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

201 적용의약품목록 ( 처방집 ) (Medicare-Medicaid Plan) 처방집 ID: 17129.000, 버전 : 7 발효일 : 아래 CHOICE 무료전화로문의하시기바랍니다. 오전 8 시 - 오후 8 시, 1 주 7 일

H8490_CY2017_LOCD_16702_KO AF 01172017 Multi-Language Insert Multi-language Interpreter Services ATTENTION: Language assistance services, free of charge, are available to you. Call 1-866-783-1444 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-783-1444 (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 1-866-783-1444 (TTY: 711) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-783-1444 (телетайп: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-783-1444 (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-866-783-1444 (TTY: 711) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-783-1444 (TTY: 711). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט.1-866-783-1444 (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 1-866-783-1444 (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-866-783-1444 (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1111-367-688-1 )رقم هاتف الصم والبكم: 711. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-783-1444 (ATS : 711). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں -1-866-783 1444 (TTY: 711).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-783-1444 (TTY: 711). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-866-783-1444 (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-866-783-1444 (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-783-1444 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-783-1444 (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 1-866-783-1444 (TTY: 711) पर क ल कर ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-783-1444 (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 1-866-783-1444 (TTY: 711) までお電話にてご連絡ください

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, 1-866-783-1444 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 1-866-783-1444(TTY: 711) 번으로전화해주십시오. 통화료는무료입니다. 본정보를다른언어로도이용하실수있습니다. 요일에상관없이오전 8 시부터오후 8 시까지 1-866-783-1444 번 (TTY 는 711 번 ) 으로전화해주십시오. 이통화는무료입니다. Puede obtener esta información gratis en otros idiomas. Llame al 1-866-783-1444 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 1-866-783-1444 (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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. I

다른언어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 1-866-783-1444 번 (TTY 사용자는 711 번 ) 으로문의해주십시오. 이통화는무료입니다. Вы можете получить эту информацию бесплатно и на других языках. Звоните по телефону 1-866-783-1444 (телетайп: 711) ежедневно с 8:00 до 20:00. Звонок бесплатный. È possibile ottenere gratuitamente queste informazioni in altre lingue. Chiamare il numero 1-866-783-1444 (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 1-866-783-1444 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 1-866-783-1444(TTY: 711) 번으로전화해주십시오. 통화료는무료입니다. 언제든영어나다른언어또는형식으로된가입자자료사본을요청하셔야할경우가입자서비스에연중무휴오전 8 시부터오후 8 시까지 1-866-783-1444(TTY: 711) 번으로전화해주십시오. 뉴욕주는 가제공하는모든서비스에대하여무료기밀지원을제공하기위해 독립소비자옹호네트워크 (Independent Consumer Advocacy Network, ICAN) 라는가입자옴부즈맨프로그램을만들었습니다. 가입자옴부즈맨 (ICAN) 의전화번호는 1-844-614-8800( 통화료무료 ) 이며온라인사이트는 icannys.org 입니다. (TTY 사용자는 711 번으로전화한다음안내에따라 844-614-8800 번으로연락해주시기바랍니다.)? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. II

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), 1-866-783-1444 번에서도확인하실수있습니다. 2. 의약품목록이바뀌기도하나요? 그렇습니다. 에서는일년내내의약품목록을추가또는삭제할수있습니다. 일반적으로, 의약품목록은다음의경우에만변경됩니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. III

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), 1-866-783-1444 번으로전화하여최신의약품목록을확인하실수있습니다. 3. 현재의약품목록에있는의약품만큼효과있는저렴한의약품이나오면어떻게되나요? 현재의약품목록에있는의약품만큼효과있는저렴한의약품을이용할수있게되는경우 : 귀하가다음번처방전에따라의약품을조제할때귀하의담당약사가저렴한의약품을제공할수있습니다. 귀하와귀하의제공자가저렴한의약품이귀하에게맞지않다고결정하는경우, 귀하의제공자는해당약사에게귀하가현재복용하고있는의약품을계속제공하라고말할수있습니다.? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. IV

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. V

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VI

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 1-866-783-1444 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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VII

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. VIII

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. IX

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. X

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 1-866-783-1444 번또는독립소비자권리옹호네트워크 (Independent Consumer Advocacy Network, ICAN) 의 1-844-614-8800 번으로전화해주십시오. (TTY 사용자는 711 번으로전화한다음안내에따라 844-614-8800 번으로연락해주시기바랍니다.)? 궁금한점이있으시면, 요일에상관없이오전 8 시부터오후 8 시까지 VNSNY CHOICE FIDA Complete, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XI

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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XII

약자정의설명 QL ST 용량한도제한 단계적치료제한 는보장되는이약품의용량을처방전당, 혹은특정시간대로제한합니다. VNSNY CHOICE FIDI Complete 에서이약품의보장범위를제공하기전에먼저본인이가진질환에대해다른의약품사용을시도해야합니다. 이약품은다른약품이효과적이지않을때만보장될수있습니다. 다음의추가적인이용관리약자는본문서내에서찾으실수있습니다. 보장을위한특별요건 약자정의설명 LA NM 접근제한약품 비우편처방약품 특정약국에서만처방이가능할수있습니다. 더자세한정보를알아보시려면 1-866-783-1444 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, 1-866-783-1444 번으로전화해주십시오 (TTY 는 771 번 ). 통화료는무료입니다. 자세한정보는 vnsnychoice.org 에서확인하실수있습니다. XIII

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 10001 전화 : VNSNY CHOICE Health Plans 의경우 : 888-634-1558 TYY 사용자 : 711 팩스 : 646-459-7729 이메일 : CivilRightsCoordinator@vnsny.org 웹사이트 : http://www.vnsny.ethicspoint.com 고충을제기하시는데도움이필요하실경우, 민권코디네이터가도와드릴수있습니다. 미연방보건복지부 (U.S. Department of Health and Human Services) 민권담당국 (Office for Civil Rights) 의민권차별항의서포털 (Office for Civil Rights Complaint Portal) 웹사이트 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 에서민권차별항의서를온라인으로제출하시거나아래우편또는전화로접수하실수도있습니다. U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-868-1019, 800-537-7697 (TDD) 민원서양식은 http://www.hhs.gov/ocr/office/file/index.html 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.

Table of Contents Analgesics... 3 Anesthetics... 13 Anti-Addiction/Substance Abuse Treatment Agents... 14 Antianxiety Agents... 16 Antibacterials... 17 Anticancer Agents... 28 Anticholinergic Agents... 37 Anticonvulsants... 38 Antidementia Agents... 42 Antidepressants... 43 Antidiabetic Agents... 46 Antifungals... 50 Antigout Agents... 53 Antihistamines... 54 Anti-Infectives (Skin And Mucous Membrane)... 59 Antimigraine Agents... 59 Antimycobacterials... 60 Antinausea Agents... 61 Antiparasite Agents... 63 Antiparkinsonian Agents... 64 Antipsychotic Agents... 65 Antivirals (Systemic)... 70 Blood Products/Modifiers/Volume Expanders... 76 유효일자 : 1

Caloric Agents... 79 Cardiovascular Agents... 84 Central Nervous System Agents... 100 Contraceptives... 103 Cough And Cold Products... 111 Dental And Oral Agents... 122 Dermatological Agents... 122 Devices... 131 Disinfectants (For Non-Dermatologic Use)... 132 Enzyme Replacement/Modifiers... 132 Eye, Ear, Nose, Throat Agents... 134 Gastrointestinal Agents... 141 Genitourinary Agents... 154 Heavy Metal Antagonists... 155 Hormonal Agents, Stimulant/Replacement/Modifying... 155 Immunological Agents... 162 Inflammatory Bowel Disease Agents... 172 Irrigating Solutions... 173 Metabolic Bone Disease Agents... 173 Miscellaneous Therapeutic Agents... 175 Ophthalmic Agents... 178 Replacement Preparations... 179 Respiratory Tract Agents... 186 Skeletal Muscle Relaxants... 191 Sleep Disorder Agents... 191 Vasodilating Agents... 193 Vitamins And Minerals... 194 유효일자 : 2

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 120-12 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 mg ALLZITAL ORAL TABLET 25-325 MG ascomp with codeine oral capsule 30-50-325-40 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

buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule 30-50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325- 40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule 50-325-40 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 50-325-40 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

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 10-325 mg (Xolox) QL (240 per 30 days) endocet oral tablet 2.5-325 mg, 5- QL (360 per 30 days) (Xolox) 325 mg endocet oral tablet 7.5-325 mg (Xolox) QL (300 per 30 days) (Oxycodone QL (360 per 30 days) endodan oral tablet 4.8355-325 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 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 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

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 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 10-325 mg (Norco) QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg (Norco) QL (360 per 30 days) 6

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 50-325-40 (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

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 5-325 mg/5 ml oxycodone-acetaminophen oral tablet 10-325 mg oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg (Oxycodone HCl/Acetaminophe n) (Xolox) (Xolox) QL (1800 per 30 days) QL (240 per 30 days) QL (360 per 30 days) 8

oxycodone-acetaminophen oral QL (300 per 30 days) (Xolox) tablet 7.5-325 mg oxycodone-aspirin oral tablet (Oxycodone QL (360 per 30 days) 4.8355-325 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 10-200 mg, QL (150 per 30 days) (Ibudone) 2.5-200 mg, 5-200 mg sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) 9

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 50-325 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) 37.5-325 mg vicodin es oral tablet 7.5-300 mg (Norco) QL (390 per 30 days) vicodin hp oral tablet 10-300 mg (Norco) QL (390 per 30 days) vicodin oral tablet 5-300 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 10-200 mg (Ibudone) QL (150 per 30 days) zebutal oral capsule 50-325-40 mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) ZUBSOLV SUBLINGUAL QL (30 per 30 days) TABLET 0.7-0.18 MG Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * 10

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

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 (Arthrotec 50) mg-mcg, 75-200 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

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

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 2.5-2.5 % (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 2.1-0.3 MG BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet 2-0.5 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

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

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 2-0.5 MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 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 0.125 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

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 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 0.225 % 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

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

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

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

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

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

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

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 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 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

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

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, 3.375 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

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 400-80 mg/5 ml (Sulfamethoxazole/ Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension 200-40 mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) sulfatrim oral suspension 200-40 (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

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

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

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

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

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

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 15-6.14 MG LONSURF ORAL TABLET 20-8.19 MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 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

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

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

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 11.25 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

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

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

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

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

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

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 7-14-21-28 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 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG 42

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

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

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 12-25 mg, 12-50 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

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, 150-500 MG, 50-1,000 MG INVOKAMET ORAL TABLET 50-500 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 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

INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG days) JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 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, 2.5-500 MG, 2.5-850 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

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg (Duetact) pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg (Actoplus Met) repaglinide oral tablet 0.5 mg, 1 mg, (Prandin) 2 mg repaglinide-metformin oral tablet 1- (Repaglinide/Metfo 500 mg, 2-500 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 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 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

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 70-30 FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX 70-30 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 2.5-500 mg, 5-500 mg (Glipizide/Metform in HCl) QL (120 per 30 days) 49

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) 1.25-250 mg, 2.5-500 mg, 5-500 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

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 1-0.05 % (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion 1-0.05 % 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

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 7 100 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

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 100,000-0.1 unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin ointment 100,000-0.1 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

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 500-0.5 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 5-120 (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 5-120 mg * (Claritin-D 12 Hour) allerclear d-24hr er tablet nondrowsy 10-240 mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-1 1.34 mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d 5-120 mg tablet 5-120 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet 2.5-60 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

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 5-120 mg tab 5-120 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 1-2.5 mg/5 ml * (Dimetapp) child wal-tap cold-allergy elx 1-2.5 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 2.5-60 (Triprolidine/Pseud mg * oephedrine) 55

compoz 25 mg gelcap 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs cold & cough nighttime liq 6.25-2.5 mg/5 ml * cvs loratadine-d 24hr tablet nondrowsy 10-240 mg * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-1 1.34 mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f 1-2.5 mg/5 ml * dimetapp cold & congest liquid 6.25-2.5 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

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 5-120 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

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 2.5-60 (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 5-120 mg * (Claritin-D 12 Hour) 58

wal-itin d 24 hour tablet 10-240 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 1-2.5 mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr 5-120 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

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

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 50-120- 300 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

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

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 250-100 mg, 62.5-25 mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET 20-120 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

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 10-100 mg, 25-100 mg, 25-250 mg (Sinemet CR) carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- (Stalevo 50) 125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg (Comtan) QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 64

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 0.125 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

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

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

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

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

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 600-300 mg abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET 600-200-300 MG COMPLERA ORAL TABLET 200-25-300 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET 200-25 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

EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET 600-300 MG EVOTAZ ORAL TABLET 300-150 MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET 150-150-200-10 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 400-100 MG/5 ML KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet 150-300 mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG 71

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 200-25-25 MG PREZCOBIX ORAL TABLET 800-150 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 150-150-200-300 MG 72

SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 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

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 400-100 MG HARVONI ORAL TABLET 90-400 MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET 12.5-75-50 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- 33.33 MG-200 MG ZEPATIER ORAL TABLET 50-100 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

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

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

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

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

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 25-200 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

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

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

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

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

insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION 3.31-9.8-3.9 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 % 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

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 0.1-15 mg, 0.2-15 mg, 0.3-15 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 20-12.5 MG, 40-12.5 MG, 40-25 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 16-12.5 mg, 32-12.5 mg, (Atacand HCT) 32-25 mg ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 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

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg (Avalide) losartan oral tablet 100 mg, 25 mg, 50 mg (Cozaar) losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50- (Hyzaar) 12.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80- (Micardis HCT) 25 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10- 25 MG, 40-5-12.5 MG, 40-5-25 MG valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg (Diovan) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320- (Diovan HCT) 12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Lotensin) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20- (Lotensin HCT) 25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg (Captopril) captopril-hydrochlorothiazide oral (Captopril/Hydroch tablet 25-15 mg, 25-25 mg, 50-15 lorothiazide) mg, 50-25 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 10-25 mg, 5-12.5 mg (Vaseretic) 본문서의XII-XIII페이지에서이테이블에있는기호및약어에대한정보를보실수있습니다. 86

fosinopril oral tablet 10 mg, 20 mg, (Fosinopril 40 mg Sodium) fosinopril-hydrochlorothiazide oral (Fosinopril/Hydroc tablet 10-12.5 mg, 20-12.5 mg hlorothiazide) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Zestril) lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20- (Zestoretic) 25 mg moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet 15-12.5 mg, 15-25 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 10-12.5 mg, 20-12.5 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

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 100-25 mg, 50-25 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 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg (Ziac) 88

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, 3.125 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 100-25 mg, 100-50 mg, 50-25 (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

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet 40-25 mg, 80-25 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

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

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

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

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN ORAL TABLET 187.5 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 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 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

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, (Exforge HCT) 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 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

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 25-25 mg torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg (Dyazide) triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 (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

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

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

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 150-10 MG, 150-5 MG, 300-10 MG, 300-5 MG TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG TEKTURNA ORAL TABLET 150 MG, 300 MG Vasodilators BIDIL ORAL TABLET 20-37.5 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

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

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

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 30-70 10 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule,er biphasic 50-50 20 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 20-10 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

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 0.15-0.03 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

