H8490_CY2017_LOCD_16702_KO AF Multi-Language Insert Multi-language Interpreter Services ATTENTION: Language assistance services, free of char

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1 201 적용의약품목록 ( 처방집 ) (Medicare-Medicaid Plan) 처방집 ID: , 버전 : 7 발효일 : 아래 CHOICE 무료전화로문의하시기바랍니다. 오전 8 시 - 오후 8 시, 1 주 7 일

2 H8490_CY2017_LOCD_16702_KO AF Multi-Language Insert Multi-language Interpreter Services ATTENTION: Language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 711) লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں (TTY: 711).

3 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください

4 2017 년도적용의약품목록 ( 처방서 ) 참여자가 를통해이용할수있는의약품목록입니다. 는 Medicare 및뉴욕주보건부 (Medicaid) 양측과모두계약을맺고완전통합이중혜택 (Fully Integrated Duals Advantage, FIDA) 시범계획을통해양프로그램의혜택을모두참여자에게제공하는관리의료계획입니다. 등록은계약갱신에따라결정됩니다. 적용의약품및 / 또는약국및제공자네트워크목록은연중변경될수있습니다. 가입자에게해당하는변경사항이있는경우변경전에통지서를보내드립니다. 혜택은매년 1 월 1 일변경될수있습니다. 의최신적용의약품목록은 vnsnychoice.org 를통해온라인으로, 또는 참여자서비스 (Participant Services) 에, 번으로전화해확인하실수있습니다. 제한및규제가적용될수있습니다. 자세한정보는 VNSNY CHOICE FIDA Complete 참여자서비스 (Participant Services) 로전화하시거나 VNSNY CHOICE FIDA Complete 참여자안내서를참고해주십시오. 적용의약품에대해서는코페이가전혀없습니다. 본정보는큰활자, 점자, 오디오등다른형식으로도무료로이용하실수있습니다. 연중무휴오전 8 시부터오후 8 시까지 (TTY: 711) 번으로전화해주십시오. 통화료는무료입니다. 본정보를다른언어로도이용하실수있습니다. 요일에상관없이오전 8 시부터오후 8 시까지 번 (TTY 는 711 번 ) 으로전화해주십시오. 이통화는무료입니다. Puede obtener esta información gratis en otros idiomas. Llame al y (TTY es 711) de 8 a.m. a 8 p.m., 7 días a la semana. La llamada es gratis. 您可以免費取得此資訊的其他語言版本 請在早上 8 時至晚上 8 時致電 (TTY 是 711) 此專線一星期七天均提供服務 此為免付費電話? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. I

5 다른언어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 번 (TTY 사용자는 711 번 ) 으로문의해주십시오. 이통화는무료입니다. Вы можете получить эту информацию бесплатно и на других языках. Звоните по телефону (телетайп: 711) ежедневно с 8:00 до 20:00. Звонок бесплатный. È possibile ottenere gratuitamente queste informazioni in altre lingue. Chiamare il numero (il numero TTY è 711) dalle 8:00 alle 20:00, 7 giorni alla settimana. La chiamata è gratuita. Ou kapab jwenn enfòmasyon sa a pou gratis nan lòt lang. Rele ak (TTY se 711) ant 8 di maten jiska 8 di swa, 7 jou pa semèn. Apèl la gratis. 본정보는큰활자, 점자, 오디오등다른형식으로도무료로이용하실수있습니다. 연중무휴오전 8 시부터오후 8 시까지 (TTY: 711) 번으로전화해주십시오. 통화료는무료입니다. 언제든영어나다른언어또는형식으로된가입자자료사본을요청하셔야할경우가입자서비스에연중무휴오전 8 시부터오후 8 시까지 (TTY: 711) 번으로전화해주십시오. 뉴욕주는 가제공하는모든서비스에대하여무료기밀지원을제공하기위해 독립소비자옹호네트워크 (Independent Consumer Advocacy Network, ICAN) 라는가입자옴부즈맨프로그램을만들었습니다. 가입자옴부즈맨 (ICAN) 의전화번호는 ( 통화료무료 ) 이며온라인사이트는 icannys.org 입니다. (TTY 사용자는 711 번으로전화한다음안내에따라 번으로연락해주시기바랍니다.)? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. II

6 자주묻는질문 (FAQ) 적용의약품목록에서궁금한점에대한해답을여기에서찾을수있습니다. 전체 FAQ 를읽어자세한정보를확인하시거나, 궁금한내용에대한답변을찾아보실수있습니다. 1. 적용의약품목록에는어떤처방약이있나요? ( 적용의약품목록을줄여서 " 의약품목록 이라고부릅니다.) 14 페이지에서시작되는적용의약품목록에있는의약품들은 VNSNY CHOICE FIDA Complete 에의해보장되는의약품들입니다. 이의약품들은저희네트워크에속한약국에서구하실수있습니다. 저희와협력하여여러분께서비스를제공하기로저희와합의한약국이저희네트워크에속한약국입니다. 이러한약국들을일컬어 네트워크약국 이라고합니다. 는다음의경우의약품목록에있는모든의약품을보장합니다. 귀하의담당의또는기타네트워크처방의의의견에따라귀하가나아지거나건강을계속유지하려면그러한의약품이필요한경우, 해당의약품이귀하의상태에의학적으로필요한경우, 및 귀하가 네트워크약국에서처방전에따라조제하는경우. 에서는특정의약품을이용하기위해추가단계가필요할수있습니다 ( 아래 5 번질문참조 ). 경우에따라서는, 어떤의약품을복용하기전에다른의약품을먼저시도하는등의추가조치를취해야할수도있습니다. 저희가보장해드리는최신의약품목록은웹사이트 vnsnychoice.org 에서확인하시거나참여자서비스 (Participant Services), 번에서도확인하실수있습니다. 2. 의약품목록이바뀌기도하나요? 그렇습니다. 에서는일년내내의약품목록을추가또는삭제할수있습니다. 일반적으로, 의약품목록은다음의경우에만변경됩니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. III

7 현재의약품목록에있는의약품만큼효과가있는새의약품이나온경우, 또는 어떤의약품이안전하지않다는사실을알게된경우. 의약품에관한규칙을변경할수도있습니다. 예를들면다음과같습니다. 어떤의약품에대한사전승인을요구할수도, 요구하지않을수도있습니다. ( 사전승인이란귀하가어떤의약품을받아도된다는 VNSNY CHOICE FIDA Complete 또는귀하의 Interdisciplinary Team (IDT) 로부터의사전허가입니다.) 귀하가이용할수있는의약품의양을추가또는변경할수있습니다 ( 일명 " 수량제한 "). 어떤의약품에대한단계별치료제한요건을추가또는변경할수있습니다. ( 단계별치료는저희가어떤의약품을보장해드리기전에귀하가다른의약품을먼저시도해야한다는의미입니다.) ( 이러한의약품규칙에대한자세한정보는 5 페이지를참조하십시오.) 귀하가복용하고있는의약품이의약품목록에서삭제되면이를통지해드립니다. 의약품적용과관련한규칙이변경되는경우에도통지해드립니다. 의약품목록이변경되는경우에대한자세한내용은아래 3 번, 4 번및 7 번질문에서확인하실수있습니다. 의최신의약품목록은온라인 vnsnychoice.org 에서언제든확인하실수있습니다. 또한참여자서비스 (Participant Services), 번으로전화하여최신의약품목록을확인하실수있습니다. 3. 현재의약품목록에있는의약품만큼효과있는저렴한의약품이나오면어떻게되나요? 현재의약품목록에있는의약품만큼효과있는저렴한의약품을이용할수있게되는경우 : 귀하가다음번처방전에따라의약품을조제할때귀하의담당약사가저렴한의약품을제공할수있습니다. 귀하와귀하의제공자가저렴한의약품이귀하에게맞지않다고결정하는경우, 귀하의제공자는해당약사에게귀하가현재복용하고있는의약품을계속제공하라고말할수있습니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. IV

8 에서더비싼의약품을의약품목록에서삭제하도록결정할수도있습니다. 같은효과가있으면서저렴한의약품이나와저희가의약품목록에서삭제한의약품을복용하시는경우, 저희가의약품목록에서해당의약품을삭제하기최소 60 일전또는귀하가재공급 ( 리필 ) 을요청할때해당사실을알려드립니다. 그럼으로써귀하는의약품목록이변경되기전에해당의약품의 60 일공급량을제공받으실수있습니다. 귀하가복용하고있는의약품에대한보장내용이변경되면, 플랜에서통상 60 일전에통지서를보내드립니다. 4. 어떤의약품이안전하지않다는사실이밝혀지면어떻게되나요? 식품의약국 (Food and Drug Administration, FDA) 에서귀하가복용하고있는의약품이안전하지않다고발표하면, 저희는해당의약품을의약품목록에서바로삭제합니다. 또한서신과전화연락을통해귀하에게안전하지않은해당의약품이의약품목록에서삭제되었음을알려드립니다. 귀하의제공자도변경사실을알게되므로, 귀하의상태에맞는다른의약품을찾도록귀하와협의할수있습니다. 5. 의약품보장내용에어떤규제또는제한이있을수있나요? 또는특정의약품을제공받으려면취해야할조치가있을수있나요? 그렇습니다. 일부의약품에는보장규칙또는귀하가제공받을수있는양에제한이있습니다. 경우에따라, 귀하가그러한의약품을제공받으려면그전에어떤조치를취해야합니다. 예를들면다음과같습니다. 사전승인 ( 또는사전허가 ): 일부의약품의경우, 귀하가처방전에따라약을조제받기전에귀하나귀하의담당의또는다른처방의가 VNSNY CHOICE FIDA Complete 또는귀하의 Interdisciplinary Team (IDT) 로부터승인을받아야합니다. 승인을받지않으면, 에서해당의약품을보장하지않을수있습니다. 수량제한 : 에서는경우에따라귀하가제공받을수있는의약품의양을제한합니다. 단계별치료 : 에서는경우에따라귀하에게단계별치료를요구합니다. 이는귀하가의학적상태에따라특정한순서로의약품들을시도해야한다는의미입니다. 귀하는어떤의약품에대해보장을받기전에다른의약품을먼저시도해야합니다. 귀하의담당의가첫번째? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. V

9 의약품이귀하에게효과가없다고판단하면, 그이후두번째의약품이보장됩니다. 귀하의의약품에추가요건이나제한이있는지확인하시려면 14 페이지에서시작되는표를참조해주십시오. 웹사이트 vnsnychoice.org 를방문하여자세한정보를확인하실수있습니다. 사전승인및단계별치료규제를설명하는온라인문서를게시해두었습니다. 사본을요청하시면받아보실수도있습니다. 이러한제한규정에대해 예외 를요청하실수있습니다. 예외에관한자세한정보는 11 번질문에서확인하십시오. 간호시설또는장기치료시설에있으면서의약품목록에없는의약품이필요하거나필요한의약품을쉽게제공받지못하는경우, 저희가도와드릴수있습니다. 신규참여자이든아니든, 필요한의약품의 31 일응급공급량을보장해드립니다 ( 단, 소지한처방전에보다짧은기간이명시된경우제외 ). 그러면귀하가담당의또는다른처방의와상의할시간이생깁니다. 의약품목록에귀하가대신복용할수있는유사한의약품이있는지, 또는예외를요청할것인지판단하도록담당의또는처방의가도움을드릴것입니다. 예외에관한자세한정보는 11 번질문에서확인하십시오. 6. 귀하가원하는의약품에제한사항이있는지, 또는해당의약품을제공받으려면취해야할조치가있는지는어떻게알수있을까요? 14 페이지의적용의약품목록에 " 규제또는제한 " 이라는제목의열이있습니다. 7. 일부의약품의보장에관한규칙을변경되면어떻게될까요? 예를들어, 어떤의약품에사전허가 ( 승인 ), 수량제한및 / 또는단계별치료규제를추가하면어떻게될까요? 저희가어떤의약품에사전승인, 수량제한및 / 또는단계별치료규제를추가하면귀하에게통지해드립니다. 해당규제요건이추가되기최소 60 일전까지, 또는귀하가다음번처방전에따라조제할때알려드리게됩니다. 그럼으로써귀하는의약품목록이변경되기전에해당의약품의 60 일공급량을제공받으실수있습니다. 그러면귀하가어떻게해야할지담당의또는기타처방의와상담할시간이생깁니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VI

10 8. 의약품목록에서의약품을찾으려면어떻게해야하나요? 의약품을찾는방법에는두가지가있습니다. 알파벳순으로검색 ( 의약품의철자를아는경우 ), 또는 의학적상태에따라검색 알파벳순으로검색하려면, I-1 페이지의알파벳순목록섹션으로가십시오. 이목록에서귀하의의약품이름을찾으면됩니다. 질환에따라검색하려면, 14 페이지에서 " 질환별의약품목록 " 이라는제목의섹션을찾으십시오. 이섹션의의약품은질환의유형에따른사용법을분류하여정리되어있습니다. 예를들어, 심장질환을앓고있으면심혈관작용약물카테고리를찾으면됩니다. 그안에심장질환을치료하는의약품들이있습니다. 9. 귀하가복용하려는의약품이의약품목록에없으면어떻게해야할까요? 귀하가원하는의약품을의약품목록에서찾을수없는경우, 참여자서비스 (Participant Services) 에 번으로전화해문의하십시오. VNSNY CHOICE FIDA Complete 에서해당의약품을보장하지않을경우, 다음중한가지조치를취하실수있습니다. 참여자서비스 (Participant Services) 로부터귀하가복용하려는의약품과비슷한의약품목록을요청합니다. 그다음담당의또는다른처방의에게해당목록을보입니다. 그렇게하면담당의또는처방의는귀하가복용하려는의약품과비슷한의약품한가지를의약품목록에서처방할수있습니다. 또는 플랜이나귀하의 IDT (Interdisciplinary Team) 에귀하의의약품을보장하도록예외를요청할수있습니다. 예외에관한자세한정보는 11 번질문에서확인하십시오. 10. 신규참여자이면서귀하의의약품을의약품목록에서찾을수없거나의약품을제공받는데문제가있을경우어떻게해야할까요? 저희가도와드릴수있습니다. 귀하가 의참여자가되고첫 90 일동안, 저희는요구에따라귀하의의약품에대해최고 90 일의임시공급량을보장해드리게되어있습니다. 그러면귀하가담당의또는기타처방의와상의할시간이생깁니다. 의약품목록에귀하가대신복용할수? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VII

11 있는유사한의약품이있는지, 또는예외를요청할것인지판단하도록담당의또는처방의가도움을드릴것입니다. 다음의경우, 귀하의의약품에대해최고 90 일의임시공급량을보장해드립니다. 귀하가의약품목록에없는의약품을복용하고있는경우, 또는 의료보험규칙상처방의가처방한양을귀하가제공받지못하게되어있는경우, 또는 또는귀하의 Interdisciplinary Team (IDT) 의사전승인이요구되는의약품인경우, 또는 귀하가단계별치료규제의일환인의약품을복용하고있는경우. 간호시설또는기타장기치료시설에거주하시는경우, 98 일까지처방약을재공급 ( 리필 ) 받으실수있습니다. 귀하는첫 90 일동안귀하의의약품을여러번리필하실수있습니다. 그러면귀하의처방의가귀하의의약품을의약품목록에있는것으로바꾸거나, 또는예외를요청할시간이생깁니다. 병원에서자택으로이전과같이귀하의의료수준이변경되며, 당사의처방집에포함되지않은의약품이필요하거나해당의약품을구할능력이제한된경우, 귀하가당사의플랜에가입한지 90 일이지났다면, 당사는귀하가네트워크약국을방문할때최대 30 일 ( 장기요양시설에거주중인경우 31 일 ) 분량의임시의약품을 1 회에한하여공급해드립니다. 이러한임시공급이후에도해당의약품에대한커버리지를계속받으려면, 이기간동안플랜의예외과정을사용하셔야합니다. 의약품의임시공급을요청하려면가입자서비스부서 (Participant Services) 로전화해주시기바랍니다. 11. 귀하의의약품을보장하도록예외를요청할수있을까요? 그렇습니다. 또는귀하의 Interdisciplinary Team (IDT) 에의약품목록에없는의약품을보장하도록예외를요청하실수있습니다. 또한 또는귀하의 IDT 에귀하의의약품에대한규칙을변경해달라고도요청하실수있습니다. 예를들어, 는보장하는의약품의양에제한을둘수도있습니다. 귀하의의약품에그러한제한이있을경우, 저희나귀하의 IDT 에해당제한을변경해더많은양을보장해달라고요청하실수있습니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VIII

12 다른예로, 저희나귀하의 IDT 에단계별치료규제나사전승인요건을없애달라고요청하실수있습니다. 12. 예외를인정받으려면얼마나걸리나요? 우선, 또는귀하의 IDT (Interdisciplinary Team) 에서귀하의예외요청을뒷받침하는처방의의소견서를수령해야합니다. 소견서를수령한후 72 시간이내에예외요청에대한결정을귀하에게통지해드립니다. 귀하나귀하의처방의가결정까지 72 시간을기다려야할경우귀하의건강에해로울수있다고판단하는경우, 귀하는신속예외를요청하실수있습니다. 이는결정시간을단축하는것입니다. 처방의가귀하의요청을뒷받침하는경우, 처방의의증빙소견서가수령되고 24 시간이내에결정을통지받을수있습니다. 13. 예외를요청하려면어떻게해야하나요? 예외를요청하시려면담당케어매니저에게전화하십시오. 담당케어매니저가귀하와귀하의처방의와협의해예외요청을도와드릴것입니다. 14. 일반의약품이무엇입니까? 일반의약품은브랜드의약품과동일한성분으로제조된의약품입니다. 브랜드의약품에비해통상가격이저렴하고보통잘얄려진이름도없습니다. 일반의약품은식품의약국 (FDA) 의승인을받은의약품입니다. 에서는브랜드의약품과일반의약품을모두보장해드립니다. 15. OTC 의약품이무엇입니까? OTC 는 비처방 (over-the-counter) 의약자입니다. VNSNY CHOICE FIDA Complete 는처방의의처방전으로명시된경우일부 OTC 의약품도보장해드립니다. 어떤 OTC 의약품이보장되는지는 의약품목록을확인하십시오.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. IX

13 16. 에서 OTC 비의약제품도보장해주나요? 는처방의의처방전으로명시된경우일부 OTC 비의약제품도보장해드립니다. 비의약품비처방 (non-drug OTC) 제품의예로는알코올패드가있습니다. 어떤 OTC 비의약제품이보장되는지는 의약품목록을확인하십시오. 17. 코페이는어떻게되나요? 의약품목록에있는의약품에대해서는코페이가부과되지않습니다. 18. 의약품이무엇입니까? 은의약품을모아놓은그룹입니다. 플랜의의약품목록에있는모든의약품은 4 개가운데하나에속합니다. 이 4 개에속하는의약품에대해서는 귀하가부담할비용이없습니다. 1 의약품은일반의약품입니다. 2 의약품은브랜드의약품입니다. 3 의약품은비 Medicare 처방일반의약품입니다. 4 의약품은비 Medicare OTC 의약품입니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. X

14 적용의약품목록 다음페이지에시작되는적용의약품목록에는 VNSNY CHOICE FIDA Complete 에서보장하는의약품에관한정보가담겨있습니다. 귀하의의약품을찾는데어려움이있을경우, I-1 에서시작되는인덱스로가십시오. 차트의첫번째열에는의약품의이름이열거되어있습니다. 브랜드의약품은대문자로 ( 예 : ROZEREM), 일반의약품은소문자이탤릭체 ( 예 : zaleplon) 로표기되어있습니다. 규제또는제한에관한정보열에서는귀하의의약품을보장함에있어 에서부과한규칙이있는지알수있습니다. 참고 : 의약품옆의 * 표시는해당의약품이 Part D 의약품 이아니라는의미입니다. 이러한의약품에대해서는다른이의제기규칙이적용됩니다. 이의제기란오류가있다고귀하가판단하는경우, 보장내용결정을검토및변경해줄것을공식적으로요청하는방식을말합니다. 예를들어, VNSNY CHOICE FIDA Complete 또는귀하의 IDT (Interdisciplinary Team) 에서귀하가원하는의약품을보장하지않거나 Medicare 나 Medicaid 에의해서더이상보장하지않기로결정한다고했을때, 귀하나귀하의담당의또는다른처방의가이결정에동의하지않으면귀하는이의를제기하실수있습니다. 이의제기방법에관한지침을요청하시려면참여자서비스 (Participant Services) 의 번또는독립소비자권리옹호네트워크 (Independent Consumer Advocacy Network, ICAN) 의 번으로전화해주십시오. (TTY 사용자는 711 번으로전화한다음안내에따라 번으로연락해주시기바랍니다.)? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XI

