ELENCO DEI FARMACI COPERTI

Transcript

1 ELENCO DEI FARMACI COPERTI Community Care Plus FIDA-MMP ICS ICS H4465_ListofCoveredDrugs_2016_81415_Approved

2 H4465_ListofCoveredDrugs_2016_81415 ICS Community Care Plus FIDA-MMP Elenco dei farmaci coperti (formulario) per il 2016 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 coperti 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 coperti di ICS Community Care Plus FIDA-MMP in qualsiasi momento sul sito Web oppure contattando i Servizi per i partecipanti di ICS Community Care Plus FIDA-MMP 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. È possibile ottenere queste informazioni gratuitamente in altre lingue. Contattare il numero ICS.2525 e TTY 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visiti il sito 1

3 chiamata è gratuita. È possibile ottenere queste informazioni gratuitamente in altre lingue. Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону ICS.2525 и телетайпу TTY 711 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 711 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 711, 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 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. Lo Stato di New York ha creato un programma di tutela dei partecipanti (Participant Ombudsman Program) per offrire gratuitamente ai Partecipanti assistenza in modo riservato su tutti i servizi offerti da ICS Community Care Plus FIDA-MMP. L Ombudsman può essere contattato tramite il numero verde oppure attraverso il sito Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 2

4 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 coperti? (Per comodità, l Elenco dei farmaci coperti viene denominato Elenco dei farmaci.) I farmaci contenuti nell Elenco dei farmaci coperti che inizia a pagina 18 sono i farmaci coperti da ICS Community Care Plus FIDA-MMP. Questi farmaci sono disponibili 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 presenti 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. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 3

5 Un elenco aggiornato dei farmaci che copriamo è inoltre disponibile sul nostro sito oppure telefonicamente contattando il Servizi per i partecipanti 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 meno un'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) prima che il Partecipante possa ottenere un farmaco.] aggiungere o modificare la quantità di farmaco che il Partecipante può ottenere (chiamata 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 4

6 presentano ulteriori informazioni in merito a cosa accade quando l Elenco dei farmaci viene modificato. È possibile controllare l Elenco aggiornato dei farmaci di ICS Community Care Plus FIDA-MMP 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 caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che il cambiamento all Elenco dei farmaci venga effettuato. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 5

7 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 (Prior approval or prior authorization): 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 6

8 l approvazione, ICS Community Care Plus FIDA-MMP potrebbe non coprire tale farmaco. Limiti di quantità (Quantity limits): A volte ICS Community Care Plus FIDA- MMP limita la quantità di farmaco che è possibile ottenere. 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 18. 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 11. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 7

9 6. 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 coperti a pagina 18, presenta 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. 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 la modifica all Elenco dei farmaci venga effettuata. 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 in ordine alfabetico, andare alla sezione Elenco alfabetico a pagina I-1. Quindi cercare il nome del farmaco nell elenco. Per la ricerca per condizione medica, andare alla sezione Elenco dei farmaci per condizione medica a pagina 18. Quindi individuare la condizione medica. Per esempio, Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 8

10 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 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: Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 9

11 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. Potrà ripresentare la prescrizione più volte per 98 giorni. 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: 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 un centro di assistenza infermieristica avanzata coperto da Medicare, Parte A (inclusi i costi farmaceutici), e ritorna alla copertura come alla Parte D Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 10

12 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. 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 11

13 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 eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 12

14 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 )? 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 13

15 Elenco dei farmaci coperti L elenco dei farmaci coperti a pagina 18 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. Abbreviazioni e simboli Questo documento può contenere le seguenti abbreviazioni per la gestione dell'utilizzo. ABBREVIAZIONI DELLE NOTE DI COPERTURA ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE PA Limitazioni alla gestione dell utilizzo Prior Authorization Restriction (Autorizzazione preventiva obbligatoria) 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 Autorizzazione preventiva obbligatoria per determinazione Parte B o Parte D (Prior Authorization 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 14

16 ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE Restriction for Part B vs Part D Determination) 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. PA NSO QL ST Autorizzazione preventiva solo per i nuovi iscritti (Prior Authorization Restriction for New Starts Only) Limitazione della quantità (Quantity Limit Restriction) Limitazione tramite terapia per fasi (Step Therapy Restriction) 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 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) altri farmaci per il trattamento della sua condizione medica. Il farmaco d interesse potrà essere coperto solo Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 15

17 ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE se uno (o più) altri farmaci non funzionano per il Partecipante. Questo documento potrebbe non contenere le seguenti ulteriori abbreviazioni relative alla copertura. ALTRI REQUISITI SPECIALI PER LA COPERTURA LA Farmaco ad accesso limitato (Limited Access Drug) Questa prescrizione potrebbe essere disponibile solo presso determinate farmacie. Per ulteriori informazioni consultare l'elenco delle farmacie oppure contattare il Servizio per i membri al numero ICS.2525, tra le 8:00 e le 20:00, dal lunedì al venerdì. Gli utenti con funzionalità TTY/TDD devono rivolgersi al numero 711. NM * Farmaco non ordinato tramite servizio postale Farmaco non di Parte D (Not a Part D Drug) Il Partecipante potrebbe ricevere oltre 1 mese di fornitura della maggior parte dei farmaci presenti nel formulario tramite ordine postale a una prezzo ridotto. I farmaci non disponibili tramite ordine postale sono annotati con NM nella colonna Requisiti/Limiti del formulario del Partecipante. Il farmaco d interesse non è un farmaco di Parte D coperto da Medicaid. Nota: Il simbolo (*) 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 Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 16

18 il Partecipante non è coperto o non è più coperto da Medicare o 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 i Servizi per i partecipanti al numero ICS.2525 oppure il Garante dei Partecipanti FIDA (FIDA Participant Ombudsman) al numero ICS Informazioni su come fare ricorso su una decisione sono disponibili anche nel Manuale del Partecipante. Di seguito sono riportati i significati dei codici utilizzati nella colonna Azioni necessarie, limitazioni o limiti per l'uso : (g) = Solo la versione generica di questo farmaco è coperta. La versione con marchio non è coperta. M = La versione con marchio di questo farmaco è nel livello 3. La versione generica è nel livello 1. PA = Autorizzazione preventiva (Prior authorization, approvazione): il Partecipante deve ricevere l'approvazione da parte del piano o dell'equipe Interdisciplinare (IDT) prima di poter ottenere questo farmaco. ST = Terapia per fasi (Step therapy): il Partecipante deve provare un altro farmaco prima di ottenere questo. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito 17

19 Analgesics Analgesics, Miscellaneous acephen * rectal suppository 120 QL (360 per 30 days) (Acetaminophen) mg acephen * rectal suppository 325 QL (30 per 30 days) (Acetaminophen) mg, 650 mg acetaminophen * oral QL (30 per 30 days) (Acetaminophen) drops,suspension acetaminophen * oral (Acetaminophen) QL (240 per 30 days) acetaminophen * oral QL (30 per 30 days) (Acetaminophen) tablet,disintegrating 80 mg acetaminophen * rectal (Acetaminophen) QL (30 per 30 days) acetaminophen-codeine oral (Acetaminophen QL (2700 per 30 days) solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (360 per 30 days) mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (180 per 30 days) mg No.3) arthritis pain relief (acetam) * (Acetaminophen) QL (180 per 30 days) buprenorphine hcl injection butalb-acetaminophen-caffeine oral capsule mg butalbital-acetaminop-caf-cod (Buprenorphine HCl) (Esgic) (Fioricet with Codeine) butalbital-acetaminophen (Tencon) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) butalbital-acetaminophen-caff oral capsule mg (Esgic) butalbital-acetaminophen-caff oral tablet mg (Esgic) butalbital-aspirin-caffeine oral capsule (Fiorinal) BUTRANS QL (4 per 28 days) children's mapap * (Acetaminophen) QL (30 per 30 days) children's non-aspirin * oral (Acetaminophen) QL (240 per 30 days) 18

20 children's non-aspirin * oral (Acetaminophen) QL (30 per 30 days) children's pain & fever relief * oral (Infants' Tylenol) QL (240 per 30 days) children's pain reliever * oral (Acetaminophen) QL (30 per 30 days) children's silapap * (Tylenol Sore QL (240 per 30 days) Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 days) codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule mg Codeine #3) 30 days) fentanyl (Duragesic) PA; QL (10 per 30 days) fentanyl citrate (Actiq) PA; QL (120 per 30 days) feverall * rectal suppository 120 QL (30 per 30 days) (Acetaminophen) mg, 325 mg, 650 mg hydrocodone-acetaminophen oral QL (2700 per 30 days) (Hycet) solution (includes Vicodin, hydrocodone-acetaminophen oral Vicodin ES and tablet mg, mg, (Norco) Vicodin HP); QL (390 mg per 30 days) hydrocodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Norco) mg, mg hydrocodone-ibuprofen (Ibudone) QL (150 per 30 days) 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) hydromorphone oral liquid (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) jr. acetaminophen * (Acetaminophen) QL (30 per 30 days) 19

21 junior mapap * (Acetaminophen) QL (30 per 30 days) LAZANDA PA; QL (30 per 30 days) mapap (acetaminophen) * oral QL (240 per 30 days) (Acetaminophen) capsule mapap (acetaminophen) * oral QL (240 per 30 days) (Acetaminophen) elixir mapap (acetaminophen) * oral (Tylenol Sore QL (120 per 30 days) liquid 500 mg/15 ml Throat) mapap (acetaminophen) * oral QL (240 per 30 days) (Infants' Tylenol) suspension mapap (acetaminophen) * oral QL (360 per 30 days) (Tylenol) tablet mapap (acetaminophen) * oral QL (30 per 30 days) (Acetaminophen) tablet,chewable mapap arthritis pain * (Acetaminophen) QL (180 per 30 days) mapap extra strength * (Tylenol) QL (240 per 30 days) methadone hcl oral tablet,soluble 40 QL (90 per 30 days) (Diskets) mg methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 days) methadone oral (Diskets) QL (360 per 30 days) morphine concentrate oral solution (Morphine Sulfate) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) morphine in dextrose 5 % injection (Morphine pt controlled analgesia syring 50 Sulfate/D5W) mg/25 ml (2 mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 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) 20

22 morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Morphine Sulfate) QL (300 per 30 days) MORPHINE ORAL TABLET QL (180 per 30 days) morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) non-aspirin extra strength * oral (Acetaminophen) QL (240 per 30 days) non-aspirin extra strength * oral (Tylenol Sore QL (120 per 30 days) Throat) non-aspirin extra strength * oral tablet (Tylenol) non-aspirin jr strength * (Acetaminophen) QL (30 per 30 days) nortemp * oral (Acetaminophen) QL (30 per 30 days) NUCYNTA QL (181 per 30 days) NUCYNTA ER QL (60 per 30 days) (Oxycodone QL (1800 per 30 days) oxycodone hcl-acetaminophen oral HCl/Acetaminophe solution mg/5 ml n) oxycodone hcl-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 days) oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 days) oxycodone oral solution (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet (Roxicodone) QL (180 per 30 days) oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-aspirin (Percodan) QL (360 per 30 days) 21

23 OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) QL (60 per 30 days) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief adult * (Tylenol Sore QL (120 per 30 days) Throat) pain relief * oral capsule (Acetaminophen) QL (240 per 30 days) pain relief * oral tablet extended QL (180 per 30 days) (Acetaminophen) release pain reliever extra strength * (Tylenol) QL (240 per 30 days) pain reliever jr strength * (Acetaminophen) QL (30 per 30 days) pharbetol * oral tablet 325 mg (Tylenol) QL (360 per 30 days) pharbetol * oral tablet 500 mg (Tylenol) QL (240 per 30 days) q-pap extra strength * (Tylenol) QL (240 per 30 days) q-pap * oral drops (Acetaminophen) QL (30 per 30 days) q-pap * oral liquid (Tylenol Sore QL (240 per 30 days) Throat) q-pap * oral tablet (Tylenol) QL (360 per 30 days) silapap * (Acetaminophen) QL (30 per 30 days) tactinal * (Tylenol) QL (360 per 30 days) tactinal extra strength * (Tylenol) QL (240 per 30 days) tramadol oral tablet (Ultram) QL (240 per 30 days) tramadol-acetaminophen (Ultracet) QL (240 per 30 days) xylon 10 (Ibudone) QL (150 per 30 days) Nonsteroidal Anti- Inflammatory Agents 22

24 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 (dr/ec) 325 mg, 500 mg, 81 mg (Ecotrin) 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 days) children's advil * (Children'S Motrin) choline,magnesium salicylate (Choline Sal/Mag Salicylate) diclofenac potassium (Diclofenac Potassium) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR) 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 (Flurbiprofen) 23