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 0.15-0.03 mg (Desogen) aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet 0.1-20 mg-mcg (Amethyst) aviane oral tablet 0.1-20 mg-mcg (Amethyst) azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet 0.4-35 mgmcg (Modicon) bekyree (28) oral tablet 0.15-0.02 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 0.4-35 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

camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg cryselle (28) oral tablet 0.3-30 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 0.15-0.03 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 0.1-20 mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg (Desogen) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 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 0.3-30 mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet 0.15-0.03 mg (Desogen) enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet 0.15-0.03 mg (Desogen) 105

errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg (Demulen 1-50-21) fallback solo 1.5 mg tablet outer 1.5 mg * (Aftera) falmina (28) oral tablet 0.1-20 mgmcg (Amethyst) femynor oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) gianvi (28) oral tablet 3-0.02 mg (Yaz) gildagia oral tablet 0.4-35 mg-mcg (Modicon) gildess 1.5/30 (21) oral tablet 1.5-30 (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 0.15-0.03 mg (Desogen) junel 1.5/30 (21) oral tablet 1.5-30 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

junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) kurvelo oral tablet 0.15-0.03 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 1.5-30 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 0.1-20 mg-mcg (Amethyst) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) lessina oral tablet 0.1-20 mg-mcg (Amethyst) levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levonor-eth estrad 0.15-0.03 outer 0.15-0.03 mg (Amethyst) levonorgestrel 1.5 mg tablet (otc) 1.5 mg * (Aftera) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (Amethyst) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) 107

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 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet 0.15-0.03 mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet 3-0.02 mg (Yaz) low-ogestrel (28) oral tablet 0.3-30 (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet 0.1-20 mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet 0.15-0.03 mg (Amethyst) microgestin 1.5/30 (21) oral tablet 1.5-30 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 0.25-35 mgmcg (Ortho-Cyclen) mononessa (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet 0.5-35 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

necon 10/11 (28) oral tablet 0.5-35/1-35 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 3-0.02 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 0.18-0.215-0.25/0.035 3x28 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) 0.25-35 mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) nortrel 0.5/35 (28) oral tablet 0.5-35 (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) 0.12-0.015 MG/24 HR ocella oral tablet 3-0.03 mg (Yaz) ogestrel (28) oral tablet 0.5-50 mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * option 2 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) 109

orsythia oral tablet 0.1-20 mg-mcg (Amethyst) philith oral tablet 0.4-35 mg-mcg (Modicon) pimtrea (28) oral tablet 0.15-0.02 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 0.15-0.03 mg (Amethyst) previfem oral tablet 0.25-35 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 0.15-0.03 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 0.25-35 mgmcg (Ortho-Cyclen) sronyx oral tablet 0.1-20 mg-mcg (Amethyst) syeda oral tablet 3-0.03 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

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 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-mcg (Desogen) vestura (28) oral tablet 3-0.02 mg (Yaz) vienva oral tablet 0.1-20 mg-mcg (Amethyst) viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) vyfemla (28) oral tablet 0.4-35 mgmcg (Modicon) wera (28) oral tablet 0.5-35 mg-mcg (Modicon) xulane transdermal patch weekly (Norelgestromin/Et 150-35 mcg/24 hr hin.estradiol) zarah oral tablet 3-0.03 mg (Yaz) zenchent (28) oral tablet 0.4-35 mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) zovia 1/50e (28) oral tablet 1-50 mg-mcg (Demulen 1-50-21) Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry 2-5-15 mg/5 ml * 25cpd-200gfn liquid 25-200 mg/5 ml * 30pse-150gfn-15dm liquid 30-15- 150 mg/5 ml * 3brm-15dm-30pse liquid 3-30-15 mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) QL (3 per 28 days) 111

3brm-30dm-50pse liquid (otc) 3-50- 30 mg/5 ml * (Neo Dm) actinel pediatric liquid 15-5-50 mg/5 ml * (Trispec Pse) adt robitussin peak cld dm max 10-200 mg/5 ml * (G-Zyncof) adult robitussin peak cold liq nondrowsy 10-100 mg/5 ml * (G-Zyncof) adult wal-tussin dm max liq (G-Zyncof) a/f,cherry menthol 10-200 mg/5 ml * adult wal-tussin dm syrup (Cough Formula a/f,s/f,chry-menthol 10-100 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 12.5-30-1,000 mg/30 Methorphan/Aceta ml * min/doxylamn) ambi 10peh-4cpm-20dm tablet 4-10- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet 40-20-400 mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet 4-60- (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 1-30-20 mg/5 ml * (Neo Dm) bionel pediatric liquid 15-5-50 mg/5 ml * (Trispec Pse) 112

biospec dmx liquid 15-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) 30-15-175 mg/5 ml * seudoephedrine) bromfed dm cough syrup 2-30-10 (Brompheniramine/ 3 $0 mg/5 ml * Pseudoephed/Dm) bromphenir-pseudoephed-dm syr (Brompheniramine/ 3 $0 (rx) 2-30-10 mg/5 ml * Pseudoephed/Dm) (Brompheniramine/ brotapp dm liquid 1-15-5 mg/5 ml * Pseudoephed/Dm) centergy dm pediatric drops 1-2-3 (Chlorpheniramine/ 3 $0 mg/ml * Phenyleph/Dm) cheratussin ac syrup (otc) 10-100 (M-Clear Wc) mg/5 ml * cheratussin dac syrup 30-10-100 (Tusnel C) mg/5 ml * child plus cough-runny nose cherry (Dextromethorphn/ flavor 1-5-160 mg/5 ml * Acetaminoph/Cp) child robitussin er 30 mg/5 ml 30 (Delsym) mg/5 ml * child sudafed pe cough-cold lq 2.5-5 (Dextromethorphan mg/5 ml * /Phenylephrine) child triaminic cgh-congst syr 5-100 (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 8.33-5-10 mg/5 (Pseudoephedrine (Pyrilamine/Pe/De ml * HCl) xtromethorphan) 113

cold multi-symptom day-night pseudoephedrine-free 2-5-10-325 mg * cold multi-symptom night liq a/f, honey lemon 6.25-5-10-325 mg/15 ml * cold relief multi-symp caplet cplt,12 day,12 night 2-5-10-325 mg * cold-flu relief d/n softgel 10-5- 325mg(d)/ 15-325-6.25mg * cold-flu relief liquid 12.5-30-1,000 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 60-400 mg * (Poly-Vent Ir) congest-eze 60-400 mg caplet 60-400 mg * (Poly-Vent Ir) coricidin hbp cold-multi sympt 6.25-15-325 mg/15 ml * (D- Methorphan/Aceta min/doxylamn) coricidin hbp softgel 10-200 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 10-400 mg * (Maxiphen) cvs chest congest + cough liq 5-100 mg/5 ml * (G-Zyncof) cvs chest congest relief dm tb 20-400 mg * (Allfen Dm) cvs child cold-cough day liq 2.5-5 (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

cvs child's chest congest liq 100 mg/5 ml * (Guaifenesin) cvs cough & sore throat susp 160-5 (Child Tylenol Plus mg/5 ml * Cough-Sore) cvs nighttime cough liquid cherry (Dextromethorphan flavor 6.25-15 mg/15 ml * Hb/Doxylamine) cvs tussin cf liquid a/f, non drowsy 5-10-100 mg/5 ml * (Maxiphen Dmx) cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * (Robitussin) cvs tussin dm cough-chest liq 10-200 mg/5 ml * (G-Zyncof) daytime cold & cough liquid 1,000-30 mg/30 ml * (Triaminic) daytime cough liquid a/f, gluten-free (Dextromethorphan 5 mg/5 ml * Hbr) daytime-nighttime cold-flu liq multisymptom 6.25-5-10-325 mg/15 ml * phen/doxylamine) (Dm/Pe/Acetamino daytime-nighttime cough liquid (Dextromethorphan 15mg/15ml(d)/ 12.5-30mg/30ml * Hb/Doxylamine) delsym cough+chest cngst dm lq 5-100 mg/5 ml * (G-Zyncof) despec-dm tablet 30-10-200 mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 10-100 mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq 10-200 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 1-7.5 MG/5 ML * ed bron gp liquid 5-100 mg/5 ml * (Rescon-Gg) entre-cough liquid 30-15-175 mg/5 ml * (Trispec Pse) 115

expectorant 100 mg/5 ml syrup 100 mg/5 ml * (Guaifenesin) expectorant dm cough liquid 20-300 mg/5 ml * (G-Zyncof) expectorant max cough-cold 30-15 (Dextromethorphan mg/5 ml * /Pseudoephed) flu hbp tablet 2-15-500 mg * (Coricidin Hbp) g tussin ac liquid 10-100 mg/5 ml * (M-Clear Wc) geri-tussin dm syrup 10-100 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 2-5- 10-325 mg * hydrocodone-chlorphen er susp 10-8 mg/5 ml * hydrocodone-homatropine 5-1.5 mg tablet 5-1.5 mg * hydrocodone-homatropine syrup 5-1.5 mg/5 ml * hydromet syrup 5-1.5 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 10-100 mg/5 ml * (M-Clear Wc) kidkare cough & cold liquid 1-15-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) liquibid d-r tablet 10-400 mg * (Maxiphen) lohist-dm syrup 2-5-10 mg/5 ml * (Ala-Hist Dm) lortuss ex liquid 30-10-100 mg/5 ml * (Tusnel C) 116

mar-cof bp liquid 2-30-7.5 mg/5 ml (Bromphenira/Pseu * doephed/codein) mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) MUCINEX FAST-MAX COLD- FLU-THRT 10-20-650-400 MG * mucinex fast-max dm max liquid (G-Zyncof) maximum strength 5-100 mg/5 ml * mucus dm 600-30 mg tablet 30-600 (Mucinex Dm) mg * mucus dm max 1,200-60 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 3-50-30 MG/5 ML * neo-tuss liquid 30-200 mg/5 ml * (G-Zyncof) (Dm/Pnight time cold med liquid 6.25-30- Ephed/Acetaminop 15-500 mg/15 ml * h/doxylam) night time cough & sore throat 12.5-30-1,000 mg/30 ml * nohist-dm liquid 4-10-15 mg/5 ml * pecgen dmx 125-15 mg/5 ml liq 15-125 mg/5 ml * pediacare multi-symt cold liq non drowsy, grape 2.5-5 mg/5 ml * phenylhistine dh liquid (otc) 2-30-10 mg/5 ml * promethazine vc-codeine syrup 6.25-5-10 mg/5 ml * promethazine-codeine syrup 6.25-10 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

promethazine-dm syrup 6.25-15 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 5-10-325 mg/15 ml * pv night-time softgel multisympt.,softgel 6.25-30-15-325 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 5-100 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 10-100 mg/5 ml * (Cough Formula Dm) ra anti-tussive dm syrup 10-100 (Cough Formula mg/5 ml * Dm) (Dra day cold-flu relief softgel a/f, Methorphan/Pe/Ac multi-symptom 5-10-325 mg * etaminophen) ra daytime cold-flu liquid a/f,antihist free 5-10-325 mg/15 ml * ra daytime-nighttime softgel cold-flu relief 10-5-325mg(d)/ 15-325- 6.25mg * ra flu formula gelcap 12.5-5-10-325 mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt 2-5-10-325 mg * (D- Methorphan/Pe/Ac etaminophen) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) 118

refenesen 400 mg tablet 400 mg * (Allfen) refenesen pe caplet 10-400 mg * (Maxiphen) relcof c liquid 6.3-100 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 10-100 mg/5 ml * robafen-dm syrup 10-100 mg/5 ml * (Cough Formula Dm) robitussin cough-chest-cong dm 10- (Guaifenesin/Dextr 200 mg * omethorphan) ROBITUSSIN LONG-ACTING LIQ 1-7.5 MG/5 ML * robitussin pediatric cough syp (Dextromethorphan a/f,long-acting 7.5 mg/5 ml * Hbr) rydex liquid 1.3-10-6.3 mg/5 ml * (Bromphenira/Pseu doephed/codein) rynex dm liquid a/f, prof use only 1- (Brompheniram/Ph 2.5-5 mg/5 ml * enylephrine/dm) safetussin dm liquid 10-100 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 2.5-5 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

sm cough-head congestion lq 20-10- 66.7 mg/5 ml * sm flu severe cold-congestion maximum strength 4-60-30-1,000 mg * sm nite time cold-flu liquid 7.5-60- 30-1,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel 6.25-30-15-325 mg * sm pain reliever cold caplet 2-30- 15-325 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 1-15-5 mg/5 ml * sm severe cold m-s caplet 30-15-500 mg * Acetaminophen) sm tussin cf syrup 30-10-100 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/ 10-325 mg * Dm/Acetamin/Gg) triaminic daytime cold-cough (Dextromethorphan children's, cherry 2.5-5 mg/5 ml * /Phenylephrine) tusnel diabetic liquid (otc) 10-100 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F 30-15-200 MG/5 ML * TUSSI PRES-B LIQUID 4-10-30 MG/5 ML * 120

tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap 30-10-200 mg * seudoephedrine) tussin dm syrup 15-100 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 6.25-15-325 mg * min/doxylamn) virtussin dac liquid 30-10-100 mg/5 ml * (Tusnel C) v-r infant non-asa cold drp 15-5-160 (Dm/Pseudoephed/ mg/1.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet 30-15-500 mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant + 7.5-2.5 mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq 1-15-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup 30-10-100 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) (Dwal-flu severe cold-cough pckt 10- Methorphan/Pe/Ac 20-650 mg * etaminophen) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ caplet 5-10-325 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 20-400 mg/5 ml liquid 20-400 mg/5 ml * (G-Zyncof) 121

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

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 0.005 % (Calcipotriene) calcipotriene topical cream 0.005 % (Dovonex) calcipotriene topical ointment 0.005 (Calcipotriene) % calcitrene topical ointment 0.005 % (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

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 0.015 % 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

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 0.016 % 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

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

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

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 0.005 % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 % (Ultravate) 128

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

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 0.025 %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion 0.025 %, 0.1 % Acetonide) triamcinolone acetonide topical (Triamcinolone ointment 0.025 %, 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 0.025 %, PA (Retin-A) 0.05 %, 0.1 % 130

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength 0.33-4 % * (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 31GX5/16 0.3 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

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, 24,000-76,000-120,000 UNIT, 3,000-9,500-15,000 UNIT, 36,000-114,000-180,000 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

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, 20,000-68,000-109,000 UNIT, 25,000-85,000-136,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-136,000-218,000 UNIT, 5,000-17,000-27,000 UNIT PA PA; LA PA QL (90 per 30 days) 133

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 0.1-70/Hypromellose/P 0.3 % * F) artificial tears eye drops strl 0.1-0.3 (Dextran % * 70/Hypromellose) ARTIFICIAL TEARS EYE OINTMENT 83-15 % * 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 0.1-0.3 % * 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

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 57.3- (Artificial Tears) 42.5 % * cvs lubricant gel eye drops 0.25-0.3 (Carboxymethylcel % * l/hypromellose) cvs lubricating eye drops dry eye (Refresh Optive) soln 0.5-0.9 % * 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 0.25-0.5 (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS 0.25-0.3 % * 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

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 0.5-0.9% eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant 0.5-0.9% eye drops 0.5-0.9 % * (Refresh Optive) lubricating plus 0.5% eye drps p/f, (Carboxymethylcel 30x0.4ml 0.5 % * lulose Sodium) lubrifresh pm eye ointment 83-15 % * (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 0.3-0.025 % (0.25 ML) QL (30 per 28 days) QL (15 per 10 days) 136