15 다음의이용관리약자는본문서내에서찾을수있습니다. 적용범위약자 약자정의설명 이용관리제한 PA PA-HRM PA NSO 사전승인제한 파트 D 에대한파트 B 의약품감정에대한사전승인제한 고위험약품에대한사전승인제한 시작약품사전승인제한 이약품의처방전을받기전에귀하 ( 혹은의사 ) 는 VNSNY CHOICE FIDA Complete 으로부터사전승인을받아야합니다. 승인을받지않으면, VNSNY CHOICE FIDA Complete 에서해당의약품을보장하지않을수있습니다. 이의약품은 Medicare 파트 B 혹은파트 D 에따른비용지급이가능할수있는약품입니다. 이약품의처방전을받기전에귀하 ( 혹은의사 ) 는이약품이 Medicare 파트 D 에의해보장되는지판단하기위해 VNSNY CHOICE FIDA Complete 으로부터사전승인을받아야합니다. 승인을받지않으면, VNSNY CHOICE FIDA Complete 에서해당의약품을보장하지않을수있습니다. 이약품은 CMS 에의해유해할수있다고판단되었기때문에 65 세이상 Medicare 적용자에게는고위험약품입니다. 65 세이상연령의참여자는이약품의처방전을받기전에 VNSNY CHOICE FIDA Complete 으로부터사전승인을받아야합니다. 승인을받지않으면, VNSNY CHOICE FIDA Complete 에서해당의약품을보장하지않을수있습니다. 새로운참여자이거나이약품을복용한적이없을경우, 귀하 ( 혹은의사 ) 는처방약을받기전에 VNSNY CHOICE FIDA Complete 으로부터사전승인을받아야합니다. 승인을받지않으면, VNSNY CHOICE FIDA Complete 에서해당의약품을보장하지않을수있습니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XII

16 약자정의설명 QL ST 용량한도제한 단계적치료제한 는보장되는이약품의용량을처방전당, 혹은특정시간대로제한합니다. VNSNY CHOICE FIDI Complete 에서이약품의보장범위를제공하기전에먼저본인이가진질환에대해다른의약품사용을시도해야합니다. 이약품은다른약품이효과적이지않을때만보장될수있습니다. 다음의추가적인이용관리약자는본문서내에서찾으실수있습니다. 보장을위한특별요건 약자정의설명 LA NM 접근제한약품 비우편처방약품 특정약국에서만처방이가능할수있습니다. 더자세한정보를알아보시려면 번으로매주평일오전 8 시부터오후 8 시사이에제공자와약국관리자혹은참여자서비스에연락하십시오. TTY/TDD 사용자는 711 번으로전화하시면됩니다. 우편처방 (mail order) 을통해적은비용으로지침서내대부분의약품의 1 개월이상분을받을수있습니다. 우편을통해처방혜택이불가능한약품은지침서내필요요건 / 제한항목의열에 Nm 라고표시되어있습니다. * 파트 D 약품이아님 이의약품은파트 D 의약품이나비처방 (OTC) 의약품및제품이아닌약품입니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XIII

17 차별금지규정 차별은법률위반입니다. 뉴욕가정방문간호서비스와전체자회사및제휴사 *( VNSNY ) 는해당하는연방민권법을준수하며인종, 피부색, 출신국가, 나이, 장애여부또는성별을이유로차별하지않습니다. VNSNY 는인종, 피부색, 출신국가, 나이, 장애또는성별을이유로개인을배제하거나다르게대우하지않습니다. VNSNY 는효과적인의사소통을위해장애를가진사람에게는자격이있는수화통역사, 다른형식으로된서면정보 ( 큰활자, 음성, 장애인용전자형식, 기타형식 ) 등무료지원및서비스를제공하고, 영어가주요사용언어가아닌사람에게는자격이있는통역사및다른언어로된정보등무료언어서비스를제공합니다. 해당서비스를이용하고자하실경우 VNSNY 민권코디네이터에게연락하십시오. VNSNY CHOICE Health Plans 의경우 : Susan Underwood VNSNY 에서인종, 피부색, 출신국가, 나이, 장애또는성별을이유로해당서비스를제공하지않았거나다른형태로차별했다고믿으시는경우, 위에기재된민권코디네이터에게고충을제기하실수있습니다. 우편또는방문 : 1250 Broadway 11th Floor, New York, New York 전화 : VNSNY CHOICE Health Plans 의경우 : TYY 사용자 : 711 팩스 : 이메일 : CivilRightsCoordinator@vnsny.org 웹사이트 : 고충을제기하시는데도움이필요하실경우, 민권코디네이터가도와드릴수있습니다. 미연방보건복지부 (U.S. Department of Health and Human Services) 민권담당국 (Office for Civil Rights) 의민권차별항의서포털 (Office for Civil Rights Complaint Portal) 웹사이트 에서민권차별항의서를온라인으로제출하시거나아래우편또는전화로접수하실수도있습니다. U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) 민원서양식은 에마련되어있습니다. * 자회사및제휴사 : 뉴욕가정방문간호서비스가정의료 (Visiting Nurse Service of New York Home Care), VNSNY 호스피스및완화치료 (VNSNY Hospice and Palliative Care), Partners in Care( 총체적으로, VNSNY 의료제공자 (VNSNY Providers) ) 와 VNSNY CHOICE 및 VNS 지속의료개발기업 (VNS Continuing Care Development Corporation)( 총체적으로, VNSNY CHOICE ). VNSNY 의료제공자및 VNSNY CHOICE 는 총체적으로 VNSNY 입니다.

18 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders 유효일자 : 1

19 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals 유효일자 : 2

20 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (360 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (60 per 30 days) 3

21 buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenorphine HCl) (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain-fever 160 mg/5 ml a/f, asa/f, ibu/f 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg * children's mapap 80 mg rapid 80 mg * (Acetaminophen) (Infants' Tylenol) (Acetaminophen) (Acetaminophen) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 4

22 codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) (Codeine Sulfate) mg, 60 mg cvs acetaminophen 8-hr 650 mg QL (180 per 30 days) (Tylenol Arthritis) caplet 650 mg * cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet mg (Xolox) QL (240 per 30 days) endocet oral tablet mg, 5- QL (360 per 30 days) (Xolox) 325 mg endocet oral tablet mg (Xolox) QL (300 per 30 days) (Oxycodone QL (360 per 30 days) endodan oral tablet mg HCl/Aspirin) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour feverall 120 mg suppository children's, outer 120 mg * feverall 325 mg suppository junior str, outer 325 mg * feverall 650 mg suppository adult, inner 650 mg * hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg (Actiq) (Duragesic) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Hycet) (Norco) PA; QL (120 per 30 days) QL (10 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (390 per 30 days) 5

23 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml hydromorphone 10 mg/ml vial p/f,sdv,latex-f 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml (Norco) (Ibudone) (Hydromorphone HCl/PF) (Dilaudid) QL (360 per 30 days) QL (150 per 30 days) (Hydromorphone HCl/PF) (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg, 8 mg HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG infant pain relv 80 mg/0.8 ml a/f, QL (30 per 30 days) (Acetaminophen) gluten-free 80 mg/0.8 ml * jr pain-fever 160 mg rapid tab QL (30 per 30 days) (Acetaminophen) junior,bubblegum 160 mg * junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) 6

24 mapap 160 mg/5 ml liquid 160 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Tylenol Arthritis) mg * PA-HRM; QL (180 per margesic oral capsule (Esgic) 30 days); AGE (Max mg 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg (Diskets) QL (360 per 30 days) methadone oral tablet 5 mg (Diskets) QL (180 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine 10 mg/ml carpuject outer,p/f,latex-free 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml syringe p/f, latexfree 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (180 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine intramuscular pen injector 10 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) 7

25 morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG MORPHINE ORAL TABLET 30 QL (120 per 30 days) MG morphine oral tablet extended QL (60 per 30 days) (MS Contin) release 100 mg, 200 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 30 mg non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (120 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 5 mg (Roxicodone) QL (180 per 30 days) oxycodone oral tablet 15 mg, 20 mg, QL (120 per 30 days) (Roxicodone) 30 mg oxycodone-acetaminophen oral solution mg/5 ml oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg (Oxycodone HCl/Acetaminophe n) (Xolox) (Xolox) QL (1800 per 30 days) QL (240 per 30 days) QL (360 per 30 days) 8

26 oxycodone-acetaminophen oral QL (300 per 30 days) (Xolox) tablet mg oxycodone-aspirin oral tablet (Oxycodone QL (360 per 30 days) mg HCl/Aspirin) OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) QL (120 per 30 days) oxymorphone oral tablet 5 mg (Opana) QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg (Opana ER) QL (60 per 30 days) pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * reprexain oral tablet mg, QL (150 per 30 days) (Ibudone) mg, mg sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) 9

27 sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (180 per tencon oral tablet mg (Tencon) 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg vicodin es oral tablet mg (Norco) QL (390 per 30 days) vicodin hp oral tablet mg (Norco) QL (390 per 30 days) vicodin oral tablet mg (Norco) QL (390 per 30 days) XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) zebutal oral capsule mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) ZUBSOLV SUBLINGUAL QL (30 per 30 days) TABLET MG Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * 10

28 ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) bufferin 325 mg tablet coated 325 mg * CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid filled,softge 200 mg * diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg (Aspirin/Calcium Carbonate/Mag) (Celebrex) (Advil) (Diclofenac Potassium) (Voltaren-XR) (Diclofenac Sodium) QL (60 per 30 days) 11

29 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecotrin ec 325 mg tablet saftey coated 325 mg * (Ecotrin) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Lodine) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Etodolac) (Fenoprofen Calcium) FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) 12

30 ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox Ds) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics QL (20 per 30 days) 13

31 Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % (Lidocaine HCl) (Xylocaine-MPF) (Pre-Attached Lta Kit) (Xylocaine) (Lidocaine HCl) (Pre-Attached Lta Kit) (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg buproban oral tablet extended release 150 mg (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) (Zyban) PA QL (30 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (90 per 30 days) 14

32 bupropion hcl (smoking deter) oral tablet extended release 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch outer, clear, step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) 15

33 nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24 hr * NICOTROL INHALATION CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 (Nicoderm Cq) QL (180 per 365 days) QL (1008 per 90 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg alprazolam oral tablet 2 mg (Xanax) QL (150 per 30 days) chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (180 per 30 days) (Tranxene T-Tab) 15 mg, 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg 16

34 diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam injection solution 2 QL (2 per 30 days) (Ativan) mg/ml lorazepam oral tablet 0.5 mg, 1 mg (Ativan) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) QL (150 per 30 days) ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) ONFI ORAL TABLET 10 MG, 20 PA NSO; QL (60 per MG 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 40 (Gentamicin mg/ml Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization (Tobi) 300 mg/5 ml tobramycin in 0.9 % nacl (Tobramycin/Sodiu intravenous piggyback 60 mg/50 ml m Chloride) QL (224 per 28 days) 17

35 tobramycin sulfate injection solution (Tobramycin 10 mg/ml, 40 mg/ml Sulfate) Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (Bacitracin) chloramphenicol sod succinate (Chloramphenicol intravenous recon soln 1 gram Sod Succinate) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate intravenous piggyback 300 mg/50 In D5w) ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Palmitate) clindamycin phosphate injection (Cleocin solution 150 (mg/ml) (6 ml), 150 Phosphate) mg/ml clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) 18

36 metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml (Metronidazole/So dium Chloride) metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrodantin) (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl gram/200 ml In Dextrose 5 %) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) 19

37 XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 1 gram/50 Sodium/Dextrose, ml, 2 gram/50 ml Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Cefepime HCl) cefepime hcl 2 gram vial latex/f, sdv, (Cefepime HCl) outer 2 gram CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML PA; QL (9 per 30 days) PA 20

38 cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial latex/f, outer 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Claforan) (Cefoxitin Sodium/Dextrose, Iso) (Cefoxitin Sodium) (Cefoxitin Sodium) (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback latexfree 1 gram/50 ml Na/Dextrose, Iso) (Ceftriaxone ceftriaxone 2 gm piggyback latexfree 2 gram/50 ml Na/Dextrose, Iso) (Ceftriaxone ceftriaxone injection recon soln 1 (Ceftriaxone gram, 10 gram, 250 mg, 500 mg Sodium) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) 21

39 cefuroxime sod 1.5 gm vial outer,latex-free 1.5 gram (Zinacef) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 (Cephalexin) mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) 22

40 clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML (Erythromycin Base) (Erythromycin Stearate) (Eryped 200) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) LA 23

41 imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg (Primaxin) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) 24

42 ampicillin sodium intravenous recon (Ampicillin soln 2 gram Sodium) ampicillin-sulbactam 1.5 gm vl 10's,sdv,latex-free 1.5 gram (Unasyn) ampicillin-sulbactam injection recon soln 15 gram, 3 gram (Unasyn) ampicillin-sulbactam intravenous recon soln 1.5 gram (Unasyn) BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, (Dicloxacillin 500 mg Sodium) nafcillin 2 gm vial 10's, latex-free 2 gram (Nafcillin Sodium) nafcillin injection recon soln 1 gram, 10 gram (Nafcillin Sodium) nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) oxacillin 2 gm vial 10's,outer 2 gram (Oxacillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin intravenous piggyback 1 gram/50 Sodium/Dextrose, ml, 2 gram/50 ml Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) penicillin g pot in dextrose (Pen G intravenous piggyback 1 million Pot/Dextroseunit/50 ml, 2 million unit/50 ml, 3 Water) million unit/50 ml 본문서의XII-XIII페이지에서이테이블에있는기호및약어에대한정보를보실수있습니다. 25

43 penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) (Cipro) (Cipro I.V.) (Ciprofloxacin Lactate) (Cipro) (Levofloxacin/D5 W) (Levofloxacin) (Levofloxacin) (Levaquin) 26

44 moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous solution mg/5 ml (Sulfamethoxazole/ Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet mg, mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) sulfatrim oral suspension (Sulfamethoxazole/ mg/5 ml Trimethoprim) Tetracyclines doxy-100 intravenous recon soln (Doxycycline 100 mg Hyclate) doxycycline hyclate intravenous (Doxycycline recon soln 100 mg Hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 20 mg (Doryx) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 (Adoxa) mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml (Vibramycin) doxycycline monohydrate oral tablet (Avidoxy) 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg (Minocin) 27

45 minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution 2 mg/ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Minocycline HCl) (Tetracycline HCl) (Tygacil) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO 28

46 azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML (Vidaza) bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 (Bleomycin unit, 30 unit Sulfate) BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous (Cyclophosphamid recon soln 1 gram, 2 gram, 500 mg e) CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST 29

47 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) doxorubicin 200 mg/100 ml vial latex-free 2 mg/ml (Doxorubicin HCl) doxorubicin intravenous solution 50 mg/25 ml (Doxorubicin HCl) doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) 30

48 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) mg/10 ml flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial sdv,p/f,latex-free 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) (Ifex) (Ifosfamide/Mesna ) PA NSO PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) 31

49 imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO; LA 32

50 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Leuprolide Acetate) (Megestrol Acetate) PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) 33

51 MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium/PF) methotrexate sodium injection (Methotrexate solution 25 mg/ml Sodium) methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PA NSO; QL (30 per 30 days) ; ST PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) 34

52 PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 200 MG, 300 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG PA NSO; LA PA NSO PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) 35

53 TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR 22.5 MG SYRINGE OUTER, L/F, SDV 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) ; ST PA NSO PA NSO PA NSO; LA; QL (60 per 30 days) 36

54 VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG (Navelbine) XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents PA NSO; LA; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; LA; QL (42 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) 37

55 Antimuscarinics/Antispasm odics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg (Atropine Sulfate) (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 38

56 divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) ST ST ST 39

57 lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) 40

58 phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG (Phenytoin Sodium) (Phenytoin Sodium) POTIGA ORAL TABLET 50 MG primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) ST; QL (90 per 30 days) ST; QL (270 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST 41

59 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, (Zonegran) ST; QL (200 per 5 days) ST; QL (1200 per 30 days) ST; QL (60 per 30 days) QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL QL (56 per 365 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG 42

60 rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg (Exelon) rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, (Exelon) 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 (Amitriptyline mg, 150 mg, 25 mg, 50 mg, 75 mg HCl) amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg (Amoxapine) BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG bupropion hcl oral tablet 100 mg, 75 mg (Wellbutrin) bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg (Wellbutrin XL) citalopram oral solution 10 mg/5 ml (Citalopram Hydrobromide) citalopram oral tablet 10 mg, 20 mg, 40 mg (Celexa) clomipramine oral capsule 25 mg, 50 mg, 75 mg (Anafranil) desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Doxepin HCl) doxepin oral concentrate 10 mg/ml (Doxepin HCl) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Irenka) duloxetine oral capsule,delayed release(dr/ec) 30 mg (Irenka) duloxetine oral capsule,delayed release(dr/ec) 40 mg (Irenka) QL (60 per 30 days) QL (30 per 30 days) ST QL (600 per 30 days) QL (30 per 30 days) (Cymbalta); QL (60 per 30 days) (Cymbalta); QL (30 per 30 days) (Irenka); QL (30 per 30 days) 43

61 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 100 mg, 150 mg Maleate) fluvoxamine oral tablet 100 mg, 25 (Fluvoxamine mg, 50 mg Maleate) imipramine hcl oral tablet 10 mg, 25 (Tofranil) mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg (Tofranil-Pm) maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg (Remeron) QL (30 per 30 days) ST ST 44

62 mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg (Remeron) (Nefazodone HCl) (Pamelor) (Nortriptyline HCl) (Symbyax) (Paxil) (Paxil CR) (Perphenazine/Ami triptyline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg (Trazodone HCl) ST; QL (30 per 30 days) 45

63 trimipramine oral capsule 100 mg, 25 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG (Trimipramine Maleate) (Effexor XR) (Venlafaxine HCl) (Venlafaxine HCl) (Precose) ST QL (90 per 30 days) QL (180 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (60 per 30 days) 46

64 INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG days) JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 ST; QL (30 per 30 MG, 25 MG days) JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG KORLYM ORAL TABLET 300 PA; QL (112 per 28 MG days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended ST; QL (60 per 30 (Fortamet) release 24hr 1,000 mg days) metformin oral tablet extended ST; QL (120 per 30 (Fortamet) release 24hr 500 mg days) miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg 47

65 pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg (Duetact) pioglitazone-metformin oral tablet mg, mg (Actoplus Met) repaglinide oral tablet 0.5 mg, 1 mg, (Prandin) 2 mg repaglinide-metformin oral tablet 1- (Repaglinide/Metfo 500 mg, mg rmin HCl) SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML QL (30 per 30 days) QL (90 per 30 days) QL (240 per 30 days) QL (150 per 30 days) PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) ST; QL (60 per 30 days) QL (24 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) 48

66 NOVOLIN 70/30 QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) 250 mg in HCl) glipizide-metformin oral tablet mg, mg (Glipizide/Metform in HCl) QL (120 per 30 days) 49

67 glyburide micronized oral tablet 1.5 PA-HRM; AGE (Max (Glynase) mg, 3 mg, 6 mg 64 Years) glyburide oral tablet 1.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) mg, mg, mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals 3-day vaginal cream 2 % * (Gyne-Lotrimin) ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 12's 2 (Miconazole % * Nitrate) AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln (Amphotericin B) 50 mg anti-fungal 1% powder 1 % * (Tolnaftate) (Miconazole antifungal 2% cream 2 % * Nitrate) baza antifungal 2% cream 12's 2 % (Miconazole * Nitrate) blis-to-sol 1% liquid 1 % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) ciclopirox topical gel 0.77 % (Ciclopirox) ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Loprox) % clotrim 1% vaginal cream 1 % * (Gyne-Lotrimin) 50