25 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) indomethacin oral capsule 50 mg (Indomethacin) indomethacin oral capsule, extended release (Indomethacin) indomethacin sodium (Indomethacin Sodium) 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 oral (Ketorolac Tromethamine) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam (Feldene) salsalate (Salsalate) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) PA-HRM QL (20 per 30 days) 24

26 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 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) lidocaine-prilocaine topical kit (Relador Pak) RELADOR PAK Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents 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) 25

27 acamprosate Name of Drug (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex) buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) PA; QL (90 per 30 days) PA; QL (90 per 30 days) CHANTIX QL (168 per 84 days) CHANTIX CONTINUING QL (56 per 28 days) MONTH BOX CHANTIX CONTINUING QL (56 per 28 days) MONTH PAK CHANTIX STARTING MONTH QL (53 per 28 days) BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICODERM CQ * QL (168 per 365 days) 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 QL (180 per 365 days) (Nicoderm Cq) hour 14 mg/24 hr, 7 mg/24 hr nicotine * transdermal patch 24 QL (168 per 365 days) (Nicoderm Cq) hour 21 mg/24 hr, 22 mg/24 hr NICOTROL QL (1008 per 90 days) ZUBSOLV PA; QL (90 per 30 days) 26

28 Antianxiety Agents Benzodiazepines alprazolam oral tablet (Xanax) QL (120 per 30 days) chlordiazepoxide hcl (Chlordiazepoxide QL (120 per 30 days) HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection (Diazepam) QL (10 per 28 days) diazepam intensol (Diazepam) QL (1200 per 30 days) diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet (Valium) QL (120 per 30 days) diazepam rectal (Diastat) lorazepam oral tablet (Ativan) QL (90 per 30 days) ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Gentamicin Sulfate) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) PA NSO; QL (480 per 30 days) PA NSO; QL (60 per 30 days) 27

29 gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 days) tobramycin in % nacl (Tobi) PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodiu m Chloride) tobramycin sulfate injection solution (Tobramycin Sulfate) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) 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 (Methenamine Mandelate) metronidazole in nacl (iso-os) (Metronidazole/So dium Chloride) metronidazole oral (Flagyl) nitrofurantoin macrocrystal oral PA-HRM; QL (120 per (Macrodantin) capsule 100 mg, 25 mg 30 days) 28

30 nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) polymyxin b sulfate (Polymyxin B Sulfate) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Cephalosporins cefaclor oral capsule (Cefaclor) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA; QL (9 per 30 days) PA; QL (60 per 30 days) 29

31 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 ML cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg (Cefazolin Sodium/Dextrose, Iso) (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO- OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Cefoxitin Sodium) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os (Ceftriaxone intravenous piggyback 1 gram/50 ml Na/Dextrose, Iso) 30

32 CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 (Ceftriaxone 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) cephalexin oral capsule (Keflex) cephalexin oral suspension for reconstitution (Cephalexin) cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO- OSM) SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Clarithromycin) release 24 hr DIFICID QL (20 per 10 days) ERYTHROCIN erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG (Erythromycin Base) 31

33 erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet (Eryped 200) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Erythromycin Stearate) erythromycin stearate oral tablet 250 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram (Azactam) CAYSTON LA imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) meropenem-0.9% sodium chloride (Meropenem-0.9% Sodium Chloride) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for reconstitution (Amoxicillin) amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 (Amoxicillin) mg, 250 mg 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 tablet,chewable (Amoxicillin/Potas sium Clav) 32

34 ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon (Ampicillin soln Sodium) ampicillin sodium intravenous recon (Ampicillin soln Sodium) ampicillin-sulbactam injection (Unasyn) ampicillin-sulbactam intravenous recon soln (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin injection (Nafcillin Sodium) nafcillin intravenous recon soln (Nafcillin Sodium) (Oxacillin oxacillin in dextrose(iso-osm) Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous (Oxacillin Sodium) (Pen G penicillin g pot in dextrose Pot/Dextrose- Water) penicillin g potassium injection (Penicillin G recon soln 20 million unit 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 (Ciprofloxacin Lactate) 33

35 levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous Trimethoprim) 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 (Avidoxy) doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension for reconstitution (Vibramycin) 34

36 doxycycline monohydrate oral tablet (Avidoxy) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Tetracycline HCl) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS PA NSO; QL (4 per 21 days) AFINITOR DISPERZ PA NSO; QL (112 per 28 days) AFINITOR ORAL TABLET 10 PA NSO; QL (56 per MG 28 days) AFINITOR ORAL TABLET 2.5 PA NSO; QL (28 per MG, 5 MG, 7.5 MG 28 days) ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) AVASTIN PA NSO azacitidine (Vidaza) BELEODAQ PA NSO bexarotene (Targretin) PA NSO; QL (420 per 30 days) bicalutamide (Casodex) bleomycin (Bleomycin PA BvD Sulfate) BLINCYTO PA NSO; QL (140 per 365 days) BOSULIF ORAL TABLET 100 PA NSO; QL (120 per MG 30 days) BOSULIF ORAL TABLET 500 PA NSO; QL (30 per MG 30 days) CAPRELSA ORAL TABLET 100 PA NSO; QL (60 per MG 30 days) 35

37 CAPRELSA ORAL TABLET 300 MG COMETRIQ COTELLIC cyclophosphamide intravenous recon soln CYCLOPHOSPHAMIDE ORAL CAPSULE (Cyclophosphamid e) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; QL (63 per 28 days) PA BvD PA BvD; ST (Cyclophosphamid cyclophosphamide oral tablet e) CYRAMZA PA NSO dactinomycin (Dactinomycin) DARZALEX PA NSO decitabine (Dacogen) PA BvD; ST 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 days) SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 112 days) SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 168 days) SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT EMPLICITI PA NSO ERIVEDGE PA NSO; QL (30 per 30 days) ETOPOPHOS etoposide intravenous (Etoposide) 36

38 exemestane (Aromasin) FARESTON FARYDAK PA NSO FASLODEX floxuridine (Floxuridine) PA BvD fluorouracil intravenous solution PA BvD 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml (Fluorouracil) flutamide (Flutamide) GAZYVA PA NSO GILOTRIF PA NSO; QL (30 per 30 days) GLEEVEC ORAL TABLET 100 PA NSO; QL (90 per MG 30 days) GLEEVEC ORAL TABLET 400 PA NSO; QL (60 per MG 30 days) HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) IBRANCE PA NSO; QL (21 per 28 days) ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 days) ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna PA BvD ) IMBRUVICA PA NSO IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML PA NSO; QL (4 per 365 days) IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML PA NSO; QL (8 per 28 days) 37

39 INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 days) IRESSA PA NSO; QL (60 per 30 days) IXEMPRA JAKAFI PA NSO; QL (60 per 30 days) KEYTRUDA PA NSO KYPROLIS PA NSO; QL (6 per 28 days) LENVIMA PA NSO letrozole (Femara) LEUKERAN leuprolide subcutaneous kit (Leuprolide Acetate) lomustine (Gleostine) LONSURF ORAL TABLET 15- PA NSO; QL (100 per 6.14 MG 28 days) LONSURF ORAL TABLET 20- PA NSO; QL (80 per 8.19 MG 28 days) LUPRON DEPOT LUPRON DEPOT (3 MONTH) QL (1 per 84 days) LUPRON DEPOT (4 MONTH) QL (1 per 84 days) LUPRON DEPOT (6 MONTH) QL (1 per 168 days) LYNPARZA PA NSO; QL (480 per 30 days) LYSODREN MATULANE megestrol oral suspension 625 mg/5 (Megestrol ml Acetate) megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 days) 38

40 MEKINIST ORAL TABLET 2 MG mercaptopurine (Mercaptopurine) methotrexate sodium (pf) injection (Methotrexate recon soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution Sodium) methotrexate sodium injection (Methotrexate Sodium) methotrexate sodium oral (Methotrexate Sodium) mitoxantrone (Mitoxantrone HCl) NEXAVAR PA NSO; QL (30 per 30 days) PA BvD PA BvD PA BvD PA BvD; ST PA NSO; QL (120 per 30 days) NILANDRON NINLARO PA NSO; QL (3 per 28 days) ODOMZO PA NSO ONCASPAR PA NSO OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST PA NSO PA NSO; QL (21 per 28 days) PROLEUKIN PURIXAN REVLIMID PA NSO; LA RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) 39

41 SUTENT PA NSO; QL (30 per 30 days) SYLVANT PA NSO SYNRIBO PA NSO; QL (28 per 28 days) TABLOID TAFINLAR PA NSO; QL (120 per 30 days) TAGRISSO PA NSO; QL (30 per 30 days) tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 PA NSO; QL (60 per MG, 25 MG 30 days) TARCEVA ORAL TABLET 150 PA NSO; QL (90 per MG 30 days) TARGRETIN ORAL PA NSO; QL (420 per 30 days) TARGRETIN TOPICAL PA NSO; QL (60 per 28 days) TASIGNA PA NSO; QL (112 per 28 days) TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) TREANDA TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL (1 per 84 days) SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB 40

42 UNITUXIN PA NSO VALSTAR VELCADE PA NSO vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; QL (120 per 30 days) XALKORI PA NSO; QL (60 per 30 days) XTANDI PA NSO; QL (120 per 30 days) YERVOY INTRAVENOUS PA NSO SOLUTION YONDELIS PA NSO ZELBORAF PA NSO; QL (240 per 30 days) ZOLADEX SUBCUTANEOUS QL (1 per 84 days) IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 28 days) IMPLANT 3.6 MG ZOLINZA ZYDELIG PA NSO; QL (60 per 30 days) ZYKADIA PA NSO; QL (140 per 28 days) ZYTIGA PA NSO; QL (120 per 30 days) Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml (Atropine Sulfate) (Atropine Sulfate) (Propantheline propantheline Bromide) STIOLTO RESPIMAT QL (4 per 28 days) 41

43 Anticonvulsants Anticonvulsants 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) 42

44 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 days) LYRICA ORAL SOLUTION QL (900 per 30 days) oxcarbazepine (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 days) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) 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, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone (Mysoline) SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 43

45 TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS QL (200 per 5 days) VIMPAT ORAL SOLUTION QL (1200 per 30 days) VIMPAT ORAL TABLET QL (60 per 30 days) zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 days) donepezil oral tablet,disintegrating (Donepezil HCl) QL (30 per 30 days) EXELON TRANSDERMAL QL (30 per 30 days) galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr galantamine oral solution (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet (Razadyne) QL (60 per 30 days) memantine oral solution (Namenda) QL (360 per 30 days) memantine oral tablet (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack (Namenda) QL (49 per 28 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK QL (28 per 28 days) NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate (Exelon) QL (60 per 30 days) Antidepressants Antidepressants amitriptyline (Amitriptyline PA NSO-HRM HCl) amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) 44

46 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 days) clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) release(dr/ec) 40 mg days) EMSAM QL (30 per 30 days) escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) (Prozac Weekly) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) fluvoxamine (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM 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) 45

47 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 days) protriptyline (Protriptyline HCl) sertraline (Zoloft) SILENOR QL (30 per 30 days) SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) trimipramine (Trimipramine PA NSO-HRM Maleate) 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 days) CYCLOSET QL (180 per 30 days) GLYXAMBI ST; QL (30 per 30 days) INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG ST; QL (60 per 30 days) INVOKAMET ORAL TABLET MG ST; QL (120 per 30 days) 46

48 INVOKANA ORAL TABLET 100 ST; QL (60 per 30 MG days) INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG days) JANUMET QL (60 per 30 days) JANUMET XR ORAL TABLET, QL (30 per 30 days) ER MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, QL (60 per 30 days) ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA QL (30 per 30 days) JARDIANCE ST; QL (30 per 30 days) JENTADUETO QL (60 per 30 days) KORLYM PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 days) pioglitazone (Actos) QL (30 per 30 days) pioglitazone-glimepiride (Duetact) QL (30 per 30 days) pioglitazone-metformin (Actoplus Met) QL (90 per 30 days) PRANDIMET QL (150 per 30 days) repaglinide (Prandin) QL (240 per 30 days) repaglinide-metformin (Prandimet) QL (150 per 30 days) SYMLINPEN 120 PA; QL (10.8 per 28 days) SYMLINPEN 60 PA; QL (6 per 28 days) 47

