ELENCO DEI FARMACI COPERTI

ELENCO DEI FARMACI COPERTI Community Care Plus FIDA-MMP 2015 1.877.ICS.2525 www.icsny.org ICS_15412000_A2TC_G_EFF01012015_ 08042014_174025_Comprehensive_R11 3 14_Approved

ICS Community Care Plus FIDA-MMP Elenco dei farmaci convenzionati (formulario) per il 2015 Questo è un elenco dei farmaci che i Partecipanti possono ottenere nell ambito del piano ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP è un piano di cure gestite basato su accordi sia con Medicare che con il New York State Department of Health (Dipartimento della sanità dello stato di New York, Medicaid) per offrire ai Partecipanti i benefici di entrambi i programmi attraverso la dimostrazione FIDA (Fully Integrated Duals Advantage, vantaggio completamente integrato per candidati idonei per entrambi i sistemi). I benefici, l Elenco dei farmaci convenzionati e le reti di farmacie e fornitori possono cambiare di volta in volta nel corso dell anno e il 1 gennaio di ciascun anno. È possibile controllare l Elenco aggiornato dei farmaci convenzionati di ICS Community Care Plus FIDA-MMP in qualsiasi momento sul sito Web www.icsny.org/care-plus oppure contattando il Servizio partecipanti (ICS Community Care Plus FIDA-MMP Participant Services) al numero 1.887.ICS.2525. Possono applicarsi limitazioni. Per ulteriori informazioni contattare il Servizio partecipanti (ICS Community Care Plus FIDA-MMP Participant Services) o leggere il manuale del partecipante (ICS Community Care Plus FIDA-MMP Participant Handbook). Non è previsto alcun ticket (contributo personale) per alcun farmaco convenzionato. Queste informazioni sono disponibili gratuitamente anche in altri formati, quali Braille o stampa a caratteri grandi. Contattare il numero 1.877.ICS.2525. La chiamata è gratuita. Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 1.855.ICS.4TTY tra le 8:00 e le 20.00 dal lunedì al venerdì. La chiamata è gratuita. You can get this information for free in other languages. Call 1.877.ICS.2525 and TTY 1.855.ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday. The call is free. 1

Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный. 您可免费获得所有这些信息的其他语言版本 请在周一至周五上午 8 点至晚上 8 点致电 ICS, 电话号码为 1.877.ICS.2525, 听障专线 (TTY) 为 1.855.ICS.4TTY 此为免费电话 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al 1.877.ICS.2525 y a la línea TTY 1.855.ICS.4TTY, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan 1.877.ICS.2525 ak TTY 1.855.ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. 이모든정보는타언어로무료로제공됩니다. 월요일 ~ 금요일, 오전 8 시 ~ 오후 8 시사이에 1.877.ICS.2525 및 TTY( 청각장애인용전화 ) 1.855.ICS.4TTY 로 ICS 에전화해주십시오. 이전화는무료입니다. Lo Stato di New York ha creato un programma di tutela dei partecipanti chiamato Independent Consumer Advocacy Network o ICAN (Rete indipendente di sostegno ai consumatori) per offrire gratuitamente ai Partecipanti assistenza in modo riservato su tutti i servizi offerti da ICS Community Care Plus FIDA-MMP. L ICAN può essere contattato tramite il numero verde 1-844-614-8800 oppure attraverso il sito www.icannys.org. Domande più comuni (FAQ) Di seguito sono disponibili risposte a possibili domande in merito a questo Elenco dei farmaci convenzionati. È possibile leggere tutta la sezione delle domande più comuni per apprendere ulteriori informazioni oppure cercare una domanda e una risposta specifiche. 1. Quali farmaci su prescrizione sono contenuti nell Elenco dei farmaci convenzionati? (Per comodità, l Elenco dei farmaci convenzionati viene denominato Elenco dei farmaci.) I farmaci contenuti nell Elenco dei farmaci convenzionati che inizia a pagina 15 sono i farmaci coperti da ICS Community Care Plus FIDA-MMP. Questi farmaci sono disponibili 2

nelle farmacie facenti parte della nostra rete. Una farmacia fa parte della nostra rete se abbiamo stipulato un accordo di collaborazione con essa per fornire servizi ai nostri Partecipanti. Tali farmacie vengono denominate farmacie di rete. ICS Community Care Plus FIDA-MMP coprirà tutti i farmaci contenuti nell Elenco dei farmaci a condizione che: il medico o altro professionista della rete che prescrive il farmaco dichiari che il Partecipante necessita di tale farmaco per guarire o mantenersi in salute; il farmaco sia necessario sotto il profilo medico per la condizione del Partecipante; e il Partecipante utilizzi la prescrizione presso una farmacia di rete ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP potrebbe richiedere procedure aggiuntive per accedere a determinati farmaci (vedere la domanda 5 di seguito). In alcuni casi potrebbe essere necessario che il Partecipante faccia qualcosa prima di poter ottenere un determinato farmaco, come per esempio provare innanzitutto un altro farmaco. Un elenco aggiornato dei farmaci convenzionati è inoltre disponibile sul nostro sito www.icsny.org/care-plus/pharmacy-benefits oppure telefonicamente contattando il Servizio partecipanti (Participant Services) al numero 1.877.ICS.2525. 2. L Elenco dei farmaci può essere modificato? Sì. ICS Community Care Plus FIDA-MMP può aggiungere o rimuovere farmaci dall Elenco dei farmaci durante il corso dell anno. In generale, l Elenco dei farmaci viene modificato solo se: diventa disponibile un nuovo farmaco che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci; oppure veniamo informati che un farmaco non è sicuro. Ci riserviamo inoltre di modificare le nostre regole relative ai farmaci. Per esempio, potremmo: decidere di richiedere o non richiedere una approvazione preventiva per un farmaco [per Approvazione preventiva (Prior approval) si intende il permesso da parte di ICS Community Care Plus FIDA-MMP o dell equipe interdisciplinare (Interdisciplinary Team, IDT) del Partecipante prima che egli/ella possa ottenere il farmaco]; 3

aggiungere o modificare la quantità di farmaco che il Partecipante può ottenere [ limiti di quantità (quantity limits)]; aggiungere o modificare le limitazioni a una terapia per fasi relative a un farmaco [Terapia per fasi (Step therapy) significa che il Partecipante deve provare un farmaco prima che un altro farmaco possa essere coperto]. (Per ulteriori informazioni su queste regole relative ai farmaci, vedere pagina 5.) Il Partecipante verrà informato quando un farmaco che sta assumendo viene rimosso dall Elenco dei farmaci. Il Partecipante verrà inoltre informato di eventuali cambiamenti alle regole relative alla copertura di un farmaco. Le Domande 3, 4 e 7 di seguito presentano ulteriori informazioni in merito a cosa accade quando l Elenco dei farmaci viene modificato. È possibile controllare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP aggiornato in qualsiasi momento sul sito www.icsny.org/care-plus/drug-list. Potrà inoltre contattare il Servizio partecipanti (Participant Services) per controllare l Elenco dei farmaci attuale al numero 1.877.ICS.2525. 3. Cosa succede se diventa disponibile un farmaco più economico che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci? Se diventa disponibile un farmaco meno costoso che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci: Il farmacista potrà consegnare il farmaco più economico la prossima volta che il Partecipante presenta la prescrizione. Se il Partecipante e il suo fornitore decidono che il farmaco più economico non è idoneo per il Partecipante, il fornitore potrà istruire il farmacista a continuare a consegnare il farmaco che il Partecipante sta assumendo attualmente. ICS Community Care Plus FIDA-MMP potrà decidere di rimuovere il farmaco più costoso dall Elenco dei farmaci. Se il Partecipante sta assumendo un farmaco che viene rimosso dall Elenco dei farmaci perché è diventato disponibile un farmaco più economico che funziona altrettanto bene, il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla rimozione di tale farmaco dall Elenco dei farmaci oppure nel momento in cui il Partecipante ripresenta la prescrizione. In tal 4

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

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

Il Partecipante verrà informato se aggiungiamo l approvazione preventiva, limiti alla quantità e/o limitazioni tramite terapia per fasi relativa a un farmaco. Il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla data di aggiunta della limitazione oppure al momento in cui ripresenterà una prescrizione. In tal caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che il cambiamento all Elenco dei farmaci venga effettuato. In tal modo avrà tempo di discutere la decisione da prendere con il proprio medico o altro professionista che effettua la prescrizione. 8. Come si fa a trovare un farmaco nell Elenco dei farmaci? Vi sono due modi per trovare un farmaco: ricerca alfabetica (se si conosce come scrivere il nome del farmaco); oppure ricerca per condizione medica. Per la ricerca alfabetica, andare all Indice a pagina I-1. Quindi cercare il nome del farmaco nell elenco. Per la ricerca per condizione medica, andare all Elenco dei farmaci per condizione medica a pagina 15. Quindi individuare la condizione medica. Per esempio, se la condizione medica è cardiaca, cercare in tale categoria. In tale categoria saranno inclusi i farmaci per trattare condizioni cardiache. 9. Cosa fare se il farmaco desiderato non è incluso nell Elenco dei farmaci? Se il farmaco d interesse non è incluso nell Elenco dei farmaci, contattare il Servizio partecipanti (Participant Services) al numero 1.855.ICS.2525 per informazioni in merito. Se ICS Community Care Plus FIDA-MMP non copre tale farmaco, procedere in base a una delle opzioni seguenti: Chiedere al Servizio partecipanti (Participant Services) un elenco dei farmaci come quello che si desidera assumere. Quindi mostrare l elenco al proprio medico o altro professionista che effettua la prescrizione, che potrà prescrivere un farmaco incluso nell Elenco dei farmaci simile a quello d interesse. Oppure Chiedere al piano o alla propria equipe interdisciplinare (Interdisciplinary Team, IDT) di fare un eccezione per coprire il farmaco. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. 7

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

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

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

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

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

ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE ST (Quantity Limit Restriction) Limitazione tramite terapia per fasi (Step Therapy Restriction) viene coperta per ciascuna prescrizione o entro un determinato periodo di tempo. Prima che ICS Community Care Plus FIDA-MMP fornisca la copertura per il farmaco d interesse è necessario che il Partecipante provi uno (o più) farmaci per il trattamento della sua condizione medica. Il farmaco d interesse potrà essere coperto solo se uno (o più) farmaci non funzionano per il Partecipante. * LA GC Abbreviazione di altre coperture Farmaco non di Parte D (Not a Part D Drug) Farmaco ad accesso limitato (Limited Access Drug) Copertura nel periodo di interruzione (Gap Coverage) Il farmaco d interesse non è un farmaco di Parte D coperto da Medicaid. Questa prescrizione potrebbe essere disponibile solo presso determinate farmacie. Per ulteriori informazioni, consultare l Elenco delle farmacie o contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, da lunedì a venerdì, dalle 8:00 alle 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito www.icsny.org/care-plus. Forniamo la copertura di questo farmaco su prescrizione nel periodo di interruzione della copertura. Per ulteriori informazioni su questo tipo di copertura, consultare il documento Evidenza di copertura (Evidence of Coverage). Nota: l asterisco (*) a fianco di un farmaco indica che il farmaco non è un farmaco di Parte D. Tali farmaci hanno regole diverse per i ricorsi. Un ricorso (appeal) è un modo formale di richiedere la revisione e il cambiamento di una decisione di copertura se si ritiene che sia stato commesso un errore. Per esempio, ICS Community Care Plus FIDA- MMP o l equipe interdisciplinare (Interdisciplinary Team, IDT) potrebbe decidere che un farmaco d interesse per il Partecipante non è coperto o non è più coperto da Medicare o 13

Medicaid. Se il Partecipante o il suo medico o altro professionista che effettua la prescrizione non è d accordo con la decisione, è possibile fare ricorso. Per istruzioni su come fare ricorso, contattare il Servizio partecipanti (Participant Services) al numero 1.877.ICS.2525 oppure la Rete di sostegno ai consumatori (ICAN) al numero 1-844-614-8800. Informazioni su come fare ricorso su una decisione sono disponibili anche nel Manuale del Partecipante. 14

If you have questions, please call ICS Community Care Plus FIDA-MMP at 1.877.ICS.2525, Monday to Friday, 8 a.m. to 8 p.m. The call is free. For more information, visit www.icsny.org/care plus. 15

16 Analgesics Analgesics, Miscellaneous acephen * (Acetaminophen) acetaminophen * oral (Acetaminophen) acetaminophen * oral (Tylenol 8 Hour) acetaminophen * rectal suppository 120 mg, 650 mg (Acetaminophen) acetaminophen-codeine oral (Acetaminophen solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine 300-15 mg, 300-30 mg No.3) acetaminophen-codeine oral tablet 300-60 mg buprenorphine hcl injection butalb-acetaminophen-caffeine oral capsule 50-325-40 mg butalbital-acetaminop-caf-cod (Tylenol-Codeine No.3) (Buprenorphine HCl) (Esgic) (Fioricet with Codeine) butalbital-acetaminophen (Tencon) butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule (Esgic) (Fiorinal) QL (2700 per 30 QL (360 per 30 QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 PA-HRM; QL (180 per 30 QL (5 per 28 butorphanol tartrate nasal (Butorphanol Tartrate) BUTRANS QL (4 per 28 children's mapap * (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's pain & fever relief * oral (Infants' Tylenol) children's pain reliever * oral (Acetaminophen) children's pain reliever * oral (Acetaminophen)

17 children's silapap * (Tylenol Sore Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule 30-50-325-40 mg Codeine #3) 30 DURAMORPH (PF) fentanyl citrate (Actiq) PA; QL (120 per 30 fentanyl transdermal patch 72 hour PA; QL (20 per 30 (Duragesic) 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 PA; QL (10 per 30 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) feverall * rectal suppository 120 mg, 325 mg, 650 mg (Acetaminophen) hydrocodone-acetaminophen oral QL (2700 per 30 (Hycet) solution hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg (Norco) (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 QL (360 per 30 hydrocodone-ibuprofen (Ibudone) QL (150 per 30 hydromorphone (pf) injection (Hydromorphone solution 10 mg/ml HCl/PF) hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl)