68 clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) clotrimazole 1% solution (otc) 1 % * (Clotrimazole) clotrimazole insert 100 mg * (Clotrimazole) clotrimazole mucous membrane troche 10 mg (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Clotrimazole) clotrimazole-7 cream 1 % * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream % (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion % methasone Dip) critic-aid clear af 2% oint 12's, w/ (Miconazole antifungal 2 % * Nitrate) cvs miconazole 3 combo pack 3pref (Miconazole applic w/cream 4 % (200 mg)- 2 % Nitrate) (9 gram) * dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream 1 % (Econazole Nitrate) fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback 100 mg/50 Nacl,Iso-Osm) ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * (Clotrimazole) fungoid-d 1% cream 1 % * (Tinactin) griseofulvin microsize oral tablet (Griseofulvin, 500 mg Microsize) inzo antifungal 2% cream 2 % * (Miconazole Nitrate) itraconazole oral capsule 100 mg (Sporanox) 51

69 ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % (Tinactin) * lamisil af defense 1% powder 1 % * (Tolnaftate) LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * (Miconazole micatin 2% antifungal cream 2 % * Nitrate) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole mg vag supp 100 (Miconazole mg * Nitrate) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole 200 mg Nitrate) MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 (Nystatin) unit/gram nyata topical powder 100,000 (Nystatin) unit/gram nystatin oral suspension 100,000 (Nystatin) unit/ml nystatin oral tablet 500,000 unit (Nystatin) 52

70 nystatin topical cream 100,000 (Nystatin) unit/gram nystatin topical ointment 100,000 (Nystatin) unit/gram nystatin topical powder 100,000 (Nystatin) unit/gram nystatin-triamcinolone topical (Nystatin/Triamcin cream 100, unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin ointment 100, unit/gram-% ) nystop topical powder 100,000 (Nystatin) unit/gram pv foot odor control 1% powder 1 % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal 1% liquid spray liquid (Tinactin) spray 1 % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine 1% cream 1 % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Tolnaftate) tolnaftate 1% spray powder 1 % * (Tinactin) (Miconazole triple paste af 2% ointment 2 % * Nitrate) vagistat-3 combo pack 200 mg- 2 % (Monistat 3) (9 gram) * voriconazole intravenous solution (Vfend IV) 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) mg Antigout Agents 53

71 Antigout Agents, Other allopurinol oral tablet 100 mg, 300 mg (Zyloprim) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg (Probenecid) probenecid-colchicine oral tablet (Probenecid/Colchi mg cine) ULORIC ORAL TABLET 40 MG, 80 MG ZURAMPIC ORAL TABLET 200 MG Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint 10 mg * (Claritin) alavert d-12 allergy-sinus tab (Claritin-D 12 mg * Hour) aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-12hr tablet mg * (Claritin-D 12 Hour) allerclear d-24hr er tablet nondrowsy mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d mg tablet mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet mg * (Triprolidine/Pseud oephedrine) banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) QL (30 per 30 days) ST; QL (30 per 30 days) 54

72 banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl 1 mg/1 ml soln children, s/f, grape (otc) 1 mg/ml * (Children'S Zyrtec) cetirizine hcl 10 mg chew tab children's,outer,u-d 10 mg * (Cetirizine HCl) cetirizine hcl 10 mg tablet 10 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Cetirizine HCl) cetirizine-pse er mg tab mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) child loratadine 5 mg/5 ml syr (Children'S grape, s/f 5 mg/5 ml * Claritin) child triaminic cold & allergy mg/5 ml * (Dimetapp) child wal-tap cold-allergy elx mg/5 ml * (Dimetapp) child wal-zyr 1 mg/ml solution cherry 1 mg/ml * (Children'S Zyrtec) CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * (Children'S Zyrtec) CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-zyr 10 mg chew tab 10 mg * (Cetirizine HCl) CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet (Triprolidine/Pseud mg * oephedrine) 55

73 compoz 25 mg gelcap 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs cold & cough nighttime liq mg/5 ml * cvs loratadine-d 24hr tablet nondrowsy mg * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f mg/5 ml * dimetapp cold & congest liquid mg/5 ml * (Diphenhydramine HCl) (Zyrtec) (Triaminic Nighttime Cold- Cough) (Claritin-D 24 Hour) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 12.5 mg/5 ml soln 12.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/ * Phenylephrine) 56

74 eq allergy relief 25 mg tablet 25 mg (Diphenhydramine * HCl) fexofenadine hcl 180 mg tablet 24 (Allegra Allergy) hour, non-drowsy (otc) 180 mg * fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) hydroxyzine hcl intramuscular (Hydroxyzine HCl) solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 (Hydroxyzine HCl) mg/5 ml hydroxyzine hcl oral tablet 10 mg, (Hydroxyzine HCl) 25 mg, 50 mg levocetirizine oral solution 2.5 mg/5 (Xyzal) ml levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Claritin) q-dryl 12.5 mg/5 ml liquid (Zzzquil) a/f,unboxed 12.5 mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 (Zzzquil) mg/5 ml * (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) fexofenadine hcl 30 mg/5 ml 30 loratadine-d 12 hour tablet nondrowsy mg * promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 sm allergy relief 1.34 mg tab 1.34 (Fexofenadine (Claritin-D 12 (Promethazine (Diphenhydramine (Diphenhydramine (Clemastine mg/5 ml * ml mg * mg * mg * HCl) Hour) HCl) HCl) HCl) Fumarate) PA-HRM; AGE (Max 64 Years) 57

75 sm sinus and allergy tablet (Chlorpheniramine/ maximum strength 4-60 mg * Pseudoephed) sm z-sleep 50 mg/30 ml liquid berry,gluten-free 50 mg/30 ml * (Zzzquil) sudogest sinus & allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) unisom 50 mg sleepgels softgel 50 mg * (Zzzquil) unisom 50 mg/30 ml liquid 50 mg/30 (Zzzquil) ml * unisom sleep aid 25 mg tablet 25 mg (Doxylamine * Succinate) vicks qlearquil night 25 mg 25 mg * (Diphenhydramine HCl) wal-act d cold & allergy tab (Triprolidine/Pseud mg * oephedrine) wal-dryl allergy 12.5 mg/5 ml children,a/f,s/f,d/f 12.5 mg/5 ml * (Zzzquil) wal-dryl allergy 25 mg capsule 25 mg * (Zzzquil) wal-dryl allergy 25 mg minitab (Diphenhydramine minitab, coated 25 mg * HCl) wal-fex allergy 180 mg tablet 180 mg * (Allegra Allergy) wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) wal-finate-d tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) wal-itin 10 mg odt non-drowsy 10 mg * (Claritin) wal-itin 10 mg tablet non-drowsy,24 hr rlf 10 mg * (Claritin) wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) wal-itin d 12 hour tablet mg * (Claritin-D 12 Hour) 58

76 wal-itin d 24 hour tablet mg (Claritin-D 24 * Hour) (Unisom wal-sleep z 25 mg odt 25 mg * Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid (Zzzquil) berry, a/f, d/f, s/f 50 mg/30 ml * (Unisom wal-som 25 mg odt 25 mg * Sleepmelts) (Doxylamine wal-som 25 mg tablet 25 mg * Succinate) wal-som 50 mg softgel softgel 50 mg (Zzzquil) * wal-phed pe sinus-allergy tab 4-10 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) wal-tap elixir mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr mg * (Zyrtec-D) ZYRTEC 10 MG ODT 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) Antimigraine Agents 59

77 Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt Mlt) 10 mg, 5 mg sumatriptan 4 mg/0.5 ml inject QL (4 per 28 days) (Imitrex) latex-free 4 mg/0.5 ml sumatriptan nasal spray,nonaerosol QL (12 per 28 days) 20 mg/actuation, 5 mg/actuation (Imitrex) sumatriptan succinate oral tablet QL (18 per 28 days) (Imitrex) 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) cartridge 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) solution 6 mg/0.5 ml sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) syringe 6 mg/0.5 ml Succinate) zolmitriptan oral tablet 2.5 mg, 5 QL (12 per 28 days) (Zomig) mg zolmitriptan oral QL (12 per 28 days) (Zomig Zmt) tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg (Dapsone) ethambutol oral tablet 100 mg, 400 mg (Myambutol) 60

78 isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 100 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 150 mg, 300 mg (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300- PA; QL (188 per 168 days) 0.5 MG aprepitant oral capsule 125 mg, 40 (Emend) mg, 80 mg aprepitant oral capsule,dose pack (Emend) 125 mg (1)- 80 mg (2) compro rectal suppository 25 mg (Compazine) cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) dronabinol oral capsule 10 mg, 2.5 PA (Marinol) mg, 5 mg 본문서의XII-XIII페이지에서이테이블에있는기호및약어에대한정보를보실수있습니다. 61

79 EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous (Granisetron solution 100 mcg/ml HCl/PF) granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) (Granisetron HCl) granisetron hcl oral tablet 1 mg (Granisetron HCl) meclizine 12.5 mg caplet caplet (otc) 12.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Meclizine HCl) medi-meclizine 25 mg tablet outer, f/c 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) ondansetron hcl oral solution 4 (Zofran) mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) mg, 8 mg ondansetron oral (Zofran Odt) tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 PA-HRM; AGE (Max (Phenergan) mg, 25 mg 64 Years) prochlorperazine edisylate injection (Prochlorperazine solution 10 mg/2 ml (5 mg/ml) Edisylate) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) 62

80 prochlorperazine rectal suppository 25 mg promethazine oral tablet 12.5 mg, 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg, 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Compazine) (Promethazine HCl) (Phenergan) (Phenergan) (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg, mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (10 per 30 days) PA 63

81 NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG (Paromomycin Sulfate) QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 100 mg (Amantadine HCl) APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine oral tablet 0.5 mg, 1 (Benztropine mg, 2 mg Mesylate) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet mg, mg, mg (Sinemet CR) carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, (Stalevo 50) mg, mg, mg entacapone oral tablet 200 mg (Comtan) QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 64

82 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg rasagiline oral tablet 0.5 mg, 1 mg (Azilect) ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) trihexyphenidyl oral tablet 2 mg, 5 mg Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG (Trihexyphenidyl HCl) QL (30 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 28 days) QL (1 per 28 days) aripiprazole oral solution 1 mg/ml (Aripiprazole) QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Aripiprazole) tablet,disintegrating 10 mg 65

83 aripiprazole oral QL (60 per 30 days) (Aripiprazole) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) chlorpromazine oral tablet 10 mg, (Chlorpromazine 100 mg, 200 mg, 25 mg, 50 mg HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating ST 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg (Fazaclo) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 ST; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) ST; QL (8 per 28 days) fluphenazine decanoate injection (Fluphenazine solution 25 mg/ml Decanoate) fluphenazine hcl injection solution (Fluphenazine 2.5 mg/ml HCl) fluphenazine hcl oral concentrate 5 (Fluphenazine mg/ml HCl) fluphenazine hcl oral elixir 2.5 mg/5 (Fluphenazine ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg HCl) (Fluphenazine HCl) 66

84 GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol dec 50 mg/ml vial 50 mg/ml haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML (Haloperidol Decanoate) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) (Haloperidol) QL (6 per 28 days) QL (0.75 per 28 days) QL (1 per 28 days) QL (1.5 per 28 days) QL (0.25 per 28 days) QL (0.5 per 28 days) QL (0.875 per 84 days) QL (1.315 per 84 days) 67

85 INVEGA TRINZA QL (1.75 per 84 days) INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA QL (2.625 per 84 days) INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 QL (30 per 30 days) MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) molindone oral tablet 10 mg (Molindone HCl) QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 20 mg, 5 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg (Perphenazine) pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 200 mg (Seroquel XR) (Seroquel XR) ST; QL (60 per 30 days) ST; QL (30 per 30 days) 68

86 REXULTI ORAL TABLET 0.25 ST; QL (120 per 30 MG days) REXULTI ORAL TABLET 0.5 MG ST; QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, ST; QL (30 per 30 2 MG, 3 MG, 4 MG days) RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) risperidone oral QL (120 per 30 days) (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG ST; QL (60 per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 400 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) (Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl) ST; QL (60 per 30 days) PA NSO-HRM; AGE (Max 64 Years) ST; QL (540 per 30 days) ST; QL (30 per 30 days) ST; QL (7 per 30 days) 69

87 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG (Epzicom) (Trizivir) (Videx EC) QL (60 per 30 days) QL (2 per 28 days) QL (1 per 28 days) 70

88 EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG 71

89 nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG 72

90 SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 (Foscavir) mg/ml oseltamivir oral capsule 30 mg (Tamiflu) QL (84 per 180 days) oseltamivir oral capsule 45 mg (Tamiflu) QL (48 per 180 days) oseltamivir oral capsule 75 mg (Tamiflu) QL (42 per 180 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) 73

91 SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG ZEPATIER ORAL TABLET MG Interferons PA QL (84 per 180 days) QL (48 per 180 days) QL (42 per 180 days) QL (540 per 180 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) 74

92 INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir 1,000 mg/20 ml vial latexfree,sdv 50 mg/ml Sodium) (Acyclovir acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous recon (Acyclovir soln 500 mg Sodium) acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) PA NSO PA NSO PA NSO; QL (4 per 28 days) 75

93 famciclovir oral tablet 125 mg, 250 mg, 500 mg (Famvir) ganciclovir sodium intravenous recon soln 500 mg (Cytovene) ribasphere oral capsule 200 mg (Rebetol) ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VEMLIDY ORAL TABLET 25 MG VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) QL (30 per 30 days) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) 76

94 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin 25,000 unit/250 ml (100 unit/ml)-0.45% nacl bag latex-free, inner 25,000 unit/250 ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) (Arixtra) (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) (Coumadin) (Coumadin) QL (18 per 30 days) PA; QL (24 per 28 days) ST; QL (60 per 30 days) PA 77

95 EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) PA; QL (12 per 28 days) PA; QL (6 per 28 days) 78

96 PROMACTA ORAL TABLET 12.5 PA; QL (30 per 30 MG, 25 MG, 50 MG, 75 MG days) ZARXIO INJECTION SYRINGE ST 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg, 1 mg (Agrylin) protamine intravenous solution 10 mg/ml (Protamine Sulfate) tranexamic acid intravenous solution 1,000 mg/10 ml (100 (Tranexamic Acid) mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg (Cilostazol) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) EFFIENT ORAL TABLET 10 MG, QL (30 per 30 days) 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % 79

97 AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % 80

98 AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 81

99 CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cvs glucose 40% gel 3's 40 % * (Dextrose) dex4 glucose 4 gm tablet chew watermelon flavor 4 gram * (Dextrose) 82

100 dex4 glucose 40% gel 40 % * (Dextrose) dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous parenteral solution 10 Water) % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringers intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5 % In Ringers) (Dextrose 5 % in Water) (Dextrose 50 % in Water) (Dextrose 50 % in Water) (Dextrose 70 % in Water) gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, caffeine free 4 gram * (Dextrose) glutose 15 gel 3 pak, outer, u-d 40 % * (Dextrose) HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % 83

101 insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents (Dextrose/Dextrin/ Maltose) (Fat Emul/Soy/Mct/Oli v/fish Oil) 84

102 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-Tts 1) (Catapres-Tts 1) (Clonidine HCl/Chlorthalidon e) (Cardura) guanfacine oral tablet 1 mg, 2 mg (Tenex) midodrine oral tablet 10 mg, 2.5 mg, (Midodrine HCl) 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml (Vazculep) prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg (Atacand) candesartan-hydrochlorothiazid oral tablet mg, mg, (Atacand HCT) mg ENTRESTO ORAL TABLET MG, MG, MG irbesartan oral tablet 150 mg, 300 mg, 75 mg (Avapro) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (180 per 30 days) QL (60 per 30 days) 85

103 irbesartan-hydrochlorothiazide oral tablet mg, mg (Avalide) losartan oral tablet 100 mg, 25 mg, 50 mg (Cozaar) losartan-hydrochlorothiazide oral tablet mg, mg, 50- (Hyzaar) 12.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) telmisartan-hydrochlorothiazid oral tablet mg, mg, 80- (Micardis HCT) 25 mg TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg (Diovan) valsartan-hydrochlorothiazide oral tablet mg, mg, 320- (Diovan HCT) 12.5 mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Lotensin) benazepril-hydrochlorothiazide oral tablet mg, mg, 20- (Lotensin HCT) 25 mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg (Captopril) captopril-hydrochlorothiazide oral (Captopril/Hydroch tablet mg, mg, lorothiazide) mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg (Vasotec) enalaprilat intravenous solution (Enalaprilat 1.25 mg/ml Dihydrate) enalapril-hydrochlorothiazide oral tablet mg, mg (Vaseretic) 본문서의XII-XIII페이지에서이테이블에있는기호및약어에대한정보를보실수있습니다. 86

104 fosinopril oral tablet 10 mg, 20 mg, (Fosinopril 40 mg Sodium) fosinopril-hydrochlorothiazide oral (Fosinopril/Hydroc tablet mg, mg hlorothiazide) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Zestril) lisinopril-hydrochlorothiazide oral tablet mg, mg, 20- (Zestoretic) 25 mg moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet mg, mg, 7.5- hlorothiazide) 12.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg (Aceon) QBRELIS ORAL SOLUTION 1 MG/ML quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Accupril) quinapril-hydrochlorothiazide oral tablet mg, mg, 20- (Accuretic) 25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg (Altace) trandolapril oral tablet 1 mg, 2 mg, 4 mg (Mavik) Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg (Cordarone) disopyramide phosphate oral capsule 100 mg, 150 mg (Norpace) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg (Tikosyn) flecainide oral tablet 100 mg, 150 mg, 50 mg (Tambocor) lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) (Lidocaine HCl/PF) ST 87

105 lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg atenolol-chlorthalidone oral tablet mg, mg (Lidocaine HCl/D5w/PF) (Mexiletine HCl) (Cordarone) (Procainamide HCl) (Rythmol SR) (Rythmol) (Quinidine Gluconate) (Quinidine Sulfate) (Quinidine Sulfate) (Sectral) (Tenormin) (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg (Betaxolol HCl) bisoprolol fumarate oral tablet 10 mg, 5 mg (Zebeta) bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg (Ziac) 88

106 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG BYVALSON ORAL TABLET 5-80 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 100 mg, 200 mg, 300 mg (Trandate) metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 (Toprol XL) mg, 50 mg metoprolol succinate oral tablet extended release 24 hr 200 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, (Lopressor HCT) mg metoprolol tartrate intravenous (Metoprolol solution 5 mg/5 ml Tartrate) metoprolol tartrate intravenous (Metoprolol syringe 5 mg/5 ml Tartrate) metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Lopressor) nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg pindolol oral tablet 10 mg, 5 mg (Pindolol) propranolol intravenous solution 1 mg/ml (Propranolol HCl) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 (Inderal LA) mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) 89

107 propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet mg, mg chlorothiazid) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg (Betapace) sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 10 mg, 20 mg, 5 mg (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 (Cardizem CD) mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg (Cardizem CD) diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) diltiazem hcl intravenous recon soln 100 mg (Diltiazem HCl) diltiazem hcl intravenous solution 5 mg/ml (Diltiazem HCl) diltiazem hcl oral capsule, extended release 180 mg, 360 mg (Cardizem CD) diltiazem hcl oral capsule, extended release 420 mg (Tiazac) diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg (Diltiazem HCl) diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 (Cardizem CD) mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg (Cardizem) 90

108 diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Cardizem LA) (Diltiazem HCl) (Cardizem LA) (Tiazac) (Verapamil HCl) (Verelan Pm) (Verelan) (Calan) (Calan SR) digitek oral tablet 125 mcg (Lanoxin) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) 91

109 digitek oral tablet 250 mcg (Lanoxin) digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) (Digoxin) digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Lanoxin) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) 92