49 SYNJARDY ST; QL (60 per 30 days) TRADJENTA QL (30 per 30 days) TRULICITY ST; QL (4 per 28 days) VICTOZA ST; QL (9 per 28 days) Insulins HUMULIN R U-500 (CONCENTRATED) QL (40 per 28 days) LANTUS QL (40 per 28 days) LANTUS SOLOSTAR QL (30 per 28 days) NOVOLIN 70/30 QL (40 per 28 days) NOVOLIN N QL (40 per 28 days) NOVOLIN R QL (40 per 28 days) NOVOLOG QL (40 per 28 days) NOVOLOG FLEXPEN QL (30 per 28 days) NOVOLOG MIX QL (40 per 28 days) NOVOLOG MIX FLEXPEN QL (30 per 28 days) NOVOLOG PENFILL QL (30 per 28 days) TOUJEO SOLOSTAR Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended release 24hr 10 mg 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 (Glucotrol XL) (Glucotrol XL) (Glipizide/Metform in HCl) (Glipizide/Metform in HCl) (Glynase) (Glynase) QL (60 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (120 per 30 days) PA-HRM; QL (400 per 30 days) PA-HRM; QL (180 per 30 days) 48

50 glyburide micronized oral tablet 6 PA-HRM; QL (120 per (Glynase) mg 30 days) glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 days) glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 days) glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 days) glyburide-metformin oral tablet PA-HRM; QL (240 per (Glucovance) mg 30 days) glyburide-metformin oral tablet 2.5- PA-HRM; QL (120 per (Glucovance) 500 mg, mg 30 days) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals 3 day vaginal * (Miconazole Nitrate) ABELCET PA BvD af * (Tinactin) aloe vesta antifungal (micon) * (Miconazole Nitrate) AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD 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) 49

51 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-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) econazole topical (Econazole Nitrate) elon dual defense * (Undecylenic Acid) fluconazole (Diflucan) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml 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) 50

52 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 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) 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, 10 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin topical powder 100,000 unit/gram (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin ) 51

53 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) allegra allergy * (Fexofenadine HCl) aller-chlor * oral syrup (Chlorpheniramine Maleate) aller-chlor * oral tablet (Chlor-Trimeton) allerclear d-12hr * (Claritin-D 12 Hour) allerclear d-24hr * (Claritin-D 24 Hour) allergy (chlorpheniramine) * (Chlor-Trimeton) allergy (diphenhydramine) * oral (Diphenhydramine tablet HCl) allergy relief (cetirizine) * oral (Zyrtec) allergy relief (loratadine) * oral (Claritin) allerhist-1 * (Clemastine Fumarate) aller-tec d * (Zyrtec-D) ambi 60pse-4cpm * (Pseudoephed/Chlo rpheniramine) aprodine * (Pseudoephedrine/ Triprolidine) banophen allergy * (Zzzquil) 52

54 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 10 mg (Zyrtec) cetirizine * oral tablet,chewable 5 mg (Zyrtec) cetirizine-pseudoephedrine * (Zyrtec-D) child allergy relf(cetirizine) * oral tablet,chewable (Zyrtec) child triaminic cold & allergy * (Dimetapp) child wal-tap cold-allergy * (Dimetapp) children's allegra allergy * (Fexofenadine HCl) children's aller-tec * (Children'S Zyrtec) CHILDREN'S CLARITIN * children's wal-dryl allergy * oral (Zzzquil) children's wal-zyr * oral (Zyrtec) CHILDREN'S ZYRTEC ALLERGY * CLARITIN LIQUI-GEL * CLARITIN * ORAL TABLET CLARITIN REDITABS * clemastine * oral tablet 1.34 mg (Clemastine Fumarate) cold & cough * oral liquid (Triaminic Nighttime Cold- Cough) cold-allergy-sinus * (Pseudoephedrine/ Triprolidine) compoz * (Diphenhydramine HCl) cyproheptadine (Cyproheptadine HCl) 53

55 dailyhist-1 * (Clemastine Fumarate) dayhist allergy * (Clemastine Fumarate) dimaphen (pe) * (Dimetapp) dimetapp cold-congestion * (Triaminic Nighttime Cold- 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 * oral capsule (Benadryl) diphenhydramine hcl * oral tablet (Diphenhydramine 50 mg HCl) ed chlorped jr * (Chlorpheniramine Maleate) fexofenadine * oral suspension (Fexofenadine HCl) fexofenadine * oral tablet 180 mg, (Fexofenadine 60 mg HCl) levocetirizine (Xyzal) loratadine * oral (Children'S 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) PA-HRM 54

56 q-dryl * oral liquid (Zzzquil) siladryl sa * (Zzzquil) simply sleep * (Diphenhydramine HCl) sinus & allergy (pseudoephed) * (Pseudoephed/Chlo rpheniramine) sleep aid (diphenhydramine) * oral (Zzzquil) sleep aid (doxylamine) * (Doxylamine Succinate) sudogest sinus & allergy * (Pseudoephed/Chlo rpheniramine) TRIAMINIC COLD & COUGH NT (PE) * unisom sleepgels * (Benadryl) wal-act d cold & allergy * (Pseudoephedrine/ Triprolidine) wal-dryl allergy * oral (Benadryl) wal-dryl allergy * oral (Diphenhydramine HCl) wal-fex allergy * (Fexofenadine HCl) wal-finate * (Chlor-Trimeton) wal-finate-d * (Pseudoephed/Chlo rpheniramine) wal-itin d * (Claritin-D 24 Hour) wal-itin d 12 hour * (Claritin-D 12 Hour) wal-itin * oral solution (Children'S Claritin) wal-itin * oral tablet (Claritin) wal-itin * oral tablet,disintegrating (Claritin) wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlo rpheniramine) wal-phed pe sinus & allergy * (Phenylephrine/Chl orpheniramine) wal-sleep z * oral capsule (Benadryl) 55

57 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 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 days) dihydroergotamine nasal (Migranal) QL (8 per 28 days) ERGOMAR QL (40 per 28 days) naratriptan (Amerge) QL (18 per 28 days) rizatriptan oral tablet (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating (Maxalt Mlt) QL (18 per 28 days) sumatriptan nasal spray (Imitrex) QL (12 per 28 days) 56

58 sumatriptan 6 mg/0.5 ml inject 2 (Sumatriptan QL (4 per 28 days) autoinjector,outer Succinate) sumatriptan oral tablet (Imitrex) QL (18 per 28 days) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) cartridge sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) pen injector 4 mg/0.5 ml Succinate) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) solution zolmitriptan oral tablet (Zomig) QL (12 per 28 days) zolmitriptan oral QL (12 per 28 days) (Zomig Zmt) tablet,disintegrating Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO PA; QL (188 per 168 days) TRECATOR Antinausea Agents Antinausea Agents AKYNZEO PA BvD dimenhydrinate injection solution (Dimenhydrinate) dramamine * oral tablet (Dimenhydrinate) driminate * (Dimenhydrinate) 57

59 dronabinol (Marinol) EMEND INTRAVENOUS QL (2 per 28 days) EMEND ORAL PA BvD granisetron (pf) intravenous (Granisetron solution HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) 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 ondansetron hcl (pf) (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection (Prochlorperazine solution Edisylate) 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 days) travel sickness (meclizine) * (Bonine) wal-dram * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) 58

60 chloroquine phosphate oral (Chloroquine Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate) PENTAM PRIMAQUINE QL (90 per 30 days) quinine sulfate (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) APOKYN QL (60 per 30 days) 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 PA-HRM ST; QL (30 per 30 days) release 24 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) 59

61 trihexyphenidyl Name of Drug Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG (Trihexyphenidyl HCl) PA-HRM QL (90 per 30 days) QL (1 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral solution (Abilify) QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML 60

62 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating (Fazaclo) ST FANAPT ORAL TABLET ST; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 days) PACK fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 days) haloperidol (Haloperidol) haloperidol decanoate (Haloperidol intramuscular solution 100 mg/ml Decanoate) haloperidol decanoate (Haldol Decanoate intramuscular solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG ST; QL (30 per 30 days) 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 ST; QL (60 per 30 days) QL (0.75 per 28 days) QL (1 per 28 days) QL (1.5 per 28 days) 61

63 INVEGA SUSTENNA QL (0.25 per 28 days) INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 days) INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA QL (0.875 per 84 days) INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA QL (1.315 per 84 days) INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA QL (1.75 per 84 days) INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA QL (2.625 per 84 days) INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 ST; QL (30 per 30 MG, 20 MG, 40 MG, 60 MG days) LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 days) loxapine succinate (Loxapine Succinate) molindone oral tablet 10 mg (Moban) QL (240 per 30 days) molindone oral tablet 25 mg (Moban) QL (270 per 30 days) molindone oral tablet 5 mg (Moban) QL (120 per 30 days) olanzapine intramuscular (Zyprexa) QL (30 per 30 days) olanzapine oral tablet (Zyprexa) QL (30 per 30 days) olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating QL (31 per 30 days) (Zyprexa Zydis) 20 mg ORAP paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg 62

64 paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine (Perphenazine) pimozide (Orap) quetiapine (Seroquel) QL (90 per 30 days) REXULTI ORAL TABLET 0.25 QL (120 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) risperidone oral solution (Risperdal) QL (480 per 30 days) risperidone oral tablet (Risperdal) QL (60 per 30 days) risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) QL (60 per 30 days) risperidone oral QL (120 per 30 days) (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 days) thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Thiothixene) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; QL (540 per 30 days) ziprasidone hcl (Geodon) QL (60 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) 63

65 APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS GENVOYA 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 64

66 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 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 days) MG TAMIFLU ORAL CAPSULE 45 QL (48 per 180 days) MG TAMIFLU ORAL CAPSULE 75 QL (42 per 180 days) MG TAMIFLU ORAL SUSPENSION QL (540 per 180 days) FOR RECONSTITUTION Hcv Antivirals DAKLINZA PA; QL (28 per 28 days) HARVONI PA; QL (30 per 30 days) OLYSIO PA; QL (28 per 28 days) 65

67 SOVALDI PA; QL (28 per 28 days) TECHNIVIE PA; QL (56 per 28 days) Interferons INTRON A INJECTION PA NSO PEGASYS PA PEGASYS PROCLICK PA PEGINTRON PA SYLATRON Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous (Acyclovir PA NSO; QL (4 per 28 days) 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 mg, 600 mg (Copegus) TYZEKA valacyclovir (Valtrex) valganciclovir (Valcyte) VIRAZOLE PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS 66

68 enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 days) enoxaparin subcutaneous syringe QL (36 per 30 days) (Lovenox) 100 mg/ml enoxaparin subcutaneous syringe QL (27.2 per 30 days) (Lovenox) 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe QL (34 per 30 days) (Lovenox) 150 mg/ml enoxaparin subcutaneous syringe 30 QL (18 per 30 days) (Lovenox) mg/0.3 ml enoxaparin subcutaneous syringe 40 QL (13.6 per 30 days) (Lovenox) mg/0.4 ml enoxaparin subcutaneous syringe 60 QL (20.4 per 30 days) (Lovenox) mg/0.6 ml fondaparinux subcutaneous syringe QL (24 per 30 days) (Arixtra) 10 mg/0.8 ml fondaparinux subcutaneous syringe QL (15 per 30 days) (Arixtra) 2.5 mg/0.5 ml fondaparinux subcutaneous syringe QL (12 per 30 days) (Arixtra) 5 mg/0.4 ml fondaparinux subcutaneous syringe QL (18 per 30 days) (Arixtra) 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin 12,500 unit/250 ml, 20,000 unit/500 Sodium,Porcine/D5 ml (40 unit/ml), 25,000 unit/500 ml W) (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection solution 10,000 unit/ml (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine) PA BvD; (PA for ESRD Only) PA BvD 67

69 heparin sodium,porcine-pf intravenous syringe 10 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container (Monoject Prefill Advanced) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) IPRIVASK jantoven (Coumadin) PA BvD PA BvD; (PA for ESRD Only) PA; QL (24 per 28 days) PRADAXA ST; QL (60 per 30 days) warfarin (Coumadin) XARELTO Blood Formation Modifiers CINRYZE PA 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 INJECTION SYRINGE 100 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL NEULASTA PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 68

70 NEUMEGA NEUPOGEN 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 PROMACTA ZARXIO Hematologic Agents, Miscellaneous aminocaproic acid oral (Aminocaproic Acid) anagrelide (Agrylin) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 days) aspirin-dipyridamole (Aggrenox) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 days) pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % 69

71 ALBUMINAR 5 % 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 70

72 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 (Dextrose 10 % d10 %-0.9 % sodium chloride and 0.9 % NaCl) 71

73 dex4 glucose * oral tablet,chewable (Dextrose) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) 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 72

74 PERIKABIVEN PA BvD 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) clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidon e) clonidine transdermal patch weekly QL (4 per 28 days) (Catapres-Tts 1) 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly QL (8 per 28 days) (Catapres-Tts 1) 0.3 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) NORTHERA PA; QL (180 per 30 days) phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) ENTRESTO PA; QL (60 per 30 days) irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) 73