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 1.4-0.6 % * REFRESH LACRI-LUBE OINTMENT 56.8-42.5 % * (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 80-20 % * (Artificial Tears) sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl 0.4-0.3 % * (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 80-20 % * (Artificial Tears) SYSTANE 0.3% EYE GEL 0.3 % * SYSTANE GEL EYE DROPS 0.4-0.3 % * ST 137

tears again 1.4 % drops 1.4 % * (Polyvinyl Alcohol) tears again eye ointment 80-20 % * (Artificial Tears) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f 0.1-0.3 % * 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 500-10,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION 0.3-0.1 % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION 3.3-3-10-0.5 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

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 3.5-400-10,000 Zn/Poly/HC) mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-10,000 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 3.5-10,000-10 mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment 3.5-400-10,000 mg-unit/g-1% neo-polycin ophthalmic ointment 3.5-400-10,000 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

ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 (Polytrim) mg/ml REFRESH OPTIVE ADVANCED DROPS 0.5-1-0.5 % * 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 0.3-0.1 % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION 0.3-0.05 % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension 0.3-0.1 (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION 0.3-0.5 % 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

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

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 500-500-30 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

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

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 95-358 mg/15 ml * (Gaviscon) almacone liquid 200-200-20 mg/5 (Maalox Maximum ml * Strength) almacone-2 liquid 400-400-40 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

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 400-400-40 mg/5 ml * comfort gel suspension regular str, cherry 200-200-20 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 1,000-60 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

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 2.5-0.025 mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet 2.5-0.025 mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) foaming antacid liquid 95-358 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 400-40 mg/5 ml * Strength) gelusil tablet chewable cool mint 200-200-25 mg * (Almacone) generlac oral solution 10 gram/15 ml (Lactulose) geri-lanta liquid 200-200-20 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

kionex 15 gm/60 ml suspension 15-19.3 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 200-200-20 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 400-400-40 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

metoclopramide hcl oral tablet 10 mg, 5 mg (Reglan) mgo 400 mg tablet 400 mg * (Magox 400) mi acid suspension 200-200-20 (Maalox Maximum mg/5 ml, 400-400-40 mg/5 ml * Strength) (Calcium mi-acid ds tablet 700-300 mg * Carb/Magnesium Hydrox) mintox maximum strength susp max (Maalox Maximum str, lemon creme 400-400-40 mg/5 Strength) ml * mintox plus tablet chewable 200-200-25 mg * (Almacone) mintox suspension mint creme 200- (Maalox Maximum 200-20 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 400-400-40 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

riginic suspension 131-31.7 mg/5 ml * (Gaviscon) ri-mox suspension 200-200-20 mg/5 (Maalox Maximum ml * Strength) sm antacid anti-gas liquid 400-400- (Maalox Maximum 30 mg/5 ml * Strength) sm foaming antacid tablet chew 80-20 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 15-20 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

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 8.6-50 (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 283-20 mg/5 ml * (Docusol Plus) eq fiber therapy powder * (Psyllium Seed equalactin 500 mg tab chew 500 mg * (With Sugar)) (Calcium Polycarbophil) 150

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 240-22.72-6.72-5.84 gram (Golytely) gavilyte-g oral recon soln 236-22.74-6.74-5.86 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 100-7.5-2.691 GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba) 151

peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram, 240-22.72-6.72-5.84 gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet 8.6-50 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 7.2-2.7 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

senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet 8.6-50 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 17.5-3.13-1.6 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 400-200- 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

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 0.5-0.4 mg (Jalyn) finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule,extended release 24hr 0.4 mg (Flomax) QL (30 per 30 days) 154

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 20.25 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

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 0.5-0.1 mg, 1-0.5 mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DUAVEE ORAL TABLET 0.45-20 MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 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

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 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, 0.625 MG, 1.25 MG, 2.5 MG (Delestrogen) (Activella) (Estropipate) mimvey lo oral tablet 0.5-0.1 mg (Activella) mimvey oral tablet 1-0.5 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, 0.625 MG, 0.9 MG, PA-HRM; AGE (Max 64 Years) 1.25 MG PREMARIN VAGINAL CREAM 0.625 MG/GRAM PREMPHASE ORAL TABLET PA-HRM; AGE (Max 0.625 MG (14)/ 0.625MG-5MG(14) 64 Years) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 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

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

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 11.25 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

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

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

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

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 15-18 % 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

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

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

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

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-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 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

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5-125 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 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 20-40-40-20 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 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

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 25-58-10 LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML IPOL INJECTION SYRINGE 40-8- 32 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 5-2.5 MCG/0.5 ML 169

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 10EXP3-4.3-3- 3.99 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

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

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 0.375 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

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 2.7-0.54 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

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 - 600 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

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

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

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

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 0.2-0.5 % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml (Cosopt) latanoprost ophthalmic drops 0.005 % (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 0.125 % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION 1-0.2 % QL (2.5 per 25 days) 178

timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS 0.004 % travoprost (benzalkonium) ophthalmic drops 0.004 % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE 0.0015 % Replacement Preparations Replacement Preparations calcitrate + vit d caplet 315-250 mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium 600 + vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium 600 + 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 600 + 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

calcium citrate - vit d caplet caplet, (Citracal-Vitamin coated 315-200 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 500-100 MG-UNIT * CALTRATE 600 + 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 315-250 (Citracal-Vitamin mg-unit * D) cvs calcium citrate-vit d tab 315-250 (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

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0.2 % dextrose-kcl-nacl intravenous solution 5-0.224-0.225 % 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

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

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 250-125 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

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

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 315-250 mg-unit * (Citracal-Vitamin D) 185

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 18-18-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE QL (60 per 30 days) 186

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 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 100-5 MCG/ACTUATION, 200-5 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

SYMBICORT 160-4.5 MCG INHALER 60 INHALATIONS 160-4.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 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 62.5-25 MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST 20-100 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

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 2.5-2.5 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

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

OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET 100-125 MG, 200-125 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

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

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 0.125 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

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 18-400 mg-mcg * a thru z advanced formula tab new formula * a thru z advanced formula tab w/ lutein & lycopene 18-500-300-250 mg-mcg-mcg-mcg * a thru z select 50+ formula tb advanced formula 0.4-300-250 mgmcg-mcg * a thru z select men 50+ tablet 300-600-300 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

a thru z select multivit tab 500-300- 250 mcg * (Biocel) a thru z select multivit tab iron-free, 50+ form 0.4-300-250 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 0.4-300-250 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 0.4-300-250 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-12 500 mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 tablet * (Vitamin B Complex) 195

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 600 + vit d 400 caplet s/f, (Os-Cal 500-Vit p/f, caplet 600 mg(1,500mg) -400 D3) unit * calcium 600 + vit d tablet 600-125 mg-unit * (Os-Cal 500-Vit D3) 196

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 18-400 mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults 50 + 0.4-300-250 mg-mcg-mcg * century ultimate men's tablet 300-600-300 mcg * century ultimate women's tab 18-400 mg-mcg * cerovite advanced form tab 18-400 mg-mcg * cerovite jr tablet chew * cerovite liquid 9 mg iron/15 ml * cerovite senior tablet * certavite sr-antioxidant tab 0.4-300- 250 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

certavite-antioxidant liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) certavite-antioxidant tablet 18-400 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 500-300- 250 mcg * (Biocel) complete multi tablet 18-500-300- (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 500 + vit d tablet oyster (Os-Cal 500-Vit shell 500 mg(1,250mg) -125 unit * D3) 198

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 0.4-300-250 mg-mcg-mcg * (Biocel) cvs spectravite adult gummy 200 (One-A-Day mcg * Vitacraves) cvs spectravite advanced tab 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) 199

cvs spectravite ultra men's tb 300-600-300 mcg * cvs spectravite ultra women tb 18-400 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 18-400 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

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 0.5-0.6-7-0.7 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 0.4-300-250 mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree 18-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ (Multiviteq one daily men's tablet gluten free Minerals/Fa/Lycop 400-300 mcg * ene) eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet 500-300- 250 mcg * (Biocel) eql century multi-vitamin tab 18-0.4 (Folic mg * Acid/Mv,Fe,Min) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) 201

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 18-0.4 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 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) essential balance tablet * (Mv,Fe,Min/Lutein ) essential daily tablet w/iron & calcium 18-0.4 mg * (Tab A Vite) feosol 65 mg tablet 325 mg (65 mg iron) * (Slow Fe) ferocon capsule 110-0.5 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 150-50-50 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

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 175.5-14.5 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 0.4-300-250 mg-mcg-mcg * (Biocel) 203

gnp century tablet adults 50+ 0.4-300-250 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 28-800 (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 0.4-300-250 (Biocel) mg-mcg-mcg * hm complete women tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) hm one daily with iron tablet glutenfree 18-400 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

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 18-400 (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 18-400 (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

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 1-60-300-12.5 mg-mg-mcg-mg * nephron fa tablet 66.6-75-1 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 1-60-300 mgmg-mcg * 3 $0 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 150 capsule 150 mg iron * (Pic 200) 206

(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 18-0.4 mg (Folic * Acid/Mv,Fe,Min) one daily essential tablet * (Multivitamin) one daily for women tablet 18-0.4 (Folic mg * Acid/Mv,Fe,Min) one daily gummy vites gummie 200 (One-A-Day mcg * Vitacraves) one daily maximum tablet 18-0.4 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 18-400 (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 207

(Multivitone-a-day men's tablet 400-300 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 13.5-0.4 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 1,500-35-400 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 1,500-35-400 unit-mg-unit/ml * (Pediatric Multivitamin No.20) (All Rx Prenatal Vitamins Covered) 208

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) 27-0.8 mg * No.130/Iron/Fa) (Prenatal Vit/Iron prenatal tablet (otc) 27-0.8 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) 27-0.8 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 5,000-60-30 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

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 18-400 (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 500-300-250 (Biocel) mcg * pv multivital tablet 0.4-162-18 mg * (Fa/Mv,Ca,Iron,Mi n/lycopene/lut) pv multivital tablet 18-500-300-250 (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

qc maximum daily multivit tab 18-0.4 mg * qc multi-vite 50 & over tablet w/lycopene * qc multi-vite tablet 18-400 mg-mcg * qc women's daily multivit tab 18-0.4 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 0.4-300- 250 mg-mcg-mcg * (Biocel) ra central-vite tablet 0.4-300-250 mg-mcg-mcg * (Biocel) ra central-vite tablet 18-400 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 18-0.4 (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

ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab 18-0.4 (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 1-60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 right step prenatal vit tab 27-0.8 mg (Prenatal Vit/Iron * Fumarate/Fa) (Multivit with Ironscooby-doo one a day tablet * Minerals) senior tabs 0.4-300-250 mg-mcgmcg * (Biocel) sentry senior multivitamin tab (Biocel) sodium/f,yeast/f 500-300-250 mcg * sentry senior tablet 0.4-300-250 mgmcg-mcg * (Biocel) (Multivitamin/Iron/ sentry tablet 18-400 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 500-300-250 mg-mcg-mcg-mcg * children's * Fum/Fa/Lyco/Lut) Iron) 212

sm complete advanced tablet 18-500-300-250 mg-mcg-mcg-mcg * sm complete multi-vit-mineral advanced formula 18-400 mg-mcg * sm complete senior formula tab * sm complete senior formula tab 0.4-300-250 mg-mcg-mcg * (Mv,Ca,Min/Iron Fum/Fa/Lyco/Lut) (Multivitamin/Iron/ Folic Acid) (Multivit with Iron- Minerals) (Biocel) sm complete tablet 27-0.4 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 100 100 Cmb mg * #2/Herbs) sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet 27-0.4 mg * sm ultimate men's complete tab 300-600-300 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

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

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 27-0.4 mg * thera-m caplet * thera-m caplet caplet 27-0.4 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

therapeutic-m tablet 0.4-250 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 1,500-35-400 unit-mgunit/ml * tri-vitamin drops 1,500-35-400 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 d2 1.25 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

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-1 100 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-12 100 mcg tablet 100 mcg * (B-12) vitamin b-12 250 mcg tablet 250 mcg * (B-12) vitamin b12 500 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-6 250 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 400-500 mcg-mg * Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) 217

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

vitamins for hair tablet * (Multivitamin) vitatrum tablet 18-500-300-250 mgmcg-mcg-mcg * Fum/Fa/Lyco/Lut) (Mv,Ca,Min/Iron vitrum 50+ senior tablet 500-300- 250 mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) vol-care rx tablet 1-60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 vp-vite rx tablet 1-60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 v-r calcium 400 + d 133 caplet 400- (Os-Cal 500-Vit 133.3 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 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 219

INDEX 3 3 day vaginal... 53 30pse-150gfn-15dm... 111 3-day vaginal... 50 8 8-MOP... 122 A a thru z... 194 a thru z advanced formula... 194 a thru z high potency... 194 a thru z select... 194, 195 a thru z select 50+ formula.. 194, 195 a thru z select women's... 195 abacavir... 70 abacavir-lamivudine... 70 abacavir-lamivudine-zidovudine... 70 abc plus... 195 ABELCET... 50 ABILIFY MAINTENA... 65 ABRAXANE... 28 ABREVA... 59 acamprosate... 14 acarbose... 46 acebutolol... 88 acephen... 3 acetaminophen... 3, 5 acetaminophen-codeine... 3 acetazolamide... 178 acetazolamide sodium... 178 acetic acid... 138, 173 acetylcysteine... 190 acid gone antacid... 144 acid reducer (famotidine)... 142, 143 acid reducer (ranitidine)... 143 acid relief (cimetidine)... 144 acitretin... 122 acne medication... 122, 124 ACNE MEDICATION... 122 ACTEMRA... 162 ACTHIB (PF)... 167 ACTIMMUNE... 175 actinel pediatric... 112 acyclovir... 75, 122 acyclovir sodium... 75 ADACEL(TDAP ADOLESN/ADULT)(PF) 167 ADAGEN... 132 adapalene... 130 ADCETRIS... 28 ADCIRCA... 193 adefovir... 75 ADEMPAS... 193 adriamycin... 28 adrucil... 28 adt robitussin peak cld dm max... 112 adult multivitamin gummies 195 adult nasal decongestant... 119 adult one daily gummies... 195 adult robitussin peak cold dm... 112 adult wal-tussin... 112 adult wal-tussin dm max... 112 adults 50 plus... 195 ADVAIR DISKUS... 186 ADVAIR HFA... 187 ADVIL... 10, 11 afeditab cr... 94 AFINITOR... 28 AFINITOR DISPERZ... 28 a-hydrocort... 157 AKTEN (PF)... 134 AKYNZEO... 61 ala-cort... 127 ala-scalp... 127 alavert... 54 alavert d-12 allergy-sinus... 54 ALBENZA... 63 albuterol sulfate... 188 alcaine... 134 alclometasone... 127 ALCOHOL PADS... 122 ALCOHOL PREP PADS... 122 ALDURAZYME... 132 ALECENSA... 28 alendronate... 173, 174 alfuzosin... 154 ALIMTA... 28 ALINIA... 63 alka-seltzer plus mucus-conges... 112 aller-chlor... 54 allerclear d-12hr... 54 allerclear d-24hr... 54 allergy (chlorpheniramine)... 54 allergy relief (cetirizine)... 56 allergy relief (clemastine)... 57 allergy relief(diphenhydramin)... 57 allerhist-1... 54 aller-tec d... 54 all-nite cold-flu... 112 allopurinol... 53, 54 ALLZITAL... 3 almacone... 144 almacone-2... 144 aloe vesta antifungal (micon). 50 alophen... 149 alosetron... 172 ALPHAGAN P... 178 alprazolam... 16 I-1