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

19 morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml, 2 mg/ml (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (180 per 30 morphine oral tablet extended QL (120 per 30 (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) non-aspirin extra strength * oral (Acetaminophen) non-aspirin extra strength * oral (Tylenol Sore Throat) non-aspirin extra strength * oral tablet (Tylenol) non-aspirin jr strength * (Acetaminophen) nortemp * oral (Acetaminophen) NUCYNTA QL (181 per 30 NUCYNTA ER QL (60 per 30 (Oxycodone QL (1800 per 30 oxycodone hcl-acetaminophen oral HCl/Acetaminophe solution 5-325 mg/5 ml n) oxycodone hcl-acetaminophen oral QL (360 per 30 tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg (Xolox) oxycodone hcl-aspirin (Percodan) QL (360 per 30 oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30

20 oxycodone oral tablet (Percolone) QL (180 per 30 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg (Xolox) QL (360 per 30 oxycodone-acetaminophen oral QL (180 per 30 (Xolox) tablet 10-650 mg oxycodone-acetaminophen oral QL (240 per 30 (Xolox) tablet 7.5-500 mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) QL (60 per 30 oxymorphone oral tablet extended QL (120 per 30 (Opana ER) release 12 hr 30 mg, 40 mg pain relief adult * (Tylenol Sore Throat) pain relief * oral capsule (Acetaminophen) pain relief * oral tablet extended release (Tylenol 8 Hour) pain reliever jr strength * (Acetaminophen) pain reliever * oral (Acetaminophen) pharbetol * (Tylenol) q-pap extra strength * (Tylenol) q-pap * oral drops (Acetaminophen) q-pap * oral liquid (Tylenol Sore Throat)

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

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

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

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

25 CHANTIX STARTING MONTH BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 21 MG/24 HR NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 7 MG/24 HR nicorelief * buccal gum (Nicorette) nicorette * buccal gum 2 mg (Nicorette) nicotine (polacrilex) * (Nicorette) nicotine * transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr (Nicoderm Cq) nicotine * transdermal patch 24 hour 21 mg/24 hr, 22 mg/24 hr (Nicoderm Cq) NICOTROL ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG ZUBSOLV SUBLINGUAL TABLET 11.4-2.9 MG ZUBSOLV SUBLINGUAL TABLET 2.9-0.71 MG, 8.6-2.1 MG ZUBSOLV SUBLINGUAL TABLET 5.7-1.4 MG Antianxiety Agents Benzodiazepines QL (53 per 28 QL (168 per 365 QL (180 per 365 QL (168 per 365 PA; QL (120 per 30 PA; QL (30 per 30 PA; QL (60 per 30 PA; QL (90 per 30 alprazolam oral tablet (Xanax) QL (90 per 30 alprazolam oral tablet extended QL (90 per 30 (Xanax XR) release 24 hr 0.5 mg

alprazolam oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating chlordiazepoxide hcl 26 (Xanax XR) (Alprazolam) (Chlordiazepoxide HCl) QL (60 per 30 QL (90 per 30 QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 QL (90 per 30 (Klonopin) mg clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 clonazepam oral QL (300 per 30 (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 (Tranxene T-Tab) 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG diazepam injection (Diazepam) QL (10 per 28 diazepam intensol (Diazepam) QL (1200 per 30 diazepam oral solution (Diazepam) QL (1200 per 30 diazepam oral tablet (Valium) QL (120 per 30 diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30

27 estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 lorazepam oral solution (Ativan) QL (150 per 30 lorazepam injection solution (Ativan) QL (2 per 30 lorazepam injection syringe (Ativan) QL (2 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam QL (2 per 30 HCl/PF)

PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older triazolam oral tablet 0.125 mg (Halcion) with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30 28 midazolam (pf) injection syringe 2 (Midazolam QL (2 per 30 mg/2 ml (1 mg/ml) HCl/PF) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 PA NSO; QL (480 per ONFI ORAL SUSPENSION 30 ONFI ORAL TABLET 10 MG, 20 PA NSO; QL (60 per MG 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older temazepam oral capsule 15 mg, with over 90 days (Restoril) 22.5 mg, 30 mg cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days temazepam oral capsule 7.5 mg (Restoril) cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30

triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 tobramycin in 0.225 % nacl (Tobi) PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodiu m Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) 29

30 clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate) nitrofurantoin macrocrystal oral capsule 100 mg (Macrodantin) nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) PA-HRM; QL (120 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30

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

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

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

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

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

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

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

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

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

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

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

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

43 TARCEVA ORAL TABLET 150 PA NSO; QL (90 per MG 30 TARGRETIN TOPICAL PA NSO; QL (60 per 28 TASIGNA PA NSO; QL (112 per 28 TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION QL (1 per 168 TRELSTAR INTRAMUSCULAR QL (1 per 84 SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 28 SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB UNITUXIN PA NSO VALSTAR VECTIBIX PA NSO VELCADE PA NSO vinblastine intravenous (Vinblastine PA BvD Sulfate) vincristine (Vincristine PA BvD Sulfate)

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

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

46 lamotrigine oral tablet, chewable dispersible (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release 24 hr (Keppra XR) LYRICA ORAL CAPSULE QL (90 per 30 LYRICA ORAL SOLUTION QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, QL (90 per 30 15 mg, 16.2 mg, 32.4 mg, 60 mg, (Phenobarbital) 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenobarbital sodium injection (Phenobarbital QL (2 per 30 solution Sodium) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, ST; QL (90 per 30 300 MG, 400 MG POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 primidone (Mysoline) QUDEXY XR ST SABRIL tiagabine (Gabitril)

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

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

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

50 venlafaxine oral capsule,extended release 24hr (Effexor XR) venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg (Venlafaxine HCl) VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 BYDUREON QL (4 per 28 BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN QL (1.2 per 28 INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET QL (180 per 30 GLYXAMBI QL (30 per 30 INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG ST; QL (60 per 30 INVOKAMET ORAL TABLET ST; QL (120 per 30 50-500 MG INVOKANA ORAL TABLET 100 ST; QL (60 per 30 MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG JANUMET QL (60 per 30 JANUMET XR ORAL TABLET, QL (30 per 30 ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG QL (60 per 30

HUMALOG MIX 50-50 QL (40 per 28 51 JANUVIA QL (30 per 30 JARDIANCE ST; QL (30 per 30 JENTADUETO QL (60 per 30 KORLYM PA; QL (112 per 28 metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (120 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended QL (120 per 30 (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET QL (150 per 30 repaglinide (Prandin) QL (240 per 30 SYMLINPEN 120 PA; QL (10.8 per 28 SYMLINPEN 60 PA; QL (6 per 28 TRADJENTA QL (30 per 30 TRULICITY QL (4 per 28 VICTOZA PA; QL (9 per 28 Insulins HUMALOG KWIKPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN QL (12 per 28 200 UNIT/ML (3 ML)

HUMALOG MIX 50-50 QL (30 per 28 KWIKPEN HUMALOG MIX 75-25 QL (40 per 28 HUMALOG MIX 75-25 QL (30 per 28 KWIKPEN HUMALOG SUBCUTANEOUS QL (30 per 28 CARTRIDGE HUMALOG SUBCUTANEOUS QL (40 per 28 HUMULIN 70/30 QL (40 per 28 HUMULIN 70/30 KWIKPEN QL (30 per 28 HUMULIN N QL (40 per 28 HUMULIN N KWIKPEN QL (30 per 28 HUMULIN R QL (40 per 28 HUMULIN R U-500 QL (40 per 28 (CONCENTRATED) LANTUS QL (40 per 28 LANTUS SOLOSTAR QL (30 per 28 NOVOLIN 70/30 QL (40 per 28 NOVOLIN N QL (40 per 28 NOVOLIN R QL (40 per 28 NOVOLOG QL (40 per 28 NOVOLOG FLEXPEN QL (30 per 28 NOVOLOG MIX 70-30 QL (40 per 28 NOVOLOG MIX 70-30 FLEXPEN QL (30 per 28 NOVOLOG PENFILL QL (30 per 28 TOUJEO SOLOSTAR QL (7.5 per 28 Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended QL (60 per 30 (Glucotrol XL) release 24hr 10 mg 52

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

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

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

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

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

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

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

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

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

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

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

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

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

haloperidol lactate Name of Drug INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML (Haloperidol Lactate) ST; QL (30 per 30 ST; QL (60 per 30 QL (0.75 per 28 QL (1 per 28 QL (1.5 per 28 QL (0.25 per 28 QL (0.5 per 28 QL (0.875 per 84 QL (1.315 per 84 QL (1.75 per 84 QL (2.625 per 84 66

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

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

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

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

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

enoxaparin subcutaneous syringe 150 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection 72 (Lovenox) (Lovenox) (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) (Heparin Sodium in 5% Dextrose) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) QL (34 per 30 QL (18 per 30 QL (13.6 per 30 QL (20.4 per 30 QL (24 per 30 QL (15 per 30 QL (12 per 30 QL (18 per 30 PA BvD; (PA for ESRD Only) PA BvD PA BvD; (PA for ESRD Only)

heparin, porcine (pf) intravenous syringe 100 unit/ml HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 units/ml) bag excel container (Monoject Prefill Advanced) (Heparin Sodium in 5% Dextrose) (Heparin Sodium in 5% Dextrose) IPRIVASK PA; QL (24 per 28 jantoven (Coumadin) PRADAXA QL (60 per 30 warfarin (Coumadin) XARELTO Blood Formation Modifiers EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PA; QL (12 per 28 PA; QL (0.6 per 28 73

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 74 PROMACTA PA; QL (12 per 28 PA; QL (6 per 28 PA; QL (30 per 30 ZARXIO ST Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 aspirin-dipyridamole (Aggrenox) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 %

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

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

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

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

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

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

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

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

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

epinephrine 1 mg/ml ampul latexfree (Epinephrine) epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose PA BvD (Milrinone intravenous piggyback 40 mg/200 Lactate/D5W) ml (200 mcg/ml) norepinephrine bitartrate (Levophed Bitartrate) papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) amlodipine-valsartan (Exforge) amlodipine-valsartan-hcthiazid (Exforge HCT) AZOR ST PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 PA BvD 84

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

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

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

Central Nervous System Agents Central Nervous System Agents 88 amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA PA; QL (60 per 30 caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release 12 hr (Kapvay) dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, QL (120 per 30 (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 dextroamphetamine-amphetamine QL (30 per 30 oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) dextroamphetamine-amphetamine QL (60 per 30 oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Adderall XR) flumazenil (Romazicon) guanfacine oral tablet extended release 24 hr (Intuniv) lithium carbonate oral capsule (Eskalith) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended release (Lithobid) lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 50 mg, 60 mg (Metadate Cd) QL (30 per 30 methylphenidate oral capsule, er QL (60 per 30 (Metadate Cd) biphasic 30-70 30 mg

89 methylphenidate oral capsule,er QL (30 per 30 (Metadate Cd) biphasic 50-50 20 mg methylphenidate oral capsule,er QL (60 per 30 (Metadate Cd) biphasic 50-50 30 mg methylphenidate oral capsule,er QL (30 per 30 (Ritalin LA) biphasic 50-50 40 mg methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet QL (90 per 30 (Ritalin-SR) extended release methylphenidate oral tablet QL (30 per 30 extended release 24hr 18 mg, 27 mg, 54 mg (Concerta) methylphenidate oral tablet QL (60 per 30 (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 STRATTERA tetrabenazine (Xenazine) PA; QL (112 per 28 XENAZINE PA; QL (112 per 28 Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 cyred (Desogen) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, (Desogen) 0.15-0.03 mg drospirenone-ethinyl estradiol (Yaz)

ELLA ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D- Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) junel fe 24 (Loestrin Fe) kimidess (28) (Mircette) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 larin 24 fe (Loestrin Fe) levonorgestrel * 1.5 mg tablet (otc) (Plan B One-Step) QL (6 per 365 levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel * oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel-ethin estradiol oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month (Levonorgestrel- Ethin Estradiol) (Amethyst) QL (91 per 84 (Levonorgestrel- QL (91 per 84 Ethin Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 next choice one dose 1.5 mg tb (rx) QL (6 per 365 (Plan B One-Step) 1.5 mg norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg (Loestrin) norethindrone-e.estradiol-iron (Loestrin Fe) 90

norethindrone-e.estradiol-iron oral tablet 1-20(5)/1-30(7) /1mg-35mcg (Loestrin Fe) (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg, (Modicon) 0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 opcicon one-step * (Plan B One-Step) QL (6 per 365 PLAN B ONE-STEP * 3 $0 QL (6 per 365 setlakin (Levonorgestrel- QL (91 per 84 Ethin Estradiol) tarina fe (Loestrin Fe) Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) adt robitussin peak cld dm max * (G-Zyncof) adult nasal decongestant * (Pseudoephedrine HCl) adult robitussin lingering cld * (Dextromethorphan Hbr) adult robitussin peak cold dm * (G-Zyncof) adult wal-tussin * (Robitussin Mucus-Chest Congest) adult wal-tussin dm max * (G-Zyncof) alka-seltzer plus mucus-conges * (Guaifenesin/Dextr omethorphan) 91