75 losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR ST valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) captopril-hydrochlorothiazide (Captopril/Hydroch lorothiazide) enalapril maleate (Vasotec) enalaprilat intravenous solution (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydroc hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Moexipril HCl) moexipril-hydrochlorothiazide (Moexipril/Hydroc hlorothiazide) 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) 74

76 disopyramide phosphate oral capsule (Norpace) flecainide (Tambocor) lidocaine (pf) intravenous syringe (Lidocaine 50 mg/5 ml (1 %) HCl/PF) lidocaine in 5 % dextrose (pf) (Lidocaine intravenous parenteral solution 8 HCl/D5w/PF) mg/ml (0.8 %) 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 (Labetalol HCl) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Lopressor) metoprolol tartrate oral (Lopressor) 75

77 nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) 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) 76

78 verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous 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 days) digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 days) digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 days) 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 days) dobutamine in d5w intravenous PA BvD parenteral solution 1,000 mg/250 ml (Dobutamine (4,000 mcg/ml), 250 mg/250 ml (1 HCl/D5W) 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) epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector (Adrenaclick) epinephrine injection solution (Epinephrine) 77

79 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 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) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA BvD 78

80 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 mg (Chlorthalidone) 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 capsule (Dyazide) triamterene-hydrochlorothiazid oral tablet (Maxzide) Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral (Cholestyramine/A powder 4 gram spartame) cholestyramine-aspartame oral powder in packet 4 gram (Questran) colestipol (Colestid) CRESTOR 79

81 endur-acin * oral tablet extended release 500 mg (Slo-Niacin) fenofibrate micronized (Lofibra) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) JUXTAPID PA KYNAMRO PA; QL (4 per 28 days) lovastatin (Mevacor) niacin * oral capsule, extended release 500 mg (Niacin) niacin * oral tablet 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 days) PRALUENT SYRINGE PA; QL (2 per 28 days) pravastatin (Pravachol) REPATHA SURECLICK PA; QL (3 per 28 days) REPATHA SYRINGE PA; QL (3 per 28 days) simvastatin (Zocor) QL (30 per 30 days) VASCEPA ZETIA Renin-Angiotensin- Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) 80

82 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 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose (Nitroglycerin/D5 intravenous solution W) nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 (Nitro-Dur) mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) amphetamine salt combo (Adderall) QL (60 per 30 days) AMPYRA PA; QL (60 per 30 days) 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 days) 81

83 dextroamphetamine oral capsule, QL (120 per 30 days) (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 days) dextroamphetamine-amphetamine QL (30 per 30 days) oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) dextroamphetamine-amphetamine QL (60 per 30 days) 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 (Lithium Carbonate) 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, 40 mg, 50 mg, 60 mg (Metadate Cd) QL (30 per 30 days) methylphenidate oral capsule, er QL (60 per 30 days) (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 days) (Metadate Cd) biphasic mg, 40 mg methylphenidate oral capsule,er QL (60 per 30 days) (Metadate Cd) biphasic mg methylphenidate oral solution (Methylin) QL (900 per 30 days) methylphenidate oral tablet (Ritalin) QL (90 per 30 days) methylphenidate oral tablet (Methylphenidate QL (90 per 30 days) extended release HCl) methylphenidate oral tablet QL (30 per 30 days) extended release 24hr 18 mg, 27 mg, 54 mg (Concerta) methylphenidate oral tablet QL (60 per 30 days) (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 days) 82

84 QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 days) STRATTERA tetrabenazine (Xenazine) PA; QL (112 per 28 days) XENAZINE PA; QL (112 per 28 days) Contraceptives Contraceptives AFTERA * 3 $0 QL (6 per 365 days) ashlyna (Seasonique) bekyree (28) (Mircette) blisovi 24 fe (Loestrin Fe) blisovi fe 1/20 (28) (Loestrin Fe) cyred (Desogen) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/ mg-mcg, (Desogen) 0.03 mg drospirenone-ethinyl estradiol (Yaz) econtra ez * (Aftera) QL (6 per 365 days) ELLA QL (6 per 365 days) ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Demulen ) gildess 1/20 (21) (Loestrin) gildess 24 fe (Loestrin Fe) gildess fe 1/20 (28) (Loestrin Fe) juleber (Desogen) junel fe 24 (Loestrin Fe) kimidess (28) (Mircette) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 days) larin 24 fe (Loestrin Fe) larin fe 1/20 (28) (Loestrin Fe) 83

85 levonorgestrel * 1.5 mg tablet (otc) (Aftera) QL (6 per 365 days) levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (12 per 365 days) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel * oral tablet 1.5 mg (Aftera) QL (6 per 365 days) levonorgestrel-ethin estradiol oral tablet mg-mcg, mg, (Amethyst) (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month mg-mcg (Levonorgestrel- Ethin Estradiol) QL (91 per 84 days) levonorgestrel-ethinyl estrad oral tablet (Amethyst) levonorgestrel-ethinyl estrad oral QL (91 per 84 days) (Amethyst) tablet mg levonorgestrel-ethinyl estrad oral QL (91 per 84 days) (Amethyst) tablets,dose pack,3 month l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 days) next choice one dose 1.5 mg tb (rx) QL (6 per 365 days) (Plan B One-Step) 1.5 mg norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 days) 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 oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), 1- (Loestrin Fe) 20(5)/1-30(7) /1mg-35mcg (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) 84

86 norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 days) opcicon one-step * (Aftera) QL (6 per 365 days) PLAN B ONE-STEP * 3 $0 QL (6 per 365 days) setlakin (Levonorgestrel- QL (91 per 84 days) Ethin Estradiol) tarina fe 1/20 (28) (Loestrin Fe) Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) actinel pediatric * (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) 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 pediatric * (Trispec Pse) 85

87 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 cheracol d * (G-Zyncof) 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 ) child mucinex chest congestion * (Robitussin Mucus-Chest Congest) 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 * (Robitussin Mucus-Chest Congest) children's mucinex cough * (G-Zyncof) childrens plus multi-symp cold * (Childrens Tylenol Plus Cold) children's silfedrine * (Pseudoephedrine HCl) children's sudafed * (Pseudoephedrine HCl) children's sudafed pe cough * (Dextromethorphan /Phenylephrine) 86

88 chlophedianol-guaifenesin * (Vanacof G) chlorpheniramine-phenyleph-dm * (Dm/Phenyleph/Ch lorpheniramine) codituss dm * (Pyrilamine/Pe/De xtromethorphan) cold multi-symptom day/night * (Dm Hb/Pe/Acetaminop hen/chlorph) 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 cold-multi sympt * (D- Methorphan/Aceta min/doxylamn) coricidin hbp * oral capsule (Guaifenesin/Dextr omethorphan) cough & cold * oral (Coricidin Hbp) cough & runny nose * (Vicks Children'S Nyquil) daytime cold & cough * (Triaminic) daytime cold-flu * (D- Methorphan/Pe/Ac etaminophen) day-time cough * (Dextromethorphan Hbr) daytime-nighttime * (Vicks Dayquil- Nyquil) daytime-nighttime cold-flu * (Dm/Pe/Acetamino phen/doxylamine) daytime-nighttime cough * (Dextromethorphan Hb/Doxylamine) 87

89 decongestant cough * (Trispec Pse) delsym cough+chest congest dm * (G-Zyncof) despec-dm (pseudoeph-dm-guaif) * oral tablet mg (Poly-Vent Dm) dextromethorphan polistirex * (Delsym) diabetic siltussin das-na * (Robitussin Mucus-Chest Congest) diabetic tussin dm * oral liquid mg/5 ml (G-Zyncof) diabetic tussin max st * (G-Zyncof) (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) 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 * (Dm Hb/Pseudoephed/A cetamin/cp) geri-tussin dm * (Cough Formula Dm) guaifenesin dac * (Tusnel C) guaifenesin * oral tablet 200 mg (Allfen) guaifenesin * oral tablet extended release 12hr (Mucinex) 88

90 head congestion day-night * hydrocodone bit-homatrop me-br * oral syrup mg/5 ml (Dm Hb/Pe/Acetaminop hen/chlorph) (Hydrocodone Bit/Homatrop Me- Br) 3 $0 hydrocodone-chlorpheniramine * (Tussionex) 3 $0 hydrocodone-homatropine * oral tablet (Tussigon) 3 $0 infants' non-aspirin cold * (Dm/Pseudoephed/ Acetaminophen) liquibid d-r * (Maxiphen) 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) mucus dm * (Mucinex Dm) mucus dm max * (Mucinex Dm) mucus relief cough * (G-Zyncof) 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) nasohist dm * (Dm/Phenyleph/Ch lorpheniramine) neo-tuss * (G-Zyncof) NEXAFED * 89

91 night time cold-flu * oral night time cold-flu relief * oral liquid night time * oral capsule nighttime cough * NITE TIME COLD-FLU RELIEF * ORAL CAPSULE nite time-d cold-flu relief * nohist-dm * non-aspirin cold * non-aspirin flu * oral tablet mg pecgen dmx * oral liquid mg/5 ml pedia relief * pedia relief cough-cold * pedia relief infant * pediacare multi-symptom cold * (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dextromethorphan Hb/Doxylamine) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/Phenyleph/Ch lorpheniramine) (Dm Hb/Pseudoephed/A cetamin/cp) (Dm/Pseudoephed/ Acetaminophen) (G-Zyncof) (D-Methorphan Hb/P-Ephed HCl/Cp) (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) 90

92 phenylhistine dh * (P-Ephed HCl/Cod/Chlorphe nir) poly-tussin * (Chlorcyclizine/Co deine) promethazine-codeine * (Promethazine HCl/Codeine) 3 $0 promethazine-dm * (Promethazine/Dex tromethorphan) 3 $0 promethazine-phenyleph-codeine * (Promethazine/Phe nyleph/codeine) 3 $0 pseudoephedrine hcl * oral (Pseudoephedrine HCl) 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 * oral tablet 200 mg (Allfen) refenesen pe * (Maxiphen) relcof c * (M-Clear Wc) 3 $0 REZIRA * 3 $0 robafen * (Robitussin Mucus-Chest Congest) robafen cough * (Robitussin) robafen dm * (Cough Formula Dm) robitussin cough-chest cong dm * (Guaifenesin/Dextr oral capsule omethorphan) ROBITUSSIN LONG-ACTING * robitussin pediatric * (Dextromethorphan Hbr) 91

93 rydex * (Bromphenira/Pseu doephed/codein) rynex dm * (Brompheniram/Ph enylephrine/dm) safe tussin dm * (G-Zyncof) scot-tussin dm * (Vicks Children'S Nyquil) scot-tussin expectorant * (Robitussin Mucus-Chest Congest) siltussin sa * (Robitussin Mucus-Chest Congest) siltussin-dm * (Cough Formula Dm) 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 MULTI-SYMPTOM COLD * triacting m-sym cold/cough * (D-Methorphan Hb/P-Ephed HCl/Cp) triaminic cold & cough (pe) * TRIAMINIC COUGH-SORE THROAT * (Dextromethorphan /Phenylephrine) tri-dex pe * (Dm/Phenyleph/Ch lorpheniramine) trymine cg * (M-Clear Wc) tusnel diabetic * (G-Zyncof) 92

94 TUSNEL NEW FORMULA * ORAL SOLUTION TUSNEL PEDIATRIC * ORAL LIQUID TUSSI PRES-B * ORAL LIQUID MG/5 ML tussin cf cough-cold * (Giltuss) tussin cf * oral (Guaifenesin/Dm/P seudoephedrine) tussin cold-congestion * (Guaifenesin/Dm/P seudoephedrine) tussin cough (dm only) * oral (Robitussin) tussin dm cough & chest * oral liquid mg/5 ml (G-Zyncof) tussin dm * oral (Cough Formula Dm) tussin maximum strength * (Dextromethorphan Hbr) tussin pe * oral liquid (Despec) valu-tapp dm * (D-Methorphan Hb/P-Epd HCl/Bpm) VANACOF * (Dvicks dayquil cold&flu relief * oral Methorphan/Pe/Ac capsule etaminophen) vicks dayquil cough * (Dextromethorphan Hbr) vicks nature fusion cough * (Dextromethorphan Hbr) vicks nyquil severe cold-flu * oral (Dm/Pe/Acetamino liquid phen/doxylamine) virdec dm * (Dm/Phenyleph/Ch lorpheniramine) virtussin ac * (M-Clear Wc) wal-phed * oral tablet 30 mg (Sudafed 12-Hour) 93