ALREX... 140 altacaine... 134 altamist... 134 altavera (28)... 103 aluminum hydroxide gel... 144 alyacen 1/35 (28)... 104 alyacen 7/7/7 (28)... 104 amabelz... 156 amantadine hcl... 64 ambi 10peh-4cpm-20dm... 112 ambi 20dm-4cpm... 112 ambi 40pse-400gfn-20dm... 112 ambi 60pse-4cpm... 54 ambi 60pse-4cpm-20dm... 112 AMBISOME... 50 amethia... 104 amethia lo... 104 amifostine crystalline... 175 amiloride... 95 amiloride-hydrochlorothiazide95 AMINO ACIDS 15 %... 79 AMINOSYN 10 %... 80 AMINOSYN 3.5 %... 80 AMINOSYN 7 %... 80 AMINOSYN 7 % WITH ELECTROLYTES... 80 AMINOSYN 8.5 %... 80 AMINOSYN 8.5 %- ELECTROLYTES... 80 AMINOSYN II 10 %... 80 AMINOSYN II 15 %... 80 AMINOSYN II 7 %... 80 AMINOSYN II 8.5 %... 80 AMINOSYN II 8.5 %- ELECTROLYTES... 80 AMINOSYN M 3.5 %... 80 AMINOSYN-HBC 7%... 81 AMINOSYN-PF 10 %... 81 AMINOSYN-PF 7 % (SULFITE-FREE)... 81 AMINOSYN-RF 5.2 %... 81 amiodarone... 87 AMITIZA... 144 amitriptyline... 43 amlactin... 122 amlodipine... 94 amlodipine-atorvastatin... 96 amlodipine-benazepril... 94 amlodipine-valsartan... 94 amlodipine-valsartan-hcthiazid... 95 ammonium lactate... 122, 123 amoxapine... 43 amoxicil-clarithromy-lansopraz... 142 amoxicillin... 24 amoxicillin-pot clavulanate... 24 amphotericin b... 50 ampicillin... 24 ampicillin sodium... 24, 25 ampicillin-sulbactam... 25 AMPYRA... 100 ANACAINE... 123 ANADROL-50... 155 anagrelide... 79 anastrozole... 28 ANDRODERM... 155 ANDROGEL... 155 androxy... 155 animal chews... 195 animal shape vitamins... 212 animal shapes plus iron... 212 ANORO ELLIPTA... 188 antacid anti-gas (ca carb-sim)... 145 antacid ultra strength... 145 antacid-antigas ii... 149 anti-diarrheal... 145 anti-diarrheal (loperamide). 144, 145 antifungal (tolnaftate)... 50, 53 antifungal cream... 50 anti-gas maximum strength.. 142 anti-itch (hc)... 127 antioxidant... 195 antitussive dm... 118 apatate forte... 195 APOKYN... 64 apraclonidine... 134 aprepitant... 61 apri... 104 APRISO... 172 aprodine... 54 APTIOM... 38 APTIVUS... 70 aquanil hc... 127 aranelle (28)... 104 ARCALYST... 162 aripiprazole... 65, 66 ARISTADA... 66 armodafinil... 191 ARNUITY ELLIPTA... 187 ARTIFICIAL TEARS (PETRO/MIN)... 134 artificial tears (pf)... 134 artificial tears (polyvin alc).. 134 artificial tears(dext70-hypro) 134 artificial tears(glycerin-peg). 134 artificial tears(hypromellose) 137 ASACOL HD... 172 ascomp with codeine... 3 ascorbic acid (vitamin c)... 200, 218 ashlyna... 104 aspirin... 11 aspirin, buffered... 11 aspirin-dipyridamole... 79 aspir-low... 11 ASSURE ID INSULIN SAFETY... 131 ASTAGRAF XL... 162 atenolol... 88 atenolol-chlorthalidone... 88 atorvastatin... 96 atovaquone... 63 atovaquone-proguanil... 63 I-2

ATRIPLA... 70 atropine... 37, 38, 134 ATROVENT HFA... 188 AUBAGIO... 100 aubra... 104 AVASTIN... 28 AVC VAGINAL... 59 aviane... 104 AVONEX... 100 AVONEX (WITH ALBUMIN)... 100 ayr saline... 134 azacitidine... 29 azathioprine... 162 azathioprine sodium... 162 azelastine... 134 AZILECT... 64 azithromycin... 22 AZOPT... 178 AZOR... 95 aztreonam... 23 azurette (28)... 104 B b complete... 195 b complex 1... 195 b complex 100... 213 b complex-vitamin b12... 196 b complex-vitamin c-folic acid... 196, 204, 214 b-100 complex... 209 b-12 dots... 195 b-50 complex... 209 bacitracin... 18, 125, 138 bacitracin-polymyxin b... 138 bacitraycin plus... 125 baclofen... 191 bal b-100... 198 bal b-50... 198 balance b-100... 195 balance b-50... 196 balanced b-100... 196, 211 balanced b-150... 198 balanced b-50... 196, 211 balsalazide... 172 balziva (28)... 104 banophen... 54 banophen allergy... 55 BANZEL... 38 baza antifungal... 50 BCG VACCINE, LIVE (PF) 167 b-complex... 211 b-complex with vitamin c... 196, 198, 212, 217 BD INSULIN PEN NEEDLE UF SHORT... 131 BD INSULIN SYRINGE ULTRA-FINE... 131 bee-zee... 196 bekyree (28)... 104 BELBUCA... 3 BELEODAQ... 29 BELSOMRA... 192 benadryl allergy... 55 benazepril... 86 benazepril-hydrochlorothiazide... 86 BENDEKA... 29 BENICAR... 85 BENICAR HCT... 85 BENLYSTA... 175 benzonatate... 112 benzoyl peroxide... 123 benztropine... 64 BETADINE... 123 beta-hc... 127 betamethasone acet,sod phos 157 betamethasone dipropionate. 127 betamethasone valerate... 127 betamethasone, augmented.. 127 BETASERON... 100 betaxolol... 88, 178 bethanechol chloride... 154 BETHKIS... 17 bexarotene... 29 BEXSERO (PF)... 167 bicalutamide... 29 bicarsim forte... 141, 142 BICILLIN C-R... 25 BICILLIN L-A... 25 BIDIL... 99 bimatoprost... 178 bio-dtuss dmx... 112 bion tears (pf)... 134 bionel pediatric... 112 biospec dmx... 113 biosupp... 196 biotin... 196 biovol... 196 bisac-evac... 149 bisacodyl... 149, 150 biscolax... 150 bismatrol... 144 bisoprolol fumarate... 88 bisoprolol-hydrochlorothiazide... 88 bleomycin... 29 bleph-10... 138 BLINCYTO... 29 blisovi 24 fe... 104 blisovi fe 1.5/30 (28)... 104 blisovi fe 1/20 (28)... 104 blis-to-sol (tolnaftate)... 50 BOOSTRIX TDAP... 167 BOSULIF... 29 bp 8 cough... 113 BREO ELLIPTA... 187 briellyn... 104 BRILINTA... 79 brimonidine... 178 BRINTELLIX... 43 BRIVIACT... 38 bromfed dm... 113 bromfenac... 140 bromocriptine... 64 brompheniramine-pseudoephdm... 111, 112, 113 I-3

brotapp dm... 113 budesonide... 172, 187 bufferin... 11 bumetanide... 95 BUNAVAIL... 14 BUPHENYL... 144 buprenorphine hcl... 4, 14 buprenorphine-naloxone... 14 buproban... 14 bupropion hcl... 43 bupropion hcl (smoking deter)15 buspirone... 175 butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC... 89 BYVALSON... 89 C c complex... 196 cabergoline... 64 CABOMETYX... 29 ca-d3-mag ox-zinc-cop-mangbor... 181, 185 caffeine citrate... 101 calci-chew... 144 calcidol... 196 calcipotriene... 123 calcitonin (salmon)... 174 calcitrate... 179 calcitrate-vitamin d... 179 calcitrene... 123 calcitriol... 123, 174 calcium 500 + d (d3)... 198 calcium 600... 179 calcium 600 + d(3) 179, 196, 197 calcium 600 with vitamin d3 182 calcium acetate... 153 calcium antacid... 145 calcium carbonate... 145, 179 calcium carbonate-vit d3-min... 179 calcium carbonate-vitamin d3.. 179, 181, 196, 197, 199, 203 CALCIUM CARBONATE- VITAMIN D3... 180 calcium chloride... 179 calcium citrate-vitamin d3.. 180, 185 calcium gluconate... 180 calcium+d... 219 CALDOLOR... 11 cal-gest antacid... 145 CALTRATE 600 + D... 180 camila... 104 camrese... 105 camrese lo... 104 CANCIDAS... 50 candesartan... 85 candesartan-hydrochlorothiazid... 85 capacet... 4 CAPASTAT... 60 CAPRELSA... 29 captopril... 86 captopril-hydrochlorothiazide 86 CARAFATE... 142 CARBAGLU... 145 carbamazepine... 38 carbidopa... 64 carbidopa-levodopa... 64 carbidopa-levodopa-entacapone... 64 CARIMUNE NF NANOFILTERED... 162 carisoprodol... 191 carteolol... 134 cartia xt... 90 carvedilol... 89 CASTELLANI PAINT... 123 CAYSTON... 23 caziant (28)... 105 cefaclor... 20 cefadroxil... 20 cefazolin... 20 cefazolin in dextrose (iso-os). 20 cefdinir... 20 cefditoren pivoxil... 20 cefepime... 20 CEFEPIME... 20 CEFEPIME IN DEXTROSE 5 %... 20 CEFEPIME IN DEXTROSE,ISO-OSM... 20 cefotaxime... 21 cefoxitin... 21 cefoxitin in dextrose, iso-osm 21 cefpodoxime... 21 cefprozil... 21 ceftazidime... 21 ceftibuten... 21 ceftriaxone... 21 ceftriaxone in dextrose,iso-os. 21 cefuroxime axetil... 21 cefuroxime sodium... 22 celecoxib... 11 CELLCEPT INTRAVENOUS... 162 CELONTIN... 38 centamin... 197 centergy dm... 113 central vite with lutein... 211 central-vite... 211 central-vite for seniors... 197 central-vite select... 201, 211 central-vite senior... 211 centram-care... 197 centravites 50 plus... 197 centrum... 197 centrum complete... 197 centrum silver... 197 century... 201, 204 century adults 50+... 204 century mature... 201, 203 I-4

century ultimate men's... 197 century ultimate women's... 197 cephalexin... 22 CEPROTIN (BLUE BAR)... 76 CERDELGA... 175 CEREZYME... 132 cerovite... 197 cerovite advanced formula... 197 cerovite jr... 197 cerovite senior... 197 certavite senior-antioxidant.. 197 certavite-antioxid (iron gluc) 198 certavite-antioxidant... 198 CERVARIX VACCINE (PF)... 168 cetirizine... 55 cetirizine-pseudoephedrine... 55 CETYLEV... 175 cevimeline... 122 CHANTIX... 15 CHANTIX CONTINUING MONTH BOX... 15 CHANTIX STARTING MONTH BOX... 15 cheratussin ac... 113 cheratussin dac... 113 chest congestion relief + dm 114 chest congestion relief pe... 114 chewable multi vitamin... 201 chewable-vite... 198 chewable-vite with iron... 198 child chest congestion + cough... 114 child complete multivitamin 201 child cough and sore throat.. 115 child mucinex chest congestion... 113 child plus cough and runnynose... 113 child triaminic cold-allergy... 55 child triaminic cough-congest... 113 child vitamin with minerals.. 199 child wal-tap cold-allergy... 55 child wal-tussin cough relief 113 CHILDREN'S ADVIL... 11 children's allegra allergy... 55 children's aller-tec... 55 children's chest congestion... 115 children's chewable... 210 children's chewable complete... 199 children's chewable vitamin. 198 children's chewable w/minerals... 202 CHILDREN'S CLARITIN... 55 children's cold-cough daytime... 114 children's complete vitamin. 210 children's cough and runnynose... 114 children's cough dm er... 114 children's mapap... 4 children's mucinex cough... 113 children's multivit w/extra c. 201 children's non-aspirin... 4, 5 children's pain reliever... 10 children's pain-fever relief... 4, 6 children's pepto... 145 children's robitussin er... 113 children's silfedrine... 113 children's soothe... 145 children's sudafed... 113 children's sudafed pe cough. 113 children's tactinal... 4 children's wal-zyr... 55 CHILDREN'S ZYRTEC ALLERGY... 55 childs chew vite... 198 child's chewable vitamins/iron... 198 child's vitamin with iron... 199 child's vitamin with vitamin c... 199 childs/iron... 198 chlophedianol-guaifenesin... 111 chloramphenicol sod succinate... 18 chlordiazepoxide hcl... 16 chlorhexidine gluconate... 122 chloroquine phosphate... 63 chlorothiazide... 95 chlorothiazide sodium... 95 chlorpheniramine-phenyleph-dm... 111 chlorpromazine... 66 chlorthalidone... 95 chlorzoxazone... 191 cholecalciferol (vitamin d3) 200, 218 cholestyramine (with sugar)... 97 cholestyramine light... 96, 97 ciclopirox... 50 cilostazol... 79 cimetidine... 142, 143 cimetidine hcl... 142 CIMZIA... 163 CIMZIA POWDER FOR RECONST... 163 CINQAIR... 190 CINRYZE... 77 CIPRODEX... 138 ciprofloxacin... 26 ciprofloxacin hcl... 26, 138 ciprofloxacin in 5 % dextrose 26 ciprofloxacin lactate... 26 citalopram... 43 citracal + d maximum... 180 citrus calcium... 180 clarithromycin... 23 CLARITIN LIQUI-GEL... 55 CLARITIN REDITABS... 55 clearlax... 150 CLEVIPREX... 95 clindamycin hcl... 18 clindamycin in 5 % dextrose.. 18 I-5

