GuildNet Gold Plus FIDA Plan

Transcript

1 GuildNet Gold Plus FIDA Plan MMP-POS Elenco dei farmaci coperti (Formulario) 2017 Il presente formulario è stato aggiornato in data <MM/YYYY>. Per informazioni più recenti o altre domande, contattare il Piano al numero oppure, per gli utenti TTY, 711. Orari: dal lunedì Este alla vademécum domenica, se dalle actualizó 8:00 el alle 8/8/ :00. Para Oppure obtener visitare información il sito más reciente o si tiene otras preguntas, comuníquese con el Plan al o, para usuarios de teléfonos de texto (TTY), al Se atiende de lunes a domingo, de 8 a.m. a 8 p.m., o visite H0811_GN478Ita_2017 List of Drugs_Accepted H0811_MEM15_GN56s_Formulary_ v5

2 GUILDNET GOLD PLUS FIDA PLAN Elenco dei farmaci coperti (Prontuario) 2017 Questo è un elenco dei farmaci che i partecipanti possono ricevere tramite GuildNet Gold Plus FIDA Plan. GuildNet Gold Plus FIDA Plan è un piano di assistenza sanitaria gestita, che stringe accordi con Medicare e il Dipartimento della Salute dello Stato di New York (Medicaid) per fornire ai partecipanti le prestazioni di entrambi i programmi, attraverso la dimostrazione Fully Integrated Duals Advantage (FIDA). L Elenco dei farmaci coperti e/o la rete di farmacie e fornitori sono soggetti a variazioni nel corso dell anno. Le invieremo un avviso prima di apportare qualsiasi modifica che condizioni le sue prestazioni. Le prestazioni sono soggette a variazioni il 1 gennaio di ogni anno. E possibile consultare l elenco aggiornato dei farmaci inclusi nella copertura di GuildNet Gold Plus FIDA Plan visitando il sito o chiamando l Assistenza partecipanti al numero (TTY/TDD: 711) dal lunedì alla domenica, tra le ore 8 e le 20. Potrebbero essere applicate eccezioni e limitazioni. Per maggiori informazioni, contattare l Assistenza partecipanti di GuildNet Gold Plus FIDA Plan oppure leggere la Guida del partecipante. Affinché GuildNet Gold Plus FIDA Plan copra i servizi richiesti, è necessario attenersi a regole specifiche. Non è previsto alcun pagamento per qualsiasi farmaco incluso nella copertura. You can get this information for free in other languages. Call , Monday through Sunday, 8am to 8pm. TTY users call 711. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al o TTY/TDD al 711, de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde o 711 mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本 請撥打 或聽障 / 語障人士專線 (TTY/TDD) 711, 星期一至星期日上午 8 時至晚上 8 時 撥打該電話免費 Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону и TTY/TDD 711. Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo oswa TTY/TDD 711, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, i

3 다른언어로작성된이정보를무료로얻으실수있습니다. 월요일 - 일요일오전 8 시부터오후 8 시사이에 번이나 TTY/TDD 711 번으로전화주세요. 통화는무료입니다. Queste informazioni sono disponibili gratuitamente in altri formati, come la stampa a caratteri grandi, il braille o la registrazione audio. Chiamare il numero , dal lunedì alla domenica, tra le ore 8 e le 20. Numero TTY: 711. La telefonata è gratuita. Per richiedere, ora o in futuro, i materiali in una lingua diversa dall inglese o in un formato alternativo, può chiamare il numero e il numero TTY/TDD 711 dal lunedì alla domenica, tra le ore 8 e le 20. Lo Stato di New York ha creato un programma di mediazione per i partecipanti chiamato ICAN (Independent Consumer Advocacy Network) per fornire ai partecipanti assistenza gratuita e riservata su qualsiasi servizio offerto da GuildNet Gold Plus FIDA Plan. La rete ICAN può essere contattata al numero oppure online all indirizzo icannys.org. (Gli utenti TTY possono chiamare il 711 e seguire le istruzioni per comporre il numero ).? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, ii

4 Domande frequenti (FAQ) Questa sezione riporta le risposte alle domande relative all Elenco dei farmaci coperti. Per ottenere maggiori informazioni potrà leggere tutte le FAQ o cercare domande e risposte specifiche. 1. Quali farmaci soggetti a prescrizione rientrano nell Elenco dei farmaci coperti? Per brevità, l Elenco dei farmaci coperti sarà chiamato Elenco dei farmaci. I farmaci inclusi nel Prontuario che iniziano a pagina 2 sono i farmaci coperti da GuildNet Gold Plus FIDA Plan. Questi farmaci sono disponibili presso le farmacie della nostra rete. Una farmacia è considerata convenzionata quando sussiste un accordo tra noi e la farmacia per la fornitura dei suoi servizi. Tali farmacie vengono definite farmacie della rete. GuildNet Gold Plus FIDA Plan coprirà tutti i farmaci inclusi nell Elenco dei farmaci se: il suo dottore o un altro prescrittore dichiara che lei necessita dei farmaci per stare meglio o guarire da una condizione medica, il farmaco è clinicamente necessario per la sua condizione, e lei ha presentato la prescrizione a una farmacia della rete di GuildNet Gold Plus FIDA Plan. GuildNet Gold Plus FIDA Plan può prevedere ulteriori passaggi per accedere a determinati farmaci (vedere la domanda numero 5 di seguito). In certi casi, potrebbe esserle richiesto di seguire una procedura specifica, come provare prima un farmaco alternativo. Può consultare un elenco aggiornato dei farmaci coperti sul nostro sito internet o chiamando l Assistenza partecipanti al numero Numero TTY/TDD: 711. Siamo disponibili dal lunedì alla domenica, dalle ore 8 alle L'Elenco dei farmaci è soggetto a variazioni? Sì. GuildNet Gold Plus FIDA Plan può aggiungere o rimuovere farmaci dal Prontuario nel corso dell anno. Generalmente, l Elenco dei farmaci cambia: se si rende disponibile un nuovo farmaco che risulta altrettanto efficace rispetto a quello attualmente incluso nell Elenco dei farmaci, oppure? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, iii

5 se veniamo a conoscenza del fatto che un farmaco non è sicuro. Potremo anche cambiare le regole relative ai nostri farmaci. Per esempio, potremo: Decidere di richiedere o no l approvazione preventiva per un farmaco. (L'approvazione preventiva è l'autorizzazione da parte di GuildNet Gold Plus FIDA Plan o del suo Team interdisciplinare (IDT) prima di ottenere un farmaco). Aggiungere o modificare la quantità di un farmaco cui ha diritto (chiamati "limiti quantitativi"). Aggiungere o cambiare le restrizioni di una terapia progressiva (step therapy) per un farmaco. (La step therapy indica che il partecipante dovrà provare un farmaco prima che possiamo coprirne un altro). (Per maggiori informazioni su queste norme relative ai farmaci, consultare le pagine iv e v). Quando un farmaco presente nel Prontuario viene rimosso, il partecipante viene informato tempestivamente. Il partecipante sarà anche informato di eventuali variazioni relative alle regole per la copertura di un farmaco. Le domande 3, 4 e 7 riportate di seguito forniscono maggiori informazioni su cosa accade nel caso in cui l Elenco dei farmaci sia oggetto di una variazione. Lei può sempre controllare l Elenco dei farmaci aggiornato di GuildNet Gold Plus FIDA Plan sul sito internet Può anche contattare l Assistenza partecipanti al numero (TTY/TDD: 711) dal lunedì alla domenica, tra le ore 8 e le 20, per consultare il Prontuario aggiornato. 3. Cosa succede se si rende disponibile un nuovo farmaco meno costoso che ha la medesima efficacia del farmaco indicato nell Elenco dei farmaci? Se si rende disponibile un nuovo farmaco che risulta altrettanto efficace rispetto a quello attualmente riportato nell Elenco dei farmaci: La prossima volta che il partecipante presenterà una prescrizione, il farmacista potrebbe consegnare il farmaco meno costoso. Se lei e il suo fornitore decidete che il farmaco più economico non è adatto a lei, il suo fornitore potrà istruire il farmacista di continuare a fornirle il farmaco abituale. GuildNet Gold Plus FIDA Plan potrà decidere di rimuovere il farmaco più costoso dall Elenco dei farmaci. Se lei sta assumendo un farmaco che viene rimosso dal Prontuario perché si è reso disponibile un farmaco più economico altrettanto efficace, la? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, iv

6 avvertiremo almeno 60 giorni prima di rimuoverlo dall Elenco dei farmaci oppure quando lei richiederà una nuova prescrizione. A quel punto lei potrà ottenere una fornitura da 60 giorni del farmaco, prima che venga apportata la modifica all Elenco dei farmaci. Riceverà una lettera almeno 60 giorni prima che la modifica diventi effettiva. 4. Cosa accade se veniamo a conoscenza del fatto che un farmaco non è sicuro? Se la Food and Drug Administration (FDA) dichiara che un farmaco che il partecipante sta assumendo non è sicuro, lo rimuoveremo immediatamente dall Elenco dei farmaci. Le invieremo anche una lettera e la chiameremo per informarla della rimozione del farmaco non sicuro dall Elenco dei farmaci. Dopo aver ricevuto questa lettera, il partecipante deve contattare il proprio medico o Coordinatore sanitario e chiedere che gli prescriva un farmaco alternativo. 5. Ci sono restrizioni o limiti alla copertura dei farmaci? Oppure esistono procedure precise da seguire per poter ottenere determinati farmaci? Sì, alcuni farmaci sono sottoposti a specifiche regole sulla copertura o a limitazioni della quantità erogabile. In certi casi, a lei o al suo medico o altro prescrittore potrebbe essere richiesto di seguire una procedura specifica per ottenere il farmaco. Per esempio: Approvazione preventiva (o autorizzazione preventiva): Per alcuni farmaci lei, il suo dottore o altro prescrittore dovrete ottenere l approvazione da GuildNet Gold Plus FIDA Plan o dal team interdisciplinare (IDT) prima di presentare la sua prescrizione. Se non si ottenesse l approvazione, GuildNet Gold Plus FIDA Plan potrebbe non coprire il farmaco. Limiti di quantità: Occasionalmente, GuildNet Gold Plus FIDA Plan potrebbe limitare la quantità di farmaci di cui potrà usufruire. Terapia progressiva (Step therapy): A volte GuildNet Gold Plus FIDA Plan richiede l applicazione della terapia progressiva. Questo significa che il partecipante dovrà provare i farmaci in un ordine specifico in base alla sua condizione medica. Potrebbe essergli richiesto di provare un farmaco prima di ottenere la copertura per un altro farmaco. Se il medico ritiene che il primo farmaco non sia adatto a lei, allora sarà coperto il secondo. Può conoscere eventuali requisiti aggiuntivi o limiti per il suo farmaco consultando le tabelle riportate da pagina 2. Può ottenere maggiori informazioni visitando il nostro sito internet all indirizzo Abbiamo pubblicato documenti online che spiegano le limitazioni? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, v

7 della nostra autorizzazione preventiva e della terapia progressiva. Se lo desidera, può richiederne una copia. Potrà anche chiedere una "deroga" rispetto a queste limitazioni. Per maggiori informazioni sulle deroghe, consultare la domanda 11. Se si trova in una struttura di accoglienza o in un altra struttura per le cure a lungo termine e necessita di un farmaco non presente sull Elenco dei farmaci, oppure se non può accedere facilmente al farmaco di cui ha bisogno, noi possiamo aiutarla. Copriremo una fornitura da 31 giorni del farmaco di cui ha bisogno, (a meno che la sua prescrizione sia valida per un minor numero di giorni), indipendentemente dal fatto che lei sia o no un nuovo Partecipante di GuildNet Gold Plus FIDA Plan. In questo modo lei avrà il tempo di discutere con il suo dottore o altro prescrittore. Quest ultimo la potrà aiutare a stabilire se esiste un farmaco simile nel Prontuario che sia adatto alle sue esigenze, oppure se richiedere una deroga. Per maggiori informazioni sulle deroghe, consultare la domanda Come saprà il partecipante se il farmaco è soggetto a limitazioni, oppure se sono previste procedure specifiche da seguire per ottenerlo? L Elenco dei farmaci a pagina 2 include una colonna intitolata "Azioni necessarie, restrizioni o limitazioni dell uso". 7. Che cosa succede se cambiamo le nostre regole relative alla copertura dei farmaci? Per esempio, se aggiungiamo limitazioni all autorizzazione preventiva (approvazione), limiti quantitativi e/o restrizioni alla terapia progressiva per un farmaco. Comunicheremo al partecipante se aggiungiamo autorizzazione preventiva (approvazione), limiti quantitativi, e/o restrizioni sulla step therapy di un farmaco. Glielo comunicheremo almeno 60 giorni prima dell introduzione della restrizione, oppure quando farà richiesta di una nuova prescrizione. Il partecipante potrà ottenere una fornitura del farmaco per 60 giorni prima che la modifica all Elenco dei farmaci diventi effettiva. Questo gli darà il tempo di consultare il suo medico o altro prescrittore in merito alla procedura da seguire.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, vi

8 8. Come si può trovare un farmaco nell Elenco dei farmaci? Di seguito sono descritti due modi per trovare un farmaco: Può cercare in ordine alfabetico (se sa come si scrive il nome del farmaco), oppure Può cercare in base alla patologia. Per effettuare la ricerca alfabetica, deve andare alla sezione Elenco alfabetico a pagina 2. Infine cerchi il nome del farmaco nell elenco. Per ricercare in base alla patologia, consulti la sezione Elenco dei farmaci per patologia a pagina 2. I farmaci di questa sezione sono raggruppati in categorie e suddivisi in base al tipo di patologia per cui vengono usati. Per esempio, in caso di problemi cardiaci dovrà consultare la categoria: Cardiovascolare, Ipertensione/Lipidi. Qui troverà i farmaci per i suoi problemi di cuore. 9. Cosa accade se il farmaco che il partecipante vuole assumere non è presente nell Elenco dei farmaci? Se il suo farmaco non è presente nell'elenco dei farmaci, la invitiamo a chiamare l Assistenza Partecipanti al numero , TTY/TDD 711, dal lunedì alla domenica, tra le ore 8 e le 20, per richiedere informazioni. Se lei viene a conoscenza del fatto che GuildNet Gold Plus FIDA Plan non coprirà il farmaco, può seguire una delle indicazioni seguenti: Chiedere all Assistenza partecipanti un elenco di farmaci equivalenti a quello che intende assumere. Mostrare l elenco al proprio medico o altro prescrittore. Il medico potrà prescriverle un farmaco presente nell Elenco dei farmaci che ha le stesse proprietà di quello da lei richiesto. Oppure Può richiedere al piano o al suo IDT di concedere una deroga in relazione alla copertura del farmaco. Per maggiori informazioni sulle deroghe, consultare la domanda Cosa fare se un nuovo partecipante di GuildNet Gold Plus FIDA Plan non è in grado di trovare il suo farmaco nell Elenco dei farmaci oppure ha difficoltà a reperire il farmaco? Noi possiamo aiutarla. Noi siamo tenuti a coprire fino a 90 giorni di forniture temporanee del farmaco, a seconda di quanto necessario, nei primi 90 giorni di partecipazione a GuildNet Gold Plus FIDA Plan. In questo modo lei avrà il tempo di discutere con il suo dottore o altro prescrittore. Quest ultimo la potrà aiutare a stabilire se esiste un farmaco simile nel Prontuario che sia adatto alle sue esigenze, oppure se richiedere una deroga.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, vii

9 Forniremo fino a 90 giorni di fornitura temporanea del farmaco se: lei sta assumendo un farmaco che non è presente nel nostro Elenco dei farmaci, oppure il regolamento del piano di assistenza sanitaria non le consente di ottenere la quantità ordinata dal suo prescrittore, oppure il farmaco richiede l approvazione preventiva di GuildNet Gold Plus FIDA Plan o del suo team interdisciplinare (IDT), oppure lei sta assumendo un farmaco che fa parte di una terapia progressiva (step therapy). Se lei risiede in una struttura di cura o in altri tipi di strutture di cura a lungo termine, potrà ripetere la prescrizione fino a 98 giorni. Durante i primi 90 giorni di adesione al piano, lei potrà rinnovare la dispensazione del farmaco più volte. In questo modo il suo prescrittore avrà il tempo di sostituire i suoi farmaci con quelli presenti nell Elenco dei farmaci, o di chiedere una deroga. Se lei sta partecipando al nostro piano e si verifica un cambiamento nel livello di assistenza, come ad esempio un ricovero o una dimissione dalla struttura di assistenza a lungo termine, le sarà permesso di ottenere una ripetizione "anticipata" dei suoi farmaci da prescrizione, se necessaria, in modo da accompagnarla nella sua transizione al nuovo livello di cura. 11. Il partecipante può chiedere una deroga per coprire il suo farmaco? Sì. Lei può richiedere a GuildNet Gold Plus FIDA Plan o al suo team interdisciplinare (IDT) di concedere una deroga per coprire un farmaco che non è incluso nell Elenco dei farmaci. Potrà anche chiedere a GuildNet Gold Plus FIDA Plan o al suo IDT di cambiare le regole per il suo farmaco. Per esempio, GuildNet Gold Plus FIDA Plan potrebbe limitare la quantità di un farmaco che è possibile coprire. Se il suo farmaco ha un limite, lei può chiedere a noi o al suo IDT di modificare il limite e aumentare la copertura. Altri esempi: Il partecipante può chiedere a noi o al suo IDT di revocare le restrizioni della step therapy o i requisiti di approvazione preventiva. 12. Quanto tempo ci vuole per ottenere una deroga? In primo luogo, GuildNet Gold Plus FIDA Plan o il team interdisciplinare (IDT) devono ricevere una dichiarazione dal medico a supporto della richiesta di deroga. Dopo aver ricevuto la dichiarazione, al partecipante verrà comunicata la decisione in merito alla sua richiesta di deroga entro 72 ore.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, viii

10 Se lei o il suo prescrittore ritenete che la sua salute possa essere messa a rischio da un attesa di 72 ore, potrete richiedere una procedura di deroga accelerata. Si tratta di una decisione presa in tempi più rapidi. Se il medico avalla la richiesta, il partecipante otterrà una decisione entro 24 ore dalla ricezione della dichiarazione del medico prescrittore. 13. Come si richiede una deroga? Per richiedere una deroga, contatti il suo Coordinatore sanitario. Il Coordinatore sanitario collaborerà con lei e il suo fornitore per aiutarla a richiedere una deroga. 14. Cosa sono i farmaci generici? I farmaci generici contengono gli stessi ingredienti dei farmaci di marca. Di solito costano meno rispetto al farmaco di marca, e non hanno nomi noti. I farmaci generici sono approvati dalla Food and Drug Administration (FDA). GuildNet Gold Plus FIDA Plan copre sia i farmaci di marca, sia i farmaci generici. 15. Cosa sono i farmaci OTC? OTC significa "over-the-counter", vale a dire farmaci da banco. GuildNet Gold Plus FIDA Plan include alcuni farmaci da banco quando sono indicati sulla prescrizione del proprio fornitore. Per sapere quali sono i farmaci da banco coperti, leggere l Elenco dei farmaci di GuildNet Gold Plus FIDA Plan. Ecco alcuni esempi di farmaci da banco coperti: aspirina, paracetamolo, Advil, antiacidi, fermaci per allergie e raffreddore, creme antibiotiche, lassativi, cerotti e gomme alla nicotina e vitamine. 16. GuildNet Gold Plus FIDA Plan copre i prodotti da banco non farmaceutici? GuildNet Gold Plus FIDA Plan copre alcuni prodotti da banco non farmaceutici quando sono indicati sulla prescrizione del proprio fornitore. Per sapere quali sono i prodotti da banco non farmaceutici coperti, legga l Elenco dei farmaci di GuildNet Gold Plus FIDA Plan. Ad esempio si tratta di protezioni solari (con SPF superiore a 15), shampoo topico Sebex e unguento A&D.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, ix

11 Ulteriori prodotti da banco non riportati nell Elenco dei farmaci, possono essere ottenuti utilizzando la sua carta per i farmaci da banco di GuildNet Gold Plus FIDA Plan presso una delle farmacie partecipanti. Gli articoli coperti dalla carta per i farmaci da banco del piano comprendono cerotti, pastiglie per la tosse, dentifrici e bendaggi medici. Per maggiori informazioni, si prega di consultare il capitolo 4 della Guida del partecipante. 17. A quanto ammonta la quota a carico del partecipante? Il partecipante non dovrà versare alcun contributo finanziario per i farmaci indicati nell Elenco dei farmaci. 18. Cosa sono i livelli dei farmaci? I livelli sono gruppi di farmaci inclusi nel nostro Prontuario. I farmaci di livello 1 sono farmaci generici coperti da Medicare Parte D. I farmaci di livello 2 sono farmaci di marca coperti da Medicare Parte D. I farmaci di livello 3 sono farmaci da prescrizione coperti da Medicaid che non rientrano nella Parte D. I farmaci di livello 4 sono articoli da banco (OTC) Tutti i farmaci e gli articoli presenti nell Elenco dei farmaci prevedono un contributo di spesa di 0 dollari.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, x

12 Elenco dei farmaci inclusi nella copertura L Elenco dei farmaci che inizia alla pagina successiva fornisce informazioni sui farmaci coperti da GuildNet Gold Plus FIDA Plan. Se ha problemi a trovare il suo farmaco nell elenco, controlli l Indice che inizia a pagina 157. La prima colonna della tabella riporta il nome del farmaco. I farmaci di marca sono indicati in lettere maiuscole (p. es. SYNTHROID), mentre i farmaci generici sono elencati in corsivo minuscolo (p. es. atenololo). Le informazioni contenute nella colonna "Azioni necessarie, restrizioni o limitazioni dell uso" indicano se GuildNet Gold Plus FIDA Plan applica delle regole di copertura del farmaco. Nota: Il simbolo (*) accanto al nome di un farmaco indica che questo non è un Farmaco della Parte D. Questi farmaci sono soggetti a regole diverse per i ricorsi. Un ricorso è una procedura formale di richiesta di riesame e modifica di una decisione sulla copertura, se il partecipante ritiene che sia stato commesso un errore. Ad esempio, GuildNet Gold Plus FIDA Plan o il team interdisciplinare (IDT) potrebbero decidere che il farmaco che si desidera non è coperto, o non è più coperto da Medicare o da Medicaid. Se il partecipante, il suo medico o altro prescrittore non concordano con tale decisione, sarà possibile presentare ricorso. Per chiedere istruzioni su come presentare ricorso, chiamare l Assistenza partecipanti al numero (TTY: 711) dal lunedì alla domenica, tra le ore 8 e le 20, oppure la rete ICAN al numero (Gli utenti TTY possono chiamare il 711 e seguire le istruzioni per comporre il numero ). Per informazioni su come presentare un ricorso, consultare la Guida del partecipante.? In caso di domande, contattare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711), dal lunedì alla domenica, tra le ore 8 e le 20. La telefonata è gratuita. Per maggiori informazioni, xi

13 Di seguito è riportato un elenco di abbreviazioni che possono comparire nelle pagine seguenti nella colonna Requisiti/Limiti, e indicano se sono previsti requisiti speciali per la copertura del suo farmaco. Elenco delle abbreviazioni *: Il simbolo * dopo il nome di un farmaco indica che questo non è un Farmaco della Parte D. Questi farmaci hanno regole differenti per i ricorsi. Un ricorso è una procedura formale di richiesta di riesame e modifica di una decisione sulla copertura, se il partecipante ritiene che sia stato commesso un errore. Ad esempio, GuildNet o il team interdisciplinare (IDT) potrebbero decidere che il farmaco che si desidera non è coperto, o non è più coperto da Medicare o da Medicaid. Se il partecipante, il suo medico o altro prescrittore non concordano con tale decisione, sarà possibile presentare ricorso. Per chiedere istruzioni su come presentare ricorso, può chiamare GuildNet Gold Plus FIDA Plan al numero (TTY/TDD: 711) oppure la rete ICAN al numero Per informazioni su come presentare un ricorso, consultare la Guida del partecipante. B/D PA: Questo farmaco da prescrizione può essere coperto da Medicare, Parte B o D, a seconda delle circostanze. Possono essere richieste delle informazioni che descrivono l uso e il contesto del farmaco al fine di procedere alla determinazione della copertura. LA: Disponibilità limitata. Questa prescrizione potrebbe essere dispensata solo da determinate farmacie. Per maggiori informazioni, chiami il Servizio clienti. MO: Farmaco ordinabile per posta. Questo farmaco da prescrizione è disponibile attraverso il nostro servizio di ordini per corrispondenza, nonché attraverso le nostre farmacie della rete di vendita al dettaglio. Le suggeriamo di utilizzare gli ordini per corrispondenza per i suoi farmaci per cure a lungo termine o di mantenimento (come i farmaci per la pressione alta). Le farmacie della rete di vendita al dettaglio possono essere più appropriate per prescrizioni a breve termine (come gli antibiotici). NEDS: Per alcuni farmaci, il piano limita la quantità giornaliera di farmaco che copriamo su base mensile. PA: Autorizzazione preventiva Il Piano prevede che lei o il suo medico otteniate un autorizzazione preventiva per alcuni farmaci. Ciò significa che dovrà ottenere l approvazione prima di presentare le sue prescrizioni. Se non ottenesse l approvazione, potremmo non coprire il farmaco. QL: Limiti di quantità. Per alcuni farmaci, il Piano limita la quantità di cui si può usufruire. ST: Terapia progressiva (Step therapy): In alcuni casi, il Piano prevede che lei provi alcuni farmaci per la sua condizione medica prima che sia autorizzata la copertura di un altro farmaco analogo. Ad esempio, se il Farmaco A e il Farmaco B trattano entrambi la sua condizione medica, noi potremmo coprire il Farmaco B solo se lei prova prima il Farmaco A. Qualora il Farmaco A non funzionasse per lei, allora copriremo il Farmaco B. 1

14 ANTINFETTIVI AGENTI ANTIFUNGINI LIMIT ABELCET INTRAVENOUS SUSPENSION 2 $0 B/D PA; MO AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO amphotericin b injection recon soln 1 $0 B/D PA; MO CANCIDAS INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO clotrimazole mucous membrane troche 1 $0 MO fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA fluconazole oral suspension for reconstitution 1 $0 MO fluconazole oral tablet 1 $0 MO flucytosine oral capsule 1 $0 MO griseofulvin microsize oral suspension 1 $0 MO griseofulvin microsize oral tablet 1 $0 MO griseofulvin ultramicrosize oral tablet 1 $0 MO itraconazole oral capsule 1 $0 MO; QL (120 per 30 ketoconazole oral tablet 1 $0 MO NOXAFIL ORAL SUSPENSION nystatin oral suspension 1 $0 MO nystatin oral tablet 1 $0 MO terbinafine hcl oral tablet 1 $0 MO; QL (90 per 365 voriconazole intravenous solution 1 $0 B/D PA; MO 2

15 voriconazole oral suspension for reconstitution 1 $0 MO voriconazole oral tablet 1 $0 MO ANTIVIRALI abacavir oral tablet 1 $0 MO abacavir-lamivudine-zidovudine oral tablet 1 $0 MO acyclovir oral capsule 1 $0 MO acyclovir oral suspension 200 mg/5 ml 1 $0 MO acyclovir oral tablet 1 $0 MO acyclovir sodium intravenous recon soln 500 mg 1 $0 B/D PA LIMIT acyclovir sodium intravenous solution 1 $0 B/D PA; MO adefovir oral tablet 1 $0 MO amantadine hcl oral capsule 1 $0 MO amantadine hcl oral solution 1 $0 MO amantadine hcl oral tablet 1 $0 MO APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION 2 $0 ATRIPLA ORAL TABLET BARACLUDE ORAL SOLUTION cidofovir intravenous solution 1 $0 B/D PA; MO COMPLERA ORAL TABLET CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET 2 $0 didanosine oral capsule,delayed release(dr/ec) 1 $0 MO EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet 1 $0 MO 3

16 EPIVIR HBV ORAL SOLUTION EPZICOM ORAL TABLET EVOTAZ ORAL TABLET LIMIT famciclovir oral tablet 125 mg 1 $0 MO; QL (21 per 10 famciclovir oral tablet 250 mg 1 $0 MO; QL (60 per 30 famciclovir oral tablet 500 mg 1 $0 MO; QL (21 per 7 foscarnet intravenous solution 1 $0 FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln 1 $0 B/D PA; MO GENVOYA ORAL TABLET HARVONI ORAL TABLET 2 $0 PA; MO; QL (28 per 28 ; NEDS INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution 1 $0 MO lamivudine oral tablet 1 $0 MO lamivudine-zidovudine oral tablet 1 $0 MO LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension 1 $0 MO nevirapine oral tablet 1 $0 MO nevirapine oral tablet extended release 24 hr 1 $0 MO 4

17 NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET 2 $0 PREZCOBIX ORAL TABLET PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE LIMIT ; QL (60 per 180 RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS SOLUTION REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribavirin oral capsule 1 $0 PA; MO ribavirin oral tablet 200 mg 1 $0 PA; MO rimantadine oral tablet 1 $0 MO SELZENTRY ORAL TABLET SOVALDI ORAL TABLET 2 $0 PA; MO; QL (30 per 30 ; NEDS stavudine oral capsule 1 $0 MO stavudine oral recon soln 1 $0 MO STRIBILD ORAL TABLET SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML 2 $0 PA; MO 5

18 SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TIVICAY ORAL TABLET 10 MG, 25 MG 2 $0 LIMIT 2 $0 PA; MO; LA TIVICAY ORAL TABLET 50 MG TRIUMEQ ORAL TABLET TRUVADA ORAL TABLET MG, MG, MG 2 $0 TRUVADA ORAL TABLET MG TYBOST ORAL TABLET TYZEKA ORAL TABLET valacyclovir oral tablet 1 $0 MO; QL (30 per 30 VALCYTE ORAL RECON SOLN valganciclovir oral tablet 1 $0 MO VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE INHALATION RECON SOLN 2 $0 B/D PA; MO VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ORAL TABLET ZIAGEN ORAL SOLUTION zidovudine oral capsule 1 $0 MO zidovudine oral syrup 1 $0 MO zidovudine oral tablet 1 $0 MO 6

19 CEFALOSPORINE cefaclor oral capsule 1 $0 MO cefaclor oral tablet extended release 12 hr 1 $0 MO cefadroxil oral capsule 1 $0 MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1 $0 MO cefadroxil oral tablet 1 $0 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml LIMIT 1 $0 B/D PA; MO cefazolin injection recon soln 1 gram, 500 mg 1 $0 B/D PA; MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g 1 $0 B/D PA cefazolin intravenous recon soln 1 $0 B/D PA cefdinir oral capsule 1 $0 MO cefdinir oral suspension for reconstitution 1 $0 MO CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO cefepime injection recon soln 1 $0 B/D PA; MO cefixime oral suspension for reconstitution 1 $0 MO cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 1 $0 cefotaxime injection recon soln 10 gram 1 $0 B/D PA; MO CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK 1 $0 cefotetan injection recon soln 1 $0 cefotetan intravenous recon soln 1 $0 7

20 cefoxitin in dextrose, iso-osm intravenous piggyback 1 $0 B/D PA LIMIT cefoxitin intravenous recon soln 1 gram 1 $0 B/D PA; MO cefoxitin intravenous recon soln 10 gram, 2 gram 1 $0 B/D PA cefpodoxime oral suspension for reconstitution 1 $0 MO cefpodoxime oral tablet 1 $0 MO cefprozil oral suspension for reconstitution 1 $0 MO cefprozil oral tablet 1 $0 MO CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 $0 B/D PA ceftazidime injection recon soln 1 gram, 2 gram 1 $0 MO ceftazidime injection recon soln 6 gram 1 $0 ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram 1 $0 CEFTRIAXONE INJECTION RECON SOLN 100 GRAM 1 $0 B/D PA; MO 1 $0 B/D PA; MO 1 $0 B/D PA ceftriaxone intravenous recon soln 1 gram 1 $0 MO ceftriaxone intravenous recon soln 2 gram 1 $0 B/D PA; MO cefuroxime axetil oral tablet 1 $0 MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg CEFUROXIME SODIUM INJECTION RECON SOLN 75 GRAM 1 $0 B/D PA; MO 1 $0 B/D PA cefuroxime sodium intravenous recon soln 1 $0 B/D PA cephalexin oral capsule 1 $0 MO cephalexin oral suspension for reconstitution 1 $0 MO 8

