule dr, 200 mg capsule dr, 250 mg capsule dr, 400 mg capsule dr) EMTRIVA (0 MG/ML SOLUTION, 200 MG CAPSULE) EPIVIR HBV 25 MG/5 ML SOLN EPZICOM TABLET GENVOYA TABLET lamivudine (0 mg/ml solution, 00 mg tablet, 50 mg tablet, 300 mg tablet) lamivudine/zidovudine mg tablet RETROVIR 200 MG/20 ML VIAL stavudine ( mg/ml soln recon, 5 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) TRIUMEQ TABLET on this table mean by going to page. 40

41 TRUVADA (00 MG-50 MG TABLET, 33 MG- 200 MG TABLET, 67 MG-250 MG TABLET, 200 MG-300 MG TABLET) VIDEX (2 GM SOLN, 4 GM SOLN) VIREAD (50 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZIAGEN 20 MG/ML SOLUTION zidovudine (0 mg/ml syrup, 00 mg capsule, 300 mg tablet) Anti-HIV Agents, Other FUZEON (90 MG VIAL, CONVENIENCE KIT) SELZENTRY (50 MG TABLET, 300 MG TABLET) TYBO 50 MG TABLET Anti-HIV Agents, Protease Inhibitors APTIVUS (00 MG/ML SOLUTION, 250 MG CAPSULE) CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE) EVOTAZ 300 MG-50 MG TABLET INVIRASE (200 MG CAPSULE, 500 MG TABLET) KALETRA (00-25 MG TABLET, MG TABLET, /5 ML ORAL SOLU) LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) NORVIR (80 MG/ML SOLUTION, 00 MG TABLET, 00 MG SOFTGEL CAP) PREZCOBIX 800 MG-50 MG TABLET PREZIA (75 MG TABLET, 00 MG/ML SUSPENSION, 50 MG TABLET, 600 MG TABLET, 800 MG TABLET) REYATAZ (50 MG POWDER CKET, 50 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) VIRACEPT (250 MG TABLET, 625 MG TABLET) ZETIER MG TABLET Anti-cytomegalovirus (CMV) Agents cidofovir 75 mg/ml vial, QL (28 PER 28 DAYS) on this table mean by going to page. 4

42 ganciclovir sodium 500 mg vial valganciclovir hcl 450 mg tablet ZIRGAN 0.5% OPHTHALMIC GEL Anti-hepatitis B (HBV) Agents adefovir dipivoxil 0 mg tablet BARACLUDE 0.05 MG/ML SOLUTION entecavir (0.5 mg tablet, mg tablet) INTRON A (0 MILLION UNITS VIL, 8 MILLION UNITS VIL, 8 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL) TYZEKA 600 MG TABLET Anti-hepatitis C (HCV) Agents DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) HARVONI MG TABLET MODERIBA 200 MG TABLET OLYSIO 50 MG CAPSULE PEGASYS (80 MCG/ML VIAL, 80 MCG/0.5 ML SYRINGE) PEGASYS PROCLICK (35 MCG/0.5, 80 MCG/0.5) PEGINTRON (50 MCG, 80 MCG, 20 MCG, 50 MCG) PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80 MCG, 80 MCG 4PK, 20 MCG 4PK, 20 MCG, 50 MCG, 50 MCG 4PK) RIBASPHERE 200 MG TABLET SOVALDI 400 MG TABLET VIEKIRA K, QL (28 PER 28 DAYS), QL (28 PER 28 DAYS) Anti-influenza Agents amantadine hcl (00 mg tablet, 00 mg capsule) RELENZA 5 MG DISKHALER rimantadine hcl 00 mg tablet TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) on this table mean by going to page. 42

43 Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) acyclovir sodium (50 mg/ml vial, 500 mg vial, 000 mg vial) famciclovir (25 mg tablet, 250 mg tablet, 500 mg tablet) trifluridine % drops valacyclovir hcl (500 mg tablet, 000 mg tablet) Anxiolytics Anxiolytics, Other buspirone hcl (5 mg tablet, 7.5 mg tablet, 0 mg tablet, 5 mg tablet, 30 mg tablet) doxepin hcl 0 mg/ml oral conc - FOR NEW ARTS ONLY Benzodiazepines alprazolam (0.25 mg tablet, 0.5 mg tablet, mg tablet, 2 mg tablet) clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet, 5 mg tablet) diazepam (2 mg tablet, 5 mg tablet, 0 mg tablet) diazepam (5 mg/5 ml solution, 5 mg/ml oral conc) lorazepam (0.5 mg tablet, mg tablet, 2 mg tablet) LORAZEM INTENSOL 2 MG/ML oxazepam (0 mg capsule, 5 mg capsule, 30 mg capsule) temazepam (7.5 mg capsule, 5 mg capsule, 22.5 mg capsule, 30 mg capsule) triazolam (0.25 mg tablet, 0.25 mg tablet) - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY - FOR NEW ARTS ONLY, - FOR NEW ARTS ONLY SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor XIL 0 MG/5 ML SUSPENSION - FOR NEW ARTS ONLY on this table mean by going to page. 43

44 venlafaxine hcl 225 mg tab er 24 Bipolar Agents Bipolar Agents, Other ABILIFY MAINTENA (ER 300 MG, ER 400 MG) RISPERDAL CONA 25 MG SYR - FOR NEW ARTS ONLY Mood Stabilizers lamotrigine 5 mg tb chw dsp lithium carbonate (50 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule) lithium citrate 8 meq/5 ml solution Blood Glucose Regulators Antidiabetic Agents acarbose (25 mg tablet, 50 mg tablet, 00 mg tablet) AVANDIA (2 MG TABLET, 4 MG TABLET) BYETTA (5 MCG, 0 MCG) CYCLOSET 0.8 MG TABLET FARXIGA (5 MG TABLET, 0 MG TABLET) glimepiride ( mg tablet, 2 mg tablet, 4 mg tablet) glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 0 mg tab er 24, 0 mg tablet) glipizide/metformin hcl (glipizide/metformin mg tablet, glipizide/metformin mg tablet, glipizide/metformin 5 mg-500mg tablet) GLYSET (25 MG TABLET, 50 MG TABLET, 00 MG TABLET) INVOKAMET (50-,000 MG TABLET, MG TABLET, MG TABLET, 50-,000 MG TABLET) INVOKANA (00 MG TABLET, 300 MG TABLET) JANUMET (50-,000 MG TABLET, MG TABLET) on this table mean by going to page. 44

45 JANUVIA (25 MG TABLET, 50 MG TABLET, 00 MG TABLET) metformin hcl (500 mg tabergr24h, 500 mg tab er 24, 500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 000 mg tablet) miglitol (25 mg tablet, 50 mg tablet, 00 mg tablet) nateglinide (60 mg tablet, 20 mg tablet) pioglitazone hcl (5 mg tablet, 30 mg tablet, 45 mg tablet) pioglitazone hcl/metformin hcl (/metformin 5mg-500mg tablet, /metformin 5mg-850mg tablet) repaglinide (0.5 mg tablet, mg tablet, 2 mg tablet) repaglinide/metformin hcl (repaglinide/metformin mg-500mg tablet, repaglinide/metformin 2 mg-500mg tablet) SYMLINPEN 20 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR VICTOZA 2-K 8 MG/3 ML PEN VICTOZA 3-K 8 MG/3 ML PEN Glycemic Agents CLINIMIX (4.25%-20%, 5%-20%, 5%-5%) CLINIMIX E (2.75%-5%, 2.75%-0%, 4.25%-25%, 4.25%-5%, 5%-5%, 5%-25%) dextrose 0 % and 0.2 % nacl 0 %-0.2 % dehp fr bg dextrose 0 % and 0.45 % nacl 0%-0.45% iv soln dextrose 0 % in water (0 % 0 % iv soln, 0 % 0 % dehp fr bg) dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln dextrose 5 % in water (5 % 5 % iv soln, 5 % pgy vl prt, 5 % 5 % vial, 5 % pggybk prt) - TO CONFIRM RT D COVERAGE on this table mean by going to page. 45

46 dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln GLUCAGEN ( MG HYPOKIT, DIAGNOIC MG VIAL, MG HYPOKIT 2-CK) GLUCAGON MG EMERGENCY KIT IONOSOL B-D5W IV SOLUTION IONOSOL MB-D5W IV SOLUTION NORMOSOL-R-DEXTROSE 5% IV SOLN potassium chloride in dextrose 5 % and 0.9 % sodium chloride (chloride/d5-0.9%nacl 40 meq/l soln, chloride/d5-0.9%nacl 20 meq/l soln) potassium chloride in dextrose 5 %-0.45% sodium chloride (chloride/d5-0.45nacl 0 meq/l soln, chloride/d5-0.45nacl 20 meq/l soln, chloride/d5-0.45nacl 40 meq/l soln, chloride/d5-0.45nacl 30 meq/l soln) potassium chloride in lr-d5 20 meq/l iv soln potassium chloride/d5-0.2%nacl 20 meq/l iv soln potassium chloride/d5-0.3%nacl 20 meq/l iv soln PROGLYCEM 50 MG/ML ORAL SUSP Insulins APIDRA 00 UNITS/ML VIAL APIDRA SOLOAR 00 UNITS/ML HUMALOG (00 UNITS/ML CARTRIDGE, 00 UNITS/ML VIAL) HUMALOG 00 UNITS/ML KWIKPEN HUMALOG 200 UNITS/ML KWIKPEN HUMALOG MIX KWIKPEN HUMALOG MIX VIAL HUMALOG MIX KWIKPEN HUMALOG MIX VIAL HUMULIN R 500 UNITS/ML VIAL LANTUS 00 UNITS/ML VIAL LANTUS SOLOAR 00 UNITS/ML on this table mean by going to page. 46

47 LEVEMIR 00 UNITS/ML VIAL LEVEMIR FLEXPEN 00 UNITS/ML LEVEMIR FLEXTOUCH 00 UNITS/ML NOVOLOG (00 UNIT/ML CARTRIDGE, 00 UNIT/ML VIAL) NOVOLOG 00 UNITS/ML FLEXPEN NOVOLOG MIX FLEXPEN SYRN NOVOLOG MIX VIAL TOUJEO SOLOAR 300 UNITS/ML Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin sodium (00 mg/ml, 50 mg/ml) enoxaparin sodium (80mg/0.8ml, 20mg/.8ml) enoxaparin sodium 300mg/3ml vial, QL (34 ML PER 7 DAYS), QL (27.2 ML PER 7 DAYS), QL (02 ML PER 7 DAYS) enoxaparin sodium 30mg/0.3ml syringe enoxaparin sodium 40mg/0.4ml syringe enoxaparin sodium 60mg/0.6ml syringe fondaparinux sodium (2.5 mg/0.5, 5mg/0.4ml, 7.5mg/0.6, 0mg/0.8ml), QL (0.2 ML PER 7 DAYS), QL (7.6 ML PER 7 DAYS), QL (20.4 ML PER 7 DAYS) FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 0,000 UNITS/ML SYRING, 2,500 UNITS/0.5 ML, 5,000 UNITS/0.6 ML, 8,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL) heparin sodium,porcine (000/ml vial, 5000/ml vial, 5000/ml() cartridge, 0000/ml vial, 20000/ml vial) heparin sodium,porcine/dextrose 5 % in water (sodium,porcine/d5w 25000/250 soln, sodium,porcine/d5w 20k/500ml soln, sodium,porcine/d5w 2500/250 soln, sodium,porcine/d5w 25000/500 soln) PRADAXA (75 MG CAPSULE, 0 MG CAPSULE, 50 MG CAPSULE) warfarin sodium ( mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 0 mg tablet),, on this table mean by going to page. 47

48 XARELTO (0 MG TABLET, 5 MG TABLET, 20 MG TABLET, ARTER CK) Blood Formation Modifiers anagrelide hcl (0.5 mg capsule, mg capsule) ARANESP (0 MCG/0.4 ML SYRINGE, 25 MCG/ML VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 00 MCG/ML VIAL, 00 MCG/0.5 ML SYRINGE, 50 MCG/0.3 ML SYRINGE, 50 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/ ML SYRINGE) EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 0,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL) LEUKINE 250 MCG VIAL NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/.6 ML VIAL, 480 MCG/0.8 ML SYR) PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 0,000 UNITS/ML VIAL, 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL) PROMACTA (2.5 MG TABLET, 25 MG TABLET, 50 MG TABLET) Coagulants BRILINTA (60 MG TABLET, 90 MG TABLET) tranexamic acid (650 mg tablet, 000 mg/0 vial, 000 mg/0 ampul) Platelet Modifying Agents AGGRENOX 25 MG-200 MG CAPSULE aspirin/dipyridamole 25mg-200mg cpmp 2hr cilostazol (50 mg tablet, 00 mg tablet) clopidogrel bisulfate (75 mg tablet, 300 mg tablet) on this table mean by going to page. 48

49 Cardiovascular Agents Alpha-adrenergic Agonists clonidine (0.mg/24hr, 0.2mg/24hr, 0.3mg/24hr) clonidine hcl (0. mg tablet, 0.2 mg tablet, 0.3 mg tablet) methyldopa (250 mg tablet, 500 mg tablet) methyldopate hcl 250 mg/5ml vial midodrine hcl (2.5 mg tablet, 5 mg tablet, 0 mg tablet) Alpha-adrenergic Blocking Agents CARDURA XL (4 MG TABLET, 8 MG TABLET) prazosin hcl ( mg capsule, 2 mg capsule, 5 mg capsule) Angiotensin II Receptor Antagonists candesartan cilexetil (4 mg tablet, 8 mg tablet, 6 mg tablet, 32 mg tablet) ENTREO (24 MG-26 MG TABLET, 49 MG-5 MG TABLET, 97 MG-03 MG TABLET) irbesartan (75 mg tablet, 50 mg tablet, 300 mg tablet) irbesartan/hydrochlorothiazide (irbesartan/hydrochlorothiazide mg tablet, irbesartan/hydrochlorothiazide mg tablet) losartan potassium (25 mg tablet, 50 mg tablet, 00 mg tablet) losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide mg tablet, losartan/hydrochlorothiazide mg tablet, losartan/hydrochlorothiazide 00mg-25mg tablet) telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet) on this table mean by going to page. 49