95 wal-phed pe day-night * (Diphenhydram/Pe/ Dm/Acetamin/Gg) wal-tussin cough & cold cf * (Giltuss) wal-tussin cough * oral capsule (Robitussin) wal-tussin cough * oral liquid (Dextromethorphan Hbr) 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 mouthwash 0.12 % (Peridex) pilocarpine hcl oral (Salagen) PREVIDENT 5000 SENSITIVE * 3 $0 sodium fluoride * oral tablet,chewable 0.25 mg fluorid (0.55 mg) triamcinolone acetonide dental (Sodium Fluoride) 3 $0 (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) ACNE MEDICATION * TOPICAL LOTION 5 % acne-clear * (Benzoyl Peroxide) acyclovir topical (Zovirax) QL (30 per 30 days) ALCOHOL PADS 94

96 ALCOHOL PREP PADS amlactin * topical lotion (Ammonium Lactate) ammonium lactate * 12% cream (Ammonium fragrance free (otc) Lactate) ammonium lactate * 12% lotion (Ammonium (otc) Lactate) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE benzoyl peroxide * topical gel 10 %, 5 % (Benzoyl Peroxide) BETADINE SPRAY * calcipotriene scalp (Calcipotriene) calcipotriene topical cream (Dovonex) calcipotriene topical ointment (Calcipotriene) calcitriol topical (Vectical) CASTELLANI PAINT MODIFIED * CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) PA COSENTYX PEN PA COSENTYX PEN (2 PENS) PA FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) geri-hydrolac * topical (Ammonium Lactate) imiquimod (Aldara) PA NSO; QL (24 per 30 days) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) LACTINOL HX * lobana bath * (Mineral Oil) 95

97 methoxsalen rapid (Oxsoralen-Ultra) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL skin treatment * (Ammonium Lactate) TOLAK VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM QL (15 per 30 days) Dermatological Antibacterials bacitracin * topical (Bacitracin) 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 erythromycin with ethanol topical swab Base/Ethanol) (Erythromycin Base/Ethanol) 96

98 gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) (Neomycin neosporin (neo-bac-polym) * topical Su/Bacitrac Zn/Poly) selenium sulfide (Selenium Sulfide) silver nitrate applicators (Silver Nitrate Applicator) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) triple antibiotic * topical ointment (Neomycin Su/Bacitrac Zn/Poly) Dermatological Anti- Inflammatory Agents alclometasone (Alclometasone Dipropionate) aquanil hc * (Cortizone-10) beta-hc * (Cortizone-10) betamethasone dipropionate (Betamethasone Dipropionate) betamethasone valerate topical (Betamethasone cream Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical lotion (Betamethasone Valerate) 97

99 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 scalp solution (Clobetasol 0.05 % Propionate) clobetasol scalp (Clobetasol Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Clobetasol Propionate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) 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 (Desonide) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) 98

100 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% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera (Hydrocortisone topical gel Acetate/Aloe V) hydrocortisone acetate * topical (Hydrocortisone cream 1 % Acetate) hydrocortisone acetate-aloe * (Hydrocortisone Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate topical (Hydrocortisone cream Butyrate) hydrocortisone butyrate topical ointment (Locoid) hydrocortisone butyrate topical solution (Locoid) hydrocortisone butyr-emollient (Hydrocortisone Butyrate) 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 % (Scalacort) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) 99

101 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 (Triamcinolone lotion Acetonide) triamcinolone acetonide topical (Triamcinolone ointment %, 0.1 %, 0.5 % Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical (Retin-A) PA 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) 100

102 Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2" 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-NEEDLE U- 100 SYRINGE 0.3 ML 29, 1 ML 29 X 1/2", 1/2 ML 28 PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2 " VGO 40 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 CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN 101

103 FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN ORAL TABLET,SOLUBLE lipase-protease-amylase (Lipase/Protease/A mylase) MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD STRENSIQ PA VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 days) ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette % F) 102

104 artificial tears (polyvin alc) * artificial tears * ophthalmic drops % (Polyvinyl Alcohol) (Tears Naturale) 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) atropine sulfate ophthalmic drops 1 % (Isopto Atropine) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal aerosol,spray 137 mcg (Astepro) azelastine ophthalmic (Azelastine HCl) (Dextran bion tears (pf) * 70/Hypromellose/P F) 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 * QL (30 per 25 days) 103

105 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) LACRISERT lubricant dry eye relief * (Carboxymethylcel lulose Sodium) lubricant eye (cmc-glycer)(pf) * (Carboxymethylcel l/glycerin/pf) lubricant eye (cmc-glycerin) * (Refresh Optive) lubricant eye (pg-peg 400) * (Systane) 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) (Dextran natural tears (pf) * 70/Hypromellose/P F) QL (30 per 28 days) QL (15 per 10 days) 104

106 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 ophthalmic (Patanol) phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluo rescein Sod) pure & gentle eye * (Genteal Mild To Moderate) REFRESH CELLUVISC * REFRESH CLASSIC (PF) * REFRESH LACRI-LUBE * REFRESH OPTIVE * OPHTHALMIC DROPS retaine cmc * (Carboxymethylcel lulose Sodium) saline mist * (Little Remedies) sea soft nasal mist * (Little Remedies) sodium chloride * ophthalmic (Sodium Chloride) SYSTANE * SYSTANE GEL * OPHTHALMIC DROPS,GEL tears again * ophthalmic drops tears again * ophthalmic ointment tears naturale free (pf) * (Polyvinyl Alcohol) (Lanolin/Min Oil/Petrolat, Wht) (Dextran 70/Hypromellose/P F) 105

107 tetracaine hcl (pf) ophthalmic (Tetracaine HCl/PF) ultra fresh pm * (Lanolin/Min Oil/Petrolat, Wht) vicks qlearquil(oxymetazoline) * (Oxymetazoline HCl) vicks sinex 12-hour * (Afrin) 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) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic (Levofloxacin) 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 ophthalmic (Neomycin/Polymy xin B Sulf/HC) 106

108 neomycin-polymyxin-hc otic (Neomycin/Polymy drops,suspension xin B Sulf/HC) neomycin-polymyxin-hc otic solution (Cortisporin) neo-polycin (Neomycin Su/Bacitra/Polymy xin) 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-prednisolone (Sulfacetamide/Pre dnisolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZIRGAN ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX ST bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate ophthalmic (Dexasol) diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL flunisolide nasal spray,non-aerosol QL (50 per 25 days) (Flunisolide) 25 mcg (0.025 %) 107

109 fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Fluticasone Propionate) ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate (Prednisolone Sod ophthalmic Phosphate) QL (16 per 30 days) PROLENSA RESTASIS QL (60 per 30 days) Gastrointestinal Agents Antiflatulents anti-gas maximum strength * (Phazyme) bicarsim forte * (Simethicone) gas relief extra strength * oral (Gas-X) gas relief * oral capsule 125 mg (Phazyme) gas relief * oral (Gas-X) gas-x ultra-strength * (Phazyme) mi-acid gas relief * (Gas-X) mytab gas * (Gas-X) mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Phazyme) simethicone * oral (Simethicone) 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 mg, 400 mg, 800 mg (Cimetidine) (Rx Product Only) 108

110 cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) famotidine intravenous (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole * dr 15 mg capsule na/f (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 oral (Protonix) PRILOSEC OTC * 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) 109

111 ZANTAC 75 * ZANTAC * ORAL TABLET 150 MG 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 days) antacid anti-gas * oral suspension (Maalox Maximum mg/5 ml Strength) (Calcium antacid anti-gas * oral Carbonate/Simethi cone) antacid extra-strength * oral tablet,chewable 300 mg (750 mg) (Tums) antacid plus extra strength * (Maalox Maximum Strength) anti-diarrheal * (Pepto-Bismol) anti-diarrheal (loperamide) * oral capsule (Loperamide HCl) anti-diarrheal (loperamide) * oral (Imodium A-D) bismatrol * oral suspension 262 (Pepto-Bismol) mg/15 ml BUPHENYL ORAL TABLET calci-chew * (Tums) calcium antacid * oral tablet,chewable 200 mg calcium (500 mg) calcium carbonate * oral tablet,chewable 500 mg calcium (1,250 mg) (Tums) (Tums) 110

112 calcium carbonate-vitamin d3 * oral tablet,chewable mg-unit (Calcium Carbonate/Vitamin D3) cal-gest antacid * (Tums) CARBAGLU children's soothe * (Tums) 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) GATTEX 30-VIAL PA GATTEX ONE-VIAL PA gelusil antacid & anti-gas * oral (Maalox Maximum suspension Strength) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul) imodium a-d * oral liquid (Loperamide HCl) IMODIUM A-D * ORAL TABLET kaopectate (bismuth subsalicy) * (Pepto-Bismol) lactulose (Lactulose) LINZESS QL (30 per 30 days) loperamide oral (Loperamide HCl) loperamide * oral (Loperamide HCl) LOTRONEX 111

113 maalox advanced * oral suspension (Maalox Maximum Strength) MAGNEBIND 300 * magnesium oxide * oral capsule 500 (Uromag) mg magnesium oxide * oral tablet 250 mg, 400 mg, 500 mg (Magox 400) masanti double strength * (Maalox Maximum Strength) methscopolamine oral (Methscopolamine Bromide) metoclopramide hcl injection (Metoclopramide HCl) 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 days) NUTRESTORE pep-t-med * (Pepto-Bismol To- Go) phillips * (Magox 400) pink bismuth * oral tablet,chewable (Pepto-Bismol To- Go) RAVICTI PA RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) 112

114 ri-gel ii * (Maalox Maximum Strength) ri-mox * (Maalox Maximum Strength) sodium bicarbonate * oral tablet (Sodium 650 mg Bicarbonate) (Sodium sodium polystyrene sulfonate oral Polystyrene powder Sulfonate) (Sodium sodium polystyrene sulfonate oral Polystyrene suspension 15 gram/60 ml Sulfonate) (Sodium sodium polystyrene sulfonate rectal Polystyrene enema 30 gram/120 ml Sulfonate) 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) 113

115 dok * oral tablet (Docusate Sodium) dulcolax stool softener (dss) * (Sof-Lax) enema disposable * (Enema) enema * rectal enema * 19-7 gram/118 ml (Enema) 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 (Psyllium Husk (With Sugar)) konsyl fiber * (Fibercon) KONSYL SUGAR-FREE * ORAL POWDER IN PACKET laxative peg 3350 * oral powder (Gavilax) milk of magnesia * (Milk Of Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP natural fiber laxative therapy * (Psyllium Seed (With Sugar)) 114

116 oral saline laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) peg 3350-electrolytes (Golytely) 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 * (Docusate Sodium) smoothlax * oral (Miralax) sodium chloride-nahco3-kcl-peg (Nulytely with oral recon soln 420 gram Flavor Packs) stool softener * oral capsule 240 mg (Surfak) the magic bullet * (Dulcolax) 115

117 Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) calphron * (Calcium Acetate) PHOSLYRA RENAGEL RENVELA Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ oxybutynin chloride oral tablet (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 (Trospium Chloride) 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 116

118 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/Modif ying Androgens ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo- Testosterone) PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) testosterone enanthate (Delatestryl) PA; QL (5 per 28 days) testosterone transdermal gel in PA; QL (300 per 30 (Androgel) packet 1 % (25 mg/2.5gram) days) Estrogens And Antiestrogens COMBIPATCH DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) estradiol transdermal patch weekly (Climara) 117 PA PA-HRM; QL (8 per 28 days) PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days)

119 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 days) MENEST PA-HRM PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (18 per 28 days) Glucocorticoids/Mineralocor betamethasone acet,sod phos (Celestone) cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone injection solution Sod Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone Sod Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (A-Methapred) methylprednisolone sodium succ intravenous (A-Methapred) prednisolone sodium phosphate oral PA BvD (Pediapred) solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML 118

120 triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (15 per 30 days) desmopressin nasal (Desmopressin QL (15 per 30 days) Acetate) desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA INCRELEX LUPRON DEPOT-PED LUPRON DEPOT-PED (3 QL (1 per 84 days) MONTH) INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO PA NORDITROPIN NORDIFLEX PA 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) 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 days) SOMAVERT SUPPRELIN LA QL (1 per 360 days) Progestins 119

121 DEPO-PROVERA QL (10 per 28 days) INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular (Depo-Provera) QL (1 per 84 days) medroxyprogesterone oral (Provera) MEGACE ES megestrol oral suspension (Megace Es) 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 ASTAGRAF XL PA BvD AUBAGIO PA; QL (28 per 28 days) azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF NANOFILTERED PA BvD INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD CIMZIA PA CIMZIA POWDER FOR PA RECONST cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD 120

122 ENBREL PA ENBREL SURECLICK PA FLEBOGAMMA DIF PA BvD GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD GAMMAPLEX PA BvD 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 days) leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD OCTAGAM PA BvD ORENCIA PA ORENCIA (WITH MALTOSE) PA PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; LA; QL (15 per 28 days) ZORTRESS Vaccines ACTHIB (PF) PA BvD; QL (120 per 30 days) 121

