ELENCO DEI FARMACI COPERTI

Transcript

1 ELENCO DEI FARMACI COPERTI Community Care Plus FIDA-MMP ICS ICS_ _A2TC_G_EFF _ _174025_Comprehensive_R _Approved

2 ICS Community Care Plus FIDA-MMP Elenco dei farmaci convenzionati (formulario) per il 2015 Questo è un elenco dei farmaci che i Partecipanti possono ottenere nell ambito del piano ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP è un piano di cure gestite basato su accordi sia con Medicare che con il New York State Department of Health (Dipartimento della sanità dello stato di New York, Medicaid) per offrire ai Partecipanti i benefici di entrambi i programmi attraverso la dimostrazione FIDA (Fully Integrated Duals Advantage, vantaggio completamente integrato per candidati idonei per entrambi i sistemi). I benefici, l Elenco dei farmaci convenzionati e le reti di farmacie e fornitori possono cambiare di volta in volta nel corso dell anno e il 1 gennaio di ciascun anno. È possibile controllare l Elenco aggiornato dei farmaci convenzionati di ICS Community Care Plus FIDA-MMP in qualsiasi momento sul sito Web oppure contattando il Servizio partecipanti (ICS Community Care Plus FIDA-MMP Participant Services) al numero ICS Possono applicarsi limitazioni. Per ulteriori informazioni contattare il Servizio partecipanti (ICS Community Care Plus FIDA-MMP Participant Services) o leggere il manuale del partecipante (ICS Community Care Plus FIDA-MMP Participant Handbook). Non è previsto alcun ticket (contributo personale) per alcun farmaco convenzionato. Queste informazioni sono disponibili gratuitamente anche in altri formati, quali Braille o stampa a caratteri grandi. Contattare il numero ICS La chiamata è gratuita. Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri ICS.2525 e TTY ICS.4TTY tra le 8:00 e le dal lunedì al venerdì. La chiamata è gratuita. You can get this information for free in other languages. Call ICS.2525 and TTY ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday. The call is free. 1

3 Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону ICS.2525 и телетайпу ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный. 您可免费获得所有这些信息的其他语言版本 请在周一至周五上午 8 点至晚上 8 点致电 ICS, 电话号码为 ICS.2525, 听障专线 (TTY) 为 ICS.4TTY 此为免费电话 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al ICS.2525 y a la línea TTY ICS.4TTY, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan ICS.2525 ak TTY ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. 이모든정보는타언어로무료로제공됩니다. 월요일 ~ 금요일, 오전 8 시 ~ 오후 8 시사이에 ICS.2525 및 TTY( 청각장애인용전화 ) ICS.4TTY 로 ICS 에전화해주십시오. 이전화는무료입니다. Lo Stato di New York ha creato un programma di tutela dei partecipanti chiamato Independent Consumer Advocacy Network o ICAN (Rete indipendente di sostegno ai consumatori) per offrire gratuitamente ai Partecipanti assistenza in modo riservato su tutti i servizi offerti da ICS Community Care Plus FIDA-MMP. L ICAN può essere contattato tramite il numero verde oppure attraverso il sito Domande più comuni (FAQ) Di seguito sono disponibili risposte a possibili domande in merito a questo Elenco dei farmaci convenzionati. È possibile leggere tutta la sezione delle domande più comuni per apprendere ulteriori informazioni oppure cercare una domanda e una risposta specifiche. 1. Quali farmaci su prescrizione sono contenuti nell Elenco dei farmaci convenzionati? (Per comodità, l Elenco dei farmaci convenzionati viene denominato Elenco dei farmaci.) I farmaci contenuti nell Elenco dei farmaci convenzionati che inizia a pagina 15 sono i farmaci coperti da ICS Community Care Plus FIDA-MMP. Questi farmaci sono disponibili 2

4 nelle farmacie facenti parte della nostra rete. Una farmacia fa parte della nostra rete se abbiamo stipulato un accordo di collaborazione con essa per fornire servizi ai nostri Partecipanti. Tali farmacie vengono denominate farmacie di rete. ICS Community Care Plus FIDA-MMP coprirà tutti i farmaci contenuti nell Elenco dei farmaci a condizione che: il medico o altro professionista della rete che prescrive il farmaco dichiari che il Partecipante necessita di tale farmaco per guarire o mantenersi in salute; il farmaco sia necessario sotto il profilo medico per la condizione del Partecipante; e il Partecipante utilizzi la prescrizione presso una farmacia di rete ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP potrebbe richiedere procedure aggiuntive per accedere a determinati farmaci (vedere la domanda 5 di seguito). In alcuni casi potrebbe essere necessario che il Partecipante faccia qualcosa prima di poter ottenere un determinato farmaco, come per esempio provare innanzitutto un altro farmaco. Un elenco aggiornato dei farmaci convenzionati è inoltre disponibile sul nostro sito oppure telefonicamente contattando il Servizio partecipanti (Participant Services) al numero ICS L Elenco dei farmaci può essere modificato? Sì. ICS Community Care Plus FIDA-MMP può aggiungere o rimuovere farmaci dall Elenco dei farmaci durante il corso dell anno. In generale, l Elenco dei farmaci viene modificato solo se: diventa disponibile un nuovo farmaco che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci; oppure veniamo informati che un farmaco non è sicuro. Ci riserviamo inoltre di modificare le nostre regole relative ai farmaci. Per esempio, potremmo: decidere di richiedere o non richiedere una approvazione preventiva per un farmaco [per Approvazione preventiva (Prior approval) si intende il permesso da parte di ICS Community Care Plus FIDA-MMP o dell equipe interdisciplinare (Interdisciplinary Team, IDT) del Partecipante prima che egli/ella possa ottenere il farmaco]; 3

5 aggiungere o modificare la quantità di farmaco che il Partecipante può ottenere [ limiti di quantità (quantity limits)]; aggiungere o modificare le limitazioni a una terapia per fasi relative a un farmaco [Terapia per fasi (Step therapy) significa che il Partecipante deve provare un farmaco prima che un altro farmaco possa essere coperto]. (Per ulteriori informazioni su queste regole relative ai farmaci, vedere pagina 5.) Il Partecipante verrà informato quando un farmaco che sta assumendo viene rimosso dall Elenco dei farmaci. Il Partecipante verrà inoltre informato di eventuali cambiamenti alle regole relative alla copertura di un farmaco. Le Domande 3, 4 e 7 di seguito presentano ulteriori informazioni in merito a cosa accade quando l Elenco dei farmaci viene modificato. È possibile controllare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP aggiornato in qualsiasi momento sul sito Potrà inoltre contattare il Servizio partecipanti (Participant Services) per controllare l Elenco dei farmaci attuale al numero ICS Cosa succede se diventa disponibile un farmaco più economico che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci? Se diventa disponibile un farmaco meno costoso che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci: Il farmacista potrà consegnare il farmaco più economico la prossima volta che il Partecipante presenta la prescrizione. Se il Partecipante e il suo fornitore decidono che il farmaco più economico non è idoneo per il Partecipante, il fornitore potrà istruire il farmacista a continuare a consegnare il farmaco che il Partecipante sta assumendo attualmente. ICS Community Care Plus FIDA-MMP potrà decidere di rimuovere il farmaco più costoso dall Elenco dei farmaci. Se il Partecipante sta assumendo un farmaco che viene rimosso dall Elenco dei farmaci perché è diventato disponibile un farmaco più economico che funziona altrettanto bene, il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla rimozione di tale farmaco dall Elenco dei farmaci oppure nel momento in cui il Partecipante ripresenta la prescrizione. In tal 4

6 caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che il cambiamento all Elenco dei farmaci venga effettuato. ICS Community Care Plus FIDA-MMP informerà i membri di tali cambiamenti tramite posta e includerà informazioni relative a come inoltrare una lagnanza, un ricorso o una richiesta di eccezione. ICS Community Care Plus FIDA-MMP pubblicherà inoltre tali informazioni sul sito Web, disponibile all indirizzo e informerà i membri con decorrenza annuale del formulario aggiornato. Tali informazioni possono essere fornite anche in formati diversi. 4. Cosa succede se veniamo informati che un farmaco non è sicuro? Se l ente statunitense preposto alla vigilanza sugli alimenti e sui farmaci (Food and Drug Administration, FDA) dichiara che un farmaco che il Partecipante sta assumendo non è sicuro, tale farmaco verrà rimosso immediatamente dall Elenco dei farmaci. Il Partecipante sarà informato tramite lettera e riceverà una telefonata per essere informato che il farmaco non sicuro è stato rimosso dall Elenco dei farmaci. Il Partecipante verrà istruito a contattare il medico che ha eseguito la prescrizione non appena possibile per ottenere istruzioni per la sostituzione del farmaco sospeso. Il responsabile delle cure potrà essere contattato per ulteriore assistenza. 5. Vi sono limitazioni relative alla copertura dei farmaci? Oppure è necessario fare qualcosa per ottenere determinati farmaci? Sì, per alcuni farmaci vi sono determinate regole o limitazioni relative alla quantità che può essere ottenuta. In alcuni casi è necessario fare qualcosa prima di poter ottenere il farmaco. Per esempio: Approvazione preventiva (o autorizzazione preventiva): Per alcuni farmaci, il Partecipante o il suo medico o altro professionista che effettua la prescrizione deve ottenere l approvazione da parte di ICS Community Care Plus FIDA-MMP o della propria equipe interdisciplinare (Interdisciplinary Team, IDT) prima di presentare la prescrizione. Se non ottiene l approvazione, ICS Community Care Plus FIDA-MMP potrebbe non coprire tale farmaco. Limiti di quantità: A volte ICS Community Care Plus FIDA-MMP limita la quantità di farmaco che è possibile ottenere. 5

7 Terapia per fasi: A volte ICS Community Care Plus FIDA-MMP richiede che il Partecipante si sottoponga a una terapia per fasi. Ciò significa che il Partecipante dovrà provare dei farmaci per la sua condizione medica in un determinato ordine. Potrebbe essere necessario provare un farmaco prima che un altro farmaco venga coperto. Se il medico del Partecipante ritiene che il primo farmaco non funzioni per il Partecipante, allora il secondo farmaco sarà coperto. Per determinare se per il farmaco d interesse sono previsti eventuali requisiti aggiuntivi o limiti, consultare le tabelle a partire da pagina 15. Ulteriori informazioni sono disponibili sul sito Web Sul sito sono disponibili documenti che spiegano l autorizzazione preventiva e le limitazioni della terapia per fasi. È inoltre possibile richiedere una copia tramite posta. È possibile richiedere una eccezione per tali limiti. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. Se il Partecipante si trova in una residenza sanitaria o in altra struttura di cura a lungo termine e necessita di un farmaco che non è incluso nell Elenco dei farmaci, oppure se il farmaco necessario non è facilmente disponibile, è possibile richiedere la nostra assistenza. Copriremo una fornitura di emergenza di 31 giorni del farmaco necessario (a meno che la prescrizione non preveda meno giorni), indipendentemente dal fatto che il Partecipante si sia appena iscritto a ICS Community Care Plus FIDA-MMP. In tal modo avrà tempo di parlare con il proprio medico o altro professionista che effettua la prescrizione. Il medico potrà aiutare il Partecipante a decidere se nell Elenco dei farmaci esiste un farmaco simile che può assumere in alternativa oppure se sia necessario richiedere un eccezione. Per ulteriori informazioni sulle eccezioni, vedere la domanda Come si fa a sapere se per il farmaco d interesse sono previste limitazioni oppure se sono previste azioni specifiche per ottenere tale farmaco? L Elenco dei farmaci convenzionati, a partire da pagina 15, ha una colonna denominata Azioni necessarie, limitazioni o limiti per l uso. 7. Cosa succede se le regole relative alle modalità di copertura per alcuni farmaci vengono modificate? Per esempio, se viene aggiunta l autorizzazione (approvazione) preventiva, un limite di quantità oppure limitazioni tramite terapia per fasi relativa a un farmaco. 6

8 Il Partecipante verrà informato se aggiungiamo l approvazione preventiva, limiti alla quantità e/o limitazioni tramite terapia per fasi relativa a un farmaco. Il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla data di aggiunta della limitazione oppure al momento in cui ripresenterà una prescrizione. In tal caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che il cambiamento all Elenco dei farmaci venga effettuato. In tal modo avrà tempo di discutere la decisione da prendere con il proprio medico o altro professionista che effettua la prescrizione. 8. Come si fa a trovare un farmaco nell Elenco dei farmaci? Vi sono due modi per trovare un farmaco: ricerca alfabetica (se si conosce come scrivere il nome del farmaco); oppure ricerca per condizione medica. Per la ricerca alfabetica, andare all Indice a pagina I-1. Quindi cercare il nome del farmaco nell elenco. Per la ricerca per condizione medica, andare all Elenco dei farmaci per condizione medica a pagina 15. Quindi individuare la condizione medica. Per esempio, se la condizione medica è cardiaca, cercare in tale categoria. In tale categoria saranno inclusi i farmaci per trattare condizioni cardiache. 9. Cosa fare se il farmaco desiderato non è incluso nell Elenco dei farmaci? Se il farmaco d interesse non è incluso nell Elenco dei farmaci, contattare il Servizio partecipanti (Participant Services) al numero ICS.2525 per informazioni in merito. Se ICS Community Care Plus FIDA-MMP non copre tale farmaco, procedere in base a una delle opzioni seguenti: Chiedere al Servizio partecipanti (Participant Services) un elenco dei farmaci come quello che si desidera assumere. Quindi mostrare l elenco al proprio medico o altro professionista che effettua la prescrizione, che potrà prescrivere un farmaco incluso nell Elenco dei farmaci simile a quello d interesse. Oppure Chiedere al piano o alla propria equipe interdisciplinare (Interdisciplinary Team, IDT) di fare un eccezione per coprire il farmaco. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. 7

9 10. Cosa fare se il Partecipante si è appena iscritto a ICS Community Care Plus FIDA-MMP e non trova il proprio farmaco nell Elenco dei farmaci oppure ha problemi a ottenere il farmaco? Possiamo fornire il nostro aiuto. Ci impegniamo a coprire fino a 90 giorni di forniture temporanee del farmaco d interesse, secondo necessità, durante i primi 90 giorni di iscrizione come Partecipante di ICS Community Care Plus FIDA-MMP. In tal modo avrà tempo di parlare con il proprio medico o altro professionista che effettua la prescrizione. Il medico potrà aiutare il Partecipante a decidere se nell Elenco dei farmaci esiste un farmaco simile che può assumere in alternativa oppure se sia necessario richiedere un eccezione. Copriremo fino a 90 giorni di forniture temporanee del farmaco d interesse se: il Partecipante sta assumendo un farmaco che non è incluso nell Elenco dei farmaci; oppure le regole del piano sanitario non consentono al Partecipante di ottenere la quantità richiesta dal professionista che effettua la prescrizione; oppure per il farmaco è prevista l approvazione preventiva da parte di ICS Community Care Plus FIDA-MMP o dell equipe interdisciplinare (Interdisciplinary Team, IDT) del Partecipante; oppure il Partecipante sta assumendo un farmaco che fa parte di una limitazione tramite terapia per fasi. Se il Partecipante risiede in una residenza sanitaria o in altra struttura di cura a lungo termine, potrà ripresentare la prescrizione per un massimo di 98 giorni. Durante i 98 giorni potrà ripresentare la prescrizione più volte. In tal modo il professionista che ha effettuato la prescrizione avrà il tempo di modificare i farmaci per usare quelli che sono inclusi nell Elenco dei farmaci oppure di richiedere un eccezione. Se il Partecipante è interessato da un cambiamento di livello di cura da un tipo di trattamento a un altro, può essere idoneo per una fornitura di farmaco non incluso nell Elenco dei farmaci per un massimo di 90 giorni, in modo che il medico o il professionista che effettua la prescrizione abbia il tempo di individuare un farmaco idoneo in elenco o di richiedere un eccezione. Il Partecipante potrà essere idoneo per una fornitura di transizione del livello di cura se: 8

10 fa ingresso in una struttura di cura a lungo termine (Long-Term Care, LTC) da un ospedale o da altra struttura lascia una struttura LTC e fa rientro nella comunità viene dimesso dall ospedale per recarsi a casa termina una permanenza in una casa di accoglienza con personale specializzato coperta da Medicare, Parte A (inclusi i costi farmaceutici), e ritorna alla copertura come alla Parte D ritorna dallo stato di ricoverato in casa di accoglienza ai benefici standard Medicare come da Parte A e B oppure viene dimesso da un ospedale psichiatrico con regimi farmaceutici altamente individualizzati. 11. È possibile richiedere un eccezione per coprire un farmaco? Sì. È possibile chiedere a ICS Community Care Plus FIDA-MMP o alla propria equipe interdisciplinare (Interdisciplinary Team, IDT) di effettuare un eccezione per coprire un farmaco che non è incluso nell Elenco dei farmaci. È inoltre possibile chiedere a ICS Community Care Plus FIDA-MMP o alla propria IDT di modificare le regole relative al farmaco d interesse. Per esempio, ICS Community Care Plus FIDA-MMP potrebbe limitare la quantità di un farmaco che è coperto. Se per il farmaco d interesse è previsto un limite, è possibile richiedere a noi o alla propria IDT di modificare tale limite e coprire una quantità maggiore. Altri esempi: È possibile richiedere a noi o alla propria IDT di non imporre le limitazioni della terapia per fasi o i requisiti di approvazione preventiva. 12. Quanto tempo è necessario per ottenere un eccezione? Innanzitutto ICS Community Care Plus FIDA-MMP o l equipe interdisciplinare (Interdisciplinary Team, IDT) deve ricevere una dichiarazione da parte del professionista che effettua la prescrizione a supporto della richiesta di eccezione da parte del Partecipante. Una volta ricevuta la dichiarazione, la decisione in merito alla richiesta di eccezione viene presa entro 72 ore. 9

11 Se il Partecipante o il professionista che effettua la prescrizione ritiene che la salute del Partecipante potrebbe essere compromessa durante l attesa di 72 ore per una decisione, è possibile richiedere un eccezione accelerata. In tal modo la decisione viene presa più rapidamente e, se il professionista che effettua la prescrizione supporta la richiesta da parte del Partecipante, la decisione verrà presa entro 24 ore dal momento in cui viene ricevuta la dichiarazione di supporto. 13. Come si fa a richiedere un eccezione? Per richiedere un eccezione, contattare il proprio Responsabile delle cure (Care Manager). Il Responsabile delle cure collaborerà con il Partecipante e il professionista che effettua la prescrizione per assisterli nella richiesta di un eccezione. 14. Cosa sono i farmaci generici? I farmaci generici sono composti dagli stessi ingredienti dei farmaci di marca. Solitamente costano meno dei farmaci di marca e non hanno nomi conosciuti. I farmaci generici sono approvati dall ente statunitense per la vigilanza sugli alimenti e i farmaci (Food and Drug Administration, FDA). ICS Community Care Plus FIDA-MMP copre sia farmaci di marca che farmaci generici. 15. Che cosa sono i farmaci OTC? OTC significa over-the-counter, ovvero da banco. ICS Community Care Plus FIDA- MMP copre alcuni farmaci OTC se vengono prescritti dal fornitore del Partecipante. Per sapere quali farmaci OTC sono coperti, consultare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP. 16. ICS Community Care Plus FIDA-MMP copre prodotti OTC non farmaceutici? ICS Community Care Plus FIDA-MMP copre alcuni prodotti OTC non farmaceutici, quali garze e bende, tamponi imbevuti d alcool, siringhe e aghi per insulina, ecc. se vengono inclusi nella prescrizione da parte del fornitore del Partecipante. Per sapere quali prodotti OTC non farmaceutici sono coperti, consultare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP. 17. Qual è il contributo addebitato al Partecipante ( ticket )? 10

12 Il Partecipante non sarà soggetto ad alcun pagamento parziale per farmaci inclusi nell Elenco dei farmaci. 18. Che cosa sono i livelli di farmaci? I livelli sono gruppi di farmaci. Ogni farmaco nell Elenco dei farmaci del piano è incluso in uno di 4 livelli. Il Partecipante non è soggetto ad alcun costo per i farmaci in tutti i livelli. Livello 1: farmaci generici coperti da Medicare Livello 2: farmaci di marca e specialistici coperti da Medicare Livello 3: farmaci generici e di marca non Parte D coperti da Medicaid Livello 4: farmaci OTC (Over-The-Counter, da banco) coperti da Medicaid Elenco dei farmaci convenzionati L elenco dei farmaci convenzionati che inizia alla pagina seguente fornisce informazioni sui farmaci coperti da ICS Community Care Plus FIDA-MMP. Se l individuazione del farmaco nell elenco risulta problematica, consultare l Indice che inizia a pagina I-1. La prima colonna dell elenco indica il nome del farmaco. I farmaci di marca sono scritti in carattere maiuscolo (per es. AVONEX) e i farmaci generici in minuscolo corsivo (per es. amoxicillina). Le informazioni nella colonna delle azioni, limitazioni o limiti all uso indica se ICS Community Care Plus FIDA-MMP prevede regole per la copertura di tale farmaco. 11