50 telmisartan/hydrochlorothiazide (telmisartan/hydrochlorothiazid mg tablet, telmisartan/hydrochlorothiazid mg tablet, telmisartan/hydrochlorothiazid 80 mg-25mg tablet) valsartan (40 mg tablet, 80 mg tablet, 60 mg tablet, 320 mg tablet) valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide mg tablet, valsartan/hydrochlorothiazide mg tablet, valsartan/hydrochlorothiazide 60-25mg tablet, valsartan/hydrochlorothiazide 320mg-25mg tablet, valsartan/hydrochlorothiazide mg tablet) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tablet, 0 mg tablet, 20 mg tablet, 40 mg tablet) benazepril hcl/hydrochlorothiazide (benazepril/hydrochlorothiazide mg tablet, benazepril/hydrochlorothiazide 0-2.5mg tablet, benazepril/hydrochlorothiazide mg tablet, benazepril/hydrochlorothiazide 20 mg-25mg tablet) captopril (2.5 mg tablet, 25 mg tablet, 50 mg tablet, 00 mg tablet) captopril/hydrochlorothiazide (captopril/hydrochlorothiazide 25 mg-25mg tablet, captopril/hydrochlorothiazide 25 mg- 5mg tablet, captopril/hydrochlorothiazide 50 mg-5mg tablet, captopril/hydrochlorothiazide 50 mg-25mg tablet) enalapril maleate (2.5 mg tablet, 5 mg tablet, 0 mg tablet, 20 mg tablet) enalapril maleate/hydrochlorothiazide (enalapril/hydrochlorothiazide 5mg-2.5mg tablet, enalapril/hydrochlorothiazide 0 mg- 25mg tablet) lisinopril (2.5 mg tablet, 5 mg tablet, 0 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) on this table mean by going to page. 50

51 lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide 0-2.5mg tablet, lisinopril/hydrochlorothiazide mg tablet, lisinopril/hydrochlorothiazide 20 mg-25mg tablet) quinapril hcl (5 mg tablet, 0 mg tablet, 20 mg tablet, 40 mg tablet) quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 0-2.5mg tablet, quinapril/hydrochlorothiazide 20 mg- 25mg tablet, quinapril/hydrochlorothiazide mg tablet) ramipril (.25 mg capsule, 2.5 mg capsule, 5 mg capsule, 0 mg capsule) Antiarrhythmics amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 200 mg tablet, 400 mg tablet) disopyramide phosphate (00 mg capsule, 50 mg capsule) dofetilide (25 mcg capsule, 250 mcg capsule, 500 mcg capsule) flecainide acetate (50 mg tablet, 00 mg tablet, 50 mg tablet) mexiletine hcl (50 mg capsule, 200 mg capsule, 250 mg capsule) MULTAQ 400 MG TABLET propafenone hcl (50 mg tablet, 225 mg cap er 2h, 225 mg tablet, 300 mg tablet, 325 mg cap er 2h, 425 mg cap er 2h) quinidine gluconate 324 mg tablet er quinidine sulfate (200 mg tablet, 300 mg tablet) sotalol hcl (80 mg tablet, 20 mg tablet, 60 mg tablet, 240 mg tablet) TIKOSYN (25 MCG CAPSULE, 250 MCG CAPSULE, 500 MCG CAPSULE) Beta-adrenergic Blocking Agents acebutolol hcl (200 mg capsule, 400 mg capsule) atenolol (25 mg tablet, 50 mg tablet, 00 mg tablet) on this table mean by going to page. 5

52 bisoprolol fumarate (5 mg tablet, 0 mg tablet) bisoprolol fumarate/hydrochlorothiazide (fumarate/hctz mg tablet, fumarate/hctz mg tablet, fumarate/hctz mg tablet) carvedilol (3.25 mg tablet, 6.25 mg tablet, 2.5 mg tablet, 25 mg tablet) COREG CR (0 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE) labetalol hcl (5 mg/ml vial, 00 mg tablet, 200 mg tablet, 300 mg tablet) metoprolol succinate (25 mg tab er, 50 mg tab er, 00 mg tab er, 200 mg tab er) metoprolol tartrate (5 mg/5 ml syringe, 5 mg/5 ml ampul, 5 mg/5 ml vial, 25 mg tablet, 50 mg tablet, 00 mg tablet) metoprolol tartrate/hydrochlorothiazide (metoprolol/hydrochlorothiazide 50 mg-25mg tablet, metoprolol/hydrochlorothiazide 00mg- 50mg tablet, metoprolol/hydrochlorothiazide 00mg-25mg tablet) nadolol/bendroflumethiazide (nadolol/bendroflumethiazide 40 mg tablet, nadolol/bendroflumethiazide 80 mg tablet) pindolol (5 mg tablet, 0 mg tablet) propranolol hcl ( mg/ml vial, 0 mg tablet, 20 mg tablet, 40 mg tablet, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 20 mg cap sa 24h, 60 mg cap sa 24h) propranolol hcl/hydrochlorothiazide (propranolol/hydrochlorothiazid 40 tablet, propranolol/hydrochlorothiazid 80 tablet) Calcium Channel Blocking Agents AFEDITAB CR (30 MG TABLET, 60 MG TABLET) amlodipine besylate (2.5 mg tablet, 5 mg tablet, 0 mg tablet) CARTIA XT (20 MG CAPSULE, 80 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE) DILT-CD (20 MG CAPSULE, 80 MG CAPSULE, 240 MG CAPSULE) on this table mean by going to page. 52

53 DILT-XR (20 MG CAPSULE, 80 MG CAPSULE, 240 MG CAPSULE) diltiazem hcl (30 mg tablet, 60 mg cap er 2h, 60 mg tablet, 90 mg cap er 2h, 90 mg tablet, 20 mg cap er 2h, 20 mg cap er 24h, 20 mg cap er deg, 20 mg capsule er, 20 mg tablet, 80 mg cap er 24h, 80 mg capsule er, 80 mg cap er deg, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 420 mg capsule er) MATZIM LA (80 MG TABLET, 240 MG TABLET, 300 MG TABLET, 360 MG TABLET, 420 MG TABLET) NIFEDICAL XL (30 MG TABLET, 60 MG TABLET) nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er) nimodipine 30 mg capsule TAZTIA XT (20 MG CAPSULE, 80 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg tablet, 80 mg tablet, 00 mg cap24h pct, 20 mg cap24h pel, 20 mg tablet, 20 mg tablet er, 80 mg tablet er, 80 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel) Cardiovascular Agents, Other DEMSER 250 MG CAPSULE DIGOX 25 MCG TABLET digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) digoxin 25 mcg tablet NORTHERA (00 MG CAPSULE, 200 MG CAPSULE) NORTHERA 300 MG CAPSULE pentoxifylline 400 mg tablet er RANEXA (ER 500 MG TABLET, ER,000 MG TABLET) QL (62 PER 3 DAYS), QL (42 PER 4 DAYS), QL (84 PER 4 DAYS) on this table mean by going to page. 53

54 TEKTURNA (50 MG TABLET, 300 MG TABLET) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide (25 mg tablet, 250 mg tablet) acetazolamide sodium 500 mg vial methazolamide 50 mg tablet Diuretics, Loop bumetanide (0.25 mg/ml vial, 0.5 mg tablet, mg tablet, 2 mg tablet) furosemide (0 mg/ml solution, 0 mg/ml vial, 20 mg tablet, 40 mg tablet, 80 mg tablet) torsemide (5 mg tablet, 0 mg tablet, 20 mg tablet, 00 mg tablet) Diuretics, Potassium-sparing amiloride hcl 5 mg tablet amiloride/hydrochlorothiazide 5 mg-50 mg tablet spironolact/hydrochlorothiazid 25 mg-25mg tablet spironolactone (50 mg tablet, 00 mg tablet) spironolactone 25 mg tablet triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid mg capsule, triamterene/hydrochlorothiazid mg tablet, triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet) Diuretics, Thiazide candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 6-2.5mg tablet, candesartan/hydrochlorothiazid mg tablet, candesartan/hydrochlorothiazid 32mg-25mg tablet) chlorthalidone (25 mg tablet, 50 mg tablet) hydrochlorothiazide (2.5 mg capsule, 2.5 mg tablet, 25 mg tablet, 50 mg tablet) indapamide (.25 mg tablet, 2.5 mg tablet) on this table mean by going to page. 54

55 metolazone (2.5 mg tablet, 5 mg tablet, 0 mg tablet) Dyslipidemics, Fibric Acid Derivatives fenofibrate (40 mg tablet, 50 mg capsule, 54 mg tablet, 20 mg tablet, 50 mg capsule, 60 mg tablet) fenofibrate nanocrystallized (48 mg tablet, 45mg tablet) fenofibrate,micronized (43 mg capsule, 67 mg capsule, 30 mg capsule, 34mg capsule, 200 mg capsule) fenofibric acid (35 mg tablet, 05 mg tablet) fenofibric acid (choline) ((choline) 45 mg capsule dr, (choline) 35 mg capsule dr) fenoprofen calcium 400 mg capsule FIBRICOR (35 MG TABLET, 05 MG TABLET) gemfibrozil 600 mg tablet Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium (0 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) lovastatin (0 mg tablet, 20 mg tablet, 40 mg tablet) pravastatin sodium (0 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) simvastatin (5 mg tablet, 0 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) Dyslipidemics, Other cholestyramine (with sugar) (suar) 4 powder, suar) 4 powd pack) cholestyramine/aspartame (cholestyramine/aspartame 4 powd pack, cholestyramine/aspartame 4 powder) colestipol hcl ( tablet, 5 packet, 5 ranules) JUXTAPID (5 MG CAPSULE, 0 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) KYNAMRO 200 MG/ML SYRINGE on this table mean by going to page. 55

56 niacin (500 mg tab er, 750 mg tab er, 000 mg tab er) omega-3 acid ethyl esters g capsule PREVALITE (CKET, POWDER) RETHA 40 MG/ML SURECLICK RETHA 40 MG/ML SYRINGE RETHA 420 MG/3.5ML PUSHTRONX VYTORIN (0-80 MG TABLET, 0-0 MG TABLET, 0-40 MG TABLET, 0-20 MG TABLET) WELCHOL 625 MG TABLET ZETIA 0 MG TABLET Vasodilators, Direct-acting Arterial hydralazine hcl (0 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 00 mg tablet) minoxidil (2.5 mg tablet, 0 mg tablet) Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate (5 mg tablet, 0 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er) isosorbide mononitrate (0 mg tablet, 20 mg tablet, 30 mg tab er 24h, 60 mg tab er 24h, 20 mg tab er 24h) nitroglycerin (0.mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 50 mg/0ml vial) NITROAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6 MG TABLET),,, on this table mean by going to page. 56

57 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulf-, QL (62 PER 3 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 0 mg cap er, dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 20 mg cap er, dextroamphetamine/amphetamine 25 mg cap er, dextroamphetamine/amphetamine 30 mg cap er) dextroamphetamine sulf- QL (93 PER 3 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 0 mg tablet, dextroamphetamine/amphetamine 2.5 mg tablet, dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 20 mg tablet) dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 0 mg tablet, 0 mg capsule er, 5 mg capsule er) dextroamphetamine/amphetamine 30 mg tablet QL (62 PER 3 DAYS) Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 0 mg tablet) guanfacine hcl ( mg tab er, 2 mg tab er, 3 mg tab er, 4 mg tab er) METADATE ER 20 MG TABLET, QL (3 PER 3 DAYS) on this table mean by going to page. 57

58 methylphenidate hcl (5 mg tablet, 5 mg/5 ml solution, 0 mg tablet, 0 mg/5 ml solution, 0 mg cpbp 30-70, 8 mg tab er 24, 20 mg cpbp 30-70, 20 mg tablet, 20 mg cpbp 50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 50-50, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70) RATTERA (0 MG CAPSULE, 8 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE, 00 MG CAPSULE) Central Nervous System, Other HETLIOZ 20 MG CAPSULE HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) NUEDEXTA 20-0 MG CAPSULE riluzole 50 mg tablet tetrabenazine (2.5 mg tablet, 25 mg tablet) XENAZINE (2.5 MG TABLET, 25 MG TABLET) Fibromyalgia Agents LYRICA 20 MG/ML ORAL SOLUTION SAVELLA (2.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 00 MG TABLET) Multiple Sclerosis Agents AMPYRA ER 0 MG TABLET AUBAGIO (7 MG TABLET, 4 MG TABLET) AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT, PREFILLED SYR 30 MCG) AVONEX PEN (30 MCG/0.5 ML, 30 MCG/0.5 ML KIT) BETASERON (0.3 MG VIAL, 0.3 MG KIT) COXONE 40 MG/ML SYRINGE GILENYA 0.5 MG CAPSULE GLATO 20 MG/ML SYRINGE REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE, TITRATION CK) QL (400 ML PER 3 DAYS) QL (62 PER 3 DAYS) on this table mean by going to page. 58