123 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; QL (3 per 365 days) ENGERIX-B PEDIATRIC (PF) PA BvD; QL (3 per 365 days) GARDASIL (PF) QL (1.5 per 365 days) GARDASIL 9 (PF) QL (1.5 per 365 days) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) PA BvD 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) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) QL (2 per 365 days) 122

124 PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QL (2 per 365 days) QUADRACEL (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) PA BvD; QL (3 per INTRAMUSCULAR 365 days) SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD PA BvD; QL (3 per 365 days) PA BvD TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) QL (2 per 365 days) YF-VAX (PF) ZOSTAVAX (PF) QL (1 per 365 days) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents 123

125 APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) LACTATED RINGERS IRRIGATION ringers irrigation (Ringers Solution) 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 Sodium) QL (300 per 28 days) alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) mg calcitonin (salmon) (Miacalcin) QL (3.7 per 28 days) 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) 124

126 doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) FORTEO PA; QL (2.4 per 28 days) FORTICAL QL (3.7 per 28 days) ibandronate intravenous solution PA BvD; (PA for (Ibandronate ESRD Only); QL (3 Sodium) per 84 days) ibandronate intravenous syringe (Boniva) PA BvD; QL (3 per 84 days) ibandronate oral (Boniva) QL (1 per 28 days) MIACALCIN INJECTION PA BvD; (PA for ESRD Only) NATPARA PA; QL (2 per 28 days) paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL (1 per 180 days) risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 28 days) 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 ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) (Zoledronic Acid/Mannitol and Water) (Reclast) QL (100 per 300 days) PA BvD 125 PA

127 ACTEMRA SUBCUTANEOUS PA ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Amifostine Crystalline) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST BENLYSTA INTRAVENOUS PA RECON SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) buspirone (Buspirone HCl) CERDELGA PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Proben ecid) COPAXONE SUBCUTANEOUS SYRINGE CYSTADANE douche vinegar & water extra * (Acetic Acid) droperidol injection solution (Droperidol) dutasteride (Avodart) dutasteride-tamsulosin (Jalyn) QL (30 per 30 days) 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 126

128 GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA PA; QL (28 per 28 days) 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 days) KEVEYIS PA NSO; QL (120 per 30 days) LEMTRADA PA 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) mesna (Mesnex) MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN MINERAL OIL * mineral oil * topical (Mineral Oil) morrhuate sodium (Sodium Morrhuate) OTEZLA PA; QL (60 per 30 days) 127

129 OTEZLA STARTER PA; QL (60 per 30 days) OTREXUP (PF) PLEGRIDY ST probenecid (Probenecid) PROCYSBI pyridostigmine bromide oral tablet (Mestinon) RASUVO (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIGNIFOR QL (60 per 30 days) SIMPONI PA SIMPONI ARIA PA STELARA SUBCUTANEOUS PA SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " summer's eve disposable douche * vaginal solution (Acetic Acid) summers eve extra cleansing * (Acetic Acid) 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 days) PA; QL (60 per 30 days) THALOMID PA NSO; QL (60 per 30 days) TYBOST QL (30 per 30 days) ULORIC ST; QL (30 per 30 days) 128

130 XELJANZ Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) PA; QL (60 per 30 days) 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) levobunolol (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 days) DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA timolol maleate ophthalmic drops (Timoptic) timolol maleate ophthalmic gel forming solution (Timoptic-Xe) TRAVATAN Z QL (2.5 per 25 days) travoprost (benzalkonium) (Travoprost QL (2.5 per 25 days) (Benzalkonium)) Parasympathomimetic (Cholinergic Agents) 129

131 Parasympathomimetic (Cholinergic Agents) pyridostigmine bromide oral tablet extended release Replacement Preparations Replacement Preparations ca-d3-mag ox-zinc-cop-mang-bor * oral tablet,chewable (Pyridostigmine Bromide) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) calcitrate * (Calcium Citrate) calcium d (d3) * (Caltrate D) calcium d * oral tablet 500 mg(1,250mg) -400 unit (Caltrate D) calcium 500 with d * (Caltrate D) calcium 600 * (Calcium Carbonate) calcium d(3) * oral capsule (Calcium Carbonate/Vitamin D3) calcium d(3) * oral tablet (Caltrate D) calcium 600 with vitamin d3 * oral (Calcium Carbonate/Vitamin D3) calcium carbonate * oral (Calcium Carbonate) calcium carbonate * oral tablet 260 (Calcium mg calcium (648 mg) Carbonate) (Calcium calcium carbonate-vitamin d2 * 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) 130

132 calcium carbonate-vitamin d3 * oral tablet 1,000 mg(2,500 mg)-800 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate-vitamin d3 * oral tablet,chewable 500 mg(1,250mg) unit (Caltrate D) (Calcium Vit 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 (650 mg) (Calcium Lactate) calcium+d * oral tablet (Caltrate D) CALTRATE D * CALTRATE WITH VITAMIN D3 * citracal + d maximum * (Citracal-Vitamin D) (Citric citric acid-sodium citrate Acid/Sodium Citrate) citrus calcium * oral tablet (Citracal-Vitamin mg-unit D) d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % 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) PA BvD; (PA for ESRD Only) 131

133 dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) 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 with sodium chloride (Dextrose 5 %-0.2 % NaCl) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) hi-cal plus vit d * (Caltrate 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 10 (Potassium Chloride) klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) klor-con sprinkle (Micro-K) liquid calcium with vitamin d * (Calcium Carbonate/Vitamin D3) mag 64 * (Slow-Mag) mag-delay * (Slow-Mag) mag-g * (Magonate) 132

134 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 sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) magnesium sulfate in water (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Calcium Carbonate) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oysco 500/d * oral tablet (Caltrate D) oysco d * (Caltrate D) oysco-500 * (Calcium Carbonate) oyster shell calcium 500 * (Calcium Carbonate) (Calcium oyster shell calcium with d * Carbonate/Vitamin D2) oyster shell calcium-vit d3 * (Caltrate D) oystercal-d * (Caltrate D) pediatric electrolyte * oral solution (Pedialyte) pediatric freezer pops * (Pedialyte) PHOS-NAK * 133

135 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 (Klor-Con-Ef) potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l (Potassium Chloride In 0.9%NaCl) potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution potassium chloride intravenous potassium chloride oral capsule, extended release (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Micro-K) potassium chloride oral liquid (Potassium Chloride) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended release (K-Tab ER) potassium chloride oral tablet,er particles/crystals 10 meq (K-Tab ER) potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) 134

136 potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl (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 (Urocit-K) potassium citrate-citric acid oral (Potassium packet 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 solution 1 meq/ml (8.4 %) Bicarbonate) sodium bicarbonate intravenous (Sodium syringe Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride 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 %) sodium chloride intravenous (Sodium Chloride) 135

137 sodium citrate-citric acid (Citric Acid/Sodium Citrate) sodium lactate (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 days) ADVAIR HFA QL (12 per 28 days) BREO ELLIPTA QL (60 per 30 days) DULERA QL (13 per 28 days) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION QL (60 per 30 days) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) QL (21.2 per 28 days) QVAR QL (17.4 per 25 days) Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) 136

138 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) ATROVENT HFA QL (25.8 per 28 days) COMBIVENT RESPIMAT QL (8 per 30 days) metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 days) PROAIR RESPICLICK QL (2 per 30 days) SEREVENT DISKUS QL (60 per 30 days) SPIRIVA RESPIMAT QL (4 per 30 days) SPIRIVA WITH HANDIHALER QL (30 per 30 days) 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 (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL (1 per 28 days) 137

139 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine (Acetadote) PA BvD cromolyn inhalation (Cromolyn PA BvD Sodium) cromolyn * nasal (Nasalcrom) DALIRESP QL (30 per 30 days) ESBRIET PA; QL (270 per 30 days) KALYDECO PA; QL (60 per 30 days) NUCALA PA; QL (1 per 28 days) OFEV PA ORKAMBI PA; QL (120 per 30 days) PROLASTIN-C sodium chloride * inhalation solution for nebulization 0.9 % (Pulmosal) 3 $0 XOLAIR PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) chlorzoxazone cyclobenzaprine oral tablet 10 mg, 5 mg (Parafon Forte DSC) (Fexmid) PA-HRM; QL (120 per 30 days) PA-HRM PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxall (Skelaxin) PA-HRM metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents 138

140 Sleep Disorder Agents BELSOMRA (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) HETLIOZ PA NUVIGIL PA ROZEREM XYREM LA zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days) 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 (30 per 30 days) 139

141 zolpidem oral tablet,ext release multiphase Vasodilating Agents Vasodilating Agents (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 days) ADCIRCA PA; QL (60 per 30 days) ADEMPAS PA; QL (90 per 30 days) epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 days) OPSUMIT PA; QL (30 per 30 days) ORENITRAM PA REMODULIN PA BvD sildenafil intravenous (Revatio) PA; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 days) TRACLEER PA; LA; QL (60 per 30 days) TYVASO PA BvD TYVASO REFILL KIT PA BvD TYVASO STARTER KIT PA BvD Vitamins And Minerals Vitamins And Minerals a thru z advanced formula * (Multivitamin/Iron/ Folic Acid) 140

142 a thru z high potency * (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) airshield * oral tablet, effervescent 5, unit-mg-unit (Vit A,C, and E/Dietary Supp 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 vitamins * oral tablet (Vit A,C and 1,000 unit-200 mg-60 unit-2 mg E/Lutein/Minerals) 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) 141

143 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) balanced b-100 * oral tablet 0.4 mg (Vitamin B Complex/Folic Acid) balanced b-100 * oral tablet 100 mg (Vit B Complex 100 Cmb #3/Herbs) balanced b-150 * (Vitamin B Complex) balanced b-50 complex * (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) 142

144 b-complex with vitamin c * oral (Fa/Vit B Complex tablet mcg-mg and C/Rice Bran) 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 mgmcg Folic Acid) (Multivitamin/Iron/ 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) centrum * oral liquid (Multivits W- Min/Ferrous Gluc) centrum silver * oral tablet (Biocel) century adults 50+ * (Biocel) century mature * oral tablet (Multivitamin W- Minerals/Lutein) century mature * oral tablet mg-mcg-mcg, mcg (Biocel) century * oral tablet mg-mcg (Multivitamin/Iron/ Folic Acid) 143

145 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) 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) 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) childs chew vite * (Multivitamin) child's vitamin with iron * (Multivitamins with Iron) child's vitamin with vitamin c * (Multivitamin) childs/iron * (Multivitamins with Iron) cholecalciferol (vitamin d3) * oral capsule 1,000 unit, 10,000 unit, 5,000 unit (D3-50) 144

146 cholecalciferol (vitamin d3) * oral drops 5,000 unit/ml (Just D) cholecalciferol (vitamin d3) * oral (Cholecalciferol liquid (Vitamin D3)) cholecalciferol (vitamin d3) * oral tablet,chewable (Vitamin D3) 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) 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 multi-vitamins/iron * (Multivitamins with Iron) daily teen multi-vitamin * (Multivitamin/Iron/ Folic Acid) 145

147 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) 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) 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) * (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) (Fe fe fumarate-doss-fa-bcomp and c * Fumarate/Doss/Fa/ 3 $0 Bcomp,C) fe fumarate-vit c-b12-if-fa * oral (Fe Fumarate/Vit capsule mg C/B12-If/Fa) 3 $0 ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 146

148 ferretts * (Ferrous Fumarate) ferrex 150 * (Pic 200) 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 (Folic Acid) fosfree * (Calcium/Multivita mins W-Iron) geravim * (Pediavit) geriaton * (Pediavit) gummi bear multivitamin * (Multivitamin) gummy swirls * (Multivitamin) 147

149 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 * (Vit A,C and E/Lutein/Minerals) 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) 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) 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) 148

150 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 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 with iron * (Multivitamin/Ferr ous Gluconate) 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 with iron * (Multivitamins with Iron) multivitamin with minerals * oral (Multivits W- liquid Min/Ferrous Gluc) multivitamin with minerals * oral (Multivitamin with tablet Minerals) 149

151 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 0.5 mg tab chew (Pedi M.Vit No.17 chewable, d/f, s/f 0.5 mg with Fluoride) my favorite multiple * (Multivitamin) my-vitalife * (Multivitamin with Minerals) NASCOBAL * 3 $0 natural b-100 * (Vitamin B Complex) natural b-100 complex * (Vit B Complex 100 Cmb #2/Herbs) niacinamide * oral tablet extended release (Niacinamide) nu-iron * (Pic 200) ocutabs * (Beta-Carotene(A) W-C and E/Min) 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 maximum (with ca) * (Tab A Vite) one daily multi-vit w-mineral * (Multivitamins with Iron) one daily multivitamin * oral tablet (Multivitamin) one daily multivitamin * oral tablet 400 mcg (Quintabs) 150