13 Abbreviazioni e simboli Questo documento può contenere le seguenti abbreviazioni. ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE PA Limitazioni alla gestione dell utilizzo Autorizzazione preventiva obbligatoria (Prior Authorization Restriction) Il Partecipante o il suo medico devono ottenere l autorizzazione preventiva da parte di ICS Community Care Plus FIDA- MMP prima di presentare la prescrizione per il farmaco d interesse. Senza l approvazione preventiva, ICS Community Care Plus FIDA-MMP potrebbe non coprire il farmaco. PA BvD PA NSO QL Autorizzazione preventiva obbligatoria per determinazione Parte B o Parte D (Prior Authorization Restriction for Part B vs Part D Determination) Autorizzazione preventiva solo per i nuovi iscritti (Prior Authorization Restriction for New Starts Only) Limitazione della quantità Questo farmaco potrebbe essere idoneo per il pagamento in base a Medicare Parte B o Parte D. Il Partecipante (o il suo medico) devono ottenere l autorizzazione preventiva da parte di ICS Community Care Plus FIDA-MMP per determinare che il farmaco è coperto da Medicare Parte D prima di presentare la prescrizione per tale farmaco. Senza l approvazione preventiva, FIDA Care Complete potrebbe non coprire il farmaco. Se il Partecipante è un nuovo membro o se non ha mai assunto questo farmaco in precedenza, il Partecipante (o il suo medico) devono ottenere l autorizzazione preventiva da parte di ICS Community Care Plus FIDA-MMP prima di presentare la prescrizione per il farmaco d interesse. Senza l approvazione preventiva, FIDA Care Complete potrebbe non coprire il farmaco. ICS Community Care Plus FIDA-MMP limita la quantità di questo farmaco che 12

14 ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE ST (Quantity Limit Restriction) Limitazione tramite terapia per fasi (Step Therapy Restriction) viene coperta per ciascuna prescrizione o entro un determinato periodo di tempo. Prima che ICS Community Care Plus FIDA-MMP fornisca la copertura per il farmaco d interesse è necessario che il Partecipante provi uno (o più) farmaci per il trattamento della sua condizione medica. Il farmaco d interesse potrà essere coperto solo se uno (o più) farmaci non funzionano per il Partecipante. * LA GC Abbreviazione di altre coperture Farmaco non di Parte D (Not a Part D Drug) Farmaco ad accesso limitato (Limited Access Drug) Copertura nel periodo di interruzione (Gap Coverage) Il farmaco d interesse non è un farmaco di Parte D coperto da Medicaid. Questa prescrizione potrebbe essere disponibile solo presso determinate farmacie. Per ulteriori informazioni, consultare l Elenco delle farmacie o contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, da lunedì a venerdì, dalle 8:00 alle 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito Forniamo la copertura di questo farmaco su prescrizione nel periodo di interruzione della copertura. Per ulteriori informazioni su questo tipo di copertura, consultare il documento Evidenza di copertura (Evidence of Coverage). Nota: l asterisco (*) a fianco di un farmaco indica che il farmaco non è un farmaco di Parte D. Tali farmaci hanno regole diverse per i ricorsi. Un ricorso (appeal) è un modo formale di richiedere la revisione e il cambiamento di una decisione di copertura se si ritiene che sia stato commesso un errore. Per esempio, ICS Community Care Plus FIDA- MMP o l equipe interdisciplinare (Interdisciplinary Team, IDT) potrebbe decidere che un farmaco d interesse per il Partecipante non è coperto o non è più coperto da Medicare o 13

15 Medicaid. Se il Partecipante o il suo medico o altro professionista che effettua la prescrizione non è d accordo con la decisione, è possibile fare ricorso. Per istruzioni su come fare ricorso, contattare il Servizio partecipanti (Participant Services) al numero ICS.2525 oppure la Rete di sostegno ai consumatori (ICAN) al numero Informazioni su come fare ricorso su una decisione sono disponibili anche nel Manuale del Partecipante. 14

16 If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday to Friday, 8 a.m. to 8 p.m. The call is free. For more information, visit plus. 15

17 16 Analgesics Analgesics, Miscellaneous acephen * (Acetaminophen) acetaminophen * oral (Acetaminophen) acetaminophen * oral (Tylenol 8 Hour) acetaminophen * rectal suppository 120 mg, 650 mg (Acetaminophen) acetaminophen-codeine oral (Acetaminophen solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine mg, mg No.3) acetaminophen-codeine oral tablet mg buprenorphine hcl injection butalb-acetaminophen-caffeine oral capsule mg butalbital-acetaminop-caf-cod (Tylenol-Codeine No.3) (Buprenorphine HCl) (Esgic) (Fioricet with Codeine) butalbital-acetaminophen (Tencon) butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule (Esgic) (Fiorinal) QL (2700 per 30 QL (360 per 30 QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 QL (5 per 28 butorphanol tartrate nasal (Butorphanol Tartrate) BUTRANS QL (4 per 28 children's mapap * (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's pain & fever relief * oral (Infants' Tylenol) children's pain reliever * oral (Acetaminophen) children's pain reliever * oral (Acetaminophen)

18 17 children's silapap * (Tylenol Sore Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule mg Codeine #3) 30 DURAMORPH (PF) fentanyl citrate (Actiq) PA; QL (120 per 30 fentanyl transdermal patch 72 hour PA; QL (20 per 30 (Duragesic) 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 PA; QL (10 per 30 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) feverall * rectal suppository 120 mg, 325 mg, 650 mg (Acetaminophen) hydrocodone-acetaminophen oral QL (2700 per 30 (Hycet) solution hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Norco) (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 QL (360 per 30 hydrocodone-ibuprofen (Ibudone) QL (150 per 30 hydromorphone (pf) injection (Hydromorphone solution 10 mg/ml HCl/PF) hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl)

19 18 hydromorphone oral liquid (Dilaudid) QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 QL (180 per 30 (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 infant acetaminophen * (Acetaminophen) infantaire * (Acetaminophen) infant's pain reliever * (Acetaminophen) jr. acetaminophen * (Acetaminophen) junior mapap * (Acetaminophen) LAZANDA PA; QL (30 per 30 levorphanol tartrate (Levorphanol QL (180 per 30 Tartrate) mapap (acetaminophen) * oral capsule (Acetaminophen) mapap (acetaminophen) * oral elixir (Acetaminophen) mapap (acetaminophen) * oral (Tylenol Sore liquid 500 mg/15 ml Throat) mapap (acetaminophen) * oral suspension (Infants' Tylenol) mapap (acetaminophen) * oral tablet (Tylenol) mapap (acetaminophen) * oral tablet,chewable (Acetaminophen) mapap arthritis pain * (Tylenol 8 Hour) mapap extra strength * (Tylenol) methadone hcl oral tablet,soluble QL (90 per 30 (Diskets) 40 mg methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Msir) QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate)

20 19 morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml, 2 mg/ml (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (180 per 30 morphine oral tablet extended QL (120 per 30 (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) non-aspirin extra strength * oral (Acetaminophen) non-aspirin extra strength * oral (Tylenol Sore Throat) non-aspirin extra strength * oral tablet (Tylenol) non-aspirin jr strength * (Acetaminophen) nortemp * oral (Acetaminophen) NUCYNTA QL (181 per 30 NUCYNTA ER QL (60 per 30 (Oxycodone QL (1800 per 30 oxycodone hcl-acetaminophen oral HCl/Acetaminophe solution mg/5 ml n) oxycodone hcl-acetaminophen oral QL (360 per 30 tablet mg, mg, mg, mg (Xolox) oxycodone hcl-aspirin (Percodan) QL (360 per 30 oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30

21 20 oxycodone oral tablet (Percolone) QL (180 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg (Xolox) QL (360 per 30 oxycodone-acetaminophen oral QL (180 per 30 (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 (Xolox) tablet mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL QL (60 per 30 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 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) QL (60 per 30 oxymorphone oral tablet extended QL (120 per 30 (Opana ER) release 12 hr 30 mg, 40 mg pain relief adult * (Tylenol Sore Throat) pain relief * oral capsule (Acetaminophen) pain relief * oral tablet extended release (Tylenol 8 Hour) pain reliever jr strength * (Acetaminophen) pain reliever * oral (Acetaminophen) pharbetol * (Tylenol) q-pap extra strength * (Tylenol) q-pap * oral drops (Acetaminophen) q-pap * oral liquid (Tylenol Sore Throat)

22 21 q-pap * oral tablet (Tylenol) silapap * (Acetaminophen) tactinal * (Tylenol) tactinal extra strength * (Tylenol) tramadol oral tablet (Ultram) QL (240 per 30 tramadol-acetaminophen (Ultracet) QL (240 per 30 xylon 10 (Ibudone) QL (150 per 30 Nonsteroidal Anti-Inflammatory Agents advil * oral tablet (Motrin Ib) advil * oral tablet,chewable (Ibuprofen) aspirin * oral tablet (Ecotrin) aspirin * oral tablet,chewable (Bayer Chewable Aspirin) aspirin * oral tablet,delayed release (Ecotrin) (dr/ec) 325 mg, 500 mg, 81 mg aspirin * rectal (Aspirin) aspirin, buffered * (Aspirin/Calcium Carbonate/Mag) aspir-low * (Ecotrin) bufferin * oral tablet 325 mg (Aspirin/Calcium Carbonate/Mag) CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) QL (60 per 30 children's advil * (Children'S Motrin) choline,magnesium salicylate (Choline Sal/Mag Salicylate) COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR)

23 22 diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) Sodium) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) e.c. prin * (Ecotrin) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR PA flurbiprofen (Ansaid) ibuprofen * 100 mg/5 ml susp (Children'S children's (otc) Motrin) ibuprofen jr strength * (Ibuprofen) ibuprofen * oral (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen * oral tablet 100 mg, 200 mg (Motrin Ib) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (120 per 30 indomethacin oral capsule, PA-HRM; QL (60 per (Indomethacin) extended release 30 indomethacin sodium (Indocin I.V.) PA-HRM infant's ibuprofen * (Infants' Motrin) INFANT'S MOTRIN * 3 $0 ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac injection cartridge 15 QL (40 per 30 (Toradol) mg/ml

24 ketorolac injection cartridge 30 mg/ml (Toradol) ketorolac injection solution 15 (Ketorolac mg/ml Tromethamine) ketorolac injection solution 30 (Ketorolac mg/ml (1 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac Tromethamine) ketorolac oral (Ketorolac Tromethamine) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (dr/ec) (Ec-Naprosyn) naproxen sodium oral tablet 275 (Anaprox) mg, 550 mg piroxicam (Feldene) salsalate (Salsalate) sb aspirin * 325 mg tablet na/f, caffeine-free st joseph aspirin * (Bayer Chewable Aspirin) st. joseph aspirin * (Ecotrin) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) tri-buffered aspirin * (Aspirin/Calcium Carbonate/Mag) VOLTAREN TOPICAL wal-profen * oral (Advil) Anesthetics Local Anesthetics QL (20 per 30 QL (40 per 30 QL (20 per 30 QL (20 per 30 QL (20 per 30 23

25 24 glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) lidocaine hcl injection solution (Xylocaine) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) lidocaine topical ointment (Lidocaine) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Relador Pak) PA BvD RELADOR PAK PA BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) buprenorphine hcl sublingual (Subutex) buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) PA; QL (90 per 30 PA; QL (90 per 30 CHANTIX QL (168 per 84 CHANTIX CONTINUING QL (56 per 28 MONTH BOX CHANTIX CONTINUING QL (56 per 28 MONTH PAK

26 25 CHANTIX STARTING MONTH BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 21 MG/24 HR NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 7 MG/24 HR nicorelief * buccal gum (Nicorette) nicorette * buccal gum 2 mg (Nicorette) nicotine (polacrilex) * (Nicorette) nicotine * transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr (Nicoderm Cq) nicotine * transdermal patch 24 hour 21 mg/24 hr, 22 mg/24 hr (Nicoderm Cq) NICOTROL ZUBSOLV SUBLINGUAL TABLET MG ZUBSOLV SUBLINGUAL TABLET MG ZUBSOLV SUBLINGUAL TABLET MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines QL (53 per 28 QL (168 per 365 QL (180 per 365 QL (168 per 365 PA; QL (120 per 30 PA; QL (30 per 30 PA; QL (60 per 30 PA; QL (90 per 30 alprazolam oral tablet (Xanax) QL (90 per 30 alprazolam oral tablet extended QL (90 per 30 (Xanax XR) release 24 hr 0.5 mg

27 alprazolam oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating chlordiazepoxide hcl 26 (Xanax XR) (Alprazolam) (Chlordiazepoxide HCl) QL (60 per 30 QL (90 per 30 QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 QL (90 per 30 (Klonopin) mg clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 clonazepam oral QL (300 per 30 (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 (Tranxene T-Tab) 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG diazepam injection (Diazepam) QL (10 per 28 diazepam intensol (Diazepam) QL (1200 per 30 diazepam oral solution (Diazepam) QL (1200 per 30 diazepam oral tablet (Valium) QL (120 per 30 diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg (Estazolam) 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

28 27 estazolam oral tablet 2 mg (Estazolam) 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 flurazepam oral capsule 15 mg (Flurazepam HCl) 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 flurazepam oral capsule 30 mg (Flurazepam HCl) 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 lorazepam oral solution (Ativan) QL (150 per 30 lorazepam injection solution (Ativan) QL (2 per 30 lorazepam injection syringe (Ativan) QL (2 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam QL (2 per 30 HCl/PF)

29 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older triazolam oral tablet mg (Halcion) with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per midazolam (pf) injection syringe 2 (Midazolam QL (2 per 30 mg/2 ml (1 mg/ml) HCl/PF) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 PA NSO; QL (480 per ONFI ORAL SUSPENSION 30 ONFI ORAL TABLET 10 MG, 20 PA NSO; QL (60 per MG 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older temazepam oral capsule 15 mg, with over 90 days (Restoril) 22.5 mg, 30 mg cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days temazepam oral capsule 7.5 mg (Restoril) cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30

30 triazolam oral tablet 0.25 mg (Halcion) 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 Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 tobramycin in % nacl (Tobi) PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodiu m Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) 29

31 30 clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate) nitrofurantoin macrocrystal oral capsule 100 mg (Macrodantin) nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) PA-HRM; QL (120 per 30 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 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

32 vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 (Cefazolin Sodium) ml cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, 300 g (Cefazolin Sodium) cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % PA; QL (9 per 30 ST; QL (60 per 30 31

33 CEFEPIME IN DEXTROSE,ISO- OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (Ceftriaxone Na/Dextrose, Iso) ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln (Ceftriaxone 1 gram Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) 32

34 33 cephalexin oral suspension for reconstitution (Cephalexin) cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO- OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 24 hr (Biaxin XL) DIFICID QL (20 per 10 ERYTHROCIN erythromycin base oral (Erythromycin tablet,delayed release (dr/ec) 250 Base) mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml (Eryped 200) erythromycin ethylsuccinate oral (Erythromycin tablet 400 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin release(dr/ec) Base) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet 250 mg (Erythromycin Stearate)

35 34 Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON LA imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for reconstitution (Amoxil) amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 mg, 250 mg (Amoxicillin) amoxicillin-pot clavulanate oral suspension for reconstitution (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet extended release 12 hr (Augmentin XR) amoxicillin-pot clavulanate oral (Amoxicillin/Potas tablet,chewable sium Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection (Unasyn) ampicillin-sulbactam intravenous recon soln (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium)

36 35 nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- Water) penicillin g potassium (Penicillin G Potassium) penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam (Zosyn) Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution 400 mg/40 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous Trimethoprim)

37 Anticancer Agents 36 sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension Trimethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/ Trimethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 50 mg (Adoxa) doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension for reconstitution (Vibramycin) doxycycline monohydrate oral tablet (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL Anticancer Agents

38 ABRAXANE ADCETRIS PA NSO; QL (4 per 21 AFINITOR DISPERZ PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 PA NSO; QL (56 per MG 28 AFINITOR ORAL TABLET 2.5 PA NSO; QL (28 per MG, 5 MG, 7.5 MG 28 ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) ARRANON ARZERRA PA NSO AVASTIN PA NSO azacitidine (Vidaza) BELEODAQ PA NSO bexarotene (Targretin) PA NSO; QL (420 per 30 bicalutamide (Casodex) bleomycin (Bleomycin PA BvD Sulfate) BLINCYTO PA NSO; QL (140 per 365 BOSULIF ORAL TABLET 100 PA NSO; QL (120 per MG 30 BOSULIF ORAL TABLET 500 PA NSO; QL (30 per MG 30 CAPRELSA ORAL TABLET 100 PA NSO; QL (60 per MG 30 CAPRELSA ORAL TABLET 300 PA NSO; QL (30 per MG 30 carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) 37

39 38 COMETRIQ PA NSO; QL (112 per 28 cyclophosphamide intravenous (Cyclophosphamid PA BvD recon soln e) CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamid PA BvD; ST e) CYRAMZA PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) decitabine (Dacogen) doxorubicin hcl intravenous recon PA BvD (Doxorubicin HCl) soln 10 mg doxorubicin hcl peg-liposomal PA BvD (Doxil) intravenous suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD DROXIA ELIGARD SUBCUTANEOUS QL (1 per 84 SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 112 SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 168 SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 28 SYRINGE 7.5 MG (1 MONTH) EMCYT epirubicin intravenous solution 50 mg/25 ml (Ellence) ERBITUX PA NSO ERIVEDGE PA NSO; QL (30 per 30

40 ETOPOPHOS etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON FARYDAK FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) fluorouracil intravenous solution PA BvD 2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil) mg/10 ml flutamide (Flutamide) GAZYVA gemcitabine intravenous recon soln 1 gram (Gemzar) GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG HALAVEN PA NSO; QL (6 per 21 PA NSO; QL (40 per 28 PA NSO; QL (30 per 30 PA NSO; QL (90 per 30 PA NSO; QL (60 per 30 PA NSO; QL (24 per 28 HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) IBRANCE PA NSO; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 39

41 40 ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna PA BvD ) IMBRUVICA PA NSO; QL (120 per 30 INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IRESSA PA NSO; QL (60 per 30 ISTODAX PA NSO IXEMPRA JAKAFI PA NSO; QL (60 per 30 JEVTANA KADCYLA PA NSO KEYTRUDA PA NSO KYPROLIS PA NSO; QL (6 per 28 LENVIMA PA NSO letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT QL (1 per 28 LUPRON DEPOT (3 MONTH) QL (1 per 84 LUPRON DEPOT (4 MONTH) QL (1 per 84 LUPRON DEPOT (6 MONTH) QL (1 per 168 LUPRON DEPOT-PED QL (1 per 28

42 LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 41 LYNPARZA LYSODREN MARQIBO MATULANE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (Megace Es) QL (1 per 84 PA NSO; QL (480 per 30 PA NSO; QL (4 per 28 megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 PA NSO; QL (90 per MG 30 MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 melphalan hcl intravenous (Alkeran) mercaptopurine (Purinethol) methotrexate sodium (pf) injection (Methotrexate PA BvD recon soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate PA BvD solution Sodium) methotrexate sodium injection (Methotrexate PA BvD Sodium) methotrexate sodium oral (Methotrexate PA BvD; ST Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Mitoxantrone HCl) MUSTARGEN NEXAVAR PA NSO; QL (120 per 30 NILANDRON

43 ONCASPAR PA NSO OPDIVO INTRAVENOUS PA NSO SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel (Paclitaxel) PERJETA PA NSO POMALYST PROLEUKIN PURIXAN REVLIMID PA NSO; QL (21 per 28 PA NSO; LA; QL (21 per 28 RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 PA NSO; QL (30 per 30 MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 STIVARGA PA NSO; QL (84 per 28 SUTENT PA NSO; QL (30 per 30 SYLVANT PA NSO SYNRIBO PA NSO; QL (28 per 28 TABLOID TAFINLAR PA NSO; QL (120 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG PA NSO; QL (60 per 30 42