110 dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) epinephrine 0.3 mg auto-inject outer 0.3 mg/0.3 ml epinephrine hcl (pf) injection solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection auto-injector 0.15 mg/0.3 ml epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml (Dobutamine HCl/D5W) (Dobutamine HCl) (Dopamine HCl/D5W) (Dopamine HCl) (Epipen 2-Pak) (Epinephrine HCl/PF) (Epipen 2-Pak) (Epipen 2-Pak) (Epinephrine) (Hydralazine HCl) QL (4 per 30 days) QL (4 per 30 days) QL (4 per 30 days) QL (4 per 30 days) QL (4 per 30 days) 93

111 hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN ORAL TABLET MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg, mg (Hydralazine HCl) (Milrinone Lactate/D5W) (Milrinone Lactate) (Levophed Bitartrate) (Adalat CC) (Norvasc) (Lotrel) (Exforge) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (60 per 30 days); AGE (Max 64 Years) 94

112 amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) mg AZOR ORAL TABLET MG, MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg (Felodipine) isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine er 60 mg tablet f/c 60 mg (Adalat CC) nifedipine oral tablet extended release 24hr 30 mg, 60 mg (Adalat CC) nifedipine oral tablet extended release 24hr 90 mg (Procardia XL) Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, 1 mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG 95

113 furosemide injection solution 10 mg/ml (Furosemide) furosemide injection syringe 10 mg/ml (Furosemide) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) indapamide oral tablet 1.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 10 mg, 2.5 mg, 5 mg (Zaroxolyn) spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule mg, mg (Dyazide) triamterene-hydrochlorothiazid oral tablet mg, mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, (Caduet) mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) cholestyramine light oral powder in packet 4 gram (Questran) 96

114 cholestyramine light packet 4 gram (Cholestyramine/A spartame) cholestyramine packet outer 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 (Lofibra) mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg (Lofibra) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG JUXTAPID ORAL CAPSULE 5 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 40 mg (Lovastatin) niacin 50 mg caplet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) niacin 500 mg tablet 500 mg * (Slo-Niacin) PA; QL (30 per 30 days) PA; QL (90 per 30 days) PA; QL (45 per 30 days) PA; QL (4 per 28 days) QL (30 per 30 days) 97

115 niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg (Niaspan) niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram (Cholestyramine/A spartame) prevalite packet outer 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Cholestyramine/A spartame) (Crestor) (Zocor) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 QL (240 per 30 days) GRAM VASCEPA ORAL CAPSULE 1 QL (120 per 30 days) GRAM 98

116 WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) TEKAMLO ORAL TABLET MG, MG, MG, MG TEKTURNA HCT ORAL TABLET MG, MG, MG, MG TEKTURNA ORAL TABLET 150 MG, 300 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg (Isochron) isosorbide dinitrate oral tablet extended release 40 mg (Isochron) isosorbide mononitrate oral tablet (Isosorbide 10 mg, 20 mg Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 (Imdur) mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil) NITRO-BID TRANSDERMAL OINTMENT 2 % ST ST ST QL (30 per 30 days) QL (60 per 30 days) 99

117 nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 14 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG (Nitroglycerin/D5 W) (Nitroglycerin) (Nitrostat) (Nitro-Dur) (Nitro-Dur) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (28 per 28 days) PA PA PA PA 100

118 caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended release 12 hr 0.1 mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG flumazenil intravenous solution 0.1 mg/ml GILENYA ORAL CAPSULE 0.5 MG guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML lithium carbonate oral capsule 150 mg, 300 mg, 600 mg (Cafcit) (Caffeine Citrate) (Kapvay) (Focalin) (Dexedrine) (Dexedrine) (Adderall XR) (Adderall XR) (Adderall) (Romazicon) (Intuniv) (Lithium Carbonate) PA QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA PA; QL (28 per 28 days) PA 101

119 lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg, 40 mg methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg, 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA ORAL CAPSULE MG PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML (Lithobid) (Lithobid) (Lithium Citrate) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Methylin) (Ritalin) (Methylphenidate HCl) (Concerta) (Concerta) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA PA 102

120 REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Contraceptives Contraceptives altavera (28) oral tablet mg (Amethyst) PA PA PA QL (60 per 30 days) QL (60 per 30 days) PA; QL (14 per 30 days) PA; QL (60 per 30 days) PA; QL (112 per 28 days) PA; QL (1 per 28 days) 103

121 alyacen 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) (Seasonique) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) apri oral tablet mg (Desogen) aranelle (28) oral tablet 0.5/1/ mg-mcg (Modicon) ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet mg-mcg (Amethyst) aviane oral tablet mg-mcg (Amethyst) azurette (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet mgmcg (Modicon) bekyree (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) blisovi fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) briellyn oral tablet mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (Seasonique) (7) QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) 104

122 camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg cryselle (28) oral tablet mgmcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Seasonique) (Desogen) (Norgestrel-Ethinyl Estradiol) (Modicon) (Modicon) cyred oral tablet mg (Desogen) dasetta 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet mg (Desogen) drospirenone-ethinyl estradiol oral tablet mg, mg (Yaz) econtra ez 1.5 mg tablet inner 1.5 mg * (Aftera) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) elinest oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg (Desogen) enpresse oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet mg (Desogen) 105

123 errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet mg-mcg (Ortho-Cyclen) ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg (Demulen ) fallback solo 1.5 mg tablet outer 1.5 mg * (Aftera) falmina (28) oral tablet mgmcg (Amethyst) femynor oral tablet mg-mcg (Ortho-Cyclen) gianvi (28) oral tablet mg (Yaz) gildagia oral tablet mg-mcg (Modicon) gildess 1.5/30 (21) oral tablet (Loestrin) mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) heather oral tablet 0.35 mg (Nor-Q-D) introvale oral tablets,dose pack,3 (Levonorgestrelmonth 0.15 mg-30 mcg Ethin Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 (Levonorgestrelmonth 0.15 mg-30 mcg Ethin Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet mg (Desogen) junel 1.5/30 (21) oral tablet mg-mcg (Loestrin) junel 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) 106

124 junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen ) kimidess (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) kurvelo oral tablet mg (Amethyst) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) larin 1.5/30 (21) oral tablet mg-mcg (Loestrin) larin 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) larissia oral tablet mg-mcg (Amethyst) leena 28 oral tablet 0.5/1/ mg-mcg (Modicon) lessina oral tablet mg-mcg (Amethyst) levonest (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) levonor-eth estrad outer mg (Amethyst) levonorgestrel 1.5 mg tablet (otc) 1.5 mg * (Aftera) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Amethyst) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) 107

125 levonorgestrel-ethinyl estrad oral QL (91 per 84 days) tablets,dose pack,3 month 0.15 mg- 30 mcg (Amethyst) levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet mg (Yaz) low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet mg (Amethyst) microgestin 1.5/30 (21) oral tablet mg-mcg (Loestrin) microgestin 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) (Loestrin Fe) mono-linyah oral tablet mgmcg (Ortho-Cyclen) mononessa (28) oral tablet mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet mg-mcg (Modicon) necon 1/35 (28) oral tablet 1-35 mgmcg (Modicon) necon 1/50 (28) oral tablet 1-50 mgmcg (Norinyl 1+50) 108

126 necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg (Modicon) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) next choice one dose 1.5 mg tb (otc) QL (6 per 365 days) (Aftera) 1.5 mg * nikki (28) oral tablet mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) norg-ee / x28 day regimen 0.18/0.215/0.25 mg-35 (Ortho-Cyclen) mcg (28) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, (Ortho-Cyclen) mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg (Modicon) nortrel 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) NUVARING VAGINAL RING ST; QL (1 per 28 days) MG/24 HR ocella oral tablet mg (Yaz) ogestrel (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * option mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) 109

127 orsythia oral tablet mg-mcg (Amethyst) philith oral tablet mg-mcg (Modicon) pimtrea (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg (Modicon) portia oral tablet mg (Amethyst) previfem oral tablet mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) react 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet mg (Desogen) setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) sprintec (28) oral tablet mgmcg (Ortho-Cyclen) sronyx oral tablet mg-mcg (Amethyst) syeda oral tablet mg (Yaz) tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) 110

128 trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg (Desogen) vestura (28) oral tablet mg (Yaz) vienva oral tablet mg-mcg (Amethyst) viorele (28) oral tablet mgx21 /0.01 mg x 5 (Mircette) vyfemla (28) oral tablet mgmcg (Modicon) wera (28) oral tablet mg-mcg (Modicon) xulane transdermal patch weekly (Norelgestromin/Et mcg/24 hr hin.estradiol) zarah oral tablet mg (Yaz) zenchent (28) oral tablet mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen ) zovia 1/50e (28) oral tablet 1-50 mg-mcg (Demulen ) Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-150gfn-15dm liquid mg/5 ml * 3brm-15dm-30pse liquid mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) QL (3 per 28 days) 111

129 3brm-30dm-50pse liquid (otc) mg/5 ml * (Neo Dm) actinel pediatric liquid mg/5 ml * (Trispec Pse) adt robitussin peak cld dm max mg/5 ml * (G-Zyncof) adult robitussin peak cold liq nondrowsy mg/5 ml * (G-Zyncof) adult wal-tussin dm max liq (G-Zyncof) a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup (Cough Formula a/f,s/f,chry-menthol mg/5 ml Dm) * adult wal-tussin liquid 100 mg/5 ml * (Guaifenesin) alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr 200 mg * omethorphan) (Dall-nite liquid ,000 mg/30 Methorphan/Aceta ml * min/doxylamn) ambi 10peh-4cpm-20dm tablet (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 100 mg capsule 100 mg * (Zonatuss) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid mg/5 ml * (Neo Dm) bionel pediatric liquid mg/5 ml * (Trispec Pse) 112

130 biospec dmx liquid mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) mg/5 ml * seudoephedrine) bromfed dm cough syrup (Brompheniramine/ 3 $0 mg/5 ml * Pseudoephed/Dm) bromphenir-pseudoephed-dm syr (Brompheniramine/ 3 $0 (rx) mg/5 ml * Pseudoephed/Dm) (Brompheniramine/ brotapp dm liquid mg/5 ml * Pseudoephed/Dm) centergy dm pediatric drops (Chlorpheniramine/ 3 $0 mg/ml * Phenyleph/Dm) cheratussin ac syrup (otc) (M-Clear Wc) mg/5 ml * cheratussin dac syrup (Tusnel C) mg/5 ml * child plus cough-runny nose cherry (Dextromethorphn/ flavor mg/5 ml * Acetaminoph/Cp) child robitussin er 30 mg/5 ml 30 (Delsym) mg/5 ml * child sudafed pe cough-cold lq (Dextromethorphan mg/5 ml * /Phenylephrine) child triaminic cgh-congst syr (Cough Formula mg/5 ml * Dm) (Dextromethorphan child wal-tussin 7.5 mg odt 7.5 mg * Hbr) children's mucinex cough liq a/f 5- (G-Zyncof) 100 mg/5 ml * children's silfedrine liq 15 mg/5 ml (Pseudoephedrine * HCl) chl mucinex chest congest liq a/f (Guaifenesin) 100 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * codituss dm syrup mg/5 (Pseudoephedrine (Pyrilamine/Pe/De ml * HCl) xtromethorphan) 113

131 cold multi-symptom day-night pseudoephedrine-free mg * cold multi-symptom night liq a/f, honey lemon mg/15 ml * cold relief multi-symp caplet cplt,12 day,12 night mg * cold-flu relief d/n softgel mg(d)/ mg * cold-flu relief liquid ,000 mg/30 ml * (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm/Pe/Acetamino phen/doxylamine) (Dm Hb/Pe/Acetaminop hen/chlorph) (Vicks Dayquil- Nyquil) (D- Methorphan/Aceta min/doxylamn) congestac tablet mg * (Poly-Vent Ir) congest-eze mg caplet mg * (Poly-Vent Ir) coricidin hbp cold-multi sympt mg/15 ml * (D- Methorphan/Aceta min/doxylamn) coricidin hbp softgel mg * (Guaifenesin/Dextr omethorphan) cough & cold tablet 4-30 mg * (Coricidin Hbp) cough relief liquid 15 mg/5 ml * (Dextromethorphan Hbr) cvs chest cong relief pe tab mg * (Maxiphen) cvs chest congest + cough liq mg/5 ml * (G-Zyncof) cvs chest congest relief dm tb mg * (Allfen Dm) cvs child cold-cough day liq (Dextromethorphan mg/5 ml * /Phenylephrine) cvs child cough & runny nose 1-5- (Dextromethorphn/ 160 mg/5 ml * Acetaminoph/Cp) cvs child cough dm er 30 mg/5 30 mg/5 ml * (Delsym) 114

132 cvs child's chest congest liq 100 mg/5 ml * (Guaifenesin) cvs cough & sore throat susp (Child Tylenol Plus mg/5 ml * Cough-Sore) cvs nighttime cough liquid cherry (Dextromethorphan flavor mg/15 ml * Hb/Doxylamine) cvs tussin cf liquid a/f, non drowsy mg/5 ml * (Maxiphen Dmx) cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * (Robitussin) cvs tussin dm cough-chest liq mg/5 ml * (G-Zyncof) daytime cold & cough liquid 1, mg/30 ml * (Triaminic) daytime cough liquid a/f, gluten-free (Dextromethorphan 5 mg/5 ml * Hbr) daytime-nighttime cold-flu liq multisymptom mg/15 ml * phen/doxylamine) (Dm/Pe/Acetamino daytime-nighttime cough liquid (Dextromethorphan 15mg/15ml(d)/ mg/30ml * Hb/Doxylamine) delsym cough+chest cngst dm lq mg/5 ml * (G-Zyncof) despec-dm tablet mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq mg/5 ml * (G-Zyncof) diabetic tussin ex liquid a/f,d/f,na/f,s/f 100 mg/5 ml * (Guaifenesin) DIMETAPP LONG-ACTING COUGH LIQ MG/5 ML * ed bron gp liquid mg/5 ml * (Rescon-Gg) entre-cough liquid mg/5 ml * (Trispec Pse) 115

133 expectorant 100 mg/5 ml syrup 100 mg/5 ml * (Guaifenesin) expectorant dm cough liquid mg/5 ml * (G-Zyncof) expectorant max cough-cold (Dextromethorphan mg/5 ml * /Pseudoephed) flu hbp tablet mg * (Coricidin Hbp) g tussin ac liquid mg/5 ml * (M-Clear Wc) geri-tussin dm syrup mg/5 (Cough Formula ml * Dm) guaifenesin 200 mg tablet (otc) 200 mg * (Allfen) guaifenesin er 1,200 mg tablet 1,200 (Mucinex) mg * guaifenesin er 600 mg tablet 600 mg * (Mucinex) head congestion day-night pack mg * hydrocodone-chlorphen er susp 10-8 mg/5 ml * hydrocodone-homatropine mg tablet mg * hydrocodone-homatropine syrup mg/5 ml * hydromet syrup mg/5 ml * (Dm Hb/Pe/Acetaminop hen/chlorph) (Tussionex) 3 $0 (Tussigon) 3 $0 (Hydrocodone Bit/Homatrop Me- Br) (Hydrocodone Bit/Homatrop Me- Br) 3 $0 3 $0 iophen-c nr liquid mg/5 ml * (M-Clear Wc) kidkare cough & cold liquid (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) liquibid d-r tablet mg * (Maxiphen) lohist-dm syrup mg/5 ml * (Ala-Hist Dm) lortuss ex liquid mg/5 ml * (Tusnel C) 116

134 mar-cof bp liquid mg/5 ml (Bromphenira/Pseu * doephed/codein) mar-cof cg liquid mg/5 ml * (M-Clear Wc) MUCINEX FAST-MAX COLD- FLU-THRT MG * mucinex fast-max dm max liquid (G-Zyncof) maximum strength mg/5 ml * mucus dm mg tablet (Mucinex Dm) mg * mucus dm max 1, mg tab 60- (Mucinex Dm) 1,200 mg * mucus relief 400 mg tablet d/f 400 (Allfen) mg * nasal-sinus decongest tab 30 mg * (Sudafed 12-Hour) NEO DM SYRUP MG/5 ML * neo-tuss liquid mg/5 ml * (G-Zyncof) (Dm/Pnight time cold med liquid Ephed/Acetaminop mg/15 ml * h/doxylam) night time cough & sore throat ,000 mg/30 ml * nohist-dm liquid mg/5 ml * pecgen dmx mg/5 ml liq mg/5 ml * pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * promethazine vc-codeine syrup mg/5 ml * promethazine-codeine syrup mg/5 ml * (D- Methorphan/Aceta min/doxylamn) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) 3 $0 3 $0 117

135 promethazine-dm syrup mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime mg/15 ml * pv night-time softgel multisympt.,softgel mg * (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 (Sudafed 12-Hour) (Sudafed 12-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid mg/5 ml * (Rescon-Gg) q-tussin 100 mg/5 ml solution a/f, non-drowsy 100 mg/5 ml * (Guaifenesin) q-tussin dm syrup mg/5 ml * (Cough Formula Dm) ra anti-tussive dm syrup (Cough Formula mg/5 ml * Dm) (Dra day cold-flu relief softgel a/f, Methorphan/Pe/Ac multi-symptom mg * etaminophen) ra daytime cold-flu liquid a/f,antihist free mg/15 ml * ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * (D- Methorphan/Pe/Ac etaminophen) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) 118

136 refenesen 400 mg tablet 400 mg * (Allfen) refenesen pe caplet mg * (Maxiphen) relcof c liquid mg/5 ml * (M-Clear Wc) REZIRA SOLUTION 60-5 MG/5 ML * 3 $0 robafen 100 mg/5 ml syrup 100 mg/5 ml * (Guaifenesin) robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * (Robitussin) robafen dm clear oral syrup mg/5 ml * robafen-dm syrup mg/5 ml * (Cough Formula Dm) robitussin cough-chest-cong dm 10- (Guaifenesin/Dextr 200 mg * omethorphan) ROBITUSSIN LONG-ACTING LIQ MG/5 ML * robitussin pediatric cough syp (Dextromethorphan a/f,long-acting 7.5 mg/5 ml * Hbr) rydex liquid mg/5 ml * (Bromphenira/Pseu doephed/codein) rynex dm liquid a/f, prof use only 1- (Brompheniram/Ph mg/5 ml * enylephrine/dm) safetussin dm liquid mg/5 ml * (G-Zyncof) scot-tussin 100 mg/5 ml liq 100 (Guaifenesin) mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * sm adult nasal decongestant lq 15 mg/5 ml * sm cold & cough liquid children's, day time mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * (Vicks Children'S Nyquil) (Guaifenesin) (Pseudoephedrine HCl) (Dextromethorphan /Phenylephrine) (Vicks Children'S Nyquil) 119

137 sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm nite time cold-flu liquid ,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) (Chlorpheniramin/ Pseudoephed/Dm) (Dm/Pseudoephed/ sm pedia relief liquid mg/5 ml * sm severe cold m-s caplet mg * Acetaminophen) sm tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) sudafed 30 mg tablet nondrowsy,max-str 30 mg * (Sudafed 12-Hour) sudogest 30 mg tablet boxed 30 mg * (Sudafed 12-Hour) sudogest 60 mg tablet 60 mg * (Sudafed 12-Hour) suphedrin liquid 15 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ mg * Dm/Acetamin/Gg) triaminic daytime cold-cough (Dextromethorphan children's, cherry mg/5 ml * /Phenylephrine) tusnel diabetic liquid (otc) mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * 120

138 tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap mg * seudoephedrine) tussin dm syrup mg/5 ml * (Cough Formula Dm) vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) vicks nature fusion cough liq 5 mg/5 (Dextromethorphan ml * Hbr) (Dvicks nyquil liquicaps cold & flu Methorphan/Aceta mg * min/doxylamn) virtussin dac liquid mg/5 ml * (Tusnel C) v-r infant non-asa cold drp (Dm/Pseudoephed/ mg/1.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) (Dwal-flu severe cold-cough pckt 10- Methorphan/Pe/Ac mg * etaminophen) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ caplet mg * Dm/Acetamin/Gg) wal-tussin cough 15 mg softgel 15 mg * (Robitussin) wal-tussin max str cough syrup (Dextromethorphan maximum strength 15 mg/5 ml * Hbr) zephrex-d 30 mg tablet 30 mg * (Sudafed 12-Hour) zyncof mg/5 ml liquid mg/5 ml * (G-Zyncof) 121