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

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

cold multi-symptom nighttime * (Dm/Pe/Acetamino phen/doxylamine) cold relief m/s day/night * (Dm Hb/Pe/Acetaminop hen/chlorph) (Dcold-flu relief * oral liquid 12.5-30- Methorphan/Aceta 1,000 mg/30 ml min/doxylamn) cold-flu relief, day/night * (Vicks Dayquil- Nyquil) congestac * (Poly-Vent Ir) coricidin hbp * oral capsule (Guaifenesin/Dextr omethorphan) cough & cold * oral (Coricidin Hbp) cough & runny nose * oral liquid 1- (Vicks Children'S 5 mg/5 ml Nyquil) creo-terpin (dm-guaifenesin) * (Cough Formula Dm) daytime cold & cough * (Triaminic) daytime cold-flu * (D- Methorphan/Pe/Ac etaminophen) day-time cough * (Dextromethorphan Hbr) daytime mucus relief dm * (G-Zyncof) daytime-nighttime * (Vicks Dayquil- Nyquil) daytime-nighttime cold-flu * (Dm/Pe/Acetamino phen/doxylamine) daytime-nighttime cough * (Dextromethorphan Hb/Doxylamine) decongestant cough * (Trispec Pse) delsym cough+chest congest dm * (G-Zyncof) despec-dm (pseudoeph-dm-guaif) * oral tablet 30-10-200 mg (Poly-Vent Dm) 94

95 dexchlorphen-pse-chlophedianol * (Panatuss Ped) dextromethorphan polistirex * (Delsym) diabetic siltussin das-na * (Robitussin Mucus-Chest Congest) diabetic tussin dm * (G-Zyncof) diabetic tussin ex * oral (Robitussin Mucus-Chest Congest) dimaphen dm * (Brompheniram/Ph enylephrine/dm) (D-Methorphan d-methorphan hb-p-epd hcl-bpm * Hb/P-Epd oral syrup 2-30-10 mg/5 ml HCl/Bpm) 3 $0 dm-phenyleph-chlorpheniramine * (Dm/Phenyleph/Ch oral drops 1-2-3 mg/ml lorpheniramine) ed bron gp * (Despec) entre-cough * (Trispec Pse) exefen dmx * (Poly-Vent Dm) expectorant dm * oral liquid (G-Zyncof) expectorant max strength * (Dextromethorphan /Pseudoephed) expectorant * oral (Robitussin Mucus-Chest Congest) flu formula daytime-nighttime * (Dm/Pe/Acetamino ph/diphenhydram) flu severe cold-congestion * (Theraflu) geri-tussin dm * (Cough Formula Dm) guaiatussin ac * (M-Clear Wc) guaifenesin dac * (Tusnel C) guaifenesin * oral tablet 200 mg (Allfen) guaifenesin * oral tablet extended release 12hr (Mucinex)

head congestion day-night * Name of Drug hydrocodone bit-homatrop me-br * oral syrup 5-1.5 mg/5 ml hydrocodone-chlorpheniramine * hydrocodone-homatropine * oral syrup 5-1.5 mg/5 ml hydrocodone-homatropine * oral tablet (Dm Hb/Pe/Acetaminop hen/chlorph) (Hydrocodone Bit/Homatrop Me- Br) (Hydrocodone/Chl orphen P-Stirex) (Hydrocodone Bit/Homatrop Me- Br) 3 $0 3 $0 3 $0 (Tussigon) 3 $0 infants' non-aspirin cold * (Dm/Pseudoephed/ Acetaminophen) intense cough reliever * oral liquid (G-Zyncof) kidkare cough/cold * (D-Methorphan Hb/P-Ephed HCl/Cp) liquibid d-r * (Maxiphen) lohist peb dm * (Ala-Hist Dm) lortuss ex * oral syrup (Tusnel C) mar-cof bp * (Bromphenira/Pseu doephed/codein) 3 $0 mar-cof cg * (M-Clear Wc) 3 $0 maximum strength flu * (Coricidin Hbp) medi-brom * (D-Methorphan Hb/P-Epd HCl/Bpm) mesehist dm * (D-Methorphan Hb/P-Ephed HCl/Cp) mucinex fast-max dm max * (G-Zyncof) mucus dm * (Mucinex Dm) mucus dm max * (Mucinex Dm) 96

mucus relief * oral tablet 400 mg (Allfen) multi-symptom cold night time * (Theraflu) multi-symptom cold-cough * (Dm Hb/Pseudoephed/A cetamin/cp) nasal & sinus decongestant * (Sudafed 12-Hour) neo-tuss * (G-Zyncof) NEXAFED * night time cold-flu * oral (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/Pnight time cold-flu relief * oral Ephed/Acetaminop liquid h/doxylam) (Dm/Pnight time * oral capsule Ephed/Acetaminop h/doxylam) nighttime cold-flu * (D- Methorphan/Aceta min/doxylamn) nighttime cough * (Dextromethorphan Hb/Doxylamine) nite time cold-flu * (D- Methorphan/Aceta min/doxylamn) nite time-d cold-flu relief * (Dm/P- Ephed/Acetaminop h/doxylam) nohist-dm * (Dm/Phenyleph/Ch lorpheniramine) non-aspirin cold * (Dm Hb/Pseudoephed/A cetamin/cp) non-aspirin flu * oral tablet 30-15- 500 mg (Dm/Pseudoephed/ Acetaminophen) 97

pecgen dmx * oral liquid 15-125 mg/5 ml pedia relief * pedia relief infant * pediacare multi-symptom cold * phenylhistine dh * poly-tussin * promethazine-codeine * promethazine-dm * promethazine-phenyleph-codeine * pseudoephedrine hcl * oral (G-Zyncof) (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Promethazine/Phe nyleph/codeine) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 pseudoephedrine hcl * oral (Sudafed 12-Hour) q-tapp dm * (D-Methorphan Hb/P-Epd HCl/Bpm) q-tussin * (Robitussin Mucus-Chest Congest) q-tussin dm * (Cough Formula Dm) refenesen * (Allfen) refenesen pe * (Maxiphen) relcof c * (M-Clear Wc) 3 $0 REZIRA * 3 $0 98

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

THERAFLU SEVERE COLD- COUGH * triacting m-sym cold/cough * triaminic cold & cough (pe) * triaminic cough-nasal congesti * TRIAMINIC COUGH-SORE THROAT * (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Phenylephrine) (Dextromethorphan /Pseudoephed) tri-dex pe * (Dm/Phenyleph/Ch lorpheniramine) trigofen dm * (Accuhist Pdx) trymine cg * (M-Clear Wc) tusnel diabetic * (G-Zyncof) TUSNEL PEDIATRIC * ORAL LIQUID tussin cf cough-cold * (Giltuss) tussin cf * oral (Guaifenesin/Dm/P seudoephedrine) tussin cold-congestion * (Guaifenesin/Dm/P seudoephedrine) tussin cough (dm only) * oral (Dextromethorphan Hbr) tussin dm cough & chest * oral liquid 10-200 mg/5 ml (G-Zyncof) tussin dm * oral (Cough Formula Dm) tussin maximum strength cough * (Dextromethorphan Hbr) tussin pe * oral liquid (Despec) valu-tapp dm * (D-Methorphan Hb/P-Epd HCl/Bpm) 100

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

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

DRYSOL DAB-O-MATIC FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) geri-hydrolac * topical (Lac-Hydrin Twelve) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) LACTINOL HX * lobana bath * (Mineral Oil) mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.015 % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL silver nitrate applicators (Silver Nitrate Applicator) skin treatment * (Lac-Hydrin Twelve) VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM QL (15 per 30 Dermatological Antibacterials bacitracin * topical (Bacitracin) 103

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

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

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

hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Cortizone-10) 3 $0 hydrocortisone topical lotion 2 %, 2.5 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream Valerate) hydrocortisone valerate topical ointment (Westcort) hydroskin * topical lotion (Cortizone-10) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) recort plus * (Hydrocortisone) tacrolimus topical (Protopic) triamcinolone acetonide topical (Triamcinolone cream Acetonide) triamcinolone acetonide topical lotion (Kenalog) triamcinolone acetonide topical ointment 0.025 %, 0.05 %, 0.1 %, 0.5 % (Triderm) 107

triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical cream (Retin-A) PA tretinoin topical gel 0.01 %, 0.025 PA (Retin-A) % Scabicides And Pediculicides lice cream rinse * (Nix) lice killing * (Piperonyl Butoxide/Pyrethrin s) lice treatment (permethrin) * (Nix) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA- FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE 108

INSULIN SYRINGE-NEEDLE U- 100 SYRINGE PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U- 100 109 Disinfectants (For Non-Dermatologic Use) Disinfectants (For Non-Dermatologic Use) iodine * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA PA CIMZIA POWDER FOR PA RECONST CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS QL (30 per 30 lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD

110 VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 ZENPEP Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) alaway * (Zaditor) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette 0.1-0.3 % F) artificial tears * ophthalmic drops 0.1-0.3 % artificial tears * ophthalmic drops 0.5-0.6 % artificial tears * ophthalmic ointment (Tears Naturale) (Polyvinyl Alcohol/Povidone) (Petrolat,Wht/Min Oil/Sod Chl) artificial tears(glycerin-peg) * (Glycerin/Propylen e Glycol) artificial tears(hypromellose) * (Genteal Mild To Moderate) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal (Astepro) QL (30 per 25 azelastine ophthalmic (Optivar) bion tears (pf) * (Dextran 70/Hypromellose/P F)

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

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

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

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

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

116 mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Gas-X) simethicone * oral (Infants' Mylicon) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) acid relief (cimetidine) * (Tagamet Hb) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine hcl oral (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 (Rx Product Only) (Tagamet) mg, 400 mg, 800 mg cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole * dr 15 mg capsule 2x14 day course (otc) (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol (Cytotec) omeprazole magnesium * (Omeprazole Magnesium) omeprazole oral capsule,delayed release(dr/ec) (Prilosec) omeprazole * oral tablet,delayed release (dr/ec) (Omeprazole) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) 3 $0 oral capsule 20-1.1 mg-gram pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) PRILOSEC OTC *

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

118 anti-diarrheal (loperamide) * oral (Imodium A-D) bismatrol * oral suspension 262 mg/15 ml (Pepto-Bismol) bismatrol * oral tablet,chewable (Pepto-Bismol) BUPHENYL ORAL TABLET calci-chew * (Tums) calcium carbonate * oral tablet,chewable 500 mg calcium (Tums) (1,250 mg) CALCIUM CARBONATE- VITAMIN D3 * ORAL TABLET,CHEWABLE 500-100 MG-UNIT cal-gest antacid * (Tums) children's soothe * (Tums) CHOLBAM comfort gel extra strength * (Maalox Maximum Strength) cromolyn oral (Gastrocrom) diamode * (Imodium A-D) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Maalox Maximum Strength) foaming antacid * (Gaviscon) gelusil antacid & anti-gas * oral (Maalox Maximum suspension Strength) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul)

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

RELISTOR SUBCUTANEOUS ri-gel ii * (Maalox Maximum Strength) ri-mox * (Maalox Maximum Strength) sodium bicarbonate * oral tablet (Sodium 650 mg Bicarbonate) soothe (bismuth subsalicylate) * (Bismuth oral Subsalicylate) soothe regular strength * (Pepto-Bismol) stomach relief * oral (Bismuth Subsalicylate) ultra strength antacid * (Tums) ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives alophen * (Dulcolax) bisac-evac * (Dulcolax) bisacodyl * oral (Dulcolax) bisacodyl * rectal (Dulcolax) biscolax * (Dulcolax) clearlax * oral (Gavilax) colace * oral capsule 100 mg (Sof-Lax) doc-q-lace * (Sof-Lax) docu * (Docusate Sodium) docusate sodium * oral (Docusate Sodium) docusol * (Docusate Sodium) dok * oral capsule (Sof-Lax) dok * oral tablet (Docusate Sodium) dulcolax stool softener (dss) * (Sof-Lax) enema disposable * (Enema) enema * rectal enema * 19-7 gram/118 ml (Enema) PA; QL (28 per 28 120

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

calcium 600 with vitamin d3 * oral calcium carbonate * oral calcium carbonate * oral tablet 260 mg calcium (648 mg) calcium carbonate-vitamin d2 * calcium carbonate-vitamin d3 * oral capsule 600 mg(1,500mg) -100 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * oral tablet calcium carbonate-vitamin d3 * oral tablet,chewable 500 mg(1,250mg) -400 unit (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Caltrate 600) (Calcium Carbonate/Vitamin D2) (Calcium Carbonate/Vitamin D3) (Os-Cal 500+D) (Os-Cal 500+D) calcium chloride intravenous (Calcium Chloride) calcium citrate-vitamin d3 * oral (Citracal-Vitamin tablet 315-250 mg-unit D) calcium gluconate intravenous (Calcium Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg) Gluconate) calcium lactate * oral tablet 84 mg (648 mg), 84 mg (650 mg) (Calcium Lactate) calcium+d * oral tablet (Os-Cal 500+D) CALTRATE 600 + D * CALTRATE-600 + D VIT D3 (800) * CENTRUM PRO NUTRIENTS * citracal + d maximum * (Citracal-Vitamin D) PA BvD; (PA for ESRD Only) 139

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

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

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

potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) (Potassium potassium chloride-0.45 % nacl Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%NaCl) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 (Potassium Chloride/D5- meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) potassium citrate-citric acid oral (Potassium packet 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium solution 1,100-334 mg/5 ml Citrate/Citric Acid) (Potassium potassium phosphate m-/d-basic Phos,M-Basic-D- Basic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium solution Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) 143

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

145 montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution PA BvD (Albuterol Sulfate) for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr (Vospire ER) ANORO ELLIPTA QL (60 per 30 ATROVENT HFA QL (25.8 per 28 COMBIVENT RESPIMAT QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 PROAIR RESPICLICK QL (2 per 25 SEREVENT DISKUS QL (60 per 30 SPIRIVA RESPIMAT QL (4 per 30 SPIRIVA WITH HANDIHALER QL (30 per 30 STIOLTO RESPIMAT QL (4 per 28 STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous)

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

COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL PA ROZEREM XYREM LA zaleplon (Sonata) zolpidem oral tablet (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 147

zolpidem oral tablet,ext release multiphase Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents (Phentolamine phentolamine injection Mesylate) Vasodilating Agents Vasodilating Agents 148 (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 ADCIRCA PA; QL (60 per 30 ADEMPAS PA; QL (90 per 30 epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 OPSUMIT PA; QL (30 per 30 ORENITRAM PA REMODULIN PA BvD sildenafil intravenous (Revatio) PA; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 TRACLEER PA; LA; QL (60 per 30 TYVASO PA BvD TYVASO REFILL KIT PA BvD PA