44 43 TARCEVA ORAL TABLET 150 PA NSO; QL (90 per MG 30 TARGRETIN TOPICAL PA NSO; QL (60 per 28 TASIGNA PA NSO; QL (112 per 28 TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION QL (1 per 168 TRELSTAR INTRAMUSCULAR QL (1 per 84 SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 28 SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB UNITUXIN PA NSO VALSTAR VECTIBIX PA NSO VELCADE PA NSO vinblastine intravenous (Vinblastine PA BvD Sulfate) vincristine (Vincristine PA BvD Sulfate)

45 Anticonvulsants 44 vincristine sulfate intravenous (Vincristine PA BvD solution 1 mg/ml Sulfate) vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; QL (120 per 30 XALKORI PA NSO; QL (60 per 30 XTANDI PA NSO; QL (120 per 30 YERVOY PA NSO ZALTRAP INTRAVENOUS PA NSO SOLUTION ZELBORAF PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS QL (1 per 84 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 28 IMPLANT 3.6 MG ZOLINZA ZYDELIG PA NSO; QL (60 per 30 ZYKADIA PA NSO; QL (140 per 28 ZYTIGA PA NSO; QL (120 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline Anticonvulsants (Atropine Sulfate) (Atropine Sulfate) (Propantheline Bromide)

46 45 APTIOM ST BANZEL ST carbamazepine (Tegretol) carbamazepine oral capsule, er multiphase 12 hr (Carbatrol) carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended release 12 hr (Tegretol XR) carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr (Depakote ER) divalproex oral tablet,delayed release (dr/ec) (Depakote) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA ORAL TABLET ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release 24hr (Lamictal XR)

47 46 lamotrigine oral tablet, chewable dispersible (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release 24 hr (Keppra XR) LYRICA ORAL CAPSULE QL (90 per 30 LYRICA ORAL SOLUTION QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, QL (90 per mg, 16.2 mg, 32.4 mg, 60 mg, (Phenobarbital) 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenobarbital sodium injection (Phenobarbital QL (2 per 30 solution Sodium) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, ST; QL (90 per MG, 400 MG POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 primidone (Mysoline) QUDEXY XR ST SABRIL tiagabine (Gabitril)

48 47 topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) TRILEPTAL ORAL SUSPENSION TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS ST; QL (200 per 5 VIMPAT ORAL SOLUTION ST; QL (1200 per 30 VIMPAT ORAL TABLET ST; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 EXELON TRANSDERMAL QL (30 per 30 galantamine oral capsule,ext rel. QL (30 per 30 (Razadyne ER) pellets 24 hr galantamine oral solution (Razadyne) QL (200 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 memantine oral tablet (Namenda) QL (60 per 30 memantine oral tablets,dose pack (Namenda) QL (49 per 28 NAMENDA ORAL SOLUTION QL (360 per 30 NAMENDA ORAL TABLET QL (60 per 30 NAMENDA TITRATION PAK QL (49 per 28 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK QL (28 per 28

49 48 NAMENDA XR ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline PA NSO-HRM HCl) amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release, 150 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr (Wellbutrin XL) citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed QL (60 per 30 (Irenka) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed QL (30 per 30 (Irenka) release(dr/ec) 30 mg duloxetine oral capsule,delayed QL (30 per 30 (Irenka) release(dr/ec) 40 mg EMSAM QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) (Prozac Weekly) fluoxetine oral solution (Fluoxetine HCl)

50 49 fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 24hr (Luvox CR) fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM IRENKA QL (30 per 30 KHEDEZLA ST; QL (30 per 30 maprotiline (Maprotiline HCl) MARPLAN mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) paroxetine hcl oral tablet extended release 24 hr (Paxil CR) PAXIL ORAL SUSPENSION perphenazine-amitriptyline (Perphenazine/Ami PA NSO-HRM triptyline HCl) phenelzine (Nardil) PRISTIQ ST; QL (30 per 30 protriptyline (Vivactil) sertraline (Zoloft) SILENOR QL (30 per 30 SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl)

51 50 venlafaxine oral capsule,extended release 24hr (Effexor XR) venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg (Venlafaxine HCl) VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 BYDUREON QL (4 per 28 BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN QL (1.2 per 28 INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET QL (180 per 30 GLYXAMBI QL (30 per 30 INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG ST; QL (60 per 30 INVOKAMET ORAL TABLET ST; QL (120 per MG INVOKANA ORAL TABLET 100 ST; QL (60 per 30 MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG JANUMET QL (60 per 30 JANUMET XR ORAL TABLET, QL (30 per 30 ER MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG QL (60 per 30

52 HUMALOG MIX QL (40 per JANUVIA QL (30 per 30 JARDIANCE ST; QL (30 per 30 JENTADUETO QL (60 per 30 KORLYM PA; QL (112 per 28 metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (120 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended QL (120 per 30 (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET QL (150 per 30 repaglinide (Prandin) QL (240 per 30 SYMLINPEN 120 PA; QL (10.8 per 28 SYMLINPEN 60 PA; QL (6 per 28 TRADJENTA QL (30 per 30 TRULICITY QL (4 per 28 VICTOZA PA; QL (9 per 28 Insulins HUMALOG KWIKPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN QL (12 per UNIT/ML (3 ML)

53 HUMALOG MIX QL (30 per 28 KWIKPEN HUMALOG MIX QL (40 per 28 HUMALOG MIX QL (30 per 28 KWIKPEN HUMALOG SUBCUTANEOUS QL (30 per 28 CARTRIDGE HUMALOG SUBCUTANEOUS QL (40 per 28 HUMULIN 70/30 QL (40 per 28 HUMULIN 70/30 KWIKPEN QL (30 per 28 HUMULIN N QL (40 per 28 HUMULIN N KWIKPEN QL (30 per 28 HUMULIN R QL (40 per 28 HUMULIN R U-500 QL (40 per 28 (CONCENTRATED) LANTUS QL (40 per 28 LANTUS SOLOSTAR QL (30 per 28 NOVOLIN 70/30 QL (40 per 28 NOVOLIN N QL (40 per 28 NOVOLIN R QL (40 per 28 NOVOLOG QL (40 per 28 NOVOLOG FLEXPEN QL (30 per 28 NOVOLOG MIX QL (40 per 28 NOVOLOG MIX FLEXPEN QL (30 per 28 NOVOLOG PENFILL QL (30 per 28 TOUJEO SOLOSTAR QL (7.5 per 28 Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended QL (60 per 30 (Glucotrol XL) release 24hr 10 mg 52

54 glipizide oral tablet extended release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg glyburide micronized oral tablet 1.5 mg glyburide micronized oral tablet 3 mg glyburide micronized oral tablet 6 mg 53 (Glucotrol XL) (Glipizide/Metform in HCl) (Glipizide/Metform in HCl) QL (30 per 30 QL (60 per 30 QL (120 per 30 (Glynase) PA-HRM; QL (400 per 30 (Glynase) PA-HRM; QL (180 per 30 (Glynase) PA-HRM; QL (120 per 30 glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 glyburide-metformin oral tablet PA-HRM; QL (240 per (Glucovance) mg 30 glyburide-metformin oral tablet 2.5- PA-HRM; QL (120 per (Glucovance) 500 mg, mg 30 tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (180 per 30 Antifungals Antifungals 3 day vaginal * (Miconazole Nitrate) ABELCET PA BvD af * (Tinactin) aloe vesta * topical ointment 2 % (Miconazole Nitrate) AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD

55 antifungal (tolnaftate) * topical (Tolnaftate) antifungal (tolnaftate) * topical (Tolnaftate) antifungal * topical solution (Undecylenic Acid) baza antifungal * (Nuzole) blis-to-sol (tolnaftate) * (Tolnaftate) CANCIDAS ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole * 1% cream (otc) (Lotrimin AF) clotrimazole * 1% solution (otc) (Clotrimazole) clotrimazole 3 day * (Gyne-Lotrimin) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Lotrimin) clotrimazole * vaginal cream (Gyne-Lotrimin) clotrimazole * vaginal tablet (Clotrimazole) clotrimazole-3 * (Gyne-Lotrimin) clotrimazole-7 * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion methasone Dip) critic-aid clear af * (Miconazole Nitrate) dermafungal * (Miconazole Nitrate) desenex (clotrimazole) * (Lotrimin AF) econazole topical (Econazole Nitrate) elon dual defense * (Undecylenic Acid) 54

56 fluconazole (Diflucan) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) flucytosine (Ancobon) foot odor control * (Tinactin) fungi cure * (Clotrimazole) FUNGI-NAIL * TOPICAL fungoid-d * (Tinactin) griseofulvin microsize oral tablet (Grifulvin V) inzo antifungal * (Nuzole) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LAMISIL (AEROSOL) * lamisil af * topical aerosol powder (Tinactin) lamisil af * topical powder (Tolnaftate) LAMISIL AT * TOPICAL LOTRIMIN ULTRA * micatin * (Nuzole) miconazole 7 * vaginal suppository (Miconazole Nitrate) miconazole nitrate * topical cream (Nuzole) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal kit 200 mg- 2 % (9 gram) (Monistat 3) miconazole nitrate vaginal suppository 200 mg (Monistat 3) 55

57 MONISTAT 3 * VAGINAL COMB PACK,PREFILL APPL & CREAM MONISTAT 3 * VAGINAL KIT monistat 7 * vaginal (Miconazole Nitrate) myco nail a * (Undecylenic Acid) NOXAFIL ORAL NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin ) podactin * (Tolnaftate) remedy phytoplex antifungal * (Miconazole topical ointment Nitrate) terbinafine hcl oral (Lamisil) terbinafine hcl * topical (Desenex) tolnaftate * topical (Tinactin) tolnaftate * topical (Tolnaftate) triple paste af * (Miconazole Nitrate) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) Antihistamines Antihistamines alavert d-12 allergy-sinus * (Claritin-D 12 Hour) aller-chlor * oral syrup (Chlorpheniramine Maleate) aller-chlor * oral tablet (Chlor-Trimeton) 56

58 allerclear d-12hr * (Claritin-D 12 Hour) allerclear d-24hr * (Claritin-D 24 Hour) allergy (chlorpheniramine) * (Chlor-Trimeton) allergy relief (cetirizine) * oral (Zyrtec) allergy relief (loratadine) * oral (Claritin) allerhist-1 * (Tavist-1) aller-tec d * (Zyrtec-D) ambi 60pse-4cpm * (Pseudoephed/Chlo rpheniramine) aprodine * (Pseudoephedrine/ Triprolidine) banophen allergy * (Zzzquil) banophen * oral capsule 25 mg (Benadryl) banophen * oral (Diphenhydramine HCl) benadryl allergy * oral tablet (Diphenhydramine HCl) cetirizine * oral solution (Children'S Zyrtec) cetirizine * oral tablet (Zyrtec) cetirizine * oral tablet,chewable (Zyrtec) cetirizine-pseudoephedrine * (Zyrtec-D) child triaminic cold & allergy * (Dimetapp) child wal-tap cold-allergy * (Dimetapp) children's aller-tec * (Children'S Zyrtec) children's cetirizine * oral tablet,chewable 5 mg (Zyrtec) CHILDREN'S CLARITIN * ORAL children's wal-dryl allergy * oral (Zzzquil) children's wal-zyr * oral (Zyrtec) CHILDREN'S ZYRTEC ALLERGY * CLARITIN * 57

59 58 CLARITIN LIQUI-GEL * CLARITIN REDITABS * CLARITIN-D 12 HOUR * CLARITIN-D 24 HOUR * clemastine oral syrup (Clemastine Fumarate) clemastine * oral tablet 1.34 mg (Tavist-1) clemastine oral tablet 2.68 mg (Clemastine Fumarate) cold & cough * oral liquid (Triaminic Cold and Cough) compoz * (Diphenhydramine HCl) cyproheptadine (Cyproheptadine HCl) dailyhist-1 * (Tavist-1) dayhist allergy * (Tavist-1) dimaphen (pe) * (Dimetapp) dimetapp cold-congestion * (Triaminic Cold and Cough) diphenhist * oral capsule (Benadryl) diphenhist * oral (Zzzquil) diphenhist * oral tablet 25 mg (Diphenhydramine HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) diphenhydramine hcl injection (Diphenhydramine syringe HCl) diphenhydramine hcl * oral capsule (Benadryl) diphenhydramine hcl * oral tablet (Diphenhydramine 50 mg HCl) ed chlorped jr * (Chlorpheniramine Maleate) geri-dryl * oral capsule (Benadryl) levocetirizine (Xyzal) PA-HRM PA-HRM PA-HRM

60 loradamed * (Claritin) loratadine * oral (Claritin) loratadine * oral (Claritin) loratadine-d * oral tablet extended (Claritin-D 12 release 12 hr Hour) loratadine-d * oral tablet extended (Claritin-D 24 release 24 hr Hour) nyt-time sleep * (Diphenhydramine HCl) phenylephrine-chlorpheniramine * (Phenylephrine/Chl oral tablet 4-10 mg orpheniramine) promethazine oral syrup (Promethazine HCl) q-dryl * oral liquid (Zzzquil) q-tapp * (Pseudoephedrine/ Brompheniramin) siladryl sa * (Zzzquil) simply sleep * (Diphenhydramine HCl) sinus & allergy (pseudoephed) * (Pseudoephed/Chlo rpheniramine) sleep aid (diphenhydramine) * oral (Zzzquil) sleep-tabs * (Diphenhydramine HCl) sudogest cold & allergy * (Pseudoephed/Chlo rpheniramine) TRIAMINIC COLD & COUGH NT (PE) * ultra sleep (doxylamine succ) * (Doxylamine Succinate) unisom sleepgels * (Benadryl) wal-act d cold & allergy * (Pseudoephedrine/ Triprolidine) wal-dryl allergy * oral (Benadryl) PA-HRM 59

61 wal-dryl allergy * oral (Diphenhydramine HCl) wal-finate * (Chlor-Trimeton) wal-finate-d * (Pseudoephed/Chlo rpheniramine) wal-itin * (Claritin) wal-itin d * (Claritin-D 24 Hour) wal-itin d 12 hour * (Claritin-D 12 Hour) wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlo rpheniramine) wal-phed pe sinus & allergy * (Phenylephrine/Chl orpheniramine) wal-sleep z * oral capsule (Benadryl) wal-sleep z * oral liquid (Zzzquil) wal-sleep z * oral (Unisom tablet,disintegrating Sleepmelts) wal-som (diphenhydramine) * oral capsule (Benadryl) wal-tap * (Dimetapp) wal-zyr (cetirizine) * oral (Children'S Zyrtec) wal-zyr (cetirizine) * oral (Zyrtec) wal-zyr d * (Zyrtec-D) z-sleep * oral capsule (Benadryl) z-sleep * oral liquid (Zzzquil) ZYRTEC * ORAL CAPSULE ZYRTEC * ORAL TABLET ZYRTEC * ORAL TABLET,DISINTEGRATING Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA * AVC VAGINAL 60

62 61 clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 dihydroergotamine nasal (Migranal) QL (4 per 28 ERGOMAR QL (40 per 28 naratriptan (Amerge) QL (18 per 28 rizatriptan oral tablet (Maxalt) QL (18 per 28 rizatriptan oral QL (18 per 28 (Maxalt Mlt) tablet,disintegrating sumatriptan nasal spray (Imitrex) QL (12 per 28 sumatriptan oral tablet (Imitrex) QL (18 per 28 sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) cartridge sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) pen injector sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) solution zolmitriptan oral tablet (Zomig) QL (12 per 28 zolmitriptan oral QL (12 per 28 (Zomig Zmt) tablet,disintegrating Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin)

63 62 rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO TRECATOR Antinausea Agents Antinausea Agents ambizine * (Meclizine HCl) dimenhydrinate injection solution (Dimenhydrinate) dramamine * oral tablet (Dimenhydrinate) driminate * (Dimenhydrinate) dronabinol (Marinol) PA; QL (188 per 168 EMEND INTRAVENOUS QL (2 per 28 EMEND ORAL CAPSULE 125 PA BvD; QL (1 per 1 MG day) EMEND ORAL CAPSULE 40 MG QL (1 per 1 day) EMEND ORAL CAPSULE 80 MG PA BvD; QL (2 per 1 day) EMEND ORAL CAPSULE,DOSE PA BvD; QL (3 per 1 PACK day) granisetron (pf) intravenous (Granisetron solution HCl/PF) granisetron hcl intravenous solution (Kytril) 1 mg/ml (1 ml) granisetron hcl oral (Granisetron HCl) PA BvD meclizine * 12.5 mg caplet caplet (otc) (Meclizine HCl) meclizine * 25 mg tablet (otc) (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness * (Dimenhydrinate) motion sickness (meclizine) * (Meclizine HCl) ondansetron (Zofran Odt) PA BvD

64 63 ondansetron hcl (pf) (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection solution (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine PA-HRM HCl) promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (10 per 30 travel sickness (meclizine) * (Bonine) wal-dram * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) metronidazole in nacl (iso-os) (Metronidazole/So dium Chloride) metronidazole oral (Flagyl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate)

65 PENTAM PRIMAQUINE QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (42 per 7 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) APOKYN QL (60 per 30 AZILECT benztropine oral (Benztropine Mesylate) bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet (Sinemet CR) extended release carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) NEUPRO pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG PA-HRM ST; QL (30 per 30 PA-HRM QL (90 per 30 64

66 65 ABILIFY DISCMELT ORAL QL (60 per 30 TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR QL (161.2 per 28 ABILIFY MAINTENA QL (1 per 28 ABILIFY ORAL SOLUTION QL (900 per 30 aripiprazole oral solution (Abilify) QL (900 per 30 aripiprazole oral tablet 10 mg, 15 QL (30 per 30 (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating ST; QL (90 per 30 (Fazaclo) 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating ST; QL (180 per 30 (Fazaclo) 150 mg clozapine oral tablet,disintegrating ST; QL (120 per 30 (Fazaclo) 200 mg FANAPT ORAL TABLET ST; QL (60 per 30 FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 PACK fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 haloperidol (Haloperidol) haloperidol decanoate (Haloperidol intramuscular solution 100 mg/ml Decanoate) haloperidol decanoate intramuscular solution 50 mg/ml (Haldol Decanoate 50)

67 haloperidol lactate Name of Drug INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 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 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML (Haloperidol Lactate) ST; QL (30 per 30 ST; QL (60 per 30 QL (0.75 per 28 QL (1 per 28 QL (1.5 per 28 QL (0.25 per 28 QL (0.5 per 28 QL (0.875 per 84 QL (1.315 per 84 QL (1.75 per 84 QL (2.625 per 84 66

68 LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST; QL (30 per 30 ST; QL (60 per 30 loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral QL (30 per 30 tablet,disintegrating 10 mg, 15 mg, 5 mg (Zyprexa Zydis) olanzapine oral QL (31 per 30 (Zyprexa Zydis) tablet,disintegrating 20 mg ORAP paliperidone oral tablet extended QL (30 per 30 (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 (Invega) release 24hr 6 mg perphenazine (Perphenazine) pimozide (Orap) quetiapine (Seroquel) QL (90 per 30 REXULTI ORAL TABLET 0.25 ST; QL (120 per 30 MG REXULTI ORAL TABLET 0.5 ST; QL (60 per 30 MG REXULTI ORAL TABLET 1 MG, ST; QL (30 per 30 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) QL (60 per 30 risperidone oral QL (120 per 30 (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg 67

69 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ 68 SAPHRIS (BLACK CHERRY) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG ST; QL (60 per 30 ST; QL (60 per 30 ST; QL (30 per 30 thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Thiothixene) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; QL (540 per 30 ziprasidone hcl (Geodon) QL (60 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG QL (2 per 28 Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) APTIVUS ATRIPLA COMPLERA

70 FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir) lamivudine-zidovudine (Combivir) LEXIVA nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 hr (Viramune XR) NORVIR PREZCOBIX PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine (Zerit) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 69