139 Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane mouthwash 0.12 % oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide dental paste 0.1 % (Peridex) (Triamcinolone Acetonide) (Peridex) (Salagen) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% gel 10 % * (Benzoyl Peroxide) acne medication 10% lotion 10 % * (Benzoyl Peroxide) acne medication 5% gel 5 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acyclovir topical ointment 5 % (Zovirax) QL (5 per 4 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS (Ammonium amlactin 12% lotion 12 % * Lactate) ammonium lactate 12% cream (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate 12% lotion (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate topical cream 12 (Ammonium % Lactate) 122

140 ammonium lactate topical lotion 12 (Ammonium % Lactate) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (Benzoyl Peroxide) (otc) 10 % * benzoyl peroxide 5% gel aqueous (Benzoyl Peroxide) (otc) 5 % * BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % (Calcipotriene) calcipotriene topical cream % (Dovonex) calcipotriene topical ointment (Calcipotriene) % calcitrene topical ointment % (Calcipotriene) calcitriol topical ointment 3 (Vectical) mcg/gram CASTELLANI PAINT 1.5% COLORLESS 1.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML (Coleman 100 Max cutter backwoods 25% spray 25 % * Insect Repel) (Coleman 100 Max cutter skinsations 7% spray 7 % * Insect Repel) cvs skin treatment body lotion 12 % (Ammonium * Lactate) diclofenac sodium topical gel 3 % (Solaraze) PA PA PA PA QL (340 per 180 days) QL (354 per 180 days) 123

141 fluorouracil topical cream 0.5 %, 5 % (Carac) fluorouracil topical solution 2 %, 5 % (Fluorouracil) geri-hydrolac 12% lotion 12 % * (Ammonium Lactate) geri-hydrolac 5% lotion 5 % * (Ammonium Lactate) imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) INSECT REPELLENT 20% QL (236 per 180 days) SPRAY 20 % * LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 10 mg (Oxsoralen-Ultra) NATRAPEL 20% SPRAY 20 % * QL (354 per 180 days) off active 15% spray 15 % * (Coleman 100 Max QL (340 per 180 days) Insect Repel) off deep woods 25% spray 25 % * (Coleman 100 Max QL (340 per 180 days) Insect Repel) off deep woods dry 25% spray 25 % (Coleman High- QL (226 per 180 days) * Dry Insect Repel) off familycare 15% rplnt i spr 15 % (Coleman High- QL (142 per 180 days) * Dry Insect Repel) PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 % * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox topical solution 0.5 % (Condylox) potassium hydroxide topical (Potassium solution 5 % Hydroxide) pv acne pimple 10% gel 10 % * (Benzoyl Peroxide) repel sportsmen 25% spray 25 % * (Coleman 100 Max QL (368 per 180 days) Insect Repel) 124

142 repel sportsmen max 40% spray 40 (Coleman 100 Max % * Insect Repel) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ 80 MG/ML AUTOINJECTOR P/F,LATEX- FREE,OUTER 80 MG/ML TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg zinc oxide 20% ointment 20 % * (Boudreauxs) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Cleocin T) cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * (Neomycin Su/Bacitrac Zn/Poly) QL (368 per 180 days) PA PA PA 125

143 ery pads topical swab 2 % (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical (Erythromycin solution 2 % Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab 2 % Base/Ethanol) gentamicin topical cream 0.1 % (Gentamicin Sulfate) gentamicin topical ointment 0.1 % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, 1 % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) silver nitrate topical ointment 10 % (Silver Nitrate) silver nitrate topical solution 10 %, 25 %, 50 % (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % (Silvadene) sulfacetamide sodium (acne) topical suspension 10 % (Klaron) (Neomycin triple antibiotic ointment 3.5mg-400 Su/Bacitrac unit- 5,000 unit/gram * Zn/Poly) 126

144 Dermatological Anti- Inflammatory Agents ala-cort topical cream 1 %, 2.5 % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) (Alclometasone alclometasone topical cream 0.05 % Dipropionate) alclometasone topical ointment 0.05 (Alclometasone % Dipropionate) anti-itch 1% lotion 1 % * (Cortizone-10) aquanil hc 1% lotion 1 % * (Cortizone-10) beta hc 1% lotion 1 % * (Cortizone-10) betamethasone valerate topical (Luxiq) foam 0.12 % betamethasone, augmented topical (Diprolene AF) cream 0.05 % betamethasone, augmented topical (Diprolene) lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) (Clobetasol clobetasol scalp solution 0.05 % Propionate) clobetasol topical foam 0.05 % (Olux) betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0.1 % lotion 0.1 % ointment 0.1 % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 127

145 clobetasol topical gel 0.05 % (Clobetasol Propionate) clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0.1 % (Cloderm) cormax scalp solution 0.05 % (Clobetasol Propionate) cortaid 1% cream 12 hr, anti-itch 1 % * (Hydrocortisone) cortizone-10 1% creme maximum strength 1 % * (Hydrocortisone) cortizone-10 1% ointment 1 % * (Hydrocortisone) dermarest eczema 1% lotion 1 % * (Cortizone-10) desonide topical cream 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) fluocinonide 0.05% cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluocinonide-e topical cream 0.05 % (Vanos) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 % (Ultravate) 128

146 halobetasol propionate topical ointment 0.05 % (Ultravate) hydro skin 1% lotion 1 % * (Cortizone-10) hydrocortisone 0.5% cream (otc) 0.5 % * (Hydrocortisone) hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone 1% cream maximum strength (otc) 1 % * (Hydrocortisone) hydrocortisone 1% cream maximum (Hydrocortisone strength 1 % * Acetate) hydrocortisone 1% lotion (otc) 1 % * (Cortizone-10) hydrocortisone 1% ointment carton (otc) 1 % * (Hydrocortisone) hydrocortisone buty 0.1% cream 0.1 % (Locoid) hydrocortisone butyrate topical ointment 0.1 % (Locoid) hydrocortisone butyrate topical solution 0.1 % (Locoid) hydrocortisone butyr-emollient topical cream 0.1 % (Locoid) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream 0.2 % Valerate) hydrocortisone valerate topical (Hydrocortisone ointment 0.2 % Valerate) mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % (Elocon) neosporin 1% anti-itch cream 1 % * (Hydrocortisone) prednicarbate topical cream 0.1 % (Dermatop) 129

147 prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) procto-pak topical cream with perineal applicator 1 % (Hydrocortisone) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) recort plus 1% cream 1 % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical (Triamcinolone cream %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion %, 0.1 % Acetonide) triamcinolone acetonide topical (Triamcinolone ointment %, 0.1 %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone Acetonide) tridesilon topical cream 0.05 % (Desowen) u-cort topical cream 1-10 % (Hydrocortisone Acetate/Urea) Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel PA (Retin-A Micro) with pump 0.04 %, 0.1 % tretinoin topical cream %, PA (Retin-A) 0.05 %, 0.1 % 130

148 tretinoin topical gel 0.01 %, %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * (Retin-A) (Piperonyl Butoxide/Pyrethrin s) cvs permethrin 1% lotion 1 % * (Nix) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * (Nix) sm lice treatment 1% crm rinse 1 % * (Nix) v-r lice cream rinse 1 % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 31GX5/ ML 31 GAUGE X 5/16 BD INSULIN SYR 0.5 ML 31GX5/16" 0.5 ML 31 GAUGE X 5/16 BD INSULIN SYR 1 ML 31GX5/16" 1 ML 31 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" BLADDER CONTROL PAD X- LONG 9'S,X-LONG * GAUZE PAD TOPICAL BANDAGE 2 X 2 " PA 131

149 GAUZE PADS, STERILE 2"X2" 2 X 2 " INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PANTILINERS PAD * PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG 132

150 FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT PA PA; LA PA QL (90 per 30 days) 133

151 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetracaine HCl) altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % (Iopidine) artificial tears * (Dextran 70/Hypromellose) artificial tears 1.4 % drops 1.4 % * (Polyvinyl Alcohol) (Dextran artificial tears drops p/f, sterile /Hypromellose/P 0.3 % * F) artificial tears eye drops strl (Dextran % * 70/Hypromellose) ARTIFICIAL TEARS EYE OINTMENT % * atropine ophthalmic drops 1 % (Isopto Atropine) ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 137 mcg (0.1 %) (Astepro) azelastine ophthalmic drops 0.05 % (Azelastine HCl) (Dextran bion tears eye drops % * 70/Hypromellose/P F) carteolol ophthalmic drops 1 % (Carteolol HCl) cromolyn ophthalmic drops 4 % (Cromolyn Sodium) cvs artificial tears drops sterile 1- (Glycerin/Propylen 0.3 % * e Glycol) QL (30 per 25 days) 134

152 cvs lubricant 0.6% eye drops 0.6 % * cvs lubricant dry eye rlf 1% 1 % * (Propylene Glycol) (Carboxymethylcel lulose Sodium) cvs lubricant eye ointment p/f (Artificial Tears) 42.5 % * cvs lubricant gel eye drops (Carboxymethylcel % * l/hypromellose) cvs lubricating eye drops dry eye (Refresh Optive) soln % * cvs nasal spray 0.05% 0.05 % * (Afrin) cvs saline 0.65% nose spray 0.65 % (Little Remedies) * cyclopentolate ophthalmic drops 0.5 (Cyclogyl) %, 1 %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * (Isopto homatropaire ophthalmic drops 5 % Homatropine) genteal tears 0.1%-0.3% drop 0.1- (Dextran 0.3 % * 70/Hypromellose) 135

153 homatropine hbr ophthalmic drops 5 % ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % isopto tears 0.5% eye drops 0.5 % * (Isopto Homatropine) (Atrovent) (Atrovent) (Genteal Mild To Moderate) LACRISERT OPHTHALMIC INSERT 5 MG little remedies stuffy nose kt w/ nasal aspirator 0.65 % * (Little Remedies) lubricant % eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant % eye drops % * (Refresh Optive) lubricating plus 0.5% eye drps p/f, (Carboxymethylcel 30x0.4ml 0.5 % * lulose Sodium) lubrifresh pm eye ointment % * (Artificial Tears) mucinex sinus-max nasal spray full force 0.05 % * (Afrin) muro-128 2% eye drops 2 % * (Sodium Chloride) muro-128 5% eye drops 5 % * (Sodium Chloride) muro-128 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0.1 % (Naphazoline HCl) natural balance tears drops 0.4 % * (Genteal Mild To Moderate) nature's tears drops 0.4 % * (Genteal Mild To Moderate) neo-synephrine 12 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * (Little Remedies) olopatadine ophthalmic drops 0.1 % (Patanol) OTOVEL OTIC SOLUTION % (0.25 ML) QL (30 per 28 days) QL (15 per 10 days) 136

154 PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops 10 %, 2.5 % proparacaine ophthalmic drops 0.5 % pure & gentle eye drops lubricant 0.3 % * pv artificial tears 0.4 % * pv lubricant 1.4 % eye drops 1.4 % * pv pure-gentle eye drops sterile 0.3 % * REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * (Mydfrin) (Proparacaine HCl) (Genteal Mild To Moderate) (Genteal Mild To Moderate) (Polyvinyl Alcohol) (Genteal Mild To Moderate) retaine cmc 0.5% eye drops 0.5 % * (Carboxymethylcel lulose Sodium) retaine hpmc 0.3% eye drops 0.3 % * (Hypromellose/PF) retaine pm eye ointment % * (Artificial Tears) sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl % * (Systane Ultra) sochlor 5% eye drops 5 % * (Sodium Chloride) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) soothe night time lub eye oint % * (Artificial Tears) SYSTANE 0.3% EYE GEL 0.3 % * SYSTANE GEL EYE DROPS % * ST 137

155 tears again 1.4 % drops 1.4 % * (Polyvinyl Alcohol) tears again eye ointment % * (Artificial Tears) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f % * F) tears pure drops * (Dextran 70/Hypromellose) ultra fresh pm ointment * (Lanolin/Mineral Oil/Petrolatum) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 12 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment ,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) gentamicin ophthalmic drops 0.3 % (Garamycin) 138

156 gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic drops 0.5 % (Levofloxacin) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment ,000 Zn/Poly/HC) mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension , mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-1% neo-polycin ophthalmic ointment ,000 mg-unit-unit/g (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Bacitra/Polymy xin) ofloxacin ophthalmic drops 0.3 % (Floxin) 139

157 ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 (Polytrim) mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic (Sulfacetamide drops 10 % Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide ointment 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre ophthalmic drops 10 %-0.23 % dnisolone Sp) (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % (Bromfenac Sodium) dexamethasone sodium phosphate (Dexamethasone ophthalmic drops 0.1 % Sod Phosphate) ST 140

158 diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS MULTIDOSE OPHTHALMIC DROPS 0.05 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Gastrointestinal Agents Antiflatulents (Diclofenac Sodium) (Flunisolide) (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) QL (50 per 25 days) QL (5.5 per 30 days) QL (60 per 30 days) 141

159 bicarsim forte 125 mg tablet 125 mg * (Simethicone) cvs gas relief 125 mg chew tab extra strength 125 mg * (Gas-X) cvs gas relief 125 mg softgel softgel 125 mg * (Gas-X) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 125 mg chew tablet max str,lactose-free 125 mg * (Gas-X) gas relief 20 mg/0.3 ml drops dyefree 40 mg/0.6 ml * (Infants' Mylicon) gas relief 80 tablet chew 80 mg * (Gas-X) gas-x ultra strength softgel 180 mg * (Gas-X) mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 125 mg tab 125 mg * (Gas-X) simethicone 180 mg softgel 180 mg * (Gas-X) v-r anti-gas 166 mg softgel 166 mg * (Gas-X) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Cimetidine) 142

160 cvs acid reducer 150 mg tablet maximum strength 150 mg * (Zantac) cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 20 mg/2 ml vial latexfree, p/f, sdv 20 mg/2 ml (Famotidine/PF) famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) gnp acid reducer 10 mg tablet 10 mg * (Pepcid Ac) lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg (Prevacid) misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 14-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg (Prilosec) pantoprazole intravenous recon soln (Protonix IV) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) 143

161 pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl 50 mg/2 ml vial sdv 50 (Ranitidine HCl) mg/2 ml (25 mg/ml) ranitidine hcl injection solution 25 mg/ml (Ranitidine HCl) ranitidine hcl oral capsule 150 mg, 300 mg (Ranitidine HCl) ranitidine hcl oral syrup 15 mg/ml (Ranitidine HCl) ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * (Zantac) zantac 75 mg tablet 75 mg * (Zantac) Gastrointestinal Agents, Other acid gone antacid liquid mg/15 ml * (Gaviscon) almacone liquid mg/5 (Maalox Maximum ml * Strength) almacone-2 liquid mg/5 (Maalox Maximum ml * Strength) aluminum hydroxide gel sugar-free (Aluminum 320 mg/5 ml * Hydroxide) AMITIZA ORAL CAPSULE 24 MCG, 8 MCG anti-diarrheal 2 mg caplet caplet 2 mg * (Imodium A-D) bismatrol suspension 262 mg/15 ml * (Pepto-Bismol) BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * (Tums) QL (60 per 30 days) 144

162 calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * calcium antacid 750 mg tb chew gluten-free 300 mg (750 mg) * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * comfort gel suspension regular str, cherry mg/5 ml * constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml cvs antacid ultra tab chew ultra strength 400 mg calcium (1,000 mg) * cvs antacid-antigas tab chew 1, mg * cvs anti-diarrheal 2 mg sftgel softgel 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * cvs flavor chew antacid 750 mg 300 mg (750 mg) * (Tums) (Tums) (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) (Gastrocrom) (Tums) (Calcium Carbonate/Simethi cone) (Loperamide HCl) (Pepto-Bismol) (Tums) 145

163 cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) foaming antacid liquid mg/15 ml * (Gaviscon) GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400- (Maalox Maximum mg/5 ml * Strength) gelusil tablet chewable cool mint mg * (Almacone) generlac oral solution 10 gram/15 ml (Lactulose) geri-lanta liquid mg/5 (Maalox Maximum ml * Strength) glycopyrrolate injection solution 0.2 mg/ml (Robinul) glycopyrrolate oral tablet 1 mg, 2 mg (Robinul) imodium a-d 1 mg/7.5 ml liquid mint (Loperamide HCl) 1 mg/7.5 ml * imodium a-d 2 mg softgel 2 mg * (Loperamide HCl) kaopectate 262 mg/15 ml susp 262 mg/15 ml * (Pepto-Bismol) PA PA 146

164 kionex 15 gm/60 ml suspension gram/60 ml kionex oral powder (Sodium Polystyrene Sulfon/Sorb) (Sodium Polystyrene Sulfon/Sorb) lactulose oral solution 10 gram/15 (Lactulose) ml LINZESS ORAL CAPSULE 145 MCG, 290 MCG loperamide 1 mg/5 ml liquid 1 mg/5 (Loperamide HCl) ml * loperamide 1 mg/7.5 ml susp mint 1 (Loperamide HCl) mg/7.5 ml * loperamide oral capsule 2 mg (Loperamide HCl) maalox advanced suspension (Maalox Maximum regular strength mg/5 Strength) ml * magnesium 250 mg tablet p/f 250 (Magox 400) mg * magnesium 400 mg tablet glutenfree 400 mg * (Magox 400) magnesium oxide 500 mg tablet (Magox 400) p/f,s/f,lactose-free 500 mg * magnesium-oxide 400 mg tablet (Magox 400) 241.3mg elemental 400 mg * masanti liquid mg/5 ml (Maalox Maximum * Strength) medi-first pep-t-med tab chew 262 (Pepto-Bismol) mg * methscopolamine oral tablet 2.5 mg, metoclopramide hcl injection (Methscopolamine (Metoclopramide 5 mg solution 5 mg/ml Bromide) HCl) metoclopramide hcl oral solution 5 mg/5 ml (Metoclopramide HCl) QL (30 per 30 days) 147

165 metoclopramide hcl oral tablet 10 mg, 5 mg (Reglan) mgo 400 mg tablet 400 mg * (Magox 400) mi acid suspension (Maalox Maximum mg/5 ml, mg/5 ml * Strength) (Calcium mi-acid ds tablet mg * Carb/Magnesium Hydrox) mintox maximum strength susp max (Maalox Maximum str, lemon creme mg/5 Strength) ml * mintox plus tablet chewable mg * (Almacone) mintox suspension mint creme 200- (Maalox Maximum mg/5 ml * Strength) MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol) ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension mg/5 ml * (Maalox Maximum Strength) QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 148

166 riginic suspension mg/5 ml * (Gaviscon) ri-mox suspension mg/5 (Maalox Maximum ml * Strength) sm antacid anti-gas liquid (Maalox Maximum 30 mg/5 ml * Strength) sm foaming antacid tablet chew mg * (Gaviscon) sm stomach relief caplet 262 mg * (Kaopectate) sodium bicarb 650 mg tablet 10 gr (Sodium 650 mg * Bicarbonate) (Sodium sodium polystyrene (sorb free) oral Polystyrene suspension 15 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps (with sorbitol) oral suspension gram/60 ml (Sodium Polystyrene Sulfonate) (Kaopectate) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 10 mg suppository 10 mg * (Dulcolax) bisacodyl 10 mg suppository 10 mg * (Dulcolax) QL (30 per 30 days) ST; QL (60 per 30 days) 149