152 one daily multivit-iron(folic) * (Multivitamin/Iron/ Folic Acid) one daily * oral tablet (Multivitamin) one daily plus iron * oral tablet (Multivitamins with Iron) 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 (Vit A,C and unit-200 mg-60 unit-2 mg E/Lutein/Minerals) 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) poly-vitamins * (Multivitamin) prenatal formula * oral tablet 28 mg (Classic Prenatal) iron- 800 mcg 151

153 prenatal * oral tablet 28 mg iron- 800 mcg (Prenatal) prenatal tablet * (Classic Prenatal) 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 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 M.Vit No.17 fluoride (2.2 mg) with Fluoride) 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) spectravite senior * oral tablet mcg (Biocel) spectravite senior w-lycopene * (Multivitamin W- Minerals/Lutein) (All Rx Prenatal Vitamins Covered) 152

154 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) sunvite * (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) super b complex-vitamin c * (Vita-Bee with C) super b maxi complex * (Vitamin B Complex/Folic Acid) 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 * (Vitamin B Complex/Folic Acid) 153

155 super quints b-50 * (Vitamin B Complex) 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) thera-d * (Vitamin D3) theradex m * (Multivit,Ther Iron,Ca,Fa and 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) therapeutic liquid * (Multivitamins,The rapeutic) therapeutic m + beta-carotene * (Tab A Vite) therapeutic vitamin & mineral * (Multivitamins,The r W-Minerals) therapeutic vitamins/minerals * (Multivitamins with Min No.7/Fa) 3 $0 154

156 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) 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) vision * (Beta-Carotene(A) W-C and E/Min) vision formula * (Beta-Carotene(A) W-C and E/Min) vision formula (with lutein) * (Vit A,C and E/Lutein/Minerals) vision plus lutein * (Multivitamin W- vit b cmplx 3-fa-vit c-biotin * oral tablet mg-mg-mcg Minerals/Lutein) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 155

157 vit b cmplx no3-fa-c-biot-zinc * vit b complex-folic acid * oral tablet vitalets * oral tablet,chewable vitamin a * oral capsule 10,000 unit, 25,000 unit (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Vitamin B Complex/Folic Acid) (Multivitamins with Iron) 3 $0 (Vitamin A) vitamin b complex * (Vitamin B Complex) vitamin b-100 complex * (Vitamin B Complex) vitamin b12-folic acid * oral (Cyanocobalamin/ Folic Acid) vitamin b-6 * oral tablet 250 mg, 50 mg (Pyridoxine HCl) vitamin c * oral syrup (Ascorbic Acid) vitamin c * oral tablet 1,000 mg, 250 mg (Ascorbic Acid) vitamin c * oral tablet extended release (Ascorbic Acid) vitamin c * oral tablet,chewable 250 mg, 500 mg (Ascorbic Acid) vitamin d3 * oral capsule 1,000 unit, 4,000 unit (D3-50) vitamin d3 * oral tablet 1,000 unit, 400 unit (Vitamin D3) vitamins & minerals * (Multivitamins,The r W-Minerals) vitamins b complex * oral tablet (Vitamin B Complex) (Vit B vitamins b complex * oral tablet 500 Comp/C/Fa/Iron/Vi mg-400 mcg- 18 mg iron t E) 156

158 vitamins b1,b2,b3,b5, and b6 * oral tablet 0.4 mg (Vitamin B Complex/Folic Acid) 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) 157

159 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 DISCMELT ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen acetaminophen acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid , 127 acetylcysteine acid gone antacid acid reducer (famotidine) acid relief (cimetidine) acitretin acne medication... 96, 97 ACNE MEDICATION acne-clear ACTEMRA , 129 ACTHIB (PF) ACTIMMUNE actinel pediatric acyclovir... 67, 97 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 125 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adt robitussin peak cld dm max adult multivitamin gummies 144 adult nasal decongestant adult one daily gummies adult robitussin lingering cld.. 87 adult robitussin peak cold dm 87 adult wal-tussin adult wal-tussin dm max adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA advil af 50 AFINITOR AFINITOR DISPERZ AFTERA AGGRENOX airshield AKTEN (PF) AKYNZEO alavert d-12 allergy-sinus 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 ALDURAZYME alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges allegra allergy aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy (diphenhydramine) allergy relief (cetirizine) allergy relief (loratadine) allerhist aller-tec d allopurinol almacone almacone aloe vesta antifungal (micon). 50 alophen ALPHAGAN P I-1 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

160 alprazolam ALREX altacaine altamist aluminum hydroxide gel amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amifostine crystalline amiloride amiloride-hydrochlorothiazide80 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 amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 32, 33 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 antacid anti-gas antacid extra-strength antacid plus extra strength anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide) antifungal antifungal (tolnaftate) anti-gas maximum strength antioxidant antioxidant vitamins apatate forte APOKYN apraclonidine APRISO , 127 aprodine APTIOM APTIVUS aquanil hc ARCALYST aripiprazole ARISTADA... 61, 62 arthritis pain relief (acetam) artificial tears artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc) artificial tears(glycerin-peg). 105 artificial tears(hypromellose) 105 ASACOL HD ascorbic acid ashlyna aspirin aspirin, buffered aspirin-dipyridamole aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 42, 105 atropine sulfate ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine I-2 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

161 azathioprine sodium azelastine , 106 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... 28, 98, 108 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b balanced b balanced b balanced b-50 complex balsalazide banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) 125 b-complex b-complex with vitamin c BD ECLIPSE LUER-LOK BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bekyree (28) BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE SPRAY beta-hc betamethasone acet,sod phos 121 betamethasone dipropionate. 100 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 77, 132 bethanechol chloride BETHKIS... 27, 28 bexarotene BEXSERO (PF) bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO blisovi 24 fe blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF BREO ELLIPTA BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine bromphenex dm brompheniramine-pseudoephdm brompheniram-phenylephrinedm budesonide bufferin bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 18, 26 buprenorphine-naloxone bupropion hcl... 26, 45 buspirone butalb-acetaminophen-caffeine butalbital-acetaminop-caf-cod 18 butalbital-acetaminophen butalbital-acetaminophen-caff 18 butalbital-aspirin-caffeine BUTRANS BYSTOLIC C c complex cabergoline I-3 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

162 ca-d3-mag ox-zinc-cop-mangbor caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitriol... 97, 127, 128 calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) calcium 600 with vitamin d3 133 calcium acetate calcium antacid calcium carbonate , 134 calcium carbonate-mag carb-fa calcium carbonate-vitamin d calcium carbonate-vitamin d , 134 calcium chloride calcium citrate-vitamin d calcium gluconate calcium lactate calcium+d CALDOLOR cal-gest antacid calphron CALTRATE D CALTRATE WITH VITAMIN D CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 75 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT MODIFIED CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 30 CEFAZOLIN IN DEXTROSE (ISO-OS) cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 31 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os 31 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil cefuroxime sodium celecoxib CELLCEPT INTRAVENOUS CELONTIN centamin central vite with lutein central-vite central-vite for seniors central-vite select. 147, 150, 156 central-vite senior centram-care centravites 50 plus centrum centrum complete centrum silver century century adults century mature century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula certavite senior-antioxidant certavite-antioxid (iron gluc) 147 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine... 53, 54 cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK I-4 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

163 CHANTIX STARTING MONTH BOX cheracol d cheratussin dac chest congestion relief + dm.. 88 chest congestion relief d chest congestion relief pe chewable multi vitamin child allergy relf(cetirizine) child complete multivitamin 148 child cough & sore throat child mucinex chest congestion child plus cough & runny nose child triaminic cold & allergy 54 child triaminic cough-congest 88 child vitamin with minerals. 148 child wal-tap cold-allergy child wal-tussin cough relief.. 88 children's advil children's allegra allergy children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 148 children's chewable w/minerals CHILDREN'S CLARITIN children's complete vitamin. 148 children's mapap children's mucinex cough children's multivit w/extra c. 148 children's non-aspirin children's pain & fever relief. 19 children's pain reliever childrens plus multi-symp cold children's silapap children's silfedrine children's soothe children's sudafed children's sudafed pe cough children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3). 148 cholestyramine (with sugar) cholestyramine-aspartame choline,magnesium salicylate 23 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 34, 108, 109 ciprofloxacin in 5 % dextrose 34 ciprofloxacin lactate citalopram citracal + d maximum citric acid-sodium citrate citrus calcium clarithromycin CLARITIN CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 28 clindamycin palmitate hcl clindamycin phosphate... 28, 57, 98, 99 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 I-5 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

164 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... 74, 75 clonidine hcl... 74, 83 clonidine hcl-chlorthalidone.. 74 clopidogrel clorazepate dipotassium clotrimazole... 50, 51 clotrimazole 3 day clotrimazole clotrimazole-betamethasone.. 51 clozapine COARTEM codeine sulfate codeine-butalbital-asa-caffein 19 codituss dm colace colchicine colchicine-probenecid cold & cough cold multi-symptom day/night 89 cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 140 COMETRIQ comfort gel extra strength COMPLERA complete complete multi complete multivitamin complete multivitamin-mineral complete senior compoz COMVAX (PF) CONDYLOX congestac COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR cortisone cortizone CORTIZONE COSENTYX (2 SYRINGES) 97 COSENTYX PEN COSENTYX PEN (2 PENS). 97 COTELLIC cough & cold cough & runny nose CREON CRESTOR critic-aid clear af CRIXIVAN cromolyn , 113, 141 CUBICIN cyanocobalamin (vitamin b-12) cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) D d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride 73 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin daily gummies daily multiple daily multi-vitamin daily multivitamin with iron. 149 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 149 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dantrolene sodium I-6 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

165 dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX dayhist allergy daytime cold & cough daytime cold-flu day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough+chest congest dm DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol.. 85 desonide desoximetasone despec-dm (pseudoeph-dmguaif) dex4 glucose dexamethasone dexamethasone sodium phosphate , 121 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextromethorphan polistirex.. 90 dextrose 10 % and 0.2 % nacl 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).. 73 dextrose 5 %-lactated ringers135 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 diabetic siltussin das-na diabetic tussin dm diabetic tussin max st diamode diazepam diazepam intensol diclofenac potassium diclofenac sodium... 23, 110 diclofenac-misoprostol dicloxacillin dicyclomine , 114 didanosine DIFICID diflunisal digitek digoxin DIGOXIN dihydroergotamine DILANTIN CAPSULE 30 MG diltiazem hcl dilt-xr dimaphen (pe) 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 doxorubicin hcl I-7 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

166 doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate... 34, 35 doxycycline monohydrate dramamine driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol 85 DROXIA DUAVEE dulcolax stool softener (dss) 116 DULERA duloxetine... 45, 46 DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM E e.c. prin econazole econtra ez ed bron gp ed chlorped jr EDURANT EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND... 58, 59 EMPLICITI EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 76 ENBREL ENBREL SURECLICK endur-acin enema enema disposable enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin entacapone entecavir entre-cough ENTRESTO ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle equalactin ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 32, 109 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate.. 32 erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein. 150 essential daily ESTRACE estradiol estradiol valerate estradiol/norethindrone acet. 120 estradiol-norethindrone acet. 120 estropipate ethambutol ethamolin ethinyl estradiol/drospirenone 85 ethosuximide ethynodiol d-ethinyl estradiol 85 etodolac ETOPOPHOS etoposide EVOTAZ EXELON exemestane EXJADE expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche F FABRAZYME famciclovir famotidine , 112 famotidine (pf) famotidine (pf)-nacl (iso-os) 111 FANAPT FARESTON FARYDAK I-8 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

167 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 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate ferotrinsic ferretts ferrex ferrex 150 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate ferrous sulfate , 151 FETZIMA feverall fexofenadine fiber (calcium polycarbophil) fiber laxative (methylcellulo)117 fiber smooth fiber therapy fiber therapy (psyllium/sugar) fiber-lax finasteride FIRAZYR 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 , 140 FLOVENT HFA floxuridine flu formula daytime-nighttime 90 flu severe cold-congestion fluconazole fluconazole in dextrose(iso-o) 51 fluconazole in nacl (iso-osm). 51 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluocinonide-emollient base. 101 fluorometholone FLUOROPLEX fluorouracil... 37, 97 fluoxetine fluoxymesterone fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 110 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 % fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD GAZYVA gelusil antacid & anti-gas gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentamicin... 28, 99, 109 gentamicin in nacl (iso-osm).. 28 gentamicin sulfate gentamicin sulfate (ped) (pf).. 28 gentamicin sulfate (pf) I-9 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