149 TYVASO STARTER KIT PA BvD VENTAVIS PA BvD Vitamins And Minerals Vitamins And Minerals a thru z advanced formula * (Multivitamin/Iron/ Folic Acid) a thru z high potency * oral tablet (Multivitamin W- Minerals/Lutein) a thru z select 50+ formula * (Biocel) a thru z select * oral tablet (Multivitamin W- Minerals/Lutein) a thru z select * oral tablet 300-600-300 mcg, 500-300-250 mcg (Biocel) a thru z select women's * (Multivits W- Fe,Other Min/Lut) abc plus * (Biocel) adult multivitamin gummies * (One-A-Day Vitacraves) adult one daily gummies * (One-A-Day Vitacraves) adults 50+ daily formula * (Biocel) adults' daily formula * (Multivitamin/Iron/ Folic Acid) (Vit A,C, and airshield * oral tablet, effervescent E/Dietary Supp 5,000-1000-30 unit-mg-unit No.12) animal chews * (Multivitamin) animal shape vitamins * (Multivitamin) animal shapes plus iron * (Multivitamins with Iron) antioxidant * (Beta-Carotene(A) W-C and E/Min) antioxidant formula * (Beta-Carotene(A) W-C and E/Min)

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

balanced b-150 * (Vitamin B Complex) balanced b-50 * oral tablet (Vitamin B Complex) b-complex * oral tablet (Vitamin B Complex) b-complex with vitamin c * oral (B Complex with capsule Vitamin C) b-complex with vitamin c * oral tablet (Vita-Bee with C) bee-zee * (Multivitamin with Minerals) biosupp * (Multivitamin with Minerals) biotin * oral tablet 300 mcg (Biotin) biovol * (Multivitamin with Minerals) c complex * (Ascorbic Acid) calcidol * (Drisdol) centamin * (Multivits W- Min/Ferrous Gluc) central vite with lutein * (Biocel) central-vite for seniors * (Multivitamin W/Iron, Minerals) central-vite * oral tablet 18-400 (Multivitamin/Iron/ mg-mcg Folic Acid) central-vite select * oral tablet (Multivitamin W- Minerals/Lutein) central-vite senior * (Biocel) centram-care * (Multivits W- Min/Ferrous Gluc) centravites 50 plus * (Multivitamin W/Iron, Minerals) centrum complete * (Multivitamin/Iron/ Folic Acid) 151

centrum * oral liquid (Multivits W- Min/Ferrous Gluc) centrum silver * oral tablet (Biocel) centrum ultra women's * (Multivitamin/Iron/ Folic Acid) century adults 50+ * (Biocel) century advanced formula * (Multivits W- Fe,Other Min/Lut) century mature * oral tablet (Multivitamin W- Minerals/Lutein) century mature * oral tablet 0.4-300-250 mg-mcg-mcg, 500-300-250 mcg (Biocel) century * oral tablet 18-400 mgmcg Folic Acid) (Multivitamin/Iron/ century ultimate women's * oral (Multivitamin/Iron/ tablet 18-400 mg-mcg Folic Acid) cerovite * (Multivits W- Min/Ferrous Gluc) cerovite advanced formula * (Multivitamin/Iron/ Folic Acid) cerovite jr * (Multivitamin W/Iron, Minerals) cerovite senior * (Multivitamin W- Minerals/Lutein) certavite senior-antioxidant * (Biocel) certavite-antioxid (iron gluc) * oral (Multivits W- liquid 9 mg iron/15 ml Min/Ferrous Gluc) certavite-antioxidant * (Multivitamin/Iron/ Folic Acid) chewable multi vitamin * (Multivitamin) chewable-vite * (Multivitamin) chewable-vite with iron * (Multivitamins with Iron) 152

child complete multivitamin * (Pedi Mv No.58/Ferrous Fumarate) child vitamin with minerals * (Multivitamin W/Iron, Minerals) children's chewable * (Multivitamin) children's chewable complete * oral tablet,chewable (Multivitamin) children's chewable vitamin * (Multivitamin) children's chewable w/minerals * (Multivitamin W/Iron, Minerals) children's complete vitamin * (Pedi Mv No.67/Ferrous Fumarate) children's multivit w/extra c * (Multivitamin) children's vitamin with iron * (Multivitamins with Iron) childs chew vite * (Multivitamin) child's chewable vitamins/iron * (Multivitamins oral tablet,chewable with Iron) child's vitamin with iron * (Multivitamins with Iron) child's vitamin with vitamin c * (Multivitamin) childs/iron * (Multivitamins with Iron) compete * (Multivitamin W/Iron, Minerals) complete 50+ * (Biocel) complete multi 50+ * (Biocel) complete multivitamin * oral tablet (Multivits,Th W- Fe,Other Min) complete multivitamin * oral tablet 0.4-300-250 mg-mcg-mcg (Biocel) complete multivitamin-mineral * (Multivitamin/Iron/ oral tablet Folic Acid) 153

complete senior * oral tablet (Multivitamin W/Iron, Minerals) complete senior * oral tablet 0.4-300-250 mg-mcg-mcg (Biocel) cyanocobalamin (vitamin b-12) * (Cyanocobalamin injection (Vitamin B-12)) 3 $0 cyanocobalamin (vitamin b-12) * (Cyanocobalamin oral drops 1,000 mcg/ml (Vitamin B-12)) cyanocobalamin (vitamin b-12) * oral tablet 1,000 mcg, 100 mcg, 250 (B-12) mcg, 500 mcg daily gummies * (One-A-Day Vitacraves) daily multiple * oral tablet (Multivitamin) daily multiple * oral tablet 18-400 (Multivitamin/Iron/ mg-mcg Folic Acid) daily multi-vitamin * (Multivitamin) daily multivitamin with iron * (Multivitamin/Iron/ Folic Acid) daily multivitamin-minerals * (Multivitamin with Minerals) daily multi-vitamins/iron * (Multivitamins with Iron) daily teen multi-vitamin * (Multivitamin/Iron/ Folic Acid) daily value * (Multivitamin) daily vitamin * (Multivitamin) daily vitamin formula * (Multivitamin) daily vitamin formula + iron * (Multivitamin/Iron/ Folic Acid) daily vitamin formula-minerals * (Multivitamin with Minerals) daily vitamin with iron * (Multivitamins with Iron) 154

155 daily vites/iron * (Multivitamins with Iron) daily-vite * (Multivitamin) dino-life * (Multivitamin) dino-life with extra c * (Multivitamin) dino-life with iron-zinc * (Multivitamin W/Iron, Minerals) ECEE PLUS * eldertonic * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) eql central-vite select * tablet (Multivitamin W- Minerals/Lutein) ergocalciferol (vitamin d2) * oral capsule (Drisdol) 3 $0 ergocalciferol (vitamin d2) * oral drops (Drisdol) essentia * (Multivitamin/Iron/ Folic Acid) essential balance with lutein * (Multivits W- Fe,Other Min/Lut) essential daily * (Tab A Vite) essential one daily * (Multivitamin) fa-8 * (Folic Acid) fe fumarate-doss-fa-bcomp and c * (Fe Fumarate/Doss/Fa/ Bcomp and C) 3 $0 fe fumarate-vit c-b12-if-fa * oral (Fe Fumarate/Vit capsule 110-0.5 mg C/B12-If/Fa) 3 $0 ferate * oral tablet (Fergon) ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 ferretts * (Ferrous Fumarate) ferrex 150 * (Pic 200)

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

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

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

multiple vitamin-minerals * (Multivitamin with Minerals) multiple vitamins * (Multivitamin) multiple vitamins with iron * (Multivitamins with Iron) multivital platinum * oral tablet (Multivitamin W- Minerals/Lutein) multivital platinum * oral tablet 500-300-250 mcg (Biocel) multivitamin 50 plus * (Multivitamin W- Minerals/Lutein) multi-vitamin hp/minerals * (Multivitamins,The r W-Minerals) multivitamin * oral tablet (Multivitamin) multivitamin with iron * (Multivitamins with Iron) multivitamin with minerals * oral (Multivits W- liquid Min/Ferrous Gluc) multivitamin with minerals * oral (Multivitamin with tablet Minerals) multivitamins with min no.7-fa * (Multivitamins oral capsule 1 mg with Min No.7/Fa) 3 $0 multi-vite * (Multivitamin/Iron/ Folic Acid) multi-vite 50 & over * (Multivitamin W- Minerals/Lutein) multivit-fluor 0.25 mg/ml drop 0.25 (Pedi Mvi No.82 mg/ml with Fluoride) my favorite multiple * (Multivitamin) my-vitalife * (Multivitamin with Minerals) NASCOBAL * 3 $0 natural b-100 * (Vitamin B Complex) 159

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

161 one daily plus iron * oral tablet 18- (Multivitamin/Iron/ 400 mg-mcg Folic Acid) one daily plus minerals * (Multivitamin with Minerals) one daily with iron * (Multivitamins with Iron) one-a-day essential * (Multivitamin) one-a-day maximum formula * (Multivitamin with Minerals) one-a-day teen advantage * oral (Multivitamin/Iron/ tablet 18-400 mg-mcg Folic Acid) one-a-day teen advantage * oral (Multivits,Ca,Mine tablet 9 mg iron-400 mcg rals/iron/fa) opti-vitamins * oral tablet (Beta-Carotene(A) W-C and E/Min) opti-vitamins * oral tablet 1,000 (Ocuvite with unit-200 mg-60 unit-2 mg Lutein) pediatric multivitamin * (Multivitamin) pharmacist favorite multi-vit * (Multivitamin) phytonadione * oral tablet 100 mcg (Phytonadione) poly-iron * (Pic 200) poly-vita * (Pediatric Multivit Comb No.20) poly-vita (iron) * (Ped Multivit #46/Iron Sulfate) poly-vitamin * (Pediatric Multivit Comb No.20) poly-vitamin with iron * (Ped Multivit #46/Iron Sulfate) polyvitamin/iron * (Multivitamin W/Iron, Minerals) poly-vitamins * (Multivitamin) prenatal formula * oral tablet 28-0.8 mg (Classic Prenatal) prenatal * oral tablet 28-0.8 mg (Classic Prenatal)

prenatal vit#96-ferrous fum-fa * (Prenatal Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) prenatal vitamins oral tablet 27 mg (Pnv with iron- 1 mg Ca,No.72/Iron/Fa) PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG prenatal vit-iron fumarate-fa * (Classic Prenatal) prosight * (A/C/E/Zinc/Sod Selenate/Copper) pyridoxine * injection (Pyridoxine HCl) 3 $0 ra central-vite select * tab p/f (Multivitamin W/Iron, Minerals) scooby-doo one a day * (Multivitamin W/Iron, Minerals) senior tabs * (Biocel) sentry * oral tablet 18-400 mg-mcg (Multivitamin/Iron/ Folic Acid) sentry senior * (Biocel) sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) sodium fluoride oral tablet 1 mg (Pedi Mvi No.82 fluoride (2.2 mg) with Fluoride) sodium fluoride * oral tablet,chewable 0.25 mg fluorid (Sodium Fluoride) 3 $0 (0.55 mg) spectravite adult 50+ * oral tablet (Biocel) spectravite advanced formula * oral (Multivitamin/Iron/ tablet Folic Acid) spectravite * oral liquid (Pediavit) spectravite * oral tablet,chewable (Multivitamins with Iron) spectravite senior * oral tablet (Multivitamin W/Iron, Minerals) (All Rx Prenatal Vitamins Covered) 162

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

super thera vite m * (Multivitamins,The r W-Minerals) superior 35 * (Multivitamin W/Iron, Minerals) superplex-t * (Vita-Bee with C) support * (Multivitamin with Minerals) support-500 * (B Complex with Vitamin C) 3 $0 tab-a-vite * (Multivitamin) tab-a-vite/iron * (Multivitamins with Iron) tab-a-vite-minerals * (Multivitamin with Minerals) thera m plus (ferrous fumarat) * (Multivits,Ca,Mine rals/iron/fa) thera vitamin * (Multivitamins,The rapeutic) theradex m * (Multivit,Ther Iron,Ca,Fa and Min) thera-m * oral tablet (Multivits,Th W- Fe,Other Min) thera-m * oral tablet 27-0.4 mg (Multivit,Ther Iron,Ca,Fa and Min) thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine mcg rals/iron/fa) theramill forte * oral capsule (Multivitamin with Minerals) therapeutic liquid * (Multivitamins,The rapeutic) therapeutic m + beta-carotene * (Tab A Vite) therapeutic vitamin & mineral * (Multivitamins,The r W-Minerals) 164

therapeutic vitamins/minerals * (Multivitamins with Min No.7/Fa) 3 $0 therapeutic-m * oral tablet 9 mg (Multivits,Ca,Mine iron-400 mcg rals/iron/fa) (Multivit,Ther therapeutic-m vitamin/minerals * Iron,Ca,Fa and oral tablet 27-0.4 mg Min) thera-tabs * (Multivitamins,The rapeutic) theratrum complete 50 plus * (Multivitamin W/Iron, Minerals) theratrum complete 50 plus/lut * (Multivitamin W- Minerals/Lutein) therems * (Multivitamins,The rapeutic) therems-h * (Multivits,Th W- Fe,Other Min) therems-m * (Multivits,Th W- Fe,Other Min) thiamine hcl * injection (Thiamine HCl) 3 $0 thiamine hcl * oral tablet 500 mg (Thiamine HCl) total b/c * (Vita-Bee with C) totalday multiple * (Multivitamin with Minerals) tri-vi-sol * (Vit A Palmitate/Vit C/Vit D3) tri-vita * (Pedi Multivits A,C, and D3 No.21) tri-vitamin * (Pedi Multivits A,C, and D3 No.21) ultra b-100 complex * oral tablet (Vitamin B Complex) 165