71 70 VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER rimantadine (Flumadine) SYNAGIS TAMIFLU ORAL CAPSULE 30 QL (84 per 180 MG TAMIFLU ORAL CAPSULE 45 QL (48 per 180 MG TAMIFLU ORAL CAPSULE 75 QL (42 per 180 MG TAMIFLU ORAL SUSPENSION QL (540 per 180 FOR RECONSTITUTION Hcv Antivirals DAKLINZA PA; QL (28 per 28 HARVONI PA; QL (30 per 30 OLYSIO PA; QL (28 per 28 SOVALDI PA; QL (28 per 28 TECHNIVIE PA; QL (56 per 28 VIEKIRA PAK PA; QL (112 per 28 Interferons INTRON A INJECTION PA NSO PEGASYS PA

72 71 PEGASYS PROCLICK PA PEGINTRON PA PEGINTRON REDIPEN PA SYLATRON PA NSO; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous recon (Acyclovir PA BvD soln Sodium) acyclovir sodium intravenous (Acyclovir PA BvD solution Sodium) adefovir (Hepsera) entecavir (Baraclude) famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 (Copegus) mg, 600 mg TYZEKA valacyclovir (Valtrex) valganciclovir (Valcyte) VIRAZOLE PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 enoxaparin subcutaneous syringe QL (36 per 30 (Lovenox) 100 mg/ml enoxaparin subcutaneous syringe QL (27.2 per 30 (Lovenox) 120 mg/0.8 ml, 80 mg/0.8 ml

73 enoxaparin subcutaneous syringe 150 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 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 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection 72 (Lovenox) (Lovenox) (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) (Heparin Sodium in 5% Dextrose) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) QL (34 per 30 QL (18 per 30 QL (13.6 per 30 QL (20.4 per 30 QL (24 per 30 QL (15 per 30 QL (12 per 30 QL (18 per 30 PA BvD; (PA for ESRD Only) PA BvD PA BvD; (PA for ESRD Only)

74 heparin, porcine (pf) intravenous syringe 100 unit/ml HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 units/ml) bag excel container (Monoject Prefill Advanced) (Heparin Sodium in 5% Dextrose) (Heparin Sodium in 5% Dextrose) IPRIVASK PA; QL (24 per 28 jantoven (Coumadin) PRADAXA QL (60 per 30 warfarin (Coumadin) XARELTO Blood Formation Modifiers EPOGEN 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 GRANIX LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PA; QL (12 per 28 PA; QL (0.6 per 28 73

75 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 74 PROMACTA PA; QL (12 per 28 PA; QL (6 per 28 PA; QL (30 per 30 ZARXIO ST Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 aspirin-dipyridamole (Aggrenox) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 %

76 ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % Caloric Agents Caloric Agents AMINO ACIDS 15 % PA BvD AMINOSYN 10 % PA BvD AMINOSYN 3.5 % PA BvD AMINOSYN 7 % PA BvD AMINOSYN 7 % WITH PA BvD ELECTROLYTES AMINOSYN 8.5 % PA BvD AMINOSYN 8.5 %- PA BvD ELECTROLYTES AMINOSYN II 10 % PA BvD AMINOSYN II 15 % PA BvD AMINOSYN II 7 % PA BvD AMINOSYN II 8.5 % PA BvD AMINOSYN II 8.5 %- PA BvD ELECTROLYTES AMINOSYN M 3.5 % PA BvD AMINOSYN-HBC 7% PA BvD AMINOSYN-PF 10 % PA BvD AMINOSYN-PF 7 % (SULFITE- PA BvD FREE) AMINOSYN-RF 5.2 % PA BvD 75

77 76 CLINIMIX 5%/D15W SULFITE PA BvD FREE CLINIMIX 5%/D25W SULFITE- PA BvD FREE CLINIMIX 2.75%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%/D10W SULF PA BvD FREE CLINIMIX 4.25%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%-D20W SULF- PA BvD FREE CLINIMIX 4.25%-D25W SULF- PA BvD FREE CLINIMIX 5%-D20W(SULFITE- PA BvD FREE) CLINIMIX E 2.75%/D10W SUL PA BvD FREE CLINIMIX E 2.75%/D5W SULF PA BvD FREE CLINIMIX E 4.25%/D10W SUL PA BvD FREE CLINIMIX E 4.25%/D25W SUL PA BvD FREE CLINIMIX E 4.25%/D5W SULF PA BvD FREE CLINIMIX E 5%/D15W SULFIT PA BvD FREE CLINIMIX E 5%/D20W SULFIT PA BvD FREE CLINIMIX E 5%/D25W SULFIT PA BvD FREE CLINISOL SF 15 % PA BvD cysteine (l-cysteine) intravenous PA BvD (Cysteine HCl) solution

78 d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % NaCl) d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dex4 glucose * oral tablet,chewable (Dextrose) dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in Water) dextrose 20 % in water (d20w) (Dextrose 20 % in Water) dextrose 25 % in water (d25w) (Dextrose 25 % in Water) dextrose 40 % in water (d40w) (Dextrose 40 % in Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) dextrose 5 %-lactated ringers (Dextrose 5%- Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in Water) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 77

79 78 dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2 % NaCl) FREAMINE HBC 6.9 % PA BvD FREAMINE III 10 % PA BvD gluco burst * (Dextrose) glucose gel * (Dextrose) glucose * oral tablet,chewable (Dextrose) glutose 15 * (Dextrose) HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD insta-glucose * (Dextrose/Dextrin/ Maltose) INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD PERIKABIVEN PA BvD potassium chloride in lr-d5 (Potassium intravenous parenteral solution Chloride In Lr-D5) PREMASOL 10 % PA BvD PREMASOL 6 % PA BvD PROCALAMINE 3% PA BvD PROSOL 20 % PA BvD TRAVASOL 10 % PA BvD TROPHAMINE 10 % PA BvD TROPHAMINE 6% PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres)

80 79 clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidon e) clonidine transdermal patch weekly QL (4 per 28 (Catapres-Tts 1) 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly QL (8 per 28 (Catapres-Tts 1) 0.3 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) nasal decongestant (pe) * oral tablet 10 mg (Medi-Phenyl) NORTHERA PA; QL (180 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) sudogest pe * (Medi-Phenyl) wal-phed pe * (Medi-Phenyl) Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) ENTRESTO PA; QL (60 per 30 irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR ST valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT)

81 Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) captopril-hydrochlorothiazide (Captopril/Hydroch lorothiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydroc hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg (Cordarone) amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) lidocaine (pf) intravenous syringe (Lidocaine 50 mg/5 ml (1 %) HCl/PF) 80

82 lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) (Lidocaine HCl/D5w/PF) 81 mexiletine (Mexiletine HCl) MULTAQ procainamide injection (Procainamide HCl) propafenone oral capsule,extended release 12 hr (Rythmol SR) propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl)

83 propranolol oral capsule,extended release 24 hr (Inderal LA) propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro chlorothiazid) sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg (Cardizem CD) diltiazem hcl oral capsule,extended release 12 hr (Cardizem CD) diltiazem hcl oral capsule,extended release 24hr (Cardizem CD) diltiazem hcl oral tablet (Cardizem CD) diltiazem hcl oral tablet extended release 24 hr (Cardizem LA) dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 24 hr (Verelan) verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous 82

84 83 ADRENALIN 1 MG/ML VIAL SUV ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) adrenalin injection solution 1 mg/ml (1:1,000) (1ml) (Epinephrine) CORLANOR ST DEMSER digitek oral tablet 125 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 dobutamine in d5w intravenous PA BvD parenteral solution 1,000 mg/250 (Dobutamine ml (4,000 mcg/ml), 250 mg/250 ml HCl/D5W) (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose (Dopamine PA BvD intravenous solution HCl/D5W) dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate)

85 epinephrine 1 mg/ml ampul latexfree (Epinephrine) epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET MCG, 62.5 MCG milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose PA BvD (Milrinone intravenous piggyback 40 mg/200 Lactate/D5W) ml (200 mcg/ml) norepinephrine bitartrate (Levophed Bitartrate) papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) amlodipine-valsartan (Exforge) amlodipine-valsartan-hcthiazid (Exforge HCT) AZOR ST PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 PA BvD 84

86 CLEVIPREX INTRAVENOUS EMULSION felodipine (Felodipine) isradipine (Isradipine) nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 60 mg (Adalat CC) Diuretics amiloride oral (Midamor) amiloride-hydrochlorothiazide (Amiloride/Hydroc hlorothiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 (Chlorthalidone) mg DYRENIUM furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) hydrochlorothiazide oral tablet (Hydrochlorothiazi de) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral (Maxzide) tablet Dyslipidemics 85

87 86 amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral (Cholestyramine/A powder 4 gram spartame) cholestyramine-aspartame oral (Cholestyramine/A powder in packet 4 gram spartame) colestipol (Colestid) CRESTOR endur-acin * oral tablet extended release 500 mg (Slo-Niacin) fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lipogen * (Inositol/Choline/V it B Comp) lovastatin (Mevacor) niacin * oral capsule, extended release 500 mg (Niacin) niacin * oral tablet 100 mg, 50 mg, 500 mg (Slo-Niacin) niacin oral tablet extended release 24 hr (Niaspan) niacin * oral tablet extended release 500 mg (Slo-Niacin) niacinamide * oral tablet 500 mg (Niacinamide) omega-3 acid ethyl esters (Lovaza) PRALUENT PEN PA; QL (2 per 28 PRALUENT SYRINGE PA; QL (2 per 28 pravastatin (Pravachol) REPATHA SURECLICK PA; QL (3 per 28

88 87 REPATHA SYRINGE PA; QL (3 per 28 simvastatin (Zocor) QL (30 per 30 VASCEPA WELCHOL ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators BIDIL isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr (Imdur) minitran transdermal patch 24 hour QL (30 per 30 (Nitro-Dur) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 (Nitro-Dur) 0.4 mg/hr minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose (Nitroglycerin/D5 intravenous solution W) nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 QL (30 per 30 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) nitroglycerin transdermal patch 24 QL (60 per 30 (Nitro-Dur) hour 0.4 mg/hr NITROSTAT PROGLYCEM

89 Central Nervous System Agents Central Nervous System Agents 88 amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA PA; QL (60 per 30 caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release 12 hr (Kapvay) dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, QL (120 per 30 (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 dextroamphetamine-amphetamine QL (30 per 30 oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) dextroamphetamine-amphetamine QL (60 per 30 oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Adderall XR) flumazenil (Romazicon) guanfacine oral tablet extended release 24 hr (Intuniv) lithium carbonate oral capsule (Eskalith) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended release (Lithobid) lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic mg, 20 mg, 50 mg, 60 mg (Metadate Cd) QL (30 per 30 methylphenidate oral capsule, er QL (60 per 30 (Metadate Cd) biphasic mg

90 89 methylphenidate oral capsule,er QL (30 per 30 (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (60 per 30 (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 (Ritalin LA) biphasic mg methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet QL (90 per 30 (Ritalin-SR) extended release methylphenidate oral tablet QL (30 per 30 extended release 24hr 18 mg, 27 mg, 54 mg (Concerta) methylphenidate oral tablet QL (60 per 30 (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 STRATTERA tetrabenazine (Xenazine) PA; QL (112 per 28 XENAZINE PA; QL (112 per 28 Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 cyred (Desogen) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/ mg-mcg, (Desogen) mg drospirenone-ethinyl estradiol (Yaz)

91 ELLA ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D- Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) junel fe 24 (Loestrin Fe) kimidess (28) (Mircette) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 larin 24 fe (Loestrin Fe) levonorgestrel * 1.5 mg tablet (otc) (Plan B One-Step) QL (6 per 365 levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel * oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel-ethin estradiol oral tablet mg-mcg, mg, (6)/75-40 (5)/125-30(10) (Amethyst) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month mg-mcg levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month (Levonorgestrel- Ethin Estradiol) (Amethyst) QL (91 per 84 (Levonorgestrel- QL (91 per 84 Ethin Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 next choice one dose 1.5 mg tb (rx) QL (6 per 365 (Plan B One-Step) 1.5 mg norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, mg-mcg (Loestrin) norethindrone-e.estradiol-iron (Loestrin Fe) 90

92 norethindrone-e.estradiol-iron oral tablet 1-20(5)/1-30(7) /1mg-35mcg (Loestrin Fe) (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet mg-mcg, mgmcg, /1-35 mg-mcg/mg-mcg, (Modicon) 0.5/0.75/1 mg- 35 mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 opcicon one-step * (Plan B One-Step) QL (6 per 365 PLAN B ONE-STEP * 3 $0 QL (6 per 365 setlakin (Levonorgestrel- QL (91 per 84 Ethin Estradiol) tarina fe (Loestrin Fe) Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) adt robitussin peak cld dm max * (G-Zyncof) adult nasal decongestant * (Pseudoephedrine HCl) adult robitussin lingering cld * (Dextromethorphan Hbr) adult robitussin peak cold dm * (G-Zyncof) adult wal-tussin * (Robitussin Mucus-Chest Congest) adult wal-tussin dm max * (G-Zyncof) alka-seltzer plus mucus-conges * (Guaifenesin/Dextr omethorphan) 91

93 92 alka-seltzer plus sinus-cough * (D- Methorphan/Pe/Ac etaminophen) ambi 10peh-4cpm-20dm * (Dm/Phenyleph/Ch lorpheniramine) ambi 20dm-4cpm * (Coricidin Hbp) ambi 40pse-400gfn-20dm * (Poly-Vent Dm) ambi 60pse-4cpm-20dm * (D-Methorphan Hb/P-Ephed HCl/Cp) benzonatate * (Zonatuss) 3 $0 bio-dtuss dmx * (D-Methorphan Hb/P-Epd HCl/Bpm) bionel * (Guaifenesin/Dm/P seudoephedrine) bionel pediatric * (Trispec Pse) biospec dmx * (G-Zyncof) bromphenex dm * (D-Methorphan Hb/P-Epd HCl/Bpm) brompheniramine-pseudoeph-dm * (D-Methorphan Hb/P-Epd HCl/Bpm) brompheniram-phenylephrine-dm * (Ala-Hist Dm) 3 $0 broncotron-s * (G-Zyncof) cardec dm (phenyleph-chlorphn) * (Accuhist Pdx) cheratussin ac * (M-Clear Wc) cheratussin dac * (Tusnel C) chest congestion relief + dm * (Allfen Dm) chest congestion relief d * (Poly-Vent Ir) chest congestion relief pe * (Maxiphen) child cough & sore throat * (D-Methorphan Hb/Acetaminophen )

94 child mucinex chest congestion * (Robitussin Mucus-Chest Congest) child mucus relief cough * (G-Zyncof) child plus cough & runny nose * (Dextromethorphn/ Acetaminoph/Cp) child triaminic cough-congest * (Cough Formula Dm) child wal-tussin cough relief * (Dextromethorphan Hbr) children's chest congestion * CHILDREN'S DIMETAPP COLD &FLU * (Robitussin Mucus-Chest Congest) children's flu relief * (Childrens Tylenol Plus Cold) children's mucinex cough * (G-Zyncof) children's silfedrine * (Pseudoephedrine HCl) children's sudafed * (Pseudoephedrine HCl) children's sudafed pe cough * (Dextromethorphan /Phenylephrine) chlophedianol-guaifenesin * (Vanacof G) chlorpheniramine-phenyleph-dm * (Dm/Phenyleph/Ch lorpheniramine) codituss dm * (Pyrilamine/Pe/De xtromethorphan) cold multi-symptom * (Comtrex Cold and Cough) cold multi-symptom day/night * (Dm Hb/Pe/Acetaminop hen/chlorph) 93

95 cold multi-symptom nighttime * (Dm/Pe/Acetamino phen/doxylamine) cold relief m/s day/night * (Dm Hb/Pe/Acetaminop hen/chlorph) (Dcold-flu relief * oral liquid Methorphan/Aceta 1,000 mg/30 ml min/doxylamn) cold-flu relief, day/night * (Vicks Dayquil- Nyquil) congestac * (Poly-Vent Ir) coricidin hbp * oral capsule (Guaifenesin/Dextr omethorphan) cough & cold * oral (Coricidin Hbp) cough & runny nose * oral liquid 1- (Vicks Children'S 5 mg/5 ml Nyquil) creo-terpin (dm-guaifenesin) * (Cough Formula Dm) daytime cold & cough * (Triaminic) daytime cold-flu * (D- Methorphan/Pe/Ac etaminophen) day-time cough * (Dextromethorphan Hbr) daytime mucus relief dm * (G-Zyncof) daytime-nighttime * (Vicks Dayquil- Nyquil) daytime-nighttime cold-flu * (Dm/Pe/Acetamino phen/doxylamine) daytime-nighttime cough * (Dextromethorphan Hb/Doxylamine) decongestant cough * (Trispec Pse) delsym cough+chest congest dm * (G-Zyncof) despec-dm (pseudoeph-dm-guaif) * oral tablet mg (Poly-Vent Dm) 94

96 95 dexchlorphen-pse-chlophedianol * (Panatuss Ped) dextromethorphan polistirex * (Delsym) diabetic siltussin das-na * (Robitussin Mucus-Chest Congest) diabetic tussin dm * (G-Zyncof) diabetic tussin ex * oral (Robitussin Mucus-Chest Congest) dimaphen dm * (Brompheniram/Ph enylephrine/dm) (D-Methorphan d-methorphan hb-p-epd hcl-bpm * Hb/P-Epd oral syrup mg/5 ml HCl/Bpm) 3 $0 dm-phenyleph-chlorpheniramine * (Dm/Phenyleph/Ch oral drops mg/ml lorpheniramine) ed bron gp * (Despec) entre-cough * (Trispec Pse) exefen dmx * (Poly-Vent Dm) expectorant dm * oral liquid (G-Zyncof) expectorant max strength * (Dextromethorphan /Pseudoephed) expectorant * oral (Robitussin Mucus-Chest Congest) flu formula daytime-nighttime * (Dm/Pe/Acetamino ph/diphenhydram) flu severe cold-congestion * (Theraflu) geri-tussin dm * (Cough Formula Dm) guaiatussin ac * (M-Clear Wc) guaifenesin dac * (Tusnel C) guaifenesin * oral tablet 200 mg (Allfen) guaifenesin * oral tablet extended release 12hr (Mucinex)

97 head congestion day-night * Name of Drug hydrocodone bit-homatrop me-br * oral syrup mg/5 ml hydrocodone-chlorpheniramine * hydrocodone-homatropine * oral syrup mg/5 ml hydrocodone-homatropine * oral tablet (Dm Hb/Pe/Acetaminop hen/chlorph) (Hydrocodone Bit/Homatrop Me- Br) (Hydrocodone/Chl orphen P-Stirex) (Hydrocodone Bit/Homatrop Me- Br) 3 $0 3 $0 3 $0 (Tussigon) 3 $0 infants' non-aspirin cold * (Dm/Pseudoephed/ Acetaminophen) intense cough reliever * oral liquid (G-Zyncof) kidkare cough/cold * (D-Methorphan Hb/P-Ephed HCl/Cp) liquibid d-r * (Maxiphen) lohist peb dm * (Ala-Hist Dm) lortuss ex * oral syrup (Tusnel C) mar-cof bp * (Bromphenira/Pseu doephed/codein) 3 $0 mar-cof cg * (M-Clear Wc) 3 $0 maximum strength flu * (Coricidin Hbp) medi-brom * (D-Methorphan Hb/P-Epd HCl/Bpm) mesehist dm * (D-Methorphan Hb/P-Ephed HCl/Cp) mucinex fast-max dm max * (G-Zyncof) mucus dm * (Mucinex Dm) mucus dm max * (Mucinex Dm) 96

98 mucus relief * oral tablet 400 mg (Allfen) multi-symptom cold night time * (Theraflu) multi-symptom cold-cough * (Dm Hb/Pseudoephed/A cetamin/cp) nasal & sinus decongestant * (Sudafed 12-Hour) neo-tuss * (G-Zyncof) NEXAFED * night time cold-flu * oral (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/Pnight time cold-flu relief * oral Ephed/Acetaminop liquid h/doxylam) (Dm/Pnight time * oral capsule Ephed/Acetaminop h/doxylam) nighttime cold-flu * (D- Methorphan/Aceta min/doxylamn) nighttime cough * (Dextromethorphan Hb/Doxylamine) nite time cold-flu * (D- Methorphan/Aceta min/doxylamn) nite time-d cold-flu relief * (Dm/P- Ephed/Acetaminop h/doxylam) nohist-dm * (Dm/Phenyleph/Ch lorpheniramine) non-aspirin cold * (Dm Hb/Pseudoephed/A cetamin/cp) non-aspirin flu * oral tablet mg (Dm/Pseudoephed/ Acetaminophen) 97