21 cephalexin oral tablet 1 $0 MO SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML 2 $0 SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE LIMIT TEFLARO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO ERITROMICINE / ALTRI MACROLIDI azithromycin intravenous recon soln 1 $0 B/D PA; MO azithromycin oral packet 1 $0 MO azithromycin oral suspension for reconstitution 1 $0 MO azithromycin oral tablet 1 $0 MO clarithromycin oral suspension for reconstitution 1 $0 MO clarithromycin oral tablet 1 $0 MO clarithromycin oral tablet extended release 24 hr 1 $0 MO e.e.s. 400 oral tablet 1 $0 MO ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION erythrocin (as stearate) oral tablet 250 mg 1 $0 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 B/D PA; NEDS erythromycin ethylsuccinate oral tablet 1 $0 MO erythromycin oral capsule,delayed release(dr/ec) 1 $0 MO erythromycin oral tablet 1 $0 MO ANTINFETTIVI VARI ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ; QL (180 per 30 9

22 LIMIT ALINIA ORAL TABLET ; QL (12 per 30 amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 1 $0 B/D PA; MO atovaquone oral suspension 1 $0 MO atovaquone-proguanil oral tablet 1 $0 MO aztreonam injection recon soln 1 $0 MO baciim intramuscular recon soln 1 $0 B/D PA bacitracin intramuscular recon soln 1 $0 MO CAPASTAT INJECTION RECON SOLN 2 $0 B/D PA CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln ; QL (84 per 28 1 $0 B/D PA chloroquine phosphate oral tablet 1 $0 MO clindamycin hcl oral capsule 1 $0 MO clindamycin palmitate hcl oral recon soln 1 $0 MO clindamycin pediatric oral recon soln 1 $0 clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO COARTEM ORAL TABLET colistin (colistimethate na) injection recon soln 1 $0 B/D PA; MO CUBICIN INTRAVENOUS RECON SOLN CYCLOSERINE ORAL CAPSULE 1 $0 MO 10

23 DAPSONE ORAL TABLET LIMIT DARAPRIM ORAL TABLET 2 $0 PA; MO; NEDS ethambutol oral tablet 1 $0 MO gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml 1 $0 MO 1 $0 1 $0 gentamicin injection solution 40 mg/ml 1 $0 B/D PA; MO hydroxychloroquine oral tablet 1 $0 MO imipenem-cilastatin intravenous recon soln 1 $0 B/D PA; MO INVANZ INJECTION RECON SOLN 2 $0 B/D PA; MO INVANZ INTRAVENOUS RECON SOLN 2 $0 B/D PA isonarif oral capsule 1 $0 MO isoniazid injection solution 1 $0 isoniazid oral solution 1 $0 MO isoniazid oral tablet 1 $0 MO ivermectin oral tablet 1 $0 MO kanamycin injection solution 1 $0 B/D PA linezolid intravenous parenteral solution 1 $0 PA linezolid oral suspension for reconstitution 1 $0 PA; MO linezolid oral tablet 1 $0 PA; MO linezolid-0.9% sodium chloride intravenous parenteral solution 1 $0 PA mefloquine oral tablet 1 $0 MO meropenem intravenous recon soln 1 $0 B/D PA; MO 11

24 MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 500 MG/50 ML 1 $0 B/D PA metro i.v. intravenous piggyback 1 $0 MO metronidazole in nacl (iso-os) intravenous piggyback 1 $0 MO metronidazole oral capsule 1 $0 MO metronidazole oral tablet 1 $0 MO LIMIT NEBUPENT INHALATION RECON SOLN 2 $0 B/D PA; MO neomycin oral tablet 1 $0 MO paromomycin oral capsule 1 $0 MO PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION RECON SOLN 2 $0 B/D PA; MO polymyxin b sulfate injection recon soln 1 $0 MO PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET pyrazinamide oral tablet 1 $0 MO quinine sulfate oral capsule 1 $0 PA; MO rifabutin oral capsule 1 $0 MO rifampin intravenous recon soln 1 $0 B/D PA; MO rifampin oral capsule 1 $0 MO SIRTURO ORAL TABLET ; LA STREPTOMYCIN INTRAMUSCULAR RECON SOLN 2 $0 B/D PA; MO SYNERCID INTRAVENOUS RECON SOLN 2 $0 B/D PA tinidazole oral tablet 1 $0 MO TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (224 per 30 12

25 tobramycin in % nacl inhalation solution for nebulization tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml LIMIT 1 $0 B/D PA; MO 1 $0 MO tobramycin sulfate injection recon soln 1 $0 B/D PA tobramycin sulfate injection solution 1 $0 B/D PA; MO TRECATOR ORAL TABLET TYGACIL INTRAVENOUS RECON SOLN XIFAXAN ORAL TABLET 550 MG PENICILLINE amoxicillin oral capsule 1 $0 MO amoxicillin oral suspension for reconstitution 1 $0 MO amoxicillin oral tablet 1 $0 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 $0 MO amoxicillin-pot clavulanate oral suspension for reconstitution 1 $0 MO amoxicillin-pot clavulanate oral tablet 1 $0 MO amoxicillin-pot clavulanate oral tablet extended release 12 hr 1 $0 MO amoxicillin-pot clavulanate oral tablet,chewable 1 $0 MO ampicillin oral capsule 1 $0 MO ampicillin oral suspension for reconstitution 1 $0 MO ampicillin sodium injection recon soln 1 $0 B/D PA; MO ampicillin sodium intravenous recon soln 1 $0 B/D PA ampicillin-sulbactam injection recon soln 1.5 gram ampicillin-sulbactam injection recon soln 15 gram 1 $0 MO 1 $0 B/D PA ampicillin-sulbactam injection recon soln 3 gram 1 $0 B/D PA; MO 13

26 ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram 1 $0 LIMIT 1 $0 B/D PA; MO BICILLIN C-R INTRAMUSCULAR SYRINGE BICILLIN L-A INTRAMUSCULAR SYRINGE dicloxacillin oral capsule 1 $0 MO nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml 1 $0 B/D PA 1 $0 B/D PA; MO nafcillin injection recon soln 1 $0 B/D PA; MO nafcillin intravenous recon soln 1 $0 B/D PA; MO oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml 1 $0 1 $0 MO oxacillin injection recon soln 1 gram, 2 gram 1 $0 B/D PA; MO oxacillin injection recon soln 10 gram 1 $0 MO oxacillin intravenous recon soln 1 gram 1 $0 B/D PA oxacillin intravenous recon soln 2 gram 1 $0 penicillin g potassium injection recon soln 1 $0 B/D PA; MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml 1 $0 MO 1 $0 B/D PA penicillin g sodium injection recon soln 1 $0 B/D PA; MO penicillin v potassium oral recon soln 1 $0 MO penicillin v potassium oral tablet 1 $0 MO piperacillin-tazobactam intravenous recon soln 1 $0 B/D PA; MO 14

27 CHINOLONI AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK ciprofloxacin (mixture) oral tablet, er multiphase 24 hr LIMIT 2 $0 B/D PA; MO 1 $0 MO ciprofloxacin hcl oral tablet 1 $0 MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 $0 B/D PA; MO 1 $0 B/D PA ciprofloxacin oral suspension,microcapsule recon 1 $0 levofloxacin in d5w intravenous piggyback 250 mg/50 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml 1 $0 1 $0 MO levofloxacin intravenous solution 1 $0 B/D PA; MO levofloxacin oral solution 1 $0 MO levofloxacin oral tablet 1 $0 MO moxifloxacin oral tablet 1 $0 MO ofloxacin oral tablet 400 mg 1 $0 MO SULFAMIDICI/AGENTI COLLEGATI sulfadiazine oral tablet 1 $0 MO sulfamethoxazole-trimethoprim intravenous solution 1 $0 B/D PA; MO sulfamethoxazole-trimethoprim oral suspension 1 $0 MO sulfamethoxazole-trimethoprim oral tablet 1 $0 MO TETRACICLINE demeclocycline oral tablet 1 $0 MO doxy-100 intravenous recon soln 1 $0 MO; NEDS 15

28 LIMIT doxycycline hyclate intravenous recon soln 1 $0 B/D PA; NEDS doxycycline hyclate oral capsule 1 $0 MO doxycycline hyclate oral tablet 100 mg, 20 mg 1 $0 MO doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 200 mg, 50 mg 1 $0 MO 1 $0 doxycycline monohydrate oral capsule 1 $0 MO doxycycline monohydrate oral tablet 1 $0 MO minocycline oral capsule 1 $0 MO minocycline oral tablet 1 $0 MO minocycline oral tablet extended release 24 hr 1 $0 MO morgidox oral capsule 100 mg 1 $0 MO ORACEA ORAL CAPSULE,IR - AY REL,BIPHASE tetracycline oral capsule 1 $0 MO AGENTI PER VIE URINARIE methenamine hippurate oral tablet 1 $0 MO methenamine mandelate oral tablet 1 gram 1 $0 MO nitrofurantoin macrocrystal oral capsule 1 $0 MO nitrofurantoin monohyd/m-cryst oral capsule 1 $0 MO trimethoprim oral tablet 1 $0 MO VANCOMICINA VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML 1 $0 B/D PA 1 $0 B/D PA; MO 16

29 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG 1 $0 B/D PA LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA; MO vancomycin oral capsule 1 $0 MO FARMACI ANTINEOPLASTICI / IMMUNOSOPPRESSORI AGENTI AGGIUNTIVI amifostine crystalline intravenous recon soln 1 $0 B/D PA; MO dexrazoxane hcl intravenous recon soln 250 mg 1 $0 B/D PA dexrazoxane hcl intravenous recon soln 500 mg 1 $0 B/D PA; MO ELITEK INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg 1 $0 B/D PA; MO leucovorin calcium injection recon soln 500 mg 1 $0 B/D PA leucovorin calcium oral tablet 1 $0 MO levoleucovorin calcium intravenous solution 1 $0 B/D PA mesna intravenous solution 1 $0 B/D PA; MO MESNEX ORAL TABLET XGEVA SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO FARMACI ANTINEOPLASTICI / IMMUNOSOPPRESSORI ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO 17

30 adrucil intravenous solution 2.5 gram/50 ml 1 $0 B/D PA adrucil intravenous solution 5 gram/100 ml, 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION LIMIT 1 $0 B/D PA; MO 2 $0 PA; MO; NEDS AFINITOR ORAL TABLET 2 $0 PA; MO; NEDS ALECENSA ORAL CAPSULE 2 $0 PA; MO ALIMTA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO anastrozole oral tablet 1 $0 MO ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 2 $0 B/D PA; MO AVASTIN INTRAVENOUS SOLUTION 2 $0 B/D PA; MO azacitidine injection recon soln 1 $0 MO AZASAN ORAL TABLET 2 $0 B/D PA; MO azathioprine oral tablet 1 $0 B/D PA; MO azathioprine sodium injection recon soln 1 $0 B/D PA BELEODAQ INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO BENDEKA INTRAVENOUS SOLUTION 2 $0 PA; MO bexarotene oral capsule 1 $0 PA; MO bicalutamide oral tablet 1 $0 MO BICNU INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO bleomycin injection recon soln 1 $0 B/D PA; MO BOSULIF ORAL TABLET 2 $0 PA; MO; NEDS BUSULFEX INTRAVENOUS SOLUTION 2 $0 B/D PA CABOMETYX ORAL TABLET 2 $0 PA; LA CAMPATH INTRAVENOUS SOLUTION 2 $0 B/D PA CAPRELSA ORAL TABLET carboplatin intravenous solution 1 $0 B/D PA; MO 18

31 LIMIT CELLCEPT INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO cisplatin intravenous solution 1 $0 B/D PA; MO cladribine intravenous solution 1 $0 B/D PA; MO COMETRIQ ORAL CAPSULE 2 $0 PA; MO COTELLIC ORAL TABLET 2 $0 PA; MO; LA CYCLOPHOSPHAMIDE ORAL CAPSULE 2 $0 B/D PA; MO cyclosporine intravenous solution 1 $0 B/D PA cyclosporine modified oral capsule 1 $0 B/D PA; MO cyclosporine modified oral solution 1 $0 B/D PA; MO cyclosporine oral capsule 1 $0 B/D PA; MO CYRAMZA INTRAVENOUS SOLUTION 2 $0 PA; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml) 1 $0 B/D PA; MO cytarabine (pf) injection solution 20 mg/ml 1 $0 B/D PA cytarabine injection solution 1 $0 B/D PA; MO dacarbazine intravenous recon soln 1 $0 B/D PA; MO DARZALEX INTRAVENOUS SOLUTION 2 $0 PA; MO; LA daunorubicin intravenous solution 1 $0 B/D PA DAUNOXOME INTRAVENOUS SOLUTION 2 $0 decitabine intravenous recon soln 1 $0 B/D PA; MO doxorubicin intravenous recon soln 1 $0 B/D PA doxorubicin intravenous solution 1 $0 B/D PA; MO DOXORUBICIN, PEG-LIPOSOMAL INTRAVENOUS SUSPENSION 2 $0 B/D PA; MO DROXIA ORAL CAPSULE 19

32 ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO ELIGARD SUBCUTANEOUS SYRINGE 2 $0 PA; MO EMCYT ORAL CAPSULE EMPLICITI INTRAVENOUS RECON SOLN 2 $0 PA; MO ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR LIMIT 2 $0 B/D PA; MO epirubicin intravenous solution 200 mg/100 ml 2 $0 B/D PA epirubicin intravenous solution 50 mg/25 ml 2 $0 B/D PA; MO ERIVEDGE ORAL CAPSULE 2 $0 PA; MO ERWINAZE INJECTION RECON SOLN 2 $0 PA; MO etoposide intravenous solution 1 $0 B/D PA; MO exemestane oral tablet 1 $0 MO FARESTON ORAL TABLET FARYDAK ORAL CAPSULE 2 $0 PA; MO FASLODEX INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO fludarabine intravenous recon soln 1 $0 B/D PA; MO fludarabine intravenous solution 1 $0 B/D PA fluorouracil intravenous solution 1 $0 B/D PA; MO flutamide oral capsule 1 $0 MO GAZYVA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO gemcitabine intravenous recon soln 1 gram 1 $0 B/D PA; MO gemcitabine intravenous recon soln 2 gram 1 $0 B/D PA gemcitabine intravenous recon soln 200 mg 1 $0 B/D PA; MO 20

33 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA gengraf oral capsule 100 mg, 25 mg 1 $0 B/D PA; MO gengraf oral solution 1 $0 B/D PA; MO GILOTRIF ORAL TABLET 2 $0 PA; MO GLEOSTINE ORAL CAPSULE HERCEPTIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO HEXALEN ORAL CAPSULE hydroxyurea oral capsule 1 $0 MO IBRANCE ORAL CAPSULE 2 $0 PA; MO; QL (21 per 28 ICLUSIG ORAL TABLET 2 $0 PA; MO idarubicin intravenous solution 1 $0 B/D PA ifosfamide intravenous recon soln 1 gram 1 $0 B/D PA; MO ifosfamide intravenous recon soln 3 gram 1 $0 B/D PA; MO ifosfamide intravenous solution 1 $0 B/D PA imatinib oral tablet 100 mg 1 $0 PA; MO imatinib oral tablet 400 mg 1 $0 PA; MO; QL (60 per 30 IMBRUVICA ORAL CAPSULE 2 $0 PA; MO INLYTA ORAL TABLET 2 $0 PA; MO IRESSA ORAL TABLET 2 $0 PA; MO irinotecan intravenous solution 100 mg/5 ml 1 $0 B/D PA; MO irinotecan intravenous solution 40 mg/2 ml 1 $0 B/D PA; MO irinotecan intravenous solution 500 mg/25 ml 1 $0 B/D PA ISTODAX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO 21

34 JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 2 $0 PA; MO LIMIT JAKAFI ORAL TABLET 25 MG 2 $0 PA; MO; QL (60 per 30 KADCYLA INTRAVENOUS RECON SOLN 100 MG KADCYLA INTRAVENOUS RECON SOLN 160 MG 2 $0 PA; MO; NEDS 2 $0 PA; MO KEYTRUDA INTRAVENOUS RECON SOLN 2 $0 PA; MO KEYTRUDA INTRAVENOUS SOLUTION 2 $0 PA; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2) 2 $0 PA; MO 2 $0 PA letrozole oral tablet 1 $0 MO LEUKERAN ORAL TABLET leuprolide subcutaneous kit 1 $0 MO LONSURF ORAL TABLET 2 $0 PA; MO LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO 22

35 LUPRON DEPOT-PED INTRAMUSCULAR KIT 2 $0 PA; MO LYNPARZA ORAL CAPSULE 2 $0 PA; MO LYSODREN ORAL TABLET MATULANE ORAL CAPSULE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 1 $0 PA; MO megestrol oral tablet 1 $0 PA; MO MEKINIST ORAL TABLET 2 $0 PA melphalan hcl intravenous recon soln 1 $0 B/D PA mercaptopurine oral tablet 1 $0 MO methotrexate sodium (pf) injection recon soln 1 $0 B/D PA LIMIT methotrexate sodium (pf) injection solution 1 $0 B/D PA; MO methotrexate sodium injection solution 1 $0 B/D PA; MO methotrexate sodium oral tablet 1 $0 B/D PA; MO mitomycin intravenous recon soln 1 $0 B/D PA; MO mitoxantrone intravenous concentrate 1 $0 B/D PA; MO MUSTARGEN INJECTION RECON SOLN 2 $0 B/D PA; MO mycophenolate mofetil oral capsule 1 $0 B/D PA; MO mycophenolate mofetil oral suspension for reconstitution 1 $0 B/D PA; MO mycophenolate mofetil oral tablet 1 $0 B/D PA; MO mycophenolate sodium oral tablet,delayed release (dr/ec) 1 $0 B/D PA; MO NEORAL ORAL CAPSULE 2 $0 B/D PA; MO NEORAL ORAL SOLUTION 2 $0 B/D PA; MO NEXAVAR ORAL TABLET 2 $0 PA; MO NILANDRON ORAL TABLET 23

36 NINLARO ORAL CAPSULE 2 $0 PA; MO LIMIT NULOJIX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO octreotide acetate injection solution 1 $0 PA; MO octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) 1 $0 PA; MO 1 $0 PA; MO ODOMZO ORAL CAPSULE 2 $0 PA; MO; LA ONCASPAR INJECTION SOLUTION 2 $0 PA; MO OPDIVO INTRAVENOUS SOLUTION 2 $0 PA; MO oxaliplatin intravenous recon soln 100 mg 1 $0 B/D PA; MO oxaliplatin intravenous recon soln 50 mg 1 $0 B/D PA oxaliplatin intravenous solution 100 mg/20 ml 1 $0 B/D PA; MO oxaliplatin intravenous solution 50 mg/10 ml (5 mg/ml) 1 $0 B/D PA; MO paclitaxel intravenous concentrate 1 $0 B/D PA; MO PERJETA INTRAVENOUS SOLUTION 2 $0 PA; MO POMALYST ORAL CAPSULE 2 $0 PA; MO PORTRAZZA INTRAVENOUS SOLUTION 2 $0 PA; MO PURIXAN ORAL SUSPENSION RAPAMUNE ORAL SOLUTION 2 $0 B/D PA; MO RAPAMUNE ORAL TABLET 2 $0 B/D PA; MO REVLIMID ORAL CAPSULE 2 $0 PA; MO; LA RITUXAN INTRAVENOUS CONCENTRATE 2 $0 PA; MO SANDIMMUNE ORAL CAPSULE 2 $0 B/D PA; MO SANDIMMUNE ORAL SOLUTION 2 $0 B/D PA; MO SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 2 $0 PA; MO 24

37 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 2 $0 PA; MO SIGNIFOR SUBCUTANEOUS SOLUTION 2 $0 PA; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PA LIMIT 2 $0 B/D PA; MO sirolimus oral tablet 1 $0 B/D PA; MO SOLTAMOX ORAL SOLUTION SOMATULINE DEPOT SUBCUTANEOUS SYRINGE SPRYCEL ORAL TABLET 100 MG, 140 MG, 80 MG 2 $0 B/D PA; MO 2 $0 PA; MO; QL (30 per 30 ; NEDS SPRYCEL ORAL TABLET 20 MG, 50 MG 2 $0 PA; MO; NEDS SPRYCEL ORAL TABLET 70 MG 2 $0 PA; MO; QL (60 per 30 ; NEDS STIVARGA ORAL TABLET 2 $0 PA; MO SUTENT ORAL CAPSULE 2 $0 PA; MO; NEDS SYNRIBO SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO TABLOID ORAL TABLET tacrolimus oral capsule 1 $0 B/D PA; MO TAFINLAR ORAL CAPSULE 2 $0 PA; NEDS TAGRISSO ORAL TABLET 2 $0 PA; MO; LA tamoxifen oral tablet 1 $0 MO TARCEVA ORAL TABLET 100 MG, 25 MG 2 $0 PA; MO; NEDS TARCEVA ORAL TABLET 150 MG 2 $0 PA; MO; QL (30 per 30 ; NEDS TARGRETIN TOPICAL GEL TASIGNA ORAL CAPSULE 2 $0 PA; MO 25

38 TECENTRIQ INTRAVENOUS SOLUTION 2 $0 PA; LA THALOMID ORAL CAPSULE 2 $0 PA; MO thiotepa injection recon soln 1 $0 PA; MO LIMIT toposar intravenous solution 1 $0 B/D PA; MO topotecan intravenous recon soln 1 $0 B/D PA topotecan intravenous solution 1 $0 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO TREANDA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO TRELSTAR INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO tretinoin (chemotherapy) oral capsule 1 $0 MO TRISENOX INTRAVENOUS SOLUTION 2 $0 B/D PA; MO TYKERB ORAL TABLET 2 $0 PA; MO; NEDS VELCADE INJECTION RECON SOLN 2 $0 B/D PA; MO VENCLEXTA ORAL TABLET 2 $0 PA; LA VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 2 $0 PA; LA vinblastine intravenous solution 1 $0 B/D PA; MO vincasar pfs intravenous solution 1 mg/ml 1 $0 B/D PA vincasar pfs intravenous solution 2 mg/2 ml 1 $0 B/D PA; MO vincristine intravenous solution 1 $0 B/D PA; MO vinorelbine intravenous solution 1 $0 B/D PA; MO VOTRIENT ORAL TABLET 2 $0 PA; MO; NEDS XALKORI ORAL CAPSULE 2 $0 PA; MO XTANDI ORAL CAPSULE 2 $0 PA; MO; QL (120 per 30 YERVOY INTRAVENOUS SOLUTION 2 $0 PA; MO 26

39 YONIS INTRAVENOUS RECON SOLN 2 $0 PA; MO ZALTRAP INTRAVENOUS SOLUTION 2 $0 PA; MO LIMIT ZELBORAF ORAL TABLET 2 $0 PA; MO; NEDS ZOLINZA ORAL CAPSULE ZORTRESS ORAL TABLET 2 $0 B/D PA; MO ZYIG ORAL TABLET 2 $0 PA; MO ZYKADIA ORAL CAPSULE 2 $0 PA; MO; QL (150 per 30 ZYTIGA ORAL TABLET ; NEDS FARMACI AUTONOMICI / SNC, NEUROLOGIA / PSICHIATRIA ANTICONVULSIVANTI APTIOM ORAL TABLET 2 $0 PA; MO BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 2 $0 PA; MO BRIVIACT INTRAVENOUS SOLUTION 2 $0 PA BRIVIACT ORAL SOLUTION 2 $0 PA BRIVIACT ORAL TABLET 2 $0 PA carbamazepine oral capsule, er multiphase 12 hr 1 $0 MO carbamazepine oral suspension 100 mg/5 ml 1 $0 MO carbamazepine oral tablet 1 $0 MO carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg 1 $0 1 $0 MO carbamazepine oral tablet,chewable 1 $0 MO CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 1 $0 MO 27

40 clonazepam oral tablet,disintegrating 1 $0 PA; MO DIASTAT RECTAL KIT 2 $0 PA; MO diazepam rectal kit 1 $0 PA; MO DILANTIN 30 MG ORAL CAPSULE divalproex oral capsule, sprinkle 1 $0 MO divalproex oral tablet extended release 24 hr 1 $0 MO divalproex oral tablet,delayed release (dr/ec) 1 $0 MO epitol oral tablet 1 $0 MO ethosuximide oral capsule 1 $0 MO ethosuximide oral solution 1 $0 MO felbamate oral suspension 1 $0 MO felbamate oral tablet 1 $0 MO LIMIT fosphenytoin injection solution 1 $0 B/D PA; MO FYCOMPA ORAL SUSPENSION 2 $0 PA FYCOMPA ORAL TABLET 2 $0 PA; MO gabapentin oral capsule 1 $0 MO gabapentin oral solution 250 mg/5 ml 1 $0 MO gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 1 $0 gabapentin oral tablet 600 mg, 800 mg 1 $0 MO GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 1 $0 MO lamotrigine oral tablet disintegrating, dose pk 1 $0 MO lamotrigine oral tablet extended release 24hr 1 $0 MO lamotrigine oral tablet, chewable dispersible 1 $0 MO lamotrigine oral tablet,disintegrating 1 $0 MO lamotrigine oral tablets,dose pack 25 mg (35) 1 $0 28

41 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 1 $0 1 $0 MO LIMIT levetiracetam intravenous solution 1 $0 B/D PA; MO levetiracetam oral solution 100 mg/ml 1 $0 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 1 $0 levetiracetam oral tablet 1 $0 MO levetiracetam oral tablet extended release 24 hr 1 $0 MO LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION 2 $0 PA; MO ONFI ORAL TABLET 10 MG, 20 MG 2 $0 PA; MO oxcarbazepine oral suspension 1 $0 MO oxcarbazepine oral tablet 1 $0 MO PEGANONE ORAL TABLET phenobarbital oral elixir 1 $0 PA; MO phenobarbital oral tablet 1 $0 PA; MO PHENYTEK ORAL CAPSULE phenytoin oral suspension 100 mg/4 ml 1 $0 phenytoin oral suspension 125 mg/5 ml 1 $0 MO phenytoin oral tablet,chewable 1 $0 MO phenytoin sodium extended oral capsule 1 $0 MO phenytoin sodium intravenous solution 1 $0 B/D PA; MO phenytoin sodium intravenous syringe 1 $0 B/D PA POTIGA ORAL TABLET 2 $0 PA; MO primidone oral tablet 1 $0 MO roweepra oral tablet 1 $0 29

42 SABRIL ORAL POWDER IN PACKET 2 $0 PA; MO SABRIL ORAL TABLET 2 $0 PA; MO SPRITAM ORAL TABLET FOR SUSPENSION 2 $0 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG tiagabine oral tablet 1 $0 MO topiramate oral capsule, sprinkle 1 $0 PA; MO TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 2 $0 PA; MO topiramate oral tablet 1 $0 PA; MO LIMIT valproate sodium intravenous solution 1 $0 B/D PA; MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) 1 $0 MO 1 $0 valproic acid oral capsule 1 $0 MO VIMPAT INTRAVENOUS SOLUTION 2 $0 PA VIMPAT ORAL SOLUTION 2 $0 PA; MO VIMPAT ORAL TABLET 2 $0 PA; MO zonisamide oral capsule 1 $0 PA; MO AGENTI ANTI-PARKINSON APOKYN SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO AZILECT ORAL TABLET benztropine injection solution 1 $0 B/D PA; MO benztropine oral tablet 1 $0 PA; MO bromocriptine oral capsule 1 $0 MO bromocriptine oral tablet 1 $0 MO carbidopa oral tablet 1 $0 MO 30

43 carbidopa-levodopa oral tablet 1 $0 MO carbidopa-levodopa oral tablet extended release 1 $0 MO carbidopa-levodopa oral tablet,disintegrating 1 $0 MO carbidopa-levodopa-entacapone oral tablet 1 $0 MO entacapone oral tablet 1 $0 MO NEUPRO TRANSDERMAL PATCH 24 HOUR 2 $0 PA; MO pramipexole oral tablet 1 $0 MO pramipexole oral tablet extended release 24 hr mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg 1 $0 MO ropinirole oral tablet 1 $0 MO ropinirole oral tablet extended release 24 hr 1 $0 MO selegiline hcl oral capsule 1 $0 MO selegiline hcl oral tablet 1 $0 MO tolcapone oral tablet 1 $0 MO trihexyphenidyl oral elixir 1 $0 PA; MO trihexyphenidyl oral tablet 1 $0 PA; MO TERAPIA EMICRANIA / CEFALEA A GRAPPOLO dihydroergotamine injection solution 1 $0 MO dihydroergotamine nasal spray,non-aerosol 1 $0 MO migergot rectal suppository 1 $0 MO LIMIT naratriptan oral tablet 1 $0 MO; QL (18 per 28 rizatriptan oral tablet 1 $0 MO; QL (36 per 30 rizatriptan oral tablet,disintegrating 1 $0 MO; QL (36 per 30 sumatriptan nasal spray,non-aerosol 1 $0 MO sumatriptan succinate oral tablet 1 $0 MO; QL (9 per 30 sumatriptan succinate subcutaneous cartridge 1 $0 MO; QL (10 per 30 sumatriptan succinate subcutaneous pen injector 1 $0 MO; QL (10 per 30 31

44 LIMIT sumatriptan succinate subcutaneous solution 1 $0 MO; QL (10 per 30 sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 1 $0 QL (10 per 30 zolmitriptan oral tablet 1 $0 MO; QL (12 per 30 zolmitriptan oral tablet,disintegrating 1 $0 MO; QL (12 per 30 NEUROLOGICI VARI AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 2 $0 PA; MO; NEDS AUBAGIO ORAL TABLET 2 $0 PA; MO donepezil oral tablet 1 $0 MO; QL (30 per 30 donepezil oral tablet,disintegrating 1 $0 MO; QL (30 per 30 galantamine oral capsule,ext rel. pellets 24 hr 1 $0 MO; QL (30 per 30 galantamine oral solution 1 $0 MO galantamine oral tablet 1 $0 MO GILENYA ORAL CAPSULE glatopa subcutaneous syringe 1 $0 PA; MO KEVEYIS ORAL TABLET 2 $0 PA; MO memantine oral solution 1 $0 PA; MO memantine oral tablet 1 $0 PA; MO memantine oral tablets,dose pack 1 $0 PA; MO NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 2 $0 PA; MO 2 $0 PA; MO NUEDEXTA ORAL CAPSULE rivastigmine tartrate oral capsule 1.5 mg 1 $0 MO; QL (240 per 30 rivastigmine tartrate oral capsule 3 mg 1 $0 MO; QL (120 per 30 32

45 LIMIT rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 $0 MO; QL (60 per 30 rivastigmine transdermal patch 24 hour 1 $0 MO; QL (30 per 30 TECFIDERA ORAL CAPSULE,AYED RELEASE(DR/EC) tetrabenazine oral tablet 1 $0 PA; MO TYSABRI INTRAVENOUS SOLUTION 2 $0 PA; MO RILASSANTI MUSCOLARI / TERAPIA ANTISPASMODICA baclofen oral tablet 1 $0 MO cyclobenzaprine oral tablet 1 $0 PA; MO dantrolene oral capsule 1 $0 MO meprobamate oral tablet 1 $0 PA; MO MESTINON ORAL SYRUP metaxalone oral tablet 1 $0 PA; MO pyridostigmine bromide oral tablet 1 $0 MO pyridostigmine bromide oral tablet extended release 1 $0 MO regonol injection solution 2 $0 B/D PA tizanidine oral capsule 1 $0 MO tizanidine oral tablet 1 $0 MO ANALGESICI NARCOTICI acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml, 360 mg-36 mg /15 ml (15 ml) acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg 1 $0 QL (4500 per 30 1 $0 MO; QL (4500 per 30 1 $0 MO; QL (360 per 30 33

46 LIMIT acetaminophen-codeine oral tablet mg 1 $0 MO; QL (180 per 30 buprenorphine hcl injection solution 1 $0 B/D PA; MO; QL (267 per 30 buprenorphine hcl injection syringe 1 $0 B/D PA; QL (267 per 30 buprenorphine hcl sublingual tablet 2 mg 1 $0 MO; QL (300 per 30 buprenorphine hcl sublingual tablet 8 mg 1 $0 MO; QL (75 per 30 butalbital-acetaminop-caf-cod oral capsule 1 $0 PA; MO; QL (360 per 30 butalbital-acetaminophen oral tablet 1 $0 MO; QL (360 per 30 butalbital-acetaminophen-caff oral capsule 1 $0 MO; QL (360 per 30 butalbital-acetaminophen-caff oral tablet mg 1 $0 MO; QL (360 per 30 butalbital-aspirin-caffeine oral capsule 1 $0 MO codeine sulfate oral tablet 1 $0 MO; QL (180 per 30 diskets oral tablet,soluble 1 $0 QL (30 per 30 duramorph (pf) injection solution 0.5 mg/ml 1 $0 B/D PA; MO; QL (4000 per 30 duramorph (pf) injection solution 1 mg/ml 1 $0 B/D PA; QL (2000 per 30 endocet oral tablet mg, mg, mg, mg fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg 1 $0 MO; QL (360 per 30 1 $0 PA; MO; QL (39 per 30 1 $0 PA; MO; QL (29 per 30 34