unicomplex-m * (Multivitamin W/Iron, Minerals) vision * (Beta-Carotene(A) W-C and E/Min) vision formula * (Beta-Carotene(A) W-C and E/Min) vision formula (with lutein) * (Ocuvite with Lutein) vision plus lutein * (Multivitamin W- Minerals/Lutein) vit b cmplx 3-fa-vit c-biotin * oral (Vit B Cmplx tablet 1-60-300 mg-mg-mcg 3/Fa/Vit C/Biotin) 3 $0 (Vit B Cmplx vit b cmplx no3-fa-c-biot-zinc * No3/Fa/C/Biot/Zin 3 $0 c) vitabee/c * (Vita-Bee with C) vitalets * oral tablet,chewable (Multivitamins with Iron) vitamin a * oral capsule 10,000 unit, 25,000 unit (Vitamin A) vitamin b complex * (Vitamin B Complex) vitamin b complex with c * (B Complex with Vitamin C) vitamin b-1 * oral tablet (Thiamine HCl) vitamin b-100 complex * (Vitamin B Complex) vitamin b12-folic acid * oral (Cyanocobalamin/ Folic Acid) vitamin b-6 * oral tablet 100 mg, 25 mg, 250 mg, 50 mg (Pyridoxine HCl) vitamin c * oral capsule, extended release (Ascorbic Acid) vitamin c * oral syrup (Ascorbic Acid) 166

vitamin c * oral tablet 1,000 mg, 250 mg, 500 mg (Ascorbic Acid) vitamin c * oral tablet extended release (Ascorbic Acid) vitamin c * oral tablet,chewable 250 mg, 500 mg (Ascorbic Acid) vitamins & minerals * (Multivitamins,The r W-Minerals) vitamins b complex * oral capsule (Vitamin B Complex) vitamins b complex * oral tablet (Vitamin B Complex) (Vit B vitamins b complex * oral tablet Comp/C/Fa/Iron/Vi 500 mg-400 mcg- 18 mg iron t E) vitamins for hair * oral tablet (Multivitamin) vitrum senior * oral tablet (Multivitamin W- Minerals/Lutein) vitrum senior * oral tablet 500-300- 250 mcg (Biocel) womens daily gummies * (One-A-Day Vitacraves) women's daily multivitamin * (Tab A Vite) yelets * (Multivitamin/Iron/ Folic Acid) zoo chews * (Multivitamin) 167

INDEX 3 3 day vaginal... 53 30pse-150gfn-15dm... 91 8 8-MOP... 101 A a thru z advanced formula... 149 a thru z high potency... 149 a thru z select... 149 a thru z select 50+ formula... 149 a thru z select women's... 149 abacavir... 68 abacavir-lamivudine-zidovudine... 68 abc plus... 149 ABELCET... 53 ABILIFY... 65 ABILIFY DISCMELT... 64, 65 ABILIFY MAINTENA... 65 ABRAXANE... 36, 37 ABREVA... 60 acamprosate... 24 acarbose... 50 acebutolol... 81 acephen... 16 acetaminophen... 16 acetaminophen-codeine... 16 acetazolamide... 137 acetazolamide sodium... 137 acetic acid... 113, 132 acetylcysteine... 146 acid gone antacid... 117 acid reducer (famotidine)... 116 acid relief (cimetidine)... 116 acitretin... 101 acne medication... 101 ACNE MEDICATION... 102 acne-clear... 102 ACTEMRA... 133, 134 ACTHIB (PF)... 130 ACTIMMUNE... 134 acyclovir... 71, 102 acyclovir sodium... 71 ADACEL(TDAP ADOLESN/ADULT)(PF) 130 ADAGEN... 109 adapalene... 108 ADCETRIS... 37 ADCIRCA... 148 adefovir... 71 ADEMPAS... 148 adrenalin... 83 ADRENALIN... 82, 83 adt robitussin peak cld dm max... 91 adult multivitamin gummies 149 adult nasal decongestant... 91 adult one daily gummies... 149 adult robitussin lingering cld.. 91 adult robitussin peak cold dm 91 adult wal-tussin... 91 adult wal-tussin dm max... 91 adults 50+ daily formula... 149 adults' daily formula... 149 ADVAIR DISKUS... 144 ADVAIR HFA... 144 advil... 21 af 53 AFINITOR... 37 AFINITOR DISPERZ... 37 AGGRENOX... 74 airshield... 149 AKTEN (PF)... 110 alavert d-12 allergy-sinus... 56 alaway... 110 ALBENZA... 63 ALBUKED-25... 74 ALBUKED-5... 74 ALBUMIN, HUMAN 25 %... 74 ALBUMIN, HUMAN 5 %... 74 ALBUMINAR 25 %... 74 ALBUMINAR 5 %... 74 ALBURX (HUMAN) 5 %... 75 ALBUTEIN 25 %... 75 ALBUTEIN 5 %... 75 albuterol sulfate... 145 alclometasone... 104 ALCOHOL PADS... 102 ALCOHOL PREP PADS... 102 ALCOH-WIPE... 102 ALDURAZYME... 109 alendronate... 132 alfuzosin... 124 ALIMTA... 37 ALINIA... 63 alka-seltzer plus mucus-conges... 91 alka-seltzer plus sinus-cough. 92 aller-chlor... 56 allerclear d-12hr... 57 allerclear d-24hr... 57 allergy (chlorpheniramine)... 57 allergy relief (cetirizine)... 57 allergy relief (loratadine)... 57 allerhist-1... 57 I-1 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

aller-tec d... 57 allopurinol... 134 almacone... 117 almacone-2... 117 aloe vesta... 53 alophen... 120 alosetron... 131 ALPHAGAN P... 137 alprazolam... 25, 26 ALREX... 115 altacaine... 110 altamist... 110 aluminum chloride... 102 aluminum hydroxide gel... 117 amantadine hcl... 64 ambi 10peh-4cpm-20dm... 92 ambi 20dm-4cpm... 92 ambi 40pse-400gfn-20dm... 92 ambi 60pse-4cpm... 57 ambi 60pse-4cpm-20dm... 92 AMBISOME... 53 ambizine... 62 amifostine crystalline... 134 amiloride... 85 amiloride-hydrochlorothiazide85 AMINO ACIDS 15 %... 75 aminocaproic acid... 74 AMINOSYN 10 %... 75 AMINOSYN 3.5 %... 75 AMINOSYN 7 %... 75 AMINOSYN 7 % WITH ELECTROLYTES... 75 AMINOSYN 8.5 %... 75 AMINOSYN 8.5 %- ELECTROLYTES... 75 AMINOSYN II 10 %... 75 AMINOSYN II 15 %... 75 AMINOSYN II 7 %... 75 AMINOSYN II 8.5 %... 75 AMINOSYN II 8.5 %- ELECTROLYTES... 75 AMINOSYN M 3.5 %... 75 AMINOSYN-HBC 7%... 75 AMINOSYN-PF 10 %... 75 AMINOSYN-PF 7 % (SULFITE-FREE)... 75 AMINOSYN-RF 5.2 %... 75 amiodarone... 80 amiodarone hcl... 80 AMITIZA... 117 amitriptyline... 48 amlactin... 102 amlodipine... 84 amlodipine-atorvastatin... 85, 86 amlodipine-benazepril... 84 amlodipine-valsartan... 84 amlodipine-valsartan-hcthiazid... 84 ammonium lactate... 102 amoxapine... 48 amoxicil-clarithromy-lansopraz... 116 amoxicillin... 34 amoxicillin-pot clavulanate... 34 amphetamine salt combo... 88 amphotericin b... 53 ampicillin... 34 ampicillin sodium... 34 ampicillin-sulbactam... 34 AMPYRA... 88 ANACAINE... 102 anagrelide... 74 anastrozole... 37 ANDRODERM... 124 ANDROGEL... 124 animal chews... 149 animal shape vitamins... 149 animal shapes plus iron... 149 ANORO ELLIPTA... 145 antacid... 117 antacid anti-gas... 117 antacid extra-strength... 117 antacid plus anti-gas... 117 anticoag citrate phos dextrose... 134 anti-diarrheal... 117 anti-diarrheal (loperamide).. 117, 118 antifungal... 54 antifungal (tolnaftate)... 54 anti-gas maximum strength.. 115 antioxidant... 149 antioxidant formula... 149 antioxidant vitamins... 150 apatate forte... 150 APOKYN... 64 apraclonidine... 110 APRISO... 131 aprodine... 57 APTIOM... 44, 45 APTIVUS... 68 aquanil hc... 104 ARALAST NP... 146 ARCALYST... 128 aripiprazole... 65 ARRANON... 37 artificial tears... 110 artificial tears (petro/min)... 110 artificial tears (pf)... 110 artificial tears(glycerin-peg). 110 artificial tears(hypromellose) 110 ARZERRA... 37 ASACOL HD... 132 ascorbic acid... 150 ashlyna... 89 aspirin... 21, 23 aspirin, buffered... 21 aspirin-dipyridamole... 74 aspir-low... 21 I-2 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

ASSURE ID INSULIN SAFETY... 108 ASTAGRAF XL... 128 atenolol... 81 atenolol-chlorthalidone... 81 atorvastatin... 86 atovaquone... 63 atovaquone-proguanil... 63 ATRIPLA... 68 atropine... 44, 110 ATROVENT HFA... 145 AUBAGIO... 128 AVASTIN... 37 AVC VAGINAL... 60 AVODART... 134 AVONEX... 134 AVONEX (WITH ALBUMIN)... 134 ayr saline... 110 azacitidine... 37 azathioprine... 128 azathioprine sodium... 128 azelastine... 110 AZILECT... 64 azithromycin... 33 AZOPT... 137 AZOR... 84 aztreonam... 34 B b complete... 150 b complex 1... 150 b complex-vitamin b12... 150 b complex-vitamin c-folic acid... 150 b-100 complex... 150 b-12 dots... 150 b-50 complex... 150 bacitracin... 29, 103, 113 bacitracin-polymyxin b... 113 bacitraycin plus... 104 baclofen... 146 bal b-100... 150 bal b-50... 150 balance b-100... 150 balance b-50... 150 balanced b-100... 150 balanced b-150... 151 balanced b-50... 151 balsalazide... 132 banophen... 57 banophen allergy... 57 BANZEL... 45 baza antifungal... 54 BCG VACCINE, LIVE (PF) 130 b-complex... 151 b-complex with vitamin c... 151 BD INSULIN PEN NEEDLE UF SHORT... 108 BD INSULIN SYRINGE ULTRA-FINE... 108 bee-zee... 151 BELEODAQ... 37 benadryl allergy... 57 benazepril... 80 benazepril-hydrochlorothiazide... 80 BENICAR... 79 BENICAR HCT... 79 BENLYSTA... 134 benzonatate... 92 benzoyl peroxide... 102 benztropine... 64 BETADINE SPRAY... 102 beta-hc... 105 betamethasone acet,sod phos 126 betamethasone dipropionate. 105 betamethasone valerate... 105 betamethasone, augmented.. 105 BETASERON... 134 betaxolol... 81, 137 bethanechol chloride... 134 BETHKIS... 29 bexarotene... 37 BEXSERO (PF)... 130 bicalutamide... 37 bicarsim forte... 115 BICILLIN C-R... 34 BICILLIN L-A... 34 BIDIL... 87 BILTRICIDE... 63 bimatoprost... 137 bio-dtuss dmx... 92 bion tears (pf)... 110 bionel... 92 bionel pediatric... 92 biospec dmx... 92 biosupp... 151 biotin... 151 biovol... 151 bisac-evac... 120 bisacodyl... 120 biscolax... 120 bismatrol... 118 bisoprolol fumarate... 81 bisoprolol-hydrochlorothiazide... 81 bleomycin... 37 BLINCYTO... 37 blis-to-sol (tolnaftate)... 54 BOOSTRIX TDAP... 130 BOSULIF... 37 BOTOX... 134 BREO ELLIPTA... 144 BRILINTA... 74 brimonidine... 137 BRINTELLIX... 48 bromfenac... 115 bromocriptine... 64 bromphenex dm... 92 I-3 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

brompheniramine-pseudoephdm... 92 brompheniram-phenylephrinedm... 92 broncotron-s... 92 budesonide... 132 bufferin... 21 bumetanide... 85 BUMINATE 25 %... 75 BUMINATE 5 %... 75 BUPHENYL... 118 buprenorphine hcl... 16, 24 buprenorphine-naloxone... 24 bupropion hcl... 24, 48 buspirone... 134 butalb-acetaminophen-caffeine... 16 butalbital-acetaminop-caf-cod 16 butalbital-acetaminophen... 16 butalbital-acetaminophen-caff 16 butalbital-aspirin-caffeine... 16 butorphanol tartrate... 16 BUTRANS... 16 BYDUREON... 50 BYETTA... 50 BYSTOLIC... 81 C c complex... 151 cabergoline... 64 ca-d3-mag ox-zinc-cop-mangbor... 138 caffeine citrated... 88 caffeine-sodium benzoate... 88 calci-chew... 118 calcidol... 151 calcionate... 138 calcipotriene... 102 calcitonin (salmon)... 132 calcitrate... 138 calcitrate-vitamin d... 138 calcitriol... 102, 132 calcium 500 + d... 138 calcium 500 + d (d3)... 138 calcium 500 with d... 138 calcium 600... 138 calcium 600 + d(3)... 138 calcium 600 with vitamin d3 139 calcium acetate... 123 CALCIUM ACETATE... 123 calcium carbonate... 118, 139 calcium carbonate-mag carb-fa... 123 calcium carbonate-vitamin d2... 139 calcium carbonate-vitamin d3... 139 CALCIUM CARBONATE- VITAMIN D3... 118 calcium chloride... 139 calcium citrate-vitamin d3... 139 calcium gluconate... 139 calcium lactate... 139 calcium+d... 139 CALDOLOR... 21 cal-gest antacid... 118 calphron... 123 CALTRATE 600 + D... 139 CALTRATE-600 + D VIT D3 (800)... 139 CANCIDAS... 54 candesartan... 79 candesartan-hydrochlorothiazid... 79 CAPASTAT... 61 CAPRELSA... 37 captopril... 80 captopril-hydrochlorothiazide 80 CARAFATE... 116 carbamazepine... 45 carbidopa... 64 carbidopa-levodopa... 64 carbidopa-levodopa-entacapone... 64 carboplatin... 37 cardec dm (phenyleph-chlorphn)... 92 CARIMUNE NF NANOFILTERED... 128 carisoprodol... 146 carteolol... 111 cartia xt... 82 carvedilol... 81 CASTELLANI PAINT MODIFIED... 102 CAYSTON... 34 cefaclor... 31 cefadroxil... 31 cefazolin... 31 cefazolin in dextrose (iso-os). 31 cefdinir... 31 cefditoren pivoxil... 31 cefepime... 31 CEFEPIME IN DEXTROSE 5 %... 31 CEFEPIME IN DEXTROSE,ISO-OSM... 32 cefotaxime... 32 cefoxitin... 32 cefoxitin in dextrose, iso-osm 32 cefpodoxime... 32 cefprozil... 32 ceftazidime... 32 ceftibuten... 32 ceftriaxone... 32 CEFTRIAXONE... 32 ceftriaxone in dextrose,iso-os. 32 CEFTRIAXONE IN DEXTROSE,ISO-OS... 32 cefuroxime axetil... 32 cefuroxime sodium... 32 I-4 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