59 TECFIDERA (DR 20 MG CAPSULE, DR 240 MG CAPSULE) TYSABRI 300 MG/5 ML VIAL Dental and Oral Agents chlorhexidine gluconate 0.2 % mouthwash PERIOGARD 0.2% ORAL RINSE pilocarpine hcl (5 mg tablet, 7.5 mg tablet) triamcinolone acetonide 0. % paste (g) Dermatological Agents 8-MOP 0 MG CAPSULE acitretin (0 mg capsule, 7.5 mg capsule, 25 mg capsule) adapalene 0. % gel (gram) ammonium lactate (2 % lotion, 2 % cream (g)) calcipotriene (0.005 % oint. (g), % solution) CLARAVIS (0 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE) clindamycin phosphate ( % lotion, % solution) COSENTYX 50 MG/ML PEN INJECT COSENTYX 50 MG/ML SYRINGE COSENTYX 300 MG DOSE-2 PENS COSENTYX 300 MG DOSE-2 SYRINGE diclofenac sodium % gel (gram) erythromycin/benzoyl peroxide 3 %-5 % gel (gram) fluocinolone acetonide 0.0 % oil fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g)) imiquimod 5 % cream pack MYORISAN (0 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) podofilox 0.5 % solution, - FOR NEW ARTS ONLY on this table mean by going to page. 59

60 REGRANEX 0.0% GEL, QL (5 GM PER 30 DAYS) SANTYL OINTMENT selenium sulfide 2.5 % lotion sulfacetamide sodium 0 % suspension tacrolimus (0.03 % (g), 0. % (g)) TAZORAC (0.05% GEL, 0.% GEL) TAZORAC (0.05%, 0.%) TOLAK 4% CREAM tretinoin (0.0 % gel (gram), % gel (gram), % cream (g), 0.05 % cream (g), 0. % cream (g)) UVADEX 20 MCG/ML VIAL ZENATANE (0 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE) Enzyme Replacement/Modifiers, QL (30 GM PER 30 DAYS), QL (00 GM PER 30 DAYS), QL (60 GM PER 30 DAYS) ADAGEN 250 UNITS/ML VIAL ALDURAZYME 2.9 MG/5 ML VIAL CEREZYME 400 UNITS VIAL CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE, DR 2,000 CAPSULE, DR 24,000 CAPSULE, DR 36,000 CAPSULE) CYADANE POWDER CYAGON (50 MG CAPSULE, 50 MG CAPSULE) ELAPRASE 6 MG/3 ML VIAL ELELYSO 200 UNITS VIAL FABRAZYME (5 MG VIAL, 35 MG VIAL) KUVAN (00 MG TABLET, 00 MG POWDER CKET, 500 MG POWDER CKET) LUMIZYME 50 MG VIAL NAGLAZYME 5 MG/5 ML VIAL NCREAZE (DR 4,200 CAP, DR 0,500 CAP, DR 6,800 CAP, DR 2,000 CAP) sodium phenylbutyrate 0.94 g/g powder on this table mean by going to page. 60

61 RENSIQ (8 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80 MG/0.8 ML VIAL) SUCRAID 8,500 UNITS/ML SOLN VPRIV 400 UNITS VIAL ZAVESCA 00 MG CAPSULE ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE, DR 0,000 CAPSULE, DR 5,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE) Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine hcl (0 mg capsule, 20 mg tablet) glycopyrrolate (0.2 mg/ml vial, mg/5 ml syringe, mg tablet, 2 mg tablet) Gastrointestinal Agents, Other cromolyn sodium 20 mg/ml oral conc diphenoxylate hcl/atropine sulfate (hcl/atropine mg tablet, hcl/atropine /5 liquid) GATTEX (5 MG ONE-VIAL, 5 MG 30-VIAL) loperamide hcl 2 mg capsule metoclopramide hcl (5 mg tablet, 5 mg/ml vial, 0 mg tablet) MOVANTIK (2.5 MG TABLET, 25 MG TABLET) RELIOR (8 MG/0.4 ML SYRINGE, 2 MG/0.6 ML KIT, 2 MG/0.6 ML VIAL) ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) Histamine2 (H2) Receptor Antagonists famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg tablet) famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback famotidine/pf 20 mg/2 ml vial on this table mean by going to page. 6

62 ranitidine hcl (5 mg/ml syrup, 25 mg/ml vial, 50 mg/2 ml vial, 50 mg capsule, 50 mg tablet, 300 mg tablet, 300 mg capsule) Irritable Bowel Syndrome Agents alosetron hcl (0.5 mg tablet, mg tablet) AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) Laxatives CONULOSE 0 GM/5 ML SOLN ENULOSE 0 GM/5 ML SOLUTION GAVILYTE-C SOLUTION GAVILYTE-G SOLUTION GAVILYTE-N SOLUTION GENERLAC 0 GM/5 ML SOLUTION lactulose (0 g/5 ml, 20 g/30 ml) peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl (3350/na sulf,bicarb,cl/kcl g soln, 3350/na sulf,bicarb,cl/kcl g soln) polyethylene glycol 3350 (3350 7g powd pack, g/dose powder) TRILYTE WITH FLAVOR CKETS Protectants CARAFATE GM/0 ML SUSP misoprostol (00 mcg tablet, 200 mcg tablet) sucralfate g tablet Proton Pump Inhibitors esomeprazole sodium (20 mg vial, 40 mg vial) lansoprazole (5 mg capsule dr, 30 mg capsule dr) omeprazole (0 mg capsule dr, 20 mg capsule dr) omeprazole 40 mg capsule dr pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) on this table mean by going to page. 62

63 PROTONIX IV 40 MG VIAL Genitourinary Agents Antispasmodics, Urinary darifenacin hydrobromide (7.5 mg tab er, 5 mg tab er) MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) oxybutynin chloride (5 mg tablet, 5 mg tab er 24, 0 mg tab er 24, 5 mg tab er 24) OXYTROL 3.9 MG/24HR TCH tolterodine tartrate ( mg tablet, 2 mg tablet, 2 mg cap er 24h, 4 mg cap er 24h) TOVIAZ (ER 4 MG TABLET, ER 8 MG TABLET) trospium chloride (20 mg tablet, 60 mg cap er 24h),,,, VESICARE (5 MG TABLET, 0 MG TABLET), Benign Prostatic Hypertrophy Agents AVODART 0.5 MG SOFTGEL doxazosin mesylate ( mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) dutasteride 0.5 mg capsule finasteride 5 mg tablet tamsulosin hcl 0.4 mg cap er 24h terazosin hcl ( mg capsule, 2 mg capsule, 5 mg capsule, 0 mg capsule) Genitourinary Agents, Other bethanechol chloride (5 mg tablet, 0 mg tablet, 25 mg tablet, 50 mg tablet) ELMIRON 00 MG CAPSULE THIOLA 00 MG TABLET Phosphate Binders FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 750 MG POWDER CKET,,000 MG POWDER CK,,000 MG TABLET CHEW) on this table mean by going to page. 63

64 RENAGEL (400 MG TABLET, 800 MG TABLET) RENVELA (0.8 GM POWDER CKET, 2.4 GM POWDER CKET, 800 MG TABLET) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) A-HYDROCORT 00 MG VIAL betamethasone dipropionate 0.05 % lotion betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), betamethasone/propylene 0.05 % oint. (g)) betamethasone valerate (0. % cream (g), 0. % lotion, 0. % oint. (g)) clobetasol propionate (0.05 % shampoo, 0.05 % cream (g), 0.05 % oint. (g), 0.05 % gel (gram)) clobetasol propionate/emoll 0.05 % cream (g) CLODAN 0.05% SHAMPOO clotrimazole/betamethasone dip %-0.05 % cream (g) DEPO-MEDROL 20 MG/ML VIAL desonide 0.05 % lotion dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, mg tablet,.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) fludrocortisone acetate 0. mg tablet fluocinolone acetonide (0.0 % cream (g), % oint. (g), % cream (g)) fluocinolone acetonide oil 0.0 % drops fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g)) fluocinonide/emollient base 0.05 % cream (g) fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g)) hydrocortisone ( % oint. (g), % cream (g), 2.5 % cream (g), 2.5 % oint. (g), 2.5 % cream/appl, 5 mg tablet, 0 mg tablet, 20 mg tablet) hydrocortisone butyrate (0. % oint. (g), 0. % solution) on this table mean by going to page. 64

65 hydrocortisone valerate 0.2 % cream (g) methylprednisolone (4 mg tablet, 4 mg tab ds pk, 8 mg tablet, 6 mg tablet, 32 mg tablet) methylprednisolone acetate (40 mg/ml vial, 80 mg/ml vial) methylprednisolone sodium succinate (25 mg vial, 000 mg vial) mometasone furoate (0. % cream (g), 0. % oint. (g), 0. % solution) prednisolone 5 mg/5 ml solution prednisolone sod phosphate (5 mg/5 ml, 5 mg/5 ml, 25 mg/5 ml) prednisone ( mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg tab ds pk, 0 mg tablet, 0 mg tab ds pk, 20 mg tablet) PROCTOSOL-HC 2.5% CREAM PROCTOZONE-HC 2.5% CREAM SOLU-CORTEF (250 MG VIAL, 500 MG VIAL,,000 MG VIAL) triamcinolone acetonide (0.025 % cream (g), % oint. (g), % lotion, 0. % oint. (g), 0. % cream (g), 0.5 % oint. (g), 0.5 % cream (g)) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0. mg tablet, 0. mg/ml solution, 0.2 mg tablet, 4 mcg/ml vial, 4 mcg/ml ampul, 0/spray spray/pump) GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK MG, MINIQUICK.2 MG, MINIQUICK.4 MG, MINIQUICK.6 MG, MINIQUICK.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 2 MG CARTRIDGE) HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 2 MG CARTRIDGE, 24 MG CARTRIDGE) INCRELEX 40 MG/4 ML VIAL NORDITROPIN FLEXPRO (5 MG/.5, 0 MG/.5, 5 MG/.5, 30 MG/3 ML) NORDITROPIN NORDIFLEX 30 MG/3 on this table mean by going to page. 65

66 NUTROPIN AQ (20 MG/2ML CART, CARTRIDGE) NUTROPIN AQ NUSPIN (5, 0, 20) OMNITROPE (5 MG/.5 ML CRTG, 5.8 MG VIAL, 0 MG/.5 ML CRTG) PREGNYL 0,000 UNITS VIAL SAIZEN (5 MG VIAL, 8.8 MG VIAL, 8.8 MG CLICK.EASY CARTG) SEROIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL) ZORBTIVE 8.8 MG VIAL Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM 300 MG TABLET Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 TABLET oxandrolone (2.5 mg tablet, 0 mg tablet) Androgens ANDRODERM (2 MG/24HR, 4 MG/24HR) ANDROGEL %(5G) GEL CKET danazol (50 mg capsule, 00 mg capsule, 200 mg capsule) TEIM % (50MG) GEL testosterone (.25 g(%) gel md pmp, 50 mg (%) gel (gram), 50 mg (%) gel packet) testosterone cypionate (00 mg/ml vial, 200 mg/ml vial) testosterone enanthate 200 mg/ml vial VOGELXO (2.5 MG/.25 PUMP, 50 MG/5 GEL, 50 MG/5 GEL CKT) Estrogens AMETHIA MG TAB AMETHY MCG TABLET APRI 28 DAY TABLET on this table mean by going to page. 66

67 ARANELLE 28 TABLET AUBRA-28 TABLET AVIANE-28 TABLET BALZIVA 28 TABLET BRIELLYN TABLET CRYSELLE-28 TABLET CYCLAFEM ( TABLET, TABLET) DELYLA-28 TABLET desog-e.estradiol/e.estradiol 2-5 tablet EMOQUETTE 28 DAY TABLET ENPRESSE-28 TABLET ERACE 0.0% CREAM estradiol (.025mg/24h,.0375mg/24, 0.05mg/24h, 0.06mg/24h,.075mg/24h, 0.mg/24hr) estradiol (0.5 mg tablet, mg tablet, 2 mg tablet) estradiol/norethindrone acet mg tablet ethinyl estradiol/drospirenone 0.03mg-3mg tablet FALMINA-28 TABLET GIANVI 3 MG-0.02 MG TABLET GILDAGIA 0.4 MG MG TAB GILDESS.5 MG-30 MCG TABLET INTROVALE MG TABLET JINTELI MG-5 MCG TABLET JUNEL ( MG-20 MCG TABLET,.5 MG-30 MCG TABLET) JUNEL FE ( MG-20 MCG TABLET,.5 MG-30 MCG TABLET) KARIVA 28 DAY TABLET KELNOR TABLET LARIN (.5 MG-30 MCG TABLET, 2-20 TABLET) LARIN FE (-20 TABLET,.5-30 TABLET) on this table mean by going to page. 67

68 LEENA 28 TABLET LESSINA-28 TABLET LEVONE-28 TABLET levonorgestrel-ethinyl estradiol ( tablet, tbdspk 3mo, tablet, 90-20mcg tablet) LEVORA-28 TABLET LORYNA 3 MG-0.02 MG TABLET LUTERA-28 TABLET MARLISSA-28 TABLET MICROGEIN ( TAB, 2-20 TABLET) MICROGEIN FE (-20 TABLET,.5-30 TAB) MONONESSA 28 TABLET NECON ( TABLET, TABLET, TABLET) NIKKI 3 MG-0.02 MG TABLET norethindrone ac-eth estradiol mg-5mcg tablet NORTREL ( TABLET, -35 TABLET, TABLET) OCELLA 3 MG-0.03 MG TABLET ORSYTHIA-28 TABLET PIMTREA 28 DAY TABLET PIRMELLA TABLET PORTIA-28 TABLET PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, MG TABLET, 0.9 MG TABLET,.25 MG TABLET) PREMARIN VAGINAL CREAM-APPL PREMPHASE MG TABLET PREMPRO (0.3 MG-.5 MG TABLET, MG TABLET, MG TABLET, MG TABLET) PREVIFEM TABLET QUASENSE MG TABLET RECLIPSEN 28 DAY TABLET on this table mean by going to page. 68