167 bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 10 mg suppository 10 mg * (Dulcolax) clearlax powder 14 once-daily doses (Gavilax) 17 gram/dose * cvs enema disposable 19-7 gram/118 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 100 mg mini enema 100 mg/5 ml * (Docusate Sodium) cvs purelax powder 14 once-daily doses 17 gram/dose * (Gavilax) cvs purelax powder packet s/f, 10 daily doses 17 gram * (Miralax) doc-q-lace 100 mg softgel 100 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml * (Docusate Sodium) docusate sodium 100 mg tablet crushable 100 mg * (Docusate Sodium) docusate sodium-senna tablet (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 100 mg softgel softgel 100 mg * (Colace) dok 100 mg tablet 100 mg * (Docusate Sodium) dulcolax ss 100 mg softgel 100 mg * (Colace) enema disposable 19-7 gram/118 ml * (Enema) enema ready to use latex-free 19-7 gram/118 ml * (Enema) enemeez mini enema 5cc tubes, outer 283 mg/5 ml * (Docusate Sodium) enemeez plus mini enema outer mg/5 ml * (Docusol Plus) eq fiber therapy powder * (Psyllium Seed equalactin 500 mg tab chew 500 mg * (With Sugar)) (Calcium Polycarbophil) 150

168 evac-u-gen 8.6 mg tablet 8.6 mg * (Senokot) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy powder 2 gram/19 gram * (Citrucel) fiber-lax captabs 500mg polycarbophil 625 mg * (Fibercon) FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln gram (Golytely) gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram (Golytely) (Nulytely with Flavor Packs) glycolax powder 31 doses (otc) 17 gram/dose * (Gavilax) healthylax powder packet 14x17gm, outer 17 gram * (Miralax) hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * konsyl psyllium fiber packet orange, (Psyllium Husk gluten free 3.4 gram * (With Sugar)) kro gentlelax 17 gram powder 17 gram/dose * (Gavilax) magic bullet 10 mg suppos 10 mg * (Dulcolax) milk of magnesia suspension 400 (Milk Of mg/5 ml * Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon gram/15 ml * Phos,Di-Ba) 151

169 peg 3350-electrolytes oral recon soln gram, gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 100 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon gram/15 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 17 gram/dose Glycol 3350) polyethylene glycol 3350 oral (Polyethylene powder in packet 17 gram Glycol 3350) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (Gavilax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 17 gram * (Miralax) promolaxin 100 mg tablet 100 mg * (Docusate Sodium) pv fiber therapy powder * (Methylcellulose) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) qc mineral oil heavy * (Mineral Oil) ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * (Enema) ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * (Gavilax) reguloid powder * (Psyllium Seed (With Sugar)) senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) senna 8.6 mg tablet 8.6 mg * (Senokot) senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) 152

170 senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/15 ml syrup 60 mg/15 ml * (Docusate Sodium) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet s/f, 10 daily doses 17 gram * (Miralax) stool softener 240 mg softgel softgel 240 mg * (Surfak) SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) (Calcium magnebind 400 oral tablet Carbonate/Mag 1 mg Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG VELPHORO ORAL TABLET,CHEWABLE 500 MG 153

171 Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG (Urecholine) oxybutynin chloride oral syrup 5 (Oxybutynin mg/5 ml Chloride) oxybutynin chloride oral tablet 5 mg (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 (Ditropan XL) mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended (Trospium release 24hr 60 mg Chloride) trospium oral tablet 20 mg (Trospium Chloride) VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg (Uroxatral) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule,extended release 24hr 0.4 mg (Flomax) QL (30 per 30 days) 154

172 terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG deferoxamine injection recon soln 2 gram, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) (Terazosin HCl) (Desferal) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 10 mg (Fluoxymesterone) PA PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) 155

173 danazol oral capsule 100 mg, 200 mg, 50 mg oxandrolone oral tablet 10 mg, 2.5 mg testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr (Danazol) (Oxandrin) (Depo- Testosterone) (Testosterone Enanthate) (Testim) (Vogelxo) (Androgel) (Activella) (Vagifem) (Vivelle-Dot) (Climara) PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) 156

174 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG (Delestrogen) (Activella) (Estropipate) mimvey lo oral tablet mg (Activella) mimvey oral tablet mg (Activella) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, PA-HRM; AGE (Max 64 Years) 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET PA-HRM; AGE (Max MG (14)/ 0.625MG-5MG(14) 64 Years) PREMPRO ORAL TABLET MG, MG, MG, MG PA-HRM; AGE (Max 64 Years) raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 10 QL (18 per 28 days) MCG yuvafem vaginal tablet 10 mcg (Vagifem) QL (18 per 28 days) Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 100 mg (Hydrocortisone Sod Succinate) betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) cortisone oral tablet 25 mg (Cortisone Acetate) 157

175 dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone injection solution 10 mg/ml, 4 mg/ml Sod Phosphate) fludrocortisone oral tablet 0.1 mg (Fludrocortisone Acetate) hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg (Medrol) methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (Solu-Medrol) methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml (Prednisone) prednisone oral tablet 1 mg, 2.5 mg, (Prednisone) 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg (Prednisone) prednisone oral tablets,dose pack 10 (Prednisone) mg, 5 mg SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone suspension 10 mg/ml, 40 mg/ml Acetonide) Pituitary 158

176 desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG, 7.5 MG (PED) (DDAVP) (Desmopressin Acetate) (Desmopressin Acetate) (DDAVP) QL (15 per 30 days) QL (15 per 30 days) PA PA PA PA QL (1 per 84 days) 159

177 NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) PA PA PA PA PA PA PA 160

178 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml (Hydroxyprogester one Caproate) (Depo-Provera) (Depo-Provera) (Provera) (Megace) (Aygestin) (Progesterone) PA QL (1 per 28 days) QL (1 per 360 days) PA PA QL (10 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) 161

179 progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Prometrium) (Levothyroxine Sodium) (Levoxyl) (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG PA PA azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon (Azathioprine soln 100 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG 162

180 CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 mg/5 ml cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 100 mg, 25 mg, 50 mg (Sandimmune) (Neoral) (Neoral) (Sandimmune) (Neoral) PA PA PA PA PA 163

181 gengraf oral solution 100 mg/ml (Neoral) HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- PA UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PA PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS PA SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) PA 164

182 IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil hcl intravenous recon soln 500 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML (Arava) (Cellcept) (Cellcept) (Cellcept) (Cellcept) (Myfortic) OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PA; QL (18.76 per 28 days) PA PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 165

183 OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg STELARA INTRAVENOUS SOLUTION 130 MG/26 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML (Rapamune) PA PA PA PA PA 166

184 tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML (Hecoria) XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML PA; LA; QL (15 per 28 days) PA; QL (60 per 30 days) PA; QL (30 per 30 days) 167

185 CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 168

186 HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML 169

187 MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML QL (2 per 365 days) QL (2 per 365 days) 170

188 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML 171

189 TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) colocort rectal enema 100 mg/60 ml (Cortenema) QL (2 per 365 days) QL (1 per 365 days) 172

190 DELZICOL DR 400 MG CAPSULE 400 MG DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG DIPENTUM ORAL CAPSULE 250 MG hydrocortisone rectal enema 100 mg/60 ml LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 800 mg UCERIS RECTAL FOAM 2 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 (Cortenema) (Asacol Hd) % (Acetic Acid) LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution (Mannitol/Sorbitol g/100 ml Solution) water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml (Alendronate Sodium) ST QL (300 per 28 days) 173

191 alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) mg calcitonin (salmon) nasal QL (3.7 per 28 days) spray,non-aerosol 200 unit/actuation (Miacalcin) calcitriol intravenous solution 1 mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg (Zemplar) PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML 174

192 RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG QL (60 per 30 days) risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 30 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 mg BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER 1 GRAM/1.7 ML (Zometa) (Zoledronic Acid/Mannitol- Water) (Reclast) (Amifostine Crystalline) (Buspirone HCl) QL (100 per 300 days) PA PA 175

193 droperidol injection solution 2.5 mg/ml (Droperidol) ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg (Ergoloid Mesylates) EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML fomepizole intravenous solution 1 gram/ml (Fomepizole) FUSILEV INTRAVENOUS RECON SOLN 50 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg (Guanidine HCl) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg (Vistaril) INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEVEYIS ORAL TABLET 50 MG leucovorin calcium 200 mg vial sdv, (Leucovorin p/f, latex-free 200 mg Calcium) leucovorin calcium injection recon (Leucovorin soln 100 mg, 350 mg, 50 mg Calcium) leucovorin calcium oral tablet 10 (Leucovorin mg, 15 mg, 25 mg, 5 mg Calcium) levocarnitine (with sugar) oral (Levocarnitine solution 100 mg/ml (With Sugar)) levocarnitine oral tablet 330 mg (Carnitor) levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 100 mg/ml (Mesnex) PA; LA PA PA; QL (120 per 30 days) 176

194 MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MINERAL OIL HEAVY * ORENCIA CLICKJECT PA SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 180 mg (Mestinon) ra feminine care douche * (Acetic Acid) REMICADE INTRAVENOUS PA RECON SOLN 100 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS QL (60 per 30 days) SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) summer's eve dche-xtra clns 12's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 12's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML THALOMID ORAL CAPSULE 100 PA NSO; QL (60 per MG, 150 MG, 200 MG, 50 MG 30 days) THIOLA ORAL TABLET 100 MG topical light mineral oil * (Mineral Oil) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) 177

195 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 125 mg, 250 mg (Acetazolamide) acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.15 %, 0.2 % (Alphagan P) COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % (Metipranolol) PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % QL (2.5 per 25 days) 178

196 timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg calcium (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3-min chew tb 600 mg (1,500 mg)-400 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous syringe 100 mg/ml (10 %) (Timolol Maleate) (Timoptic-Xe) (Travoprost (Benzalkonium)) (Citracal-Vitamin D) (Calcium Citrate) (Calcium Vit D) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Calcium Carb/Vit D3/Minerals) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (30 per 30 days) 179

197 calcium citrate - vit d caplet caplet, (Citracal-Vitamin coated mg-unit * D) calcium gluconate 500 mg tab 45 (Calcium mg (500 mg) * Gluconate) calcium gluconate 648 mg tab 61 (Calcium mg (648 mg) * Gluconate) CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * CALTRATE D SOFT CHEW TAB CHOCOLATE TRUFFLE 600 MG (1,500 MG)-800 UNIT * citracal + d maximum caplet 315- (Citracal-Vitamin 250 mg-unit * D) citrus calcium + d tablet (Citracal-Vitamin mg-unit * D) cvs calcium citrate-vit d tab (Citracal-Vitamin mg-unit * D) cvs magnesium 250 mg tablet 250 mg * (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d10 %-0.45 % sodium chloride (Dextrose 10 % intravenous parenteral solution and 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % intravenous parenteral solution and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and intravenous parenteral solution 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 intravenous parenteral solution % NaCl) dextrose 10 % and 0.2 % nacl (Dextrose 10 % intravenous parenteral solution and 0.2 % NaCl) dextrose 5 %-lactated ringers (Dextrose 5%- intravenous parenteral solution Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 intravenous parenteral solution % NaCl) 180

198 dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Potassium Chloride/D5-0.2%NaCl) (Klor-Con-Ef) (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Potassium particles/crystals 10 meq Chloride) klor-con m15 oral tablet,er (Potassium particles/crystals 15 meq Chloride) 본문서의XII-XIII페이지에서이테이블에있는기호및약어에대한정보를보실수있습니다. 181

199 klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) klor-con sprinkle oral capsule, (Potassium extended release 10 meq, 8 meq Chloride) (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(1,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d (Calcium softgel, s/f, p/f 600 mg calcium- 200 Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 (Magnesium mg) * Gluconate) magnesium 250 mg tablet 250 mg * (Magnesium) magnesium 300 mg capsule 300 mg (Magnesium * Oxide/Magnesium) magnesium sulfate in d5w (Magnesium intravenous piggyback 1 gram/100 Sulfate/D5W) ml magnesium gluc 500 mg tablet 27 (Magnesium mg (500 mg) * Gluconate) magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml (Magnesium Sulfate in Water) (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) 182

200 natural calcium 500 mg tablet 500 (Calcium mg calcium (1,250 mg) * Carbonate) NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION 12'S,LATEX-FREE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 71.5 mg tablet 71.5 mg * (Slow-Mag) oralyte electrolyte soln * (Pedialyte) oralyte freezer pops * (Pedialyte) oysco d tablet mg-unit * (Calcium Carbonate/Vitamin D3) oysco-500 tablet 500 mg calcium (1,250 mg) * oyster shell calcium 500 mg tb 500mg elemental ca 500 mg calcium (1,250 mg) * oyster shell calcium-vit d tab 500 mg(1,250mg) -200 unit * (Calcium Carbonate) (Calcium Carbonate) (Calcium Carbonate/Vitamin D2) pediatric electrolyte solution * (Pedialyte) PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml (Potassium Acetate) 183

201 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con) (Klor-Con 10) (Klor-Con 10) (Potassium Chloride) 184

202 potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 10 meq tablet 10 meq potassium cl er 10 meq tablet f/c 10 meq ra cal 600-vit d3-min chew tab 600 mg calcium- 400 unit-40 mg * ra oyster shell-vitamin d tab s/f, p/f 250 (625)-125 mg-unit * (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) (Potassium Chloride/D5-0.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con 10) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Calcium Carbonate/Vitamin D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral (Ringers Solution) solution sm calcium citrate-vit d cplt caplet, gluten-free mg-unit * (Citracal-Vitamin D) 185

203 sm magnesium 250 mg tablet 250 mg * (Magnesium) sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml (Sodium Acetate) sodium bicarbonate intravenous (Sodium syringe 8.4 % (1 meq/ml) Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution 0.45 % 0.45 %) sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) sodium chloride 3 % intravenous (Sodium Chloride parenteral solution 3 % 3 %) sodium chloride 5 % intravenous (Sodium Chloride parenteral solution 5 % 5 %) sodium chloride intravenous parenteral solution 2.5 meq/ml (Sodium Chloride) sodium lactate intravenous solution 5 meq/ml (Sodium Lactate) sodium phosphate intravenous (Sodium Phos,Msolution 3 mmol/ml Basic-D-Basic) TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE QL (60 per 30 days) 186

204 ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION (Pulmicort) QL (12 per 28 days) QL (30 per 30 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) QL (21.2 per 28 days) QL (17.4 per 25 days) 187

205 SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION (Albuterol Sulfate) (Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER) QL (12 per 25 days) QL (11 per 25 days) QL (60 per 30 days) QL (25.8 per 28 days) QL (8 per 30 days) QL (30 per 30 days) 188

206 ipratropium bromide inhalation solution 0.02 % metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theophylline er 400 mg tablet 400 mg theophylline er 600 mg tablet 600 mg (Ipratropium Bromide) (Metaproterenol Sulfate) (Metaproterenol Sulfate) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline Anhydrous) QL (60 per 30 days) QL (4 per 28 days) QL (4 per 28 days) 189

207 theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 400 mg, 600 mg VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) (Acetadote) (Cromolyn Sodium) (Nasalcrom) PA QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) 190

208 OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg (Soma) (Parafon Forte DSC) (Fexmid) (Dantrium) metaxall oral tablet 800 mg (Skelaxin) metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Skelaxin) (Robaxin) (Dantrium) (Zanaflex) tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg (Nuvigil) PA; QL (60 per 30 days) PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA 191

209 BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG SILENOR ORAL TABLET 3 MG, 6 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (30 per 30 days) QL (30 per 30 days) LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) 192

210 zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA 193

211 REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z advanced formula tab w/ lutein & lycopene mg-mcg-mcg-mcg * a thru z select 50+ formula tb advanced formula mgmcg-mcg * a thru z select men 50+ tablet mcg * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals/Lut) (Mv,Ca,Min/Iron Fum/Fa/Lyco/Lut) (Biocel) (Biocel) PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (400 per 365 days) 194

212 a thru z select multivit tab mcg * (Biocel) a thru z select multivit tab iron-free, 50+ form mg-mcg-mcg * (Biocel) a thru z select tablet new (Multivitamin with formulation * Minerals/Lut) a thru z select women's tablet * (Mv,Fe,Min/Lutein ) abc plus tablet mgmcg-mcg * (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult multivitamin gummies (One-A-Day assorted flavors 200 mcg * Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults 50+ multivitamin tablet mg-mcg-mcg * (Biocel) animal chews tablet * (Multivitamin) antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula #1 tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 tablet * (Vitamin B Complex) 195

213 balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-100 tablet * (Vitamin B Complex) balanced b-100 tablet 100 mg * (Vit B Complex 100 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b12 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) bee-zee tablet * (Multivitamin with Minerals) biosupp liquid * (Multivitamin with Minerals) biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) calcium 1,000 + d3 caplet 1,000 (Os-Cal 500-Vit mg(2,500 mg)-800 unit * D3) calcium vit d 400 caplet s/f, (Os-Cal 500-Vit p/f, caplet 600 mg(1,500mg) -400 D3) unit * calcium vit d tablet mg-unit * (Os-Cal 500-Vit D3) 196

214 calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(1,500mg) -400 unit * centamin liquid 9 mg iron/15 ml * central-vite seniors tablet * centram-care multivit-min liq 9 mg iron/15 ml * centravites 50 plus tablet * centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults mg-mcg-mcg * century ultimate men's tablet mcg * century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * cerovite jr tablet chew * cerovite liquid 9 mg iron/15 ml * cerovite senior tablet * certavite sr-antioxidant tab mg-mcg-mcg * (Os-Cal 500-Vit D3) (Os-Cal 500-Vit D3) (Multivit- Minerals/Ferrous Gluc) (Multivit with Iron- Minerals) (Multivit- Minerals/Ferrous Gluc) (Multivit with Iron- Minerals) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit with Iron- Minerals) (Multivit- Minerals/Ferrous Gluc) (Multivitamin with Minerals/Lut) (Biocel) 197

215 certavite-antioxidant liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) certavite-antioxidant tablet mg-mcg * chewable-vite tablet * (Multivitamin) chew-vites-iron tablet chew * (Multivitamin with Iron) child chew + iron tab chew * (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Fer-In-Sol) childrens chew vitamin tab * (Multivitamin) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) childrens vit-iron tab chew * (Multivitamin with Iron) compete tablet * (Multivit with Iron- Minerals) complete multi 50+ tablet mcg * (Biocel) complete multi tablet (Mv,Ca,Min/Iron 250 mg-mcg-mcg-mcg * Fum/Fa/Lyco/Lut) complete multivitamin tab * (Multivit,Tx Iron,Other Mins) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-100 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-150 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs calcium vit d tablet oyster (Os-Cal 500-Vit shell 500 mg(1,250mg) -125 unit * D3) 198

216 cvs calcium 600-vit d3 800 tab 600 (Os-Cal 500-Vit mg(1,500mg) -800 unit * D3) cvs calcium 600-vit d3 800 tab p/f, (Os-Cal 500-Vit s/f,gluten-free 600 mg(1,500mg) - D3) 800 unit * cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) cvs daily gummies p/f, gluten-free (One-A-Day 200 mcg * Vitacraves) cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs gummy swirls chewable * (Multivitamin) cvs hair, skin and nails cplt * (Multivitamin with Minerals) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs mg-mcg-mcg * (Biocel) cvs spectravite adult gummy 200 (One-A-Day mcg * Vitacraves) cvs spectravite advanced tab (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) 199

217 cvs spectravite ultra men's tb mcg * cvs spectravite ultra women tb mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vitamin b-100 complx tb * (Biocel) (Multivitamin/Iron/ Folic Acid) (Vita-Bee with C) (Vitamin B Complex) cvs vitamin c 1,000 mg tb chw 1,000 (Ascorbic Acid) mg * cvs vitamin d3 1,000 unit sfgl softgel (D3-50) 1,000 unit * cvs women's daily gummies (One-A-Day p/f,gummies 200 mcg * Vitacraves) cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin 3 $0 1,000 mcg/ml * (Vitamin B-12)) d3 dots 2,000 unit tablet p/f 2,000 (Cholecalciferol unit * (Vitamin D3)) (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) daily multivitamin-iron tablet 18- daily vitamin formula-iron tab 18- (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * 400 mg-mcg * Folic Acid) Folic Acid) 200