99 pecgen dmx * oral liquid mg/5 ml pedia relief * pedia relief infant * pediacare multi-symptom cold * phenylhistine dh * poly-tussin * promethazine-codeine * promethazine-dm * promethazine-phenyleph-codeine * pseudoephedrine hcl * oral (G-Zyncof) (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Promethazine/Phe nyleph/codeine) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 pseudoephedrine hcl * oral (Sudafed 12-Hour) q-tapp dm * (D-Methorphan Hb/P-Epd HCl/Bpm) q-tussin * (Robitussin Mucus-Chest Congest) q-tussin dm * (Cough Formula Dm) refenesen * (Allfen) refenesen pe * (Maxiphen) relcof c * (M-Clear Wc) 3 $0 REZIRA * 3 $0 98

100 robafen * (Robitussin Mucus-Chest Congest) robafen cough * (Dextromethorphan Hbr) robafen dm * (Cough Formula Dm) robitussin cough-chest-cong dm * (Guaifenesin/Dextr omethorphan) ROBITUSSIN LONG-ACTING * robitussin pediatric * (Dextromethorphan Hbr) rydex * (Bromphenira/Pseu doephed/codein) safe tussin dm * (G-Zyncof) scot-tussin dm * (Vicks Children'S Nyquil) scot-tussin expectorant * (Robitussin Mucus-Chest Congest) siltussin dm das * (G-Zyncof) siltussin sa * (Robitussin Mucus-Chest Congest) sudogest * (Sudafed 12-Hour) suphedrin * oral (Pseudoephedrine HCl) suphedrine pe day-night * (Diphenhydram/Pe/ Dm/Acetamin/Gg) suphedrine severe cold max str * (Dm/Pseudoephed/ Acetaminophen) THERAFLU DAYTIME COLD- COUGH * THERAFLU NIGHTTIME SEVERE COLD * 99

101 THERAFLU SEVERE COLD- COUGH * triacting m-sym cold/cough * triaminic cold & cough (pe) * triaminic cough-nasal congesti * TRIAMINIC COUGH-SORE THROAT * (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Phenylephrine) (Dextromethorphan /Pseudoephed) tri-dex pe * (Dm/Phenyleph/Ch lorpheniramine) trigofen dm * (Accuhist Pdx) trymine cg * (M-Clear Wc) tusnel diabetic * (G-Zyncof) TUSNEL PEDIATRIC * ORAL LIQUID tussin cf cough-cold * (Giltuss) tussin cf * oral (Guaifenesin/Dm/P seudoephedrine) tussin cold-congestion * (Guaifenesin/Dm/P seudoephedrine) tussin cough (dm only) * oral (Dextromethorphan Hbr) tussin dm cough & chest * oral liquid mg/5 ml (G-Zyncof) tussin dm * oral (Cough Formula Dm) tussin maximum strength cough * (Dextromethorphan Hbr) tussin pe * oral liquid (Despec) valu-tapp dm * (D-Methorphan Hb/P-Epd HCl/Bpm) 100

102 vicks dayquil cough * (Dextromethorphan Hbr) vicks nature fusion cough * (Dextromethorphan Hbr) virdec dm * (Accuhist Pdx) wal-phed * oral tablet 30 mg (Sudafed 12-Hour) wal-phed pe day-night * (Diphenhydram/Pe/ Dm/Acetamin/Gg) wal-tussin cough * (Dextromethorphan Hbr) wal-tussin cough & cold cf * (Giltuss) wal-tussin dm * (Cough Formula Dm) zephrex-d * (Sudafed 12-Hour) ZONATUSS * 3 $0 zyncof * oral liquid (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous membrane (Peridex) PHOS-FLUR * DENTAL SOLUTION pilocarpine hcl oral (Salagen) PREVIDENT 5000 SENSITIVE * 3 $0 triamcinolone acetonide dental (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) acne medication * topical gel 10 % (Benzoyl Peroxide) acne medication * topical lotion 10 % (Benzoyl Peroxide) 101

103 102 ACNE MEDICATION * TOPICAL LOTION 5 % acne-clear * (Benzoyl Peroxide) acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Aluminum Chloride) amlactin * topical lotion (Lac-Hydrin Twelve) ammonium lactate * 12% cream (Ammonium fragrance free (otc) Lactate) ammonium lactate * 12% lotion (Lac-Hydrin (otc) Twelve) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE benzoyl peroxide * 10% gel aqueous (rx) (Benzac Ac) 3 $0 benzoyl peroxide * topical gel 10 %, 5 % (Benzoyl Peroxide) BETADINE SPRAY * calcipotriene topical cream (Dovonex) calcipotriene topical ointment (Calcipotriene) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CASTELLANI PAINT MODIFIED * CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) PA NSO COSENTYX PEN PA NSO COSENTYX PEN (2 PENS) PA NSO

104 DRYSOL DAB-O-MATIC FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) geri-hydrolac * topical (Lac-Hydrin Twelve) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) LACTINOL HX * lobana bath * (Mineral Oil) mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL silver nitrate applicators (Silver Nitrate Applicator) skin treatment * (Lac-Hydrin Twelve) VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM QL (15 per 30 Dermatological Antibacterials bacitracin * topical (Bacitracin) 103

105 104 bacitraycin plus * topical ointment 500 unit/gram (Bacitracin) clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical (Erythromycin solution Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) alclometasone topical ointment (Alclometasone Dipropionate) aquanil hc * (Cortizone-10)

106 105 beta-hc * (Cortizone-10) betamethasone dipropionate topical cream (Diprosone) betamethasone dipropionate topical (Betamethasone lotion Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical (Betamethasone cream Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical (Betamethasone lotion Valerate) betamethasone valerate topical (Betamethasone ointment Valerate) betamethasone, augmented topical cream (Diprolene AF) betamethasone, augmented topical (Betamethasone gel Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical ointment (Diprolene) clobetasol propionate topical (Clobetasol solution 0.05 % Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm)

107 hydrocortisone acetate-aloe * Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) 106 CORDRAN TOPICAL OINTMENT cortizone-10 * topical cream (Hydrocortisone) CORTIZONE-10 * TOPICAL LOTION cortizone-10 * topical ointment (Hydrocortisone) dermarest eczema (hydrocort) * (Cortizone-10) desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hydrocortisone * 1% cream maximum strength (otc) (Hydrocortisone) hydrocortisone * 1% lotion (rx) (Rederm) 3 $0 hydrocortisone * 1% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera (Hydrocortisone topical gel Acetate/Aloe V) hydrocortisone acetate * topical (Hydrocortisone cream 1 % Acetate) (Hydrocortisone PA; AGE (Min 2 Years)

108 hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Cortizone-10) 3 $0 hydrocortisone topical lotion 2 %, 2.5 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream Valerate) hydrocortisone valerate topical ointment (Westcort) hydroskin * topical lotion (Cortizone-10) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) recort plus * (Hydrocortisone) tacrolimus topical (Protopic) triamcinolone acetonide topical (Triamcinolone cream Acetonide) triamcinolone acetonide topical lotion (Kenalog) triamcinolone acetonide topical ointment %, 0.05 %, 0.1 %, 0.5 % (Triderm) 107

109 triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical cream (Retin-A) PA tretinoin topical gel 0.01 %, PA (Retin-A) % Scabicides And Pediculicides lice cream rinse * (Nix) lice killing * (Piperonyl Butoxide/Pyrethrin s) lice treatment (permethrin) * (Nix) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA- FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE 108

110 INSULIN SYRINGE-NEEDLE U- 100 SYRINGE PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U Disinfectants (For Non-Dermatologic Use) Disinfectants (For Non-Dermatologic Use) iodine * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA PA CIMZIA POWDER FOR PA RECONST CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS QL (30 per 30 lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD

111 110 VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 ZENPEP Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) alaway * (Zaditor) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette % F) artificial tears * ophthalmic drops % artificial tears * ophthalmic drops % artificial tears * ophthalmic ointment (Tears Naturale) (Polyvinyl Alcohol/Povidone) (Petrolat,Wht/Min Oil/Sod Chl) artificial tears(glycerin-peg) * (Glycerin/Propylen e Glycol) artificial tears(hypromellose) * (Genteal Mild To Moderate) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal (Astepro) QL (30 per 25 azelastine ophthalmic (Optivar) bion tears (pf) * (Dextran 70/Hypromellose/P F)

112 111 carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN deep sea nasal * (Little Remedies) dristan long lasting * (Oxymetazoline HCl) epinastine (Elestat) eq gentle * (Genteal Mild To Moderate) GENTEAL MILD TO MODERATE * GENTEAL GEL * GENTEAL MILD * GENTEAL SEVERE * homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) isopto tears * (Genteal Mild To Moderate) ketotifen fumarate * (Zaditor) LACRISERT liquitears * (Polyvinyl Alcohol) lubricant dry eye relief * (Carboxymethylcel lulose Sodium) lubricant eye (cmc-glycer)(pf) * (Carboxymethylcel l/glycerin/pf) lubricant eye (cmc-glycerin) * (Refresh Optive) QL (30 per 28 QL (15 per 10

113 112 lubricant eye (polyv alcohol) * (Polyvinyl Alcohol) lubricant eye (propyl glycol) * (Propylene Glycol) lubricant eye drops * ophthalmic (Carboxymethylcel dropperette lulose Sodium) lubricant eye drops * ophthalmic drops (Refresh Tears) lubricant gel * (Carboxymethylcel l/hypromellose) lubricating drops * (Refresh Optive) lubrifresh pm * (Genteal Pm) muro 128 * (Sodium Chloride) naphazoline (Naphazoline HCl) nasal decongestant (oxymetazl) * (Afrin) natural balance * (Genteal Mild To Moderate) natural tears (pf) * (Dextran 70/Hypromellose/P F) nature's tears * (Genteal Mild To Moderate) neo-synephrine 12 h spr (oxym) * (Oxymetazoline HCl) nighttime relief eye * (Petrolat,Wht/Min Oil/Sod Chl) ocean nasal * (Little Remedies) olopatadine (Patanase) QL (30.5 per 30 PATADAY ST PATANOL ST phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluo rescein Sod)

114 pure & gentle eye * (Genteal Mild To Moderate) REFRESH CLASSIC (PF) * REFRESH LACRI-LUBE * REFRESH LIQUIGEL * REFRESH OPTIVE * retaine cmc * (Carboxymethylcel lulose Sodium) saline mist * (Little Remedies) sea soft nasal mist * (Little Remedies) sochlor * ophthalmic (Sodium Chloride) sodium chloride * ophthalmic (Sodium Chloride) STERILE LUBRICANT * tears again * ophthalmic drops (Polyvinyl Alcohol) tears again * ophthalmic ointment (Lanolin/Min Oil/Petrolat, Wht) TEARS NATURALE II * tetracaine hcl (Tetcaine) ultra fresh pm * (Lanolin/Min Oil/Petrolat, Wht) vicks qlearquil(oxymetazoline) * (Oxymetazoline HCl) vicks sinex 12-hour * (Afrin) wal-zyr (ketotifen) * (Zaditor) zyrtec itchy eye drops (keto) * (Zaditor) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy xin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) 113

115 sulfacetamide-prednisolone dnisolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZYLET 114 COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic (Quixin) MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-polymyxin (Neomycin Su/Bacitra/Polymy xin) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) REFRESH OPTIVE ADVANCED * sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide drops 10 % Sodium) (Sulfacetamide/Pre

116 115 Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate ophthalmic (Dexasol) diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (16 per 30 ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX QL (34 per 28 NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate (Prednisolone Sod ophthalmic Phosphate) PROLENSA RESTASIS QL (60 per 30 Gastrointestinal Agents Antiflatulents anti-gas maximum strength * (Gas-X) bicarsim forte * (Simethicone) gas free extra strength * (Gas-X) gas relief 80 * (Gas-X) gas relief extra strength * oral (Gas-X) gas relief * oral (Gas-X) gas-x ultra-strength * (Gas-X) mi-acid gas relief * (Gas-X) mylanta gas * (Gas-X) mytab gas * (Gas-X)

117 116 mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Gas-X) simethicone * oral (Infants' Mylicon) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) acid relief (cimetidine) * (Tagamet Hb) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine hcl oral (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 (Rx Product Only) (Tagamet) mg, 400 mg, 800 mg cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole * dr 15 mg capsule 2x14 day course (otc) (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol (Cytotec) omeprazole magnesium * (Omeprazole Magnesium) omeprazole oral capsule,delayed release(dr/ec) (Prilosec) omeprazole * oral tablet,delayed release (dr/ec) (Omeprazole) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) 3 $0 oral capsule mg-gram pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) PRILOSEC OTC *

118 117 pub famotidine * 20 mg tablet max strength (otc) (Pepcid Ac) ra omepraz-bicarb 20-1,100 cap 3x14 day course (otc) (Zegerid Otc) ranitidine 150 mg tablet maximum strength (otc) (Zantac) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg ranitidine hcl * oral tablet 75 mg (Zantac) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) wal-zan 75 * (Zantac) zantac 75 * (Zantac) Gastrointestinal Agents, Other acid gone antacid * (Gaviscon) almacone * oral suspension (Maalox Maximum Strength) almacone-2 * (Maalox Maximum Strength) aluminum hydroxide gel * oral (Aluminum suspension 320 mg/5 ml Hydroxide) AMITIZA QL (60 per 30 (Calcium antacid anti-gas * oral Carbonate/Simethi cone) antacid extra-strength * oral tablet,chewable 300 mg (750 mg) (Tums) antacid * oral (Tums) antacid plus anti-gas * oral (Maalox Maximum suspension Strength) anti-diarrheal * (Pepto-Bismol) anti-diarrheal (loperamide) * oral capsule (Loperamide HCl)

119 118 anti-diarrheal (loperamide) * oral (Imodium A-D) bismatrol * oral suspension 262 mg/15 ml (Pepto-Bismol) bismatrol * oral tablet,chewable (Pepto-Bismol) BUPHENYL ORAL TABLET calci-chew * (Tums) calcium carbonate * oral tablet,chewable 500 mg calcium (Tums) (1,250 mg) CALCIUM CARBONATE- VITAMIN D3 * ORAL TABLET,CHEWABLE MG-UNIT cal-gest antacid * (Tums) children's soothe * (Tums) CHOLBAM comfort gel extra strength * (Maalox Maximum Strength) cromolyn oral (Gastrocrom) diamode * (Imodium A-D) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Maalox Maximum Strength) foaming antacid * (Gaviscon) gelusil antacid & anti-gas * oral (Maalox Maximum suspension Strength) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul)

120 119 imodium a-d * oral liquid (Loperamide HCl) IMODIUM A-D * ORAL TABLET kaopectate (bismuth subsalicy) * (Pepto-Bismol) lactulose oral solution (Lactulose) loperamide oral (Loperamide HCl) loperamide * oral (Loperamide HCl) maalox advanced * oral suspension (Maalox Maximum Strength) MAGNEBIND 300 * magnesium oxide * oral capsule 500 mg (Uromag) magnesium oxide * oral tablet 250 mg, 400 mg, 500 mg (Magox 400) masanti double strength * (Maalox Maximum Strength) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) mgo * (Magox 400) mi-acid * oral suspension (Maalox Maximum Strength) mi-acid * oral tablet,chewable (Rolaids) mintox * (Maalox Maximum Strength) mintox maximum strength * (Maalox Maximum Strength) mintox plus * (Almacone) MOVANTIK QL (30 per 30 NUTRESTORE pep-t-med * (Pepto-Bismol) phillips * (Magox 400) RELISTOR SUBCUTANEOUS PA; QL (28 per 28

121 RELISTOR SUBCUTANEOUS ri-gel ii * (Maalox Maximum Strength) ri-mox * (Maalox Maximum Strength) sodium bicarbonate * oral tablet (Sodium 650 mg Bicarbonate) soothe (bismuth subsalicylate) * (Bismuth oral Subsalicylate) soothe regular strength * (Pepto-Bismol) stomach relief * oral (Bismuth Subsalicylate) ultra strength antacid * (Tums) ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives alophen * (Dulcolax) bisac-evac * (Dulcolax) bisacodyl * oral (Dulcolax) bisacodyl * rectal (Dulcolax) biscolax * (Dulcolax) clearlax * oral (Gavilax) colace * oral capsule 100 mg (Sof-Lax) doc-q-lace * (Sof-Lax) docu * (Docusate Sodium) docusate sodium * oral (Docusate Sodium) docusol * (Docusate Sodium) dok * oral capsule (Sof-Lax) dok * oral tablet (Docusate Sodium) dulcolax stool softener (dss) * (Sof-Lax) enema disposable * (Enema) enema * rectal enema * 19-7 gram/118 ml (Enema) PA; QL (28 per

122 enemeez * (Docusate Sodium) enemeez plus * (Docusol Plus) equalactin * (Calcium Polycarbophil) fiber (calcium polycarbophil) * (Fibercon) fiber laxative (methylcellulo) * (Citrucel) fiber smooth * (Psyllium Seed) fiber therapy (psyllium/sugar) * (Psyllium Seed (With Sugar)) fiber therapy * oral powder 2 gram/19 gram (Citrucel) fiber therapy * oral tablet (Citrucel) fiber-lax * (Fibercon) FLEET BISACODYL * gentlelax * (Gavilax) glycolax * oral powder (Gavilax) 3 $0 healthylax * (Miralax) hydrocil instant * (Psyllium Seed) konsyl (sugar) * oral (Metamucil) konsyl fiber * (Fibercon) konsyl sugar-free * oral powder in packet (Psyllium Husk) laxative peg 3350 * oral powder (Gavilax) laxative peg 3350 * oral powder in packet (Miralax) milk of magnesia * (Milk Of Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP natural fiber laxative therapy * (Psyllium Seed (With Sugar)) oral saline laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) peg 3350-electrolytes (Golytely) 121

123 122 PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) peri-colace * (Sennosides/Docus ate Sodium) phillips liqui-gels * (Sof-Lax) phosphate laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder Glycol 3350) polyethylene glycol 3350 * oral powder in packet (Miralax) promolaxin * (Docusate Sodium) purelax * oral powder (Gavilax) purelax * oral powder in packet (Miralax) reguloid * oral powder (Psyllium Seed (With Sugar)) senexon * oral syrup (Sennosides) senexon * oral tablet (Senokot) senna lax * (Senokot) senna laxative * oral tablet 8.6 mg (Senokot) senna * oral capsule (Sennosides) senna * oral syrup 8.8 mg/5 ml (Sennosides) senna with docusate sodium * (Sennosides/Docus ate Sodium) senokot-s * (Sennosides/Docus ate Sodium) silace * oral liquid (Docusate Sodium) silace * oral syrup (Colace) smoothlax * oral (Miralax) sodium chloride-nahco3-kcl-peg (Nulytely with oral recon soln 420 gram Flavor Packs) stool softener * oral capsule 240 mg (Surfak)

124 123 the magic bullet * (Dulcolax) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) CALCIUM ACETATE * ORAL TABLET 668 MG (169 MG CALCIUM) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) calphron * (Calcium Acetate) PHOSLYRA RENAGEL RENVELA sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr (Ditropan XL) tolterodine oral capsule,extended release 24hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended release 24hr (Sanctura XR)

125 124 trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS EXJADE FERRIPROX JADENU sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) (Sodium Thiosulfate) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) PA; QL (30 per 30 PA; QL (300 per 30 PA; QL (150 per 30 PA; QL (300 per 30 PA; QL (150 per 30

126 125 danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo- PA Testosterone) testosterone enanthate (Delatestryl) PA; QL (5 per 28 testosterone transdermal gel in PA; QL (150 per 30 (Androgel) packet 1 % (25 mg/2.5gram) Estrogens And Antiestrogens COMBIPATCH PA-HRM; QL (8 per 28 DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) estradiol transdermal patch weekly (Climara) PA-HRM; QL (8 per 28 PA-HRM; QL (4 per 28 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM ESTRASORB PA-HRM; QL (97.44 per 28 estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 MENEST PA-HRM norethindrone ac-eth estradiol oral PA-HRM (Femhrt) tablet 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista)

127 VAGIFEM QL (18 per 28 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone PA BvD injection Sod Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone PA BvD Sod Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ PA BvD (A-Methapred) injection recon soln 125 mg, 40 mg methylprednisolone sodium succ PA BvD (A-Methapred) intravenous prednisolone sodium phosphate PA BvD (Orapred) oral solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (15 per 30 desmopressin nasal (Desmopressin QL (15 per 30 Acetate) desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA 126