clindamycin palmitate hcl... 18 clindamycin pediatric... 18 clindamycin phosphate... 18, 59, 125 CLINIMIX 5%/D15W SULFITE FREE... 81 CLINIMIX 5%/D25W SULFITE-FREE... 81 CLINIMIX 2.75%/D5W SULFIT FREE... 81 CLINIMIX 4.25%/D10W SULF FREE... 81 CLINIMIX 4.25%/D5W SULFIT FREE... 81 CLINIMIX 4.25%-D20W SULF-FREE... 81 CLINIMIX 4.25%-D25W SULF-FREE... 81 CLINIMIX 5%- D20W(SULFITE-FREE)... 82 CLINIMIX E 2.75%/D10W SUL FREE... 82 CLINIMIX E 2.75%/D5W SULF FREE... 82 CLINIMIX E 4.25%/D10W SUL FREE... 82 CLINIMIX E 4.25%/D25W SUL FREE... 82 CLINIMIX E 4.25%/D5W SULF FREE... 82 CLINIMIX E 5%/D15W SULFIT FREE... 82 CLINIMIX E 5%/D20W SULFIT FREE... 82 CLINIMIX E 5%/D25W SULFIT FREE... 82 CLINISOL SF 15 %... 82 clobetasol... 127, 128 clobetasol-emollient... 128 clocortolone pivalate... 128 clomipramine... 43 clonazepam... 16 clonidine... 85 clonidine hcl... 84, 85, 101 clopidogrel... 79 clorazepate dipotassium... 16 clorpres... 85 clotrimazole... 50, 51 clotrimazole-7... 51 clotrimazole-betamethasone... 51 clozapine... 66 COARTEM... 63 codeine sulfate... 5 codituss dm... 113 COLCRYS... 54 cold and cough (diphenhydr-pe)... 56 cold and cough (pe-dm)... 119 cold multi-symptom day/night... 114 cold multi-symptom nighttime... 114 cold relief m/s day/night... 114 cold-allergy-sinus... 55 cold-flu relief... 114 cold-flu relief, day/night... 114 colestipol... 97 colistin (colistimethate na)... 18 colocort... 172 COLY-MYCIN S... 138 COMBIGAN... 178 COMBIPATCH... 156 COMBIVENT RESPIMAT. 188 COMETRIQ... 29 comfort gel... 145 comfort gel extra strength... 145 compete... 198 COMPLERA... 70 complete... 213 complete 50+... 204 complete multi... 198 complete multi 50+... 198 complete multivitamin. 198, 201 complete multivitamin-mineral... 201, 213 complete senior... 198, 213 complete women... 204 compoz... 56 compro... 61 COMVAX (PF)... 168 CONDYLOX... 123 congestac... 114 congest-eze... 114 constulose... 145 COPAXONE... 101 coricidin hbp... 114 coricidin hbp cold-multi sympt... 114 CORLANOR... 91 cormax... 128 cortaid... 128 cortisone... 157 cortizone-10... 128 COSENTYX... 123 COSENTYX (2 SYRINGES)... 123 COSENTYX PEN... 123 COSENTYX PEN (2 PENS) 123 COTELLIC... 29 cough and cold... 114 cough and runny nose... 119 cough relief... 114 CREON... 132 critic-aid clear af... 51 CRIXIVAN... 70 cromolyn... 134, 145, 190 cryselle (28)... 105 CUBICIN... 18 CUPRIMINE... 155 cutter backwoods... 123 cutter skinsations... 123 cyanocobalamin (vitamin b-12)... 195, 200, 212, 217 cyclafem 1/35 (28)... 105 cyclafem 7/7/7 (28)... 105 I-6

cyclobenzaprine... 191 cyclopentolate... 135 cyclophosphamide... 29 CYCLOPHOSPHAMIDE... 29 CYCLOSET... 46 cyclosporine... 163 cyclosporine modified... 163 cyproheptadine... 56 CYRAMZA... 30 cyred... 105 CYSTADANE... 175 CYSTARAN... 135 D d10 %-0.45 % sodium chloride... 180 d2.5 %-0.45 % sodium chloride... 180 d3 dots... 200 d5 % and 0.9 % sodium chloride... 180 d5 %-0.45 % sodium chloride... 180 daily gummies... 199 daily multiple... 199, 200 daily multi-vitamin... 206 daily multivitamin with iron 200 daily multi-vitamins/iron... 200 daily value... 200 daily vitamin formula... 200 daily vitamin formula-iron... 200 daily vitamin formula-minerals... 200 daily vitamin with iron... 200 daily vites/iron... 201 dailyhist-1... 56 daily-vite... 200, 201 DAKLINZA... 74 DALIRESP... 190 danazol... 156 dantrolene... 191 dapsone... 60 DAPTACEL (DTAP PEDIATRIC) (PF)... 168 daptomycin... 18 DARAPRIM... 63 DARZALEX... 30 dasetta 1/35 (28)... 105 dasetta 7/7/7 (28)... 105 dayhist allergy... 56 daysee... 105 daytime cold and cough... 115 daytime cold-flu... 118 daytime cold-flu relief (pe).. 118 day-time cough... 115 daytime-nighttime... 118 daytime-nighttime cold-flu.. 115 daytime-nighttime cough... 115 deblitane... 105 decitabine... 30 decongestant cough... 120 deep sea nasal... 135 deferoxamine... 155 delsym cough-chest congest dm... 115 delta d3... 201 delyla (28)... 105 DELZICOL... 173 DEMSER... 91 DEPEN TITRATABS... 155 DEPO-PROVERA... 161 dermafungal... 51 dermarest eczema (hydrocort)... 128 DESCOVY... 70 desipramine... 43 desmopressin... 158, 159 desog-e.estradiol/e.estradiol. 105 desogestrel-ethinyl estradiol 105 desonide... 128 desoximetasone... 128 despec-dm (pseudoeph-dmguaif)... 115 dex4 glucose... 82, 83 dexamethasone... 158 dexamethasone sodium phosphate... 140, 158 dexmethylphenidate... 101 dextroamphetamine... 101 dextroamphetamineamphetamine... 101 dextromethorphan polistirex 115 dextrose 10 % and 0.2 % nacl... 180 dextrose 10 % in water (d10w)... 83 dextrose 20 % in water (d20w)... 83 dextrose 25 % in water (d25w)... 83 dextrose 40 % in water (d40w)... 83 dextrose 5 % in ringers... 83 dextrose 5 % in water (d5w).. 83 dextrose 5 %-lactated ringers180 dextrose 5%-0.2 % sod chloride... 180 dextrose 5%-0.3 % sod.chloride... 181 dextrose 50 % in water (d50w)... 83 dextrose 70 % in water (d70w)... 83 dextrose with sodium chloride... 181 dextrose-kcl-nacl... 181 diabetic tussin dm... 115 diabetic tussin ex... 115 diamode... 146 diazepam... 16, 17 diazepam intensol... 16 diclofenac potassium... 11 diclofenac sodium.. 11, 123, 141 diclofenac-misoprostol... 12 dicloxacillin... 25 dicyclomine... 146 I-7

didanosine... 70 DIFICID... 23 diflunisal... 12 digitek... 91, 92 digoxin... 92 DIGOXIN... 92 dihydroergotamine... 59, 60 DILANTIN... 38 diltiazem hcl... 90, 91 dilt-xr... 91 dimaphen (pe)... 56 dimenhydrinate... 61 dimetapp cold-congestion... 56 DIMETAPP LONG-ACTING (CPM-DM)... 115 dino-life... 201 dino-life with extra c... 201 dino-life with iron-zinc... 201 DIPENTUM... 173 diphenhist... 56 diphenhydramine hcl... 56 diphenoxylate-atropine... 146 dipyridamole... 79 disopyramide phosphate... 87 disulfiram... 15 divalproex... 39 dobutamine... 93 dobutamine in d5w... 93 doc-q-lace... 150 docu... 150 docusate sodium... 150 docusol... 150 dofetilide... 87 dok... 150 donepezil... 42 dopamine... 93 dopamine in 5 % dextrose... 93 dorzolamide... 178 dorzolamide-timolol... 178 douche vinegar and water extra... 177 doxazosin... 85 doxepin... 43 doxercalciferol... 174 doxorubicin... 30 doxorubicin, peg-liposomal... 30 doxy-100... 27 doxycycline hyclate... 27 doxycycline monohydrate... 27 dramamine... 61 dramamine less drowsy... 61 driminate... 61 dristan long lasting... 135 dronabinol... 61 droperidol... 176 drospirenone-ethinyl estradiol... 105 DROXIA... 30 DUAVEE... 156 dulcolax stool softener (dss) 150 DULERA... 187 duloxetine... 43 DUREZOL... 141 dutasteride... 154 dutasteride-tamsulosin... 154 d-vi-sol... 201 DYRENIUM... 95 E e.c. prin... 12 e.e.s. 400... 23 e.e.s. granules... 23 econazole... 51 econtra ez... 105 ecotrin... 12 ed a-hist... 56 ed bron gp... 115 ed chlorped jr... 56 EDURANT... 70 effer-k... 181 EFFIENT... 79 ELAPRASE... 132 eldertonic... 201 electrolyte-48 in d5w... 181 ELIGARD... 30 ELIGARD (3 MONTH)... 30 ELIGARD (4 MONTH)... 30 ELIGARD (6 MONTH)... 30 elinest... 105 eliphos... 153 ELIQUIS... 76 ELITEK... 132 ELLA... 105 ellis tonic... 201 ELMIRON... 176 EMCYT... 30 EMEND... 62 emoquette... 105 EMPLICITI... 30 EMSAM... 44 EMTRIVA... 70, 71 enalapril maleate... 86 enalaprilat... 86 enalapril-hydrochlorothiazide 86 ENBREL... 163 ENBREL SURECLICK... 163 endocet... 5 endodan... 5 endur-acin... 97 enema... 150, 152 enema disposable... 150 enemeez... 150 enemeez plus... 150 ENGERIX-B (PF)... 168 ENGERIX-B PEDIATRIC (PF)... 168 enoxaparin... 76 enpresse... 105 enskyce... 105 entacapone... 64 entecavir... 75 entre-cough... 115 ENTRESTO... 85 enulose... 146 ENVARSUS XR... 163 EPCLUSA... 74 epinastine... 135 I-8

epinephrine... 93 epinephrine hcl (pf)... 93 EPIPEN... 93 EPIPEN 2-PAK... 93 EPIPEN JR 2-PAK... 93 epitol... 39 EPIVIR HBV... 71 eplerenone... 99 EPOGEN... 78 epoprostenol (glycine)... 193 EPZICOM... 71 eq gentle... 135 equalactin... 150 ergocalciferol (vitamin d2). 202, 216 ergoloid... 176 ERGOMAR... 60 ERIVEDGE... 30 errin... 106 ery pads... 126 ery-tab... 23 ERY-TAB... 23 ERYTHROCIN... 23 erythrocin (as stearate)... 23 erythromycin... 23, 138 erythromycin ethylsuccinate.. 23 erythromycin with ethanol... 126 ESBRIET... 190 escitalopram oxalate... 44 esmolol... 89 esomeprazole sodium... 143 essentia... 202 essential balance with lutein 202 essential daily... 202 estarylla... 106 ESTRACE... 156 estradiol... 156 estradiol valerate... 157 estradiol-norethindrone acet. 157 estropipate... 157 eszopiclone... 192 ethambutol... 60 ethosuximide... 39 ethynodiol diac-eth estradiol 106 etodolac... 12 ETOPOPHOS... 30 etoposide... 30 evac-u-gen (sennosides)... 151 EVOTAZ... 71 exemestane... 30 EXJADE... 155 EXONDYS 51... 176 expectorant... 116 expectorant dm... 116 expectorant max strength... 116 EXTAVIA... 101 extra cleansing douche... 177 eye health plus lutein... 202 F FABRAZYME... 133 fallback solo... 106 falmina (28)... 106 famciclovir... 76 famotidine... 143 famotidine (pf)... 143 famotidine (pf)-nacl (iso-os) 143 FANAPT... 66 FARESTON... 31 FARYDAK... 31 FASLODEX... 31 felbamate... 39 felodipine... 95 feminine care douche... 177 FEMRING... 157 femynor... 106 fenofibrate... 97 fenofibrate micronized... 97 fenofibrate nanocrystallized... 97 fenofibric acid... 97 fenofibric acid (choline)... 97 fenoprofen... 12 fentanyl... 5 fentanyl citrate... 5 feosol... 202 ferocon... 202 ferretts... 202 ferrex 150... 202 ferrex 150 plus... 202 ferric x-150... 202 FERRIPROX... 155 ferrocite... 202 ferrous fumarate... 203 ferrous gluconate... 203, 204 ferrous sulfate... 198, 203 FETZIMA... 44 feverall... 5 fexofenadine... 57 fiber (calcium polycarbophil)... 151 fiber laxative (methylcellulo)153 fiber smooth... 153 fiber therapy (m-cell/sugar).. 151 fiber therapy (m-cellulose)... 150 fiber therapy (psyllium/sugar)... 150 fiber therapy sugar free... 152 fiber-lax... 151 finasteride... 154 FIRAZYR... 93 flavor chews antacid... 145 FLEBOGAMMA DIF... 163 flecainide... 87 FLECTOR... 12 FLEET BISACODYL... 151 flintstones complete (iron)... 203 flintstones multivitamin... 203 flintstones with iron... 203 flintstones/extra c... 203 FLOVENT DISKUS... 187 FLOVENT HFA... 187 floxuridine... 31 flu formula daytime-nighttime... 118 flu hbp... 116 flu relief therapy daytime... 118 flu severe cold-congestion... 120 I-9

flucaine... 135 fluconazole... 51 fluconazole in nacl (iso-osm). 51 flucytosine... 51 fludrocortisone... 158 flumazenil... 101 flunisolide... 141 fluocinonide... 128 fluocinonide-e... 128 fluorometholone... 141 fluorouracil... 31, 124 fluoxetine... 44 fluphenazine decanoate... 66 fluphenazine hcl... 66 flurbiprofen... 12 flurbiprofen sodium... 141 flutamide... 31 fluticasone... 128, 141 fluvoxamine... 44 foaming antacid... 146, 149 folic acid... 203 fomepizole... 176 fondaparinux... 76, 77 foot odor control... 53 FORTEO... 174 FORTICAL... 174 foscarnet... 73 fosfree... 203 fosinopril... 87 fosinopril-hydrochlorothiazide... 87 fosphenytoin... 39 FREAMINE HBC 6.9 %... 83 FREAMINE III 10 %... 83 fungi cure... 51 fungoid-d... 51 furosemide... 96 FUSILEV... 176 FUZEON... 71 FYCOMPA... 39 G g tussin ac... 116 gabapentin... 39 GABITRIL... 39 galantamine... 42 GAMASTAN S/D... 163 GAMMAGARD LIQUID... 163 GAMMAPLEX... 163 ganciclovir sodium... 76 GARDASIL (PF)... 168 GARDASIL 9 (PF)... 168 gas relief... 142 gas relief 80... 142 gas relief extra strength... 142 gas-x ultra-strength... 142 gatifloxacin... 138 GATTEX 30-VIAL... 146 GATTEX ONE-VIAL... 146 GAUZE PAD... 131 gavilyte-c... 151 gavilyte-g... 151 gavilyte-n... 151 GAZYVA... 31 gelusil antacid and anti-gas.. 146 gemfibrozil... 97 generlac... 146 gengraf... 163, 164 GENOTROPIN... 159 GENOTROPIN MINIQUICK... 159 gentak... 138 gentamicin... 17, 126, 138, 139 gentamicin in nacl (iso-osm).. 17 gentamicin sulfate (ped) (pf).. 17 gentamicin sulfate (pf)... 17 GENTEAL GEL... 135 GENTEAL MILD... 135 GENTEAL SEVERE... 135 genteal tears... 135 gentlelax... 151 GENVOYA... 71 GEODON... 67 geravim... 203 geriaton... 203 geri-hydrolac... 124 geri-lanta... 146 geri-tussin dm... 116 gianvi (28)... 106 gildagia... 106 gildess 1.5/30 (21)... 106 gildess 1/20 (21)... 106 gildess 24 fe... 106 gildess fe 1.5/30 (28)... 106 gildess fe 1/20 (28)... 106 GILENYA... 101 GILOTRIF... 31 GLEOSTINE... 31 glimepiride... 49 glipizide... 49 glipizide-metformin... 49 GLUCAGEN HYPOKIT... 176 GLUCAGON EMERGENCY KIT (HUMAN)... 176 gluco burst... 83 glucose... 83 glucose gel... 82 glutose 15... 83 glyburide... 50 glyburide micronized... 50 glyburide-metformin... 50 glycolax... 151 glycopyrrolate... 146 glydo... 13, 14 GLYXAMBI... 46 granisetron (pf)... 62 granisetron hcl... 62 GRANIX... 78 griseofulvin microsize... 51 guaifenesin... 116 guanfacine... 85, 101 guanidine... 176 gummi bear multivitamin... 204, 210 gummy swirls... 199 H hair vitamins... 204 I-10