168 GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-tussin dm gildess 1/20 (21) gildess 24 fe gildess fe 1/20 (28) GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin... 49, 50 glycolax glycopyrrolate glydo GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin guaifenesin dac guanfacine... 75, 84 guanidine gummi bear multivitamin gummy swirls H hair vitamins hair,skin & nails 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.. 69 heparin (porcine) in nacl (pf). 69 heparin sodium,porcine-pf heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN hi-b complex hi-cal plus vit d high potency multivit-multimin homatropine hbr honey bears honey bears with iron-zinc HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone bit-homatrop mebr hydrocodone-acetaminophen. 19 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen hydrocortisone , 102, 121 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone acetate-aloe hydrocortisone acetate-urea. 101 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate 121 hydrocortisone valerate hydromorphone... 19, 20 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 iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO I-10 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

169 IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant's ibuprofen INFANT'S MOTRIN infants' non-aspirin cold INLYTA insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA... 62, 63 INVEGA TRINZA INVIRASE INVOKAMET INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide 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 itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO jr. acetaminophen juleber junel fe junior mapap JUXTAPID K KABIVEN KALETRA KALYDECO kaopectate (bismuth subsalicy) KEDBUMIN KELP (IODINE) ketoconazole ketoprofen ketorolac... 24, 110 KEVEYIS KEYTRUDA kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28) KINERET KINRIX (PF) klor-con klor-con m klor-con m klor-con m klor-con sprinkle konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM KRYSTEXXA KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN I-11 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

170 lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe larin fe 1/20 (28) latanoprost LATUDA laxative peg LAZANDA leflunomide LEMTRADA LENVIMA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 34, 109 levofloxacin in d5w levonorgestrel... 85, 86 levonorgestrel-ethin estradiol. 86 levonorgestrel-ethinyl estrad.. 86 levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 25, 76 lidocaine hcl lidocaine in 5 % dextrose (pf) 76 lidocaine-prilocaine... 25, 26 life-pack women's linezolid LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III liquibid d-r liquid calcium with vitamin d LIQUI-E lisinopril lisinopril-hydrochlorothiazide 76 lithium carbonate lithium citrate little animals little animals-iron l-norgest-eth estr/ethin estra lobana bath lomustine LONSURF loperamide loratadine loratadine-d lorazepam oral solution lortuss ex losartan losartan-hydrochlorothiazide. 75 LOTEMAX LOTRONEX lovastatin loxapine succinate lubricant dry eye relief lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 106 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 107 lubricant eye (propyl glycol) 107 lubricant eye drops lubricant gel lubricating drops lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA lysiplex plus LYSODREN M maalox advanced MACUVITE MACUVITE EYE CARE 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 masanti double strength MATULANE I-12 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

171 matzim la maximum daily multivitamin maximum strength flu meclizine medi-brom medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol... 39, 123 MEKINIST meloxicam memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's one daily MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem meropenem-0.9% sodium chloride mesehist dm mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxall metaxalone metformin methadone methadone hcl methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 29, 57, 99 metronidazole in nacl (iso-os) 29 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate midodrine milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mineral oil MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat montelukast morphine... 20, 21 MORPHINE morphine concentrate morphine in dextrose 5 % morrhuate sodium motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL mucus dm mucus dm max mucus relief mucus relief cough MULTAQ I-13 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

172 multi complete with iron multi-day with iron multi-delyn with iron multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multi-symptom cold-cough multivital platinum 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 my favorite multiple myco nail a mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife N nabumetone nadolol nafcillin NAGLAZYME naloxone naltrexone naltrexone hcl NAMENDA XR NAMZARIC naphazoline naproxen... 24, 25 naproxen sodium naratriptan nasal & sinus decongestant nasal decongestant (oxymetazl) NASCOBAL nasohist dm NATACYN nateglinide NATPARA natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy 117 natural tears (pf) nature's tears NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc 109 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss NEPHRAMINE 5.4 % NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR niacin niacinamide... 82, 154 nicardipine NICODERM CQ nicorelief nicorette nicotine nicotine (polacrilex) NICOTROL nifedipine night time night time cold-flu night time cold-flu relief nighttime cough nighttime relief eye NILANDRON NINLARO NITE TIME COLD-FLU RELIEF nite time-d cold-flu relief NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose. 83 NITROSTAT nohist-dm non-aspirin cold non-aspirin extra strength non-aspirin flu non-aspirin jr strength NORDITROPIN FLEXPRO 122 NORDITROPIN NORDIFLEX norelgestromin/ethin.estradiol 86 norepinephrine bitartrate I-14 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

173 norethindrone norethindrone (contraceptive) 86 norethindrone acetate norethindrone ac-eth estradiol 86 norethindrone-e.estradiol-iron 86 norethindrone-ethinyl estrad.. 86 norethindrone-mestranol norgestimate-ethinyl estradiol 86 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH nortemp NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA NUCYNTA ER NUEDEXTA nu-iron NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone nyt-time sleep O ocean nasal OCTAGAM octreotide acetate ocutabs ODOMZO OFEV ofloxacin... 34, 109 olanzapine... 63, 64 olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate ONCASPAR oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily one daily 50 plus one daily complete one daily energy one daily essential one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 154 one daily plus iron , 155 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula155 one-a-day teen advantage ONFI opcicon one-step OPDIVO OPSUMIT opti-vitamins oral saline laxative ORAP ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORKAMBI OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 33 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone oxycodone hcl-acetaminophen oxycodone hcl-aspirin oxycodone-acetaminophen... 21, 22 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 pain relief pain relief adult pain reliever extra strength pain reliever jr strength paliperidone PANRETIN I-15 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

174 pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PAXIL pecgen dmx pedi m.vit no.17 with fluoride pedia relief pedia relief cough-cold pedia relief infant pediacare multi-symptom cold93 PEDIARIX (PF) pediatric electrolyte pediatric freezer pops pediatric multivitamin PEDVAX HIB (PF) peg 3350-electrolytes peg 3350-na sulf,bicarb,cl-kcl PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 103 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 permethrin perphenazine perphenazine-amitriptyline persa-gel pharbetol pharmacist favorite multi-vit 155 phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 75, 107 phenylephrine-chlorpheniramine phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended phillips phillips liqui-gels PHOSLYRA PHOS-NAK phosphate laxative PHOSPHOLINE IODIDE phosphorus # phytonadione PICATO pilocarpine hcl... 96, 133 pimozide pindolol pink bismuth 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 podofilox podophyllum resin polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-tussin poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron poly-vitamins POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 137 potassium bicarbonate-cit ac 137 potassium chlorid-d5-0.45%nacl potassium chloride 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 potassium citrate-citric acid. 138 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN I-16 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

175 PRALUENT SYRINGE pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 121 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal prenatal formula prenatal tablet prenatal vit#96-ferrous fum-fa prenatal vitamin with minerals prenatal vitamins prenatal vit-iron fumarate-fa 156 preparation h hydrocortisone 102 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 PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 55, 59 promethazine hcl promethazine-codeine promethazine-dm promethazine-phenylephcodeine promolaxin propafenone... 76, 77 propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod 107 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure & gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide 131, 133 pyridoxine Q q-dryl q-pap q-pap extra strength q-tapp dm q-tussin q-tussin dm QUADRACEL (PF) quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 76 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE RASUVO (PF) RAVICTI REBIF (WITH ALBUMIN). 131 REBIF REBIDOSE REBIF TITRATION PACK 131 RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid RELADOR PAK relcof c RELENZA DISKHALER I-17 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

176 RELISTOR remedy phytoplex antifungal. 52 REMICADE REMODULIN RENAGEL RENVELA repaglinide repaglinide-metformin REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR RESTASIS retaine cmc RETROVIR REVLIMID REXULTI REYATAZ REZIRA ribavirin... 67, 68 RIDAURA rifabutin rifampin RIFATER ri-gel ii riluzole rimantadine ri-mox ringers , 138 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 rynex dm 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... 60, 61 selenium sulfide SELZENTRY senexon senior tabs senna senna lax senna laxative senna with docusate sodium. 118 senokot-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROSTIM sertraline setlakin SIGNIFOR silace siladryl sa silapap sildenafil oral tablet 20 mg SILENOR siltussin sa siltussin-dm 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).. 56 sleep aid (doxylamine) smoothlax sodium acetate sodium bicarbonate , 139 sodium chloride , 127, 139, 141 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... 96, 156 sodium lactate sodium phosphate sodium polystyrene sulfonate , 116 sodium thiosulfate sod-pot-k cit-sod cit-cit acid. 139 SOLTAMOX I-18 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

177 SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT 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 PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ 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 sucralfate sudogest sudogest sinus & allergy sulfacetamide sodium , 110 sulfacetamide sodium (acne).. 99 sulfacetamide-prednisolone. 110 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac sumatriptan nasal spray sumatriptan succinate... 57, 58 summer's eve disposable douche summers eve extra cleansing 131 sunvite super b complex-vitamin c super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYPRINE SYSTANE SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 124 tactinal tactinal extra strength TAFINLAR TAGRISSO TAMIFLU... 66, 67 tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA TAZORAC taztia xt tears again tears naturale free (pf) TECFIDERA , 132 TECHNIVIE TEFLARO I-19 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

178 telmisartan telmisartan-hydrochlorothiazid TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline , 141 terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracaine hcl (pf) tetracycline THALOMID the magic bullet theophylline theophylline anhydrous theophylline in dextrose 5 % 141 thera m plus (ferrous fumarat) thera vitamin thera-d theradex m THERAFLU DAYTIME COLD-COUGH THERAFLU MULTI- SYMPTOM COLD thera-m 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 thiamine hcl thioridazine thiothixene tiagabine TICE BCG TIKOSYN timolol maleate... 77, 133 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate TOLAK tolazamide tolbutamide tolmetin tolnaftate tolterodine topiramate toposar intravenous 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 96, 102, 121 triaminic cold & cough (pe) TRIAMINIC COLD & COUGH NT (PE) TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid TRIBENZOR tri-buffered aspirin tri-dex pe trifluoperazine trifluridine trihexyphenidyl trimethoprim trimipramine triple antibiotic triple paste af TRIUMEQ tri-vi-sol tri-vita tri-vitamin TROKENDI XR I-20 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

179 TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL NEW FORMULA.. 95 TUSNEL PEDIATRIC TUSSI PRES-B tussin cf tussin cf cough-cold tussin cold-congestion tussin cough (dm only) tussin dm tussin dm cough & chest tussin maximum strength 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 strength antacid unisom sleepgels UNITUXIN ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 44 valsartan valsartan-hydrochlorothiazide 75 VALSTAR valu-tapp dm VANACOF vancomycin vancomycin in d5w VAQTA (PF) VARIVAX (PF) VASCEPA VELCADE venlafaxine verapamil VERSACLOZ VGO vicks dayquil cold&flu relief. 95 vicks dayquil cough vicks nature fusion cough vicks nyquil severe cold-flu vicks qlearquil(oxymetazoline) vicks sinex 12-hour VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD virtussin ac vision vision formula vision formula (with lutein). 159 vision plus lutein vit b cmplx 3-fa-vit c-biotin. 159 vit b cmplx no3-fa-c-biot-zinc vit b complex-folic acid vitalets vitamin a vitamin b complex vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c vitamin d vitamins & minerals vitamins b complex vitamins b1,b2,b3,b5, and b6 161 vitamins for hair VITEKTA vitrum senior VOLTAREN voriconazole VOTRIENT VPRIV W wal-act d cold & allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 12 hour wal-phed... 56, 96 wal-phed pe day-night wal-phed pe sinus & allergy wal-profen wal-sleep z wal-som (diphenhydramine).. 57 I-21 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

180 wal-tap wal-tussin cough wal-tussin cough & cold cf wal-tussin dm wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile womens daily gummies women's daily multivitamin. 161 X XALKORI XARELTO XELJANZ XENAZINE XIFAXAN XOLAIR XTANDI xylon XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon ZANTAC ZANTAC ZARXIO ZAVESCA ZELBORAF ZEMPLAR ZENPEP zephrex-d ZETIA ZIAGEN zidovudine zinc oxide ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) ZOVIRAX z-sleep ZUBSOLV ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA ZYVOX Questo formulario è stato aggiornato in data 31/12/2015. Per eventuali domande, si prega di contattare ICS Community Care Plus FIDA-MMP al numero ICS.2525, dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito I-22 Formulario ICS Community Care Plus FIDA-MMP per il 2015 ID del formulario: , Versione: 9 In vigore da: 1 Gen 2016

181 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