47 fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg LIMIT 1 $0 PA; MO; QL (120 per 30 1 $0 PA; MO; QL (116 per 30 1 $0 PA; MO; QL (77 per 30 1 $0 PA; MO; QL (58 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr 1 $0 MO; QL (9 per 30 fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg 1 $0 MO; QL (10 per 30 1 $0 QL (5550 per 30 1 $0 MO; QL (5550 per 30 1 $0 MO; QL (360 per 30 hydrocodone-ibuprofen oral tablet 1 $0 MO; QL (50 per 30 hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml 1 $0 B/D PA; MO; QL (120 per 30 hydromorphone oral liquid 1 $0 MO; QL (1500 per 30 hydromorphone oral tablet 1 $0 MO; QL (180 per 30 ibuprofen-oxycodone oral tablet 1 $0 MO; QL (28 per 30 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG ; QL (60 per 30 levorphanol tartrate oral tablet 1 $0 MO; QL (120 per 30 35

48 LIMIT methadone injection solution 1 $0 B/D PA; QL (160 per 30 methadone intensol oral concentrate 1 $0 MO; QL (120 per 30 methadone oral concentrate 1 $0 MO; QL (120 per 30 methadone oral solution 10 mg/5 ml 1 $0 MO; QL (600 per 30 methadone oral solution 5 mg/5 ml 1 $0 MO; QL (1200 per 30 methadone oral tablet 10 mg 1 $0 MO; QL (120 per 30 methadone oral tablet 5 mg 1 $0 MO; QL (240 per 30 methadone oral tablet,soluble 1 $0 QL (30 per 30 methadose oral concentrate 1 $0 MO; QL (120 per 30 methadose oral tablet,soluble 1 $0 MO; QL (30 per 30 morphine (pf) injection solution 0.5 mg/ml 1 $0 B/D PA; QL (2400 per 30 morphine (pf) injection solution 1 mg/ml 1 $0 B/D PA; MO; QL (1200 per 30 morphine concentrate oral solution 1 $0 MO; QL (300 per 30 morphine intravenous cartridge 10 mg/ml 1 $0 B/D PA MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML 1 $0 B/D PA morphine intravenous syringe 10 mg/ml 1 $0 B/D PA; QL (200 per 30 morphine intravenous syringe 8 mg/ml 1 $0 B/D PA; QL (250 per 30 36

49 morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg LIMIT 1 $0 MO; QL (50 per 30 1 $0 MO; QL (60 per 30 morphine oral capsule,extend.release pellets 1 $0 MO; QL (60 per 30 morphine oral solution 1 $0 MO; QL (900 per 30 morphine oral tablet 1 $0 MO; QL (180 per 30 morphine oral tablet extended release 100 mg 1 $0 MO; QL (60 per 30 morphine oral tablet extended release 15 mg, 30 mg, 60 mg 1 $0 MO; QL (90 per 30 morphine oral tablet extended release 200 mg 1 $0 MO; QL (30 per 30 oxycodone oral capsule 1 $0 MO; QL (360 per 30 oxycodone oral concentrate 1 $0 MO; QL (180 per 30 oxycodone oral solution 1 $0 MO; QL (1200 per 30 oxycodone oral tablet 10 mg, 15 mg, 20 mg 1 $0 MO; QL (180 per 30 oxycodone oral tablet 30 mg 1 $0 MO; QL (134 per 30 oxycodone oral tablet 5 mg 1 $0 MO; QL (360 per 30 oxycodone-acetaminophen oral solution 1 $0 QL (800 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg 1 $0 MO; QL (360 per 30 oxycodone-aspirin oral tablet 1 $0 MO; QL (360 per 30 37

50 LIMIT oxymorphone oral tablet 10 mg 1 $0 MO; QL (200 per 30 oxymorphone oral tablet 5 mg 1 $0 MO; QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg 1 $0 MO; QL (90 per 30 1 $0 MO; QL (67 per 30 1 $0 MO; QL (50 per 30 reprexain oral tablet 1 $0 MO; QL (50 per 30 roxicet oral tablet 1 $0 QL (360 per 30 zamicet oral solution 1 $0 QL (5550 per 30 ANALGESICI NON NARCOTICI 8 HOUR PAIN RELIEVER ORAL TABLET EXTENDED RELEASE ACEPHEN RECTAL SUPPOSITORY 120 MG, 650 MG 4 $0 MO; * 4 $0 MO; * ACEPHEN RECTAL SUPPOSITORY 325 MG aceta-gesic oral tablet acetaminophen extra strength oral tablet acetaminophen oral drops,suspension acetaminophen oral elixir acetaminophen oral liquid 160 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) 4 $0 MO; * acetaminophen oral solution 325 mg/10.15 ml, 650 mg/20.3 ml acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 4 $0 MO; * acetaminophen oral tablet extended release 38

51 acetaminophen oral tablet,disintegrating 80 mg acetaminophen pain relief oral tablet acetaminophen pm extra str oral tablet acetaminophen pm oral tablet acetaminophen rectal suppository advil oral tablet 100 mg 4 $0 MO; * ARTHRITIS PAIN RELIEF (ACETAM) ORAL TABLET EXTENDED RELEASE ARTHRITIS PAIN RELIEVER ORAL TABLET EXTENDED RELEASE ASPIR-81 ORAL TABLET,AYED RELEASE (DR/EC) aspirin childrens oral tablet,chewable ASPIRIN LOW DOSE ORAL TABLET,AYED RELEASE (DR/EC) 4 $0 MO; * aspirin oral tablet 325 mg 4 $0 MO; * aspirin oral tablet 500 mg, 81 mg aspirin oral tablet,chewable 4 $0 MO; * aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg, 81 mg 4 $0 MO; * aspirin oral tablet,delayed release (dr/ec) 650 mg aspirin rectal suppository 4 $0 MO; * ASPIR-LOW ORAL TABLET,AYED RELEASE (DR/EC) 4 $0 MO; * aspir-trin oral tablet,delayed release (dr/ec) 4 $0 MO; * athenol oral tablet bayer advanced oral tablet bayer aspirin oral tablet 4 $0 MO; * bufferin oral tablet LIMIT 39

52 LIMIT buprenorphine-naloxone sublingual tablet 1 $0 MO; QL (90 per 30 butorphanol tartrate injection solution 1 mg/ml 1 $0 MO; QL (720 per 30 butorphanol tartrate injection solution 2 mg/ml 1 $0 MO; QL (360 per 30 butorphanol tartrate nasal spray,non-aerosol 1 $0 MO; QL (5 per 30 celecoxib oral capsule 1 $0 MO child pain rel-fever reducer rectal suppository CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML, 160 MG/5 ML (5 ML) CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE CHILDREN'S MAPAP ORAL TABLET,DISINTEGRATING 4 $0 MO; * children's non-aspirin oral suspension CHILDREN'S PAIN RELIEF ORAL SUSPENSION CHILDREN'S PAIN RELIEVER ORAL SUSPENSION CHILDREN'S PAIN RELIEVER ORAL TABLET,DISINTEGRATING CHILDREN'S PAIN-FEVER RELIEF ORAL LIQUID CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET,CHEWABLE children's pain-fever relief oral tablet,disintegrating 4 $0 MO; * 4 $0 MO; * 4 $0 MO; * CHILDREN'S Q-PAP ORAL SUSPENSION 4 $0 MO; * 40

53 CHILDREN'S SILAPAP ORAL LIQUID children's triaminic fever oral liquid diclofenac potassium oral tablet 1 $0 MO diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 1 $0 MO 1 $0 MO diclofenac sodium topical drops 1 $0 MO diclofenac sodium topical gel 1 % 1 $0 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 1 $0 MO diflunisal oral tablet 1 $0 MO diphenhydramine-acetaminophen oral tablet E.C. PRIN ORAL TABLET,AYED RELEASE (DR/EC) ed-apap oral liquid enteric coated aspirin oral tablet,delayed release (dr/ec) etodolac oral capsule 1 $0 MO etodolac oral tablet 1 $0 MO etodolac oral tablet extended release 24 hr 1 $0 MO excedrin menstrual complete oral tablet extra strength bayer oral tablet fenoprofen oral tablet 1 $0 MO fever reducer an pain reliever oral suspension FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG, 650 MG flurbiprofen oral tablet 1 $0 MO headache pm oral tablet LIMIT 41

54 HEADACHE RELIEF (ASA-ACET-CAF) ORAL TABLET IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral drops,suspension ibuprofen oral suspension 1 $0 MO ibuprofen oral tablet 200 mg 4 $0 MO; * ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 $0 MO indomethacin oral capsule 1 $0 MO indomethacin oral capsule, extended release 1 $0 MO infant fever reducer-pain relf oral suspension INFANT'S IBUPROFEN ORAL DROPS,SUSPENSION INFANTS' PAIN AND FEVER ORAL SUSPENSION INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML INFANTS' PAIN RELIEF ORAL SUSPENSION infant's pain reliever oral drops,suspension infants' triaminic fever oral liquid jr. acetaminophen oral tablet,disintegrating jr. strength pain reliever oral tablet,disintegrating junior mapap oral tablet,disintegrating 4 $0 MO; * ketoprofen oral capsule 1 $0 MO ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg MAPAP (ACETAMINOPHEN) ORAL CAPSULE 1 $0 MO 4 $0 MO; * LIMIT 42

55 MAPAP (ACETAMINOPHEN) ORAL LIQUID 160 MG/5 ML 4 $0 MO; * mapap (acetaminophen) oral liquid 500 mg/15 ml 4 $0 MO; * mapap (acetaminophen) oral suspension MAPAP (ACETAMINOPHEN) ORAL TABLET 4 $0 MO; * MAPAP (ACETAMINOPHEN) ORAL TABLET,CHEWABLE MAPAP ARTHRITIS PAIN ORAL TABLET EXTENDED RELEASE 4 $0 MO; * 4 $0 MO; * MAPAP EXTRA STRENGTH ORAL TABLET 4 $0 MO; * mapap infants' oral suspension mapap pm oral tablet 4 $0 MO; * masophen oral tablet meclofenamate oral capsule 1 $0 MO mefenamic acid oral capsule 1 $0 MO meloxicam oral suspension 1 $0 MO meloxicam oral tablet 1 $0 MO migraine formula oral tablet migraine relief oral tablet nabumetone oral tablet 1 $0 MO LIMIT nalbuphine injection solution 10 mg/ml 1 $0 B/D PA; MO; QL (200 per 30 nalbuphine injection solution 20 mg/ml 1 $0 B/D PA; MO; QL (100 per 30 naloxone injection solution 1 $0 MO naloxone injection syringe 1 mg/ml 1 $0 MO naltrexone oral tablet 1 $0 MO NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 750 MG 43

56 naproxen oral suspension 1 $0 MO naproxen oral tablet 1 $0 MO naproxen oral tablet,delayed release (dr/ec) 1 $0 MO naproxen sodium oral tablet 275 mg, 550 mg 1 $0 MO naproxen sodium oral tablet, er multiphase 24 hr 375 mg 1 $0 MO NARCAN NASAL SPRAY,NON-AEROSOL non-aspirin children's oral tablet,chewable NON-ASPIRIN EXTRA STRENGTH ORAL TABLET non-aspirin nightime oral tablet non-aspirin oral suspension NON-ASPIRIN ORAL TABLET non-aspirin oral tablet,chewable 80 mg NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR NUCYNTA ORAL TABLET oxaprozin oral tablet 1 $0 MO PAIN AND FEVER ORAL TABLET 4 $0 MO; * pain relief (acetamin-asp-caf) oral tablet PAIN RELIEF EXTRA STRENGTH ORAL TABLET PAIN RELIEF ORAL TABLET PAIN RELIEF ORAL TABLET EXTENDED RELEASE pain relief pm oral tablet LIMIT 44

57 PAIN RELIEF REGULAR STRENGTH ORAL TABLET pain reliever (acetam-aspirin) oral tablet PAIN RELIEVER EXTRA STRENGTH ORAL TABLET PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET pain reliever plus oral tablet 4 $0 MO; * pain reliever pm ex-strength oral tablet pain reliever pm oral tablet mg pediacare fever reducer oral suspension PHARBETOL ORAL TABLET 325 MG pharbetol oral tablet 500 mg piroxicam oral capsule 1 $0 MO PROVIL ORAL TABLET Q-PAP EXTRA STRENGTH ORAL TABLET 4 $0 MO; * Q-PAP ORAL DROPS 4 $0 MO; * Q-PAP ORAL LIQUID 4 $0 MO; * Q-PAP ORAL TABLET 325 MG Q-PAP ORAL TABLET 500 MG 4 $0 MO; * severe allergy oral tablet LIMIT SUBOXONE SUBLINGUAL FILM 12-3 MG ; QL (60 per 30 SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG ; QL (90 per 30 sulindac oral tablet 1 $0 MO TACTINAL EXTRA STRENGTH ORAL TABLET TACTINAL ORAL TABLET 45

58 tolmetin oral capsule 1 $0 MO tolmetin oral tablet 1 $0 MO LIMIT tramadol oral tablet 1 $0 MO; QL (240 per 30 tramadol oral tablet extended release 24 hr 1 $0 MO; QL (30 per 30 tramadol oral tablet, er multiphase 24 hr 1 $0 MO; QL (30 per 30 tramadol-acetaminophen oral tablet 1 $0 MO; QL (240 per 30 TRI-BUFFERED ASPIRIN ORAL TABLET 4 $0 MO; * tylophen oral capsule VOLTAREN GEL TOPICAL GEL 1 % 2 $0 ST; MO wal-profen oral capsule wal-profen oral tablet FARMACI PSICOTERAPEUTICI ABILIFY INTRAMUSCULAR SOLUTION 2 $0 B/D PA; MO ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 2 $0 B/D PA; MO alprazolam oral tablet 1 $0 MO alprazolam oral tablet extended release 24 hr 1 $0 PA; MO alprazolam oral tablet,disintegrating 1 $0 MO amitriptyline oral tablet 1 $0 PA; MO amoxapine oral tablet 1 $0 MO aripiprazole oral tablet 10 mg 1 $0 MO; QL (90 per 30 aripiprazole oral tablet 15 mg, 20 mg 1 $0 MO; QL (60 per 30 aripiprazole oral tablet 2 mg 1 $0 MO; QL (450 per 30 aripiprazole oral tablet 30 mg 1 $0 MO; QL (30 per 30 46

59 LIMIT aripiprazole oral tablet 5 mg 1 $0 MO; QL (180 per 30 aripiprazole oral tablet,disintegrating 10 mg 1 $0 MO; QL (90 per 30 aripiprazole oral tablet,disintegrating 15 mg 1 $0 MO; QL (60 per 30 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING BRISLE ORAL CAPSULE bupropion hcl oral tablet 1 $0 MO bupropion hcl oral tablet extended release 1 $0 MO bupropion hcl oral tablet extended release 24 hr 1 $0 MO buspirone oral tablet 1 $0 MO chlorpromazine injection solution 1 $0 MO chlorpromazine oral tablet 1 $0 MO citalopram oral solution 1 $0 MO citalopram oral tablet 1 $0 MO clomipramine oral capsule 1 $0 PA; MO clonidine hcl oral tablet extended release 12 hr 1 $0 MO clorazepate dipotassium oral tablet 1 $0 PA; MO clozapine oral tablet 1 $0 MO clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG 1 $0 2 $0 desipramine oral tablet 1 $0 MO dexmethylphenidate oral capsule,er biphasic $0 MO dexmethylphenidate oral tablet 1 $0 MO dextroamphetamine oral capsule, extended release 1 $0 MO 47

60 dextroamphetamine oral tablet 1 $0 MO dextroamphetamine-amphetamine oral capsule,extended release 24hr 1 $0 MO dextroamphetamine-amphetamine oral tablet 1 $0 MO diazepam intensol oral concentrate 1 $0 PA; MO diazepam oral concentrate 1 $0 PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 $0 PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) 1 $0 PA diazepam oral tablet 1 $0 PA; MO doxepin oral capsule 1 $0 PA; MO doxepin oral concentrate 1 $0 PA; MO duloxetine oral capsule,delayed release(dr/ec) 1 $0 MO EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet 1 $0 PA; MO escitalopram oxalate oral solution 1 $0 MO escitalopram oxalate oral tablet 1 $0 MO LIMIT eszopiclone oral tablet 1 $0 MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG ; QL (60 per 30 FANAPT ORAL TABLET 10 MG 2 $0 QL (60 per 30 FANAPT ORAL TABLETS,DOSE PACK ; QL (8 per 28 FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 2 $0 ; QL (30 per 30 ; QL (30 per 30 fluoxetine oral capsule 1 $0 MO fluoxetine oral capsule,delayed release(dr/ec) 1 $0 MO 48

61 fluoxetine oral solution 1 $0 MO fluoxetine oral tablet 10 mg, 20 mg 1 $0 MO FLUOXETINE ORAL TABLET 60 MG LIMIT fluphenazine decanoate injection solution 1 $0 B/D PA; MO fluphenazine hcl injection solution 1 $0 B/D PA; MO fluphenazine hcl oral concentrate 1 $0 MO fluphenazine hcl oral elixir 1 $0 MO fluphenazine hcl oral tablet 1 $0 MO fluvoxamine oral capsule,extended release 24hr 1 $0 MO fluvoxamine oral tablet 1 $0 MO FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR GEODON INTRAMUSCULAR RECON SOLN 2 $0 B/D PA; MO guanfacine oral tablet extended release 24 hr 1 $0 MO guanidine oral tablet 1 $0 MO haloperidol decanoate intramuscular solution 1 $0 B/D PA; MO haloperidol lactate injection solution 1 $0 B/D PA; MO haloperidol lactate oral concentrate 1 $0 MO haloperidol oral tablet 1 $0 MO HETLIOZ ORAL CAPSULE 2 $0 PA; MO; QL (30 per 30 imipramine hcl oral tablet 1 $0 PA; MO imipramine pamoate oral capsule 1 $0 PA; MO INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE IRENKA ORAL CAPSULE,AYED RELEASE(DR/EC) 49

62 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR LATUDA ORAL TABLET lithium carbonate oral capsule 1 $0 MO lithium carbonate oral tablet 1 $0 MO lithium carbonate oral tablet extended release 1 $0 MO lithium citrate oral solution 8 meq/5 ml 1 $0 MO lithium citrate oral solution 8 meq/5 ml (5 ml) 1 $0 lorazepam intensol oral concentrate 1 $0 PA; MO lorazepam oral concentrate 1 $0 PA; MO lorazepam oral tablet 1 $0 PA; MO loxapine succinate oral capsule 1 $0 MO maprotiline oral tablet 1 $0 MO MARPLAN ORAL TABLET metadate er oral tablet extended release 1 $0 MO methamphetamine oral tablet 1 $0 PA; MO methylphenidate oral capsule, er biphasic $0 MO methylphenidate oral capsule,er biphasic $0 MO methylphenidate oral solution 1 $0 MO methylphenidate oral tablet 1 $0 MO methylphenidate oral tablet extended release 1 $0 MO methylphenidate oral tablet extended release 24hr 18 mg 1 $0 MO mirtazapine oral tablet 1 $0 MO mirtazapine oral tablet,disintegrating 1 $0 MO modafinil oral tablet 1 $0 PA; MO molindone oral tablet 1 $0 nefazodone oral tablet 1 $0 MO LIMIT 50

63 nortriptyline oral capsule 1 $0 MO nortriptyline oral solution 1 $0 MO LIMIT NUPLAZID ORAL TABLET 2 $0 PA; QL (60 per 30 olanzapine intramuscular recon soln 1 $0 MO olanzapine oral tablet 1 $0 MO olanzapine oral tablet,disintegrating 1 $0 MO olanzapine-fluoxetine oral capsule 1 $0 MO oxazepam oral capsule 1 $0 PA; MO paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 mg 1 $0 MO; QL (30 per 30 1 $0 MO; QL (60 per 30 paroxetine hcl oral tablet 1 $0 MO paroxetine hcl oral tablet extended release 24 hr 1 $0 MO PAXIL ORAL SUSPENSION perphenazine oral tablet 1 $0 MO perphenazine-amitriptyline oral tablet 1 $0 PA; MO phenelzine oral tablet 1 $0 MO pimozide oral tablet 1 $0 MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR protriptyline oral tablet 1 $0 MO quetiapine oral tablet 1 $0 MO REXULTI ORAL TABLET RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO risperidone oral solution 1 $0 MO risperidone oral tablet 1 $0 MO 51

64 risperidone oral tablet,disintegrating 1 $0 MO LIMIT ROZEREM ORAL TABLET ; QL (30 per 30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG ; QL (60 per 30 SAPHRIS SUBLINGUAL TABLET 2 $0 QL (60 per 30 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral concentrate 1 $0 MO sertraline oral tablet 1 $0 MO STRATTERA ORAL CAPSULE SURMONTIL ORAL CAPSULE 2 $0 PA; MO temazepam oral capsule 1 $0 PA; MO thioridazine oral tablet 1 $0 PA; MO thiothixene oral capsule 1 $0 MO tranylcypromine oral tablet 1 $0 MO trazodone oral tablet 1 $0 MO trifluoperazine oral tablet 1 $0 MO trimipramine oral capsule 1 $0 PA; MO TRINTELLIX ORAL TABLET 2 $0 venlafaxine oral capsule,extended release 24hr 1 $0 MO venlafaxine oral tablet 1 $0 MO venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG 1 $0 MO VERSACLOZ ORAL SUSPENSION 2 $0 VIIBRYD ORAL TABLET 52

65 LIMIT VIIBRYD ORAL TABLETS,DOSE PACK ; QL (30 per 30 VRAYLAR ORAL CAPSULE 1.5 MG 2 $0 QL (120 per 30 VRAYLAR ORAL CAPSULE 3 MG 2 $0 QL (60 per 30 VRAYLAR ORAL CAPSULE 4.5 MG 2 $0 QL (40 per 30 VRAYLAR ORAL CAPSULE 6 MG 2 $0 QL (30 per 30 VRAYLAR ORAL CAPSULE,DOSE PACK 2 $0 QL (7 per 30 XYREM ORAL SOLUTION ; LA ziprasidone hcl oral capsule 1 $0 MO zolpidem oral tablet 1 $0 MO; QL (30 per 30 zolpidem oral tablet,ext release multiphase 1 $0 MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG CARDIOVASCOLARE, IPERTENSIONE / LIPIDI AGENTI ANTI-ARITMICI 2 $0 B/D PA 2 $0 B/D PA; MO amiodarone intravenous solution 1 $0 B/D PA; MO amiodarone intravenous syringe 1 $0 amiodarone oral tablet 1 $0 MO dofetilide oral capsule 1 $0 flecainide oral tablet 1 $0 MO lidocaine (pf) intravenous solution 1 $0 B/D PA; MO mexiletine oral capsule 1 $0 MO MULTAQ ORAL TABLET pacerone oral tablet 100 mg, 200 mg, 400 mg 1 $0 MO 53

66 procainamide injection solution 100 mg/ml 1 $0 MO procainamide injection solution 500 mg/ml 1 $0 propafenone oral capsule,extended release 12 hr 1 $0 MO propafenone oral tablet 1 $0 MO quinidine gluconate injection solution 1 $0 MO quinidine gluconate oral tablet extended release 1 $0 MO quinidine sulfate oral tablet 1 $0 MO sorine oral tablet 120 mg, 160 mg, 80 mg 1 $0 MO sorine oral tablet 240 mg 1 $0 sotalol af oral tablet 1 $0 MO sotalol oral tablet 1 $0 MO TIKOSYN ORAL CAPSULE TERAPIA ANTIPERTENSIVA acebutolol oral capsule 1 $0 MO afeditab cr oral tablet extended release 1 $0 MO amiloride oral tablet 1 $0 MO amiloride-hydrochlorothiazide oral tablet 1 $0 MO amlodipine oral tablet 1 $0 MO amlodipine-benazepril oral capsule 1 $0 MO amlodipine-valsartan oral tablet 1 $0 MO amlodipine-valsartan-hcthiazid oral tablet 1 $0 MO atenolol oral tablet 1 $0 MO atenolol-chlorthalidone oral tablet 1 $0 MO benazepril oral tablet 1 $0 MO benazepril-hydrochlorothiazide oral tablet 1 $0 MO betaxolol oral tablet 1 $0 MO bisoprolol fumarate oral tablet 1 $0 MO LIMIT 54

67 bisoprolol-hydrochlorothiazide oral tablet 1 $0 MO bumetanide injection solution 1 $0 MO bumetanide oral tablet 1 $0 MO BYSTOLIC ORAL TABLET candesartan oral tablet 1 $0 MO candesartan-hydrochlorothiazid oral tablet 1 $0 MO captopril oral tablet 1 $0 MO captopril-hydrochlorothiazide oral tablet 1 $0 MO cartia xt oral capsule,extended release 24hr 1 $0 MO carvedilol oral tablet 1 $0 MO chlorothiazide oral tablet 1 $0 MO chlorothiazide sodium intravenous recon soln 1 $0 MO chlorthalidone oral tablet 25 mg, 50 mg 1 $0 MO clonidine hcl oral tablet 1 $0 MO clonidine transdermal patch weekly 1 $0 MO COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 2 $0 ST; MO DEMSER ORAL CAPSULE 2 $0 PA; MO dilt-cd oral capsule,extended release 24hr 1 $0 MO diltiazem hcl intravenous recon soln 1 $0 B/D PA diltiazem hcl intravenous solution 1 $0 B/D PA diltiazem hcl oral capsule, extended release 1 $0 MO diltiazem hcl oral capsule,ext release degradable 1 $0 MO diltiazem hcl oral capsule,extended release 12 hr 1 $0 MO diltiazem hcl oral capsule,extended release 24hr 1 $0 MO diltiazem hcl oral tablet 1 $0 MO diltiazem hcl oral tablet extended release 24 hr 1 $0 MO LIMIT dilt-xr oral capsule,ext release degradable 1 $0 MO 55

68 diltzac er oral capsule, extended release 1 $0 MO doxazosin oral tablet 1 $0 MO enalapril maleate oral tablet 1 $0 MO enalapril-hydrochlorothiazide oral tablet 1 $0 MO eplerenone oral tablet 1 $0 MO eprosartan oral tablet 1 $0 MO felodipine oral tablet extended release 24 hr 1 $0 MO fosinopril oral tablet 1 $0 MO fosinopril-hydrochlorothiazide oral tablet 1 $0 MO LIMIT furosemide injection solution 1 $0 B/D PA; MO furosemide injection syringe 1 $0 B/D PA; MO furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 1 $0 MO furosemide oral tablet 1 $0 MO hydralazine injection solution 1 $0 B/D PA; MO hydralazine oral tablet 1 $0 MO hydrochlorothiazide oral capsule 1 $0 MO hydrochlorothiazide oral tablet 1 $0 MO indapamide oral tablet 1 $0 MO irbesartan oral tablet 1 $0 MO irbesartan-hydrochlorothiazide oral tablet 1 $0 MO isradipine oral capsule 1 $0 MO labetalol intravenous solution 1 $0 B/D PA; MO labetalol intravenous syringe 20 mg/4 ml (5 mg/ml) 1 $0 B/D PA labetalol oral tablet 1 $0 MO lisinopril oral tablet 1 $0 MO lisinopril-hydrochlorothiazide oral tablet 1 $0 MO 56

69 losartan oral tablet 1 $0 MO losartan-hydrochlorothiazide oral tablet 1 $0 MO matzim la oral tablet extended release 24 hr 1 $0 MO methyclothiazide oral tablet 1 $0 MO methyldopa-hydrochlorothiazide oral tablet 1 $0 PA; MO metolazone oral tablet 1 $0 MO metoprolol succinate oral tablet extended release 24 hr 1 $0 MO metoprolol ta-hydrochlorothiaz oral tablet 1 $0 MO LIMIT metoprolol tartrate intravenous solution 1 $0 B/D PA; MO; NEDS metoprolol tartrate intravenous syringe 1 $0 B/D PA; NEDS metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 $0 MO metoprolol tartrate oral tablet 37.5 mg, 75 mg 1 $0 minoxidil oral tablet 1 $0 MO moexipril oral tablet 1 $0 MO moexipril-hydrochlorothiazide oral tablet 1 $0 MO nadolol oral tablet 1 $0 MO nadolol-bendroflumethiazide oral tablet 1 $0 MO nicardipine intravenous solution 1 $0 MO nicardipine oral capsule 1 $0 MO nifedical xl oral tablet extended release 24hr 1 $0 MO nifedipine oral tablet extended release 1 $0 MO nifedipine oral tablet extended release 24hr 1 $0 MO nimodipine oral capsule 1 $0 MO perindopril erbumine oral tablet 1 $0 MO phenoxybenzamine oral capsule 1 $0 PA; MO pindolol oral tablet 1 $0 MO 57

70 prazosin oral capsule 1 $0 MO propranolol intravenous solution 1 $0 B/D PA propranolol oral capsule,extended release 24 hr 1 $0 MO propranolol oral solution 1 $0 MO propranolol oral tablet 1 $0 MO propranolol-hydrochlorothiazid oral tablet 1 $0 MO quinapril oral tablet 1 $0 MO quinapril-hydrochlorothiazide oral tablet 1 $0 MO ramipril oral capsule 1 $0 MO LIMIT REMODULIN INJECTION SOLUTION 2 $0 B/D PA; MO reserpine oral tablet 1 $0 PA; MO spironolactone oral tablet 1 $0 MO spironolacton-hydrochlorothiaz oral tablet 1 $0 MO taztia xt oral capsule, extended release 1 $0 MO TEKTURNA HCT ORAL TABLET TEKTURNA ORAL TABLET telmisartan oral tablet 1 $0 MO telmisartan-hydrochlorothiazid oral tablet 1 $0 MO terazosin oral capsule 1 $0 MO timolol maleate oral tablet 1 $0 MO torsemide intravenous solution 20 mg/2 ml (10 mg/ml) TORSEMIDE INTRAVENOUS SOLUTION 50 MG/5 ML (10 MG/ML) 1 $0 1 $0 torsemide oral tablet 1 $0 MO trandolapril oral tablet 1 $0 MO trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1 $0 MO 58

71 triamterene-hydrochlorothiazid oral capsule 1 $0 MO triamterene-hydrochlorothiazid oral tablet 1 $0 MO LIMIT UPTRAVI ORAL TABLET 2 $0 PA; MO; QL (60 per 30 UPTRAVI ORAL TABLETS,DOSE PACK 2 $0 PA; MO valsartan oral tablet 1 $0 MO valsartan-hydrochlorothiazide oral tablet 1 $0 MO verapamil intravenous solution 1 $0 B/D PA; MO verapamil intravenous syringe 1 $0 B/D PA verapamil oral capsule, 24 hr er pellet ct 1 $0 MO verapamil oral capsule,ext rel. pellets 24 hr 1 $0 MO verapamil oral tablet 1 $0 MO verapamil oral tablet extended release 1 $0 MO GLICOSIDI CARDIACI digitek oral tablet 1 $0 PA; MO digox oral tablet 1 $0 MO digoxin injection solution 1 $0 PA; MO digoxin oral solution 50 mcg/ml 1 $0 PA; MO digoxin oral tablet 1 $0 PA; MO LANOXIN ORAL TABLET TERAPIA COAGULAZIONE aspirin-dipyridamole oral capsule, er multiphase 12 hr 1 $0 MO BRILINTA ORAL TABLET cilostazol oral tablet 1 $0 MO clopidogrel oral tablet 300 mg 1 $0 MO; QL (1 per 30 clopidogrel oral tablet 75 mg 1 $0 MO COUMADIN ORAL TABLET 59