128 127 HUMATROPE PA INCRELEX NORDITROPIN FLEXPRO PA NUTROPIN PA NUTROPIN AQ NUSPIN PA NUTROPIN AQ PA SUBCUTANEOUS octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml (Sandostatin) octreotide acetate injection solution (Octreotide 50 mcg/ml Acetate) octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE PA PREGNYL SAIZEN PA SAIZEN CLICK.EASY PA SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS PA RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT QL (1 per 28 SOMAVERT SUPPRELIN LA QL (1 per 360 TEV-TROPIN PA vasopressin (Pitressin) ZOMACTON PA Progestins DEPO-PROVERA QL (10 per 28 INTRAMUSCULAR SOLUTION medroxyprogesterone QL (1 per 84 (Depo-Provera) intramuscular suspension

129 128 medroxyprogesterone (Medroxyprogester intramuscular syringe one Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST QL (1 per 84 ASTAGRAF XL PA BvD AUBAGIO PA; QL (28 per 28 azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF PA BvD NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL PA ENBREL SURECLICK PA FLEBOGAMMA DIF PA BvD

130 129 GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD GAMMAPLEX PA BvD GAMUNEX-C INJECTION PA BvD SOLUTION HUMIRA PA HUMIRA PEN PA HUMIRA PEN CROHN'S-UC-HS PA START HYPERRAB S/D (PF) HYQVIA PA BvD ILARIS (PF) PA IMOGAM RABIES-HT (PF) KINERET PA; QL (18.76 per 28 leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD OCTAGAM PA BvD ORENCIA PA; QL (4 per 28 ORENCIA (WITH MALTOSE) PA PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RAPAMUNE ORAL TABLET 1 PA BvD MG, 2 MG RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; LA; QL (15 per 28 ZORTRESS PA BvD; QL (120 per 30

131 130 Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD ENGERIX-B PEDIATRIC (PF) PA BvD GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE PA BvD (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF)

132 131 MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) PA BvD ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED PA BvD (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) QL (1 per 365 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron (Alosetron HCl) APRISO

133 132 ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) water for irrigation, sterile (Water For Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution (Alendronate QL (300 per 28 Sodium) alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 (Fosamax) mg calcitonin (salmon) (Miacalcin) QL (3.7 per 28 calcitriol intravenous solution 1 PA BvD; (PA for (Calcitriol) mcg/ml ESRD Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only)

134 133 doxercalciferol oral (Hectorol) etidronate disodium (Etidronate Disodium) PA BvD; (PA for ESRD Only) FORTEO PA; QL (2.4 per 28 FORTICAL QL (3.7 per 28 ibandronate intravenous solution (Ibandronate Sodium) PA BvD; (PA for ESRD Only); QL (3 per 84 ibandronate intravenous syringe (Boniva) PA BvD; QL (3 per 84 ibandronate oral (Boniva) QL (1 per 28 MIACALCIN INJECTION PA BvD; (PA for ESRD Only) NATPARA PA; QL (2 per 28 paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL (1 per 180 risedronate oral tablet 150 mg (Actonel) QL (1 per 28 XGEVA PA; QL (1.7 per 28 ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents (Zoledronic Acid/Mannitol and Water) (Reclast) QL (100 per 300

135 allopurinol (Zyloprim) amifostine crystalline (Amifostine Crystalline) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST BENLYSTA INTRAVENOUS PA RECON SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) BOTOX INJECTION RECON PA; QL (4 per 90 SOLN 100 UNIT BOTOX INJECTION RECON PA; QL (1 per 90 SOLN 200 UNIT buspirone (Buspirone HCl) CERDELGA PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Proben ecid) COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE douche vinegar & water extra * (Acetic Acid) droperidol injection solution (Droperidol) 134 ACTEMRA INTRAVENOUS ACTEMRA SUBCUTANEOUS ACTIMMUNE PA; QL (40 per 30 PA; QL (3.6 per 28

136 levoleucovorin calcium Calcium) mesna (Mesnex) MESNEX ORAL 135 ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS ST extra cleansing douche * (Acetic Acid) feminine care douche * (Acetic Acid) finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) FUSILEV GILENYA PA; QL (28 per 28 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral solution 10 PA-HRM (Hydroxyzine HCl) mg/5 ml hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 LEMTRADA PA; QL (9.6 per 365 leucovorin calcium injection recon (Leucovorin soln 100 mg, 200 mg, 350 mg Calcium) leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine PA BvD; (PA for (With Sugar)) ESRD Only) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) (Levoleucovorin

137 136 MESTINON ORAL SYRUP MINERAL OIL * mineral oil light * (Mineral Oil) morrhuate sodium (Sodium Morrhuate) OTEZLA OTEZLA STARTER PLEGRIDY ST probenecid (Probenecid) PROCYSBI pyridostigmine bromide (Mestinon) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIMPONI ARIA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " summer's eve disposable douche * vaginal solution (Acetic Acid) PA; QL (60 per 30 PA; QL (60 per 30 PA; QL (12 per 28 PA; QL (3 per 28 PA; QL (0.5 per 28 PA; QL (3 per 28 PA; QL (0.5 per 28 PA

138 137 summers eve extra cleansing * (Acetic Acid) SUSPENDOL-S * SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG PA; QL (14 per 30 PA; QL (60 per 30 THALOMID PA NSO; QL (60 per 30 TYBOST QL (30 per 30 ULORIC ST; QL (30 per 30 XELJANZ PA; QL (60 per 30 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic (Betaxolol HCl) bimatoprost (Bimatoprost) brimonidine (Alphagan P) (drops: 0.15%, 0.20%) COMBIGAN dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan)

139 138 levobunolol (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming solution (Timoptic-Xe) TRAVATAN Z QL (2.5 per 25 travoprost (benzalkonium) (Travoprost QL (2.5 per 25 (Benzalkonium)) Replacement Preparations Replacement Preparations ca-d3-mag ox-zinc-cop-mang-bor * oral tablet,chewable calcionate * (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Calcium Glubionate) calcitrate * (Calcium Citrate) calcitrate-vitamin d * (Citracal-Vitamin D) calcium d (d3) * (Os-Cal 500+D) calcium d * oral tablet 500 mg(1,250mg) -400 unit (Os-Cal 500+D) calcium 500 with d * (Os-Cal 500+D) calcium 600 * (Caltrate 600) calcium d(3) * oral capsule (Calcium Carbonate/Vitamin D3) calcium d(3) * oral tablet (Os-Cal 500+D)

140 calcium 600 with vitamin d3 * oral calcium carbonate * oral calcium carbonate * oral tablet 260 mg calcium (648 mg) calcium carbonate-vitamin d2 * calcium carbonate-vitamin d3 * oral capsule 600 mg(1,500mg) -100 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * oral tablet calcium carbonate-vitamin d3 * oral tablet,chewable 500 mg(1,250mg) -400 unit (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Caltrate 600) (Calcium Carbonate/Vitamin D2) (Calcium Carbonate/Vitamin D3) (Os-Cal 500+D) (Os-Cal 500+D) calcium chloride intravenous (Calcium Chloride) calcium citrate-vitamin d3 * oral (Citracal-Vitamin tablet mg-unit D) calcium gluconate intravenous (Calcium Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg) Gluconate) calcium lactate * oral tablet 84 mg (648 mg), 84 mg (650 mg) (Calcium Lactate) calcium+d * oral tablet (Os-Cal 500+D) CALTRATE D * CALTRATE D VIT D3 (800) * CENTRUM PRO NUTRIENTS * citracal + d maximum * (Citracal-Vitamin D) PA BvD; (PA for ESRD Only) 139

141 140 citric acid-sodium citrate (Citric Acid/Sodium Citrate) citrus calcium * oral tablet (Citracal-Vitamin D) coral calcium * oral tablet (Caltrate 600) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) enfalyte * (Pedialyte) hi-cal plus vit d * (Os-Cal 500+D) HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KELP (IODINE) * KLOR-CON klor-con 10 (Potassium Chloride) KLOR-CON 8 klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) klor-con sprinkle (Micro-K) KLOR-CON/EF liquid calcium with vitamin d * (Calcium Carbonate/Vitamin D3) mag 64 * (Magnesium Chloride)

142 141 mag-delay * (Magnesium Chloride) mag-g * (Magonate) magnesium (oxide/aa chelate) * (Magnesium Oxide/Mag Aa Chelate) magnesium chloride injection (Magnesium Chloride) magnesium gluconate * oral tablet (Magonate) magnesium * oral tablet 250 mg (Magnesium) magnesium sulf in 0.45% nacl (Magnesium Sulf In 0.45% NaCl) magnesium sulfate in d5w (Magnesium intravenous piggyback 1 gram/100 Sulfate/D5W) ml, 4 gram/100 ml magnesium sulfate in water (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Caltrate 600) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * (Pedialyte) oysco 500/d * oral tablet (Os-Cal 500+D) oysco d * (Os-Cal 500+D) oysco-500 * (Caltrate 600) oyster shell calcium 500 * (Caltrate 600) oyster shell calcium with d * (Calcium Carbonate/Vitamin D2) oyster shell calcium-vit d3 * (Os-Cal 500+D)

143 142 oystercal-d * (Os-Cal 500+D) pediatric electrolyte * oral solution (Pedialyte) pediatric freezer pops * (Pedialyte) PHOS-NAK * phosphorus #1 (K-Phos Neutral) PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l (Klor-Con-Ef) (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended release (Micro-K) potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended release (Klor-Con 8) potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con 8)

144 potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) (Potassium potassium chloride-0.45 % nacl Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%NaCl) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 (Potassium Chloride/D5- meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) potassium citrate-citric acid oral (Potassium packet 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium solution 1, mg/5 ml Citrate/Citric Acid) (Potassium potassium phosphate m-/d-basic Phos,M-Basic-D- Basic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium solution Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) 143

145 144 sodium chloride intravenous (Sodium Chloride) sodium citrate-citric acid (Citric Acid/Sodium Citrate) sodium lactate intravenous (Sodium Lactate) sodium phosphate (Sodium Phos,M- Basic-D-Basic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS QL (60 per 30 ADVAIR HFA QL (12 per 28 BREO ELLIPTA QL (60 per 30 DULERA QL (13 per 28 FLOVENT DISKUS QL (60 per 30 INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS QL (120 per 30 INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION QL (12 per 28 HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION QL (24 per 28 HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION QL (21.2 per 28 HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (17.4 per 25 Antileukotrienes

146 145 montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution PA BvD (Albuterol Sulfate) for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr (Vospire ER) ANORO ELLIPTA QL (60 per 30 ATROVENT HFA QL (25.8 per 28 COMBIVENT RESPIMAT QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 PROAIR RESPICLICK QL (2 per 25 SEREVENT DISKUS QL (60 per 30 SPIRIVA RESPIMAT QL (4 per 30 SPIRIVA WITH HANDIHALER QL (30 per 30 STIOLTO RESPIMAT QL (4 per 28 STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg 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 (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous)

147 146 theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL (1 per 28 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine (Acetadote) PA BvD ARALAST NP cromolyn inhalation (Cromolyn PA BvD Sodium) cromolyn * nasal (Nasalcrom) DALIRESP QL (30 per 30 ESBRIET PA; QL (270 per 30 KALYDECO PA; QL (60 per 30 OFEV PA; QL (60 per 30 ORKAMBI PA; QL (120 per 30 sodium chloride * inhalation solution for nebulization 0.9 % (Pulmosal) 3 $0 XOLAIR PA; QL (6 per 28 ZEMAIRA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) chlorzoxazone COMFORT PAC- CYCLOBENZAPRINE (Parafon Forte DSC) PA-HRM; QL (120 per 30 PA-HRM PA-HRM

148 COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL PA ROZEREM XYREM LA zaleplon (Sonata) zolpidem oral tablet (Ambien) 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 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

149 zolpidem oral tablet,ext release multiphase Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents (Phentolamine phentolamine injection Mesylate) Vasodilating Agents Vasodilating Agents 148 (Ambien CR) 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 ADCIRCA PA; QL (60 per 30 ADEMPAS PA; QL (90 per 30 epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 OPSUMIT PA; QL (30 per 30 ORENITRAM PA REMODULIN PA BvD sildenafil intravenous (Revatio) PA; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 TRACLEER PA; LA; QL (60 per 30 TYVASO PA BvD TYVASO REFILL KIT PA BvD PA

150 149 TYVASO STARTER KIT PA BvD VENTAVIS PA BvD Vitamins And Minerals Vitamins And Minerals a thru z advanced formula * (Multivitamin/Iron/ Folic Acid) a thru z high potency * oral tablet (Multivitamin W- Minerals/Lutein) a thru z select 50+ formula * (Biocel) a thru z select * oral tablet (Multivitamin W- Minerals/Lutein) a thru z select * oral tablet mcg, mcg (Biocel) a thru z select women's * (Multivits W- Fe,Other Min/Lut) abc plus * (Biocel) adult multivitamin gummies * (One-A-Day Vitacraves) adult one daily gummies * (One-A-Day Vitacraves) adults 50+ daily formula * (Biocel) adults' daily formula * (Multivitamin/Iron/ Folic Acid) (Vit A,C, and airshield * oral tablet, effervescent E/Dietary Supp 5, unit-mg-unit No.12) animal chews * (Multivitamin) animal shape vitamins * (Multivitamin) animal shapes plus iron * (Multivitamins with Iron) antioxidant * (Beta-Carotene(A) W-C and E/Min) antioxidant formula * (Beta-Carotene(A) W-C and E/Min)

151 antioxidant vitamins * oral tablet (Multivitamin with Minerals) antioxidant vitamins * oral tablet (Ocuvite with 1,000 unit-200 mg-60 unit-2 mg Lutein) apatate forte * (Multivitamin with Minerals) ascorbic acid * oral tablet extended release 1,500 mg (Ascorbic Acid) ascorbic acid * oral (Ascorbic Acid) b complete * (Vitamin B Complex) b complex 1 * (Vitamin B Complex) b complex-vitamin b12 * (Vitamin B Complex) b complex-vitamin c-folic acid * (Dialyvite 800) b-100 complex * oral tablet (Vitamin B Complex) b-12 dots * (B-12) b-50 complex * oral tablet (Vitamin B Complex) bal b-100 * (Vitamin B Complex) bal b-50 * (Vitamin B Complex) balance b-100 * (Vitamin B Complex) balance b-50 * (Vitamin B Complex) balanced b-100 * oral (Vitamin B Complex) (Vit B Complex balanced b-100 * oral tablet Cmb mg #3/Herbs) 150

152 balanced b-150 * (Vitamin B Complex) balanced b-50 * oral tablet (Vitamin B Complex) b-complex * oral tablet (Vitamin B Complex) b-complex with vitamin c * oral (B Complex with capsule Vitamin C) b-complex with vitamin c * oral tablet (Vita-Bee with C) bee-zee * (Multivitamin with Minerals) biosupp * (Multivitamin with Minerals) biotin * oral tablet 300 mcg (Biotin) biovol * (Multivitamin with Minerals) c complex * (Ascorbic Acid) calcidol * (Drisdol) centamin * (Multivits W- Min/Ferrous Gluc) central vite with lutein * (Biocel) central-vite for seniors * (Multivitamin W/Iron, Minerals) central-vite * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) central-vite select * oral tablet (Multivitamin W- Minerals/Lutein) central-vite senior * (Biocel) centram-care * (Multivits W- Min/Ferrous Gluc) centravites 50 plus * (Multivitamin W/Iron, Minerals) centrum complete * (Multivitamin/Iron/ Folic Acid) 151

153 centrum * oral liquid (Multivits W- Min/Ferrous Gluc) centrum silver * oral tablet (Biocel) centrum ultra women's * (Multivitamin/Iron/ Folic Acid) century adults 50+ * (Biocel) century advanced formula * (Multivits W- Fe,Other Min/Lut) century mature * oral tablet (Multivitamin W- Minerals/Lutein) century mature * oral tablet mg-mcg-mcg, mcg (Biocel) century * oral tablet mgmcg Folic Acid) (Multivitamin/Iron/ century ultimate women's * oral (Multivitamin/Iron/ tablet mg-mcg Folic Acid) cerovite * (Multivits W- Min/Ferrous Gluc) cerovite advanced formula * (Multivitamin/Iron/ Folic Acid) cerovite jr * (Multivitamin W/Iron, Minerals) cerovite senior * (Multivitamin W- Minerals/Lutein) certavite senior-antioxidant * (Biocel) certavite-antioxid (iron gluc) * oral (Multivits W- liquid 9 mg iron/15 ml Min/Ferrous Gluc) certavite-antioxidant * (Multivitamin/Iron/ Folic Acid) chewable multi vitamin * (Multivitamin) chewable-vite * (Multivitamin) chewable-vite with iron * (Multivitamins with Iron) 152

154 child complete multivitamin * (Pedi Mv No.58/Ferrous Fumarate) child vitamin with minerals * (Multivitamin W/Iron, Minerals) children's chewable * (Multivitamin) children's chewable complete * oral tablet,chewable (Multivitamin) children's chewable vitamin * (Multivitamin) children's chewable w/minerals * (Multivitamin W/Iron, Minerals) children's complete vitamin * (Pedi Mv No.67/Ferrous Fumarate) children's multivit w/extra c * (Multivitamin) children's vitamin with iron * (Multivitamins with Iron) childs chew vite * (Multivitamin) child's chewable vitamins/iron * (Multivitamins oral tablet,chewable with Iron) child's vitamin with iron * (Multivitamins with Iron) child's vitamin with vitamin c * (Multivitamin) childs/iron * (Multivitamins with Iron) compete * (Multivitamin W/Iron, Minerals) complete 50+ * (Biocel) complete multi 50+ * (Biocel) complete multivitamin * oral tablet (Multivits,Th W- Fe,Other Min) complete multivitamin * oral tablet mg-mcg-mcg (Biocel) complete multivitamin-mineral * (Multivitamin/Iron/ oral tablet Folic Acid) 153

155 complete senior * oral tablet (Multivitamin W/Iron, Minerals) complete senior * oral tablet mg-mcg-mcg (Biocel) cyanocobalamin (vitamin b-12) * (Cyanocobalamin injection (Vitamin B-12)) 3 $0 cyanocobalamin (vitamin b-12) * (Cyanocobalamin oral drops 1,000 mcg/ml (Vitamin B-12)) cyanocobalamin (vitamin b-12) * oral tablet 1,000 mcg, 100 mcg, 250 (B-12) mcg, 500 mcg daily gummies * (One-A-Day Vitacraves) daily multiple * oral tablet (Multivitamin) daily multiple * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) daily multi-vitamin * (Multivitamin) daily multivitamin with iron * (Multivitamin/Iron/ Folic Acid) daily multivitamin-minerals * (Multivitamin with Minerals) daily multi-vitamins/iron * (Multivitamins with Iron) daily teen multi-vitamin * (Multivitamin/Iron/ Folic Acid) daily value * (Multivitamin) daily vitamin * (Multivitamin) daily vitamin formula * (Multivitamin) daily vitamin formula + iron * (Multivitamin/Iron/ Folic Acid) daily vitamin formula-minerals * (Multivitamin with Minerals) daily vitamin with iron * (Multivitamins with Iron) 154

156 155 daily vites/iron * (Multivitamins with Iron) daily-vite * (Multivitamin) dino-life * (Multivitamin) dino-life with extra c * (Multivitamin) dino-life with iron-zinc * (Multivitamin W/Iron, Minerals) ECEE PLUS * eldertonic * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) eql central-vite select * tablet (Multivitamin W- Minerals/Lutein) ergocalciferol (vitamin d2) * oral capsule (Drisdol) 3 $0 ergocalciferol (vitamin d2) * oral drops (Drisdol) essentia * (Multivitamin/Iron/ Folic Acid) essential balance with lutein * (Multivits W- Fe,Other Min/Lut) essential daily * (Tab A Vite) essential one daily * (Multivitamin) fa-8 * (Folic Acid) fe fumarate-doss-fa-bcomp and c * (Fe Fumarate/Doss/Fa/ Bcomp and C) 3 $0 fe fumarate-vit c-b12-if-fa * oral (Fe Fumarate/Vit capsule mg C/B12-If/Fa) 3 $0 ferate * oral tablet (Fergon) ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 ferretts * (Ferrous Fumarate) ferrex 150 * (Pic 200)