cefuroxime-dextrose (iso-osm)... 32 celecoxib... 21 CELLCEPT INTRAVENOUS... 128 CELONTIN... 45 centamin... 151 central vite with lutein... 151 central-vite... 151 central-vite for seniors... 151 central-vite select. 151, 155, 162 central-vite senior... 151 centram-care... 151 centravites 50 plus... 151 centrum... 152 centrum complete... 151 CENTRUM PRO NUTRIENTS... 139 centrum silver... 152 centrum ultra women's... 152 century... 152 century adults 50+... 152 century advanced formula... 152 century mature... 152 century ultimate women's... 152 cephalexin... 32, 33 CEPROTIN (BLUE BAR)... 71 CERDELGA... 134 CEREZYME... 109 cerovite... 152 cerovite advanced formula... 152 cerovite jr... 152 cerovite senior... 152 certavite senior-antioxidant.. 152 certavite-antioxid (iron gluc) 152 certavite-antioxidant... 152 CERVARIX VACCINE (PF)... 130 cetirizine... 57 cetirizine-pseudoephedrine... 57 cevimeline... 101 CHANTIX... 24 CHANTIX CONTINUING MONTH BOX... 24 CHANTIX CONTINUING MONTH PAK... 24 CHANTIX STARTING MONTH BOX... 25 cheratussin ac... 92 cheratussin dac... 92 chest congestion relief + dm.. 92 chest congestion relief d... 92 chest congestion relief pe... 92 chewable multi vitamin... 152 chewable-vite... 152 chewable-vite with iron... 152 child complete multivitamin 153 child cough & sore throat... 92 child mucinex chest congestion... 93 child mucus relief cough... 93 child plus cough & runny nose... 93 child triaminic cold & allergy 57 child triaminic cough-congest 93 child vitamin with minerals.. 153 child wal-tap cold-allergy... 57 child wal-tussin cough relief.. 93 children's advil... 21 children's aller-tec... 57 children's cetirizine... 57 children's chest congestion... 93 children's chewable... 153 children's chewable complete... 153 children's chewable vitamin. 153 children's chewable w/minerals... 153 CHILDREN'S CLARITIN... 57 children's complete vitamin. 153 CHILDREN'S DIMETAPP COLD &FLU... 93 children's flu relief... 93 children's mapap... 16 children's mucinex cough... 93 children's multivit w/extra c. 153 children's non-aspirin... 16 children's pain & fever relief.. 16 children's pain reliever... 16 children's silapap... 17 children's silfedrine... 93 children's soothe... 118 children's sudafed... 93 children's sudafed pe cough... 93 children's vitamin with iron.. 153 children's wal-dryl allergy... 57 children's wal-zyr... 57 CHILDREN'S ZYRTEC ALLERGY... 57 childs chew vite... 153 child's chewable vitamins/iron... 153 child's vitamin with iron... 153 child's vitamin with vitamin c... 153 childs/iron... 153 chlophedianol-guaifenesin... 93 chloramphenicol sod succinate... 29 chlordiazepoxide hcl... 26 chlorhexidine gluconate... 101 chloroquine phosphate... 63 chlorothiazide... 85 chlorothiazide sodium... 85 chlorpheniramine-phenyleph-dm... 93 chlorpromazine... 65 chlorthalidone... 85 chlorzoxazone... 146 CHOLBAM... 118 I-5 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

cholestyramine (with sugar)... 86 cholestyramine-aspartame... 86 choline,magnesium salicylate 21 ciclopirox... 54 ciclopirox-ure-camph-menth-euc... 54 cilostazol... 74 cimetidine... 116 cimetidine hcl... 116 CIMZIA... 109 CIMZIA POWDER FOR RECONST... 109 CIPRODEX... 113 ciprofloxacin... 35 ciprofloxacin hcl... 35, 113 ciprofloxacin in 5 % dextrose 35 ciprofloxacin lactate... 35 cisplatin... 37 citalopram... 48 citracal + d maximum... 139 citric acid-sodium citrate... 140 citrus calcium... 140 clarithromycin... 33 CLARITIN... 57 CLARITIN LIQUI-GEL... 58 CLARITIN REDITABS... 58 CLARITIN-D 12 HOUR... 58 CLARITIN-D 24 HOUR... 58 clearlax... 120 clemastine... 58 CLEVIPREX... 85 clindamycin hcl... 29 clindamycin in 5 % dextrose.. 30 clindamycin palmitate hcl... 30 clindamycin phosphate... 30, 61, 104 CLINIMIX 5%/D15W SULFITE FREE... 76 CLINIMIX 5%/D25W SULFITE-FREE... 76 CLINIMIX 2.75%/D5W SULFIT FREE... 76 CLINIMIX 4.25%/D10W SULF FREE... 76 CLINIMIX 4.25%/D5W SULFIT FREE... 76 CLINIMIX 4.25%-D20W SULF-FREE... 76 CLINIMIX 4.25%-D25W SULF-FREE... 76 CLINIMIX 5%- D20W(SULFITE-FREE)... 76 CLINIMIX E 2.75%/D10W SUL FREE... 76 CLINIMIX E 2.75%/D5W SULF FREE... 76 CLINIMIX E 4.25%/D10W SUL FREE... 76 CLINIMIX E 4.25%/D25W SUL FREE... 76 CLINIMIX E 4.25%/D5W SULF FREE... 76 CLINIMIX E 5%/D15W SULFIT FREE... 76 CLINIMIX E 5%/D20W SULFIT FREE... 76 CLINIMIX E 5%/D25W SULFIT FREE... 76 CLINISOL SF 15 %... 76 clobetasol... 105 clobetasol propionate... 105 clobetasol-emollient... 105 clocortolone pivalate... 105 clomipramine... 48 clonazepam... 26 clonidine... 79 clonidine hcl... 78, 88 clonidine hcl-chlorthalidone.. 79 clopidogrel... 74 clorazepate dipotassium... 26 clotrimazole... 54 clotrimazole 3 day... 54 clotrimazole-3... 54 clotrimazole-7... 54 clotrimazole-betamethasone... 54 clozapine... 65 COARTEM... 63 codeine sulfate... 17 codeine-butalbital-asa-caffein 17 codituss dm... 93 colace... 120 colchicine... 134 colchicine-probenecid... 134 COLCRYS... 134 cold & cough... 58 cold multi-symptom... 93 cold multi-symptom day/night 93 cold multi-symptom nighttime... 94 cold relief m/s day/night... 94 cold-flu relief... 94 cold-flu relief, day/night... 94 colestipol... 86 colistin (colistimethate na)... 30 COLY-MYCIN S... 114 COMBIGAN... 137 COMBIPATCH... 125 COMBIVENT RESPIMAT. 145 COMETRIQ... 38 comfort gel extra strength... 118 COMFORT PAC- CYCLOBENZAPRINE... 146 COMFORT PAC-IBUPROFEN... 21 COMFORT PAC- MELOXICAM... 21 COMFORT PAC-NAPROXEN... 21 COMFORT PAC-TIZANIDINE... 147 I-6 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

compete... 153 COMPLERA... 68 complete 50+... 153 complete multi 50+... 153 complete multivitamin... 153 complete multivitamin-mineral... 153 complete senior... 154 compoz... 58 COMVAX (PF)... 130 CONDYLOX... 102 congestac... 94 COPAXONE... 134 coral calcium... 140 CORDRAN... 106 coricidin hbp... 94 CORLANOR... 83 cortisone... 126 cortizone-10... 106 CORTIZONE-10... 106 COSENTYX (2 SYRINGES)... 102 COSENTYX PEN... 102 COSENTYX PEN (2 PENS) 102 cough & cold... 94 cough & runny nose... 94 CREON... 109 creo-terpin (dm-guaifenesin). 94 CRESTOR... 86 critic-aid clear af... 54 CRIXIVAN... 68 cromolyn... 111, 118, 146 CUBICIN... 30 CURITY GAUZE... 134 cyanocobalamin (vitamin b-12)... 154 cyclobenzaprine... 147 CYCLOGYL... 111 cyclopentolate... 111 cyclophosphamide... 38 CYCLOPHOSPHAMIDE... 38 CYCLOSET... 50 cyclosporine... 128 cyclosporine modified... 128 cyclosporine, modified... 128 cyproheptadine... 58 CYRAMZA... 38 cyred... 89 CYSTADANE... 134 CYSTARAN... 111 cysteine (l-cysteine)... 76 cytarabine... 38 cytarabine (pf)... 38 D d10 % & 0.45 % sodium chloride... 77 d10 %-0.9 % sodium chloride 77 d2.5 %-0.45 % sodium chloride... 77 d5 % and 0.9 % sodium chloride... 77 d5 %-0.45 % sodium chloride 77 dacarbazine... 38 dactinomycin... 38 daily gummies... 154 daily multiple... 154 daily multi-vitamin... 154 daily multivitamin with iron 154 daily multivitamin-minerals. 154 daily multi-vitamins/iron... 154 daily teen multi-vitamin... 154 daily value... 154 daily vitamin... 154 daily vitamin formula... 154 daily vitamin formula + iron 154 daily vitamin formula-minerals... 154 daily vitamin with iron... 154 daily vites/iron... 155 dailyhist-1... 58 daily-vite... 155 DAKLINZA... 70 DALIRESP... 146 danazol... 125 dantrolene... 147 dantrolene sodium... 147 dapsone... 61 DAPTACEL (DTAP PEDIATRIC) (PF)... 130 DARAPRIM... 63 dayhist allergy... 58 daytime cold & cough... 94 daytime cold-flu... 94 day-time cough... 94 daytime mucus relief dm... 94 daytime-nighttime... 94 daytime-nighttime cold-flu... 94 daytime-nighttime cough... 94 deblitane... 89 decitabine... 38 decongestant cough... 94 deep sea nasal... 111 deferoxamine... 124 delsym cough+chest congest dm... 94 DELZICOL... 132 DEMSER... 83 DEPEN TITRATABS... 124 DEPO-PROVERA... 127 dermafungal... 54 dermarest eczema (hydrocort)... 106 desenex (clotrimazole)... 54 desipramine... 48 desmopressin... 126 desog-e.estradiol/e.estradiol... 89 desogestrel-ethinyl estradiol... 89 desonide... 106 desoximetasone... 106 I-7 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

despec-dm (pseudoeph-dmguaif)... 94 dex4 glucose... 77 dexamethasone... 126 dexamethasone sodium phosphate... 115, 126 dexchlorphen-pse-chlophedianol... 95 dexmethylphenidate... 88 dextroamphetamine... 88 dextroamphetamineamphetamine... 88 dextromethorphan polistirex.. 95 dextrose 10 % and 0.2 % nacl 77 dextrose 10 % in water (d10w)... 77 dextrose 2.5 % in water(d2.5w)... 77 dextrose 20 % in water (d20w)... 77 dextrose 25 % in water (d25w)... 77 dextrose 40 % in water (d40w)... 77 dextrose 5 % in ringers... 77 dextrose 5 % in water (d5w).. 77 dextrose 5 %-lactated ringers. 77 dextrose 5%-0.2 % sod chloride... 77 dextrose 5%-0.3 % sod.chloride... 77 dextrose 50 % in water (d50w)... 77 dextrose 70 % in water (d70w)... 78 dextrose with sodium chloride 78 diabetic siltussin das-na... 95 diabetic tussin dm... 95 diabetic tussin ex... 95 diamode... 118 DIASTAT ACUDIAL... 26 diazepam... 26 diazepam intensol... 26 diclofenac potassium... 21 diclofenac sodium... 21, 22, 115 diclofenac-misoprostol... 22 dicloxacillin... 34 dicyclomine... 118 didanosine... 68 DIFICID... 33 diflunisal... 22 digitek... 83 digoxin... 83 DIGOXIN... 83 dihydroergotamine... 61 DILANTIN CAPSULE 30 MG... 45 diltiazem hcl... 82 dilt-xr... 82 dimaphen (pe)... 58 dimaphen dm... 95 dimenhydrinate... 62 dimetapp cold-congestion... 58 dino-life... 155 dino-life with extra c... 155 dino-life with iron-zinc... 155 DIPENTUM... 132 diphenhist... 58 diphenhydramine hcl... 58 diphenoxylate-atropine... 118 disopyramide phosphate... 80 disulfiram... 25 divalproex... 45 d-methorphan hb-p-epd hcl-bpm... 95 dm-phenyleph-chlorpheniramine... 95 dobutamine... 83 dobutamine in d5w... 83 doc-q-lace... 120 docu... 120 docusate sodium... 120 docusol... 120 dok... 120 donepezil... 47 dopamine... 83 dopamine in 5 % dextrose... 83 dorzolamide... 137 dorzolamide-timolol... 137 douche vinegar & water extra... 134 doxazosin... 79 doxepin... 48 doxercalciferol... 132, 133 doxorubicin hcl... 38 doxorubicin hcl peg-liposomal... 38 doxorubicin, peg-liposomal... 38 doxycycline hyclate... 36 doxycycline monohydrate... 36 dramamine... 62 driminate... 62 dristan long lasting... 111 dronabinol... 62 droperidol... 134 drospirenone-ethinyl estradiol 89 DROXIA... 38 DRYSOL DAB-O-MATIC.. 103 DUAVEE... 125 dulcolax stool softener (dss). 120 DULERA... 144 duloxetine... 48 DURAMORPH (PF)... 17 DUREZOL... 115 DYRENIUM... 85 E e.c. prin... 22 ECEE PLUS... 155 econazole... 54 ed bron gp... 95 I-8 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