hair,skin and nails... 199, 215 halobetasol propionate. 128, 129 haloperidol... 67 haloperidol decanoate... 67 haloperidol lactate... 67 HARVONI... 74 HAVRIX (PF)... 169 head congestion day-night... 116 healthylax... 151 heather... 106 hemocyte... 204 heparin (porcine)... 77 heparin (porcine) in 5 % dex.. 77 heparin(porcine) in 0.45% nacl... 77 heparin, porcine (pf)... 77 HEPATAMINE 8%... 83 HERCEPTIN... 31 HETLIOZ... 192 HEXALEN... 31 hi-b complex... 204 HIBERIX (PF)... 169 hi-cal plus vit d... 211 homatropaire... 135 homatropine hbr... 136 honey bears... 204 honey bears with iron-zinc... 204 HUMATROPE... 159 HUMIRA... 164 HUMIRA PEDIATRIC CROHN'S START... 164 HUMIRA PEN... 164 HUMIRA PEN CROHN'S-UC- HS START... 164 HUMIRA PEN PSORIASIS- UVEITIS... 164 HUMULIN R U-500 (CONC) KWIKPEN... 48 HUMULIN R U-500 (CONCENTRATED)... 48 hydralazine... 93, 94 hydrochlorothiazide... 96 hydrocil instant... 151 hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine... 116 hydrocodone-homatropine... 116 hydrocodone-ibuprofen... 6 hydrocortisone... 129, 158, 173 hydrocortisone acetate... 129 hydrocortisone butyrate... 129 hydrocortisone butyr-emollient... 129 hydrocortisone valerate... 129 hydromet... 116 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin... 129 hydroxychloroquine... 63 hydroxyprogesterone caproate... 161 hydroxyurea... 31 hydroxyzine hcl... 57 hydroxyzine pamoate... 176 HYPERRAB S/D (PF)... 164 HYQVIA... 164 HYQVIA IG COMPONENT... 164 HYSINGLA ER... 6 I ibandronate... 174 IBRANCE... 31 ibuprofen... 11, 12, 13 ibuprofen jr strength... 12 icaps plus... 204 ICLUSIG... 31 iferex 150... 204 ifosfamide... 31 ifosfamide-mesna... 31 ILARIS (PF)... 164 ILEVRO... 141 imatinib... 32 IMBRUVICA... 32 imipenem-cilastatin... 24 imipramine hcl... 44 imipramine pamoate... 44 imiquimod... 124 IMLYGIC... 32 imodium a-d... 146 IMOGAM RABIES-HT (PF)... 165 IMOVAX RABIES VACCINE (PF)... 169 INCRELEX... 159 INCRUSE ELLIPTA... 188 indapamide... 96 indomethacin... 12 indomethacin sodium... 12 INFANRIX (DTAP) (PF)... 169 infant's ibuprofen... 12 infants' non-aspirin cold... 121 infant's pain reliever... 6 INFLECTRA... 176 INLYTA... 32 INSECT REPELLENT (PICARIDIN)... 124 insta-glucose... 84 INSULIN SYRINGE-NEEDLE U-100... 132 INTELENCE... 71 INTRALIPID... 84 INTRON A... 74, 75 introvale... 106 INVANZ... 24 INVEGA SUSTENNA... 67 INVEGA TRINZA... 67, 68 INVIRASE... 71 INVOKAMET... 46 INVOKAMET XR... 46 INVOKANA... 46, 47 inzo antifungal... 51 iodine... 132 IONOSOL-B IN D5W... 181 IONOSOL-MB IN D5W... 181 iophen c-nr... 116 IPOL... 169 I-11

ipratropium bromide... 136, 189 IPRIVASK... 77 irbesartan... 85 irbesartan-hydrochlorothiazide... 86 IRESSA... 32 iron high potency... 199 ISENTRESS... 71 ISOLYTE-P IN 5 % DEXTROSE... 181 ISOLYTE-S... 181 isoniazid... 61 isopto tears... 136 isosorbide dinitrate... 99 isosorbide mononitrate... 99 isradipine... 95 itraconazole... 51 ivermectin... 63 IXEMPRA... 32 IXIARO (PF)... 169 J JAKAFI... 32 jantoven... 77 JANUMET... 47 JANUMET XR... 47 JANUVIA... 47 JARDIANCE... 47 jencycla... 106 JENTADUETO... 47 JENTADUETO XR... 47 jolessa... 106 jolivette... 106 juleber... 106 junel 1.5/30 (21)... 106 junel 1/20 (21)... 106 junel fe 1.5/30 (28)... 106 junel fe 1/20 (28)... 106 junel fe 24... 107 junior mapap... 6 JUXTAPID... 97 K KABIVEN... 84 KALETRA... 71 KALYDECO... 190 KANUMA... 133 kaopectate (bismuth subsalicy)... 146 kariva (28)... 107 kelnor 1/35 (28)... 107 ketoconazole... 52 ketoprofen... 13 ketorolac... 13, 141 KEVEYIS... 176 KEYTRUDA... 32 kidkare cough/cold... 116 kids mini enema... 150 kid's vitamins... 210 kid's vitamins + extra c... 210 kids vitamins + iron... 210 kid's vitamins + iron... 210 kids vitamins complete... 210 kimidess (28)... 107 KINERET... 165 KINRIX (PF)... 169 kionex... 147 kionex (with sorbitol)... 147 KLOR-CON 10... 181 klor-con m10... 181 klor-con m15... 181 klor-con m20... 182 klor-con sprinkle... 182 kobee... 205 konsyl (sugar)... 151 konsyl fiber... 151 KONSYL SUGAR-FREE... 151 KORLYM... 47 kpn... 205 KRYSTEXXA... 133 kurvelo... 107 KUVAN... 133 KYNAMRO... 97 KYPROLIS... 32 L l norgest/e.estradiol-e.estrad 107 labetalol... 89 LACRISERT... 136 LACTATED RINGERS... 173 LACTINOL HX... 124 lactulose... 147 LAMISIL (AEROSOL)... 52 lamisil af... 52 LAMISIL AT... 52 lamivudine... 71 lamivudine-zidovudine... 71 lamotrigine... 39, 40 LANOXIN... 94 lansoprazole... 143 LANTUS... 48 LANTUS SOLOSTAR... 48 larin 1.5/30 (21)... 107 larin 1/20 (21)... 107 larin 24 fe... 107 larin fe 1.5/30 (28)... 107 larin fe 1/20 (28)... 107 larissia... 107 LARTRUVO... 32 latanoprost... 178 LATUDA... 68 laxative peg 3350... 152 LAZANDA... 6 leena 28... 107 leflunomide... 165 LEMTRADA... 101 LENVIMA... 33 lessina... 107 LETAIRIS... 193 letrozole... 33 leucovorin calcium... 176 LEUKERAN... 33 LEUKINE... 78 leuprolide... 33 levetiracetam... 40 levobunolol... 178 levocarnitine... 176 levocarnitine (with sugar)... 176 levocetirizine... 57 I-12

levofloxacin... 26, 139 levofloxacin in d5w... 26 levoleucovorin... 176 levonest (28)... 107 levonorgestrel... 107 levonorgestrel-ethinyl estrad107, 108 levonorg-eth estrad triphasic 108 levora-28... 108 levothyroxine... 162 LEXIVA... 71 LIALDA... 173 lice cream rinse... 131 lice killing... 131 lice treatment... 131 lice treatment (permethrin).. 131 lidocaine... 14 lidocaine (pf)... 14, 87 lidocaine hcl... 14 lidocaine in 5 % dextrose (pf) 88 lidocaine viscous... 14 lidocaine-prilocaine... 14 life-pack women's... 205 linezolid... 18 LINZESS... 147 liothyronine... 162 liquibid d-r... 116 liquid calcium with vitamin d... 182 lisinopril... 87 lisinopril-hydrochlorothiazide 87 lithium carbonate... 101, 102 lithium citrate... 102 little animals... 205 little animals-iron... 205 little remedies... 136 LIVALO... 97 lobana bath... 124 lohist-dm... 116 lomedia 24 fe... 108 LONSURF... 33 loperamide... 146, 147 loratadine... 55, 57 loratadine-d... 56, 57 lorazepam... 17 lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex... 116 loryna (28)... 108 losartan... 86 losartan-hydrochlorothiazide. 86 LOTEMAX... 141 lovastatin... 97 low-ogestrel (28)... 108 loxapine succinate... 68 lubricant dry eye relief... 135 lubricant eye... 135 lubricant eye (cmc-glycer)(pf)... 136 lubricant eye (cmc-glycerin) 136 lubricant eye (pg-peg 400)... 137 lubricant eye (polyv alcohol) 137 lubricant eye (propyl glycol) 135 lubricant gel... 135 lubricating drops... 135 lubricating plus... 136 lubrifresh pm... 136 LUMIGAN... 178 LUPRON DEPOT... 33 LUPRON DEPOT (3 MONTH)... 33 LUPRON DEPOT (4 MONTH)... 33 LUPRON DEPOT (6 MONTH)... 33 LUPRON DEPOT-PED... 159 LUPRON DEPOT-PED (3 MONTH)... 159 lutera (28)... 108 LYNPARZA... 33 LYRICA... 40 lysiplex plus... 205 LYSODREN... 33 lyza... 108 M maalox advanced... 147 MACUVITE EYE CARE... 205 mag 64... 182 mag-delay... 182 mag-g... 182 magnebind 400... 153 magnesium... 180, 182, 186 magnesium (oxide/aa chelate)... 182 magnesium gluconate... 182 magnesium oxide... 147, 148 magnesium sulfate... 182 magnesium sulfate in d5w... 182 magnesium sulfate in water.. 182 malathion... 131 mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline... 44 mar-cof bp... 117 mar-cof cg... 117 margesic... 7 marlissa... 108 MARPLAN... 44 masanti double strength... 147 MATULANE... 33 matzim la... 91 maximum daily multivitamin... 211 meclizine... 62 medi-meclizine... 62 medroxyprogesterone... 161 mefenamic acid... 13 mefloquine... 63 MEFOXIN IN DEXTROSE (ISO-OSM)... 22 mega multiple/chelated mineral... 205 mega multivitamin with mineral... 205 I-13

megestrol... 33, 161 MEKINIST... 33, 34 meloxicam... 13 memantine... 42 MENACTRA (PF)... 169 MENEST... 157 MENHIBRIX (PF)... 169 MENOMUNE - A/C/Y/W-135... 170 MENOMUNE - A/C/Y/W-135 (PF)... 170 men's daily gummies... 199 men's multi-vitamin... 199 men's multivitamin gummies 205 men's one daily... 201, 202 MENVEO A-C-Y-W-135-DIP (PF)... 170 MEPHYTON... 205 mercaptopurine... 34 meropenem... 24 mesalamine... 173 mesna... 176 MESNEX... 177 MESTINON... 177 metaproterenol... 189 metaxall... 191 metaxalone... 191 metformin... 47 methadone... 7 methadose... 7 methazolamide... 178 methenamine hippurate... 18 methimazole... 162 methocarbamol... 191 methotrexate sodium... 34 methotrexate sodium (pf)... 34 methoxsalen rapid... 124 methscopolamine... 147 methyclothiazide... 96 methylphenidate... 102 methylprednisolone... 158 methylprednisolone acetate.. 158 methylprednisolone sodium succ... 158 metipranolol... 178 metoclopramide hcl... 147, 148 metolazone... 96 metoprolol succinate... 89 metoprolol ta-hydrochlorothiaz... 89 metoprolol tartrate... 89 metronidazole... 19, 59, 126 metronidazole in nacl (iso-os) 19 mexiletine... 88 mgo... 148 MIACALCIN... 174 mi-acid... 148 mi-acid gas relief... 142 micatin... 52 miconazole 7... 52 miconazole nitrate... 51, 52 miconazole-3... 52 microgestin 1.5/30 (21)... 108 microgestin 1/20 (21)... 108 microgestin fe 1.5/30 (28)... 108 microgestin fe 1/20 (28)... 108 midodrine... 85 miglitol... 47 milk of magnesia... 151 milltrium senior... 205 milrinone... 94 milrinone in 5 % dextrose... 94 mimvey... 157 mimvey lo... 157 mineral oil... 152, 177 MINERAL OIL... 177 mineral oil laxative... 151 minitran... 99 minocycline... 27, 28 minoxidil... 99 mintox... 148 mintox maximum strength... 148 mintox plus... 148 MIRCERA... 78 mirtazapine... 44, 45 misoprostol... 143 mitoxantrone... 34 M-M-R II (PF)... 170 moexipril... 87 moexipril-hydrochlorothiazide... 87 molindone... 68 mometasone... 129 MONISTAT 3... 52 monistat 7... 52 mono-linyah... 108 mononessa (28)... 108 montelukast... 188 morphine... 7, 8 MORPHINE... 8 morphine concentrate... 7 motion sickness... 61 MOVANTIK... 148 MOVIPREP... 151 MOXEZA... 139 moxifloxacin... 27 MOZOBIL... 78 MUCINEX FAST-MAX COLD-FLU-THRT... 117 mucinex fast-max dm max... 117 mucinex sinus-max... 136 mucus dm... 117 mucus dm max... 117 mucus relief... 117, 118 MULTAQ... 88 multi complete with iron... 205 multi for her... 205 multi-day with iron... 205 multi-delyn... 205 multi-delyn with iron... 205 multilex... 205 multilex-t and m... 205 multiple vitamin-minerals... 206 multiple vitamins... 206 multiple vitamins with iron.. 206 I-14