69 SPRINTEC 28 DAY TABLET SRONYX MG TABLET TARINA FE -20 TABLET TRI-LEGE FE-28 DAY TABLET TRI-PREVIFEM TABLET TRI-SPRINTEC TABLET TRINESSA TABLET TRIVORA-28 TABLET VELIVET 28 DAY TABLET VEURA 3 MG-0.02 MG TABLET VYFEMLA 28 TABLET WYMZYA FE CHEWABLE TABLET ZENCHENT 0.4 MG-35 MCG TABLET ZOVIA -35E TABLET ZOVIA -50E TABLET Progestins CAMILA 0.35 MG TABLET DEPO-PROVERA 400 MG/ML VIAL DEPO-SUBQ PROVERA 04 SYRINGE ERRIN 0.35 MG TABLET hydroxyprogesterone caproate 250 mg/ml vial JOLIVETTE TABLET LYZA 0.35 MG TABLET medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 0 mg tablet, 50 mg/ml vial, 50 mg/ml syringe) MEGACE ES 625 MG/5 ML SUSP megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/0ml oral susp) megestrol acetate 625mg/5ml oral susp NORA-BE TABLET norethindrone 0.35 mg tablet - FOR NEW ARTS ONLY on this table mean by going to page. 69

70 norethindrone acetate 5 mg tablet progesterone,micronized (00 mg capsule, 200 mg capsule) Selective Estrogen Receptor Modifying Agents raloxifene hcl 60 mg tablet Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 00 mcg tablet, 2 mcg tablet, 25 mcg tablet, 37 mcg tablet, 50 mcg tablet, 75mcg tablet, 200 mcg tablet, 300 mcg tablet) liothyronine sodium (5 mcg tablet, 0 mcg/ml vial, 25 mcg tablet, 50 mcg tablet) Hormonal Agents, Suppressant (Adrenal) LYSODREN 500 MG TABLET Hormonal Agents, Suppressant (Parathyroid) SENSIR (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) Hormonal Agents, Suppressant (Pituitary) cabergoline 0.5 mg tablet ELIGARD (7.5 MG B, 7.5 MG KIT, 22.5 MG B, 22.5 MG KIT, 30 MG B, 30 MG KIT, 45 MG B, 45 MG KIT) FIRMAGON (2 X 20 MG VIALS, 2 X 20 MG KIT, 80 MG VIAL, 80 MG KIT) leuprolide acetate ( mg/0.2ml kit, mg/0.2ml vial) LUPRON DEPOT (DEPOT 3.75 MG, DEPOT-4 MONTH, DEPOT 7.5 MG, DEPOT.25 MG 3MO, DEPOT 22.5 MG 3MO, DEPOT 45 MG 6MO) LUPRON DEPOT-PED (7.5 MG KIT,.25 MG 3MO,.25 MG KIT, 5 MG KIT, 30 MG 3MO KIT) on this table mean by going to page. 70

71 octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul, 00 mcg/ml ampul, 00 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml vial, 000mcg/ml vial) SANDOATIN LAR (0 MG, 20 MG, 30 MG) SANDOATIN LAR DEPOT (0 MG VL, 0 MG KT, 20 MG VL, 20 MG KT, 30 MG KT, 30 MG VL) SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT, 40 MG VIAL, 60 MG VIAL, 60 MG KIT) SOMATULINE DEPOT (90 MG/0.3 ML, 20 MG/0.5 ML) SOMAVERT (0 MG VIAL, 5 MG VIAL, 20 MG VIAL, 25 MG VIAL, 30 MG VIAL) SYNAREL 2 MG/ML NASAL SPRAY TRELAR (3.75 MG SYRINGE, 3.75 MG VIAL,.25 MG SYRINGE,.25 MG VIAL, 22.5 MG VIAL, 22.5 MG SYRINGE) Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tablet, 0 mg tablet) propylthiouracil 50 mg tablet Immunological Agents Angioedema (HAE) Agents CINRYZE 500 UNIT VIAL FIRAZYR 30 MG/3 ML SYRINGE Immune Suppressants AAGRAF XL (0.5 MG CAPSULE, MG CAPSULE, 5 MG CAPSULE) AZASAN (75 MG TABLET, 00 MG TABLET) azathioprine 50 mg tablet azathioprine sodium 00 mg vial BENLYA (20 MG VIAL, 400 MG VIAL) - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 7

72 CELLCEPT 500 MG VIAL - TO CONFIRM RT D COVERAGE cyclosporine (25 mg capsule, 00 mg capsule, 250 mg/5ml vial, 250 mg/5ml ampul) cyclosporine, modified (25 mg capsule, 00 mg/ml solution, 00 mg capsule) ENBREL (25 MG KIT, 50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR) ENVARSUS XR (0.75 MG TABLET, MG TABLET, 4 MG TABLET) GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 00 MG/ML SOLUTION, 00 MG CAPSULE) HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML) HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN CROHN-UC-HS ARTER KINERET 00 MG/0.67 ML SYRINGE methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) methotrexate sodium/pf (sodium/pf g vial, sodium/pf 25 mg/ml vial) mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) mycophenolate sodium (80 mg tablet dr, 360 mg tablet dr) NULOJIX 250 MG VIAL ORENCIA (25 MG/ML SYRINGE, 250 MG VIAL) ORENCIA CLICKJECT 25 MG/ML PROGRAF 5 MG/ML AMPULE RAMUNE MG/ML ORAL SOLN REMICADE 00 MG VIAL sirolimus (0.5 mg tablet, mg tablet, 2 mg tablet) tacrolimus (0.5 mg capsule, mg capsule, 5 mg capsule) TORISEL 25 MG KIT TREXALL (5 MG TABLET, 7.5 MG TABLET, 0 MG TABLET, 5 MG TABLET) - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 72

73 ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG TABLET) - TO CONFIRM RT D COVERAGE Immunizing Agents, Passive ATGAM 50 MG/ML AMPUL CARIMUNE NF NANOFILTERED (3 GM VIAL, 6 GM VIAL, 2 GM VIAL) GAMMAGARD LIQUID 0% VIAL GAMMAGARD S-D (2.5 GM VL W/, 5 G (IGA<) SOLN, 5 GM VL W/SET, 0 G (IGA<) SOL, 0 GM VL W/) GAMUNEX-C ( GRAM/0 ML VIAL, 2.5 GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 0 GRAM/00 ML VIAL, 20 GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL) HYPERRAB S-D 50 UNITS/ML VIAL THYMOGLOBULIN 25 MG VIAL - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE Immunomodulators ACTIMMUNE 00 MCG/0.5 ML VIAL ARCALY 220 MG INJECTION ILARIS 80 MG VIAL leflunomide (0 mg tablet, 20 mg tablet) SIMULECT (0 MG VIAL, 20 MG VIAL) SYNAGIS (50 MG/0.5 ML VIAL, 00 MG/ ML VIAL) XELJANZ 5 MG TABLET XELJANZ XR MG TABLET Vaccines ACTHIB (VIAL, WITH DILUENT) ADACEL TDAP VIAL bcg vaccine, live/pf 50 mg vial BEXSERO PREFILLED SYRINGE BOORIX TDAP (SYRINGE, VIAL) CERVARIX VACCINE SYRINGE DAPTACEL DTAP VACCINE on this table mean by going to page. 73

74 ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) ENGERIX-B PEDIATRIC-ADOLESCENT (0 MCG/0.5 ML PED VL, PEDI 0 MCG/0.5 SYRN) GARDASIL (SYRINGE, VIAL) GARDASIL 9 (9 VIAL, 9 SYRINGE) HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML SYRINGE,,440 UNITS/ML VIAL) HIBERIX (VIAL, WITH DILUENT) IMOVAX RABIES VACCINE (VACCINE VIAL, VACCINE+DILUENT) INFANRIX DTAP VIAL IPOL VIAL IXIARO 6 MCG/0.5 ML SYRINGE M-M-R II VACCINE (VIAL, WITH DILUENT) MENACTRA VIAL MENHIBRIX VACCINE VIAL MENOMUNE-A-C-Y-W-35 (VIAL, W-DILUENT) MENVEO A-C-Y-W-35-DIP VIAL KT PEDVAXHIB VACCINE VIAL PENTACEL ACTHIB COMPONENT VIAL PROQUAD VIAL QUADRACEL DTAP-IPV VIAL RABAVERT RABIES VACCINE VIAL RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 0 MCG/ML VIAL, 0 MCG/ML SYR, 40 MCG/ML VIAL) ROTARIX VACCINE SUSPENSION ROTATEQ VACCINE TENIVAC SYRINGE tetanus, diphtheria tox,adult 2-2 lf/0.5 vial tetanus,diphtheria toxd ped/pf 5-25/0.5ml vial TRUMENBA 20 MCG/0.5 ML VACCIN TWINRIX VACCINE VIAL - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 74

75 TYPHIM VI 25 MCG/0.5 ML VIAL VAQTA (25 UNITS/0.5 ML, 50 UNITS/ML) VARIVAX VACCINE (VIAL, WITH DILUENT) VARIZIG 25 UNIT/.2 ML VIAL YF-VAX ( VIAL, 5 VIAL) ZOAVAX VIAL Inflammatory Bowel Disease Agents Aminosalicylates APRISO ER GRAM CAPSULE ASACOL HD DR 800 MG TABLET balsalazide disodium 750 mg capsule CANASA,000 MG SUPPOSITORY DELZICOL DR 400 MG CAPSULE DIPENTUM 250 MG CAPSULE LIALDA DR.2 GM TABLET PENTASA (250 MG CAPSULE, 500 MG CAPSULE) Glucocorticoids budesonide 3 mg capdr - er cortisone acetate 25 mg tablet Sulfonamides sulfasalazine (500 mg tablet, 500 mg tablet dr) Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 0 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg tablet) calcitonin,salmon,synthetic 200/spray spray/pump calcitriol (0.25 mcg capsule, 0.5 mcg capsule, mcg/ml solution, mcg/ml ampul) doxercalciferol (0.5 mcg capsule, mcg capsule, 2.5 mcg capsule, 4mcg/2ml ampul, 4mcg/2ml vial) on this table mean by going to page. 75

76 etidronate disodium (200 mg tablet, 400 mg tablet) FORTEO 600 MCG/2.4 ML PEN INJ FORTICAL 200 UNITS NASAL SPRAY ibandronate sodium (3 mg/3 ml vial, 50 mg tablet) ibandronate sodium 3 mg/3 ml syringe MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL) PROLIA 60 MG/ML SYRINGE XGEVA 20 MG/.7 ML VIAL zoledronic acid (4 mg/5 ml vial, 4 mg vial) zoledronic acid in mannitol and water for injection (acid/mannitol-water 5 mg/00ml infus. btl, acid/mannitol-water 5 mg/00ml piggyback) Miscellaneous Therapeutic Agents FERRIPROX (00 MG/ML SOLUTION, 500 MG TABLET) fomepizole g/ml vial INTRALIPID 20% IV FAT EMUL NATRA (25 MCG, 50 MCG, 75 MCG, 00 MCG) NUTRILIPID 20% IV FAT EMULSION pen needle, diabetic (, 30gx 5/6",, 3 gx3/6",, 3 gx5/6") PHYSIOLYTE IRRIGATION SOLN PHYSIOSOL IRRIGATION SOLN ringers solution irrig soln ringers solution,lactated irrig soln sodium chloride irrig solution 0.9 % irrig soln syring-needl,disp,insul,0.3 ml 30gx 5/6" disp syrin syringe with needle, insulin, safety, 0.3 ml (ge,needle,insuln,sf,0.3ml 30gx 5/6" disp, ge,needle,insuln,sf,0.3ml 29 g x/2" disp) - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 76

77 syringe with needle, insulin, safety, 0.5 ml (29 g x/2" disp, 30gx 5/6" disp) syringe with needle, insulin, safety, ml (29 g x/2" disp, 30gx 5/6" disp) syringe with needle,disposable,insulin ml (ge disp, ge 28gx/2" disp, ge 29 g x/2" disp, ge 30gx 5/6" disp, ge 30gx/2" disp) syringe with needle,insulin,0.5 ml (ml 28 gauge disp, ml 29 g x/2" disp, ml 30gx 5/6" disp, ml 30gx/2" disp) water for irrigation,sterile irrig soln Ophthalmic Agents Ophthalmic Agents, Other atropine sulfate % drops LACRISERT 5 MG EYE INSERT REASIS 0.05% EYE EMULSION Ophthalmic Anti-allergy Agents azelastine hcl 0.05 % drops cromolyn sodium 4 % drops epinastine hcl 0.05 % drops olopatadine hcl 0. % drops TADAY 0.2% EYE DROPS TANOL 0.% EYE DROPS Ophthalmic Anti-inflammatories ALREX 0.2% EYE DROPS dexamethasone sod phosphate 0. % drops diclofenac sodium 0. % drops DUREZOL 0.05% EYE DROPS fluorometholone 0. % drops susp flurbiprofen sodium 0.03 % drops ketorolac tromethamine (0.4 % drops, 0.5 % drops) LOTEMAX (EYE DROPS, OPHTHALMIC GEL) QL (60 PER 30 DAYS) QL (0 ML PER 30 DAYS) QL (0 ML PER 30 DAYS) QL (0 ML PER 30 DAYS) on this table mean by going to page. 77