ed chlorped jr... 58 EDURANT... 68 EFFIENT... 74 ELAPRASE... 109 eldertonic... 155 electrolyte-48 in d5w... 140 ELIDEL... 106 ELIGARD... 38 ELIQUIS... 71 ELITEK... 109 ELLA... 90 ellis tonic... 155 ELMIRON... 135 elon dual defense... 54 EMCYT... 38 EMEND... 62 EMSAM... 48 EMTRIVA... 68 enalapril maleate... 80 enalaprilat... 80 enalapril-hydrochlorothiazide 80 ENBREL... 128 ENBREL SURECLICK... 128 endur-acin... 86 enema... 120 enema disposable... 120 enemeez... 121 enemeez plus... 121 enfalyte... 140 ENGERIX-B (PF)... 130 ENGERIX-B PEDIATRIC (PF)... 130 enoxaparin... 71, 72 entacapone... 64 entecavir... 71 entre-cough... 95 ENTRESTO... 79 ephedrine sulfate... 83 epinastine... 111 epinephrine... 84 epinephrine hcl (pf)... 84 EPIPEN 2-PAK... 84 EPIPEN JR 2-PAK... 84 epirubicin... 38 EPIVIR HBV... 68 eplerenone... 87 EPOGEN... 73 epoprostenol (glycine)... 148 EPZICOM... 68 eq gentle... 111 equalactin... 121 ERBITUX... 38 ergocalciferol (vitamin d2)... 155 ergoloid... 135 ERGOMAR... 61 ERIVEDGE... 38 ERYTHROCIN... 33 erythromycin... 33, 114 erythromycin base... 33 ERYTHROMYCIN BASE... 33 erythromycin base-ethanol... 104 erythromycin ethylsuccinate.. 33 erythromycin stearate... 33 erythromycin with ethanol... 104 ESBRIET... 146 escitalopram oxalate... 48 esmolol... 81 esomeprazole sodium... 116 essentia... 155 essential balance with lutein 155 essential daily... 155 essential one daily... 155 estazolam... 26, 27 ESTRACE... 125 estradiol... 125 estradiol valerate... 125 estradiol/norethindrone acet. 125 estradiol-norethindrone acet. 125 ESTRASORB... 125 estropipate... 125 ethambutol... 61 ethamolin... 84 ethinyl estradiol/drospirenone 90 ethosuximide... 45 ethynodiol d-ethinyl estradiol 90 etidronate disodium... 133 etodolac... 22 ETOPOPHOS... 39 etoposide... 39 EVOTAZ... 68 exefen dmx... 95 EXELON... 47 exemestane... 39 EXJADE... 124 expectorant... 95 expectorant dm... 95 expectorant max strength... 95 EXTAVIA... 135 extra cleansing douche... 135 F fa-8... 155 FABRAZYME... 109 famciclovir... 71 famotidine... 116, 117 famotidine (pf)... 116 famotidine (pf)-nacl (iso-os) 116 FANAPT... 65 FARESTON... 39 FARYDAK... 39 FASLODEX... 39 fe fumarate-doss-fa-bcomp and c... 155 fe fumarate-vit c-b12-if-fa... 155 felbamate... 45 felodipine... 85 feminine care douche... 135 FEMRING... 125 fenofibrate... 86 fenofibrate micronized... 86 fenofibrate nanocrystallized... 86 I-9 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

fenofibric acid... 86 fenofibric acid (choline)... 86 fenoprofen... 22 fentanyl... 17 fentanyl citrate... 17 ferate... 155 ferotrinsic... 155 ferretts... 155 ferrex 150... 155 ferrex 150 plus... 156 FERRIPROX... 124 ferrocite... 156 ferrous fumarate... 156 ferrous gluconate... 156 ferrous sulfate... 156 FETZIMA... 48 feverall... 17 fiber (calcium polycarbophil)... 121 fiber laxative (methylcellulo)121 fiber smooth... 121 fiber therapy... 121 fiber therapy (psyllium/sugar)... 121 fiber-lax... 121 finasteride... 135 FIRAZYR... 84 FIRMAGON KIT W DILUENT SYRINGE... 39 flanax antacid... 118 FLEBOGAMMA DIF... 128 flecainide... 80 FLECTOR... 22 FLEET BISACODYL... 121 FLEXBUMIN 25 %... 75 FLEXBUMIN 5 %... 75 flintstones complete (iron)... 156 flintstones multivitamin... 156 flintstones with iron... 156 flintstones/extra c... 156 FLOVENT DISKUS... 144 FLOVENT HFA... 144 floxuridine... 39 flu formula daytime-nighttime 95 flu severe cold-congestion... 95 fluconazole... 55 fluconazole in dextrose(iso-o) 55 fluconazole in nacl (iso-osm). 55 flucytosine... 55 fludarabine... 39 fludrocortisone... 126 flumazenil... 88 fluocinonide... 106 fluocinonide-emollient base. 106 fluorometholone... 115 FLUOROPLEX... 103 fluorouracil... 39, 103 fluoxetine... 48, 49 FLUOXETINE... 49 fluoxymesterone... 125 fluphenazine decanoate... 65 fluphenazine hcl... 65 flurazepam... 27 flurbiprofen... 22 flurbiprofen sodium... 115 flutamide... 39 fluticasone... 106, 115 fluvoxamine... 49 foaming antacid... 118 folic acid... 156 FOLIC ACID... 156 fomepizole... 135 fondaparinux... 72 foot odor control... 55 FORTEO... 133 FORTICAL... 133 foscarnet... 70 fosfree... 156 fosinopril... 80 fosinopril-hydrochlorothiazide... 80 fosphenytoin... 45 FREAMINE HBC 6.9 %... 78 FREAMINE III 10 %... 78 fruity chews... 156 fungi cure... 55 FUNGI-NAIL... 55 fungoid-d... 55 furosemide... 85 FUSILEV... 135 FUZEON... 69 FYCOMPA... 45 G gabapentin... 45 GABITRIL... 45 galantamine... 47 GAMASTAN S/D... 129 GAMMAGARD LIQUID... 129 GAMMAPLEX... 129 GAMUNEX-C... 129 ganciclovir sodium... 71 GARDASIL (PF)... 130 GARDASIL 9 (PF)... 130 gas free extra strength... 115 gas relief... 115 gas relief 80... 115 gas relief extra strength... 115 gas-x ultra-strength... 115 gatifloxacin... 114 GAZYVA... 39 gelusil antacid & anti-gas... 118 gemcitabine... 39 gemfibrozil... 86 GENOTROPIN... 126 GENOTROPIN MINIQUICK... 126 gentamicin... 29, 104, 114 gentamicin in nacl (iso-osm).. 29 gentamicin sulfate... 114 I-10 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

gentamicin sulfate (ped) (pf).. 29 gentamicin sulfate (pf)... 29 GENTEAL MILD TO MODERATE... 111 GENTEAL GEL... 111 GENTEAL MILD... 111 GENTEAL SEVERE... 111 gentlelax... 121 GEODON... 65 geravim... 156 geriaton... 156 geri-dryl... 58 geri-hydrolac... 103 geri-tussin dm... 95 germ defense... 157 gildess 24 fe... 90 GILENYA... 135 GILOTRIF... 39 GLEEVEC... 39 glimepiride... 52 glipizide... 52, 53 glipizide-metformin... 53 GLUCAGEN HYPOKIT... 135 GLUCAGON EMERGENCY KIT (HUMAN)... 135 gluco burst... 78 glucose... 78 glucose gel... 78 glutose 15... 78 glyburide... 53 glyburide micronized... 53 glyburide-metformin... 53 GLYCINE... 132 glycolax... 121 glycopyrrolate... 118 glydo... 23, 24 GLYXAMBI... 50 granisetron (pf)... 62 granisetron hcl... 62 GRANIX... 73 griseofulvin microsize... 55 guaiatussin ac... 95 guaifenesin... 95 guaifenesin dac... 95 guanfacine... 79, 88 guanidine... 135 gummi bear multivitamin... 157 gummy swirls... 157 H hair vitamins... 157 hair,skin & nails... 157 HALAVEN... 39 halobetasol propionate... 106 haloperidol... 65 haloperidol decanoate... 65 haloperidol lactate... 66 HARVONI... 70 HAVRIX (PF)... 130 head congestion day-night... 96 healthy eyes... 157 healthylax... 121 hemocyte... 157 heparin (porcine)... 72 heparin (porcine) in 5 % dex. 72, 73 HEPARIN (PORCINE) IN 5 % DEX... 72 heparin (porcine) in nacl (pf). 72 HEPARIN(PORCINE) IN 0.45% NACL... 73 heparin, porcine (pf)... 72, 73 HEPATAMINE 8%... 78 HEPATASOL 8 %... 78 HERCEPTIN... 39 HEXALEN... 39 hi-b complex... 157 hi-cal plus vit d... 140 high potency multivit-multimin... 157 homatropine hbr... 111 honey bears... 157 honey bears with iron-zinc... 157 HUMALOG... 52 HUMALOG KWIKPEN... 51 HUMALOG MIX 50-50... 51 HUMALOG MIX 50-50 KWIKPEN... 52 HUMALOG MIX 75-25... 52 HUMALOG MIX 75-25 KWIKPEN... 52 HUMATROPE... 127 HUMIRA... 129 HUMIRA PEN... 129 HUMIRA PEN CROHN'S-UC- HS START... 129 HUMULIN 70/30... 52 HUMULIN 70/30 KWIKPEN 52 HUMULIN N... 52 HUMULIN N KWIKPEN... 52 HUMULIN R... 52 HUMULIN R U-500 (CONCENTRATED)... 52 hydralazine... 84 hydrochlorothiazide... 85 hydrocil instant... 121 hydrocodone bit-homatrop mebr... 96 hydrocodone-acetaminophen. 17 hydrocodone-chlorpheniramine... 96 hydrocodone-homatropine... 96 hydrocodone-ibuprofen... 17 hydrocortisone... 106, 107, 126 hydrocortisone acet-aloe vera... 106 hydrocortisone acetate... 106 hydrocortisone acetate-aloe.. 106 hydrocortisone acetate-urea. 106 hydrocortisone butyrate... 106 I-11 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

hydrocortisone butyr-emollient... 107 hydrocortisone sod succinate 126 hydrocortisone valerate... 107 hydromorphone... 17, 18 hydromorphone (pf)... 17 hydroskin... 107 hydroxychloroquine... 63 hydroxyurea... 39 hydroxyzine hcl... 135 hydroxyzine pamoate... 135 HYPERLYTE CR... 140 HYPERRAB S/D (PF)... 129 HYQVIA... 129 I ibandronate... 133 IBRANCE... 39 ibuprofen... 22 ibuprofen jr strength... 22 icaps plus... 157 ICLUSIG... 39, 40 iferex 150... 157 ifosfamide... 40 ifosfamide-mesna... 40 ILARIS (PF)... 129 ILEVRO... 115 IMBRUVICA... 40 imipenem-cilastatin... 34 imipramine hcl... 49 imipramine pamoate... 49 imiquimod... 103 imodium a-d... 119 IMODIUM A-D... 119 IMOGAM RABIES-HT (PF)... 129 IMOVAX RABIES VACCINE (PF)... 130 INCRELEX... 127 indapamide... 85 indomethacin... 22 indomethacin sodium... 22 INFANRIX (DTAP) (PF)... 130 infant acetaminophen... 18 infantaire... 18 infant's ibuprofen... 22 INFANT'S MOTRIN... 22 infants' non-aspirin cold... 96 infant's pain reliever... 18 INLYTA... 40 insta-glucose... 78 INSULIN SYRINGE... 108 INSULIN SYRINGE NEEDLELESS... 108 INSULIN SYRINGE-NEEDLE U-100... 109 INTELENCE... 69 intense cough reliever... 96 INTRALIPID... 78 INTRON A... 70 INVANZ... 34 INVEGA... 66 INVEGA SUSTENNA... 66 INVEGA TRINZA... 66 INVIRASE... 69 INVOKAMET... 50 INVOKANA... 50 inzo antifungal... 55 iodine... 109 IONOSOL-B IN D5W... 140 IONOSOL-MB IN D5W... 140 IPOL... 130 ipratropium bromide... 111 IPRIVASK... 73 irbesartan... 79 irbesartan-hydrochlorothiazide... 79 IRENKA... 49 IRESSA... 40 iron high potency... 157 ISENTRESS... 69 ISOLYTE M IN 5 % DEXTROSE... 140 ISOLYTE-H IN 5 % DEXTROSE... 140 ISOLYTE-P IN 5 % DEXTROSE... 140 ISOLYTE-S... 140 isoniazid... 61 isopto tears... 111 isosorbide dinitrate... 87 isosorbide mononitrate... 87 isotretinoin... 103 isradipine... 85 ISTODAX... 40 itraconazole... 55 ivermectin... 63 i-vite... 157 IXEMPRA... 40 IXIARO (PF)... 130 J JADENU... 124 JAKAFI... 40 JALYN... 135 jantoven... 73 JANUMET... 50 JANUMET XR... 50 JANUVIA... 51 JARDIANCE... 51 JENTADUETO... 51 JEVTANA... 40 jr. acetaminophen... 18 junel fe 24... 90 junior mapap... 18 K KABIVEN... 78 KADCYLA... 40 KALETRA... 69 KALYDECO... 146 kaopectate (bismuth subsalicy)... 119 I-12 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