72 EFFIENT ORAL TABLET ELIQUIS ORAL TABLET LIMIT enoxaparin subcutaneous solution 1 $0 MO; QL (180 per 30 ; NEDS enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml 1 $0 MO; QL (60 per 30 ; NEDS 1 $0 MO; QL (48 per 30 ; NEDS enoxaparin subcutaneous syringe 30 mg/0.3 ml 1 $0 MO; QL (18 per 30 ; NEDS enoxaparin subcutaneous syringe 40 mg/0.4 ml 1 $0 MO; QL (24 per 30 ; NEDS enoxaparin subcutaneous syringe 60 mg/0.6 ml 1 $0 MO; QL (36 per 30 ; NEDS fondaparinux subcutaneous syringe 10 mg/0.8 ml 1 $0 MO; QL (24 per 30 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 1 $0 MO; QL (15 per 30 fondaparinux subcutaneous syringe 5 mg/0.4 ml 1 $0 MO; QL (12 per 30 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 1 $0 MO; QL (18 per 30 FRAGMIN SUBCUTANEOUS SOLUTION ; QL (30 per 30 FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML FRAGMIN SUBCUTANEOUS SYRINGE 15,000 ANTI-XA UNIT/0.6 ML FRAGMIN SUBCUTANEOUS SYRINGE 18,000 ANTI-XA UNIT/0.72 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML ; QL (30 per 30 ; QL (15 per 30 ; QL (18 per 30 ; QL (21.6 per 30 ; QL (6 per 30 60

73 FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) in nacl (pf) intravenous parenteral solution 2,000 unit/1,000 ml LIMIT ; QL (9 per 30 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA heparin (porcine) injection cartridge 1 $0 B/D PA; MO heparin (porcine) injection solution 1 $0 B/D PA; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO heparin, porcine (pf) injection solution 1 $0 B/D PA; MO heparin, porcine (pf) injection syringe 1 $0 B/D PA; MO jantoven oral tablet 1 $0 MO MEPHYTON ORAL TABLET 3 $0 MO; * pentoxifylline oral tablet extended release 1 $0 MO PRADAXA ORAL CAPSULE PROMACTA ORAL TABLET 2 $0 PA; MO tranexamic acid intravenous solution 1 $0 B/D PA; MO VITAMIN K INJECTION SOLUTION 3 $0 MO; * VITAMIN K1 INJECTION SOLUTION 3 $0 MO; * 61

74 warfarin oral tablet 1 $0 MO XARELTO ORAL TABLET XARELTO ORAL TABLETS,DOSE PACK LIPIDI / AGENTI CHE ABBASSANO IL COLESTEROLO amlodipine-atorvastatin oral tablet 1 $0 MO atorvastatin oral tablet 1 $0 MO cholestyramine (with sugar) oral powder 1 $0 MO cholestyramine (with sugar) oral powder in packet 1 $0 MO cholestyramine light oral powder 1 $0 MO cholestyramine light oral powder in packet 1 $0 MO colestipol oral granules 1 $0 MO colestipol oral packet 1 $0 MO colestipol oral tablet 1 $0 MO fenofibrate micronized oral capsule 1 $0 MO fenofibrate nanocrystallized oral tablet 1 $0 MO fenofibrate oral tablet 160 mg, 54 mg 1 $0 MO fenofibric acid (choline) oral capsule,delayed release(dr/ec) 1 $0 MO fenofibric acid oral tablet 1 $0 MO fluvastatin oral capsule 1 $0 MO fluvastatin oral tablet extended release 24 hr 1 $0 MO gemfibrozil oral tablet 1 $0 MO JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG LIMIT 2 $0 PA; MO; LA 2 $0 PA; MO KYNAMRO SUBCUTANEOUS SYRINGE 2 $0 PA; MO 62

75 lovastatin oral tablet 1 $0 MO niacin (inositol niacinate) oral capsule 500 mg 4 $0 MO; * niacin (niacinamide) oral tablet niacin oral tablet 100 mg, 50 mg, 500 mg 4 $0 MO; * niacin oral tablet extended release 24 hr 1 $0 MO niacin oral tablet extended release 500 mg, 750 mg 4 $0 MO; * niacinamide oral tablet 4 $0 MO; * omega-3 acid ethyl esters oral capsule 1 $0 MO PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 75 MG/ML LIMIT 2 $0 PA; MO; QL (2 per 28 2 $0 PA; MO; QL (4 per 28 2 $0 PA; MO; QL (2 per 28 2 $0 PA; MO; QL (4 per 28 pravastatin oral tablet 1 $0 MO prevalite oral powder 1 $0 MO prevalite oral powder in packet 1 $0 MO REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS SYRINGE rosuvastatin oral tablet 1 $0 2 $0 PA; MO; QL (3 per 28 2 $0 PA; MO; QL (3 per 28 simvastatin oral tablet 1 $0 MO slo-niacin oral tablet extended release 500 mg 4 $0 MO; * VYTORIN ORAL TABLET VYTORIN ORAL TABLET 63

76 VYTORIN ORAL TABLET VYTORIN ORAL TABLET WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL TABLET LIMIT ZETIA ORAL TABLET ; QL (30 per 30 AGENTI CARDIOVASCOLARI VARI ENTRESTO ORAL TABLET 2 $0 PA; MO RANEXA ORAL TABLET EXTENDED RELEASE 12 HR VECAMYL ORAL TABLET 2 $0 NITRATI ISORDIL ORAL TABLET isosorbide dinitrate oral tablet 1 $0 MO isosorbide dinitrate oral tablet extended release 1 $0 MO isosorbide dinitrate sublingual tablet 1 $0 MO isosorbide mononitrate oral tablet 1 $0 MO isosorbide mononitrate oral tablet extended release 24 hr 1 $0 MO nitro-bid transdermal ointment 1 $0 MO nitroglycerin intravenous solution 1 $0 B/D PA nitroglycerin transdermal patch 24 hour 1 $0 MO nitroglycerin translingual aerosol,spray 1 $0 MO nitroglycerin translingual spray,non-aerosol 1 $0 MO NITROSTAT SUBLINGUAL TABLET TERAPIA DERMATOLOGICA / TOPICA ANTIPSORIASICI / ANTISEBORROICI acitretin oral capsule 10 mg 1 $0 MO 64

77 acitretin oral capsule 17.5 mg, 25 mg 1 $0 MO; NEDS calcipotriene scalp solution 1 $0 MO calcipotriene topical cream 1 $0 MO calcipotriene topical ointment 1 $0 MO calcipotriene-betamethasone topical ointment 1 $0 MO calcitrene topical ointment calcitriol topical ointment 1 $0 MO selenium sulfide topical lotion 1 $0 MO FARMACI PER USTIONI silver sulfadiazine topical cream 1 $0 MO ssd topical cream 1 $0 MO CHERATOLITICI hydrisalic topical gel SAL-PLANT TOPICAL GEL 4 $0 MO; * wart remover topical gel DERMATOLOGICI VARI ammonium lactate topical cream 1 $0 MO ammonium lactate topical lotion 1 $0 MO CARAC TOPICAL CREAM diaper rash topical ointment diclofenac sodium topical gel 3 % 1 $0 PA; MO ELI TOPICAL CREAM 2 $0 ST; MO fluorouracil topical cream 1 $0 MO fluorouracil topical solution 1 $0 MO imiquimod topical cream in packet 1 $0 MO methoxsalen rapid oral capsule 1 $0 MO PANRETIN TOPICAL GEL LIMIT 65

78 podofilox topical solution 1 $0 MO LIMIT REGRANEX TOPICAL GEL ; QL (30 per 30 tacrolimus topical ointment 1 $0 MO VALCHLOR TOPICAL GEL zinc oxide topical ointment, 40 % zinc oxide topical ointment 20 % 4 $0 MO; * ZYCLARA TOPICAL CREAM IN METERED- DOSE PUMP ZYCLARA TOPICAL CREAM IN PACKET TERAPIA PER ACNE ACNE MEDICATION TOPICAL LOTION 5 % 4 $0 MO; * adapalene topical cream 1 $0 PA; MO adapalene topical gel 1 $0 PA; MO adapalene topical gel with pump 1 $0 PA; MO amnesteem oral capsule 1 $0 MO benzoyl peroxide topical gel 10 % 4 $0 MO; * benzoyl peroxide topical lotion 4 $0 MO; * claravis oral capsule 1 $0 MO clindamycin phosphate topical foam 1 $0 MO clindamycin phosphate topical gel 1 $0 MO clindamycin phosphate topical lotion 1 $0 MO clindamycin phosphate topical solution 1 $0 MO clindamycin phosphate topical swab 1 $0 MO clindamycin-benzoyl peroxide topical gel 1 $0 MO ery pads topical swab 1 $0 MO erythromycin with ethanol topical gel 1 $0 MO erythromycin with ethanol topical solution 1 $0 MO 66

79 erythromycin with ethanol topical swab 1 $0 MO erythromycin-benzoyl peroxide topical gel 1 $0 MO metronidazole topical cream 1 $0 MO metronidazole topical gel 1 $0 MO metronidazole topical gel with pump 1 $0 MO metronidazole topical lotion 1 $0 MO persa-gel topical gel rosadan topical cream 1 $0 MO rosadan topical gel 1 $0 MO TAZORAC TOPICAL CREAM TAZORAC TOPICAL GEL tretinoin microspheres topical gel 1 $0 PA; MO tretinoin microspheres topical gel with pump 1 $0 PA; MO tretinoin topical cream 1 $0 PA; MO tretinoin topical gel 1 $0 PA; MO ANESTETICI TOPICI lidocaine (pf) injection solution 10 mg/ml (1 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) LIMIT 1 $0 B/D PA; MO lidocaine (pf) injection solution 15 mg/ml (1.5 %) 1 $0 B/D PA LIDOCAINE (PF) INJECTION SOLUTION 20 MG/ML (2 %) 1 $0 B/D PA; MO lidocaine hcl injection solution 1 $0 B/D PA; MO lidocaine hcl laryngotracheal solution 1 $0 MO lidocaine hcl mucous membrane gel 1 $0 MO lidocaine hcl mucous membrane jelly in applicator 1 $0 MO lidocaine hcl mucous membrane solution 1 $0 MO lidocaine hcl urethral gel 1 $0 MO 67

80 lidocaine topical adhesive patch,medicated 1 $0 PA; MO lidocaine topical ointment 1 $0 MO lidocaine viscous mucous membrane solution 1 $0 MO lidocaine-prilocaine topical cream 1 $0 MO ANTIBATTERICI TOPICI ANTIBIOTIC (NEOMY-BACIT-POLYM) TOPICAL OINTMENT bacitracin topical ointment 4 $0 MO; * bacitracin zinc topical packet bacitraycin plus topical ointment 500 unit/gram gentamicin topical cream 1 $0 MO gentamicin topical ointment 1 $0 MO mupirocin calcium topical cream 1 $0 MO mupirocin topical ointment 1 $0 MO sulfacetamide sodium (acne) topical suspension 1 $0 MO SULFAMYLON TOPICAL CREAM triple antibiotic topical ointment 4 $0 MO; * ANTIMICOTICI TOPICI ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER 4 $0 MO; * ANTIFUNGAL CREAM TOPICAL CREAM ATHLETE'S FOOT (TERBINAFINE) TOPICAL CREAM athlete's foot (tolnaftate) topical cream baza antifungal topical cream 4 $0 MO; * ciclodan topical cream 1 $0 MO LIMIT 68

81 ciclodan topical solution 1 $0 MO ciclopirox topical cream 1 $0 MO ciclopirox topical gel 1 $0 MO ciclopirox topical shampoo 1 $0 MO ciclopirox topical solution 1 $0 MO ciclopirox topical suspension 1 $0 MO clotrimazole topical cream 1 $0 MO clotrimazole topical solution 1 $0 MO clotrimazole-betamethasone topical cream 1 $0 MO clotrimazole-betamethasone topical lotion 1 $0 MO econazole topical cream 1 $0 MO fungoid-d topical cream INZO ANTIFUNGAL TOPICAL CREAM ketoconazole topical cream 1 $0 MO ketoconazole topical foam 1 $0 MO ketoconazole topical shampoo 1 $0 MO ketodan topical foam 1 $0 lamisil af topical powder lamisil at topical cream 4 $0 MO; * miconazole nitrate topical cream 4 $0 MO; * nyamyc topical powder 1 $0 MO nystatin topical cream 1 $0 MO nystatin topical ointment 1 $0 MO nystatin topical powder 1 $0 MO nystatin-triamcinolone topical cream 1 $0 MO nystatin-triamcinolone topical ointment 1 $0 MO nystop topical powder 1 $0 MO LIMIT 69

82 podactin topical powder terbinafine hcl topical cream 4 $0 MO; * tinactin topical powder 4 $0 MO; * tolnaftate topical cream tolnaftate topical powder ANTIVIRALI TOPICI ABREVA TOPICAL CREAM 4 $0 MO; * acyclovir topical ointment 1 $0 MO DENAVIR TOPICAL CREAM CORTICOSTEROIDI TOPICI ala-cort topical cream 1 $0 MO alclometasone topical cream 1 $0 MO alclometasone topical ointment 1 $0 MO amcinonide topical cream 1 $0 MO amcinonide topical lotion 1 $0 MO amcinonide topical ointment 1 $0 MO betamethasone dipropionate topical cream 1 $0 MO betamethasone dipropionate topical lotion 1 $0 MO betamethasone dipropionate topical ointment 1 $0 MO betamethasone valerate topical cream 1 $0 MO betamethasone valerate topical foam 1 $0 MO betamethasone valerate topical lotion 1 $0 MO betamethasone valerate topical ointment 1 $0 MO betamethasone, augmented topical cream 1 $0 MO betamethasone, augmented topical gel 1 $0 MO betamethasone, augmented topical lotion 1 $0 MO betamethasone, augmented topical ointment 1 $0 MO LIMIT 70

83 clobetasol scalp solution 1 $0 MO clobetasol topical cream 1 $0 MO clobetasol topical foam 1 $0 MO clobetasol topical gel 1 $0 MO clobetasol topical lotion 1 $0 MO clobetasol topical ointment 1 $0 MO clobetasol topical shampoo 1 $0 MO clobetasol-emollient topical cream 1 $0 MO clobetasol-emollient topical foam 1 $0 MO cormax scalp solution 1 $0 desonide topical cream 1 $0 MO desonide topical lotion 1 $0 MO desonide topical ointment 1 $0 MO desoximetasone topical cream 1 $0 MO desoximetasone topical gel 1 $0 MO desoximetasone topical ointment 1 $0 MO diflorasone topical cream 1 $0 MO diflorasone topical ointment 1 $0 MO fluocinolone and shower cap scalp oil 1 $0 MO fluocinolone topical cream 1 $0 MO fluocinolone topical oil 1 $0 MO fluocinolone topical ointment 1 $0 MO fluocinolone topical solution 1 $0 MO fluocinonide topical cream 1 $0 MO fluocinonide topical gel 1 $0 MO fluocinonide topical ointment 1 $0 MO fluocinonide topical solution 1 $0 MO LIMIT 71

84 fluocinonide-e topical cream 1 $0 MO fluocinonide-emollient topical cream 1 $0 MO fluticasone topical cream 1 $0 MO fluticasone topical lotion 1 $0 MO fluticasone topical ointment 1 $0 MO halobetasol propionate topical cream 1 $0 MO halobetasol propionate topical ointment 1 $0 MO hydrocortisone acetate topical cream 1 % hydrocortisone butyrate topical cream 1 $0 MO hydrocortisone butyrate topical ointment 1 $0 MO hydrocortisone butyrate topical solution 1 $0 MO hydrocortisone butyr-emollient topical cream 1 $0 MO hydrocortisone topical cream 1 %, 2.5 % 1 $0 MO hydrocortisone topical lotion 2.5 % 1 $0 MO hydrocortisone topical ointment 1 %, 2.5 % 1 $0 MO hydrocortisone valerate topical cream 1 $0 MO hydrocortisone valerate topical ointment 1 $0 MO hydrocortisone-min oil-wht pet topical ointment 1 $0 MO HYDROSKIN TOPICAL LOTION 4 $0 MO; * mometasone topical cream 1 $0 MO mometasone topical ointment 1 $0 MO mometasone topical solution 1 $0 MO prednicarbate topical cream 1 $0 MO prednicarbate topical ointment 1 $0 MO triamcinolone acetonide topical aerosol 1 $0 MO triamcinolone acetonide topical cream 1 $0 MO triamcinolone acetonide topical lotion 1 $0 MO LIMIT 72

85 triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % 1 $0 MO trianex topical ointment 1 $0 MO triderm topical cream 1 $0 MO ENZIMI TOPICI SANTYL TOPICAL OINTMENT SCABICIDI / PEDICULICIDI TOPICI LICE TREATMENT (PERMETHRIN) TOPICAL LIQUID lice treatment topical liquid 1 % lindane topical lotion 1 $0 MO lindane topical shampoo 1 $0 MO malathion topical lotion 1 $0 MO permethrin topical cream 1 $0 MO permethrin topical liquid 4 $0 MO; * AGENTI DIAGNOSTICI / VARI SOLUZIONI PER LAVAGGI lactated ringers irrigation solution 1 $0 MO neomycin-polymyxin b gu irrigation solution 1 $0 MO AGENTI VARI acamprosate oral tablet,delayed release (dr/ec) 1 $0 MO LIMIT ADAGEN INTRAMUSCULAR SOLUTION 2 $0 B/D PA; MO alendronate oral tablet 40 mg 1 $0 MO; QL (30 per 30 anagrelide oral capsule 1 $0 MO ARALAST NP INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO AURYXIA ORAL TABLET CARBAGLU ORAL TABLET, DISPERSIBLE 2 $0 PA; MO; LA 73

86 cevimeline oral capsule 1 $0 MO CHEMET ORAL CAPSULE CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 10 % in water (d10w) intravenous parenteral solution dextrose 20 % in water (d20w) intravenous parenteral solution dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 40 % in water (d40w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 1 $0 1 $0 B/D PA LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA; MO 74

87 dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA disulfiram oral tablet 1 $0 MO etidronate disodium oral tablet 1 $0 MO EXJADE ORAL TABLET, DISPERSIBLE FERRIPROX ORAL TABLET 2 $0 PA; MO FOSRENOL ORAL POWDER IN PACKET FOSRENOL ORAL TABLET,CHEWABLE INCRELEX SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO kionex oral powder 1 $0 MO kionex oral suspension 1 $0 MO levocarnitine (with sugar) oral solution 1 $0 B/D PA; MO levocarnitine intravenous solution 1 $0 B/D PA; MO levocarnitine oral tablet 1 $0 B/D PA; MO midodrine oral tablet 1 $0 MO NORTHERA ORAL CAPSULE 2 $0 PA; MO pilocarpine hcl oral tablet 1 $0 MO 75

88 RAVICTI ORAL LIQUID 2 $0 PA; MO RENVELA ORAL POWDER IN PACKET riluzole oral tablet 1 $0 MO risedronate oral tablet 30 mg 1 $0 MO sevelamer carbonate oral tablet 1 $0 MO sodium chloride 0.9 % intravenous parenteral solution 1 $0 MO sodium chloride 0.9 % intravenous piggyback 1 $0 MO sodium chloride irrigation solution 1 $0 MO sodium polystyrene (sorb free) oral suspension 1 $0 MO sodium polystyrene sulfonate oral powder 1 $0 MO sodium polystyrene sulfonate oral suspension 1 $0 sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML 1 $0 1 $0 sps oral suspension 1 $0 MO sps rectal enema 1 $0 SYPRINE ORAL CAPSULE ZOLEDRONIC ACID-MANNITOL-WATER INTRAVENOUS PIGGYBACK 5 MG/100 ML zoledronic acid-mannitol-water intravenous solution NUTRACEUTICI 1 $0 PA 1 $0 PA; MO central vite oral tablet complete premium vitamin oral tablet DETERRENTI PER FUMATORI buproban oral tablet extended release 1 $0 LIMIT 76

89 bupropion hcl (smoking deter) oral tablet extended release CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 $0 MO CHANTIX ORAL TABLET CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK NICORELIEF BUCCAL GUM 4 $0 MO; * nicorelief buccal lozenge nicotine (polacrilex) buccal gum 4 $0 MO; * nicotine (polacrilex) buccal lozenge 4 $0 MO; * nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr 4 $0 MO; * NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON- AEROSOL FARMACI PER ORECCHIO, NASO E GOLA AGENTI VARI 12 HOUR NASAL SPRAY NASAL SPRAY,NON-AEROSOL afrin no drip(oxymetazolin) nasal mist anefrin nasal mist anefrin nasal spray,non-aerosol ayr saline nasal aerosol,spray 4 $0 MO; * AYR SALINE NASAL DROPS 4 $0 MO; * LIMIT azelastine nasal aerosol,spray 1 $0 MO; QL (60 per 30 azelastine nasal spray,non-aerosol 1 $0 MO; QL (60 per 30 baby ayr saline nasal drops 77

90 children's saline nasal spray nasal aerosol,spray chlorhexidine gluconate mucous membrane mouthwash 1 $0 MO DEEP SEA NASAL NASAL AEROSOL,SPRAY denta 5000 plus dental cream 1 $0 MO dentagel dental gel 1 $0 MO DRISTAN LONG LASTING NASAL MIST ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % nasal decongestant (oxymetazl) nasal spray,nonaerosol NASAL SPRAY (OXYMETAZOLINE) NASAL SPRAY,NON-AEROSOL LIMIT 1 $0 MO; QL (60 per 30 1 $0 MO; QL (30 per 30 4 $0 MO; * nasal spray (sodium chloride) nasal aerosol,spray NASAL SPRAY 12 HOUR NASAL MIST NASAL SPRAY 12 HOUR NASAL SPRAY,NON-AEROSOL nasal spray extra moisturizing nasal spray,nonaerosol nasal spray long acting nasal spray,non-aerosol no drip nasal spray,non-aerosol NRS NASAL RELIEF NASAL SPRAY,NON- AEROSOL ocean for kids nasal aerosol,spray OCEAN NASAL NASAL AEROSOL,SPRAY 4 $0 MO; * olopatadine nasal spray,non-aerosol 1 $0 MO; QL (30.5 per 30 oralone dental paste 1 $0 MO 78

91 paroex oral rinse mucous membrane mouthwash 1 $0 MO periogard mucous membrane mouthwash 1 $0 MO saline mist nasal aerosol,spray 4 $0 MO; * saline nasal nasal aerosol,spray saline nose nasal aerosol,spray sea soft nasal mist nasal aerosol,spray sf 5000 plus dental cream 1 $0 MO sf dental gel 1 $0 MO sinus nasal spray nasal spray,non-aerosol SINUS RELIEF (OXYMETAZOLINE) NASAL MIST sinus relief (oxymetazoline) nasal spray,nonaerosol triamcinolone acetonide dental paste 1 $0 MO PREPAR VARIE PER OTITE acetasol hc otic drops 1 $0 MO acetic acid otic solution 1 $0 MO acetic acid-aluminum acetate otic drops 1 $0 MO fluocinolone acetonide oil otic drops 1 $0 MO hydrocortisone-acetic acid otic drops 1 $0 MO ofloxacin otic drops 1 $0 MO STEROIDI / ANTIBIOTICI PER OTITE CORTISPORIN-TC OTIC DROPS,SUSPENSION neomycin-polymyxin-hc otic drops,suspension 1 $0 MO neomycin-polymyxin-hc otic solution 1 $0 MO ENDOCRINOLOGIA/DIABETE ORMONI SURRENALICI LIMIT 79

92 ACTHAR H.P. INJECTION GEL 2 $0 PA; MO LIMIT a-hydrocort injection recon soln 1 $0 B/D PA; MO cortisone oral tablet 1 $0 MO dexamethasone intensol oral drops 1 $0 MO dexamethasone oral elixir 1 $0 MO dexamethasone oral solution 1 $0 MO dexamethasone oral tablet 1 $0 MO dexamethasone sodium phos (pf) injection solution dexamethasone sodium phosphate injection solution dexamethasone sodium phosphate injection syringe 1 $0 B/D PA; MO 1 $0 B/D PA; MO 1 $0 B/D PA; MO fludrocortisone oral tablet 1 $0 MO hydrocortisone oral tablet 1 $0 MO KENALOG INJECTION SUSPENSION methylprednisolone acetate injection suspension 1 $0 B/D PA; MO methylprednisolone oral tablet 1 $0 MO methylprednisolone oral tablets,dose pack 1 $0 MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1 $0 B/D PA; MO 1 $0 B/D PA; MO millipred oral tablet 1 $0 MO prednisolone oral solution 15 mg/5 ml 1 $0 MO prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating 1 $0 MO 1 $0 MO 80

93 prednisone intensol oral concentrate 1 $0 MO prednisone oral solution 1 $0 MO prednisone oral tablet 1 $0 MO prednisone oral tablets,dose pack 1 $0 MO SOLU-CORTEF (PF) INJECTION RECON SOLN LIMIT 2 $0 B/D PA; MO SOLU-CORTEF INJECTION RECON SOLN 2 $0 B/D PA; MO triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml 1 $0 MO 1 $0 veripred 20 oral solution 1 $0 MO AGENTI ANTITIROIDEI methimazole oral tablet 10 mg, 5 mg 1 $0 MO propylthiouracil oral tablet 1 $0 MO TERAPIA PER DIABETE acarbose oral tablet 1 $0 MO ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG ALCOHOL PADS TOPICAL PADS, MEDICATED BYDUREON SUBCUTANEOUS PEN INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 $0 ST; MO; QL (60 per 30 2 $0 ST; MO; QL (30 per 30 BYETTA SUBCUTANEOUS PEN INJECTOR CYCLOSET ORAL TABLET 2 $0 ST; MO FARXIGA ORAL TABLET 81

94 GAUZE PADS 2 X 2 glimepiride oral tablet 1 $0 MO glipizide oral tablet 1 $0 MO glipizide oral tablet extended release 24hr 1 $0 MO LIMIT glipizide-metformin oral tablet mg 1 $0 MO; QL (240 per 30 glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT INJECTION RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 $0 MO; QL (120 per 30 glyburide micronized oral tablet 1 $0 ST; MO glyburide oral tablet 1 $0 ST; MO glyburide-metformin oral tablet 1 $0 ST; MO HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN N SUBCUTANEOUS SUSPENSION HUMULIN R INJECTION SOLUTION HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 2 $0 INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML 82

95 LIMIT JANUMET ORAL TABLET ; QL (60 per 30 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR ; QL (60 per 30 JANUVIA ORAL TABLET ; QL (30 per 30 JARDIANCE ORAL TABLET KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN ; QL (30 per 30 LEVEMIR SUBCUTANEOUS SOLUTION metformin oral tablet 1 $0 MO metformin oral tablet extended release 24 hr 1 $0 MO metformin oral tablet extended release 24hr 1 $0 MO metformin oral tablet,er gast.retention 24 hr 1 $0 MO nateglinide oral tablet 1 $0 MO NEEDLES, INSULIN DISP.,SAFETY NOVOFINE NEEDLE NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION NOVOLIN R INJECTION SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX SUBCUTANEOUS SOLUTION NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION 83

96 NOVOTWIST NEEDLE LIMIT ONGLYZA ORAL TABLET ; QL (30 per 30 pioglitazone oral tablet 1 $0 MO pioglitazone-glimepiride oral tablet 1 $0 MO; QL (30 per 30 pioglitazone-metformin oral tablet 1 $0 MO; QL (90 per 30 PROGLYCEM ORAL SUSPENSION repaglinide oral tablet 0.5 mg 1 $0 MO; QL (930 per 30 repaglinide oral tablet 1 mg 1 $0 MO; QL (480 per 30 repaglinide oral tablet 2 mg 1 $0 MO; QL (240 per 30 repaglinide-metformin oral tablet 1 $0 MO SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR SYNJARDY ORAL TABLET tolazamide oral tablet 1 $0 MO tolbutamide oral tablet 1 $0 MO TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 84

97 ORMONI VARI LIMIT ALDURAZYME INTRAVENOUS SOLUTION 2 $0 B/D PA; MO ANADROL-50 ORAL TABLET 2 $0 PA; MO 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) androxy oral tablet cabergoline oral tablet 1 $0 MO; QL (20 per 30 calcitonin (salmon) nasal spray,non-aerosol 1 $0 MO calcitriol intravenous solution 1 mcg/ml 1 $0 B/D PA; MO calcitriol oral capsule 1 $0 B/D PA; MO calcitriol oral solution 1 $0 B/D PA; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR RECON SOLN 2 $0 B/D PA; MO 2 $0 PA; MO danazol oral capsule 1 $0 MO desmopressin injection solution 1 $0 MO desmopressin nasal aerosol,spray 1 $0 MO desmopressin nasal solution 1 $0 MO desmopressin nasal spray,non-aerosol 1 $0 MO desmopressin oral tablet 1 $0 MO ELAPRASE INTRAVENOUS SOLUTION 2 $0 B/D PA; MO ELELYSO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO FABRAZYME INTRAVENOUS RECON SOLN 2 $0 PA; MO fortical nasal spray,non-aerosol 1 $0 MO 85

98 KORLYM ORAL TABLET 2 $0 PA; MO KUVAN ORAL TABLET,SOLUBLE 2 $0 PA; MO methyltestosterone oral capsule 1 $0 MO LIMIT MIACALCIN INJECTION SOLUTION 2 $0 B/D PA; MO MYOZYME INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO NAGLAZYME INTRAVENOUS SOLUTION 2 $0 B/D PA; MO NATPARA SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO NOVAREL INTRAMUSCULAR RECON SOLN 2 $0 PA; MO oxandrolone oral tablet 1 $0 MO pamidronate intravenous recon soln 1 $0 B/D PA; MO pamidronate intravenous solution 1 $0 B/D PA; MO paricalcitol oral capsule 1 $0 B/D PA; MO PREGNYL INTRAMUSCULAR RECON SOLN 2 $0 PA; MO SAMSCA ORAL TABLET 15 MG 2 $0 PA; MO; QL (30 per 30 ; NEDS SAMSCA ORAL TABLET 30 MG 2 $0 PA; MO; QL (60 per 30 ; NEDS SENSIPAR ORAL TABLET SOMAVERT SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO SYNAREL NASAL SPRAY,NON-AEROSOL testosterone cypionate intramuscular oil 1 $0 B/D PA; MO testosterone enanthate intramuscular oil 1 $0 B/D PA; MO VPRIV INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO ZAVESCA ORAL CAPSULE ZEMPLAR INTRAVENOUS SOLUTION 2 $0 B/D PA; MO zoledronic acid intravenous recon soln 1 $0 B/D PA zoledronic acid intravenous solution 1 $0 B/D PA; MO 86

99 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML ORMONI TIROIDEI LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG LIMIT 2 $0 B/D PA; MO levothyroxine oral tablet 1 $0 MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 1 $0 MO liothyronine intravenous solution 1 $0 MO liothyronine oral tablet 1 $0 MO SYNTHROID ORAL TABLET unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGIA ANTIDIARROICI / ANTISPASTICI 1 $0 MO ANTI-DIARRHEA ORAL TABLET ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET 4 $0 MO; * atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1 $0 BISMATROL ORAL SUSPENSION 262 MG/15 ML 4 $0 MO; * bismatrol oral suspension 525 mg/15 ml BISMATROL ORAL TABLET,CHEWABLE bismuth maximum strength oral suspension BISMUTH ORAL SUSPENSION bismuth oral tablet,chewable diarrhea relief (bismuth subs) oral suspension 87

100 dicyclomine oral capsule 1 $0 MO dicyclomine oral solution 1 $0 MO dicyclomine oral tablet 1 $0 MO glycopyrrolate injection solution 1 $0 MO glycopyrrolate oral tablet 1 $0 MO kaopectate (bismuth subsalicy) oral suspension 4 $0 MO; * kao-tin (bismuth subsalicylat) oral suspension kola-pectin ds oral suspension loperamide oral capsule 1 $0 MO loperamide oral tablet methscopolamine oral tablet 1 $0 MO PEPTIC RELIEF ORAL SUSPENSION PEPTIC RELIEF ORAL TABLET,CHEWABLE pepto-bismol oral tablet,chewable 4 $0 MO; * pepto-bismol to-go oral tablet,chewable pink bismuth oral suspension PINK BISMUTH ORAL TABLET,CHEWABLE 4 $0 MO; * soothe (bismuth subsalicylate) oral tablet,chewable soothe regular strength oral suspension stomach relief max strength oral suspension STOMACH RELIEF ORAL SUSPENSION 262 MG/15 ML STOMACH RELIEF ORAL TABLET,CHEWABLE STOMACH RELIEF ORIGINAL ORAL SUSPENSION AGENTI TERAPEUTICI VARI LIMIT 88