78 neomycin/polymyxin b sulfate/dexamethasone (neo/polymyx sulf/dexameth 0. % drops susp, neo/polymyx sulf/dexameth 3.5-0k-. oint. (g)) prednisolone acetate % drops susp prednisolone sod phosphate % drops TOBRADEX EYE OINTMENT tobramycin/dexamethasone 0.3 %-0.% drops susp VEXOL % EYE DROPS Ophthalmic Antiglaucoma Agents acetazolamide 500 mg capsule er ALPHAGAN P 0.% DROPS apraclonidine hcl 0.5 % drops AZOPT % EYE DROPS brimonidine tartrate (0.5 % drops, 0.2 % drops) dorzolamide hcl 2 % drops dorzolamide hcl/timolol maleat / drops levobunolol hcl 0.5 % drops methazolamide 25 mg tablet pilocarpine hcl ( % drops, 2 % drops, 4 % drops) SIMBRINZA %-0.2% EYE DROPS timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel, 0.5 % drops) Ophthalmic Prostaglandin and Prostamide Analogs latanoprost % drops LUMIGAN 0.0% EYE DROPS travoprost (benzalkonium) % drops QL (0 ML PER 30 DAYS) QL (0 ML PER 30 DAYS) QL (5 ML PER 30 DAYS) QL (5 ML PER 30 DAYS) QL (5 ML PER 30 DAYS) Otic Agents acetic acid 2 % solution neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin sulf/hc 3.5-0k- solution, neomycin/polymyxin sulf/hc 3.5-0k- drops susp) on this table mean by going to page. 78

79 Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS (00-50, , ) QL (60 PER 30 DAYS) ADVAIR HFA (45-2 MCG, 5-2 MCG, MCG) ASMANEX (TWIHALER 0 MCG #30, TWIHALER 220 MCG #60, TWIHALER 220 MCG #30, TWIHALR 220 MCG #20) ASMANEX HFA (00 MCG, 200 MCG) BREO ELLIPTA MCG INH budesonide (0.25mg/2ml, 0.5 mg/2ml, mg/2 ml) budesonide 32mcg spray/pump FLOVENT HFA (0 MCG, 220 MCG) FLOVENT HFA 44 MCG INHALER flunisolide 25 mcg spray fluticasone propionate 50 mcg spray susp mometasone furoate 50 mcg spray/pump PULMICORT MG/2 ML RESPULE PULMICORT FLEXHALER (90 MCG, 80 MCG) QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER SYMBICORT ( MCG, MCG) QL (2 GM PER 30 DAYS) - TO CONFIRM RT D COVERAGE QL (24 GM PER 30 DAYS) QL (2.2 GM PER 30 DAYS) - TO CONFIRM RT D COVERAGE QL (8.7 GM PER 30 DAYS) QL (7.4 GM PER 30 DAYS) Antihistamines azelastine hcl (37 mcg spray/pump, 205.5mcg spray/pump) diphenhydramine hcl 50 mg/ml vial levocetirizine dihydrochloride 5 mg tablet olopatadine hcl 0.6 % spray/pump Antileukotrienes montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 0 mg tablet) on this table mean by going to page. 79

80 zafirlukast (0 mg tablet, 20 mg tablet) ZYFLO 600 MG FILMTAB ZYFLO CR 600 MG TABLET Bronchodilators, Anticholinergic ATROVENT HFA INHALER COMBIVENT RESPIMAT INHAL SPRAY ipratropium bromide (2 mcg, 42 mcg) ipratropium bromide 0.2 mg/ml solution ipratropium/albuterol sulfate 0.5-3mg/3 ampulneb SPIRIVA 8 MCG CP-HANDIHALER SPIRIVA RESPIMAT.25 MCG INH SPIRIVA RESPIMAT 2.5 MCG INH TUDORZA PRESSAIR 400 MCG INH - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE Bronchodilators, Sympathomimetic ADRENACLICK (0.5 MG AUTO-INJCT, 0.3 MG AUTO-INJECT) albuterol sulfate (0.63mg/3ml vial-neb, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 5 mg/ml solution) epinephrine 0.3mg/0.3 auto injct EPIPEN 0.3 MG AUTO-INJECTOR EPIPEN 2-K 0.3 MG AUTO-INJCT EPIPEN JR 0.5 MG AUTO-INJCT EPIPEN JR 2-K 0.5 MG INJCTR metaproterenol sulfate (0 mg tablet, 0 mg/5 ml syrup, 20 mg tablet) PROAIR HFA 90 MCG INHALER SEREVENT DISKUS 50 MCG terbutaline sulfate ( mg/ml vial, 2.5 mg tablet, 5 mg tablet) VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG INH) QL (2 PER 60 DAYS) - TO CONFIRM RT D COVERAGE QL (2 PER 60 DAYS) QL (2 PER 60 DAYS) QL (2 PER 60 DAYS) QL (2 PER 60 DAYS) QL (60 PER 30 DAYS) on this table mean by going to page. 80

81 Cystic Fibrosis Agents CAYON 75 MG INHAL SOLUTION KALYDECO (50 MG GRANULES CKET, 75 MG GRANULES CKET, 50 MG TABLET), QL (62 PER 3 DAYS) ORKAMBI 200 MG-25 MG TABLET PULMOZYME MG/ML AMPUL tobramycin in 0.225% nacl 300 mg/5ml ampulneb, Mast Cell Stabilizers cromolyn sodium 20 mg/2 ml ampul-neb Phosphodiesterase Inhibitors, Airways Disease aminophylline (250mg/0ml vial, 250mg/0ml ampul, 500mg/20ml vial, 500mg/20ml ampul) DALIRESP 500 MCG TABLET THEO-24 (ER 00 MG CAPSULE, ER 200 MG CAPSULE, ER 300 MG CAPSULE, ER 400 MG CAPSULE) theophylline anhydrous (00 mg tab er 2h, 200 mg tab er 2h, 300 mg tab er 2h, 400 mg tab er 24h, 450 mg tab er 2h, 600 mg tab er 24h) Pulmonary Antihypertensives ADCIRCA 20 MG TABLET ADEMS (0.5 MG TABLET, MG TABLET,.5 MG TABLET, 2 MG TABLET, 2.5 MG TABLET) LETAIRIS (5 MG TABLET, 0 MG TABLET) OPSUMIT 0 MG TABLET REMODULIN ( MG/ML VIAL, 2.5 MG/ML VIAL, 5 MG/ML VIAL, 0 MG/ML VIAL) sildenafil citrate 20 mg tablet TRACLEER (62.5 MG TABLET, 25 MG TABLET) Respiratory Tract Agents, Other acetylcysteine (00 mg/ml vial, 200 mg/ml vial) ARALA NP (500 MG VIAL,,000 MG VIAL) ESBRIET 267 MG CAPSULE - TO CONFIRM RT D COVERAGE, QL (93 PER 3 DAYS), QL (3 PER 3 DAYS) - TO CONFIRM RT D COVERAGE,, LA - TO CONFIRM RT D COVERAGE on this table mean by going to page. 8

82 GLASSIA GM/50 ML VIAL OFEV (00 MG CAPSULE, 50 MG CAPSULE) PROLAIN C,000 MG VIAL TYZINE PEDIATRIC 0.05% DROP XOLAIR 50 MG VIAL ZEMAIRA,000 MG VIAL Skeletal Muscle Relaxants cyclobenzaprine hcl 0 mg tablet methocarbamol (500 mg tablet, 750 mg tablet) Sleep Disorder Agents GABA Receptor Modulators zaleplon (5 mg capsule, 0 mg capsule) zolpidem tartrate (5 mg tablet, 0 mg tablet) Sleep Disorders, Other modafinil (00 mg tablet, 200 mg tablet) ROZEREM 8 MG TABLET XYREM 500 MG/ML ORAL SOLUTION LA Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers ammonium chloride 5 meq/ml vial CARBAGLU 200 MG DISPER TABLET CUPRIMINE 250 MG CAPSULE DEPEN 250 MG TITRATAB EXJADE (25 MG TABLET, 250 MG TABLET, 500 MG TABLET) JADENU (90 MG TABLET, 80 MG TABLET, 360 MG TABLET) sodium lactate 5 meq/ml vial sodium polystyrene sulfonate (5 g/60 ml oral susp, 30 g/20ml enema, 50 g/200ml enema, powder) on this table mean by going to page. 82

83 SYPRINE 250 MG CAPSULE Electrolyte/Mineral Replacement 0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9 % syringe, 0.9 % pggybk prt, 0.9 % 0.9 % vial, 0.9 % pgy vl prt) AMINOSYN II (7%, 8.5%, 0%) AMINOSYN II 8.5%-ELECTROLYTES AMINOSYN M 3.5% IV SOLUTION AMINOSYN WITH ELECTROLYTES (7%- ELECTROLYTE, 8.5%-ELECTROLYTES) AMINOSYN-HBC 7% IV SOLUTION AMINOSYN-PF (7%, 0%) calcium acetate 667 mg capsule CLINIMIX (2.75%-5%, 4.25%-5%, 4.25%-25%, 4.25%-0%, 5%-25%) CLINIMIX E 4.25%-0% SOLUTION CLINIMIX E 5%-20% SOLUTION CLINISOL 5% SOLUTION dextrose 5%-lactated ringers 5 % iv soln FLUOR-A-DAY (0.25 MG TAB, 0.5 MG TAB, MG TABLET) FLUORITAB (0.5 MG TABLET, MG TABLET) FREAMINE HBC 6.9% IV SOLN HETAMINE 8% IV SOLUTION ISOLYTE P-DEXTROSE 5% SOLN ISOLYTE S IV SOLUTION-EXCEL KLOR-CON 0 MEQ TABLET KLOR-CON 8 MEQ TABLET KLOR-CON M0 TABLET KLOR-CON M5 TABLET KLOR-CON M20 TABLET LUDENT FLUORIDE (0.25 MG TB CHW, 0.5 MG TB CHEW, MG TAB CHEW) magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial) - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 83

84 NEPHRAMINE 5.4% IV SOLUTION NORMOSOL-M AND DEXTROSE 5% NORMOSOL-R PH 7.4 IV SOLUTION PLASMA-LYTE 48 IV SOLUTION PLASMA-LYTE 56-DEXTROSE 5% PLASMA-LYTE A PH 7.4 SOLN. potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 8 meq capsule er, 8 meq tablet er, 0 meq tablet er, 0 meq tab er prt, 0 meq capsule er, 20 meq tablet er, 20 meq tab er prt) potassium chloride (20meq/5ml, 40meq/5ml) potassium chloride in 0.9%nacl 20 meq/l iv soln potassium chloride in 5 % dextrose in water (20 meq/l soln, 40 meq/l soln) potassium chloride-0.45% nacl 20 meq/l iv soln potassium citrate (5 tablet er, 0 tablet er, 5 tablet er) PREMASOL (6%, 0%) PROCALAMINE IV SOLUTION PROSOL 20% INJECTION ringers solution iv soln ringers solution,lactated iv soln sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 % 0.45 % iv soln) sodium chloride 2.5 meq/ml vial sodium chloride 3 % 3 % iv soln sodium chloride 5 % 5 % iv soln sodium fluoride (0.25(0.55) tab chew, 0.5(.)mg tab chew, mg(2.2mg) tab chew, mg(2.2mg) tablet) TPN ELECTROLYTES VIAL TRAVASOL 0% SOLN VIAFLEX TROPHAMINE 0% IV SOLUTION - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE - TO CONFIRM RT D COVERAGE on this table mean by going to page. 84

85 Vitamins ACTIVE OB SOFTGEL ATABEX EC CAPLET BAL-CARE DHA COMBO CK BAL-CARE DHA ESSENTIAL CK BP FOLINATAL PLUS B TABLET C-NATE DHA SOFTGEL CADEAU DHA SOFTGEL CALCIUM-PNV MG SFTGL CITRANATAL 90 DHA COMBO CK CITRANATAL ASSURE COMBO CK CITRANATAL B-CALM COMBO CK CITRANATAL DHA CK CITRANATAL HARMONY CAPSULE CITRANATAL RX TABLET COMPLETE NATAL DHA COMPLETENATE TABLET CHEW CONCEPT DHA CAPSULE CONCEPT OB CAPSULE DOTHELLE DHA SOFTGEL DUET DHA 400 COMBO CK DUET DHA 430 MG COMBO CK DUET DHA BALANCED (25 MG IRON) DUET DHA EC (400 EC, 430 EC) ELITE OB DHA SOFTGEL ELITE-OB 400 CAPSULE ENBRACE HR SOFTGEL EXTRA-VIRT PLUS DHA SOFTGEL FOCALGIN 90 DHA COMBO CK FOCALGIN CA COMBO CK FOCALGIN-B TABLET on this table mean by going to page. 85

86 FOLBECAL TABLET FOLET DHA COMBO CK FOLET ONE SOFTGEL FOLIVANE-OB CAPSULE FOLIVANE-PRX DHA NF CAPSULE GEICARE DHA COMBO CK HEMENATAL OB + DHA COMBO CK HEMENATAL OB TABLET INATAL ADVANCE TABLET INATAL ULTRA TABLET INFANATE BALANCE SOFTGEL INFANATE PLUS SOFTGEL KOSHER PRENATAL PLUS IRON TAB M-VIT CAPLET MACNATAL CN DHA SOFTGEL MARNATAL-F CAPSULE MAXINATE TABLET MYNATAL (CAPSULE, ULTRACAPLET) MYNATAL ADVANCE TABLET MYNATAL PLUS CAPTAB MYNATAL-Z CAPTAB MYNATE 90 PLUS CAPLET SA NATACHEW TABLET NATALVIRT 90 DHA COMBO CK NATALVIRT CA COMBO CK NATALVIT TABLET NATELLE ONE CAPSULE NEEVODHA CAPSULE NEABS ABC PRENATAL COMBO PK NEABS DHA COMBO CK NEABS TABLET on this table mean by going to page. 86