multi-symptom cold night time... 118 multivital... 210 multivital platinum... 210 multivitamin... 206, 213 multivitamin 50 plus... 209 multi-vitamin hp/minerals... 206 multi-vitamin with fluoride.. 206 multivitamin with iron. 206, 213 multivitamin with minerals.. 206 multi-vite... 211 multi-vite 50 and over... 211 mupirocin... 126 mupirocin calcium... 126 muro 128... 136 my favorite multiple... 206 my way... 108 mycophenolate mofetil... 165 mycophenolate mofetil hcl... 165 mycophenolate sodium... 165 MYOZYME... 133 MYRBETRIQ... 154 mytab gas... 142 mytab gas maximum strength... 142 my-vitalife... 206 myzilra... 108 N nabumetone... 13 nadolol... 89 nafcillin... 25 NAGLAZYME... 133 naloxone... 15 naltrexone... 15 NAMENDA XR... 42 NAMZARIC... 42 naphazoline... 136 naproxen... 13 naproxen sodium... 13 naratriptan... 60 NARCAN... 15 nasal and sinus decongestant 117 nasal spray (oxymetazoline). 135 NASCOBAL... 206 NATACYN... 139 nateglinide... 47 NATPARA... 174 NATRAPEL... 124 natural b-100... 219 natural b-100 complex... 213 natural balance... 136 natural calcium... 183 natural fiber laxative therapy 151 nature's tears (hypromellose) 136 NEBUPENT... 64 necon 0.5/35 (28)... 108 necon 1/35 (28)... 108 necon 1/50 (28)... 108 necon 10/11 (28)... 109 necon 7/7/7 (28)... 109 nefazodone... 45 NEO DM... 117 neomycin... 17 neomycin-bacitracin-poly-hc 139 neomycin-bacitracin-polymyxin... 139 neomycin-polymyxin b gu... 126 neomycin-polymyxin b- dexameth... 139 neomycin-polymyxingramicidin... 139 neomycin-polymyxin-hc... 139 neo-polycin... 139 neo-polycin hc... 139 neosporin (neo-bac-polym).. 126 neosporin anti-itch... 129 neo-synephrine 12 h spr (oxym)... 136 neo-tuss... 117 nephplex rx... 206 NEPHRAMINE 5.4 %... 84 nephron fa... 206 nephro-vite rx... 206 NEULASTA... 78 NEUPOGEN... 78 NEUPRO... 65 NEVANAC... 141 nevirapine... 72 NEXAVAR... 34 next choice one dose... 109 niacin... 97, 98 niacinamide... 98, 206 niacor... 98 nicardipine... 95 nicorelief... 15 nicorette... 15 nicotine... 15, 16 nicotine (polacrilex)... 15 NICOTROL... 16 nifedical xl... 95 nifedipine... 95 night time... 118 night time cold medicine... 117 night time cold-flu... 120 night time cold-flu relief... 120 night time cough-sore throat 117 nighttime cough... 115 nikki (28)... 109 NILANDRON... 34 nilutamide... 34 NINLARO... 34 NITRO-BID... 99 nitrofurantoin macrocrystal... 19 nitrofurantoin monohyd/m-cryst... 19 nitroglycerin... 100 nitroglycerin in 5 % dextrose 100 NITROSTAT... 100 NIX CREME RINSE... 131 nohist-dm... 117 non-aspirin cold... 120 non-aspirin extra strength... 8, 9 non-aspirin flu... 121 non-aspirin jr strength... 5 nora-be... 109 NORDITROPIN FLEXPRO 160 I-15

norepinephrine bitartrate... 94 norethindrone (contraceptive)... 109 norethindrone acetate... 161 norethindrone ac-eth estradiol... 109 norethindrone-e.estradiol-iron... 109 norgestimate-ethinyl estradiol... 109 norlyroc... 109 NORMOSOL-M IN 5 % DEXTROSE... 183 NORMOSOL-R... 183 NORMOSOL-R PH 7.4... 183 nortemp... 8 NORTHERA... 85 nortrel 0.5/35 (28)... 109 nortrel 1/35 (21)... 109 nortrel 1/35 (28)... 109 nortrel 7/7/7 (28)... 109 nortriptyline... 45 NORVIR... 72 NOVOLIN 70/30... 49 NOVOLIN N... 49 NOVOLIN R... 49 NOVOLOG... 49 NOVOLOG FLEXPEN... 49 NOVOLOG MIX 70-30... 49 NOVOLOG MIX 70-30 FLEXPEN... 49 NOVOLOG PENFILL... 49 NOXAFIL... 52 NUCALA... 190 NUCYNTA... 8 NUCYNTA ER... 8 NUEDEXTA... 102 nu-iron... 206 NULOJIX... 165 nu-mag... 183 NUPLAZID... 68 NUTRESTORE... 148 NUTRILIPID... 84 NUTROPIN AQ... 160 NUTROPIN AQ NUSPIN... 160 NUVARING... 109 nyamyc... 52 nyata... 52 nystatin... 52, 53 nystatin-triamcinolone... 53 nystop... 53 nyt-time sleep... 57 O OCALIVA... 148 ocean nasal... 136 ocella... 109 OCTAGAM... 165 octreotide acetate... 160 ocutabs... 207 ODEFSEY... 72 ODOMZO... 34 OFEV... 191 off active... 124 off deep woods... 124 off deep woods dry... 124 off familycare (with deet)... 124 ofloxacin... 27, 139, 140 ogestrel (28)... 109 olanzapine... 68 olanzapine-fluoxetine... 45 olopatadine... 136 OLYSIO... 74 omeprazole... 143 omeprazole magnesium... 143 OMNITROPE... 160 ONCASPAR... 34 once daily... 207 oncovite... 207 ondansetron... 62 ondansetron hcl... 62 ondansetron hcl (pf)... 62 one daily... 207, 211 one daily 50 plus... 202 one daily complete... 207 one daily energy... 211 one daily essential 202, 204, 207 one daily for women... 207 one daily gummy vites... 207 one daily maximum... 207, 211 one daily maximum (with ca)... 202 one daily multi-vit w-mineral... 207 one daily multivitamin... 207 one daily multivit-iron(folic) 207 one daily plus iron 204, 207, 211 one daily plus minerals... 207 one daily with iron... 207 one-a-day essential... 207 one-a-day maximum formula207 one-a-day men's multivitamin... 208 one-a-day teen advantage... 208 ONFI... 17 ONIVYDE... 34 opcicon one-step... 109 OPDIVO... 34 OPSUMIT... 193 option 2... 109 oral saline laxative... 151 oralone... 122 oralyte... 183 ORENCIA... 165 ORENCIA (WITH MALTOSE)... 165 ORENCIA CLICKJECT... 177 ORENITRAM... 193 ORFADIN... 133 ORKAMBI... 191 orsythia... 110 oseltamivir... 73 OTEZLA... 165 OTEZLA STARTER... 165 OTOVEL... 136 OTREXUP (PF)... 166 oxacillin... 25 I-16

oxacillin in dextrose(iso-osm) 25 oxandrolone... 156 oxcarbazepine... 40 OXTELLAR XR... 40 oxybutynin chloride... 154 oxycodone... 8 oxycodone-acetaminophen.. 8, 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9 oysco 500/d... 208 oysco d... 183 oysco-500... 183 oyster shell calcium 500... 183 oyster shell calcium-vit d2.. 183, 185 oyster shell calcium-vit d3... 208 oystercal-d... 208 P pacerone... 88 pain relief... 9 pain relief adult... 5 pain reliever jr strength... 9 paliperidone... 68 PANRETIN... 124 PANTILINERS... 132 pantoprazole... 143 paricalcitol... 174 paromomycin... 64 paroxetine hcl... 45 PASER... 61 PATADAY... 137 PAXIL... 45 pecgen dmx... 117 pedia relief... 120 pedia relief infant... 121 pediacare multi-symptom cold... 117 PEDIARIX (PF)... 170 pediatric electrolyte... 180, 183, 185, 186 pediatric freezer pops... 185 pediatric multivitamin.. 206, 212 PEDVAX HIB (PF)... 170 peg 3350-electrolytes... 152 PEGANONE... 40 PEGASYS... 75 PEGASYS PROCLICK... 75 peg-electrolyte soln... 152 PEGINTRON... 75 PEN NEEDLE, DIABETIC. 132 penicillin g pot in dextrose... 25 penicillin g potassium... 26 penicillin g procaine... 26 penicillin v potassium... 26 PENTACEL (PF)... 170 PENTAM... 64 pentoxifylline... 79 pep-t-med... 147 peri-colace... 152 PERIKABIVEN... 84 perindopril erbumine... 87 periogard... 122 permethrin... 131 perphenazine... 68 perphenazine-amitriptyline... 45 perry prenatal... 208 persa-gel... 124 pfizerpen-g... 26 pharbetol... 9 pharmacist favorite multi-vit 208 phenadoz... 62 phenelzine... 45 phenobarbital... 40 phenylephrine hcl... 85, 137 phenylhistine dh... 117 phenytoin... 40 phenytoin sodium... 41 phenytoin sodium extended... 40 philith... 110 phillips... 148 phillips liqui-gels... 152 PHOSLYRA... 153 phosphate laxative... 152 PHOSPHOLINE IODIDE... 178 phytonadione (vitamin k1).. 208, 218 PICATO... 124 pilocarpine hcl... 122, 178 pimozide... 68 pimtrea (28)... 110 pindolol... 89 pink bismuth... 148 pioglitazone... 47 pioglitazone-glimepiride... 48 pioglitazone-metformin... 48 piperacillin-tazobactam... 26 pirmella... 110 piroxicam... 13 PLASMA-LYTE 148... 183 PLASMA-LYTE A... 183 PLASMA-LYTE-56 IN 5 % DEXTROSE... 183 PLEGRIDY... 102 podofilox... 124 polyethylene glycol 3350... 152 poly-iron... 208 polymyxin b sulfate... 19 polymyxin b sulf-trimethoprim... 140 poly-vita... 208 poly-vita (iron)... 208 poly-vitamin... 208 poly-vitamin with iron... 209 polyvitamin/iron... 209 poly-vitamins... 209 POMALYST... 34 portia... 110 PORTRAZZA... 34 potassium acetate... 183 potassium chlorid-d5-0.45%nacl... 184 potassium chloride... 184, 185 potassium chloride in 0.9%nacl... 184 I-17

potassium chloride in 5 % dex... 184 potassium chloride in lr-d5.. 184 potassium chloride-0.45 % nacl... 185 potassium chloride-d5-0.2%nacl... 185 potassium chloride-d5-0.3%nacl... 185 potassium chloride-d5-0.9%nacl... 185 potassium citrate... 185 potassium citrate-citric acid. 185 potassium hydroxide... 124 POTIGA... 41 PRADAXA... 77 PRALUENT PEN... 98 PRALUENT SYRINGE... 98 pramipexole... 65 pravastatin... 98 prazosin... 85 prednicarbate... 129, 130 prednisolone acetate... 141 prednisolone sodium phosphate... 141, 158 prednisone... 158 PREMARIN... 157 PREMASOL 10 %... 84 PREMASOL 6 %... 84 PREMPHASE... 157 PREMPRO... 157 prenatal... 204, 209, 213 prenatal formula... 209, 210 prenatal plus (calcium carb). 208 prenatal tablet... 212 prenatal vit#96-ferrous fum-fa... 209 prenatal vitamin... 199, 202, 209 prenatal vitamin plus low iron... 209 prenatal vit-iron fumarate-fa 209 preparation h hydrocortisone 130 PREVAIL BLADDER CONTROL PAD... 131 prevalite... 98 previfem... 110 PREZCOBIX... 72 PREZISTA... 72 PRIFTIN... 61 PRILOSEC OTC... 143 PRIMAQUINE... 64 primidone... 41 PRISTIQ... 45 PRIVIGEN... 166 PROAIR HFA... 189 PROAIR RESPICLICK... 189 probenecid... 54 probenecid-colchicine... 54 procainamide... 88 PROCALAMINE 3%... 84 prochlorperazine... 63 prochlorperazine edisylate... 62 prochlorperazine maleate... 62 PROCRIT... 78 procto-med hc... 130 procto-pak... 130 proctosol hc... 130 proctozone-hc... 130 PROCYSBI... 177 progesterone in oil... 161 progesterone micronized... 162 PROGLYCEM... 100 PROGRAF... 166 PROLASTIN-C... 191 PROLENSA... 141 PROLEUKIN... 34 PROLIA... 174 PROMACTA... 79 promethazine... 57, 63 promethazine vc-codeine... 117 promethazine-codeine... 117 promethazine-dm... 118 promethegan... 63 promolaxin... 152 propafenone... 88 propantheline... 38 proparacaine... 137 propranolol... 89, 90 propranolol-hydrochlorothiazid... 90 propylthiouracil... 162 PROQUAD (PF)... 170 prosight... 209 PROSOL 20 %... 84 protamine... 79 protriptyline... 45 pseudoephedrine hcl... 118 PULMOZYME... 133 pure and gentle eye... 137 purelax... 150 PURIXAN... 35 pyrazinamide... 61 pyridostigmine bromide... 177 pyridoxine (vitamin b6)... 210 Q QBRELIS... 87 q-dryl... 57 q-pap... 9 q-pap extra strength... 9 q-tussin... 118 q-tussin dm... 118 QUADRACEL (PF)... 170 quasense... 110 quetiapine... 68 quinapril... 87 quinapril-hydrochlorothiazide 87 quinidine gluconate... 88 quinidine sulfate... 88 quinine sulfate... 64 QVAR... 187 R RABAVERT (PF)... 170 raloxifene... 157 ramipril... 87 RANEXA... 94 ranitidine hcl... 144 I-18

RAPAMUNE... 166 rasagiline... 65 RASUVO (PF)... 166 RAVICTI... 148 RAYALDEE... 175 react... 110 REBIF (WITH ALBUMIN) 103 REBIF REBIDOSE... 103 REBIF TITRATION PACK 103 reclipsen (28)... 110 RECOMBIVAX HB (PF)... 170, 171 recort plus... 130 refenesen... 119 refenesen pe... 119 REFRESH CELLUVISC... 137 REFRESH CLASSIC (PF).. 137 REFRESH LACRI-LUBE... 137 REFRESH OPTIVE ADVANCED... 140 reguloid... 152 relcof c... 119 RELENZA DISKHALER... 73 RELISTOR... 148 remedy phytoplex antifungal. 53 REMICADE... 177 REMODULIN... 194 RENAGEL... 153 rena-vite rx... 212 RENVELA... 153 repaglinide... 48 repaglinide-metformin... 48 REPATHA PUSHTRONEX.. 98 REPATHA SURECLICK... 98 REPATHA SYRINGE... 98 repel sportsmen... 124 repel sportsmen max... 125 reprexain... 9 RESCRIPTOR... 72 RESTASIS... 141 RESTASIS MULTIDOSE... 141 retaine cmc... 137 retaine hpmc... 137 retaine pm... 137 RETROVIR... 72 revive plus... 135 REVLIMID... 35 revonto... 191 REXULTI... 69 REYATAZ... 72 REZIRA... 119 ribasphere... 76 RIDAURA... 166 rifabutin... 61 rifampin... 61 RIFATER... 61 ri-gel ii... 148 right step prenatal vitamins.. 212 riginic... 149 riluzole... 103 rimantadine... 73 ri-mox... 149 ringers... 173, 185 risedronate... 175 RISPERDAL CONSTA... 69 risperidone... 69 RITUXAN... 35 rivastigmine... 43 rivastigmine tartrate... 43 rizatriptan... 60 robafen... 119 robafen cough... 119 robafen dm... 119 robafen dm clear... 119 robitussin cough-chest cong dm... 119 ROBITUSSIN LONG-ACTING... 119 robitussin pediatric... 119 ropinirole... 65 rosadan... 126 rosuvastatin... 98 ROTARIX... 171 ROTATEQ VACCINE... 171 ROWEEPRA... 41 ROZEREM... 192 RUBRACA... 35 rydex... 119 rynex dm... 119 S SABRIL... 41 safe tussin dm... 119 SAIZEN... 160 SAIZEN CLICK.EASY... 160 saline nose... 135 SANDOSTATIN LAR DEPOT... 161 SANTYL... 125 SAPHRIS (BLACK CHERRY)... 69 SAVELLA... 103 scooby-doo one a day... 212 scot-tussin dm... 119 scot-tussin expectorant... 119 sea soft nasal mist... 137 selegiline hcl... 65 selenium sulfide... 126 SELZENTRY... 72 senexon... 152 senior tabs... 212 senna... 152 senna lax... 153 senna with docusate sodium. 150 senokot-s... 153 SENSIPAR... 177 sentry... 212 sentry senior... 212 SEREVENT DISKUS... 189 SEROQUEL XR... 69 SEROSTIM... 161 sertraline... 45 setlakin... 110 sharobel... 110 SIGNIFOR... 177 silace... 153 siladryl sa... 57 I-19