101 ACID GONE ANTACID ORAL SUSPENSION ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION ALMACONE ORAL SUSPENSION ALMACONE-2 ORAL SUSPENSION LIMIT alosetron oral tablet 1 $0 PA; MO; QL (60 per 30 aluminum hydroxide gel oral suspension 320 mg/5 ml 4 $0 MO; * AMITIZA ORAL CAPSULE ; QL (60 per 30 antacid (calcium carb-mag hyd) oral tablet,chewable mg ANTACID ANTI-GAS DOUBLE STR ORAL SUSPENSION ANTACID ANTI-GAS ORAL SUSPENSION ANTACID EXTRA-STRENGTH ORAL SUSPENSION MG/5 ML antacid liquid oral suspension antacid m oral suspension ANTACID MAXIMUM STRENGTH ORAL SUSPENSION ANTACID ORAL SUSPENSION ANTACID PLUS ANTI-GAS ORAL SUSPENSION antacid regular strength oral suspension antacid ultra strength oral tablet,chewable 1,177 mg ANTACID-ANTIGAS ORAL SUSPENSION MG/5 ML ANTACID-SIMETHICONE ORAL SUSPENSION 89

102 APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR balsalazide oral capsule 1 $0 MO bisacodyl oral tablet,delayed release (dr/ec) 4 $0 MO; * BISA-LAX ORAL TABLET,AYED RELEASE (DR/EC) budesonide oral capsule,delayed,extend.release 1 $0 MO CANASA RECTAL SUPPOSITORY children's pepto oral tablet,chewable children's soothe oral tablet,chewable CHOLBAM ORAL CAPSULE 2 $0 PA; MO CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT LIMIT 2 $0 B/D PA; ST; MO 2 $0 ST; MO CIMZIA SUBCUTANEOUS SYRINGE KIT 2 $0 ST; MO citrate of magnesia oral solution citroma oral solution citrucel oral tablet 4 $0 MO; * CLEARLAX ORAL POWDER col-rite oral capsule comfort gel extra strength oral suspension comfort gel oral suspension compro rectal suppository 1 $0 MO constulose oral solution 1 $0 MO cromolyn oral concentrate 1 $0 MO CYSTADANE ORAL POWDER dimenhydrinate oral tablet 4 $0 MO; * 90

103 DIOCTO ORAL LIQUID DIPENTUM ORAL CAPSULE disposable enema rectal enema DOC-Q-LACE ORAL CAPSULE 4 $0 MO; * DOC-Q-LAX ORAL TABLET 4 $0 MO; * DOCU ORAL LIQUID 4 $0 MO; * docu soft oral capsule docusate sodium oral capsule 100 mg 4 $0 MO; * docusate sodium oral capsule 250 mg docusate sodium oral liquid 4 $0 MO; * DOCUSIL ORAL CAPSULE DOK ORAL CAPSULE 100 MG 4 $0 MO; * dok oral capsule 250 mg dok plus oral tablet DRIMINATE ORAL TABLET LIMIT dronabinol oral capsule 1 $0 B/D PA; MO DUCODYL ORAL TABLET,AYED RELEASE (DR/EC) ENEMA DISPOSABLE RECTAL ENEMA ENEMA RECTAL ENEMA 19-7 GRAM/118 ML enulose oral solution 1 $0 MO evac-u-gen (sennosides) oral tablet FIBER (CALCIUM POLYCARBOPHIL) ORAL TABLET FIBER (PSYLLIUM HUSK/SUGAR) ORAL POWDER 3.4 GRAM/11 GRAM fiber (psyllium husk/sugar) oral powder 3.4 gram/12 gram 4 $0 MO; * 91

104 FIBER (WITH ASPARTAME) ORAL POWDER FIBER LAXATIVE (CA POLYCARBO) ORAL TABLET fiber laxative (husk/sugar) oral powder FIBER LAXATIVE (METHYLCELLULO) ORAL TABLET fiber laxative-orange oral powder FIBER ORAL POWDER fiber smooth oral powder 4 $0 MO; * fiber supplement oral powder FIBER THERAPY (M-CELL/SUGAR) ORAL POWDER 2 GRAM/19 GRAM FIBER THERAPY (M-CELLULOSE) ORAL TABLET FIBER THERAPY (PSYLLIUM SEED) ORAL POWDER FIBER-LAX ORAL TABLET 4 $0 MO; * fibertab oral tablet FIBER-TABS ORAL TABLET FLEET ENEMA RECTAL ENEMA 4 $0 MO; * fleet glycerin (adult) rectal suppository FLEET LAXATIVE ORAL TABLET,AYED RELEASE (DR/EC) FOAMING ANTACID ORAL TABLET,CHEWABLE GATTEX 30-VIAL SUBCUTANEOUS KIT 2 $0 PA; MO GATTEX ONE-VIAL SUBCUTANEOUS KIT 2 $0 PA; MO GAVILAX ORAL POWDER 4 $0 MO; * gavilyte-c oral recon soln 1 $0 MO LIMIT 92

105 gavilyte-g oral recon soln 1 $0 MO gavilyte-n oral recon soln 1 $0 MO generlac oral solution 1 $0 MO GENTLE LAXATIVE ORAL TABLET,AYED RELEASE (DR/EC) glycerin (adult) rectal suppository glycerin (child) rectal suppository glycerin (infant) rectal suppository GLYCOLAX ORAL POWDER LIMIT granisetron (pf) intravenous solution 1 $0 B/D PA; MO granisetron hcl intravenous solution 1 $0 B/D PA; MO granisetron hcl oral tablet 1 $0 B/D PA; MO hydrocortisone rectal cream 1 $0 hydrocortisone rectal enema 1 $0 MO KONSYL (SUGAR) ORAL POWDER 3.4 GRAM/11 GRAM konsyl (sugar) oral powder 3.4 gram/12 gram 4 $0 MO; * konsyl easy mix oral powder KONSYL FIBER ORAL TABLET konsyl sugar-free oral powder 4 $0 MO; * KONSYL SUGAR-FREE ORAL POWDER IN PACKET 4 $0 MO; * konsyl-d oral powder 4 $0 MO; * lactulose oral solution 1 $0 MO LAXATIVE (BISACODYL) ORAL TABLET LAXATIVE (BISACODYL) ORAL TABLET,AYED RELEASE (DR/EC) laxative (glycerin-pediatric) rectal suppository 93

106 laxative (sennosides) oral tablet 17.2 mg, 25 mg LAXATIVE FEMININE ORAL TABLET laxative peg 3350 oral powder laxative pills oral tablet laxative pills regular oral tablet LAXATIVE PLUS STOOL SOFTENER ORAL TABLET LIALDA ORAL TABLET,AYED RELEASE (DR/EC) LIMIT LINZESS ORAL CAPSULE ; QL (30 per 30 LIQUID ANTACID ORAL SUSPENSION MG/5 ML maalox maximum strength oral suspension 4 $0 MO; * mag-al plus extra strength oral suspension MAG-AL PLUS ORAL SUSPENSION magnesium citrate oral solution 4 $0 MO; * meclizine oral tablet 12.5 mg, 25 mg 1 $0 MO meclizine oral tablet,chewable mesalamine rectal enema 1 $0 MO mesalamine with cleansing wipe rectal enema kit 1 $0 MO metoclopramide hcl injection solution 1 $0 B/D PA; MO metoclopramide hcl injection syringe 1 $0 B/D PA metoclopramide hcl oral solution 1 $0 MO metoclopramide hcl oral tablet 1 $0 MO MI-ACID ORAL SUSPENSION 4 $0 MO; * MI-ACID ORAL TABLET,CHEWABLE milk of magnesia concentrated oral suspension 4 $0 MO; * MILK OF MAGNESIA ORAL SUSPENSION 4 $0 MO; * 94

107 mineral oil extra heavy oral oil mineral oil heavy oral oil 4 $0 MO; * mineral oil laxative oral oil 4 $0 MO; * mineral oil oral oil 4 $0 MO; * mintox maximum strength oral suspension 4 $0 MO; * MINTOX ORAL SUSPENSION 4 $0 MO; * MOTION SICKNESS ORAL TABLET MOTION SICKNESS RELIEF ORAL TABLET motion sickness relief(mecliz) oral tablet,chewable MOTION-TIME ORAL TABLET,CHEWABLE MOVANTIK ORAL TABLET MOVIPREP ORAL POWDER IN PACKET NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM natural fiber laxative s/f oral powder natural fiber laxative smooth oral powder NATURAL FIBER LAXATIVE THERAPY ORAL POWDER natural laxative oral tablet LIMIT ondansetron hcl (pf) injection solution 1 $0 B/D PA; MO ondansetron hcl (pf) injection syringe 1 $0 B/D PA ondansetron hcl intravenous solution 1 $0 B/D PA; MO ondansetron hcl oral solution 1 $0 B/D PA; MO ondansetron hcl oral tablet 24 mg 1 $0 B/D PA ondansetron hcl oral tablet 4 mg, 8 mg 1 $0 B/D PA; MO ondansetron oral tablet,disintegrating 1 $0 B/D PA; MO p-col rite oral tablet 95

108 pediatric enema rectal enema peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram 1 $0 MO 1 $0 PEG3350 ORAL POWDER peg-3350 with flavor packs oral recon soln 1 $0 peg-electrolyte soln oral recon soln 1 $0 perdiem overnight relief oral tablet 4 $0 MO; * polyethylene glycol 3350 oral powder 1 $0 MO polyethylene glycol 3350 oral powder in packet 1 $0 MO powderlax oral powder prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 1 $0 MO prochlorperazine maleate oral tablet 1 $0 MO prochlorperazine rectal suppository 1 $0 MO procto-pak rectal cream 1 $0 MO proctosol hc rectal cream 1 $0 MO proctozone-hc rectal cream 1 $0 MO READY-TO-USE ENEMA RECTAL ENEMA REGULOID ORAL POWDER 4 $0 MO; * REGULOID, SUGAR FREE ORAL POWDER RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE INTRAVENOUS RECON SOLN 2 $0 PA; MO SANCUSO TRANSDERMAL PATCH WEEKLY SANI-SUPP (ADULT) RECTAL SUPPOSITORY LIMIT 2 $0 B/D PA; MO; QL (2 per 15 4 $0 MO; * 96

109 sani-supp (child) rectal suppository sani-supp (infant) rectal suppository 4 $0 MO; * SENEXON ORAL TABLET 4 $0 MO; * SENEXON-S ORAL TABLET 4 $0 MO; * SENNA LAX ORAL TABLET 4 $0 MO; * SENNA LAXATIVE ORAL TABLET 8.6 MG senna laxative-stool softener oral tablet SENNA ORAL TABLET SENNA PLUS ORAL TABLET 4 $0 MO; * SENNA WITH DOCUSATE SODIUM ORAL TABLET senna-gen oral tablet 4 $0 MO; * SENNA-S ORAL TABLET 4 $0 MO; * SENNA-TIME S ORAL TABLET SENNO ORAL TABLET sennosides-docusate sodium oral tablet sen-o-tab oral tablet SILACE ORAL LIQUID 4 $0 MO; * smoothlax oral powder sodium bicarbonate oral tablet 4 $0 MO; * sof-lax oral capsule soluble fiber oral tablet STOOL SOFTENER ORAL CAPSULE 100 MG, 250 MG STOOL SOFTENER-LAXATIVE ORAL TABLET STOOL SOFTENER-STIMULANT LAXAT ORAL TABLET 4 $0 MO; * LIMIT 97

110 sulfasalazine oral tablet 1 $0 MO sulfasalazine oral tablet,delayed release (dr/ec) 1 $0 MO TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY TRAVEL SICKNESS (MECLIZINE) ORAL TABLET,CHEWABLE LIMIT ; QL (10 per 30 4 $0 MO; * TRAVEL SICKNESS ORAL TABLET trilyte with flavor packets oral recon soln 1 $0 MO tums ultra oral tablet,chewable 1,177 mg ursodiol oral capsule 1 $0 MO ursodiol oral tablet 1 $0 MO VARUBI ORAL TABLET 2 $0 B/D PA; MO wal-dram oral tablet wal-mucil fiber (aspartame) oral powder wal-mucil fiber (sugar) oral powder wal-mucil natural fiber lax oral powder woman's laxative oral tablet WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET women's laxative (bisacodyl) oral tablet,delayed release (dr/ec) ZENPEP ORAL CAPSULE,AYED RELEASE(DR/EC) TERAPIA PER ULCERA acid controller oral tablet 10 mg ACID CONTROLLER ORAL TABLET 20 MG ACID REDUCER (FAMOTIDINE) ORAL TABLET 98

111 ACID REDUCER (RANITIDINE) ORAL TABLET amoxicil-clarithromy-lansopraz oral combo pack 1 $0 MO CARAFATE ORAL SUSPENSION cimetidine hcl oral solution 1 $0 MO cimetidine oral tablet 1 $0 MO DEXILANT ORAL CAPSULE,BIPHASE AYED RELEAS esomeprazole sodium intravenous recon soln 1 $0 B/D PA LIMIT famotidine (pf) intravenous solution 1 $0 B/D PA; MO famotidine (pf)-nacl (iso-os) intravenous piggyback 1 $0 B/D PA famotidine intravenous solution 1 $0 B/D PA; MO famotidine oral suspension 1 $0 MO famotidine oral tablet 10 mg 4 $0 MO; * famotidine oral tablet 20 mg, 40 mg 1 $0 MO HEARTBURN RELIEF (FAMOTIDINE) ORAL TABLET 10 MG heartburn relief (famotidine) oral tablet 20 mg HEARTBURN RELIEF (RANITIDINE) ORAL TABLET 150 MG heartburn relief 24 hour oral capsule,delayed release(dr/ec) HEARTBURN TREATMENT 24 HOUR ORAL CAPSULE,AYED RELEASE(DR/EC) lansoprazole oral capsule,delayed release(dr/ec) 1 $0 MO misoprostol oral tablet 1 $0 MO nizatidine oral capsule 1 $0 MO nizatidine oral solution 1 $0 MO 99

112 omeprazole oral capsule,delayed release(dr/ec) 1 $0 MO omeprazole oral tablet,delayed release (dr/ec) 4 $0 MO; * pantoprazole oral tablet,delayed release (dr/ec) 1 $0 MO pepcid ac oral tablet 20 mg 4 $0 MO; * LIMIT ranitidine hcl injection solution 1 $0 B/D PA; MO ranitidine hcl oral capsule 1 $0 MO ranitidine hcl oral syrup 1 $0 MO ranitidine hcl oral tablet 150 mg, 300 mg 1 $0 MO ranitidine hcl oral tablet 75 mg 4 $0 MO; * sucralfate oral tablet 1 $0 MO wal-zan 150 oral tablet wal-zan 75 oral tablet zantac maximum strength oral tablet 4 $0 MO; * zantac oral tablet 150 mg 4 $0 MO; * IMMUNOLOGIA, VACCINI / BIOTECNOLOGIE FARMACI BIOTECNOLOGICI ACTIMMUNE SUBCUTANEOUS SOLUTION 2 $0 PA; MO ARCALYST SUBCUTANEOUS RECON SOLN 2 $0 PA; MO AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT AVONEX INTRAMUSCULAR PEN INJECTOR KIT 2 $0 PA; MO; QL (4 per 28 2 $0 PA; MO; QL (4 per 28 AVONEX INTRAMUSCULAR SYRINGE KIT 2 $0 PA; MO; QL (4 per 28 EGRIFTA SUBCUTANEOUS RECON SOLN 2 $0 PA; MO EXTAVIA SUBCUTANEOUS KIT 2 $0 PA; MO; QL (15 per

113 LIMIT EXTAVIA SUBCUTANEOUS RECON SOLN 2 $0 PA; QL (15 per 30 ILARIS (PF) SUBCUTANEOUS RECON SOLN 2 $0 PA; MO; LA INTRON A INJECTION RECON SOLN 2 $0 B/D PA; MO INTRON A INJECTION SOLUTION 2 $0 B/D PA; MO LEUKINE INJECTION RECON SOLN 2 $0 PA; MO MOZOBIL SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO NEUMEGA SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO; QL (21 per 30 NEUPOGEN INJECTION SOLUTION 2 $0 PA; MO NEUPOGEN INJECTION SYRINGE 2 $0 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR 2 $0 PA; MO 2 $0 PA; MO PEGASYS SUBCUTANEOUS SOLUTION 2 $0 PA; MO; QL (4 per 28 PEGASYS SUBCUTANEOUS SYRINGE 2 $0 PA; MO; QL (4 per 28 PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 2 $0 PA; MO; QL (5 per 30 PEGINTRON SUBCUTANEOUS KIT 2 $0 PA; MO; QL (5 per 30 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 2 $0 PA; MO; QL (24 per 30 2 $0 PA; MO; QL (6 per 30 PROLEUKIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 2 $0 PA; MO; QL (6 per

114 REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE SYLATRON 4-PACK SUBCUTANEOUS KIT 200 MCG, 300 MCG LIMIT 2 $0 PA; MO; QL (6 per 28 2 $0 PA; MO; QL (4.2 per $0 PA; MO; QL (6 per 28 2 $0 PA SYLATRON SUBCUTANEOUS KIT 2 $0 PA; MO VACCINI / IMMUNOLOGICI VARI ACTHIB (PF) INTRAMUSCULAR RECON SOLN ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO BEXSERO (PF) INTRAMUSCULAR SYRINGE BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION BOOSTRIX TDAP INTRAMUSCULAR SYRINGE CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE COMVAX (PF) INTRAMUSCULAR SUSPENSION DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 2 $0 B/D PA; MO 102

115 ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE LIMIT 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO fomepizole intravenous solution 1 $0 B/D PA; MO GAMMAGARD LIQUID INJECTION SOLUTION GAMMAGARD S/D INTRAVENOUS RECON SOLN GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 2 $0 PA; MO 2 $0 PA 2 $0 PA; MO GAMUNEX-C INJECTION SOLUTION 2 $0 PA; MO GARDASIL (PF) INTRAMUSCULAR SUSPENSION GARDASIL (PF) INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 2 $0 2 $0 2 $0 103

116 IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 2 $0 IPOL INJECTION SUSPENSION IXIARO (PF) INTRAMUSCULAR SYRINGE KINRIX (PF) INTRAMUSCULAR SUSPENSION 2 $0 KINRIX (PF) INTRAMUSCULAR SYRINGE MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT M-M-R II (PF) SUBCUTANEOUS RECON SOLN PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 2 $0 2 $0 2 $0 LIMIT 104

117 RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION LIMIT 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA 2 $0 ROTATEQ VACCINE ORAL SUSPENSION TENIVAC (PF) INTRAMUSCULAR SYRINGE tetanus toxoid,adsorbed (pf) intramuscular suspension TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 1 $0 B/D PA; MO TRUMENBA INTRAMUSCULAR SYRINGE 2 $0 TWINRIX (PF) INTRAMUSCULAR SUSPENSION 2 $0 B/D PA; MO 2 $0 B/D PA; MO TWINRIX (PF) INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO TYPHIM VI INTRAMUSCULAR SOLUTION 2 $0 TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE 2 $0 VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION VARIZIG INTRAMUSCULAR SOLUTION 105

118 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION MUSCOLOSCHELETRICO / REUMATOLOGIA TERAPIA PER GOTTA LIMIT ; QL (1 per 365 allopurinol oral tablet 1 $0 MO colchicine-probenecid oral tablet 1 $0 MO COLCRYS ORAL TABLET probenecid oral tablet 1 $0 MO ULORIC ORAL TABLET TERAPIA PER OSTEOPOROSI alendronate oral solution 1 $0 MO; QL (375 per 30 alendronate oral tablet 10 mg, 5 mg 1 $0 MO; QL (30 per 30 alendronate oral tablet 35 mg, 70 mg 1 $0 MO; QL (5 per 30 FORTEO SUBCUTANEOUS PEN INJECTOR ; QL (2.4 per 28 ibandronate oral tablet 1 $0 MO; QL (1 per 30 PROLIA SUBCUTANEOUS SYRINGE 2 $0 PA; MO raloxifene oral tablet 1 $0 MO risedronate oral tablet 1 $0 MO risedronate oral tablet,delayed release (dr/ec) 1 $0 MO ALTRI REUMATOLOGICI ACTEMRA INTRAVENOUS SOLUTION 2 $0 B/D PA; ST; MO BENLYSTA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO CUPRIMINE ORAL CAPSULE DEPEN TITRATABS ORAL TABLET 2 $0 PA; MO 106

119 LIMIT ENBREL SUBCUTANEOUS RECON SOLN ; QL (8 per 28 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML ; QL (4 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (6 per 28 ; QL (3 per 28 ; QL (6 per 180 ; QL (6 per 180 ; QL (4 per 28 ; QL (2 per 28 ; QL (4 per 28 leflunomide oral tablet 1 $0 MO; QL (30 per 30 SAVELLA ORAL TABLET ; QL (60 per 30 SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 per 30 XELJANZ ORAL TABLET 2 $0 ST; MO XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR OSTETRICIA E GINECOLOGIA ESTROGENI / PROGESTINICI 2 $0 ST 107

120 camila oral tablet 1 $0 MO COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY CRINONE VAGINAL GEL 2 $0 PA; MO ESTROGEN INTRAMUSCULAR OIL 10 MG/ML DEPO-PROVERA INTRAMUSCULAR SOLUTION DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE LIMIT 2 $0 B/D PA; MO errin oral tablet 1 $0 MO ESTRACE VAGINAL CREAM estradiol oral tablet 1 $0 PA; MO estradiol transdermal patch semiweekly 1 $0 MO estradiol transdermal patch weekly 1 $0 MO estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 $0 MO heather oral tablet 1 $0 MO HYDROXYPROGESTERONE CAPROATE INTRAMUSCULAR OIL 2 $0 PA jencycla oral tablet 1 $0 MO jinteli oral tablet 1 $0 MO jolivette oral tablet 1 $0 MO lyza oral tablet 1 $0 MO medroxyprogesterone intramuscular suspension 1 $0 MO; QL (1 per 90 medroxyprogesterone intramuscular syringe 1 $0 MO; QL (1 per 90 medroxyprogesterone oral tablet 1 $0 MO norethindrone (contraceptive) oral tablet 1 $0 MO norethindrone acetate oral tablet 1 $0 MO 108

121 LIMIT PREMARIN INJECTION RECON SOLN 2 $0 B/D PA; MO PREMARIN VAGINAL CREAM progesterone micronized oral capsule 1 $0 MO VARI OSTETRICIA / GINECOLOGIA CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal cream 1 $0 MO clotrimazole 3 day vaginal cream clotrimazole vaginal cream 4 $0 MO; * clotrimazole-3 vaginal cream metronidazole vaginal gel 1 $0 MO MICONAZOLE 7 VAGINAL SUPPOSITORY 4 $0 MO; *; QL (7 per 30 miconazole nitrate vaginal suppository ; QL (7 per 30 miconazole-3 vaginal suppository 1 $0 MO; QL (3 per 3 NUVARING VAGINAL RING terconazole vaginal cream 1 $0 MO terconazole vaginal suppository 1 $0 MO; QL (3 per 3 tranexamic acid oral tablet 1 $0 MO vandazole vaginal gel 1 $0 MO CONTRACCETTIVI ORALI / AGENTI COLLEGATI altavera (28) oral tablet 1 $0 MO alyacen 1/35 (28) oral tablet 1 $0 MO alyacen 7/7/7 (28) oral tablet 1 $0 MO amethia lo oral tablets,dose pack,3 month 1 $0 MO amethia oral tablets,dose pack,3 month 1 $0 MO amethyst oral tablet 1 $0 MO apri oral tablet 1 $0 MO 109

122 aranelle (28) oral tablet 1 $0 MO ashlyna oral tablets,dose pack,3 month 1 $0 MO aubra oral tablet 1 $0 MO aviane oral tablet 1 $0 MO azurette (28) oral tablet 1 $0 MO balziva (28) oral tablet 1 $0 MO blisovi 24 fe oral tablet 1 $0 MO blisovi fe 1.5/30 (28) oral tablet 1 $0 MO blisovi fe 1/20 (28) oral tablet 1 $0 MO briellyn oral tablet 1 $0 MO camrese lo oral tablets,dose pack,3 month 1 $0 MO camrese oral tablets,dose pack,3 month 1 $0 MO caziant (28) oral tablet 1 $0 MO chateal oral tablet 1 $0 MO cryselle (28) oral tablet 1 $0 MO cyclafem 1/35 (28) oral tablet 1 $0 MO cyclafem 7/7/7 (28) oral tablet 1 $0 MO dasetta 1/35 (28) oral tablet 1 $0 MO dasetta 7/7/7 (28) oral tablet 1 $0 MO daysee oral tablets,dose pack,3 month 1 $0 MO desog-e.estradiol/e.estradiol oral tablet 1 $0 MO drospirenone-ethinyl estradiol oral tablet 1 $0 MO ECONTRA EZ ORAL TABLET elinest oral tablet 1 $0 MO ELLA ORAL TABLET emoquette oral tablet 1 $0 MO enpresse oral tablet 1 $0 MO LIMIT 110

123 enskyce oral tablet 1 $0 MO estarylla oral tablet 1 $0 MO FALLBACK SOLO ORAL TABLET falmina (28) oral tablet 1 $0 MO gianvi (28) oral tablet 1 $0 MO gildess 1.5/30 (21) oral tablet 1 $0 MO gildess 1/20 (21) oral tablet 1 $0 MO gildess fe 1.5/30 (28) oral tablet 1 $0 MO gildess fe 1/20 (28) oral tablet 1 $0 MO introvale oral tablets,dose pack,3 month 1 $0 MO jolessa oral tablets,dose pack,3 month 1 $0 MO junel 1.5/30 (21) oral tablet 1 $0 MO junel 1/20 (21) oral tablet 1 $0 MO junel fe 1.5/30 (28) oral tablet 1 $0 MO junel fe 1/20 (28) oral tablet 1 $0 MO junel fe 24 oral tablet 1 $0 MO kariva (28) oral tablet 1 $0 MO kelnor 1/35 (28) oral tablet 1 $0 MO kimidess (28) oral tablet 1 $0 MO kurvelo oral tablet 1 $0 MO l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) 1 $0 MO 1 $0 layolis fe oral tablet,chewable 1 $0 MO lessina oral tablet 1 $0 MO levonest (28) oral tablet 1 $0 MO levonorgestrel oral tablet 1 $0 LIMIT 111

124 levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1 $0 MO 1 $0 1 $0 MO levonorg-eth estrad triphasic oral tablet 1 $0 levora-28 oral tablet 1 $0 MO loryna (28) oral tablet 1 $0 MO low-ogestrel (28) oral tablet 1 $0 MO lutera (28) oral tablet 1 $0 MO marlissa oral tablet 1 $0 MO microgestin 1.5/30 (21) oral tablet 1 $0 MO microgestin 1/20 (21) oral tablet 1 $0 MO microgestin fe 1.5/30 (28) oral tablet 1 $0 MO microgestin fe 1/20 (28) oral tablet 1 $0 MO mono-linyah oral tablet 1 $0 MO mononessa (28) oral tablet 1 $0 MO MY WAY ORAL TABLET myzilra oral tablet 1 $0 MO necon 0.5/35 (28) oral tablet 1 $0 MO necon 1/35 (28) oral tablet 1 $0 MO necon 10/11 (28) oral tablet 1 $0 MO necon 7/7/7 (28) oral tablet 1 $0 MO NEXT CHOICE ONE DOSE ORAL TABLET next choice oral tablet 1 $0 nikki (28) oral tablet 1 $0 MO noreth-ethinyl estradiol-iron oral tablet,chewable 1 $0 MO LIMIT 112

125 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg 1 $0 MO nortrel 0.5/35 (28) oral tablet 1 $0 MO nortrel 1/35 (21) oral tablet 1 $0 MO nortrel 1/35 (28) oral tablet 1 $0 MO nortrel 7/7/7 (28) oral tablet 1 $0 MO ocella oral tablet 1 $0 MO ogestrel (28) oral tablet 1 $0 MO OPCICON ONE-STEP ORAL TABLET orsythia oral tablet 1 $0 MO philith oral tablet 1 $0 MO pimtrea (28) oral tablet 1 $0 MO pirmella oral tablet 1 $0 MO portia oral tablet 1 $0 MO previfem oral tablet 1 $0 MO quasense oral tablets,dose pack,3 month 1 $0 MO reclipsen (28) oral tablet 1 $0 MO sprintec (28) oral tablet 1 $0 MO sronyx oral tablet 1 $0 MO syeda oral tablet 1 $0 MO tilia fe oral tablet 1 $0 MO tri-estarylla oral tablet 1 $0 MO tri-legest fe oral tablet 1 $0 MO tri-linyah oral tablet 1 $0 MO trinessa (28) oral tablet 1 $0 MO tri-previfem (28) oral tablet 1 $0 MO tri-sprintec (28) oral tablet 1 $0 MO LIMIT trivora (28) oral tablet 1 $0 MO 113

126 velivet triphasic regimen (28) oral tablet 1 $0 MO vestura (28) oral tablet 1 $0 MO viorele (28) oral tablet 1 $0 MO wera (28) oral tablet 1 $0 MO wymzya fe oral tablet,chewable 1 $0 MO zarah oral tablet 1 $0 MO zenchent (28) oral tablet 1 $0 MO zenchent fe oral tablet,chewable 1 $0 MO zovia 1/35e (28) oral tablet 1 $0 MO zovia 1/50e (28) oral tablet 1 $0 MO OSSITOCICI METHYLERGONOVINE INJECTION SOLUTION LIMIT 1 $0 B/D PA; MO methylergonovine oral tablet 1 $0 MO OFTALMOLOGIA ANTIBIOTICI ak-poly-bac ophthalmic ointment 1 $0 MO AZASITE OPHTHALMIC DROPS bacitracin ophthalmic ointment 1 $0 MO bacitracin-polymyxin b ophthalmic ointment 1 $0 MO CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic drops 1 $0 MO erythromycin ophthalmic ointment 1 $0 MO garamycin ophthalmic drops 1 $0 gatifloxacin ophthalmic drops 1 $0 MO gentak ophthalmic ointment 1 $0 MO gentamicin ophthalmic drops 1 $0 MO 114

127 gentamicin ophthalmic ointment 1 $0 MO levofloxacin ophthalmic drops 1 $0 MO NATACYN OPHTHALMIC DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic ointment 1 $0 MO neomycin-polymyxin-gramicidin ophthalmic drops 1 $0 MO neo-polycin ophthalmic ointment 1 $0 MO ofloxacin ophthalmic drops 1 $0 MO polycin ophthalmic ointment 1 $0 polymyxin b sulf-trimethoprim ophthalmic drops 1 $0 MO tobramycin ophthalmic drops 1 $0 MO TOBREX OPHTHALMIC OINTMENT VIGAMOX OPHTHALMIC DROPS ANTIVIRALI trifluridine ophthalmic drops 1 $0 MO ZIRGAN OPHTHALMIC GEL BETA-BLOCCANTI betaxolol ophthalmic drops 1 $0 MO BETIMOL OPHTHALMIC DROPS 0.25 % BETOPTIC S OPHTHALMIC DROPS,SUSPENSION carteolol ophthalmic drops 1 $0 MO levobunolol ophthalmic drops 0.5 % 1 $0 MO metipranolol ophthalmic drops 1 $0 timolol maleate ophthalmic drops 1 $0 MO timolol maleate ophthalmic gel forming solution 1 $0 MO LIMIT 115

128 MIOTICI INIBITORI LA COLINESTERASI PHOSPHOLINE IODIDE OPHTHALMIC DROPS MIOTICI AD AZIONE DIRETTA pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 1 $0 MO OFTALMOLOGICI VARI AKWA TEARS (POLYVINYL ALCOHOL) OPHTHALMIC DROPS ARTIFICIAL TEARS (PETRO/MIN) OPHTHALMIC OINTMENT ARTIFICIAL TEARS (POLYVIN ALC) OPHTHALMIC DROPS ARTIFICIAL TEARS(PVALCH-POVID) OPHTHALMIC DROPS 4 $0 MO; * 4 $0 MO; * 4 $0 MO; * azelastine ophthalmic drops 1 $0 MO cromolyn ophthalmic drops 1 $0 MO CYSTARAN OPHTHALMIC DROPS epinastine ophthalmic drops 1 $0 MO gonak ophthalmic drops goniovisc ophthalmic drops 4 $0 MO; * LASTACAFT OPHTHALMIC DROPS LIQUITEARS OPHTHALMIC DROPS 4 $0 MO; * LUBRICANT EYE (PG-PEG 400) OPHTHALMIC DROPS lubricant eye drops ophthalmic dropperette lubricant eye ophthalmic ointment %, % LUBRICATING PLUS OPHTHALMIC DROPPERETTE LIMIT 116