87 NEWGEN TABLET NEXA PLUS SOFTGEL NIACOR 500 MG TABLET NIVA-PLUS TABLET O-CAL FA TABLET O-CAL PRENATAL TABLET OB COMPLETE CAPLET OB COMPLETE GOLD SOFTGEL OB COMPLETE ONE SOFTGEL OB COMPLETE PETITE SOFTGEL OB COMPLETE PREMIER TABLET OB COMPLETE WITH DHA SOFTGEL OBETRIX DHA COMBO K OBETRIX EC CAPLET OBETRIX ONE SOFTGEL OBTREX DHA PRENATAL VITAMIN OBTREX PRENATAL CAPLET IRE OB PLUS DHA COMBO CK PNV 29- TABLET pnv no.5/iron fumarate/fa 29 mg- mg tab chew PNV OB+DHA COMBO CK pnv w-o ca no5/iron fum/fa 06.5-mg capsule pnv with ca#74/iron/folic acid 27 mg- mg tablet pnv with ca,no.72/iron,carb/fa 29 mg- mg tablet pnv with ca,no.72/iron/fa 27 mg- mg tablet pnv#79/iron/fa/lmfolate ca/dha mg capsule PNV-DHA + DOCUSATE SOFTGEL PNV-DHA SOFTGEL PNV-OMEGA SOFTGEL on this table mean by going to page. 87

88 PNV-SELECT TABLET PNV-TOTAL SOFTGEL PNV-VP-U CAPSULE pnv5/iron fumarate/fa/dss mg tablet PR NATAL 400 COMBO CK PR NATAL 400 EC COMBO CK PR NATAL 430 COMBO CK PR NATAL 430 EC COMBO CK PREFERA OB TABLET PREFERA-OB ONE SOFTGEL PREFERA-OB PLUS DHA COMBO CK PREFOL-DHA CAPSULE PRENA CHEW TABLET PRENA PEARL SOFTGEL PRENA TRUE COMBO CK PRENAISSANCE 90 DHA COMBO CK PRENAISSANCE BALANCE SOFTGEL PRENAISSANCE CAPSULE PRENAISSANCE DHA COMBO CK PRENAISSANCE NEXT TABLET PRENAISSANCE NEXT-B TABLET PRENAISSANCE PLUS SOFTGEL PRENAISSANCE PROMISE COMBO PCK PRENAPLUS TABLET PRENATA CHEWABLE TABLET PRENATABS FA TABLET PRENATABS RX TABLET prenatal vit #60/iron fum/fa 27 mg- mg tablet prenatal vit 5/iron cb/fa/dss mg tablet PRENATE AM TABLET PRENATE CHEWABLE TABLET on this table mean by going to page. 88

89 PRENATE DHA SOFTGEL PRENATE ELITE TABLET PRENATE ENHANCE SOFTGEL PRENATE ESSENTIAL SOFTGEL PRENATE MINI SOFTGEL PRENATE PIXIE SOFTGEL PRENATE REORE SOFTGEL PRENATE AR TABLET PREPLUS CA-FE 27 MG-FA MG TB PREQUE 0 TABLET PRETAB 29 MG- MG TABLET PROVIDA DHA CAPSULE PROVIDA OB CAPSULE PUREFE OB PLUS CAPSULE PUREFE PLUS CAPSULE R-NATAL OB SOFTGEL RELNATE DHA PRENATAL SOFTGEL RULAVITE DHA SOFTGEL SE-NATAL 9 (9 CHEWABLE TABLET, 9 TABLET) SE-TAN DHA CAPSULE SELECT-OB + DHA CK SELECT-OB CHEWABLE CAPLET TARON-BC TABLET TARON-C DHA CAPSULE TARON-PREX PRENATAL DHA CAP THRIVITE 9 TABLET THRIVITE RX TABLET TL FOLATE TABLET TL-CARE DHA SOFTGEL TL-SELECT CAPSULE TRI-TABS DHA COMBO CK on this table mean by going to page. 89

90 TRIADVANCE TABLET TRICARE PRENATAL DHA ONE SFTGL TRICARE PRENATAL TABLET TRICARE PRENATAL WITH DHA CK TRINATAL GT TABLET TRINATAL RX TABLET TRINATE TABLET TRIART DHA SOFTGEL TRIVEEN-DUO DHA COMBO CK TRIVEEN-ONE CAPSULE TRIVEEN-PRX RNF CAPSULE TRU NATAL DHA ULTIMATECARE ONE CAPSULE ULTIMATECARE ONE NF CAPSULE VEMAVITE-PRX 2 CAPSULE VENA-BAL DHA COMBO CK VENATAL-FA TABLET VINACAL PRENATAL TABLET VINATE CARE CHEWABLE TABLET VINATE DHA GELCAP VINATE DHA RF GELCAP VINATE GT TABLET VINATE II TABLET VINATE ONE TABLET VINATE PN CARE TABLET VINATE ULTRA TABLET VINATE-M TABLET VIRT NATE TABLET VIRT-ADVANCE TABLET VIRT-BAL DHA COMBO CK VIRT-BAL DHA PLUS COMBO CK on this table mean by going to page. 90

91 VIRT-C DHA SOFTGEL VIRT-CARE ONE CAPSULE VIRT-NATE DHA SOFTGEL VIRT-NATE TABLET VIRT-PN DHA SOFTGEL VIRT-PN PLUS SOFTGEL VIRT-PN TABLET VIRT-SELECT CAPSULE VIRT-VITE GT TABLET VIRTPREX CAPSULE VITAFOL FE+ DOCUSATE COMBO PCK VITAFOL GUMMIES VITAFOL NANO TABLET VITAFOL ULTRA SOFTGEL VITAFOL-OB CAPLET VITAFOL-OB+DHA COMBO CK VITAFOL-ONE CAPSULE VITAMEDMD ONE RX SOFTGEL VITAMEDMD PLUS RX COMBO CK VITAMEDMD REDICHEW RX TAB CHEW VITAPEARL SOFTGEL VITATRUE COMBO CK VIVA DHA PRENATAL SOFTGEL VOL-NATE TABLET VOL-PLUS TABLET VOL-TAB RX TABLET VP CH ULTRA SOFTGEL VP-CH PLUS SOFTGEL VP-CH-PNV PRENATAL SOFTGEL VP-ERA OB PLUS TABLET VP-GGR-B6 TABLET on this table mean by going to page. 9

92 VP-HEME OB + DHA COMBO CK VP-HEME OB TABLET VP-HEME ONE SOFTGEL VP-PNV-DHA (CAPSULE, SOFTGEL) ZATEAN-CH CAPSULE ZATEAN-PN DHA CAPSULE ZATEAN-PN PLUS SOFTGEL ZATEAN-PN TABLET ZINGIBER TABLET Uncategorized Unclassified EZ FLU 6-7 (FLUZON QUAD PED) EZ FLU (AFLURIA) KIT EZ FLU (FLUVIRIN) KIT FLUARIX QUAD SYRINGE FLULAVAL QUAD ( SYR, VIAL) FLUMI QUAD NASAL VAC FLUZONE INTRADERM QUAD FLUZONE QUAD ( SYRINGE, VIAL) FLUZONE QUAD PEDI SYR on this table mean by going to page. 92

93 Index of Drugs % sodium chloride MOP A A-HYDROCORT abacavir sulfate abacavir sulfate/lamivudine/zidovudine ABELCET ABILIFY MAINTENA acamprosate calcium acarbose acebutolol hcl acetaminophen with codeine phosphate acetazolamide acetazolamide sodium acetic acid acetylcysteine acitretin ACTHIB ACTIMMUNE ACTIVE OB acyclovir acyclovir sodium ADACEL TDAP ADAGEN adapalene ADCIRCA adefovir dipivoxil ADEMS ADRENACLICK ADRUCIL ADVAIR DISKUS ADVAIR HFA AFEDITAB CR AFINITOR AFINITOR DISPERZ AGGRENOX , , ALBENZA albuterol sulfate ALDURAZYME ALECENSA alendronate sodium ALIMTA ALINIA allopurinol alosetron hcl ALPHAGAN P alprazolam ALREX amantadine hcl AMBISOME AMETHIA AMETHY amifostine crystalline amiloride hcl amiloride hcl/hydrochlorothiazide aminophylline AMINOSYN II AMINOSYN II WITH ELECTROLYTES AMINOSYN M AMINOSYN WITH ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF amiodarone hcl AMITIZA amitriptyline hcl amlodipine besylate ammonium chloride ammonium lactate amoxapine amoxicillin amoxicillin/potassium clavulanate amphotericin b ampicillin sodium ampicillin sodium/sulbactam sodium ampicillin trihydrate AMPYRA ANADROL

94 anagrelide hcl anastrozole ANDRODERM ANDROGEL ANZEMET APIDRA APIDRA SOLOAR APOKYN apraclonidine hcl APRI APRISO APTIOM APTIVUS ARALA NP ARANELLE ARANESP ARCALY aripiprazole ARIADA ARZERRA ASACOL HD ASMANEX ASMANEX HFA aspirin/dipyridamole AAGRAF XL ATABEX EC atenolol ATGAM atorvastatin calcium atovaquone atovaquone/proguanil hcl ATRIPLA atropine sulfate ATROVENT HFA AUBAGIO AUBRA AVANDIA AVAIN AVELOX IV AVIANE AVODART AVONEX 58 AVONEX PEN 58 azacitidine 3 AZASAN 7 azathioprine 7 azathioprine sodium 7 azelastine hcl 77,79 AZILECT 36 azithromycin 9 AZOPT 78 aztreonam 7 B BACIIM 5 bacitracin 5 bacitracin/polymyxin b sulfate 5 baclofen 39 BAL-CARE DHA 85 BAL-CARE DHA ESSENTIAL 85 balsalazide disodium 75 BALZIVA 67 BANZEL 23 BARACLUDE 42 bcg vaccine, live/pf 73 BELEODAQ 3 benazepril hcl 50 benazepril hcl/hydrochlorothiazide 50 BENLYA 7 benztropine mesylate 35 betamethasone dipropionate 64 betamethasone dipropionate/propylene glycol 64 betamethasone valerate BETASERON bethanechol chloride bexarotene BEXSERO bicalutamide BICILLIN L-A BILTRICIDE bisoprolol fumarate bisoprolol fumarate/hydrochlorothiazide

95 bleomycin sulfate BOORIX TDAP BOSULIF BREO ELLIPTA BRIELLYN BRILINTA brimonidine tartrate BRIVIACT bromocriptine mesylate budesonide bumetanide buprenorphine hcl buprenorphine hcl/naloxone hcl bupropion hcl buspirone hcl BYETTA C C-NATE DHA cabergoline CABOMETYX CADEAU DHA CAFERGOT calcipotriene calcitonin,salmon,synthetic calcitriol calcium acetate CALCIUM PNV CAMILA CANASA CANCIDAS candesartan cilexetil candesartan cilexetil/hydrochlorothiazide CAAT SULFATE CAPRELSA captopril captopril/hydrochlorothiazide CARAFATE CARBAGLU carbamazepine carbidopa/levodopa , , carbidopa/levodopa/entacapone CARDURA XL CARIMUNE NF NANOFILTERED CARTIA XT carvedilol CAYON cefaclor cefadroxil cefazolin sodium cefazolin sodium/dextrose, iso-osmotic cefdinir cefepime hcl cefixime cefotetan disodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftriaxone sodium cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT CELONTIN cephalexin CEREZYME CERVARIX CHANTIX chloramphenicol sod succ chlorhexidine gluconate chloroquine phosphate chlorpromazine hcl chlorthalidone cholestyramine (with sugar) cholestyramine/aspartame ciclopirox ciclopirox olamine cidofovir cilostazol CINRYZE CIPRO HC CIPRODEX

96 ciprofloxacin 20 ciprofloxacin hcl 20 ciprofloxacin lactate 20 ciprofloxacin/ciprofloxacin hcl 20 cisplatin 3 citalopram hydrobromide 24 CITRANATAL 90 DHA 85 CITRANATAL ASSURE 85 CITRANATAL B-CALM 85 CITRANATAL DHA 85 CITRANATAL HARMONY 85 CITRANATAL RX 85 CLARAVIS 59 COMPLETE NATAL DHA COMPLETENATE COMPRO CONCEPT DHA CONCEPT OB CONULOSE COXONE COREG CR cortisone acetate COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) COSENTYX SYRINGE COTELLIC clarithromycin 9 3 clindamycin hcl 5 CREON 60 clindamycin phosphate CLINIMIX CLINIMIX E 5,59 45,83 45,83 CRIXIVAN cromolyn sodium CRYSELLE 4 6,77,8 67 CLINISOL 83 CUBICIN 6 clobetasol propionate 64 CUPRIMINE 82 clobetasol propionate/emollient base 64 CYCLAFEM 67 CLODAN 64 cyclobenzaprine hcl 82 clomipramine hcl 25 cyclophosphamide 29 clonazepam 22 CYCLOSET 44 clonidine 49 cyclosporine 72 clonidine hcl 49 clopidogrel bisulfate 48 clorazepate dipotassium 43 clotrimazole 27 clotrimazole/betamethasone dipropionate clozapine COARTEM codeine sulfate colchicine colchicine/probenecid COLCRYS colestipol hcl colistin (as colistimethate sodium) COMBIVENT RESPIMAT COMETRIQ COMPLERA 40 cyclosporine, modified CYRAMZA CYADANE CYAGON D DAKLINZA 42 DALIRESP 8 danazol 66 dantrolene sodium 39 dapsone 29 DAPTACEL DTAP 73 DARAPRIM 35 darifenacin hydrobromide 63 DARZALEX 34 daunorubicin hcl 3 96