sildenafil... 194 SILENOR... 192 siltussin sa... 119 silver nitrate... 126 silver sulfadiazine... 126 SIMBRINZA... 178 simethicone... 142 simply sleep... 57 SIMPONI... 166 SIMPONI ARIA... 166 simvastatin... 98 sinus and allergy(pseudoephed)... 58 sirolimus... 166 SIRTURO... 61 skin treatment... 123 sleep aid (diphenhydramine).. 57 sleep aid (doxylamine)... 57 smoflipid... 84 smoothlax... 153 sochlor... 137 sodium acetate... 186 sodium bicarbonate... 149, 186 sodium chloride... 137, 173, 186, 191 sodium chloride 0.45 %... 186 sodium chloride 0.9 %... 186 sodium chloride 3 %... 186 sodium chloride 5 %... 186 sodium fluoride... 213 sodium lactate... 186 sodium phosphate... 186 sodium polystyrene (sorb free)... 149 sodium polystyrene sulfonate... 149 SOLTAMOX... 35 SOLU-CORTEF (PF)... 158 SOMATULINE DEPOT... 161 SOMAVERT... 161 soothe (bismuth subsalicylate)... 149 soothe night time lubricant... 137 soothe regular strength... 149 sorbitol... 173 sorbitol-mannitol... 173 sorine... 90 sotalol... 90 sotalol af... 90 SOVALDI... 74 spectravite adult... 199 spectravite adult 50+... 199 spectravite advanced formula... 199 spectravite senior... 199 spectravite senior w-lycopene... 199 spectravite ultra men's sr... 200 spectravite ultra women... 200 SPIRIVA RESPIMAT... 189 SPIRIVA WITH HANDIHALER... 189 spironolactone... 96 spironolacton-hydrochlorothiaz... 96 sprintec (28)... 110 SPRITAM... 41 SPRYCEL... 35 sps (with sorbitol)... 149 sronyx... 110 ssd... 126 st joseph aspirin... 13 st. joseph aspirin... 13 stavudine... 72 STELARA... 166 STERILE GAUZE PAD... 132 STIOLTO RESPIMAT... 189 STIVARGA... 35 stomach relief... 149 stool softener... 153 STRATTERA... 103 STRENSIQ... 133 streptomycin... 17 stress 500... 210 stress 500 plus zinc... 210 stress b with zinc... 214 stress b-biotin... 213 stress formula... 214 stress formula 600 c... 214 stress formula plus iron... 214 stress formula with iron... 214 stress formula with iron(sulf)214 stress formula with zinc... 214 STRIBILD... 72 STRIVERDI RESPIMAT... 189 SUBOXONE... 16 sucralfate... 144 sudafed... 120 sudogest... 120 sudogest sinus and allergy... 58 sulfacetamide sodium... 140 sulfacetamide sodium (acne) 126 sulfacetamide-prednisolone.. 140 sulfadiazine... 27 sulfamethoxazole-trimethoprim... 27 sulfasalazine... 27 sulfatrim... 27 sulindac... 13 sumatriptan... 60 sumatriptan succinate... 60 summer's eve disposable douche... 177 summers eve extra cleansing 177 sunvite... 214 super b complex-vitamin c.. 200, 213, 214 super b maxi complex... 214 super b/c... 214 super b-50 complex... 214 super b-50 complex plus... 214 super multiple... 214 super multivitamin... 214 super quints... 215 super quints b-50... 215 super thera vite m... 215 I-20

superior 35... 215 superplex-t... 215 suphedrin... 120 suphedrine pe day-night... 120 suphedrine severe cold max str... 120 support... 215 support-500... 215 SUPPRELIN LA... 161 SUPRAX... 22 SUPREP BOWEL PREP KIT... 153 SURMONTIL... 45 SUSTIVA... 73 SUTENT... 35 syeda... 110 SYLATRON... 75 SYLVANT... 35 SYMBICORT... 188 SYMLINPEN 120... 48 SYMLINPEN 60... 48 SYNAGIS... 74 SYNAREL... 177 SYNERCID... 19 SYNJARDY... 48 SYNRIBO... 35 SYPRINE... 155 SYSTANE GEL... 137 T tab-a-vite... 215 tab-a-vite/iron... 215 tab-a-vite-minerals... 215 TABLOID... 35 tacrolimus... 130, 167 tactinal... 10 tactinal extra strength... 10 TAFINLAR... 35 TAGRISSO... 35 TALTZ AUTOINJECTOR.. 125 TALTZ AUTOINJECTOR (3 PACK)... 125 TALTZ SYRINGE... 125 TAMIFLU... 74 tamoxifen... 35 tamsulosin... 154 TARCEVA... 35 TARGRETIN... 35, 36 tarina fe 1/20 (28)... 110 TASIGNA... 36 tazicef... 22 TAZORAC... 130 taztia xt... 91 tears again... 138 tears again (pva)... 138 tears naturale free (pf)... 138 tears pure... 138 TECENTRIQ... 36 TECFIDERA... 103 TECHNIVIE... 74 TEFLARO... 22 TEKAMLO... 99 TEKTURNA... 99 TEKTURNA HCT... 99 telmisartan... 86 telmisartan-hydrochlorothiazid... 86 TEMODAR... 36 tencon... 10 TENIVAC (PF)... 171 terazosin... 155 terbinafine hcl... 53 terbutaline... 189 terconazole... 59 testosterone... 156 testosterone cypionate... 156 testosterone enanthate... 156 TETANUS,DIPHTHERIA TOX PED(PF)... 171 TETANUS-DIPHTHERIA TOXOIDS-TD... 171 tetrabenazine... 103 tetracycline... 28 THALOMID... 177 the magic bullet... 151 theophylline... 189, 190 theophylline in dextrose 5 % 190 thera m plus (ferrous fumarat)... 215 thera vitamin... 215 thera-d... 215 theradex m... 215 thera-m... 215 therapeutic liquid... 204 therapeutic m + beta-carotene... 212 therapeutic-m... 215 therapeutic-m vitamin/minerals... 213, 216 thera-tabs... 216 theratrum complete 50 plus.. 216 theratrum complete with lutein... 216 therems... 216 THIOLA... 177 thioridazine... 69 thiotepa... 36 thiothixene... 69 tiagabine... 41 TICE BCG... 171 tigecycline... 28 tilia fe... 110 timolol maleate... 90, 179 TIVICAY... 73 tizanidine... 191 TOBI PODHALER... 17 TOBRADEX... 140 TOBRADEX ST... 140 tobramycin... 140 tobramycin in 0.225 % nacl... 17 tobramycin in 0.9 % nacl... 17 tobramycin sulfate... 18 tobramycin-dexamethasone.. 140 TOLAK... 125 tolazamide... 50 tolbutamide... 50 tolmetin... 13 I-21

tolnaftate... 53 tolterodine... 154 topiramate... 41 toposar... 36 torsemide... 96 total b/c... 216 totalday multiple... 216 TOUJEO SOLOSTAR... 49 TOVIAZ... 154 TPN ELECTROLYTES... 186 TPN ELECTROLYTES II... 186 TRACLEER... 194 TRADJENTA... 48 tramadol... 10 tramadol-acetaminophen... 10 trandolapril... 87 tranexamic acid... 79 TRANSDERM-SCOP... 63 tranylcypromine... 45 TRAVASOL 10 %... 84 TRAVATAN Z... 179 travel sickness (meclizine)... 63 travoprost (benzalkonium)... 179 trazodone... 45 TREANDA... 36 TRECATOR... 61 TRELSTAR... 36 tretinoin... 130, 131 tretinoin (chemotherapy)... 36 tretinoin microspheres... 130 TREXALL... 36 triacting m-sym cold/cough. 121 triamcinolone acetonide... 122, 130, 158 triaminic cold and cough (pe)... 120 triamterene-hydrochlorothiazid... 96 trianex... 130 TRIBENZOR... 86 tri-buffered aspirin... 13 tridesilon... 130 tri-estarylla... 110 trifluoperazine... 69 trifluridine... 140 trihexyphenidyl... 65 tri-legest fe... 110 tri-linyah... 110 tri-lo-estarylla... 110 tri-lo-marzia... 110 tri-lo-sprintec... 110 trilyte with flavor packets... 153 trimethoprim... 19 trimipramine... 46 trinessa (28)... 111 TRINTELLIX... 46 triple antibiotic... 125, 126 triple paste af... 53 tri-previfem (28)... 111 tri-sprintec (28)... 111 TRIUMEQ... 73 tri-vi-sol... 216 tri-vita... 216 tri-vitamin... 216 trivora (28)... 111 TROKENDI XR... 41 TROPHAMINE 10 %... 84 TROPHAMINE 6%... 84 trospium... 154 TRULICITY... 48 TRUMENBA... 171 TRUVADA... 73 tusnel diabetic... 120 TUSNEL NEW FORMULA 120 TUSSI PRES-B... 120 tussin cf... 120, 121 tussin cf (pe-dm-guaif)... 115 tussin cold-congestion... 121 tussin cough (dm only)... 115 tussin dm... 121 tussin dm cough and chest... 115 tussin pe... 118 TWINRIX (PF)... 171 TYBOST... 177 TYGACIL... 28 TYKERB... 36 TYPHIM VI... 171, 172 TYSABRI... 167 TYVASO... 194 TYZEKA... 76 U UCERIS... 173 u-cort... 130 ULORIC... 54 ultimate men's complete 50+ 213 ultra b-100 complex... 216 ultra fresh pm... 138 unicomplex-m... 216 unisom (diphenhydramine)... 58 unisom (doxylamine)... 58 unisom sleepgels... 58 UNITUXIN... 36 UPTRAVI... 194 ursodiol... 149 V VAGIFEM... 157 vagistat-3... 53 valacyclovir... 76 VALCHLOR... 125 valganciclovir... 76 valproate sodium... 41 valproic acid... 41 valproic acid (as sodium salt). 41 valsartan... 86 valsartan-hydrochlorothiazide 86 VALSTAR... 36 vancomycin... 19 vancomycin in dextrose 5 %.. 19 VAQTA (PF)... 172 VARIVAX (PF)... 172 VASCEPA... 98 v-c forte... 216 VELCADE... 36 velivet triphasic regimen (28)... 111 VELPHORO... 153 I-22

VELTASSA... 149 VEMLIDY... 76 VENCLEXTA... 36, 37 VENCLEXTA STARTING PACK... 37 venlafaxine... 46 VENTOLIN HFA... 190 verapamil... 91 VERSACLOZ... 69 VESICARE... 154 vestura (28)... 111 VGO 40... 132 VIBERZI... 149 vic-forte... 216 vicks dayquil cough... 121 vicks nature fusion cough... 121 vicks nyquil cold/flu liquicap... 121 vicks qlearquil nighttime rlf... 58 vicks qlearquil(oxymetazoline)... 138 vicks sinex 12-hour... 138 vicodin... 10 vicodin es... 10 vicodin hp... 10 VICTOZA 3-PAK... 48 VIDEX 2 GRAM PEDIATRIC... 73 VIEKIRA PAK... 74 VIEKIRA XR... 74 vienva... 111 VIGAMOX... 140 VIIBRYD... 46 VIMIZIM... 133 VIMPAT... 42 vinorelbine... 37 viorele (28)... 111 VIRACEPT... 73 VIRAZOLE... 76 VIREAD... 73 virtussin dac... 121 vision... 216 vision plus lutein... 216 vit b complex-folic acid 213, 217 vitalets... 217 vitamin a... 217 vitamin b complex... 195, 211 vitamin b-1... 217 vitamin b-100 complex... 200 vitamin b12-folic acid... 217 vitamin b-6... 217 vitamin c... 212, 217, 218, 219 vitamin d3... 212, 213, 218 vitamin k... 218 vitamin k1... 218 vitamins and minerals... 217 vitamins b complex... 195, 217 vitamins for hair... 219 vitatrum... 219 VITEKTA... 73 vitrum senior... 219 vol-care rx... 219 VOLTAREN... 13 voriconazole... 53 VOTRIENT... 37 VPRIV... 133 vp-vite rx... 219 VRAYLAR... 69 vyfemla (28)... 111 W wal-act d cold and allergy... 58 wal-dram... 63 wal-dryl allergy... 58 wal-fex allergy... 58 wal-finate... 58 wal-finate-d... 58 wal-flu severe cold-cough... 121 wal-itin... 58 wal-itin d... 59 wal-itin d 12 hour... 58 wal-phed... 59, 121 wal-phed pe day-night... 121 wal-phed pe sinus and allergy 59 wal-profen... 13 wal-sleep z... 59 wal-som (diphenhydramine).. 59 wal-som (doxylamine)... 59 wal-tap... 59 wal-tussin cough... 121 wal-tussin dm... 112 wal-tussin max strength cough... 121 wal-zan 75... 144 wal-zyr (cetirizine)... 59 wal-zyr d... 59 warfarin... 77 water for irrigation, sterile... 173 WELCHOL... 99 wera (28)... 111 womens daily gummies... 200 women's daily multivitamin. 211 women's multivitamin gummies... 219 X XALKORI... 37 XARELTO... 77 XELJANZ... 167 XELJANZ XR... 167 XIFAXAN... 20 XOLAIR... 191 XTAMPZA ER... 10 XTANDI... 37 xulane... 111 xylon 10... 10 XYREM... 192 Y yelets... 219 YERVOY... 37 YF-VAX (PF)... 172 YONDELIS... 37 yuvafem... 157 Z zafirlukast... 188 zaleplon... 192 zantac 75... 144 zarah... 111 I-23

ZARXIO... 79 ZAVESCA... 133 zebutal... 10 ZELBORAF... 37 ZEMPLAR... 175 zenatane... 125 zenchent (28)... 111 ZENPEP... 133 ZEPATIER... 74 zephrex-d... 121 ZETIA... 99 ZIAGEN... 73 zidovudine... 73 ZINBRYTA... 103 zinc oxide... 125 ZIOPTAN (PF)... 179 ziprasidone hcl... 70 ZIRGAN... 140 ZOLADEX... 37 zoledronic acid... 175 zoledronic acid-mannitol-water... 175 ZOLINZA... 37 zolmitriptan... 60 zolpidem... 193 ZOMACTON... 161 ZOMETA... 175 zonisamide... 42 zoo chews... 219 ZORBTIVE... 161 ZORTRESS... 167 ZOSTAVAX (PF)... 172 zovia 1/35e (28)... 111 zovia 1/50e (28)... 111 z-sleep... 57, 58 ZUBSOLV... 10, 16 ZURAMPIC... 54 ZYDELIG... 37 ZYKADIA... 37 ZYLET... 140 zyncof... 121 ZYPREXA RELPREVV... 70 ZYRTEC... 59 ZYTIGA... 37 I-24

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