129 LUBRIFRESH PM OPHTHALMIC OINTMENT 4 $0 MO; * natural balance ophthalmic drops 4 $0 MO; * NATURE'S TEARS (HYPROMELLOSE) OPHTHALMIC DROPS olopatadine ophthalmic drops 1 $0 MO PATADAY OPHTHALMIC DROPS 2 $0 ST; MO PAZEO OPHTHALMIC DROPS puralube ophthalmic ointment 4 $0 MO; * LIMIT RESTASIS OPHTHALMIC DROPPERETTE ; QL (60 per 30 retaine cmc ophthalmic dropperette sodium chloride ophthalmic drops 4 $0 MO; * sodium chloride ophthalmic ointment 4 $0 MO; * AGENTI ANTINFIAMMATORI NON STEROIDEI bromfenac ophthalmic drops 1 $0 MO diclofenac sodium ophthalmic drops 1 $0 MO flurbiprofen sodium ophthalmic drops 1 $0 MO ILEVRO OPHTHALMIC DROPS,SUSPENSION ketorolac ophthalmic drops 1 $0 MO FARMACI ORALI PER GLAUCOMA acetazolamide oral capsule, extended release 1 $0 MO acetazolamide oral tablet 1 $0 MO acetazolamide sodium injection recon soln 1 $0 MO methazolamide oral tablet 1 $0 MO ALTRI FARMACI PER GLAUCOMA AZOPT OPHTHALMIC DROPS,SUSPENSION COMBIGAN OPHTHALMIC DROPS dorzolamide ophthalmic drops 1 $0 MO 117

130 dorzolamide-timolol ophthalmic drops 1 $0 MO latanoprost ophthalmic drops 1 $0 MO LIMIT LUMIGAN OPHTHALMIC DROPS 0.01 % ; QL (2.5 per 30 SIMBRINZA OPHTHALMIC DROPS,SUSPENSION travoprost (benzalkonium) ophthalmic drops 1 $0 MO COMBIN STEROIDI- ANTIBIOTICI neomycin-bacitracin-poly-hc ophthalmic ointment 1 $0 MO neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neomycin-polymyxin-hc ophthalmic drops,suspension 1 $0 MO 1 $0 MO 1 $0 MO neo-polycin hc ophthalmic ointment 1 $0 TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION tobramycin-dexamethasone ophthalmic drops,suspension STEROIDI dexamethasone sodium phosphate ophthalmic drops 1 $0 MO 1 $0 MO DUREZOL OPHTHALMIC DROPS fluorometholone ophthalmic drops,suspension 1 $0 MO FML S.O.P. OPHTHALMIC OINTMENT prednisolone acetate ophthalmic drops,suspension 1 $0 MO prednisolone sodium phosphate ophthalmic drops 1 $0 MO COMBIN STEROIDI- SULFAMIDICI 118

131 BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT sulfacetamide-prednisolone ophthalmic drops 1 $0 MO SULFAMIDICI sulfacetamide sodium ophthalmic drops 1 $0 MO sulfacetamide sodium ophthalmic ointment 1 $0 MO sulfamide ophthalmic drops 1 $0 SIMPATICOMIMETICI ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine ophthalmic drops 1 $0 MO brimonidine ophthalmic drops 1 $0 MO VASOCOSTRITTORI DECONGESTIONANTI naphazoline ophthalmic drops 1 $0 MO APPARATO RESPIRATORIO E ALLERGIA AGENTI ANTISTAMINICI/ANALLERGICI 12 hour decongestant oral tablet extended release acta-tabs pe oral tablet actifed cold-allergy oral tablet 4 $0 MO; * adt robitussin peak cld dm max oral liquid 4 $0 MO; * adult cough formula dm max oral liquid adult robitussin m-s cold oral liquid adult robitussin nasal relief oral tablet adult robitussin peak cold dm oral liquid 4 $0 MO; * adult robitussin peak cold m-s oral liquid LIMIT 119

132 ADULT TUSSIN CHEST CONGESTION ORAL LIQUID ADULT TUSSIN COUGH CONGEST DM ORAL LIQUID ADULT TUSSIN DM ORAL SYRUP adult wal-tussin dm max oral liquid adult wal-tussin oral liquid ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR LIMIT 4 $0 MO; *; QL (68 per 30 alavert oral tablet,disintegrating 4 $0 MO; * ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET,CHEWABLE ; QL (34 per 30 4 $0 MO; *; QL (34 per 30 all day allergy relief(cetir) oral tablet ; QL (34 per 30 ALL DAY ALLERGY-D ORAL TABLET EXTENDED RELEASE 12 HR 4 $0 MO; *; QL (68 per 30 ALLER-CHLOR ORAL TABLET 4 $0 MO; * aller-ease oral tablet 60 mg ALLERGY (CHLORPHENIRAMINE) ORAL TABLET ALLERGY (DIPHENHYDRAMINE) ORAL CAPSULE 4 $0 MO; * ALLERGY 4-HOUR ORAL TABLET ALLERGY AND CONGESTION RELIEF ORAL TABLET EXTENDED RELEASE 12 HR ; QL (68 per 30 allergy and sinus relief oral tablet ALLERGY COMPLETE-D ORAL TABLET EXTENDED RELEASE 12 HR ; QL (68 per

133 allergy medication oral capsule ALLERGY MEDICINE ORAL CAPSULE allergy m-s nighttime oral tablet allergy multi-symptom oral tablet ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (FEXOFENADINE) ORAL TABLET 180 MG ALLERGY RELIEF (LORATADINE) ORAL SOLUTION ALLERGY RELIEF (LORATADINE) ORAL TABLET allergy relief (loratadine) oral tablet,disintegrating ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE allergy relief-d (loratadine) oral tablet extended release 12 hr LIMIT ; QL (34 per 30 4 $0 MO; * ; QL (68 per 30 allergy sinus-d oral tablet allergy-congest relief-d (cet) oral tablet extended release 12 hr ; QL (68 per 30 ALLERGY-TIME ORAL TABLET all-nite cold-flu oral liquid antitussive dm oral syrup APRODINE ORAL TABLET 4 $0 MO; * BANOPHEN ORAL CAPSULE 25 MG 4 $0 MO; * BANOPHEN ORAL CAPSULE 50 MG benzonatate oral capsule 3 $0 MO; * 121

134 broncotron oral liquid broncotron ped oral liquid BROTAPP DM ORAL ELIXIR 4 $0 MO; * BROTAPP ORAL LIQUID 4 $0 MO; * LIMIT cetiri-d oral tablet extended release 12 hr ; QL (68 per 30 cetirizine oral solution 1 mg/ml 1 $0 MO cetirizine oral solution 5 mg/5 ml cetirizine oral tablet 4 $0 MO; *; QL (34 per 30 cetirizine oral tablet,chewable 4 $0 MO; *; QL (34 per 30 cetirizine-pseudoephedrine oral tablet extended release 12 hr CHEST CONGESTION RELIEF ORAL TABLET CHEST CONGESTION RELIEF PE ORAL TABLET CHEST-SINUS CONGESTION RELIEF ORAL TABLET CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION CHILD MUCUS RELIEF COUGH ORAL LIQUID CHILD MUCUS RELIEF EXPECTORANT ORAL LIQUID 4 $0 MO; *; QL (68 per 30 CHILDREN'S CETIRIZINE ORAL SOLUTION CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE 10 MG 4 $0 MO; *; QL (34 per 30 children's chest congestion oral liquid CHILDREN'S COLD AND COUGH (PE) ORAL SOLUTION 122

135 CHILDREN'S COLD AND COUGH DM ORAL SOLUTION children's cough oral liquid children's dimetapp cold-flu oral liquid CHILDREN'S SILFEDRINE ORAL LIQUID children's wal-zyr oral solution LIMIT children's wal-zyr oral tablet,chewable ; QL (34 per 30 CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION chlorpheniramine maleate oral tablet clemastine oral tablet 2.68 mg 1 $0 PA; MO codituss dm oral liquid 4 $0 MO; * COLD AND ALLERGY PE ORAL TABLET cold and cough (pe-dm) oral liquid COLD AND COUGH ELIXIR ORAL SOLUTION COLD HEAD CONGESTION NIGHTTIME ORAL TABLET cold-flu relief oral liquid complete allergy medicine oral capsule complete allergy oral capsule CONGESTAC ORAL TABLET cough and cold mucus relief cf oral liquid cough and cold oral liquid cough control (dextromethorph) oral capsule COUGH CONTROL (GUAIFENESIN) ORAL LIQUID COUGH CONTROL CF (PE) ORAL LIQUID COUGH CONTROL DM MAX ORAL LIQUID 123

136 cough control dm oral liquid cough control dm oral syrup cough formula dm oral syrup cough relief oral liquid COUGH SUPPRESSANT-EXPECTORANT ORAL SYRUP COUGH SYRUP DM ORAL SYRUP COUGH SYRUP ORAL LIQUID cough-sore throat night oral liquid COUGHTAB ORAL TABLET cyproheptadine oral syrup 1 $0 PA; MO cyproheptadine oral tablet 1 $0 PA; MO daytime cold-flu oral liquid daytime cold-flu relief (pe) oral liquid desloratadine oral tablet 1 $0 MO desloratadine oral tablet,disintegrating 1 $0 MO despec dm-g oral liquid despec-dm (phenyleph-dm-guaif) oral liquid mg/5 ml despec-tab oral tablet mg dextromethorphan-guaifenesin oral syrup DIABETIC SILTUSSIN DAS-NA ORAL LIQUID DIABETIC SILTUSSIN-DM ORAL LIQUID DIMAPHEN DM ORAL SOLUTION 4 $0 MO; * dimetapp cold-congestion oral liquid dimetapp dm cold-cough (pe) oral solution DIPHEDRYL ORAL CAPSULE LIMIT 124

137 diphenhist oral capsule LIMIT diphenhydramine hcl injection solution 50 mg/ml 1 $0 B/D PA; MO diphenhydramine hcl oral capsule 4 $0 MO; * double-tussin dm oral liquid dristan cold oral tablet ed a-hist dm oral liquid 4 $0 MO; * ed a-hist oral liquid 4 $0 MO; * ed a-hist oral tablet 4 $0 MO; * ed a-hist pse oral tablet ed-chlortan oral tablet 4 $0 MO; * ENDACOF - DM ORAL SOLUTION EPINEPHRINE INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN 2-PAK INJECTION AUTO-INJECTOR ; QL (4 per 2 EPIPEN JR 2-PAK INJECTION AUTO- INJECTOR ; QL (4 per 2 expectorant cough syrup oral liquid expectorant oral liquid fexofenadine oral tablet 180 mg, 60 mg 4 $0 MO; * flu relief therapy nighttime oral liquid guaifenesin oral liquid guaifenesin oral tablet 200 mg 4 $0 MO; * guaifenesin oral tablet extended release 12hr 600 mg 4 $0 MO; * hydroxyzine hcl intramuscular solution 1 $0 B/D PA; MO hydroxyzine hcl oral solution 10 mg/5 ml 1 $0 MO hydroxyzine hcl oral tablet 1 $0 MO iophen dm-nr oral liquid 4 $0 MO; * 125

138 iophen-nr oral liquid 4 $0 MO; * KIDKARE COUGH/COLD ORAL LIQUID levocetirizine oral solution 1 $0 MO LIMIT levocetirizine oral tablet 1 $0 MO; QL (30 per 30 loratadine oral solution 4 $0 MO; * loratadine oral tablet 4 $0 MO; * loratadine oral tablet,disintegrating 4 $0 MO; * LORATADINE-D ORAL TABLET EXTENDED RELEASE 12 HR 4 $0 MO; *; QL (68 per 30 mapap sinus max strength (pe) oral tablet MUCAPHED ORAL TABLET MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HR MUCINEX FAST-MAX DM MAX ORAL LIQUID MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 600 MG 4 $0 MO; * 4 $0 MO; * MUCUS RELIEF COUGH ORAL LIQUID mucus relief d (pseudoephed) oral tablet mucus relief dm max oral liquid MUCUS RELIEF ER ORAL TABLET EXTENDED RELEASE 12HR 600 MG MUCUS RELIEF ORAL TABLET 200 MG MUCUS RELIEF ORAL TABLET 400 MG 4 $0 MO; * mucus relief pe oral tablet MUCUS RELIEF SINUS ORAL TABLET multi-symptom cold night time oral tablet NASAL DECONGESTANT (PE) ORAL TABLET 10 MG 126

139 NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET neo-tuss oral liquid nite time-d cold-flu relief oral liquid nite-time oral liquid NON-DROWSY ALLERGY ORAL TABLET nu-copd oral tablet ORGAN-I NR ORAL TABLET 4 $0 MO; * pain reliever pm oral tablet mg PEDIA RELIEF COUGH-COLD ORAL LIQUID pediacare multi-symptom cold oral liquid PEDIATRIC COUGH AND COLD ORAL LIQUID MG/5 ML PHARBECHLOR ORAL TABLET PHARBEDRYL ORAL CAPSULE 25 MG pharbedryl oral capsule 50 mg promethazine oral tablet 1 $0 PA; MO pseudoephedrine hcl oral liquid 4 $0 MO; * pseudoephedrine hcl oral tablet 30 mg 4 $0 MO; * pseudoephedrine hcl oral tablet 60 mg q-dryl oral capsule q-tapp dm oral elixir 4 $0 MO; * q-tapp oral liquid 4 $0 MO; * Q-TUSSIN DM ORAL SYRUP Q-TUSSIN ORAL LIQUID refenesen oral tablet LIMIT 127

140 refenesen pe oral tablet robafen cf (phenylephrine) oral liquid 4 $0 MO; * robafen cough oral capsule 4 $0 MO; * robafen dm clear oral syrup ROBAFEN DM COUGH ORAL LIQUID ROBAFEN DM COUGH-CHEST CONGEST ORAL SYRUP ROBAFEN DM ORAL SYRUP 4 $0 MO; * ROBAFEN ORAL LIQUID 4 $0 MO; * robitussin cough and cold cf oral liquid 4 $0 MO; * robitussin cough-chest cong dm oral liquid rynex dm oral solution rynex pse oral liquid SCOT-TUSSIN DM ORAL LIQUID scot-tussin expectorant oral liquid SILTUSSIN DM DAS ORAL LIQUID SILTUSSIN SA ORAL LIQUID 4 $0 MO; * SILTUSSIN-DM ORAL SYRUP sinus 12 hour oral tablet extended release SINUS AND ALLERGY PE ORAL TABLET sinus congestion and pain oral tablet sinus-allergy (phenylephrine) oral tablet sudogest 12-hour oral tablet extended release 4 $0 MO; * sudogest cold and allergy oral tablet SUDOGEST ORAL TABLET 30 MG 4 $0 MO; * sudogest oral tablet 60 mg 4 $0 MO; * SUDOGEST PE ORAL TABLET 4 $0 MO; * LIMIT 128

141 SUDOGEST SINUS AND ALLERGY ORAL TABLET SUPHEDRIN ORAL TABLET suphedrine 12 hour oral tablet extended release SUPHEDRINE ORAL TABLET suphedrine pe cold and allergy oral tablet suphedrine pe sinus headache oral tablet TAB TUSSIN ORAL TABLET tl-hist dm oral liquid TUSNEL DIABETIC ORAL LIQUID TUSSIN CF (PE-DM-GUAIF) ORAL LIQUID 4 $0 MO; * TUSSIN CF COUGH-COLD ORAL LIQUID tussin chest congestion oral liquid tussin cough (dm only) oral capsule tussin cough-chest congestion oral liquid TUSSIN DM COUGH AND CHEST ORAL SYRUP tussin dm cough oral syrup TUSSIN DM MAX ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN DM ORAL SYRUP MG/5 ML 4 $0 MO; * TUSSIN EXPECTORANT ORAL LIQUID TUSSIN ORAL LIQUID wal-act d cold and allergy oral tablet wal-dryl allergy oral capsule wal-dryl severe allergy-sinus oral tablet wal-dryl-d allergy and sinus oral tablet LIMIT 129

142 wal-fex allergy oral tablet wal-finate oral tablet wal-finate-d oral tablet wal-flu night severe cold oral liquid wal-itin d 12 hour oral tablet extended release 12 hr LIMIT ; QL (68 per 30 wal-itin oral solution wal-itin oral tablet wal-phed 12 hour oral tablet extended release wal-phed oral tablet wal-phed pe nighttime cold oral tablet wal-phed pe oral tablet wal-phed pe sinus and allergy oral tablet wal-tap dm oral solution wal-tussin cough and cold cf oral liquid wal-tussin cough oral capsule wal-tussin cough oral liquid wal-tussin dm oral syrup wal-zyr (cetirizine) oral solution wal-zyr (cetirizine) oral tablet ; QL (34 per 30 wal-zyr d oral tablet extended release 12 hr ; QL (68 per 30 zoden pd oral liquid AGENTI POLMONARI acetylcysteine solution 1 $0 B/D PA; MO ADCIRCA ORAL TABLET 2 $0 PA; MO; QL (60 per 30 ADEMPAS ORAL TABLET 2 $0 PA; MO; LA 130

143 ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml LIMIT ; QL (60 per 30 ; QL (24 per 30 1 $0 B/D PA; MO; QL (360 per 30 1 $0 B/D PA; MO; QL (60 per 30 albuterol sulfate oral syrup 1 $0 MO albuterol sulfate oral tablet 1 $0 MO albuterol sulfate oral tablet extended release 12 hr ANORO ELLIPTA INHALATION BLISTER WITH DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER BREO ELLIPTA INHALATION BLISTER WITH DEVICE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 1 $0 MO ; QL (26 per 30 ; QL (2 per 30 2 $0 QL (2 per 30 ; QL (26 per 30 1 $0 B/D PA; MO; QL (120 per

144 budesonide inhalation suspension for nebulization 1 mg/2 ml LIMIT 1 $0 B/D PA; MO budesonide nasal spray,non-aerosol 1 $0 MO CINRYZE INTRAVENOUS RECON SOLN 2 $0 PA; MO COMBIVENT RESPIMAT INHALATION MIST ; QL (8 per 30 cromolyn inhalation solution for nebulization 1 $0 B/D PA; MO; QL (240 per 30 DALIRESP ORAL TABLET ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML ESBRIET ORAL CAPSULE 2 $0 PA FIRAZYR SUBCUTANEOUS SYRINGE 2 $0 PA; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (120 per 30 ; QL (300 per 30 ; QL (12 per 30 ; QL (36 per 30 ; QL (21 per 30 1 $0 MO; QL (50 per 30 fluticasone nasal spray,suspension 1 $0 MO; QL (16 per 30 ipratropium bromide inhalation solution 1 $0 B/D PA; MO; QL (315 per 30 ipratropium-albuterol inhalation solution for nebulization 1 $0 B/D PA; MO; QL (540 per 30 KALYDECO ORAL GRANULES IN PACKET 2 $0 PA; MO; QL (60 per

145 LIMIT KALYDECO ORAL TABLET 2 $0 PA; MO; QL (60 per 30 LETAIRIS ORAL TABLET 2 $0 PA; MO; QL (30 per 30 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml, 1.25 mg/3 ml 1 $0 B/D PA; MO 1 $0 B/D PA; MO; QL (90 per 30 metaproterenol oral syrup 1 $0 MO metaproterenol oral tablet 1 $0 MO mometasone nasal spray,non-aerosol 1 $0 QL (51 per 30 montelukast oral granules in packet 1 $0 MO montelukast oral tablet 1 $0 MO montelukast oral tablet,chewable 1 $0 MO NASACORT AQ NASAL AEROSOL,SPRAY 2 $0 QL (16.5 per 30 OFEV ORAL CAPSULE 2 $0 PA; MO; QL (60 per 30 OPSUMIT ORAL TABLET 2 $0 PA; MO; LA ORKAMBI ORAL TABLET 2 $0 PA; MO PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL INHALER PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 2 $0 B/D PA; MO; QL (120 per 30 ; QL (18 per 30 PULMOZYME INHALATION SOLUTION 2 $0 B/D PA; MO SEREVENT DISKUS INHALATION BLISTER WITH DEVICE ; QL (120 per 30 sildenafil oral tablet 1 $0 PA; MO; QL (90 per

146 SYMBICORT INHALATION HFA AEROSOL INHALER LIMIT ; QL (20 per 30 terbutaline oral tablet 1 $0 MO terbutaline subcutaneous solution 1 $0 MO theophylline oral elixir 1 $0 theophylline oral solution 1 $0 theophylline oral tablet extended release 1 $0 MO theophylline oral tablet extended release 12 hr 1 $0 MO triamcinolone acetonide nasal aerosol,spray 1 $0 QL (16.5 per 30 TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED TYVASO INHALATION SOLUTION FOR NEBULIZATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 2 $0 PA; MO ; QL (54 per 30 XOLAIR SUBCUTANEOUS RECON SOLN 2 $0 PA; MO; QL (6 per 28 zafirlukast oral tablet 1 $0 MO UROLOGICI ANTICOLINERGICI / ANTISPASTICI darifenacin oral tablet extended release 24 hr 1 $0 flavoxate oral tablet 1 $0 MO GELNIQUE TRANSDERMAL GEL IN PACKET MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 2 $0 ST; MO oxybutynin chloride oral syrup 1 $0 MO oxybutynin chloride oral tablet 1 $0 MO 134

147 oxybutynin chloride oral tablet extended release 24hr 1 $0 MO tolterodine oral capsule,extended release 24hr 1 $0 MO tolterodine oral tablet 1 $0 MO trospium oral capsule,extended release 24hr 1 $0 MO trospium oral tablet 1 $0 MO VESICARE ORAL TABLET TERAPIA PER IPERPLASIA PROSTATICA BENIGNA (IPB) alfuzosin oral tablet extended release 24 hr 1 $0 MO dutasteride oral capsule 1 $0 MO dutasteride-tamsulosin oral capsule, er multiphase 24 hr 1 $0 MO finasteride oral tablet 5 mg 1 $0 MO tamsulosin oral capsule,extended release 24hr 1 $0 MO STIMOLANTI COLINERGICI bethanechol chloride oral tablet 1 $0 MO UROLOGICI VARI LIMIT CIALIS ORAL TABLET 2.5 MG, 5 MG 2 $0 PA; MO; QL (30 per 30 CYSTAGON ORAL CAPSULE ELMIRON ORAL CAPSULE potassium citrate oral tablet extended release 1 $0 MO VITAMINE, EMATINICI / ELETTROLITI ELETTROLITI ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) 135

148 antacid (calcium carbonate) oral tablet,chewable 215 mg calcium (500 mg) ANTACID EXT STR (CALCIUM CARB) ORAL TABLET,CHEWABLE antacid extra-strength oral tablet,chewable 200 mg calcium (500 mg) ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 300 MG (750 MG) antacid ultra strength oral tablet,chewable 400 mg (1,000 mg) calcarb 600 with vitamin d oral tablet 600 mg(1,500mg) -400 unit CALCITRATE ORAL TABLET 4 $0 MO; * calcium d oral tablet 500 mg(1,250mg) unit calcium d oral tablet 500 mg(1,250mg) unit 4 $0 MO; * CALCIUM 500 WITH D ORAL TABLET 4 $0 MO; * CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) UNIT 4 $0 MO; * CALCIUM 600 ORAL TABLET calcium 600 with vitamin d3 oral tablet calcium 600 with vitamin d3 oral tablet,chewable 4 $0 MO; * calcium acetate oral capsule 1 $0 MO calcium acetate oral tablet 667 mg 1 $0 MO CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) 4 $0 MO; * LIMIT 136

149 CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID ULTRA MAX ST ORAL TABLET,CHEWABLE calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -400 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate-vitamin d3 oral tablet,chewable 4 $0 MO; * 4 $0 MO; * 4 $0 MO; * calcium citrate + d oral tablet calcium citrate oral tablet 200 mg (950 mg) calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mg-unit, mg-unit calcium gluconate oral tablet 45 mg (500 mg), 60 mg (648 mg) 4 $0 MO; * 4 $0 MO; * calcium gluconate oral tablet 60 mg (650 mg) CAL-GEST ANTACID ORAL TABLET,CHEWABLE CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT 4 $0 MO; * 4 $0 MO; * LIMIT 137

150 LIMIT dextrose-kcl-nacl intravenous solution 1 $0 B/D PA; MO electrolytes-dextrose oral solution eliphos oral tablet 1 $0 MO hi-cal plus vit d oral tablet klor-con 10 oral tablet extended release 1 $0 MO klor-con 8 oral tablet extended release 1 $0 MO klor-con m10 oral tablet,er particles/crystals 1 $0 MO klor-con m15 oral tablet,er particles/crystals 1 $0 MO klor-con m20 oral tablet,er particles/crystals 1 $0 MO klor-con oral packet 1 $0 MO klor-con sprinkle oral capsule, extended release 1 $0 MO k-tab oral tablet extended release 8 meq 1 $0 lactated ringers intravenous parenteral solution 1 $0 MO MAG 64 ORAL TABLET,AYED RELEASE (DR/EC) 4 $0 MO; * mag-delay oral tablet,delayed release (dr/ec) 4 $0 MO; * magnesium oxide oral tablet 4 $0 MO; * magnesium sulfate injection solution 1 $0 B/D PA; MO magnesium sulfate injection syringe 1 $0 B/D PA NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA ORALYTE ORAL SOLUTION OYSCO 500/D ORAL TABLET 4 $0 MO; * oysco 500/d oral tablet,chewable oysco d oral tablet 4 $0 MO; * OYSCO-500 ORAL TABLET 4 $0 MO; * 138

151 OYSTER SHELL CALCIUM 500 ORAL TABLET 4 $0 MO; * oyster shell calcium oral tablet 4 $0 MO; * oyster shell calcium-vit d3 oral tablet mg-unit OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT, 500 MG(1,250MG) -400 UNIT PEDIALYTE FREEZER POPS ORAL SOLUTION 4 $0 MO; * 4 $0 MO; * PEDIALYTE ORAL SOLUTION 4 $0 MO; * PEDIALYTE SINGLES ORAL SOLUTION PEDIATRIC ELECTROLYTE ORAL SOLUTION pediatric freezer pops oral solution potassium bicarb and chloride oral tablet, effervescent potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml 1 $0 MO 1 $0 B/D PA LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 139

152 potassium chloride intravenous piggyback 10 meq/50 ml 1 $0 MO potassium chloride intravenous solution 1 $0 MO potassium chloride oral capsule, extended release 1 $0 MO potassium chloride oral liquid 1 $0 MO potassium chloride oral packet 1 $0 MO potassium chloride oral tablet extended release 1 $0 MO potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl intravenous parenteral solution potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l 1 $0 MO 1 $0 LIMIT 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA ringers intravenous parenteral solution 1 $0 B/D PA smooth antacid oral tablet,chewable sodium chloride 0.45 % intravenous parenteral solution 1 $0 MO sodium chloride 0.45 % intravenous piggyback 1 $0 sodium chloride 3 % intravenous parenteral solution sodium chloride 5 % intravenous parenteral solution 1 $0 MO 1 $0 sodium chloride intravenous parenteral solution 1 $0 MO 140

153 sodium lactate intravenous solution 1 $0 super calcium oral tablet TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) PRODOTTI VARI PER LA NUTRIZIONE 4 $0 MO; * amino acids 15 % intravenous parenteral solution 1 $0 B/D PA AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA LIMIT 141

154 AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION electrolyte-48 in d5w intravenous parenteral solution HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 1 $0 B/D PA 2 $0 B/D PA LIMIT 142

155 LIMIT intralipid intravenous emulsion 20 % 1 $0 B/D PA; MO INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION niacin flush free oral capsule 400 mg niacin (500 mg) NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 B/D PA 4 $0 MO; * 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA premasol 10 % intravenous parenteral solution 1 $0 B/D PA; MO PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 143

156 PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION LIMIT 2 $0 B/D PA; MO travasol 10 % intravenous parenteral solution 1 $0 B/D PA; MO TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION VITAMINE / EMATINICI 2 $0 B/D PA; MO 2 $0 B/D PA a thru z advanced formula oral tablet a thru z high potency oral tablet a thru z oral tablet a thru z select 50+ formula oral tablet a thru z select oral tablet, mcg a thru z select women's oral tablet adults 50+ daily formula oral tablet adults' daily formula oral tablet ANIMAL SHAPE VITAMINS ORAL TABLET,CHEWABLE antioxidant formula oral capsule 4 $0 MO; * AQUASOL E ORAL DROPS 4 $0 MO; * ascorbate calcium oral tablet ascorbic acid (vitamin c) oral tablet ascorbic acid (vitamin c) oral tablet extended release 1,000 mg 4 $0 MO; * ascorbic acid with rose hips oral tablet b complex 100 oral tablet b complex oral tablet extended release B COMPLEX-VITAMIN B12 ORAL TABLET 4 $0 MO; * b complex-vitamin c-folic acid oral tablet 4 $0 MO; * 144

157 b-100 complex oral tablet extended release balanced b-100 complex oral tablet extended release 100 mg balanced b-100 oral tablet 0.4 mg BALANCED B-100 ORAL TABLET 100 MG BALANCED B-50 ORAL TABLET b-complex oral tablet b-complex with vitamin c oral capsule 4 $0 MO; * b-complex with vitamin c oral tablet 4 $0 MO; * b-complex with vitamin c oral tablet mcg-mg b-complex with vitamin c oral tablet extended release beta carotene oral capsule 25,000 unit 4 $0 MO; * biotin oral capsule 2,500 mcg, 5 mg 4 $0 MO; * biotin oral tablet 1 mg, 300 mcg 4 $0 MO; * biotin oral tablet 800 mcg brewer's yeast oral tablet 500 mg (7.5 gr) c-1000 with rose hips oral tablet c-500 oral tablet c-500 oral tablet,chewable CALCIDOL ORAL DROPS calciferol oral drops 4 $0 MO; * cemill-1000 oral tablet centavite a-z complete-mineral oral tablet central vite with lutein oral tablet central-vite cardio oral tablet central-vite men's under 50 oral tablet LIMIT 145

158 central-vite oral tablet mg-mcg central-vite select oral tablet central-vite senior oral tablet central-vite women's under 50 oral tablet centrum oral liquid 4 $0 MO; * centrum silver ultra women's oral tablet CEROVITE ADVANCED FORMULA ORAL TABLET 4 $0 MO; * cerovite jr oral tablet,chewable CEROVITE ORAL LIQUID 4 $0 MO; * cerovite senior oral tablet 4 $0 MO; * CERTAVITE SENIOR-ANTIOXIDANT ORAL TABLET CERTAVITE-ANTIOXID (IRON GLUC) ORAL LIQUID 9 MG IRON/15 ML 4 $0 MO; * 4 $0 MO; * CERTAVITE-ANTIOXIDANT ORAL TABLET 4 $0 MO; * chewable-vite oral tablet,chewable 4 $0 MO; * chewable-vite with iron oral tablet,chewable children's chewable vitamin oral tablet,chewable CHILDS CHEW VITE ORAL TABLET,CHEWABLE CHILD'S CHEWABLE VITAMINS/IRON ORAL TABLET,CHEWABLE CHILDS/IRON ORAL TABLET,CHEWABLE 4 $0 MO; * cholecalciferol (vitamin d3) oral capsule 1,000 unit, 10,000 unit, 5,000 unit, 50,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml 4 $0 MO; * 4 $0 MO; * LIMIT 146

159 cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 400 UNIT 4 $0 MO; * cod liver oil oral capsule 4 $0 MO; * cod liver oil oral oil 4 $0 MO; * cod liver oil-ascorbic acid oral tablet,chewable complete 50+ oral tablet complete multivitamin-mineral oral tablet cranberry concentrate oral capsule cranberry urinary comfort oral capsule 4 $0 MO; * cyanocobalamin (vitamin b-12) injection solution 3 $0 MO; * cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 500 mcg D ORAL CAPSULE 4 $0 MO; * daily multiple oral tablet daily multiple vitamins/iron oral tablet daily multi-vitamins/iron oral tablet daily vitamin oral tablet daily vites/iron oral tablet 4 $0 MO; * daily-vite oral tablet 4 $0 MO; * delta d3 oral tablet 4 $0 MO; * dialyvite 800 oral tablet 4 $0 MO; * dialyvite vitamin d oral capsule 4 $0 MO; * d-vi-sol oral drops 4 $0 MO; * d-vita oral drops ELDERTONIC ORAL ELIXIR 4 $0 MO; * ergocalciferol (vitamin d2) oral capsule 3 $0 MO; * LIMIT 147