157 ferrex 150 plus * (Iron Aspgly and Ps Cmplx/C/Sucac) ferrocite * (Ferrous Fumarate) ferrous fumarate * oral tablet 324 mg (106 mg iron) (Ferrous Fumarate) ferrous gluconate * oral tablet (Fergon) ferrous sulfate * oral (Fer-In-Sol) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) ferrous sulfate * oral tablet,delayed release (dr/ec) 324 mg (65 mg iron) (Ferrous Sulfate) flintstones complete (iron) * oral (Multivitamin tablet,chewable W/Iron, Minerals) flintstones multivitamin * oral tablet,chewable (Multivitamin) flintstones with iron * (Pedi Mv No.79/Ferrous Fumarate) flintstones/extra c * oral tablet,chewable (Multivitamin) folic acid * 1,000 mcg tablet p/f,s/f (otc) (Folic Acid) FOLIC ACID * ORAL CAPSULE 20 MG folic acid * oral tablet 1 mg (Folic Acid) 3 $0 folic acid * oral tablet 400 mcg, 800 mcg (Folic Acid) fosfree * (Calcium/Multivita mins W-Iron) fruity chews * (Multivitamin) geravim * (Pediavit) geriaton * (Pediavit) 156

158 germ defense * (Vit A,C, and E/Dietary Supp No.12) gummi bear multivitamin * (Multivitamin) gummy swirls * (Multivitamin) hair vitamins * (Multivitamins with Iron) hair,skin & nails * oral tablet (Multivitamin with Minerals) hair,skin & nails * oral tablet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg Gluc/Fa/Biotin) healthy eyes * (Ocuvite with Lutein) hemocyte * (Ferrous Fumarate) hi-b complex * (Vitamin B Complex) high potency multivit-multimin * (Multivitamin W- Minerals/Lutein) honey bears * (Multivitamin) honey bears with iron-zinc * (Multivitamin W/Iron, Minerals) icaps plus * (Multivitamin with Minerals) iferex 150 * (Pic 200) iron high potency * (Fergon) i-vite * (Ocuvite with Lutein) kid's vitamins + extra c * (Multivitamin) kids vitamins + iron * (Ped Multivit #17/Iron Fumarate) kid's vitamins + iron * (Multivitamins with Iron) kid's vitamins * oral tablet,chewable (Multivitamin) 157

159 158 life-pack women's * (Multivitamin W/Iron, Minerals) LIQUI-E * little animals * (Multivitamin) little animals-iron * oral (Multivitamins tablet,chewable with Iron) lysiplex plus * oral liquid (Pediavit) MACUVITE * MACUVITE EYE CARE * maximum daily multivitamin * (Tab A Vite) mega multiple/chelated mineral * (Multivitamin with Minerals) mega multivitamin with mineral * (Multivitamin with oral tablet Minerals) men's daily gummies * (One-A-Day Vitacraves) men's multi-vitamin * (Multivitamin) men's multivitamin gummies * (One-A-Day Vitacraves) men's one daily * oral tablet (Multivitamin with Minerals) MEPHYTON * 3 $0 milltrium senior * (Multivitamin W- Minerals/Lutein) multi complete with iron * (Multivitamin/Iron/ Folic Acid) multi-day with iron * (Multivitamin/Iron/ Folic Acid) multi-delyn * (Multivitamin) multi-delyn with iron * (Multivitamin/Ferr ous Gluconate) multilex * (Multivitamin W/Iron, Minerals) multilex-t&m * (Multivits,Th W- Fe,Other Min)

160 multiple vitamin-minerals * (Multivitamin with Minerals) multiple vitamins * (Multivitamin) multiple vitamins with iron * (Multivitamins with Iron) multivital platinum * oral tablet (Multivitamin W- Minerals/Lutein) multivital platinum * oral tablet mcg (Biocel) multivitamin 50 plus * (Multivitamin W- Minerals/Lutein) multi-vitamin hp/minerals * (Multivitamins,The r W-Minerals) multivitamin * oral tablet (Multivitamin) multivitamin with iron * (Multivitamins with Iron) multivitamin with minerals * oral (Multivits W- liquid Min/Ferrous Gluc) multivitamin with minerals * oral (Multivitamin with tablet Minerals) multivitamins with min no.7-fa * (Multivitamins oral capsule 1 mg with Min No.7/Fa) 3 $0 multi-vite * (Multivitamin/Iron/ Folic Acid) multi-vite 50 & over * (Multivitamin W- Minerals/Lutein) multivit-fluor 0.25 mg/ml drop 0.25 (Pedi Mvi No.82 mg/ml with Fluoride) my favorite multiple * (Multivitamin) my-vitalife * (Multivitamin with Minerals) NASCOBAL * 3 $0 natural b-100 * (Vitamin B Complex) 159

161 natural b-100 complex * (Vit B Complex 100 Cmb #2/Herbs) nephro-vite * (Dialyvite 800) niacinamide * oral tablet extended release (Niacinamide) nu-iron * (Pic 200) ocutabs * (Beta-Carotene(A) W-C and E/Min) once daily * (Multivitamin) oncovite * (Multivitamins,The rapeutic) one daily 50 plus * (Multivitamin with Minerals) one daily complete * oral tablet (Multivitamin with Minerals) one daily energy * oral tablet (Multivitamin with Minerals) one daily essential * oral tablet (Multivitamin) one daily gummy vites * (One-A-Day Vitacraves) one daily maximum (with ca) * (Tab A Vite) one daily men's 50+ * oral tablet (Multivitamin with Minerals) one daily multi-vit w-mineral * (Multivitamins with Iron) one daily multivitamin * oral tablet (Multivitamin) one daily multivitamin * oral tablet 400 mcg (Quintabs) one daily multivit-iron(folic) * (Multivitamin/Iron/ Folic Acid) one daily * oral tablet (Multivitamin) one daily plus iron * oral tablet (Multivitamins with Iron) 160

162 161 one daily plus iron * oral tablet 18- (Multivitamin/Iron/ 400 mg-mcg Folic Acid) one daily plus minerals * (Multivitamin with Minerals) one daily with iron * (Multivitamins with Iron) one-a-day essential * (Multivitamin) one-a-day maximum formula * (Multivitamin with Minerals) one-a-day teen advantage * oral (Multivitamin/Iron/ tablet mg-mcg Folic Acid) one-a-day teen advantage * oral (Multivits,Ca,Mine tablet 9 mg iron-400 mcg rals/iron/fa) opti-vitamins * oral tablet (Beta-Carotene(A) W-C and E/Min) opti-vitamins * oral tablet 1,000 (Ocuvite with unit-200 mg-60 unit-2 mg Lutein) pediatric multivitamin * (Multivitamin) pharmacist favorite multi-vit * (Multivitamin) phytonadione * oral tablet 100 mcg (Phytonadione) poly-iron * (Pic 200) poly-vita * (Pediatric Multivit Comb No.20) poly-vita (iron) * (Ped Multivit #46/Iron Sulfate) poly-vitamin * (Pediatric Multivit Comb No.20) poly-vitamin with iron * (Ped Multivit #46/Iron Sulfate) polyvitamin/iron * (Multivitamin W/Iron, Minerals) poly-vitamins * (Multivitamin) prenatal formula * oral tablet mg (Classic Prenatal) prenatal * oral tablet mg (Classic Prenatal)

163 prenatal vit#96-ferrous fum-fa * (Prenatal Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) prenatal vitamins oral tablet 27 mg (Pnv with iron- 1 mg Ca,No.72/Iron/Fa) PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG prenatal vit-iron fumarate-fa * (Classic Prenatal) prosight * (A/C/E/Zinc/Sod Selenate/Copper) pyridoxine * injection (Pyridoxine HCl) 3 $0 ra central-vite select * tab p/f (Multivitamin W/Iron, Minerals) scooby-doo one a day * (Multivitamin W/Iron, Minerals) senior tabs * (Biocel) sentry * oral tablet mg-mcg (Multivitamin/Iron/ Folic Acid) sentry senior * (Biocel) sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) sodium fluoride oral tablet 1 mg (Pedi Mvi No.82 fluoride (2.2 mg) with Fluoride) sodium fluoride * oral tablet,chewable 0.25 mg fluorid (Sodium Fluoride) 3 $0 (0.55 mg) spectravite adult 50+ * oral tablet (Biocel) spectravite advanced formula * oral (Multivitamin/Iron/ tablet Folic Acid) spectravite * oral liquid (Pediavit) spectravite * oral tablet,chewable (Multivitamins with Iron) spectravite senior * oral tablet (Multivitamin W/Iron, Minerals) (All Rx Prenatal Vitamins Covered) 162

164 spectravite senior w-lycopene * (Multivitamin W- Minerals/Lutein) spectravite ultra women * (Multivitamin/Iron/ Folic Acid) stress 500 plus zinc * (Multivits,Stress Formula/Zinc) stress b with zinc * (Multivits,Stress Formula/Zinc) stress b-biotin * (Vitamin B Complex) stress formula * (Multivits,Stress Formula) stress formula plus iron * (Iron/Multivits,Stre ss Formula) stress formula with iron * (Vit B Comp/C/Fa/Iron/Vi t E) stress formula with zinc * (Multivits,Stress Formula/Zinc) stuart prenatal * (Classic Prenatal) sunvite * (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) super b complex-vitamin c * (Vita-Bee with C) super b/c * (B Complex with Vitamin C) super b-50 complex * (Vitamin B Complex) super b-50 complex plus * (Vitamin B Complex) super multiple * oral tablet (Multivitamin W/Iron, Minerals) super multivitamin * (Multivitamin) super quints b-50 * (Vitamin B Complex) 163

165 super thera vite m * (Multivitamins,The r W-Minerals) superior 35 * (Multivitamin W/Iron, Minerals) superplex-t * (Vita-Bee with C) support * (Multivitamin with Minerals) support-500 * (B Complex with Vitamin C) 3 $0 tab-a-vite * (Multivitamin) tab-a-vite/iron * (Multivitamins with Iron) tab-a-vite-minerals * (Multivitamin with Minerals) thera m plus (ferrous fumarat) * (Multivits,Ca,Mine rals/iron/fa) thera vitamin * (Multivitamins,The rapeutic) theradex m * (Multivit,Ther Iron,Ca,Fa and Min) thera-m * oral tablet (Multivits,Th W- Fe,Other Min) thera-m * oral tablet mg (Multivit,Ther Iron,Ca,Fa and Min) thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine mcg rals/iron/fa) theramill forte * oral capsule (Multivitamin with Minerals) therapeutic liquid * (Multivitamins,The rapeutic) therapeutic m + beta-carotene * (Tab A Vite) therapeutic vitamin & mineral * (Multivitamins,The r W-Minerals) 164

166 therapeutic vitamins/minerals * (Multivitamins with Min No.7/Fa) 3 $0 therapeutic-m * oral tablet 9 mg (Multivits,Ca,Mine iron-400 mcg rals/iron/fa) (Multivit,Ther therapeutic-m vitamin/minerals * Iron,Ca,Fa and oral tablet mg Min) thera-tabs * (Multivitamins,The rapeutic) theratrum complete 50 plus * (Multivitamin W/Iron, Minerals) theratrum complete 50 plus/lut * (Multivitamin W- Minerals/Lutein) therems * (Multivitamins,The rapeutic) therems-h * (Multivits,Th W- Fe,Other Min) therems-m * (Multivits,Th W- Fe,Other Min) thiamine hcl * injection (Thiamine HCl) 3 $0 thiamine hcl * oral tablet 500 mg (Thiamine HCl) total b/c * (Vita-Bee with C) totalday multiple * (Multivitamin with Minerals) tri-vi-sol * (Vit A Palmitate/Vit C/Vit D3) tri-vita * (Pedi Multivits A,C, and D3 No.21) tri-vitamin * (Pedi Multivits A,C, and D3 No.21) ultra b-100 complex * oral tablet (Vitamin B Complex) 165

167 unicomplex-m * (Multivitamin W/Iron, Minerals) vision * (Beta-Carotene(A) W-C and E/Min) vision formula * (Beta-Carotene(A) W-C and E/Min) vision formula (with lutein) * (Ocuvite with Lutein) vision plus lutein * (Multivitamin W- Minerals/Lutein) vit b cmplx 3-fa-vit c-biotin * oral (Vit B Cmplx tablet mg-mg-mcg 3/Fa/Vit C/Biotin) 3 $0 (Vit B Cmplx vit b cmplx no3-fa-c-biot-zinc * No3/Fa/C/Biot/Zin 3 $0 c) vitabee/c * (Vita-Bee with C) vitalets * oral tablet,chewable (Multivitamins with Iron) vitamin a * oral capsule 10,000 unit, 25,000 unit (Vitamin A) vitamin b complex * (Vitamin B Complex) vitamin b complex with c * (B Complex with Vitamin C) vitamin b-1 * oral tablet (Thiamine HCl) vitamin b-100 complex * (Vitamin B Complex) vitamin b12-folic acid * oral (Cyanocobalamin/ Folic Acid) vitamin b-6 * oral tablet 100 mg, 25 mg, 250 mg, 50 mg (Pyridoxine HCl) vitamin c * oral capsule, extended release (Ascorbic Acid) vitamin c * oral syrup (Ascorbic Acid) 166

168 vitamin c * oral tablet 1,000 mg, 250 mg, 500 mg (Ascorbic Acid) vitamin c * oral tablet extended release (Ascorbic Acid) vitamin c * oral tablet,chewable 250 mg, 500 mg (Ascorbic Acid) vitamins & minerals * (Multivitamins,The r W-Minerals) vitamins b complex * oral capsule (Vitamin B Complex) vitamins b complex * oral tablet (Vitamin B Complex) (Vit B vitamins b complex * oral tablet Comp/C/Fa/Iron/Vi 500 mg-400 mcg- 18 mg iron t E) vitamins for hair * oral tablet (Multivitamin) vitrum senior * oral tablet (Multivitamin W- Minerals/Lutein) vitrum senior * oral tablet mcg (Biocel) womens daily gummies * (One-A-Day Vitacraves) women's daily multivitamin * (Tab A Vite) yelets * (Multivitamin/Iron/ Folic Acid) zoo chews * (Multivitamin) 167

169 INDEX 3 3 day vaginal pse-150gfn-15dm MOP A a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY ABILIFY DISCMELT... 64, 65 ABILIFY MAINTENA ABRAXANE... 36, 37 ABREVA acamprosate acarbose acebutolol acephen acetaminophen acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid , 132 acetylcysteine acid gone antacid acid reducer (famotidine) acid relief (cimetidine) acitretin acne medication ACNE MEDICATION acne-clear ACTEMRA , 134 ACTHIB (PF) ACTIMMUNE acyclovir... 71, 102 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 130 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adrenalin ADRENALIN... 82, 83 adt robitussin peak cld dm max adult multivitamin gummies 149 adult nasal decongestant adult one daily gummies adult robitussin lingering cld.. 91 adult robitussin peak cold dm 91 adult wal-tussin adult wal-tussin dm max adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA advil af 53 AFINITOR AFINITOR DISPERZ AGGRENOX airshield AKTEN (PF) alavert d-12 allergy-sinus alaway ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE ALDURAZYME alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges alka-seltzer plus sinus-cough. 92 aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy relief (cetirizine) allergy relief (loratadine) allerhist I-1 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

170 aller-tec d allopurinol almacone almacone aloe vesta alophen alosetron ALPHAGAN P alprazolam... 25, 26 ALREX altacaine altamist aluminum chloride aluminum hydroxide gel amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME ambizine amifostine crystalline amiloride amiloride-hydrochlorothiazide85 AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin... 85, 86 amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL animal chews animal shape vitamins animal shapes plus iron ANORO ELLIPTA antacid antacid anti-gas antacid extra-strength antacid plus anti-gas anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide).. 117, 118 antifungal antifungal (tolnaftate) anti-gas maximum strength antioxidant antioxidant formula antioxidant vitamins apatate forte APOKYN apraclonidine APRISO aprodine APTIOM... 44, 45 APTIVUS aquanil hc ARALAST NP ARCALYST aripiprazole ARRANON artificial tears artificial tears (petro/min) artificial tears (pf) artificial tears(glycerin-peg). 110 artificial tears(hypromellose) 110 ARZERRA ASACOL HD ascorbic acid ashlyna aspirin... 21, 23 aspirin, buffered aspirin-dipyridamole aspir-low I-2 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

171 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 44, 110 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVODART AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam B b complete b complex b complex-vitamin b b complex-vitamin c-folic acid b-100 complex b-12 dots b-50 complex bacitracin... 29, 103, 113 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b balanced b balanced b balsalazide banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) 130 b-complex b-complex with vitamin c BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bee-zee BELEODAQ benadryl allergy benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE SPRAY beta-hc betamethasone acet,sod phos 126 betamethasone dipropionate. 105 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 81, 137 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL BILTRICIDE bimatoprost bio-dtuss dmx bion tears (pf) bionel bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF BOTOX BREO ELLIPTA BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine bromphenex dm I-3 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

172 brompheniramine-pseudoephdm brompheniram-phenylephrinedm broncotron-s budesonide bufferin bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 16, 24 buprenorphine-naloxone bupropion hcl... 24, 48 buspirone butalb-acetaminophen-caffeine butalbital-acetaminop-caf-cod 16 butalbital-acetaminophen butalbital-acetaminophen-caff 16 butalbital-aspirin-caffeine butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC C c complex cabergoline ca-d3-mag ox-zinc-cop-mangbor caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcionate calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitriol , 132 calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) calcium 600 with vitamin d3 139 calcium acetate CALCIUM ACETATE calcium carbonate , 139 calcium carbonate-mag carb-fa calcium carbonate-vitamin d calcium carbonate-vitamin d CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d calcium gluconate calcium lactate calcium+d CALDOLOR cal-gest antacid calphron CALTRATE D CALTRATE D VIT D3 (800) CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 80 CARAFATE carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin cardec dm (phenyleph-chlorphn) CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT MODIFIED CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 31 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 32 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os. 32 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil cefuroxime sodium I-4 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

173 cefuroxime-dextrose (iso-osm) celecoxib CELLCEPT INTRAVENOUS CELONTIN centamin central vite with lutein central-vite central-vite for seniors central-vite select. 151, 155, 162 central-vite senior centram-care centravites 50 plus centrum centrum complete CENTRUM PRO NUTRIENTS centrum silver centrum ultra women's century century adults century advanced formula century mature century ultimate women's cephalexin... 32, 33 CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula cerovite jr cerovite senior certavite senior-antioxidant certavite-antioxid (iron gluc) 152 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX cheratussin ac cheratussin dac chest congestion relief + dm.. 92 chest congestion relief d chest congestion relief pe chewable multi vitamin chewable-vite chewable-vite with iron child complete multivitamin 153 child cough & sore throat child mucinex chest congestion child mucus relief cough child plus cough & runny nose child triaminic cold & allergy 57 child triaminic cough-congest 93 child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief.. 93 children's advil children's aller-tec children's cetirizine children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 153 children's chewable w/minerals CHILDREN'S CLARITIN children's complete vitamin. 153 CHILDREN'S DIMETAPP COLD &FLU children's flu relief children's mapap children's mucinex cough children's multivit w/extra c. 153 children's non-aspirin children's pain & fever relief.. 16 children's pain reliever children's silapap children's silfedrine children's soothe children's sudafed children's sudafed pe cough children's vitamin with iron children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone CHOLBAM I-5 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

174 cholestyramine (with sugar) cholestyramine-aspartame choline,magnesium salicylate 21 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX ciprofloxacin ciprofloxacin hcl... 35, 113 ciprofloxacin in 5 % dextrose 35 ciprofloxacin lactate cisplatin citalopram citracal + d maximum citric acid-sodium citrate citrus calcium clarithromycin CLARITIN CLARITIN LIQUI-GEL CLARITIN REDITABS CLARITIN-D 12 HOUR CLARITIN-D 24 HOUR clearlax clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 30 clindamycin palmitate hcl clindamycin phosphate... 30, 61, 104 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol propionate clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 78, 88 clonidine hcl-chlorthalidone.. 79 clopidogrel clorazepate dipotassium clotrimazole clotrimazole 3 day clotrimazole clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate codeine-butalbital-asa-caffein 17 codituss dm colace colchicine colchicine-probenecid COLCRYS cold & cough cold multi-symptom cold multi-symptom day/night 93 cold multi-symptom nighttime cold relief m/s day/night cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 145 COMETRIQ comfort gel extra strength COMFORT PAC- CYCLOBENZAPRINE COMFORT PAC-IBUPROFEN COMFORT PAC- MELOXICAM COMFORT PAC-NAPROXEN COMFORT PAC-TIZANIDINE I-6 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