218 daily vite with iron tablet * (Multivitamin with Iron) daily-vite tablet * (Multivitamin) daily-vites with iron tablet * (Multivitamin with Iron) delta d3 400 unit tablet (Cholecalciferol s/f,l/f,y/f,gluten/f 400 unit * (Vitamin D3)) dino-life extra c tab chew * (Multivitamin) dino-life iron-zinc tb chew * (Multivit with Iron- Minerals) dino-life tablet chewable * (Multivitamin) d-vi-sol 400 units/ml drop 400 unit/ml * (Just D) eldertonic elixir mg * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 18 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ (Multiviteq one daily men's tablet gluten free Minerals/Fa/Lycop mcg * ene) eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet mcg * (Biocel) eql century multi-vitamin tab (Folic mg * Acid/Mv,Fe,Min) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) 201

219 eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet mg * (Tab A Vite) eql one daily men's tablet * (Multivitamin with Minerals) eql prenatal vitamin tablet 28 mg (Prenatal Vit iron- 800 mcg * No.128/Iron/Fa) ergocalciferol 8,000 units/ml 8,000 unit/ml * (Drisdol) essentia tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) essential balance tablet * (Mv,Fe,Min/Lutein ) essential daily tablet w/iron & calcium mg * (Tab A Vite) feosol 65 mg tablet 325 mg (65 mg iron) * (Slow Fe) ferocon capsule mg * (Iron Fum/Vit C/B12-If/Fa) 3 $0 ferretts 325 mg tablet 325 mg (106 mg iron) * (Ferrous Fumarate) ferrex 150 capsule outer, u-d 150 mg iron * (Pic 200) ferrex 150 plus capsule mg * (Iron Aspgly,Ps/C/Succi nic Acid) ferric x-150 capsule 150 mg iron * (Pic 200) ferrocite tablet 324 mg (106 mg iron) * (Ferrous Fumarate) 202

220 ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (106 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) (Pedi Mv flintstones with iron tab chew 18 mg No.79/Ferrous iron * Fumarate) folic acid 1 mg tablet (rx) 1 mg * (Folic Acid) 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * (Folic Acid) folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp calcium 500-vit d3 600 tab (Os-Cal 500-Vit 500mg (1,250mg) -600 unit * D3) gnp century mature tablet glutenfree mg-mcg-mcg * (Biocel) 203

221 gnp century tablet adults mg-mcg-mcg * (Biocel) gnp century tablet gluten-free 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet (Pnv133/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew multivit & minerals * (Multivitamin) hair vitamins * (Multivitamin with Iron) hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * hi-b complex tablet * (Ferrous Fumarate) (Vitamin B Complex) hm complete 50+ tablet (Biocel) mg-mcg-mcg * hm complete women tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) hm one daily with iron tablet glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 150 capsule 150 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) 204

222 kobee tablet 0.4 mg * (Vitamin B Complex/Folic Acid) kpn tablet * (Prenatal Vit Calc,Iron,Folic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) (One-A-Day Vitacraves) men's multivitamin gummies 200 mcg * MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * (Multivitamin with Minerals/Lut) multi complete-iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi for her tablet 18 mg iron-600 (Mv,Calcium,Min/I mcg-80 mcg * ron/folic/vitk) multi-day plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn liquid s/f,a/f * (Multivitamin) multi-delyn with iron liquid 10 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multilex tablet * (Multivit with Iron- Minerals) multilex-t-m-minerals tab * (Multivit,Tx Iron,Other Mins) 205

223 multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) (Multivitmultivitamin-mineral liquid 9 mg Minerals/Ferrous iron/15 ml * Gluc) multivitamins tablet * (Multivitamin) multivit-fluor 0.25 mg/ml drop 0.25 (Pedi Mvi No.82 mg/ml with Fluoride) multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * NASCOBAL 500 MCG NASAL SPRAY OUTER 500 MCG/SPRAY * nephplex rx tablet mg-mg-mcg-mg * nephron fa tablet mg * (Multivitamin with Minerals) (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Iron Fum/Docusate/Fa/ Bcomp,C) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 3 $0 3 $0 nephro-vite rx tablet mgmg-mcg * 3 $0 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 150 capsule 150 mg iron * (Pic 200) 206

224 (Beta-Carotene(A)- ocutabs tablet s/f, w/lutein * Vits C,E/Mins) once daily tablet * (Multivitamin) (Multivitamin with once daily with iron tablet * Iron) (Multivitamin,Ther oncovite tablet * apeutic) (Multivitamin with one daily complete tablet * Minerals) one daily complete tablet mg (Folic * Acid/Mv,Fe,Min) one daily essential tablet * (Multivitamin) one daily for women tablet (Folic mg * Acid/Mv,Fe,Min) one daily gummy vites gummie 200 (One-A-Day mcg * Vitacraves) one daily maximum tablet mg (Folic * Acid/Mv,Fe,Min) one daily multivitamin tab * (Multivitamin) (Multivitamin with one daily multivitamin tablet * Iron) one daily multivitamin tablet 400 (Quintabs) mcg * one daily tablet * (Multivitamin) (Multivitamin with one daily tablet * Iron) one daily tablet men's formula * (Multivitamin) (Multivitamin with one daily with minerals tablet * Minerals) one-a-day essential tablet * (Multivitamin) (Multivitamin with one-a-day max formula tab * Minerals) one daily multivitamin-iron tb 18- one daily plus iron tablet (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 207

225 (Multivitone-a-day men's tablet mcg Minerals/Fa/Lycop * ene) one-a-day teen advantage tab 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) oysco 500-vit d3 200 tablet 500 (Os-Cal 500-Vit mg(1,250mg) -200 unit * D3) oyster shell 250 mg + vit d tb 250- (Os-Cal 500-Vit 125 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Os-Cal 500-Vit mg(1,250mg) -200 unit * D3) oyster shell calcium tablet 500 (Os-Cal 500-Vit mg(1,250mg) -400 unit * D3) oyster shell calcium-vit d tab (Os-Cal 500-Vit p/f,s/f,gluten-free 500 mg(1,250mg) D3) -400 unit * oystercal-d 500 mg-400 unit tb 500 (Os-Cal 500-Vit mg(1,250mg) -400 unit * D3) perry prenatal capsule mg (Pnv with Ca * No.36/Iron/Fa) pharmacist multi-vite tab * (Multivitamin) phytonadione 1 mg/0.5 ml syr latexfree, p/f 1 mg/0.5 ml * (Phytonadione) 3 $0 poly-iron 150 mg capsule 150 mg (Pic 200) iron * (Pediatric poly-vita drops 1, unitmg-unit/ml * Multivitamin No.20) pnv prenatal plus multivit tab s/f, poly-vita with iron drops 1,500 unit- (Pnv with (Ped Multivit gluten-free 27 mg iron- 1 mg 400 unit-10 mg/ml * Ca,No.72/Iron/Fa) #46/Iron Sulfate) poly-vitamin drops 1, unit-mg-unit/ml * (Pediatric Multivitamin No.20) (All Rx Prenatal Vitamins Covered) 208

226 poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops 1,500 (Ped Multivit unit-400 unit-10 mg/ml * #46/Iron Sulfate) (Multivit with Ironpolyvitamin with iron tab chew * Minerals) prenatal caplet s/f,p/f,gluten/free 28 (Pnv95/Ferrous mg iron- 800 mcg * Fumarate/Fa) prenatal formula tablet 28 mg iron- (Pnv95/Ferrous 800 mcg * Fumarate/Fa) (Prenatal Vit prenatal tablet (otc) mg * No.130/Iron/Fa) (Prenatal Vit/Iron prenatal tablet (otc) mg * Fumarate/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg (Pnv95/Ferrous * Fumarate/Fa) prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron * Fumarate/Fa) prenatal tablet outer (otc) mg (Prenatal Vit * No.130/Iron/Fa) (Multivitamin with pub multivitamin 50 plus tab * Minerals/Lut) (Vitamin B pv b-100 complex * Complex) (Vitamin B pv b-50 complex * Complex) prenatal vitamin plus low iron oral prenatal vitamin tablet 27 mg ironprenatal vitamins tablet phosphorus prosight tablet 5, unit-mgunit * (Pnv with (Prenatal Vit (Pnv95/Ferrous (A/C/E/Zinc/Sod tablet 27 mg iron- 1 mg 800 mcg * free 28 mg iron- 800 mcg * Ca,No.72/Iron/Fa) No.124/Iron/Fa) Fumarate/Fa) Selenate/Copper) (All Rx Prenatal Vitamins Covered) 209

227 pv kid's gummy bear tab chew chewable * (Multivitamin) pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) (Pediatric pv kids vitamins chew tab 300 mcg * Multivitamin No.8/Fa) pv kids vitamins complete (Pedi Multivit mg-mcg * 9/Iron/Fa) pv kids vitamins+iron tab chew 15 (Ped Multivit mg iron * #17/Iron Fumarate) pv multivital platinum tablet * (Multivitamin with Minerals/Lut) pv multivital platinum tablet w/lutein & lycopene (Biocel) mcg * pv multivital tablet mg * (Fa/Mv,Ca,Iron,Mi n/lycopene/lut) pv multivital tablet (Mv,Ca,Min/Iron mg-mcg-mcg-mcg * Fum/Fa/Lyco/Lut) pv prenatal formula tablet 28 mg (Prenatal Vit iron- 800 mcg * No.131/Iron/Fa) pv stress 500 plus zinc tab * (Multivitamin,Stres s Formula/Zn) pv stress 500 tablet * (Multivitamin,Stres s Formula) pyridoxine 100 mg/ml vial 25's 100 mg/ml * (Pyridoxine HCl) 3 $0 pyridoxine 250 mg tablet 250 mg * (Pyridoxine HCl) (Pedi Mv qc child complete vit chew tab 18 No.67/Ferrous mg iron * Fumarate) qc children's chewable tablet * (Multivitamin) 210

228 qc maximum daily multivit tab mg * qc multi-vite 50 & over tablet w/lycopene * qc multi-vite tablet mg-mcg * qc women's daily multivit tab mg * ra balanced b-100 tablet 0.4 mg * ra balanced b-50 tablet natural,p/f * ra b-complex tablet p/f * ra b-complex tablet p/f * ra central vite select tab p/f * ra central-vite select tab p/f * (Tab A Vite) (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Tab A Vite) (Vitamin B Complex/Folic Acid) (Vitamin B Complex) (Vitamin B Complex) (Vitamin B Complex) (Multivitamin with Minerals/Lut) (Multivit with Iron- Minerals) ra central-vite senior tablet mg-mcg-mcg * (Biocel) ra central-vite tablet mg-mcg-mcg * (Biocel) ra central-vite tablet mgmcg * Folic Acid) (Multivitamin/Iron/ ra hi-cal plus vitamin d tab 500 (Os-Cal 500-Vit mg(1,250mg) -200 unit * D3) ra one daily energy tablet * (Multivitamin with Minerals) ra one daily maximum tablet (Folic mg * Acid/Mv,Fe,Min) ra one daily multi-vitamin tab p/f * (Multivitamin) ra one daily plus iron tablet * (Multivitamin with Iron) 211

229 ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab (Tab A Vite) mg * ra vit b-12 1,000 mcg/ml liq 1,000 (Cyanocobalamin mcg/ml * (Vitamin B-12)) ra vitamin b-12 1,000 mcg tab (B-12) timed-release 1,000 mcg * ra vitamin c 1,000 mg tab sa (Ascorbic Acid) w/bioflavonoids 1,000 mg * ra vitamin c 500 mg tab chew p/f (Ascorbic Acid) 500 mg * ra vitamin d3 1,000 unit tab (Cholecalciferol s/f,gluten/f,yeast/f 1,000 unit * (Vitamin D3)) rena-vite rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 right step prenatal vit tab mg (Prenatal Vit/Iron * Fumarate/Fa) (Multivit with Ironscooby-doo one a day tablet * Minerals) senior tabs mg-mcgmcg * (Biocel) sentry senior multivitamin tab (Biocel) sodium/f,yeast/f mcg * sentry senior tablet mgmcg-mcg * (Biocel) (Multivitamin/Iron/ sentry tablet mg-mcg * Folic Acid) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers (Multivitamin) * sm b complex with vit c tablet (Vita-Bee with C) gluten-free * sentry multivit & mineral cplt 18- sm animal shapes w-iron tab (Mv,Ca,Min/Iron (Multivitamin with mg-mcg-mcg-mcg * children's * Fum/Fa/Lyco/Lut) Iron) 212

230 sm complete advanced tablet mg-mcg-mcg-mcg * sm complete multi-vit-mineral advanced formula mg-mcg * sm complete senior formula tab * sm complete senior formula tab mg-mcg-mcg * (Mv,Ca,Min/Iron Fum/Fa/Lyco/Lut) (Multivitamin/Iron/ Folic Acid) (Multivit with Iron- Minerals) (Biocel) sm complete tablet mg * (Multivit with Iron,Hematinic) sm multivitamin w-iron tab * (Multivitamin with Iron) sm multivitamins tablet * (Multivitamin) (Vit B Complex sm natural balanced b-100 tab Cmb mg * #2/Herbs) sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet mg * sm ultimate men's complete tab mcg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet 1 mg fluoride (2.2 mg) stress b tablet * (Pnv95/Ferrous Fumarate/Fa) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Biocel) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi Mvi No.82 with Fluoride) (Vitamin B Complex) 213

231 stress b with zinc tablet * (Multivitamin,Stres s Formula/Zn) stress formula tablet * (Multivitamin,Stres s Formula) stress formula with iron tab * (Iron/Mv,Stress Form) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron 400 mcg- 27 mg iron * Sulf/Vite) stress formula with zinc tab * (Multivitamin,Stres s Formula/Zn) stress-c tablet * (Multivitamin,Stres s Formula) (Vit B stress-c with iron tablet 500 mg-400 Comp/C/Fa/Iron/Vi mcg- 18 mg iron * t E) (Mv-Min/Iron sunvite tablet 18 mg iron-400 mcg- Fum/Fa/K/Lyco/Lu 25 mcg * tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * (B Complex with Vitamin C) super b-50 complex capsule * (Vitamin B Complex) super b-50 complex plus tab * (Vitamin B Complex) super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) 214

232 super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) sv hair, skin and nails caplet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with thera m plus tablet 9 mg iron-400 mcg * thera tablet * thera-d 2000 tablet 2,000 unit * theradex m tablet mg * thera-m caplet * thera-m caplet caplet mg * thera-m tablet w/beta carotene 9 mg iron-400 mcg * therapeutic-m caplet caplet 9 mg iron-400 mcg * Minerals) (Multivits,Ca,Mine rals/iron/fa) (Multivitamin,Ther apeutic) (Cholecalciferol (Vitamin D3)) (Multivit,Tx,Iron/C alcm/fa/mins) (Multivit,Tx Iron,Other Mins) (Multivit,Tx,Iron/C alcm/fa/mins) (Multivits,Ca,Mine rals/iron/fa) (Multivits,Ca,Mine rals/iron/fa) 215

233 therapeutic-m tablet mgmcg * 50+) (Essential Woman thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) theratrum complete tablet w/lutein, (Mv,Fe,Min/Lutein p/f * ) therems tablet * (Multivitamin,Ther apeutic) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops 1, unit-mgunit/ml * tri-vitamin drops 1, unitmg-unit/ml * ultra b-100 complex tablet * unicomplex-m tablet * v-c forte capsule 1 mg * vic-forte capsule 1 mg * vision plus lutein vitamin tab * vision vitamins * vit d mg (50,000 unit) capsule 50,000 unit * (Pedi Multivit A,C,And D3 No.21) (Pedi Multivit A,C,And D3 No.21) (Vitamin B Complex) (Multivit with Iron- Minerals) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) 3 $0 3 $0 (Drisdol) 3 $0 216

234 vitalets tablet chewable child, orange,s/f * vitamin a 10,000 units capsule soluble 10,000 unit * (Multivitamin with Iron) (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) vitamin b complex capsule * (Vitamin B Complex) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b mg tablet 100 mg * (Thiamine HCl) vitamin b-1 50 mg tablet 50 mg * (Thiamine HCl) vitamin b-12 1,000 mcg tablet 1,000 mcg * (B-12) vitamin b mcg tablet 100 mcg * (B-12) vitamin b mcg tablet 250 mcg * (B-12) vitamin b mcg tablet 500 mcg * (B-12) vitamin b12-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b-50 complex tablet s/f,p/f,dairy-free 0.4 mg * (Vitamin B Complex/Folic Acid) vitamin b mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet Cmplx C/Rice p/f,lactose free mcg-mg * Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) 217

235 vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d 1,000 unit tablet 1,000 (Cholecalciferol unit * (Vitamin D3)) vitamin d3 1,000 unit tablet s/f,p/f (Cholecalciferol 1,000 unit * (Vitamin D3)) vitamin d3 10,000 unit softgel softgel 10,000 unit * (D3-50) vitamin d3 10,000 unit softgel softgel,p/f,s/f 10,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f (Cholecalciferol 2,000 unit * (Vitamin D3)) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Kids Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 (Cholecalciferol unit * (Vitamin D3)) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 400 unit/ml drop a/f, s/f, fruit 400 unit/ml * (Just D) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 100 mcg tablet p/f,na/f,wheat-free 100 mcg * (Phytonadione) vitamin k-1 1 mg/0.5 ml ampul 25's,latex-free 1 mg/0.5 ml * (Phytonadione) 3 $0 vitamin k-1 10 mg/ml ampul 25's,latex-free 10 mg/ml * (Phytonadione) 3 $0 218

236 vitamins for hair tablet * (Multivitamin) vitatrum tablet mgmcg-mcg-mcg * Fum/Fa/Lyco/Lut) (Mv,Ca,Min/Iron vitrum 50+ senior tablet mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) vol-care rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 vp-vite rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 v-r calcium d 133 caplet 400- (Os-Cal 500-Vit mg-unit * D3) v-r natural b-100 tablet * (Vitamin B Complex) v-r vitamin c tr 500 mg caplet 500 mg * (Ascorbic Acid) women's multivitamin gummies (One-A-Day gluten-f, lactose-f 200 mcg * Vitacraves) yelets tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 219

237 INDEX 3 3 day vaginal pse-150gfn-15dm day vaginal MOP A a thru z a thru z advanced formula a thru z high potency a thru z select , 195 a thru z select 50+ formula.. 194, 195 a thru z select women's abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen... 3 acetaminophen... 3, 5 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 173 acetylcysteine acid gone antacid acid reducer (famotidine) , 143 acid reducer (ranitidine) acid relief (cimetidine) acitretin acne medication , 124 ACNE MEDICATION ACTEMRA ACTHIB (PF) ACTIMMUNE actinel pediatric acyclovir... 75, 122 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 167 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max adult multivitamin gummies 195 adult nasal decongestant adult one daily gummies adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults 50 plus ADVAIR DISKUS ADVAIR HFA ADVIL... 10, 11 afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-12 allergy-sinus ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate , 174 alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy relief (cetirizine) allergy relief (clemastine) allergy relief(diphenhydramin) allerhist aller-tec d all-nite cold-flu allopurinol... 53, 54 ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 50 alophen alosetron ALPHAGAN P alprazolam I-1

238 ALREX altacaine altamist altavera (28) aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide95 AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate , 123 amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium... 24, 25 ampicillin-sulbactam AMPYRA ANACAINE ANADROL anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes plus iron ANORO ELLIPTA antacid anti-gas (ca carb-sim) antacid ultra strength antacid-antigas ii anti-diarrheal anti-diarrheal (loperamide). 144, 145 antifungal (tolnaftate)... 50, 53 antifungal cream anti-gas maximum strength anti-itch (hc) antioxidant antitussive dm apatate forte APOKYN apraclonidine aprepitant apri APRISO aprodine APTIOM APTIVUS aquanil hc aranelle (28) ARCALYST aripiprazole... 65, 66 ARISTADA armodafinil ARNUITY ELLIPTA ARTIFICIAL TEARS (PETRO/MIN) artificial tears (pf) artificial tears (polyvin alc) artificial tears(dext70-hypro) 134 artificial tears(glycerin-peg). 134 artificial tears(hypromellose) 137 ASACOL HD ascomp with codeine... 3 ascorbic acid (vitamin c) , 218 ashlyna aspirin aspirin, buffered aspirin-dipyridamole aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil I-2