160 ergocalciferol (vitamin d2) oral drops 4 $0 MO; * essentia oral tablet ezfe 200 oral capsule 4 $0 MO; * farbee with c oral tablet FERATE ORAL TABLET 240 MG (27 MG IRON) 4 $0 MO; * ferate oral tablet 256 mg (28 mg iron) 4 $0 MO; * FER-IRON ORAL DROPS FEROSUL ORAL ELIXIR FEROSUL ORAL TABLET 4 $0 MO; * FERREX 150 ORAL CAPSULE 4 $0 MO; * FERRO-TIME ORAL TABLET 4 $0 MO; * ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) 4 $0 MO; * ferrous gluconate oral tablet 325 mg (37 mg iron) ferrous sulfate oral drops 4 $0 MO; * ferrous sulfate oral elixir 4 $0 MO; * ferrous sulfate oral liquid 4 $0 MO; * ferrous sulfate oral solution 4 $0 MO; * ferrous sulfate oral tablet 325 mg (65 mg iron) 4 $0 MO; * ferrous sulfate oral tablet,delayed release (dr/ec) 4 $0 MO; * FERROUSUL ORAL TABLET ferus oral capsule 4 $0 MO; * fish oil-dha-epa oral capsule fluoritab oral tablet,chewable 0.5 mg fluoride (1.1 mg) 1 $0 MO folic acid oral tablet 1 mg 3 $0 MO; * LIMIT 148

161 folic acid oral tablet 400 mcg, 800 mcg 4 $0 MO; * formula e 400 oral capsule fruit c oral tablet,chewable GERAVIM ORAL LIQUID GERIATON ORAL LIQUID gummi bear multivitamin oral tablet,chewable hair vitamins oral tablet hairvite oral tablet halls defense oral lozenge high potency iron oral tablet hydroxocobalamin intramuscular solution 3 $0 MO; * icaps areds oral capsule 4 $0 MO; * IFEREX 150 ORAL CAPSULE 4 $0 MO; * IRON ORAL TABLET 325 MG (65 MG IRON) i-vite oral tablet 4 $0 MO; * i-vite protect oral tablet KIDS VITAMIN D3 ORAL TABLET,CHEWABLE lecithin-kelp-b6 ( ) oral tablet lecithin-kelp-b6 (400-20) oral tablet lecithin-kelp-b6 oral capsule little animals oral tablet,chewable little animals-iron oral tablet,chewable ludent fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg) 1 $0 MO lumitene oral capsule men's 50+ daily formula oral tablet men's daily formula oral tablet 0.4 mg LIMIT 149

162 MEN'S ONE DAILY ORAL TABLET MCG MULTI-YN ORAL LIQUID 4 $0 MO; * MULTI-YN WITH IRON ORAL LIQUID multilex-t and m oral tablet 4 $0 MO; * multiple vitamins oral tablet multivitamin oral tablet 4 $0 MO; * multi-vitamin oral tablet multivitamin with iron oral tablet multivitamin with minerals oral liquid NEPHRONEX ORAL LIQUID ocutabs oral tablet one daily essential oral tablet 0.4 mg one daily for men 50+ advanced oral tablet one daily for men oral tablet one daily for women oral tablet one daily maximum oral tablet ONE DAILY MEN'S 50+ ORAL TABLET MCG-MG one daily multivit-iron(folic) oral tablet ONE DAILY ORAL TABLET one daily plus iron oral tablet one daily women 50 plus oral tablet one daily womens 50 plus oral tablet one daily women's oral tablet 18 mg iron-400 mcg-450 mg ca one-a-day essential oral tablet 4 $0 MO; * LIMIT 150

163 ONE-A-DAY MEN'S MULTIVITAMIN ORAL TABLET 4 $0 MO; * one-a-day teen advantage oral tablet opti-vitamins oral tablet pantothenic acid oral tablet 4 $0 MO; * POLY-IRON ORAL CAPSULE 4 $0 MO; * polysaccharide iron oral capsule POLY-VITA (IRON) ORAL DROPS POLY-VITA ORAL DROPS POLY-VITAMIN ORAL DROPS POLY-VITAMIN WITH IRON ORAL DROPS POLYVITAMIN/IRON ORAL TABLET,CHEWABLE POLY-VITAMINS ORAL TABLET,CHEWABLE prenatal vitamin oral tablet 1 $0 MO PROSIGHT ORAL TABLET pyridoxine (vitamin b6) injection solution 3 $0 MO; * pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg pyridoxine (vitamin b6) oral tablet 250 mg 4 $0 MO; * RENA-VITE ORAL TABLET 4 $0 MO; * riboflavin (vitamin b2) oral tablet 100 mg, 50 mg sodium fluoride oral tablet 1 $0 MO soothing pureway-c oral tablet stress formula 600 c oral tablet stress formula advanced oral tablet STRESS FORMULA ORAL TABLET LIMIT 151

164 STRESS FORMULA WITH IRON ORAL TABLET STRESS FORMULA WITH ZINC ORAL TABLET 4 $0 MO; * 4 $0 MO; * super b-50 complex oral capsule super b-50 complex plus oral tablet super multivitamin oral tablet super quints b-50 oral tablet SUPERPLEX-T ORAL TABLET tab a vite oral tablet mg 4 $0 MO; * TAB-A-VITE ORAL TABLET 4 $0 MO; * TAB-A-VITE/IRON ORAL TABLET 4 $0 MO; * THERA M PLUS (FERROUS FUMARAT) ORAL TABLET 4 $0 MO; * THERA VITAMIN ORAL TABLET 4 $0 MO; * thera-d oral tablet theralogix companion oral tablet THERA-M ORAL TABLET THERA-M ORAL TABLET 9 MG IRON-400 MCG 4 $0 MO; * therapeutic liquid oral liquid therapeutic m + beta-carotene oral tablet therems oral tablet 4 $0 MO; * therems-m oral tablet 4 $0 MO; * thiamine hcl (vitamin b1) injection solution 3 $0 MO; * thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg TOTAL B/C ORAL TABLET TRI-VITA ORAL DROPS LIMIT 152

165 TRI-VITAMIN ORAL DROPS 4 $0 MO; * ultimate women's complete 50+ oral tablet ultra b-100 complex oral tablet vimar oral liquid vit b complex-folic acid oral tablet vitabee/c oral tablet vitamin a oral capsule 10,000 unit 4 $0 MO; * vitamin a oral capsule 25,000 unit, 8,000 unit vitamin b complex oral tablet vitamin b complex with c oral capsule VITAMIN B-1 ORAL TABLET 100 MG, 50 MG 4 $0 MO; * vitamin b-1 oral tablet 250 mg 4 $0 MO; * VITAMIN B-12 ORAL TABLET 1,000 MCG, 500 MCG vitamin b-12 oral tablet 100 mcg, 250 mcg, 50 mcg 4 $0 MO; * 4 $0 MO; * vitamin b-2 oral tablet 100 mg, 50 mg 4 $0 MO; * VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG 4 $0 MO; * vitamin c cough drops oral lozenge vitamin c drops oral lozenge vitamin c oral capsule, extended release 4 $0 MO; * vitamin c oral lozenge vitamin c oral tablet 1,000 mg 4 $0 MO; * VITAMIN C ORAL TABLET 250 MG, 500 MG 4 $0 MO; * vitamin c oral tablet extended release 1,000 mg vitamin c oral tablet extended release 500 mg 4 $0 MO; * LIMIT 153

166 VITAMIN C ORAL TABLET,CHEWABLE 250 MG, 500 MG 4 $0 MO; * vitamin c with rose hips oral tablet 4 $0 MO; * vitamin c with rose hips oral tablet extended release VITAMIN D2 ORAL CAPSULE 3 $0 MO; * vitamin d3 oral capsule 1,000 unit, 2,000 unit, 400 unit 4 $0 MO; * VITAMIN D3 ORAL CAPSULE 4,000 UNIT 4 $0 MO; * VITAMIN D3 ORAL TABLET 1,000 UNIT 4 $0 MO; * vitamin d3 oral tablet 400 unit 4 $0 MO; * vitamin d3 oral tablet,chewable 4 $0 MO; * vitamin e (dl, acetate) oral capsule 100 unit, 400 unit 4 $0 MO; * vitamin e acetate oral capsule vitamin e mixed oral capsule vitamin e oral capsule 1,000 unit, 200 unit, 400 unit 4 $0 MO; * vitamin e oral capsule 100 unit, 600 unit vitamins a and d oral capsule VITAMINS AND MINERALS ORAL TABLET VITAMINS B COMPLEX ORAL CAPSULE 4 $0 MO; * vitatrum oral tablet vitrum senior oral tablet wheat germ oil oral capsule women's 50+ daily form (gkb) oral tablet women's daily formula oral tablet zinc sulfate-vitamin c oral lozenge LIMIT 154

167 Indice 1 12 hour decongestant HOUR NASAL SPRAY HOUR PAIN RELIEVER. 38 A a thru z a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula. 144 a thru z select women's abacavir... 3 abacavir-lamivudinezidovudine... 3 ABELCET... 2 ABILIFY ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol ACEPHEN aceta-gesic acetaminophen... 38, 39 acetaminophen extra strength acetaminophen pain relief acetaminophen pm acetaminophen pm extra str.. 39 acetaminophen-codeine.. 33, 34 acetasol hc acetazolamide acetazolamide sodium acetic acid acetic acid-aluminum acetate 79 acetylcysteine acid controller ACID CONTROLLER ACID GONE ANTACID ACID REDUCER (FAMOTIDINE) ACID REDUCER (RANITIDINE) acitretin... 64, 65 ACNE MEDICATION acta-tabs pe ACTEMRA ACTHAR H.P ACTHIB (PF) actifed cold-allergy ACTIMMUNE ACTOPLUS MET XR acyclovir... 3, 70 acyclovir sodium... 3 ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCIRCA adefovir... 3 ADEMPAS adrucil adt robitussin peak cld dm max adult cough formula dm max adult robitussin m-s cold adult robitussin nasal relief. 119 adult robitussin peak cold dm adult robitussin peak cold m-s ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ADULT TUSSIN DM adult wal-tussin adult wal-tussin dm max adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVANCED ANTACID- ANTIGAS advil afeditab cr AFINITOR AFINITOR DISPERZ afrin no drip(oxymetazolin).. 77 a-hydrocort ak-poly-bac AKWA TEARS (POLYVINYL ALCOHOL) ala-cort alavert ALAVERT D-12 ALLERGY- SINUS ALBENZA... 9 albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME ALECENSA alendronate... 73, 106 alfuzosin ALIMTA ALINIA... 9, 10 ALL DAY ALLERGY (CETIRIZINE) all day allergy relief(cetir) ALL DAY ALLERGY-D ALLER-CHLOR aller-ease ALLERGY (CHLORPHENIRAMINE) ALLERGY (DIPHENHYDRAMINE) ALLERGY 4-HOUR

168 ALLERGY AND amikacin ANDROGEL CONGESTION RELIEF 120 amiloride androxy allergy and sinus relief amiloride-hydrochlorothiazide anefrin ALLERGY COMPLETE-D ANIMAL SHAPE VITAMINS amino acids 15 % allergy medication AMINOSYN 10 % ANORO ELLIPTA ALLERGY MEDICINE AMINOSYN 8.5 % ANTACID allergy m-s nighttime AMINOSYN 8.5 %- antacid (calcium carb-mag allergy multi-symptom ELECTROLYTES hyd) ALLERGY RELIEF AMINOSYN II 10 % antacid (calcium carbonate) 136 (CETIRIZINE) AMINOSYN II 15 % ANTACID (CALCIUM ALLERGY RELIEF AMINOSYN II 7 % CARBONATE) (FEXOFENADINE) AMINOSYN II 8.5 % ANTACID ANTI-GAS allergy relief (loratadine) AMINOSYN II 8.5 %- ANTACID ANTI-GAS ALLERGY RELIEF ELECTROLYTES DOUBLE STR (LORATADINE) AMINOSYN M 3.5 % ANTACID EXT STR ALLERGY AMINOSYN-HBC 7% (CALCIUM CARB) RELIEF(CHLORPHENIRA AMINOSYN-PF 10 % antacid extra-strength MN) AMINOSYN-PF 7 % ANTACID EXTRA- ALLERGY (SULFITE-FREE) STRENGTH... 89, 136 RELIEF(DIPHENHYDRA AMINOSYN-RF 5.2 % antacid liquid MIN) amiodarone antacid m allergy relief-d (loratadine) 121 AMITIZA ANTACID MAXIMUM allergy sinus-d amitriptyline STRENGTH allergy-congest relief-d (cet) amlodipine ANTACID PLUS ANTI-GAS amlodipine-atorvastatin ALLERGY-TIME amlodipine-benazepril antacid regular strength all-nite cold-flu amlodipine-valsartan antacid ultra strength... 89, 136 allopurinol amlodipine-valsartan-hcthiazid ANTACID-ANTIGAS ALMACONE ANTACID-SIMETHICONE 89 ALMACONE ammonium lactate ANTIBIOTIC (NEOMYalosetron amnesteem BACIT-POLYM) ALPHAGAN P amoxapine ANTI-DIARRHEA alprazolam amoxicil-clarithromy-lansopraz ANTI-DIARRHEAL altavera (28) (LOPERAMIDE) aluminum hydroxide gel amoxicillin ANTIFUNGAL alyacen 1/35 (28) amoxicillin-pot clavulanate.. 13 (TOLNAFTATE) alyacen 7/7/7 (28) amphotericin b... 2 ANTIFUNGAL CREAM amantadine hcl... 3 ampicillin antioxidant formula AMBISOME... 2 ampicillin sodium antitussive dm amcinonide ampicillin-sulbactam... 13, 14 APOKYN amethia AMPYRA apraclonidine amethia lo ANADROL apri amethyst anagrelide APRISO amifostine crystalline anastrozole APRODINE

169 APTIOM atropine balziva (28) APTIVUS... 3 ATROVENT HFA BANOPHEN AQUASOL E AUBAGIO BANZEL ARALAST NP aubra BARACLUDE... 3 aranelle (28) AURYXIA bayer advanced ARCALYST AVASTIN bayer aspirin aripiprazole... 46, 47 AVELOX IN NACL (ISO- baza antifungal ARISTADA OSMOTIC) BCG VACCINE, LIVE (PF) ARNUITY ELLIPTA aviane ARTHRITIS PAIN RELIEF AVONEX b-complex (ACETAM) AVONEX (WITH ALBUMIN) b-complex with vitamin c ARTHRITIS PAIN BELEODAQ RELIEVER ayr saline benazepril ARTIFICIAL TEARS AYR SALINE benazepril-hydrochlorothiazide (PETRO/MIN) azacitidine ARTIFICIAL TEARS AZASAN BENDEKA (POLYVIN ALC) AZASITE BENLYSTA ARTIFICIAL azathioprine benzonatate TEARS(PVALCH-POVID) azathioprine sodium benzoyl peroxide azelastine... 77, 116 benztropine ascorbate calcium AZILECT beta carotene ascorbic acid (vitamin c) azithromycin... 9 betamethasone dipropionate. 70 ascorbic acid with rose hips 144 AZOPT betamethasone valerate ashlyna aztreonam betamethasone, augmented ASMANEX HFA azurette (28) betaxolol... 54, 115 ASMANEX TWISTHALER B bethanechol chloride b complex BETIMOL ASPIR b complex BETOPTIC S aspirin B COMPLEX-VITAMIN B12 bexarotene aspirin childrens BEXSERO (PF) ASPIRIN LOW DOSE b complex-vitamin c-folic acid bicalutamide aspirin-dipyridamole BICILLIN C-R ASPIR-LOW b-100 complex BICILLIN L-A aspir-trin baby ayr saline BICNU ASTAGRAF XL baciim biotin atenolol bacitracin... 10, 68, 114 bisacodyl atenolol-chlorthalidone bacitracin zinc BISA-LAX athenol bacitracin-polymyxin b bismatrol ATHLETE'S FOOT bacitraycin plus BISMATROL (TERBINAFINE) baclofen bismuth athlete's foot (tolnaftate) balanced b BISMUTH atorvastatin BALANCED B bismuth maximum strength.. 87 atovaquone balanced b-100 complex bisoprolol fumarate atovaquone-proguanil BALANCED B bisoprolol-hydrochlorothiazide ATRIPLA... 3 balsalazide

170 bleomycin CABOMETYX CARBAGLU BLEPHAMIDE S.O.P calcarb 600 with vitamin d. 136 carbamazepine blisovi 24 fe CALCIDOL carbidopa blisovi fe 1.5/30 (28) calciferol carbidopa-levodopa blisovi fe 1/20 (28) calcipotriene carbidopa-levodopaentacapone BOOSTRIX TDAP calcipotriene-betamethasone BOSULIF calcitonin (salmon) carboplatin BREO ELLIPTA CALCITRATE carteolol brewer's yeast calcitrene cartia xt briellyn calcitriol... 65, 85 carvedilol BRILINTA calcium d CAYSTON brimonidine CALCIUM 500 WITH D caziant (28) BRISLE CALCIUM cefaclor... 7 BRIVIACT CALCIUM D(3) cefadroxil... 7 bromfenac calcium 600 with vitamin d3 cefazolin... 7 bromocriptine cefazolin in dextrose (iso-os).. 7 broncotron calcium acetate cefdinir... 7 broncotron ped CALCIUM ANTACID , cefepime... 7 BROTAPP CEFEPIME IN DEXTROSE 5 BROTAPP DM CALCIUM ANTACID %... 7 budesonide... 90, 131, 132 ULTRA MAX ST cefepime in dextrose,iso-osm. 7 bufferin calcium carbonate cefixime... 7 bumetanide calcium carbonate-vitamin d3 cefotaxime... 7 buprenorphine hcl cefotetan... 7 buprenorphine-naloxone calcium citrate CEFOTETAN IN buproban calcium citrate + d DEXTROSE, ISO-OSM... 7 bupropion hcl calcium citrate-vitamin d cefoxitin... 8 bupropion hcl (smoking deter) calcium gluconate cefoxitin in dextrose, iso-osm CAL-GEST ANTACID cefpodoxime... 8 buspirone camila cefprozil... 8 BUSULFEX CAMPATH ceftazidime... 8 butalbital-acetaminop-caf-cod camrese CEFTAZIDIME IN D5W camrese lo ceftriaxone... 8 butalbital-acetaminophen CANASA CEFTRIAXONE... 8 butalbital-acetaminophen-caff CANCIDAS... 2 ceftriaxone in dextrose,iso-os candesartan cefuroxime axetil... 8 butalbital-aspirin-caffeine candesartan-hydrochlorothiazid cefuroxime sodium... 8 butorphanol tartrate CEFUROXIME SODIUM... 8 BYDUREON CAPASTAT celecoxib BYETTA CAPRELSA CELLCEPT BYSTOLIC captopril CELLCEPT INTRAVENOUS C captopril-hydrochlorothiazide c-1000 with rose hips CELONTIN c CARAC cemill cabergoline CARAFATE

171 centavite a-z complete-mineral CHEST-SINUS CHILDS CHEW VITE CONGESTION RELIEF 122 CHILD'S CHEWABLE central vite chewable-vite VITAMINS/IRON central vite with lutein chewable-vite with iron CHILDS/IRON central-vite CHILD ALLERGY chloramphenicol sod succinate central-vite cardio RELF(CETIRIZINE) central-vite men's under CHILD MUCUS RELIEF chlorhexidine gluconate central-vite select COUGH chloroquine phosphate central-vite senior CHILD MUCUS RELIEF chlorothiazide central-vite women's under 50 EXPECTORANT chlorothiazide sodium child pain rel-fever reducer.. 40 chlorpheniramine maleate centrum CHILDREN'S chlorpromazine centrum silver ultra women's ACETAMINOPHEN chlorthalidone CHILDREN'S ASPIRIN CHOLBAM cephalexin... 8, 9 CHILDREN'S CETIRIZINE cholecalciferol (vitamin d3) CEREZYME , 147 CEROVITE children's chest congestion. 122 CHOLECALCIFEROL CEROVITE ADVANCED children's chewable vitamin146 (VITAMIN D3) FORMULA CHILDREN'S COLD AND cholestyramine (with sugar). 62 cerovite jr COUGH (PE) cholestyramine light cerovite senior CHILDREN'S COLD AND CHORIONIC CERTAVITE SENIOR- COUGH DM GONADOTROPIN, ANTIOXIDANT children's cough HUMAN CERTAVITE-ANTIOXID children's dimetapp cold-flu CIALIS (IRON GLUC) ciclodan... 68, 69 CERTAVITE- CHILDREN'S MAPAP ciclopirox ANTIOXIDANT children's non-aspirin cidofovir... 3 CERVARIX VACCINE (PF) CHILDREN'S PAIN RELIEF cilostazol CILOXAN cetiri-d CHILDREN'S PAIN cimetidine cetirizine RELIEVER cimetidine hcl cetirizine-pseudoephedrine. 122 children's pain-fever relief CIMZIA cevimeline CHILDREN'S PAIN-FEVER CIMZIA POWDER FOR CHANTIX RELIEF RECONST CHANTIX CONTINUING children's pepto CIMZIA STARTER KIT MONTH BOX CHILDREN'S Q-PAP CINRYZE CHANTIX STARTING children's saline nasal spray. 78 ciprofloxacin MONTH BOX CHILDREN'S SILAPAP ciprofloxacin (mixture) chateal CHILDREN'S SILFEDRINE ciprofloxacin hcl... 15, 114 CHEMET ciprofloxacin lactate CHEST CONGESTION children's soothe cisplatin RELIEF children's triaminic fever citalopram CHEST CONGESTION children's wal-zyr citrate of magnesia RELIEF PE CHILD'S ALL DAY citroma ALLERGY(CETIR) citrucel

172 CITRUS CALCIUM CLINIMIX E 5%/D25W complete multivitamin-mineral cladribine SULFIT FREE claravis clobetasol complete premium vitamin clarithromycin... 9 clobetasol-emollient compro CLEARLAX clomipramine COMVAX (PF) clemastine clonazepam... 27, 28 CONGESTAC CLEOCIN clonidine constulose clindamycin hcl clonidine hcl... 47, 55 COREG CR clindamycin palmitate hcl clopidogrel cormax clindamycin pediatric clorazepate dipotassium cortisone clindamycin phosphate.. 10, 66, clotrimazole... 2, 69, 109 CORTISPORIN-TC clotrimazole 3 day COTELLIC clindamycin-benzoyl peroxide clotrimazole cough and cold clotrimazole-betamethasone. 69 cough and cold mucus relief cf CLINIMIX 5%/D15W clozapine SULFITE FREE CLOZAPINE cough control CLINIMIX 5%/D25W COARTEM (dextromethorph) SULFITE-FREE cod liver oil COUGH CONTROL CLINIMIX 2.75%/D5W cod liver oil-ascorbic acid (GUAIFENESIN) SULFIT FREE codeine sulfate COUGH CONTROL CF (PE) CLINIMIX 4.25%/D10W codituss dm SULF FREE colchicine-probenecid cough control dm CLINIMIX 4.25%/D5W COLCRYS COUGH CONTROL DM SULFIT FREE COLD AND ALLERGY PE MAX CLINIMIX 4.25%-D20W cough formula dm SULF-FREE cold and cough (pe-dm) cough relief CLINIMIX 4.25%-D25W COLD AND COUGH ELIXIR COUGH SUPPRESSANT- SULF-FREE EXPECTORANT CLINIMIX 5%- COLD HEAD CONGESTION COUGH SYRUP D20W(SULFITE-FREE) 142 NIGHTTIME COUGH SYRUP DM CLINIMIX E 2.75%/D10W cold-flu relief cough-sore throat night SUL FREE colestipol COUGHTAB CLINIMIX E 2.75%/D5W colistin (colistimethate na) COUMADIN SULF FREE col-rite cranberry concentrate CLINIMIX E 4.25%/D10W COMBIGAN cranberry urinary comfort SUL FREE COMBIPATCH CRINONE CLINIMIX E 4.25%/D25W COMBIVENT RESPIMAT 132 CRIXIVAN... 3 SUL FREE COMETRIQ cromolyn... 90, 116, 132 CLINIMIX E 4.25%/D5W comfort gel cryselle (28) SULF FREE comfort gel extra strength CUBICIN CLINIMIX E 5%/D15W COMPLERA... 3 CUPRIMINE SULFIT FREE complete cyanocobalamin (vitamin b-12) CLINIMIX E 5%/D20W complete allergy SULFIT FREE complete allergy medicine cyclafem 1/35 (28) cyclafem 7/7/7 (28)

173 cyclobenzaprine daytime cold-flu relief (pe). 124 dextrose 20 % in water (d20w) CYCLOPHOSPHAMIDE decitabine CYCLOSERINE DEEP SEA NASAL dextrose 25 % in water (d25w) CYCLOSET ESTROGEN cyclosporine delta d dextrose 30 % in water (d30w) cyclosporine modified demeclocycline cyproheptadine DEMSER dextrose 40 % in water (d40w) CYRAMZA DENAVIR CYSTADANE denta 5000 plus dextrose 5 % in water (d5w). 74 CYSTAGON dentagel dextrose 5 %-lactated ringers75 CYSTARAN DEPEN TITRATABS dextrose 5%-0.2 % sod cytarabine DEPO-PROVERA chloride cytarabine (pf) DEPO-SUBQ PROVERA 104 dextrose 5%-0.3 % D sod.chloride d10 %-0.45 % sodium chloride DESCOVY... 3 dextrose 50 % in water (d50w) desipramine d2.5 %-0.45 % sodium desloratadine dextrose 70 % in water (d70w) chloride desmopressin D desog-e.estradiol/e.estradiol dextrose with sodium chloride d5 % and 0.9 % sodium chloride desonide dextrose-kcl-nacl d5 %-0.45 % sodium chloride desoximetasone DIABETIC SILTUSSIN DAS despec dm-g NA dacarbazine despec-dm (phenyleph-dmguaif) DIABETIC SILTUSSIN-DM daily multiple daily multiple vitamins/iron 147 despec-tab dialyvite daily multi-vitamins/iron dexamethasone dialyvite vitamin d daily vitamin dexamethasone intensol diaper rash daily vites/iron dexamethasone sodium phos diarrhea relief (bismuth subs) daily-vite (pf) DALIRESP dexamethasone sodium DIASTAT danazol phosphate... 80, 118 diazepam... 28, 48 dantrolene DEXILANT diazepam intensol DAPSONE dexmethylphenidate diclofenac potassium DAPTACEL (DTAP dexrazoxane hcl diclofenac sodium... 41, 65, 117 PEDIATRIC) (PF) dextroamphetamine... 47, 48 diclofenac-misoprostol DARAPRIM dextroamphetamineamphetamine dicloxacillin darifenacin dicyclomine DARZALEX dextromethorphan-guaifenesin didanosine... 3 dasetta 1/35 (28) diflorasone dasetta 7/7/7 (28) dextrose 10 % and 0.2 % nacl diflunisal daunorubicin digitek DAUNOXOME dextrose 10 % in water (d10w) digox daysee digoxin daytime cold-flu dihydroergotamine

174 DILANTIN 30 MG DRISTAN LONG LASTING emoquette dilt-cd EMPLICITI diltiazem hcl dronabinol EMSAM dilt-xr drospirenone-ethinyl estradiol EMTRIVA... 3 diltzac er enalapril maleate DIMAPHEN DM DROXIA enalapril-hydrochlorothiazide dimenhydrinate DUCODYL dimetapp cold-congestion duloxetine ENBREL dimetapp dm cold-cough (pe) duramorph (pf) ENBREL SURECLICK DUREZOL ENDACOF - DM DIOCTO dutasteride endocet DIPENTUM dutasteride-tamsulosin ENEMA DIPHEDRYL d-vi-sol ENEMA DISPOSABLE diphenhist d-vita ENGERIX-B (PF) , 103 diphenhydramine hcl E ENGERIX-B PEDIATRIC diphenhydramineacetaminophen E.C. PRIN (PF) e.e.s enoxaparin diskets econazole enpresse disposable enema ECONTRA EZ enskyce disulfiram ed a-hist entacapone divalproex ed a-hist dm entecavir... 3 DOC-Q-LACE ed a-hist pse enteric coated aspirin DOC-Q-LAX ed-apap ENTRESTO DOCU ed-chlortan enulose docu soft EDURANT... 3 ENVARSUS XR docusate sodium EFFIENT epinastine DOCUSIL EGRIFTA EPINEPHRINE dofetilide ELAPRASE EPIPEN 2-PAK dok ELDERTONIC EPIPEN JR 2-PAK DOK electrolyte-48 in d5w epirubicin dok plus electrolytes-dextrose epitol donepezil ELELYSO EPIVIR HBV... 4 dorzolamide ELI eplerenone dorzolamide-timolol ELIGARD eprosartan double-tussin dm ELIGARD (3 MONTH) EPZICOM... 4 doxazosin ELIGARD (4 MONTH) ergocalciferol (vitamin d2) 147, doxepin ELIGARD (6 MONTH) doxorubicin elinest ergoloid DOXORUBICIN, PEG- eliphos ERIVEDGE LIPOSOMAL ELIQUIS errin doxy ELITEK ERWINAZE doxycycline hyclate ELIXOPHYLLIN ery pads doxycycline monohydrate ELLA ERYPED DRIMINATE ELMIRON ERYTHROCIN... 9 dristan cold EMCYT erythrocin (as stearate)

175 erythromycin... 9, 114 felbamate FIBER THERAPY (Merythromycin ethylsuccinate.. 9 felodipine CELLULOSE) erythromycin with ethanol.. 66, fenofibrate FIBER THERAPY 67 fenofibrate micronized (PSYLLIUM SEED) erythromycin-benzoyl peroxide fenofibrate nanocrystallized. 62 FIBER-LAX fenofibric acid fibertab ESBRIET fenofibric acid (choline) FIBER-TABS escitalopram oxalate fenoprofen finasteride esomeprazole sodium fentanyl FIRAZYR essentia fentanyl citrate... 34, 35 fish oil-dha-epa estarylla ferate flavoxate ESTRACE FERATE flecainide estradiol FER-IRON FLEET ENEMA estradiol valerate FEROSUL fleet glycerin (adult) eszopiclone FERREX FLEET LAXATIVE ethambutol FERRIPROX FLOVENT DISKUS ethosuximide FERRO-TIME FLOVENT HFA etidronate disodium ferrous gluconate flu relief therapy nighttime. 125 etodolac ferrous sulfate fluconazole... 2 etoposide FERROUSUL fluconazole in dextrose(iso-o) 2 evac-u-gen (sennosides) ferus fluconazole in nacl (iso-osm). 2 EVOTAZ... 4 FETZIMA flucytosine... 2 excedrin menstrual complete 41 fever reducer an pain reliever fludarabine exemestane fludrocortisone EXJADE FEVERALL flunisolide expectorant fexofenadine fluocinolone expectorant cough syrup FIBER fluocinolone acetonide oil EXTAVIA , 101 FIBER (CALCIUM fluocinolone and shower cap 71 extra strength bayer POLYCARBOPHIL) fluocinonide ezfe fiber (psyllium husk/sugar).. 91 fluocinonide-e F FIBER (PSYLLIUM fluocinonide-emollient FABRAZYME HUSK/SUGAR) fluoritab FALLBACK SOLO FIBER (WITH ASPARTAME) fluorometholone falmina (28) fluorouracil... 20, 65 famciclovir... 4 FIBER LAXATIVE (CA fluoxetine... 48, 49 famotidine POLYCARBO) FLUOXETINE famotidine (pf) fiber laxative (husk/sugar) fluphenazine decanoate famotidine (pf)-nacl (iso-os) 99 FIBER LAXATIVE fluphenazine hcl FANAPT (METHYLCELLULO) flurbiprofen farbee with c fiber laxative-orange flurbiprofen sodium FARESTON fiber smooth flutamide FARXIGA fiber supplement fluticasone... 72, 132 FARYDAK FIBER THERAPY (M- fluvastatin FASLODEX CELL/SUGAR) fluvoxamine FAZACLO FML S.O.P