175 compete COMPLERA complete complete multi complete multivitamin complete multivitamin-mineral complete senior compoz COMVAX (PF) CONDYLOX congestac COPAXONE coral calcium CORDRAN coricidin hbp CORLANOR cortisone cortizone CORTIZONE COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 102 cough & cold cough & runny nose CREON creo-terpin (dm-guaifenesin). 94 CRESTOR critic-aid clear af CRIXIVAN cromolyn , 118, 146 CUBICIN CURITY GAUZE cyanocobalamin (vitamin b-12) cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) cytarabine cytarabine (pf) D d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride 77 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 77 dacarbazine dactinomycin daily gummies daily multiple daily multi-vitamin daily multivitamin with iron 154 daily multivitamin-minerals. 154 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 154 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM dayhist allergy daytime cold & cough daytime cold-flu day-time cough daytime mucus relief dm daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough+chest congest dm DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) desenex (clotrimazole) desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone I-7 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

176 despec-dm (pseudoeph-dmguaif) dex4 glucose dexamethasone dexamethasone sodium phosphate , 126 dexchlorphen-pse-chlophedianol dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextromethorphan polistirex.. 95 dextrose 10 % and 0.2 % nacl 77 dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 77 dextrose 5 %-lactated ringers. 77 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride 78 diabetic siltussin das-na diabetic tussin dm diabetic tussin ex diamode DIASTAT ACUDIAL diazepam diazepam intensol diclofenac potassium diclofenac sodium... 21, 22, 115 diclofenac-misoprostol dicloxacillin dicyclomine didanosine DIFICID diflunisal digitek digoxin DIGOXIN dihydroergotamine DILANTIN CAPSULE 30 MG diltiazem hcl dilt-xr dimaphen (pe) dimaphen dm dimenhydrinate dimetapp cold-congestion dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine disopyramide phosphate disulfiram divalproex d-methorphan hb-p-epd hcl-bpm dm-phenyleph-chlorpheniramine dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar & water extra doxazosin doxepin doxercalciferol , 133 doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate doxycycline monohydrate dramamine driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol 89 DROXIA DRYSOL DAB-O-MATIC DUAVEE dulcolax stool softener (dss). 120 DULERA duloxetine DURAMORPH (PF) DUREZOL DYRENIUM E e.c. prin ECEE PLUS econazole ed bron gp I-8 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

177 ed chlorped jr EDURANT EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 80 ENBREL ENBREL SURECLICK endur-acin enema enema disposable enemeez enemeez plus enfalyte ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 71, 72 entacapone entecavir entre-cough ENTRESTO ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle equalactin ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 33, 114 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate.. 33 erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 155 essential daily essential one daily estazolam... 26, 27 ESTRACE estradiol estradiol valerate estradiol/norethindrone acet. 125 estradiol-norethindrone acet. 125 ESTRASORB estropipate ethambutol ethamolin ethinyl estradiol/drospirenone 90 ethosuximide ethynodiol d-ethinyl estradiol 90 etidronate disodium etodolac ETOPOPHOS etoposide EVOTAZ exefen dmx EXELON exemestane EXJADE expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche F fa FABRAZYME famciclovir famotidine , 117 famotidine (pf) famotidine (pf)-nacl (iso-os) 116 FANAPT FARESTON FARYDAK FASLODEX fe fumarate-doss-fa-bcomp and c fe fumarate-vit c-b12-if-fa felbamate felodipine feminine care douche FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized I-9 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

178 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate ferate ferotrinsic ferretts ferrex ferrex 150 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate ferrous sulfate FETZIMA feverall fiber (calcium polycarbophil) fiber laxative (methylcellulo)121 fiber smooth fiber therapy fiber therapy (psyllium/sugar) fiber-lax finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flanax antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL FLEXBUMIN 25 % FLEXBUMIN 5 % flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA floxuridine flu formula daytime-nighttime 95 flu severe cold-congestion fluconazole fluconazole in dextrose(iso-o) 55 fluconazole in nacl (iso-osm). 55 flucytosine fludarabine fludrocortisone flumazenil fluocinonide fluocinonide-emollient base. 106 fluorometholone FLUOROPLEX fluorouracil... 39, 103 fluoxetine... 48, 49 FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam flurbiprofen flurbiprofen sodium flutamide fluticasone , 115 fluvoxamine foaming antacid folic acid FOLIC ACID fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fruity chews fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas free extra strength gas relief gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GAZYVA gelusil antacid & anti-gas gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentamicin... 29, 104, 114 gentamicin in nacl (iso-osm).. 29 gentamicin sulfate I-10 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

179 gentamicin sulfate (ped) (pf).. 29 gentamicin sulfate (pf) GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE gentlelax GEODON geravim geriaton geri-dryl geri-hydrolac geri-tussin dm germ defense gildess 24 fe GILENYA GILOTRIF GLEEVEC glimepiride glipizide... 52, 53 glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin GLYCINE glycolax glycopyrrolate glydo... 23, 24 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaiatussin ac guaifenesin guaifenesin dac guanfacine... 79, 88 guanidine gummi bear multivitamin gummy swirls H hair vitamins hair,skin & nails HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthy eyes healthylax hemocyte heparin (porcine) heparin (porcine) in 5 % dex. 72, 73 HEPARIN (PORCINE) IN 5 % DEX heparin (porcine) in nacl (pf). 72 HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf)... 72, 73 HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HEXALEN hi-b complex hi-cal plus vit d high potency multivit-multimin homatropine hbr honey bears honey bears with iron-zinc HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMULIN 70/ HUMULIN 70/30 KWIKPEN 52 HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone bit-homatrop mebr hydrocodone-acetaminophen. 17 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen hydrocortisone , 107, 126 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone acetate-aloe hydrocortisone acetate-urea. 106 hydrocortisone butyrate I-11 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

180 hydrocortisone butyr-emollient hydrocortisone sod succinate 126 hydrocortisone valerate hydromorphone... 17, 18 hydromorphone (pf) hydroskin hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA I ibandronate IBRANCE ibuprofen ibuprofen jr strength icaps plus ICLUSIG... 39, 40 iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant acetaminophen infantaire infant's ibuprofen INFANT'S MOTRIN infants' non-aspirin cold infant's pain reliever INLYTA insta-glucose INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE-NEEDLE U INTELENCE intense cough reliever INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRENKA IRESSA iron high potency ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX itraconazole ivermectin i-vite IXEMPRA IXIARO (PF) J JADENU JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA jr. acetaminophen junel fe junior mapap K KABIVEN KADCYLA KALETRA KALYDECO kaopectate (bismuth subsalicy) I-12 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

181 KEDBUMIN KELP (IODINE) ketoconazole ketoprofen ketorolac... 22, 23, 115 ketotifen fumarate KEYTRUDA KHEDEZLA kidkare cough/cold kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28) KINERET KINRIX (PF) KLOR-CON klor-con KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KLOR-CON/EF konsyl (sugar) konsyl fiber konsyl sugar-free KORLYM KRYSTEXXA KUVAN KYPROLIS L l norgest/e.estradiol-e.estrad.. 90 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine... 45, 46 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost LATUDA laxative peg LAZANDA leflunomide LEMTRADA LENVIMA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 35, 114 levofloxacin in d5w levoleucovorin calcium levonorgestrel levonorgestrel-ethin estradiol. 90 levonorgestrel-ethinyl estrad.. 90 levorphanol tartrate levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 24, 80 lidocaine hcl lidocaine in 5 % dextrose (pf) 81 lidocaine-prilocaine life-pack women's linezolid LINZESS liothyronine lipase-protease-amylase lipogen LIPOSYN II LIPOSYN III liquibid d-r liquid calcium with vitamin d LIQUI-E liquitears lisinopril lisinopril-hydrochlorothiazide 80 lithium carbonate lithium citrate little animals little animals-iron l-norgest-eth estr/ethin estra lobana bath lohist peb dm lomustine loperamide loradamed loratadine loratadine-d lorazepam oral solution lortuss ex losartan losartan-hydrochlorothiazide.. 79 LOTEMAX LOTRIMIN ULTRA LOTRONEX I-13 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

182 lovastatin loxapine succinate lubricant dry eye relief lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 111 lubricant eye (polyv alcohol) 112 lubricant eye (propyl glycol) 112 lubricant eye drops lubricant gel lubricating drops lubrifresh pm LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA lysiplex plus LYSODREN M maalox advanced MACUVITE MACUVITE EYE CARE mafenide acetate mag mag-delay mag-g MAGNEBIND magnesium magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen) mapap arthritis pain mapap extra strength maprotiline mar-cof bp mar-cof cg MARPLAN MARQIBO masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu meclizine medi-brom medroxyprogesterone , 128 mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol MEKINIST meloxicam melphalan hcl intravenous memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's multivitamin gummies 158 men's one daily MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesehist dm mesna MESNEX MESTINON metaproterenol metaxalone metformin methadone methadone hcl methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 88, 89 methylprednisolone methylprednisolone acetate I-14 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

183 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 61, 63, 104 metronidazole in nacl (iso-os) 63 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate midazolam midazolam (pf)... 27, 28 midodrine milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose MINERAL OIL mineral oil laxative mineral oil light minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone MONISTAT monistat montelukast , 145 morphine MORPHINE morphine concentrate morrhuate sodium motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL mucinex fast-max dm max mucus dm mucus dm max mucus relief MULTAQ multi complete with iron multi-day with iron multi-delyn multi-delyn with iron multilex multilex-t&m multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multi-symptom cold-cough multivital platinum multivitamin multivitamin 50 plus multi-vitamin hp/minerals multivitamin with iron multivitamin with minerals multivitamins with min no.7-fa multi-vite multi-vite 50 & over mupirocin mupirocin calcium muro MUSTARGEN my favorite multiple myco nail a mycophenolate mofetil mycophenolate sodium mylanta gas MYOZYME mytab gas mytab gas maximum strength my-vitalife N nabumetone nadolol nafcillin nafcillin in dextrose iso-osm.. 35 NAGLAZYME naloxone naltrexone naltrexone hcl NAMENDA NAMENDA TITRATION PAK NAMENDA XR... 47, 48 NAMZARIC naphazoline naproxen naproxen sodium naratriptan nasal & sinus decongestant I-15 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

184 nasal decongestant (oxymetazl) nasal decongestant (pe) NASCOBAL NASONEX NATACYN nateglinide NATPARA natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy 121 natural tears (pf) nature's tears NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc 114 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss NEPHRAMINE 5.4 % nephro-vite NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR niacin niacinamide... 86, 160 nicardipine NICODERM CQ nicorelief nicorette nicotine nicotine (polacrilex) NICOTROL nifedipine night time night time cold-flu night time cold-flu relief nighttime cold-flu nighttime cough nighttime relief eye NILANDRON nite time cold-flu nite time-d cold-flu relief NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose. 87 NITROSTAT nohist-dm non-aspirin cold non-aspirin extra strength non-aspirin flu non-aspirin jr strength NORDITROPIN FLEXPRO 127 norelgestromin/ethin.estradiol 90 norepinephrine bitartrate noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) 90 norethindrone acetate norethindrone ac-eth estradiol... 90, 125 norethindrone-e.estradiol-iron... 90, 91 norethindrone-ethinyl estrad.. 91 norethindrone-mestranol norgestimate-ethinyl estradiol 91 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCYNTA NUCYNTA ER NUEDEXTA nu-iron NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING I-16 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

185 NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone nyt-time sleep O ocean nasal OCTAGAM octreotide acetate ocutabs OFEV ofloxacin... 35, 114 olanzapine olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate , 117 OMNITROPE ONCASPAR once daily oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily one daily 50 plus one daily complete one daily energy one daily essential one daily gummy vites one daily maximum (with ca) one daily men's one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 160 one daily plus iron , 161 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula161 one-a-day teen advantage ONFI opcicon one-step OPDIVO OPSUMIT opti-vitamins oral saline laxative oralyte ORAP ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORKAMBI OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) 35 oxaliplatin oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 19, 20 oxycodone hcl-acetaminophen oxycodone hcl-aspirin oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium with d oyster shell calcium-vit d oystercal-d P paclitaxel pain relief pain relief adult pain reliever pain reliever jr strength paliperidone PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PATADAY PATANOL PAXIL pecgen dmx pedi m.vit no.17 with fluoride pedia relief pedia relief infant pediacare multi-symptom cold98 PEDIARIX (PF) pediatric electrolyte pediatric freezer pops pediatric multivitamin PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl PEGANONE PEGASYS PEGASYS PROCLICK I-17 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

186 peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC. 109 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline persa-gel pharbetol pharmacist favorite multi-vit 161 phenelzine phenobarbital phenobarbital sodium phentolamine phenylephrine hcl... 79, 112 phenylephrine-chlorpheniramine phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended phillips phillips liqui-gels PHOS-FLUR PHOSLYRA PHOS-NAK phosphate laxative PHOSPHOLINE IODIDE phosphorus # phytonadione PICATO pilocarpine hcl , 138 pimozide pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam PLAN B ONE-STEP PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podactin podofilox podophyllum resin polyethylene glycol poly-iron polymyxin b sulf-trimethoprim poly-tussin poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 142 potassium bicarbonate-cit ac 142 potassium chlorid-d5-0.45%nacl potassium chloride , 143 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate-citric acid. 143 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 126 prednisone PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO I-18 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

187 prenatal prenatal formula prenatal vit#96-ferrous fum-fa prenatal vitamin with minerals prenatal vitamins PRENATAL VITAMINS prenatal vit-iron fumarate-fa 162 preparation h hydrocortisone 107 PREVIDENT 5000 SENSITIVE PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized capsules PROGLYCEM PROGRAF PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 59, 63 promethazine hcl promethazine-codeine promethazine-dm promethazine-phenylephcodeine promolaxin propafenone propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod 112 propranolol... 81, 82 propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure & gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine Q q-dryl q-pap... 20, 21 q-pap extra strength q-tapp q-tapp dm q-tussin q-tussin dm QUADRACEL (PF) QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 80 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE REBIF (WITH ALBUMIN). 136 REBIF REBIDOSE REBIF TITRATION PACK 136 RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH LIQUIGEL REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid RELADOR PAK relcof c RELENZA DISKHALER RELISTOR , 120 remedy phytoplex antifungal.. 56 REMICADE REMODULIN RENAGEL RENVELA repaglinide REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR I-19 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

188 RESTASIS retaine cmc RETROVIR REVLIMID REXULTI REYATAZ REZIRA ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ii riluzole rimantadine ri-mox ringers , 143 risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest-cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole ROTARIX ROTATEQ VACCINE ROZEREM rydex S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline mist salsalate SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs senna senna lax senna laxative senna with docusate sodium. 122 senokot-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin silace siladryl sa silapap sildenafil oral tablet 20 mg SILENOR siltussin dm das siltussin sa silver nitrate silver nitrate applicators silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus & allergy (pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 59 sleep-tabs smoothlax sochlor sodium acetate sodium bicarbonate , 143 sodium chloride , 132, 144, 146 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride sodium lactate sodium phosphate sodium polystyrene sulfonate sodium thiosulfate sod-pot-k cit-sod cit-cit acid. 144 SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT I-20 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

189 soothe (bismuth subsalicylate) soothe regular strength sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI spectravite spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL st joseph aspirin st. joseph aspirin stavudine STELARA STERILE LUBRICANT STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA streptomycin stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula plus iron stress formula with iron stress formula with zinc STRIBILD STRIVERDI RESPIMAT stuart prenatal sucralfate sudogest sudogest cold & allergy sudogest pe sulfacetamide sodium sulfacetamide sodium (acne) 104 sulfacetamide-prednisolone. 114 sulfadiazine sulfamethoxazole-trimethoprim... 35, 36 sulfasalazine sulfatrim sulfazine sulfazine ec sulindac sumatriptan nasal spray sumatriptan succinate summer's eve disposable douche summers eve extra cleansing 137 sunvite super b complex-vitamin c super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURE COMFORT INS. SYR. U SURMONTIL SUSPENDOL-S SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 129 tactinal tactinal extra strength TAFINLAR TAMIFLU tamoxifen tamsulosin TARCEVA... 42, 43 TARGRETIN tarina fe TASIGNA TAZORAC taztia xt tears again TEARS NATURALE II TECFIDERA I-21 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

190 TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracaine hcl tetracycline TEV-TROPIN THALOMID the magic bullet theophylline , 146 theophylline anhydrous theophylline in dextrose 5 % 145 thera m plus (ferrous fumarat) thera vitamin theradex m THERAFLU DAYTIME COLD-COUGH THERAFLU NIGHTTIME SEVERE COLD THERAFLU SEVERE COLD- COUGH thera-m theramill forte therapeutic liquid therapeutic m + beta-carotene therapeutic vitamin & mineral therapeutic vitamins/minerals therapeutic-m therapeutic-m vitamin/minerals thera-tabs theratrum complete 50 plus theratrum complete 50 plus/lut therems therems-h therems-m thiamine hcl thioridazine thiothixene tiagabine TICE BCG TIKOSYN timolol maleate... 82, 138 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide tolbutamide tolmetin tolnaftate tolterodine topiramate toposar intravenous topotecan TORISEL torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting m-sym cold/cough triamcinolone acetonide , 107, 126 triaminic cold & cough (pe). 100 TRIAMINIC COLD & COUGH NT (PE) triaminic cough-nasal congesti I-22 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

191 TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid triazolam... 28, 29 TRIBENZOR tri-buffered aspirin triderm tri-dex pe trifluoperazine trifluridine trigofen dm trihexyphenidyl TRILEPTAL trimethoprim triple paste af TRIUMEQ tri-vi-sol tri-vita tri-vitamin TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium , 124 TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL PEDIATRIC tussin cf tussin cf cough-cold tussin cold-congestion tussin cough (dm only) tussin dm tussin dm cough & chest tussin maximum strength cough tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULORIC ultra b-100 complex ultra fresh pm ultra sleep (doxylamine succ) 59 ultra strength antacid unicomplex-m unisom sleepgels UNITUXIN ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 47 valsartan valsartan-hydrochlorothiazide 79 VALSTAR valu-tapp dm vancomycin vancomycin in d5w VAQTA (PF) VARIVAX (PF) VASCEPA vasopressin VECTIBIX VELCADE venlafaxine VENTAVIS verapamil VERSACLOZ vicks dayquil cough vicks nature fusion cough vicks qlearquil(oxymetazoline) vicks sinex 12-hour VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMIZIM VIMPAT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD vision vision formula vision formula (with lutein). 166 vision plus lutein vit b cmplx 3-fa-vit c-biotin. 166 vit b cmplx no3-fa-c-biot-zinc vitabee/c vitalets vitamin a vitamin b complex vitamin b complex with c I-23 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

192 vitamin b vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 167 vitamins & minerals vitamins b complex vitamins for hair VITEKTA vitrum senior VOLTAREN voriconazole VOTRIENT VPRIV W wal-act d cold & allergy wal-dram wal-dryl allergy... 59, 60 wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 12 hour wal-phed... 60, 101 wal-phed pe wal-phed pe day-night wal-phed pe sinus & allergy.. 60 wal-profen wal-sleep z wal-som (diphenhydramine).. 60 wal-tap wal-tussin cough wal-tussin cough & cold cf wal-tussin dm wal-zan wal-zyr (cetirizine) wal-zyr (ketotifen) wal-zyr d warfarin water for irrigation, sterile WELCHOL womens daily gummies women's daily multivitamin. 167 X XALKORI XARELTO XELJANZ XENAZINE XGEVA XIFAXAN XOLAIR XTANDI xylon XYREM Y yelets YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP zantac ZARXIO ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP zephrex-d ZETIA ZIAGEN zidovudine zinc oxide ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem , 148 ZOMACTON ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) ZOVIRAX z-sleep ZUBSOLV ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC zyrtec itchy eye drops (keto) 113 ZYTIGA ZYVOX I-24 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: , Version: Versione: In vigore da: 1 nov 2015

193 Questo formulario è stato aggiornato in data 27 Ottobre Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, da lunedì a venerdì, dalle 8:00 alle 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito

194 1.877.ICS Ufficio amministrativo Independence Care System 257 Park Ave. South 2nd Floor New York, NY Centri di assistenza per gli iscritti 400 East Fordham Road 10th floor Bronx, New York Elm Place 5th Floor Brooklyn, NY 11201