97 decitabine DELYLA DELZICOL demeclocycline hcl DEMSER DEPEN DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA 04 DESCOVY desipramine hcl desmopressin acetate DILT-CD DILT-XR diltiazem hcl DIPENTUM diphenhydramine hcl diphenoxylate hcl/atropine sulfate disopyramide phosphate disulfiram divalproex sodium DOCEFREZ docetaxel dofetilide , desogestrel-ethinyl estradiol/ethinyl estradiol 67 donepezil hcl 23 desonide 64 desvenlafaxine 24 dexamethasone 64 dexamethasone sod phosphate 4,77 dexmethylphenidate hcl 57 dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate dextroamphetamine sulfate dextrose 0 % and 0.2 % sodium chloride dextrose 0 % and 0.45 % sodium chloride dextrose 0 % in water dextrose 2.5 % and 0.45 % sodium chloride dextrose 5 % and 0.2 % sodium chloride dextrose 5 % and 0.3 % sodium chloride dextrose 5 % and 0.45 % sodium chloride dextrose 5 % and 0.9 % sodium chloride dextrose 5 % in lactated ringers dextrose 5 % in water dorzolamide hcl dorzolamide hcl/timolol maleate DOTHELLE DHA doxazosin mesylate doxepin hcl doxercalciferol doxorubicin hcl doxorubicin hcl pegylated liposomal DOXY 00 doxycycline hyclate doxycycline monohydrate dronabinol DROXIA DUET DHA DUET DHA , DUET DHA BALANCED DUET DHA EC 45 duloxetine hcl 24 diazepam 22,43 DURAMORPH 3 diclofenac sodium dicloxacillin sodium 4,59,77 8 DUREZOL dutasteride dicyclomine hcl 6 didanosine 40 E DIFICID DIGOX digoxin dihydroergotamine mesylate DILANTIN E.E.S. 200 E.E.S. 400 econazole nitrate EDURANT ELAPRASE

98 ELELYSO ELIGARD ELITE OB DHA ELITE-OB 400 ELMIRON EMCYT EMEND EMOQUETTE EMPLICITI EMSAM EMTRIVA enalapril maleate enalapril maleate/hydrochlorothiazide ENBRACE HR ENBREL ENDOCET ENGERIX-B ADULT ENGERIX-B PEDIATRIC-ADOLESCENT enoxaparin sodium ENPRESSE entacapone entecavir ENTREO ENULOSE ENVARSUS XR epinastine hcl epinephrine EPIPEN EPIPEN 2-K EPIPEN JR EPIPEN JR 2-K EPITOL EPIVIR HBV EPOGEN EPZICOM ERGOMAR ERIVEDGE ERRIN ERWINAZE ERY-TAB ERYPED ERYPED ERYTHROCIN LACTOBIONATE 9 ERYTHROCIN EARATE 9 erythromycin base 9 erythromycin base/benzoyl peroxide 59 erythromycin base/ethyl alcohol 9 erythromycin ethylsuccinate 9 ESBRIET 8 escitalopram oxalate 25 esomeprazole sodium 62 ERACE 67 estradiol 67 estradiol/norethindrone acetate 67 ethambutol hcl 29 ethinyl estradiol/drospirenone 67 ethosuximide 2 etidronate disodium 76 etodolac 2 etoposide 33 EURAX 35 EVOTAZ 4 exemestane 33 EXJADE 82 EXTRA-VIRT PLUS DHA 85 EZ FLU 6-7 (FLUZON QUAD PED) 92 EZ FLU (AFLURIA) 92 EZ FLU (FLUVIRIN) 92 F FABRAZYME 60 FALMINA 67 famciclovir 43 famotidine 6 famotidine in sodium chloride, iso-osmotic/pf 6 famotidine/pf FANAPT FAREON FARXIGA FARYDAK FAZACLO felbamate

99 fenofibrate 55 fenofibrate nanocrystallized 55 fenofibrate,micronized 55 fenofibric acid 55 fenofibric acid (choline) 55 fenoprofen calcium 55 fentanyl 2 fentanyl citrate 3 FERRIPROX 76 FETZIMA 25 FIBRICOR 55 finasteride 63 FIRAZYR 7 FIRMAGON 70 flecainide acetate 5 FLOVENT HFA 79 FLUARIX QUAD fluconazole 27 fluconazole in dextrose, iso-osmotic 27 flucytosine 27 fludrocortisone acetate 64 FLULAVAL QUAD FLUMI QUAD flunisolide 79 fluocinolone acetonide 59,64 fluocinolone acetonide oil 64 fluocinonide 64 fluocinonide/emollient base 64 FLUOR-A-DAY 83 FLUORITAB 83 fluorometholone 77 fluorouracil 59 fluoxetine hcl 25 fluphenazine decanoate 37 fluphenazine hcl 37 flurbiprofen sodium 77 flutamide 30 fluticasone propionate 64,79 fluvoxamine maleate 25 FLUZONE INTRADERM QUAD FLUZONE QUAD FLUZONE QUAD PEDI FOCALGIN 90 DHA FOCALGIN CA FOCALGIN-B FOLBECAL FOLET DHA FOLET ONE FOLINATAL PLUS B FOLIVANE-OB FOLIVANE-PRX DHA NF fomepizole fondaparinux sodium FORTEO FORTICAL fosphenytoin sodium FOSRENOL FRAGMIN FREAMINE HBC furosemide FUZEON FYCOM G gabapentin 22 GABITRIL 22 galantamine hbr 23 GAMMAGARD LIQUID 73 GAMMAGARD S-D 73 GAMUNEX-C 73 ganciclovir sodium 42 GARDASIL 74 GARDASIL 9 74 gatifloxacin 20 GATTEX 6 GAVILYTE-C 62 GAVILYTE-G 62 GAVILYTE-N 62 gemfibrozil 55 GENERLAC 62 GENGRAF 72 GENOTROPIN 65 99

100 GENTAK gentamicin sulfate 5 5 gentamicin sulfate in sodium chloride, isoosmotic 5 gentamicin sulfate/pf 5 GENVOYA 40 GEODON 38 GEICARE DHA 86 GIANVI 67 GILDAGIA 67 GILDESS 67 GILENYA 58 GILOTRIF 32 GLASSIA 82 GLATO 58 GLEEVEC 33 GLEOINE 29 glimepiride 44 glipizide 44 glipizide/metformin hcl 44 GLUCAGEN 46 GLUCAGON EMERGENCY KIT 46 glycopyrrolate 6 GLYSET 44 granisetron hcl 26 granisetron hcl/pf 26 griseofulvin, microsize 27 guanfacine hcl 57 guanidine hcl 29 H HALAVEN 32 haloperidol 37 haloperidol decanoate 37 haloperidol lactate 37 HARVONI 42 HAVRIX 74 HEMENATAL OB 86 HEMENATAL OB + DHA 86 heparin sodium,porcine 47 heparin sodium,porcine/dextrose 5 % in water 47 HETAMINE HERCEPTIN HETLIOZ HEXALEN HIBERIX HORIZANT HUMALOG HUMALOG KWIKPEN U-00 HUMALOG KWIKPEN U-200 HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN CROHN-UC-HS ARTER HUMULIN R U-500 hydralazine hcl hydrochlorothiazide hydrocodone bitartrate/acetaminophen hydrocodone/ibuprofen hydrocortisone hydrocortisone butyrate hydrocortisone valerate hydromorphone hcl hydromorphone hcl/pf hydroxychloroquine sulfate hydroxyprogesterone caproate hydroxyurea HYPERRAB S-D I ibandronate sodium IBRANCE ibuprofen ibuprofen/oxycodone hcl ICLUSIG ILARIS imatinib mesylate IMBRUVICA

101 imipenem/cilastatin sodium imipramine hcl imiquimod IMOVAX RABIES VACCINE INATAL ADVANCE INATAL ULTRA INCRELEX indapamide INFANATE BALANCE INFANATE PLUS INFANRIX DTAP INLYTA INTELENCE INTRALIPID INTRON A INTROVALE INVANZ INVEGA INVEGA SUENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA IONOSOL B WITH DEXTROSE 5% IONOSOL MB-DEXTROSE 5% IPOL ipratropium bromide ipratropium bromide/albuterol sulfate irbesartan irbesartan/hydrochlorothiazide IRESSA ISENTRESS ISOLYTE P WITH DEXTROSE ISOLYTE S isoniazid isosorbide dinitrate isosorbide mononitrate itraconazole ivermectin IXIARO J JADENU 82 JAKAFI 32 JANUMET 44 JANUVIA 45 JEVTANA 32 JINTELI 67 JOLIVETTE 69 JUNEL 67 JUNEL FE 67 JUXTAPID 55 K KADCYLA KALETRA KALYDECO KARIVA KELNOR -35 KETEK ketoconazole ketoprofen ketorolac tromethamine KEYTRUDA KINERET KLOR-CON 0 KLOR-CON 8 KLOR-CON M0 KLOR-CON M5 KLOR-CON M20 KORLYM KOSHER PRENATAL PLUS IRON KUVAN KYNAMRO L labetalol hcl LACRISERT lactulose lamivudine lamivudine/zidovudine

102 lamotrigine lansoprazole LANTUS LANTUS SOLOAR LARIN LARIN FE latanoprost LATUDA LEENA leflunomide LENVIMA LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH levetiracetam levobunolol hcl levocetirizine dihydrochloride levofloxacin levofloxacin/dextrose 5 % in water levoleucovorin calcium LEVONE levonorgestrel-ethinyl estradiol LEVORA-28 levothyroxine sodium LEXIVA LIALDA lidocaine lidocaine hcl lidocaine hcl/pf lidocaine/prilocaine lindane linezolid linezolid in 0.9 % sodium chloride liothyronine sodium 22, lisinopril 50 lisinopril/hydrochlorothiazide 5 lithium carbonate 44 lithium citrate 44 LONSURF 30 loperamide hcl 6 lorazepam 43 LORAZEM INTENSOL 43 LORYNA 68 losartan potassium 49 losartan potassium/hydrochlorothiazide 49 LOTEMAX 77 lovastatin 55 loxapine succinate 37 LUDENT FLUORIDE 83 LUMIGAN 78 LUMIZYME 60 LUPRON DEPOT 70 LUPRON DEPOT-PED 70 LUTERA 68 LYNRZA 32 LYRICA 2,58 LYSODREN 70 LYZA 69 M M-M-R II VACCINE 74 M-VIT 86 MACNATAL CN DHA 86 magnesium sulfate 83 maprotiline hcl 24 MARLISSA 68 MARNATAL-F 86 MARPLAN 24 MATULANE 30 MATZIM LA 53 MAXINATE 86 meclizine hcl 26 medroxyprogesterone acetate 69 mefloquine hcl 35 MEGACE ES 69 02

103 megestrol acetate MEKINI memantine hcl MENACTRA MENE MENHIBRIX MENOMUNE-A-C-Y-W-35 MENVEO A-C-Y-W-35-DIP mercaptopurine meropenem mesna MESNEX METADATE ER metaproterenol sulfate metformin hcl methadone hcl methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium/pf methyldopa methyldopate hcl methylphenidate hcl methylprednisolone methylprednisolone acetate methylprednisolone sodium succinate metoclopramide hcl metolazone metoprolol succinate metoprolol tartrate metoprolol tartrate/hydrochlorothiazide metronidazole metronidazole in sodium chloride mexiletine hcl MIACALCIN miconazole nitrate MICROGEIN MICROGEIN FE midodrine hcl , , miglitol minocycline hcl minoxidil mirtazapine misoprostol MITIGARE mitoxantrone hcl modafinil MODERIBA molindone hcl mometasone furoate MONONESSA montelukast sodium MONUROL morphine sulfate MOVANTIK MOXEZA MULTAQ mupirocin MYCAMINE mycophenolate mofetil mycophenolate sodium MYNATAL MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS MYORISAN MYRBETRIQ N nabumetone nadolol/bendroflumethiazide nafcillin in dextrose, iso-osmotic nafcillin sodium NAGLAZYME naloxone hcl naltrexone hcl NAMENDA naproxen naproxen sodium , ,

104 naratriptan hcl NATACHEW NATALVIRT 90 DHA NATALVIRT CA NATALVIT nateglinide NATELLE ONE NATRA NEBUPENT NECON NEEVODHA nefazodone hcl neomycin sulfate neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin/polymyxin b neomycin sulfate/polymyxin b sulfate neomycin sulfate/polymyxin b sulfate/gramicidin d 6 neomycin sulfate/polymyxin b sulfate/hydrocortisone 78 neomycin/polymyxin b sulfate/dexamethasone 78 NEPHRAMINE NEABS NEABS ABC NEABS DHA NEUPOGEN NEUPRO nevirapine NEWGEN NEXA PLUS NEXAVAR niacin NIACOR NICOTROL NICOTROL NS NIFEDICAL XL nifedipine NIKKI NILANDRON nilutamide nimodipine NINLARO nitrofurantoin macrocrystal nitrofurantoin monohydrate/macrocrystals nitroglycerin NITROAT NIVA-PLUS NORA-BE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX norethindrone norethindrone acetate norethindrone acetate-ethinyl estradiol NORMOSOL-M AND DEXTROSE NORMOSOL-R AND DEXTROSE NORMOSOL-R PH 7.4 NORTHERA NORTREL nortriptyline hcl NORVIR NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOXAFIL NUEDEXTA NULOJIX NUPLAZID NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NYAMYC nystatin nystatin/triamcinolone acetonide NYOP O O-CAL FA O-CAL PRENATAL OB COMPLETE OB COMPLETE GOLD ,