176 FOAMING ANTACID generlac H folic acid , 149 gengraf hair vitamins fomepizole gentak hairvite fondaparinux gentamicin... 11, 68, 114, 115 halls defense FORFIVO XL gentamicin in nacl (iso-osm) 11 halobetasol propionate formula e GENTAMICIN IN NACL haloperidol FORTEO (ISO-OSM) haloperidol decanoate fortical GENTLE LAXATIVE haloperidol lactate foscarnet... 4 GENVOYA... 4 HARVONI... 4 fosinopril GEODON HAVRIX (PF) fosinopril-hydrochlorothiazide GERAVIM headache pm GERIATON HEADACHE RELIEF (ASAfosphenytoin gianvi (28) ACET-CAF) FOSRENOL gildess 1.5/30 (21) heartburn relief (famotidine) 99 FRAGMIN... 60, 61 gildess 1/20 (21) HEARTBURN RELIEF fruit c gildess fe 1.5/30 (28) (FAMOTIDINE) fungoid-d gildess fe 1/20 (28) HEARTBURN RELIEF furosemide GILENYA (RANITIDINE) FUZEON... 4 GILOTRIF heartburn relief 24 hour FYCOMPA glatopa HEARTBURN TREATMENT G GLEOSTINE HOUR gabapentin glimepiride heather GABITRIL glipizide heparin (porcine) galantamine glipizide-metformin heparin (porcine) in 5 % dex 61 GAMMAGARD LIQUID GLUCAGEN HYPOKIT heparin (porcine) in nacl (pf) 61 GAMMAGARD S/D GLUCAGON EMERGENCY heparin(porcine) in 0.45% nacl GAMMAGARD S-D (IGA < 1 KIT (HUMAN) MCG/ML) glyburide HEPARIN(PORCINE) IN GAMUNEX-C glyburide micronized % NACL ganciclovir sodium... 4 glyburide-metformin heparin, porcine (pf) garamycin glycerin (adult) HEPATAMINE 8% GARDASIL (PF) glycerin (child) HERCEPTIN GARDASIL 9 (PF) glycerin (infant) HETLIOZ gatifloxacin GLYCOLAX HEXALEN GATTEX 30-VIAL glycopyrrolate HIBERIX (PF) GATTEX ONE-VIAL gonak hi-cal plus vit d GAUZE PAD goniovisc high potency iron GAVILAX granisetron (pf) HUMIRA gavilyte-c granisetron hcl HUMIRA PEDIATRIC gavilyte-g griseofulvin microsize... 2 CROHN'S START gavilyte-n griseofulvin ultramicrosize... 2 HUMIRA PEN GAZYVA guaifenesin HUMIRA PEN CROHN'S- GELNIQUE guanfacine UC-HS START gemcitabine... 20, 21 guanidine HUMIRA PEN PSORIASISgemfibrozil gummi bear multivitamin UVEITIS

177 HUMULIN 70/ ILARIS (PF) irbesartan HUMULIN 70/30 KWIKPEN ILEVRO irbesartan-hydrochlorothiazide imatinib HUMULIN N IMBRUVICA IRENKA HUMULIN N KWIKPEN imipenem-cilastatin IRESSA HUMULIN R imipramine hcl irinotecan HUMULIN R U-500 (CONC) imipramine pamoate IRON KWIKPEN imiquimod ISENTRESS... 4 HUMULIN R U-500 IMOGAM RABIES-HT (PF) ISOLYTE S PH (CONCENTRATED) ISOLYTE-P IN 5 % hydralazine IMOVAX RABIES VACCINE DEXTROSE hydrisalic (PF) ISOLYTE-S hydrochlorothiazide INCRELEX isonarif hydrocodone-acetaminophen 35 indapamide isoniazid hydrocodone-ibuprofen indomethacin ISORDIL hydrocortisone... 72, 80, 93 INFANRIX (DTAP) (PF) isosorbide dinitrate hydrocortisone acetate infant fever reducer-pain relf 42 isosorbide mononitrate hydrocortisone butyrate INFANT'S IBUPROFEN isradipine hydrocortisone butyr-emollient INFANTS' PAIN AND ISTODAX FEVER itraconazole... 2 hydrocortisone valerate INFANTS' PAIN RELIEF ivermectin hydrocortisone-acetic acid INFANT'S PAIN RELIEF i-vite hydrocortisone-min oil-wht pet infant's pain reliever i-vite protect infants' triaminic fever IXIARO (PF) hydromorphone INLYTA J hydromorphone (pf) INSULIN PEN NEEDLE JAKAFI HYDROSKIN INSULIN SYRINGE (DISP) jantoven hydroxocobalamin U JANUMET hydroxychloroquine INTELENCE... 4 JANUMET XR HYDROXYPROGESTERON intralipid JANUVIA E CAPROATE INTRALIPID JARDIANCE hydroxyurea INTRON A jencycla hydroxyzine hcl introvale jinteli HYPERRAB S/D (PF) INVANZ jolessa I INVEGA SUSTENNA jolivette ibandronate INVEGA TRINZA jr. acetaminophen IBRANCE INVIRASE... 4 jr. strength pain reliever ibuprofen INZO ANTIFUNGAL junel 1.5/30 (21) IBUPROFEN IB IONOSOL-B IN D5W junel 1/20 (21) ibuprofen-oxycodone IONOSOL-MB IN D5W junel fe 1.5/30 (28) icaps areds iophen dm-nr junel fe 1/20 (28) ICLUSIG iophen-nr junel fe idarubicin IPOL junior mapap IFEREX ipratropium bromide... 78, 132 JUXTAPID ifosfamide ipratropium-albuterol

178 K KUVAN levobunolol KADCYLA KYNAMRO levocarnitine KADIAN L levocarnitine (with sugar) KALETRA... 4 l norgest/e.estradiol-e.estrad levocetirizine KALYDECO , levofloxacin... 15, 115 kanamycin labetalol levofloxacin in d5w kaopectate (bismuth subsalicy) lactated ringers... 73, 138 levoleucovorin calcium lactulose levonest (28) kao-tin (bismuth subsalicylat) lamisil af levonorgestrel lamisil at levonorgestrel-ethinyl estrad kariva (28) lamivudine kelnor 1/35 (28) lamivudine-zidovudine... 4 levonorg-eth estrad triphasic KENALOG lamotrigine ketoconazole... 2, 69 LANOXIN levora ketodan lansoprazole levorphanol tartrate ketoprofen LASTACAFT levothyroxine ketorolac latanoprost LEVOTHYROXINE KEVEYIS LATUDA levoxyl KEYTRUDA LAXATIVE (BISACODYL)93 LEXIVA... 4 KHEDEZLA laxative (glycerin-pediatric). 93 LIALDA KIDKARE COUGH/COLD laxative (sennosides) lice treatment LAXATIVE FEMININE LICE TREATMENT KIDS VITAMIN D laxative peg (PERMETHRIN) kimidess (28) laxative pills lidocaine KINRIX (PF) laxative pills regular lidocaine (pf)... 53, 67 kionex LAXATIVE PLUS STOOL LIDOCAINE (PF) klor-con SOFTENER lidocaine hcl klor-con layolis fe lidocaine viscous klor-con lecithin-kelp-b lidocaine-prilocaine klor-con m lecithin-kelp-b6 ( ) lindane klor-con m lecithin-kelp-b6 (400-20) linezolid klor-con m leflunomide linezolid-0.9% sodium chloride klor-con sprinkle LENVIMA kola-pectin ds lessina LINZESS KOMBIGLYZE XR LETAIRIS liothyronine konsyl (sugar) letrozole LIQUID ANTACID KONSYL (SUGAR) leucovorin calcium LIQUITEARS konsyl easy mix LEUKERAN lisinopril KONSYL FIBER LEUKINE lisinopril-hydrochlorothiazide konsyl sugar-free leuprolide KONSYL SUGAR-FREE levalbuterol hcl lithium carbonate konsyl-d LEVEMIR lithium citrate KORLYM LEVEMIR FLEXTOUCH little animals k-tab levetiracetam little animals-iron kurvelo levetiracetam in nacl (iso-os) 29 LONSURF

179 loperamide mapap (acetaminophen) mesalamine with cleansing loratadine MAPAP wipe LORATADINE-D (ACETAMINOPHEN)... 42, mesna lorazepam MESNEX lorazepam intensol MAPAP ARTHRITIS PAIN 43 MESTINON loryna (28) MAPAP EXTRA STRENGTH metadate er losartan metaproterenol losartan-hydrochlorothiazide 57 mapap infants' metaxalone lovastatin mapap pm metformin low-ogestrel (28) mapap sinus max strength (pe) methadone loxapine succinate methadone intensol lubricant eye maprotiline methadose LUBRICANT EYE (PG-PEG marlissa methamphetamine ) MARPLAN methazolamide lubricant eye drops masophen methenamine hippurate LUBRICATING PLUS MATULANE methenamine mandelate LUBRIFRESH PM matzim la methimazole ludent fluoride meclizine methotrexate sodium LUMIGAN meclofenamate methotrexate sodium (pf) lumitene medroxyprogesterone methoxsalen rapid LUPRON DEPOT mefenamic acid methscopolamine LUPRON DEPOT (3 mefloquine methyclothiazide MONTH) megestrol methyldopahydrochlorothiazide LUPRON DEPOT (4 MEKINIST MONTH) meloxicam methylergonovine LUPRON DEPOT (6 melphalan hcl METHYLERGONOVINE. 114 MONTH) memantine methylphenidate LUPRON DEPOT-PED MENACTRA (PF) methylprednisolone LUPRON DEPOT-PED (3 MENHIBRIX (PF) methylprednisolone acetate.. 80 MONTH) MENOMUNE - A/C/Y/W-135 methylprednisolone sodium lutera (28) succ LYNPARZA MENOMUNE - A/C/Y/W-135 methyltestosterone LYRICA (PF) metipranolol LYSODREN men's 50+ daily formula metoclopramide hcl lyza men's daily formula metolazone M MEN'S ONE DAILY metoprolol succinate maalox maximum strength MENVEO A-C-Y-W-135-DIP metoprolol ta-hydrochlorothiaz MAG (PF) MAG-AL PLUS MEPHYTON metoprolol tartrate mag-al plus extra strength meprobamate metro i.v mag-delay mercaptopurine metronidazole... 12, 67, 109 magnesium citrate meropenem metronidazole in nacl (iso-os) magnesium oxide MEROPENEM-0.9% magnesium sulfate SODIUM CHLORIDE mexiletine malathion mesalamine MIACALCIN

180 MI-ACID MOTION SICKNESS RELIEF nadolol MICONAZOLE nadolol-bendroflumethiazide 57 miconazole nitrate... 69, 109 motion sickness relief(mecliz) nafcillin miconazole nafcillin in dextrose iso-osm 14 microgestin 1.5/30 (21) MOTION-TIME NAGLAZYME microgestin 1/20 (21) MOVANTIK nalbuphine microgestin fe 1.5/30 (28) MOVIPREP naloxone microgestin fe 1/20 (28) moxifloxacin naltrexone midodrine MOZOBIL NAMENDA XR migergot MUCAPHED naphazoline migraine formula MUCINEX NAPRELAN CR migraine relief MUCINEX DM naproxen MILK OF MAGNESIA MUCINEX FAST-MAX DM naproxen sodium milk of magnesia concentrated MAX naratriptan MUCUS RELIEF NARCAN millipred MUCUS RELIEF COUGH 126 NASACORT AQ mineral oil mucus relief d (pseudoephed) nasal decongestant (oxymetazl) mineral oil extra heavy mineral oil heavy mucus relief dm max NASAL DECONGESTANT mineral oil laxative MUCUS RELIEF ER (PE) minocycline mucus relief pe NASAL DECONGESTANT minoxidil MUCUS RELIEF SINUS (PSEUDOEPH) MINTOX MULTAQ NASAL SPRAY mintox maximum strength MULTI-YN (OXYMETAZOLINE) mirtazapine MULTI-YN WITH IRON nasal spray (sodium chloride) misoprostol mitomycin multilex-t and m NASAL SPRAY 12 HOUR.. 78 mitoxantrone multiple vitamins nasal spray extra moisturizing M-M-R II (PF) multi-symptom cold night time modafinil nasal spray long acting moexipril multivitamin NATACYN moexipril-hydrochlorothiazide multi-vitamin nateglinide multivitamin with iron NATPARA molindone multivitamin with minerals 150 natural balance mometasone... 72, 133 mupirocin NATURAL FIBER mono-linyah mupirocin calcium LAXATIVE (SUGAR) mononessa (28) MUSTARGEN natural fiber laxative s/f montelukast MY WAY natural fiber laxative smooth 95 morgidox mycophenolate mofetil NATURAL FIBER morphine... 36, 37 mycophenolate sodium LAXATIVE THERAPY.. 95 MORPHINE MYOZYME natural laxative morphine (pf) MYRBETRIQ NATURE'S TEARS morphine concentrate myzilra (HYPROMELLOSE) MOTION SICKNESS N NEBUPENT nabumetone necon 0.5/35 (28)

181 necon 1/35 (28) nifedipine nortrel 1/35 (28) necon 10/11 (28) nikki (28) nortrel 7/7/7 (28) necon 7/7/7 (28) NILANDRON nortriptyline NEEDLES, INSULIN nimodipine NORVIR... 5 DISP.,SAFETY NINLARO NOVAREL nefazodone nite time-d cold-flu relief NOVOFINE neomycin nite-time NOVOLIN 70/ neomycin-bacitracin-poly-hc nitro-bid NOVOLIN N nitrofurantoin macrocrystal.. 16 NOVOLIN R neomycin-bacitracinpolymyxin... nitrofurantoin monohyd/m- NOVOLOG cryst NOVOLOG FLEXPEN neomycin-polymyxin b gu nitroglycerin NOVOLOG MIX neomycin-polymyxin b- NITROSTAT NOVOLOG MIX dexameth nizatidine FLEXPEN neomycin-polymyxingramicidin... no drip NOVOLOG PENFILL non-aspirin NOVOTWIST neomycin-polymyxin-hc... 79, NON-ASPIRIN NOXAFIL non-aspirin children's NRS NASAL RELIEF neo-polycin NON-ASPIRIN EXTRA nu-copd neo-polycin hc STRENGTH NUCYNTA NEORAL non-aspirin nightime NUCYNTA ER neo-tuss NON-ASPIRIN PAIN RELIEF NUEDEXTA NEPHRAMINE 5.4 % NULOJIX NEPHRONEX NON-DROWSY ALLERGY NUPLAZID NEUMEGA NUVARING NEUPOGEN NORDITROPIN FLEXPRO nyamyc NEUPRO nystatin... 2, 69 nevirapine... 4 NORDITROPIN NORDIFLEX nystatin-triamcinolone NEXAVAR nystop next choice noreth-ethinyl estradiol-iron O NEXT CHOICE ONE DOSE ocean for kids norethindrone (contraceptive) OCEAN NASAL niacin ocella niacin (inositol niacinate) norethindrone acetate octreotide acetate niacin (niacinamide) norgestimate-ethinyl estradiol ocutabs niacin flush free ODEFSEY... 5 niacinamide NORMOSOL-M IN 5 % ODOMZO nicardipine DEXTROSE OFEV nicorelief NORMOSOL-R ofloxacin... 15, 79, 115 NICORELIEF NORMOSOL-R IN 5 % ogestrel (28) nicotine DEXTROSE olanzapine nicotine (polacrilex) NORMOSOL-R PH olanzapine-fluoxetine NICOTROL NORTHERA olopatadine... 78, 117 NICOTROL NS nortrel 0.5/35 (28) omega-3 acid ethyl esters nifedical xl nortrel 1/35 (21) omeprazole

182 ONCASPAR oxycodone-aspirin p-col rite ondansetron oxymorphone PEDIA RELIEF COUGHondansetron hcl oysco 500/d COLD ondansetron hcl (pf) OYSCO 500/D pediacare fever reducer ONE DAILY oysco d pediacare multi-symptom cold one daily essential OYSCO one daily for men oyster shell calcium PEDIALYTE one daily for men 50+ OYSTER SHELL CALCIUM PEDIALYTE FREEZER advanced POPS one daily for women oyster shell calcium-vit d PEDIALYTE SINGLES one daily maximum OYSTER SHELL CALCIUM- PEDIATRIC COUGH AND ONE DAILY MEN'S VIT D COLD one daily multivit-iron(folic) P PEDIATRIC ELECTROLYTE pacerone one daily plus iron paclitaxel pediatric enema one daily women 50 plus PAIN AND FEVER pediatric freezer pops one daily women's PAIN RELIEF PEDVAX HIB (PF) one daily womens 50 plus pain relief (acetamin-asp-caf) peg 3350-electrolytes one-a-day essential PEG ONE-A-DAY MEN'S PAIN RELIEF EXTRA peg-3350 with flavor packs.. 96 MULTIVITAMIN STRENGTH PEGANONE one-a-day teen advantage pain relief pm PEGASYS ONFI PAIN RELIEF REGULAR peg-electrolyte soln ONGLYZA STRENGTH PEGINTRON OPCICON ONE-STEP PAIN RELIEVER PEGINTRON REDIPEN OPDIVO pain reliever (acetam-aspirin) penicillin g potassium OPSUMIT penicillin g procaine opti-vitamins PAIN RELIEVER EXTRA penicillin g sodium ORACEA STRENGTH penicillin v potassium oralone pain reliever plus PENTAM ORALYTE pain reliever pm... 45, 127 pentoxifylline ORGAN-I NR pain reliever pm ex-strength. 45 pepcid ac ORKAMBI paliperidone PEPTIC RELIEF orsythia pamidronate pepto-bismol oxacillin PANRETIN pepto-bismol to-go oxacillin in dextrose(iso-osm) pantoprazole perdiem overnight relief pantothenic acid PERFOROMIST oxaliplatin paricalcitol perindopril erbumine oxandrolone paroex oral rinse periogard oxaprozin paromomycin PERJETA oxazepam paroxetine hcl permethrin oxcarbazepine PASER perphenazine oxybutynin chloride , 135 PATADAY perphenazine-amitriptyline oxycodone PAXIL persa-gel oxycodone-acetaminophen PAZEO PHARBECHLOR

183 pharbedryl POMALYST PREZISTA... 5 PHARBEDRYL portia PRIFTIN pharbetol PORTRAZZA PRIMAQUINE PHARBETOL potassium bicarb and chloride primidone phenelzine PRISTIQ phenobarbital potassium chlorid-d5- PROAIR HFA phenoxybenzamine %nacl PROAIR RESPICLICK PHENYTEK potassium chloride , 140 probenecid phenytoin potassium chloride in 0.9%nacl procainamide phenytoin sodium PROCALAMINE 3% phenytoin sodium extended.. 29 potassium chloride in 5 % dex prochlorperazine philith prochlorperazine edisylate PHOSPHOLINE IODIDE potassium chloride in lr-d prochlorperazine maleate pilocarpine hcl... 75, 116 potassium chloride-0.45 % nacl PROCRIT pimozide procto-pak pimtrea (28) potassium chloride-d5- proctosol hc pindolol %nacl proctozone-hc pink bismuth potassium chloride-d5- progesterone micronized PINK BISMUTH %nacl PROGLYCEM pioglitazone potassium chloride-d5- PROLEUKIN pioglitazone-glimepiride %nacl PROLIA pioglitazone-metformin potassium citrate PROMACTA piperacillin-tazobactam POTIGA promethazine pirmella powderlax propafenone piroxicam PRADAXA propranolol PLASMA-LYTE PRALUENT PEN propranolol-hydrochlorothiazid PLASMA-LYTE A PRALUENT SYRINGE PLASMA-LYTE-56 IN 5 % pramipexole propylthiouracil DEXTROSE pravastatin PROQUAD (PF) podactin prazosin PROSIGHT podofilox prednicarbate PROSOL 20 % polycin prednisolone protriptyline polyethylene glycol prednisolone acetate PROVIL POLY-IRON prednisolone sodium phosphate pseudoephedrine hcl polymyxin b sulfate , 118 PULMOZYME polymyxin b sulf-trimethoprim prednisone puralube prednisone intensol PURIXAN polysaccharide iron PREGNYL pyrazinamide POLY-VITA PREMARIN pyridostigmine bromide POLY-VITA (IRON) premasol 10 % pyridoxine (vitamin b6) POLY-VITAMIN PREMASOL 6 % Q POLY-VITAMIN WITH prenatal vitamin oral tablet. 151 q-dryl IRON prevalite Q-PAP POLYVITAMIN/IRON previfem Q-PAP EXTRA STRENGTH POLY-VITAMINS PREZCOBIX

184 q-tapp reprexain S q-tapp dm RESCRIPTOR... 5 SABRIL Q-TUSSIN reserpine saline mist Q-TUSSIN DM RESTASIS saline nasal QUADRACEL (PF) retaine cmc saline nose quasense RETROVIR... 5 SAL-PLANT quetiapine REVLIMID SAMSCA quinapril REXULTI SANCUSO quinapril-hydrochlorothiazide REYATAZ... 5 SANDIMMUNE ribavirin... 5 SANDOSTATIN LAR quinidine gluconate riboflavin (vitamin b2) DEPOT... 24, 25 quinidine sulfate rifabutin SANI-SUPP (ADULT) quinine sulfate rifampin sani-supp (child) R riluzole sani-supp (infant) RABAVERT (PF) rimantadine... 5 SANTYL raloxifene ringers SAPHRIS ramipril risedronate... 76, 106 SAPHRIS (BLACK RANEXA RISPERDAL CONSTA CHERRY) ranitidine hcl risperidone... 51, 52 SAVELLA RAPAMUNE RITUXAN SCOT-TUSSIN DM RAVICTI rivastigmine scot-tussin expectorant READY-TO-USE ENEMA. 96 rivastigmine tartrate... 32, 33 sea soft nasal mist REBIF (WITH ALBUMIN) rizatriptan selegiline hcl ROBAFEN selenium sulfide REBIF REBIDOSE robafen cf (phenylephrine). 128 SELZENTRY... 5 REBIF TITRATION PACK robafen cough SENEXON ROBAFEN DM SENEXON-S reclipsen (28) robafen dm clear SENNA RECOMBIVAX HB (PF) ROBAFEN DM COUGH SENNA LAX refenesen ROBAFEN DM COUGH- SENNA LAXATIVE refenesen pe CHEST CONGEST senna laxative-stool softener 97 regonol robitussin cough and cold cf SENNA PLUS REGRANEX SENNA WITH DOCUSATE REGULOID robitussin cough-chest cong SODIUM REGULOID, SUGAR FREE96 dm senna-gen RELENZA DISKHALER... 5 ropinirole SENNA-S RELISTOR rosadan SENNA-TIME S REMICADE rosuvastatin SENNO REMODULIN ROTARIX sennosides-docusate sodium. 97 RENA-VITE ROTATEQ VACCINE sen-o-tab RENVELA roweepra SENSIPAR repaglinide roxicet SEREVENT DISKUS repaglinide-metformin ROZEREM SEROQUEL XR REPATHA SURECLICK rynex dm sertraline REPATHA SYRINGE rynex pse sevelamer carbonate

185 severe allergy SOLU-CORTEF SUDOGEST sf 79 SOLU-CORTEF (PF) sudogest 12-hour sf 5000 plus SOMATULINE DEPOT sudogest cold and allergy SIGNIFOR SOMAVERT SUDOGEST PE SILACE soothe (bismuth subsalicylate) SUDOGEST SINUS AND sildenafil ALLERGY SILTUSSIN DM DAS soothe regular strength sulfacetamide sodium SILTUSSIN SA soothing pureway-c sulfacetamide sodium (acne) 68 SILTUSSIN-DM sorine sulfacetamide-prednisolone 119 silver sulfadiazine sotalol sulfadiazine SIMBRINZA sotalol af sulfamethoxazole-trimethoprim SIMULECT SOVALDI simvastatin spironolactone sulfamide sinus 12 hour spironolacton-hydrochlorothiaz SULFAMYLON SINUS AND ALLERGY PE sulfasalazine sprintec (28) sulindac sinus congestion and pain SPRITAM sumatriptan sinus nasal spray SPRYCEL sumatriptan succinate... 31, 32 sinus relief (oxymetazoline). 79 sps super b-50 complex SINUS RELIEF sronyx super b-50 complex plus (OXYMETAZOLINE) ssd super calcium sinus-allergy (phenylephrine) stavudine... 5 super multivitamin STIVARGA super quints b sirolimus STOMACH RELIEF SUPERPLEX-T SIRTURO stomach relief max strength. 88 SUPHEDRIN slo-niacin STOMACH RELIEF SUPHEDRINE smooth antacid ORIGINAL suphedrine 12 hour smoothlax STOOL SOFTENER suphedrine pe cold and allergy sodium bicarbonate STOOL SOFTENER sodium chloride... 76, 117, 140 LAXATIVE suphedrine pe sinus headache sodium chloride 0.45 % STOOL SOFTENER sodium chloride 0.9 % STIMULANT LAXAT SUPRAX... 9 sodium chloride 3 % STRATTERA SURMONTIL sodium chloride 5 % STREPTOMYCIN SUSTIVA... 5 sodium fluoride STRESS FORMULA SUTENT sodium lactate stress formula 600 c syeda sodium polystyrene (sorb free) stress formula advanced SYLATRON STRESS FORMULA WITH SYLATRON 4-PACK sodium polystyrene sulfonate IRON SYMBICORT STRESS FORMULA WITH SYMLINPEN SODIUM POLYSTYRENE ZINC SYMLINPEN SULFONATE STRIBILD... 5 SYNAGIS... 5, 6 sof-lax SUBOXONE SYNAREL SOLTAMOX sucralfate SYNERCID soluble fiber sudogest SYNJARDY

186 SYNRIBO tetrabenazine topotecan SYNTHROID tetracycline torsemide SYPRINE THALOMID TORSEMIDE T theophylline TOTAL B/C tab a vite THERA M PLUS (FERROUS tramadol TAB TUSSIN FUMARAT) tramadol-acetaminophen TAB-A-VITE THERA VITAMIN trandolapril TAB-A-VITE/IRON thera-d trandolapril-verapamil TABLOID theralogix companion tranexamic acid... 61, 109 tacrolimus... 25, 66 THERA-M TRANSDERM-SCOP TACTINAL therapeutic liquid tranylcypromine TACTINAL EXTRA therapeutic m + beta-carotene travasol 10 % STRENGTH TRAVEL SICKNESS TAFINLAR therems TRAVEL SICKNESS TAGRISSO therems-m (MECLIZINE) tamoxifen thiamine hcl (vitamin b1) travoprost (benzalkonium) tamsulosin thioridazine trazodone TARCEVA thiotepa TREANDA TARGRETIN thiothixene TRECATOR TASIGNA tiagabine TRELSTAR TAZORAC TIKOSYN TRESIBA FLEXTOUCH U- taztia xt tilia fe TECENTRIQ timolol maleate... 58, 115 TRESIBA FLEXTOUCH U- TECFIDERA tinactin TEFLARO... 9 tinidazole tretinoin TEGRETOL XR TIVICAY... 6 tretinoin (chemotherapy) TEKTURNA tizanidine tretinoin microspheres TEKTURNA HCT tl-hist dm triamcinolone acetonide. 72, 73, telmisartan TOBI PODHALER , 81, 134 telmisartan-hydrochlorothiazid TOBRADEX ST triamterene-hydrochlorothiazid tobramycin temazepam tobramycin in % nacl.. 13 trianex TENIVAC (PF) tobramycin in 0.9 % nacl TRI-BUFFERED ASPIRIN. 46 terazosin tobramycin sulfate triderm terbinafine hcl... 2, 70 tobramycin-dexamethasone 118 tri-estarylla terbutaline TOBREX trifluoperazine terconazole tolazamide trifluridine testosterone cypionate tolbutamide trihexyphenidyl testosterone enanthate tolcapone tri-legest fe tetanus toxoid,adsorbed (pf) tolmetin tri-linyah tolnaftate trilyte with flavor packets TETANUS,DIPHTHERIA tolterodine trimethoprim TOX PED(PF) topiramate trimipramine TETANUS-DIPHTHERIA TOPIRAMATE trinessa (28) TOXOIDS-TD toposar TRINTELLIX

187 triple antibiotic ultra b-100 complex VIDEX 2 GRAM PEDIATRIC tri-previfem (28) unithroid TRISENOX UPTRAVI VIDEX 4 GRAM PEDIATRIC tri-sprintec (28) ursodiol TRIUMEQ... 6 V VIGAMOX TRI-VITA valacyclovir... 6 VIIBRYD... 52, 53 TRI-VITAMIN VALCHLOR vimar trivora (28) VALCYTE... 6 VIMPAT TROPHAMINE 10 % valganciclovir... 6 vinblastine TROPHAMINE 6% valproate sodium vincasar pfs trospium valproic acid vincristine TRUMENBA valproic acid (as sodium salt) vinorelbine TRUVADA viorele (28) TUDORZA PRESSAIR valsartan VIRACEPT... 6 tums ultra valsartan-hydrochlorothiazide VIRAMUNE XR... 6 TUMS ULTRA VIRAZOLE... 6 TUSNEL DIABETIC vancomycin VIREAD... 6 TUSSIN VANCOMYCIN vit b complex-folic acid TUSSIN CF (PE-DM-GUAIF) VANCOMYCIN IN 0.9% vitabee/c SODIUM CL vitamin a TUSSIN CF COUGH-COLD VANCOMYCIN IN vitamin b complex DEXTROSE 5 %... 16, 17 vitamin b complex with c tussin chest congestion vandazole vitamin b tussin cough (dm only) VAQTA (PF) VITAMIN B tussin cough-chest congestion VARIVAX (PF) vitamin b VARIZIG VITAMIN B TUSSIN DM VARUBI vitamin b tussin dm cough VECAMYL VITAMIN B TUSSIN DM COUGH AND VELCADE vitamin c CHEST velivet triphasic regimen (28) VITAMIN C , 154 TUSSIN DM MAX vitamin c cough drops TUSSIN EXPECTORANT 129 VENCLEXTA vitamin c drops TWINRIX (PF) VENCLEXTA STARTING vitamin c with rose hips TYBOST... 6 PACK VITAMIN D TYGACIL venlafaxine vitamin d TYKERB VENLAFAXINE VITAMIN D tylophen VENTOLIN HFA vitamin e TYPHIM VI verapamil vitamin e (dl, acetate) TYSABRI veripred vitamin e acetate TYVASO VERSACLOZ vitamin e mixed TYZEKA... 6 VESICARE VITAMIN K U vestura (28) VITAMIN K ULORIC VICTOZA 2-PAK vitamins a and d ultimate women's complete VICTOZA 3-PAK VITAMINS AND MINERALS

188 VITAMINS B COMPLEX. 154 vitatrum VITEKTA... 6 vitrum senior VOLTAREN GEL voriconazole... 2, 3 VOTRIENT VPRIV VRAYLAR VYTORIN VYTORIN VYTORIN VYTORIN W wal-act d cold and allergy wal-dram wal-dryl allergy wal-dryl severe allergy-sinus wal-dryl-d allergy and sinus wal-fex allergy wal-finate wal-finate-d wal-flu night severe cold wal-itin wal-itin d 12 hour wal-mucil fiber (aspartame). 98 wal-mucil fiber (sugar) wal-mucil natural fiber lax wal-phed wal-phed 12 hour wal-phed pe wal-phed pe nighttime cold 130 wal-phed pe sinus and allergy wal-profen wal-tap dm wal-tussin cough wal-tussin cough and cold cf wal-tussin dm wal-zan wal-zan wal-zyr (cetirizine) wal-zyr d warfarin wart remover WELCHOL wera (28) wheat germ oil woman's laxative women's 50+ daily form (gkb) women's daily formula women's laxative (bisacodyl)98 WOMEN'S LAXATIVE (BISACODYL) wymzya fe X XALKORI XARELTO XELJANZ XELJANZ XR XGEVA XIFAXAN XIGDUO XR XOLAIR XTANDI XYREM Y YERVOY YF-VAX (PF) YONIS Z zafirlukast ZALTRAP zamicet zantac zantac maximum strength zarah ZAVESCA ZELBORAF ZEMPLAR zenchent (28) zenchent fe ZENPEP ZETIA ZIAGEN... 6 zidovudine... 6 zinc oxide zinc sulfate-vitamin c ziprasidone hcl ZIRGAN zoden pd zoledronic acid zoledronic acid-mannitol-water ZOLEDRONIC ACID- MANNITOL-WATER ZOLINZA zolmitriptan zolpidem ZOMETA zonisamide ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZYCLARA ZYIG ZYKADIA ZYPREXA RELPREVV ZYTIGA

189 Il presente formulario è stato aggiornato in data <MM/YYYY>. Per informazioni più recenti o altre domande, contattare il Piano al numero oppure, per gli utenti TTY, 771. Orari: dal lunedì alla domenica, dalle 8:00 alle 20:00. Oppure 15 West 65th Street New York, NY Lun-Dom, dalle 8:00 alle 20: TTY: 771