239 ATRIPLA atropine... 37, 38, 134 ATROVENT HFA AUBAGIO aubra AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 204, 214 b-100 complex b-12 dots b-50 complex bacitracin... 18, 125, 138 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 211 balanced b balanced b , 211 balsalazide balziva (28) banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) 167 b-complex b-complex with vitamin c , 198, 212, 217 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bee-zee bekyree (28) BELBUCA... 3 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 157 betamethasone dipropionate. 127 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 88, 178 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide bicarsim forte , 142 BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl , 150 biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF bp 8 cough BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm bromfenac bromocriptine brompheniramine-pseudoephdm , 112, 113 I-3

240 brotapp dm budesonide , 187 bufferin bumetanide BUNAVAIL BUPHENYL buprenorphine hcl... 4, 14 buprenorphine-naloxone buproban bupropion hcl bupropion hcl (smoking deter)15 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC BYVALSON C c complex cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor , 185 caffeine citrate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol , 174 calcium d (d3) calcium calcium d(3) 179, 196, 197 calcium 600 with vitamin d3 182 calcium acetate calcium antacid calcium carbonate , 179 calcium carbonate-vit d3-min calcium carbonate-vitamin d , 181, 196, 197, 199, 203 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d , 185 calcium gluconate calcium+d CALDOLOR cal-gest antacid CALTRATE D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 86 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 20 cefdinir cefditoren pivoxil cefepime CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 21 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 21 cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT INTRAVENOUS CELONTIN centamin centergy dm central vite with lutein central-vite central-vite for seniors central-vite select , 211 central-vite senior centram-care centravites 50 plus centrum centrum complete centrum silver century , 204 century adults century mature , 203 I-4

241 century ultimate men's century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula cerovite jr cerovite senior certavite senior-antioxidant certavite-antioxid (iron gluc) 198 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX cheratussin ac cheratussin dac chest congestion relief + dm 114 chest congestion relief pe chewable multi vitamin chewable-vite chewable-vite with iron child chest congestion + cough child complete multivitamin 201 child cough and sore throat child mucinex chest congestion child plus cough and runnynose child triaminic cold-allergy child triaminic cough-congest child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 113 CHILDREN'S ADVIL children's allegra allergy children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 198 children's chewable w/minerals CHILDREN'S CLARITIN children's cold-cough daytime children's complete vitamin. 210 children's cough and runnynose children's cough dm er children's mapap... 4 children's mucinex cough children's multivit w/extra c. 201 children's non-aspirin... 4, 5 children's pain reliever children's pain-fever relief... 4, 6 children's pepto children's robitussin er children's silfedrine children's soothe children's sudafed children's sudafed pe cough. 113 children's tactinal... 4 children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 200, 218 cholestyramine (with sugar) cholestyramine light... 96, 97 ciclopirox cilostazol cimetidine , 143 cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 26, 138 ciprofloxacin in 5 % dextrose 26 ciprofloxacin lactate citalopram citracal + d maximum citrus calcium clarithromycin CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 18 I-5

242 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate... 18, 59, 125 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol , 128 clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 84, 85, 101 clopidogrel clorazepate dipotassium clorpres clotrimazole... 50, 51 clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm COLCRYS cold and cough (diphenhydr-pe) cold and cough (pe-dm) cold multi-symptom day/night cold multi-symptom nighttime cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 188 COMETRIQ comfort gel comfort gel extra strength compete COMPLERA complete complete complete multi complete multi complete multivitamin. 198, 201 complete multivitamin-mineral , 213 complete senior , 213 complete women compoz compro COMVAX (PF) CONDYLOX congestac congest-eze constulose COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR cormax cortaid cortisone cortizone COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 123 COTELLIC cough and cold cough and runny nose cough relief CREON critic-aid clear af CRIXIVAN cromolyn , 145, 190 cryselle (28) CUBICIN CUPRIMINE cutter backwoods cutter skinsations cyanocobalamin (vitamin b-12) , 200, 212, 217 cyclafem 1/35 (28) cyclafem 7/7/7 (28) I-6

243 cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride daily gummies daily multiple , 200 daily multi-vitamin daily multivitamin with iron 200 daily multi-vitamins/iron daily value daily vitamin formula daily vitamin formula-iron daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite , 201 DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough daytime cold-flu daytime cold-flu relief (pe) day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm delta d delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine desmopressin , 159 desog-e.estradiol/e.estradiol. 105 desogestrel-ethinyl estradiol 105 desonide desoximetasone despec-dm (pseudoeph-dmguaif) dex4 glucose... 82, 83 dexamethasone dexamethasone sodium phosphate , 158 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextromethorphan polistirex 115 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 83 dextrose 5 %-lactated ringers180 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm diabetic tussin ex diamode diazepam... 16, 17 diazepam intensol diclofenac potassium diclofenac sodium.. 11, 123, 141 diclofenac-misoprostol dicloxacillin dicyclomine I-7

244 didanosine DIFICID diflunisal digitek... 91, 92 digoxin DIGOXIN dihydroergotamine... 59, 60 DILANTIN diltiazem hcl... 90, 91 dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion DIMETAPP LONG-ACTING (CPM-DM) dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol doxorubicin doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) 150 DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin d-vi-sol DYRENIUM E e.c. prin e.e.s e.e.s. granules econazole econtra ez ecotrin ed a-hist ed bron gp ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA... 70, 71 enalapril maleate enalaprilat enalapril-hydrochlorothiazide 86 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin enema , 152 enema disposable enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir entre-cough ENTRESTO enulose ENVARSUS XR EPCLUSA epinastine I-8

245 epinephrine epinephrine hcl (pf) EPIPEN EPIPEN 2-PAK EPIPEN JR 2-PAK epitol EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle equalactin ergocalciferol (vitamin d2). 202, 216 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 23, 138 erythromycin ethylsuccinate.. 23 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 202 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 157 estropipate eszopiclone ethambutol ethosuximide ethynodiol diac-eth estradiol 106 etodolac ETOPOPHOS etoposide evac-u-gen (sennosides) EVOTAZ exemestane EXJADE EXONDYS expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche eye health plus lutein F FABRAZYME fallback solo falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 143 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine feminine care douche FEMRING femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 5 fentanyl citrate... 5 feosol ferocon ferretts ferrex ferrex 150 plus ferric x FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 204 ferrous sulfate , 203 FETZIMA feverall... 5 fexofenadine fiber (calcium polycarbophil) fiber laxative (methylcellulo)153 fiber smooth fiber therapy (m-cell/sugar) fiber therapy (m-cellulose) fiber therapy (psyllium/sugar) fiber therapy sugar free fiber-lax finasteride FIRAZYR flavor chews antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA floxuridine flu formula daytime-nighttime flu hbp flu relief therapy daytime flu severe cold-congestion I-9

246 flucaine fluconazole fluconazole in nacl (iso-osm). 51 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluocinonide-e fluorometholone fluorouracil... 31, 124 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 141 fluvoxamine foaming antacid , 149 folic acid fomepizole fondaparinux... 76, 77 foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure fungoid-d furosemide FUSILEV FUZEON FYCOMPA G g tussin ac gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas gemfibrozil generlac gengraf , 164 GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 17, 126, 138, 139 gentamicin in nacl (iso-osm).. 17 gentamicin sulfate (ped) (pf).. 17 gentamicin sulfate (pf) GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-lanta geri-tussin dm gianvi (28) gildagia gildess 1.5/30 (21) gildess 1/20 (21) gildess 24 fe gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate glydo... 13, 14 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin guanfacine... 85, 101 guanidine gummi bear multivitamin , 210 gummy swirls H hair vitamins I-10

247 hair,skin and nails , 215 halobetasol propionate. 128, 129 haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthylax heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex.. 77 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN hi-b complex HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine... 93, 94 hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen... 6 hydrocortisone , 158, 173 hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet hydromorphone... 6 hydromorphone (pf)... 6 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 6 I ibandronate IBRANCE ibuprofen... 11, 12, 13 ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant's ibuprofen infants' non-aspirin cold infant's pain reliever... 6 INFLECTRA INLYTA INSECT REPELLENT (PICARIDIN) insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A... 74, 75 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA... 67, 68 INVIRASE INVOKAMET INVOKAMET XR INVOKANA... 46, 47 inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W iophen c-nr IPOL I-11

248 ipratropium bromide , 189 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA iron high potency ISENTRESS ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette juleber junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe junior mapap... 6 JUXTAPID K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) kelnor 1/35 (28) ketoconazole ketoprofen ketorolac... 13, 141 KEVEYIS KEYTRUDA kidkare cough/cold kids mini enema kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kids vitamins complete kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle kobee konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM kpn KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad 107 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine... 39, 40 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) larissia LARTRUVO latanoprost LATUDA laxative peg LAZANDA... 6 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine I-12

249 levofloxacin... 26, 139 levofloxacin in d5w levoleucovorin levonest (28) levonorgestrel levonorgestrel-ethinyl estrad107, 108 levonorg-eth estrad triphasic 108 levora levothyroxine LEXIVA LIALDA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 14, 87 lidocaine hcl lidocaine in 5 % dextrose (pf) 88 lidocaine viscous lidocaine-prilocaine life-pack women's linezolid LINZESS liothyronine liquibid d-r liquid calcium with vitamin d lisinopril lisinopril-hydrochlorothiazide 87 lithium carbonate , 102 lithium citrate little animals little animals-iron little remedies LIVALO lobana bath lohist-dm lomedia 24 fe LONSURF loperamide , 147 loratadine... 55, 57 loratadine-d... 56, 57 lorazepam lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex loryna (28) losartan losartan-hydrochlorothiazide. 86 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 136 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 137 lubricant eye (propyl glycol) 135 lubricant gel lubricating drops lubricating plus lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M maalox advanced MACUVITE EYE CARE mag mag-delay mag-g magnebind magnesium , 182, 186 magnesium (oxide/aa chelate) magnesium gluconate magnesium oxide , 148 magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline mar-cof bp mar-cof cg margesic... 7 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin meclizine medi-meclizine medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral I-13

250 megestrol... 33, 161 MEKINIST... 33, 34 meloxicam memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's multivitamin gummies 205 men's one daily , 202 MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem mesalamine mesna MESNEX MESTINON metaproterenol metaxall metaxalone metformin methadone... 7 methadose... 7 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl , 148 metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 19, 59, 126 metronidazole in nacl (iso-os) 19 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 51, 52 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil , 177 MINERAL OIL mineral oil laxative minitran minocycline... 27, 28 minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine... 44, 45 misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 7, 8 MORPHINE... 8 morphine concentrate... 7 motion sickness MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL MUCINEX FAST-MAX COLD-FLU-THRT mucinex fast-max dm max mucinex sinus-max mucus dm mucus dm max mucus relief , 118 MULTAQ multi complete with iron multi for her multi-day with iron multi-delyn multi-delyn with iron multilex multilex-t and m multiple vitamin-minerals multiple vitamins multiple vitamins with iron I-14

251 multi-symptom cold night time multivital multivital platinum multivitamin , 213 multivitamin 50 plus multi-vitamin hp/minerals multi-vitamin with fluoride multivitamin with iron. 206, 213 multivitamin with minerals multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN nasal and sinus decongestant 117 nasal spray (oxymetazoline). 135 NASCOBAL NATACYN nateglinide NATPARA NATRAPEL natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy 151 nature's tears (hypromellose) 136 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone NEO DM neomycin neomycin-bacitracin-poly-hc 139 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR next choice one dose niacin... 97, 98 niacinamide... 98, 206 niacor nicardipine nicorelief nicorette nicotine... 15, 16 nicotine (polacrilex) NICOTROL nifedical xl nifedipine night time night time cold medicine night time cold-flu night time cold-flu relief night time cough-sore throat 117 nighttime cough nikki (28) NILANDRON nilutamide NINLARO NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose 100 NITROSTAT NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength... 8, 9 non-aspirin flu non-aspirin jr strength... 5 nora-be NORDITROPIN FLEXPRO 160 I-15

252 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp... 8 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 8 NUCYNTA ER... 8 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING nyamyc nyata nystatin... 52, 53 nystatin-triamcinolone nystop nyt-time sleep O OCALIVA ocean nasal ocella OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV off active off deep woods off deep woods dry off familycare (with deet) ofloxacin... 27, 139, 140 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine OLYSIO omeprazole omeprazole magnesium OMNITROPE ONCASPAR once daily oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily , 211 one daily 50 plus one daily complete one daily energy one daily essential 202, 204, 207 one daily for women one daily gummy vites one daily maximum , 211 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 207 one daily plus iron 204, 207, 211 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula207 one-a-day men's multivitamin one-a-day teen advantage ONFI ONIVYDE opcicon one-step OPDIVO OPSUMIT option oral saline laxative oralone oralyte ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orsythia oseltamivir OTEZLA OTEZLA STARTER OTOVEL OTREXUP (PF) oxacillin I-16

253 oxacillin in dextrose(iso-osm) 25 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 8 oxycodone-acetaminophen.. 8, 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9 oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium-vit d , 185 oyster shell calcium-vit d oystercal-d P pacerone pain relief... 9 pain relief adult... 5 pain reliever jr strength... 9 paliperidone PANRETIN PANTILINERS pantoprazole paricalcitol paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx pedia relief pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte , 183, 185, 186 pediatric freezer pops pediatric multivitamin.. 206, 212 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 132 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline perry prenatal persa-gel pfizerpen-g pharbetol... 9 pharmacist favorite multi-vit 208 phenadoz phenelzine phenobarbital phenylephrine hcl... 85, 137 phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended philith phillips phillips liqui-gels PHOSLYRA phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k1).. 208, 218 PICATO pilocarpine hcl , 178 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium chlorid-d5-0.45%nacl potassium chloride , 185 potassium chloride in 0.9%nacl I-17

254 potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid. 185 potassium hydroxide POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate , 130 prednisolone acetate prednisolone sodium phosphate , 158 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 209, 213 prenatal formula , 210 prenatal plus (calcium carb). 208 prenatal tablet prenatal vit#96-ferrous fum-fa prenatal vitamin , 202, 209 prenatal vitamin plus low iron prenatal vit-iron fumarate-fa 209 preparation h hydrocortisone 130 PREVAIL BLADDER CONTROL PAD prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 57, 63 promethazine vc-codeine promethazine-codeine promethazine-dm promethegan promolaxin propafenone propantheline proparacaine propranolol... 89, 90 propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure and gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q QBRELIS q-dryl q-pap... 9 q-pap extra strength... 9 q-tussin q-tussin dm QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide 87 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl I-18

255 RAPAMUNE rasagiline RASUVO (PF) RAVICTI RAYALDEE react REBIF (WITH ALBUMIN) 103 REBIF REBIDOSE REBIF TITRATION PACK 103 reclipsen (28) RECOMBIVAX HB (PF) , 171 recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 53 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX.. 98 REPATHA SURECLICK REPATHA SYRINGE repel sportsmen repel sportsmen max reprexain... 9 RESCRIPTOR RESTASIS RESTASIS MULTIDOSE retaine cmc retaine hpmc retaine pm RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA ribasphere RIDAURA rifabutin rifampin RIFATER ri-gel ii right step prenatal vitamins riginic riluzole rimantadine ri-mox ringers , 185 risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robafen dm clear robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA ROZEREM RUBRACA rydex rynex dm S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline nose SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs senna senna lax senna with docusate sodium. 150 senokot-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin sharobel SIGNIFOR silace siladryl sa I-19

256 sildenafil SILENOR siltussin sa silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 57 sleep aid (doxylamine) smoflipid smoothlax sochlor sodium acetate sodium bicarbonate , 186 sodium chloride , 173, 186, 191 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe night time lubricant soothe regular strength sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spectravite adult spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra men's sr spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd st joseph aspirin st. joseph aspirin stavudine STELARA STERILE GAUZE PAD STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin stress stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula 600 c stress formula plus iron stress formula with iron stress formula with iron(sulf)214 stress formula with zinc STRIBILD STRIVERDI RESPIMAT SUBOXONE sucralfate sudafed sudogest sudogest sinus and allergy sulfacetamide sodium sulfacetamide sodium (acne) 126 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac sumatriptan sumatriptan succinate summer's eve disposable douche summers eve extra cleansing 177 sunvite super b complex-vitamin c.. 200, 213, 214 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m I-20

257 superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYPRINE SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 167 tactinal tactinal extra strength TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN... 35, 36 tarina fe 1/20 (28) TASIGNA tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) tears pure TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID the magic bullet theophylline , 190 theophylline in dextrose 5 % 190 thera m plus (ferrous fumarat) thera vitamin thera-d theradex m thera-m therapeutic liquid therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals , 216 thera-tabs theratrum complete 50 plus theratrum complete with lutein therems THIOLA thioridazine thiotepa thiothixene tiagabine TICE BCG tigecycline tilia fe timolol maleate... 90, 179 TIVICAY tizanidine TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone TOLAK tolazamide tolbutamide tolmetin I-21

258 tolnaftate tolterodine topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin , 131 tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting m-sym cold/cough. 121 triamcinolone acetonide , 130, 158 triaminic cold and cough (pe) triamterene-hydrochlorothiazid trianex TRIBENZOR tri-buffered aspirin tridesilon tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRINTELLIX triple antibiotic , 126 triple paste af tri-previfem (28) tri-sprintec (28) TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28) TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA tusnel diabetic TUSNEL NEW FORMULA 120 TUSSI PRES-B tussin cf , 121 tussin cf (pe-dm-guaif) tussin cold-congestion tussin cough (dm only) tussin dm tussin dm cough and chest tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI , 172 TYSABRI TYVASO TYZEKA U UCERIS u-cort ULORIC ultimate men's complete ultra b-100 complex ultra fresh pm unicomplex-m unisom (diphenhydramine) unisom (doxylamine) unisom sleepgels UNITUXIN UPTRAVI ursodiol V VAGIFEM vagistat valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 41 valsartan valsartan-hydrochlorothiazide 86 VALSTAR vancomycin vancomycin in dextrose 5 %.. 19 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28) VELPHORO I-22

259 VELTASSA VEMLIDY VENCLEXTA... 36, 37 VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil VERSACLOZ VESICARE vestura (28) VGO VIBERZI vic-forte vicks dayquil cough vicks nature fusion cough vicks nyquil cold/flu liquicap vicks qlearquil nighttime rlf vicks qlearquil(oxymetazoline) vicks sinex 12-hour vicodin vicodin es vicodin hp VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine viorele (28) VIRACEPT VIRAZOLE VIREAD virtussin dac vision vision plus lutein vit b complex-folic acid 213, 217 vitalets vitamin a vitamin b complex , 211 vitamin b vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 217, 218, 219 vitamin d , 213, 218 vitamin k vitamin k vitamins and minerals vitamins b complex , 217 vitamins for hair vitatrum VITEKTA vitrum senior vol-care rx VOLTAREN voriconazole VOTRIENT VPRIV vp-vite rx VRAYLAR vyfemla (28) W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-flu severe cold-cough wal-itin wal-itin d wal-itin d 12 hour wal-phed... 59, 121 wal-phed pe day-night wal-phed pe sinus and allergy 59 wal-profen wal-sleep z wal-som (diphenhydramine).. 59 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin dm wal-tussin max strength cough wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile WELCHOL wera (28) womens daily gummies women's daily multivitamin. 211 women's multivitamin gummies X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN XOLAIR XTAMPZA ER XTANDI xulane xylon XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS yuvafem Z zafirlukast zaleplon zantac zarah I-23

260 ZARXIO ZAVESCA zebutal ZELBORAF ZEMPLAR zenatane zenchent (28) ZENPEP ZEPATIER zephrex-d ZETIA ZIAGEN zidovudine ZINBRYTA zinc oxide ZIOPTAN (PF) ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide zoo chews ZORBTIVE ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) z-sleep... 57, 58 ZUBSOLV... 10, 16 ZURAMPIC ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA I-24

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