105 OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE WITH DHA OBETRIX DHA OBETRIX EC OBETRIX ONE OBTREX OBTREX DHA OCELLA octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin olanzapine olopatadine hcl OLYSIO omega-3 acid ethyl esters omeprazole OMNITROPE ONCASR ondansetron ondansetron hcl ondansetron hcl/pf ONFI OPDIVO OPSUMIT ORAP ORENCIA ORENCIA CLICKJECT ORKAMBI ORSYTHIA oxacillin sodium oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine OXTELLAR XR oxybutynin chloride , , oxycodone hcl oxycodone hcl/acetaminophen OXYTROL P paclitaxel IRE OB PLUS DHA paliperidone NCREAZE NRETIN pantoprazole sodium paromomycin sulfate paroxetine hcl SER TADAY TANOL XIL PEDVAXHIB peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl PEGANONE PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN pen needle, diabetic penicillin g potassium penicillin v potassium PENTACEL ACTHIB COMPONENT PENTAM 300 PENTASA pentoxifylline PERIOGARD PERJETA permethrin perphenazine phenelzine sulfate phenobarbital phenytoin phenytoin sodium phenytoin sodium extended 2,

106 PHYSIOLYTE 76 PHYSIOSOL 76 pilocarpine hcl 59,78 pimozide 37 PIMTREA 68 pindolol 52 pioglitazone hcl 45 pioglitazone hcl/metformin hcl 45 piperacillin sodium/tazobactam sodium 9 PIRMELLA 68 PLASMA-LYTE PLASMA-LYTE 56 IN DEXTROSE 84 PLASMA-LYTE A PH PNV PNV OB+DHA 87 PNV-DHA 87 PNV-DHA + DOCUSATE 87 PNV-OMEGA 87 PNV-SELECT 88 PNV-TOTAL 88 PNV-VP-U 88 podofilox 59 polyethylene glycol polymyxin b sulfate 6 polymyxin b sulfate/trimethoprim 6 POMALY 32 PORTIA 68 potassium chloride 84 potassium chloride in 0.45 % sodium chloride 84 potassium chloride in 0.9 % sodium chloride 84 potassium chloride in 5 % dextrose in water 84 potassium chloride in dextrose 5 % and 0.9 % sodium chloride 46 potassium chloride in dextrose 5 %-0.2% sodium chloride 46 potassium chloride in dextrose 5 %-0.45% sodium chloride 46 potassium chloride in dextrose 5% and 0.3 % sodium chloride 46 potassium chloride in lactated ringers and 5 % dextrose 46 potassium citrate POTIGA PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PR NATAL 430 EC PRADAXA pramipexole di-hcl pravastatin sodium prazosin hcl prednisolone prednisolone acetate prednisolone sod phosphate prednisone PREFERA OB PREFERA-OB ONE PREFERA-OB PLUS DHA PREFOL-DHA PREGNYL PREMARIN PREMASOL PREMPHASE PREMPRO PRENA CHEW PRENA PEARL PRENA TRUE PRENAISSANCE PRENAISSANCE 90 DHA PRENAISSANCE BALANCE PRENAISSANCE DHA PRENAISSANCE NEXT PRENAISSANCE NEXT-B PRENAISSANCE PLUS PRENAISSANCE PROMISE PRENAPLUS PRENATA PRENATABS FA PRENATABS RX prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha ,

107 prenatal vitamin no.5/iron,carbonyl/folic acid/docusate sod 88 prenatal vitamins comb no.5/iron fumarate/folic acid 87 prenatal vitamins comb no.5/iron fumarate/folic acid/dss 88 prenatal vitamins combo no.60/ferrous fumarate/folic acid 88 prenatal vits with calcium #72/ferrous fumarate/folic acid 87 prenatal vits with calcium #72/iron,carbonyl/folic acid 87 prenatal vits with calcium #74/ferrous fumarate/folic acid prenatal vits without calc no5/ferrous fumarate/folic acid PRENATE AM PRENATE CHEWABLE PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE REORE PRENATE AR PREPLUS PREQUE 0 PRETAB PREVALITE PREVIFEM PREZCOBIX PREZIA primaquine phosphate primidone PROAIR HFA probenecid PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT 48 PROCTOSOL-HC 65 PROCTOZONE-HC 65 progesterone,micronized 70 PROGLYCEM 46 PROGRAF 72 PROLAIN C 82 PROLEUKIN 32 PROLIA 76 PROMACTA 48 promethazine hcl 26 PROMETHEGAN 26 propafenone hcl 5 propranolol hcl 52 propranolol hcl/hydrochlorothiazide 52 propylthiouracil 7 PROQUAD 74 PROSOL 84 PROTONIX IV 63 protriptyline hcl 26 PROVIDA DHA 89 PROVIDA OB 89 PULMICORT 79 PULMICORT FLEXHALER 79 PULMOZYME 8 PUREFE OB PLUS 89 PUREFE PLUS 89 PURIXAN 3 pyrazinamide 29 pyridostigmine bromide 29 Q QUADRACEL DTAP-IPV QUASENSE QUDEXY XR quetiapine fumarate quinapril hcl quinapril hcl/hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate

108 QVAR 79 RITUXAN 34 R rivastigmine tartrate 23 rizatriptan benzoate 28 R-NATAL OB RABAVERT raloxifene hcl ramipril RANEXA ropinirole hcl ROTARIX ROTATEQ ROWEEPRA ROZEREM ranitidine hcl 62 RULAVITE DHA 89 RAMUNE 72 REBIF 58 S RECLIPSEN 68 SABRIL 22 RECOMBIVAX HB REGRANEX RELENZA RELIOR RELNATE DHA REMICADE REMODULIN RENAGEL RENVELA repaglinide repaglinide/metformin hcl RETHA PUSHTRONEX RETHA SURECLICK RETHA SYRINGE RESCRIPTOR REASIS RETROVIR REVLIMID REXULTI REYATAZ RIBASPHERE rifabutin rifampin riluzole rimantadine hcl ringers solution ringers solution,lactated RISPERDAL CONA risperidone ,84 76,84 38,44 39 SAIZEN SANDOATIN LAR SANDOATIN LAR DEPOT SANTYL SAPHRIS SAVELLA SE-NATAL 9 SE-TAN DHA SELECT-OB SELECT-OB + DHA selegiline hcl selenium sulfide SELZENTRY SENSIR SEREVENT DISKUS SEROQUEL XR SEROIM sertraline hcl SIGNIFOR SIGNIFOR LAR sildenafil citrate silver sulfadiazine SIMBRINZA SIMULECT simvastatin sirolimus SIRTURO sodium chloride sodium chloride 0.45 %

109 sodium chloride 3 % sodium chloride 5 % sodium chloride irrigating solution sodium fluoride sodium lactate sodium phenylbutyrate sodium polystyrene sulfonate SOLTAMOX SOLU-CORTEF SOMATULINE DEPOT SOMAVERT sotalol hcl SOVALDI SPIRIVA SPIRIVA RESPIMAT spironolactone spironolactone/hydrochlorothiazide SPORANOX SPRINTEC SPRITAM SPRYCEL SRONYX SSD stavudine IVARGA RATTERA RENSIQ streptomycin sulfate RIBILD SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium/prednisolone sodium phosphate sulfadiazine sulfamethoxazole/trimethoprim sulfasalazine sulindac sumatriptan succinate SUPRAX , SUIVA SUTENT SYLATRON SYLATRON 4-CK SYMBICORT SYMLINPEN 20 SYMLINPEN 60 SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE syringe with needle, insulin, safety, 0.3 ml syringe with needle, insulin, safety, 0.5 ml syringe with needle, insulin, safety, ml syringe with needle,disposable,insulin ml syringe with needle,insulin,0.3 ml syringe with needle,insulin,0.5 ml T TABLOID tacrolimus TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN TARINA FE TARON-BC TARON-C DHA TARON-PREX PRENATAL TASIGNA TAXOTERE TAZORAC TAZTIA XT TECENTRIQ TECFIDERA TEFLARO , ,29 7 SURMONTIL 26 TEKTURNA 54 09

110 telmisartan telmisartan/hydrochlorothiazide temazepam TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole TEIM testosterone testosterone cypionate testosterone enanthate tetanus and diphtheria toxoids, adult tetanus,diphtheria toxoid ped/pf tetrabenazine THALOMID THEO-24 theophylline anhydrous THIOLA thioridazine hcl thiotepa thiothixene THRIVITE 9 THRIVITE RX THYMOGLOBULIN tiagabine hcl TIKOSYN timolol maleate tinidazole TIVICAY tizanidine hcl TL FOLATE TL-CARE DHA TL-SELECT TOBRADEX tobramycin tobramycin in % sodium chloride tobramycin sulfate tobramycin/dexamethasone TOLAK tolterodine tartrate topiramate topotecan hcl TORISEL torsemide TOUJEO SOLOAR TOVIAZ TPN ELECTROLYTES TRACLEER tramadol hcl tramadol hcl/acetaminophen tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVASOL travoprost (benzalkonium) trazodone hcl TRECATOR TRELAR tretinoin TREXALL TRI-LEGE FE TRI-PREVIFEM TRI-SPRINTEC TRI-TABS DHA TRIADVANCE triamcinolone acetonide triamterene/hydrochlorothiazide triazolam TRICARE TRICARE PRENATAL DHA ONE TRICARE PRENATAL WITH DHA trifluoperazine hcl trifluridine trihexyphenidyl hcl TRILYTE WITH FLAVOR CKETS trimethoprim trimipramine maleate TRINATAL GT TRINATAL RX TRINATE 63 22, , , , tolcapone 90 0

111 TRINESSA TRINTELLIX TRISENOX TRIART DHA TRIUMEQ TRIVEEN-DUO DHA TRIVEEN-ONE TRIVEEN-PRX RNF TRIVORA-28 TROKENDI XR TROPHAMINE trospium chloride TRUMENBA TRU NATAL DHA TRUVADA TUDORZA PRESSAIR TWINRIX TYBO TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA TYZINE U ULTIMATECARE ONE ULTIMATECARE ONE NF ursodiol UVADEX V valacyclovir hcl VALCHLOR valganciclovir hcl valproic acid valproic acid (as sodium salt) (valproate sodium) valsartan valsartan/hydrochlorothiazide vancomycin hcl VANDAZOLE VAQTA VARIVAX VACCINE VARIZIG VELCADE VELIVET VEMAVITE-PRX 2 VENA-BAL DHA VENATAL-FA VENCLEXTA VENCLEXTA ARTING CK venlafaxine hcl VENTOLIN HFA verapamil hcl VERSACLOZ VESICARE VEURA VEXOL VICTOZA 2-K VICTOZA 3-K VIDEX VIEKIRA K VIGAMOX VIIBRYD VIMT VINACAL VINATE CARE VINATE DHA VINATE DHA RF VINATE GT VINATE II VINATE ONE VINATE PN CARE VINATE ULTRA VINATE-M VIRACEPT VIRAMUNE XR VIREAD VIRT NATE VIRT-ADVANCE VIRT-BAL DHA ,

112 VIRT-BAL DHA PLUS VIRT-C DHA VIRT-CARE ONE VIRT-NATE VIRT-NATE DHA VIRT-PN VIRT-PN DHA VIRT-PN PLUS VIRT-SELECT VIRT-VITE GT VIRTPREX VITAFOL FE+ VITAFOL GUMMIES VITAFOL NANO VITAFOL ULTRA VITAFOL-OB VITAFOL-OB+DHA VITAFOL-ONE VITAMEDMD ONE RX VITAMEDMD PLUS RX VITAMEDMD REDICHEW RX VITAPEARL VITATRUE VITEKTA VIVA DHA VOGELXO VOL-NATE VOL-PLUS VOL-TAB RX voriconazole VOTRIENT VP CH ULTRA VP-CH PLUS VP-CH-PNV VP-ERA OB PLUS VP-GGR-B6 VP-HEME OB VP-HEME OB + DHA VP-HEME ONE VP-PNV-DHA VPRIV VRAYLAR VYFEMLA VYTORIN W warfarin sodium water for irrigation,sterile WELCHOL WYMZYA FE X XALKORI XARELTO XELJANZ XELJANZ XR XENAZINE XGEVA XIFAXAN XOLAIR XTANDI XYREM Y YERVOY 34 YF-VAX 75 Z zafirlukast zaleplon ZALTRAP ZATEAN-CH ZATEAN-PN ZATEAN-PN DHA ZATEAN-PN PLUS ZAVESCA ZELBORAF ZEMAIRA ZENATANE ZENCHENT ZENPEP ZETIER

113 ZETIA ZIAGEN zidovudine ZINGIBER ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid in mannitol and water for injection ZOLINZA zolmitriptan zolpidem tartrate ZOMIG zonisamide ZORBTIVE ZORTRESS ZOAVAX ZOSYN ZOVIA -35E ZOVIA -50E ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX

114 List of drugs by medical condition Analgesics 2 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Anti-inflammatory Agents Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/Modifiers/Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental and Oral Agents Dermatological Agents Enzyme Replacement/Modifiers Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal)

115 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Otic Agents Respiratory Tract/Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents Therapeutic Nutrients/Minerals/Electrolytes Uncategorized

116 We have made no changes to this formulary since 09/27/206. For more recent information or other questions, please contact CARE WISCONSIN at , or, for TTY users, 7, 8 a.m. - 8 p.m. The call is free. Or visit

117

118 This formulary was updated on 9/27/206. For more recent information or other questions, please contact us at or, for TTY users, Wisconsin Relay System 7, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit Care Wisconsin Health Plan P.O. Box 407 Madison, Wisconsin TTY/TDD Wisconsin Relay System 7