KEDBUMIN... 75 KELP (IODINE)... 140 ketoconazole... 55 ketoprofen... 22 ketorolac... 22, 23, 115 ketotifen fumarate... 111 KEYTRUDA... 40 KHEDEZLA... 49 kidkare cough/cold... 96 kid's vitamins... 157 kid's vitamins + extra c... 157 kids vitamins + iron... 157 kid's vitamins + iron... 157 kimidess (28)... 90 KINERET... 129 KINRIX (PF)... 130 KLOR-CON... 140 klor-con 10... 140 KLOR-CON 8... 140 klor-con m10... 140 klor-con m15... 140 klor-con m20... 140 klor-con sprinkle... 140 KLOR-CON/EF... 140 konsyl (sugar)... 121 konsyl fiber... 121 konsyl sugar-free... 121 KORLYM... 51 KRYSTEXXA... 109 KUVAN... 109 KYPROLIS... 40 L l norgest/e.estradiol-e.estrad.. 90 labetalol... 81 LACRISERT... 111 LACTATED RINGERS... 132 LACTINOL HX... 103 lactulose... 119 LAMICTAL... 45 LAMISIL (AEROSOL)... 55 lamisil af... 55 LAMISIL AT... 55 lamivudine... 69 lamivudine-zidovudine... 69 lamotrigine... 45, 46 LANOXIN... 84 lansoprazole... 116 LANTUS... 52 LANTUS SOLOSTAR... 52 larin 24 fe... 90 latanoprost... 137 LATUDA... 67 laxative peg 3350... 121 LAZANDA... 18 leflunomide... 129 LEMTRADA... 135 LENVIMA... 40 LETAIRIS... 148 letrozole... 40 leucovorin calcium... 135 LEUKERAN... 40 LEUKINE... 73 leuprolide... 40 levetiracetam... 46 levobunolol... 138 levocarnitine... 135 levocarnitine (with sugar)... 135 levocetirizine... 58 levofloxacin... 35, 114 levofloxacin in d5w... 35 levoleucovorin calcium... 135 levonorgestrel... 90 levonorgestrel-ethin estradiol. 90 levonorgestrel-ethinyl estrad.. 90 levorphanol tartrate... 18 levothyroxine... 128 LEXIVA... 69 lice cream rinse... 108 lice killing... 108 lice treatment... 108 lice treatment (permethrin)... 108 lidocaine... 24 lidocaine (pf)... 24, 80 lidocaine hcl... 24 lidocaine in 5 % dextrose (pf) 81 lidocaine-prilocaine... 24 life-pack women's... 158 linezolid... 30 LINZESS... 109 liothyronine... 128 lipase-protease-amylase... 109 lipogen... 86 LIPOSYN II... 78 LIPOSYN III... 78 liquibid d-r... 96 liquid calcium with vitamin d... 140 LIQUI-E... 158 liquitears... 111 lisinopril... 80 lisinopril-hydrochlorothiazide 80 lithium carbonate... 88 lithium citrate... 88 little animals... 158 little animals-iron... 158 l-norgest-eth estr/ethin estra... 90 lobana bath... 103 lohist peb dm... 96 lomustine... 40 loperamide... 119 loradamed... 59 loratadine... 59 loratadine-d... 59 lorazepam oral solution... 27 lortuss ex... 96 losartan... 79 losartan-hydrochlorothiazide.. 79 LOTEMAX... 115 LOTRIMIN ULTRA... 55 LOTRONEX... 109 I-13 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

lovastatin... 86 loxapine succinate... 67 lubricant dry eye relief... 111 lubricant eye (cmc-glycer)(pf)... 111 lubricant eye (cmc-glycerin) 111 lubricant eye (polyv alcohol) 112 lubricant eye (propyl glycol) 112 lubricant eye drops... 112 lubricant gel... 112 lubricating drops... 112 lubrifresh pm... 112 LUMIGAN... 138 LUMIZYME... 109 LUPRON DEPOT... 40 LUPRON DEPOT (3 MONTH)... 40 LUPRON DEPOT (4 MONTH)... 40 LUPRON DEPOT (6 MONTH)... 40 LUPRON DEPOT-PED... 40 LUPRON DEPOT-PED (3 MONTH)... 41 LYNPARZA... 41 LYRICA... 46 lysiplex plus... 158 LYSODREN... 41 M maalox advanced... 119 MACUVITE... 158 MACUVITE EYE CARE... 158 mafenide acetate... 103 mag 64... 140 mag-delay... 141 mag-g... 141 MAGNEBIND 300... 119 magnesium... 141 magnesium (oxide/aa chelate)... 141 magnesium chloride... 141 magnesium gluconate... 141 magnesium oxide... 119 magnesium sulf in 0.45% nacl... 141 magnesium sulfate... 141 magnesium sulfate in d5w... 141 magnesium sulfate in water.. 141 malathion... 108 mapap (acetaminophen)... 18 mapap arthritis pain... 18 mapap extra strength... 18 maprotiline... 49 mar-cof bp... 96 mar-cof cg... 96 MARPLAN... 49 MARQIBO... 41 masanti double strength... 119 MATULANE... 41 matzim la... 82 maximum daily multivitamin... 158 maximum strength flu... 96 meclizine... 62 medi-brom... 96 medroxyprogesterone... 127, 128 mefenamic acid... 23 mefloquine... 63 MEFOXIN IN DEXTROSE (ISO-OSM)... 33 mega multiple/chelated mineral... 158 mega multivitamin with mineral... 158 MEGACE ES... 41 megestrol... 41 MEKINIST... 41 meloxicam... 23 melphalan hcl intravenous... 41 memantine... 47 MENACTRA (PF)... 130 MENEST... 125 MENHIBRIX (PF)... 130 MENOMUNE - A/C/Y/W-135 (PF)... 130 men's daily gummies... 158 men's multi-vitamin... 158 men's multivitamin gummies 158 men's one daily... 158 MENVEO A-C-Y-W-135-DIP (PF)... 130 MENVEO MENA COMPONENT (PF)... 130 MENVEO MENCYW-135 COMPNT (PF)... 131 MEPHYTON... 158 mercaptopurine... 41 meropenem... 34 mesehist dm... 96 mesna... 135 MESNEX... 135 MESTINON... 136 metaproterenol... 145 metaxalone... 147 metformin... 51 methadone... 18 methadone hcl... 18 methazolamide... 138 methenamine hippurate... 30 methenamine mandelate... 30 methimazole... 128 methocarbamol... 147 methotrexate sodium... 41 methotrexate sodium (pf)... 41 methoxsalen rapid... 103 methscopolamine... 119 methyclothiazide... 85 methylphenidate... 88, 89 methylprednisolone... 126 methylprednisolone acetate.. 126 I-14 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

methylprednisolone sodium succ... 126 metipranolol... 138 metoclopramide hcl... 119 metolazone... 85 metoprolol succinate... 81 metoprolol ta-hydrochlorothiaz... 81 metoprolol tartrate... 81 metronidazole... 61, 63, 104 metronidazole in nacl (iso-os) 63 mexiletine... 81 mgo... 119 MIACALCIN... 133 mi-acid... 119 mi-acid gas relief... 115 micatin... 55 miconazole 7... 55 miconazole nitrate... 55 midazolam... 28 midazolam (pf)... 27, 28 midodrine... 79 milk of magnesia... 121 milltrium senior... 158 milrinone... 84 milrinone in 5 % dextrose... 84 MINERAL OIL... 136 mineral oil laxative... 121 mineral oil light... 136 minitran... 87 minocycline... 36 minoxidil... 87 mintox... 119 mintox maximum strength... 119 mintox plus... 119 MIRCERA... 73 mirtazapine... 49 misoprostol... 116 mitomycin... 41 mitoxantrone... 41 M-M-R II (PF)... 131 moexipril... 80 moexipril-hydrochlorothiazide... 80 mometasone... 107 MONISTAT 3... 56 monistat 7... 56 montelukast... 144, 145 morphine... 19 MORPHINE... 19 morphine concentrate... 18 morrhuate sodium... 136 motion sickness... 62 motion sickness (meclizine)... 62 MOVANTIK... 119 MOVIPREP... 121 MOXEZA... 114 moxifloxacin... 35 MOZOBIL... 73 mucinex fast-max dm max... 96 mucus dm... 96 mucus dm max... 96 mucus relief... 97 MULTAQ... 81 multi complete with iron... 158 multi-day with iron... 158 multi-delyn... 158 multi-delyn with iron... 158 multilex... 158 multilex-t&m... 158 multiple vitamin-minerals... 159 multiple vitamins... 159 multiple vitamins with iron.. 159 multi-symptom cold night time... 97 multi-symptom cold-cough... 97 multivital platinum... 159 multivitamin... 159 multivitamin 50 plus... 159 multi-vitamin hp/minerals... 159 multivitamin with iron... 159 multivitamin with minerals.. 159 multivitamins with min no.7-fa... 159 multi-vite... 159 multi-vite 50 & over... 159 mupirocin... 104 mupirocin calcium... 104 muro 128... 112 MUSTARGEN... 41 my favorite multiple... 159 myco nail a... 56 mycophenolate mofetil... 129 mycophenolate sodium... 129 mylanta gas... 115 MYOZYME... 109 mytab gas... 115 mytab gas maximum strength... 116 my-vitalife... 159 N nabumetone... 23 nadolol... 81 nafcillin... 35 nafcillin in dextrose iso-osm.. 35 NAGLAZYME... 109 naloxone... 25 naltrexone... 25 naltrexone hcl... 25 NAMENDA... 47 NAMENDA TITRATION PAK... 47 NAMENDA XR... 47, 48 NAMZARIC... 48 naphazoline... 112 naproxen... 23 naproxen sodium... 23 naratriptan... 61 nasal & sinus decongestant... 97 I-15 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

nasal decongestant (oxymetazl)... 112 nasal decongestant (pe)... 79 NASCOBAL... 159 NASONEX... 115 NATACYN... 114 nateglinide... 51 NATPARA... 133 natural b-100... 159 natural b-100 complex... 160 natural balance... 112 natural calcium... 141 natural fiber laxative therapy 121 natural tears (pf)... 112 nature's tears... 112 NEBUPENT... 63 nefazodone... 49 neomy sulf-bacitrac zn-poly-hc... 114 neomycin... 29 neomycin-bacitracin-poly-hc 114 neomycin-bacitracin-polymyxin... 114 neomycin-polymyxin b gu... 104 neomycin-polymyxin b- dexameth... 114 neomycin-polymyxingramicidin... 114 neomycin-polymyxin-hc... 114 neosporin anti-itch... 107 neo-synephrine 12 h spr (oxym)... 112 neo-tuss... 97 NEPHRAMINE 5.4 %... 78 nephro-vite... 160 NEULASTA... 73 NEUMEGA... 73 NEUPOGEN... 73 NEUPRO... 64 NEVANAC... 115 nevirapine... 69 NEXAFED... 97 NEXAVAR... 41 niacin... 86 niacinamide... 86, 160 nicardipine... 85 NICODERM CQ... 25 nicorelief... 25 nicorette... 25 nicotine... 25 nicotine (polacrilex)... 25 NICOTROL... 25 nifedipine... 85 night time... 97 night time cold-flu... 97 night time cold-flu relief... 97 nighttime cold-flu... 97 nighttime cough... 97 nighttime relief eye... 112 NILANDRON... 41 nite time cold-flu... 97 nite time-d cold-flu relief... 97 NITRO-BID... 87 nitrofurantoin macrocrystal... 30 nitrofurantoin monohyd/m-cryst... 30 nitroglycerin... 87 nitroglycerin in 5 % dextrose. 87 NITROSTAT... 87 nohist-dm... 97 non-aspirin cold... 97 non-aspirin extra strength... 19 non-aspirin flu... 97 non-aspirin jr strength... 19 NORDITROPIN FLEXPRO 127 norelgestromin/ethin.estradiol 90 norepinephrine bitartrate... 84 noreth-ethinyl estradiol/iron... 90 norethindrone... 90 norethindrone (contraceptive) 90 norethindrone acetate... 128 norethindrone ac-eth estradiol... 90, 125 norethindrone-e.estradiol-iron... 90, 91 norethindrone-ethinyl estrad.. 91 norethindrone-mestranol... 91 norgestimate-ethinyl estradiol 91 norgestrel-ethinyl estradiol... 91 NORMOSOL-M IN 5 % DEXTROSE... 141 NORMOSOL-R... 141 NORMOSOL-R PH 7.4... 141 nortemp... 19 NORTHERA... 79 nortriptyline... 49 NORVIR... 69 NOVOLIN 70/30... 52 NOVOLIN N... 52 NOVOLIN R... 52 NOVOLOG... 52 NOVOLOG FLEXPEN... 52 NOVOLOG MIX 70-30... 52 NOVOLOG MIX 70-30 FLEXPEN... 52 NOVOLOG PENFILL... 52 NOXAFIL... 56 NUCYNTA... 19 NUCYNTA ER... 19 NUEDEXTA... 89 nu-iron... 160 NULOJIX... 129 NUTRESTORE... 119 NUTRILIPID... 78 NUTRILYTE... 141 NUTRILYTE II... 141 NUTROPIN... 127 NUTROPIN AQ... 127 NUTROPIN AQ NUSPIN... 127 NUVARING... 91 I-16 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

NUVIGIL... 147 nystatin... 56 NYSTATIN (BULK)... 56 nystatin-triamcinolone... 56 nyt-time sleep... 59 O ocean nasal... 112 OCTAGAM... 129 octreotide acetate... 127 ocutabs... 160 OFEV... 146 ofloxacin... 35, 114 olanzapine... 67 olanzapine-fluoxetine... 49 olopatadine... 112 OLYSIO... 70 omega-3 acid ethyl esters... 86 omeprazole... 116 omeprazole magnesium... 116 omeprazole-sodium bicarbonate... 116, 117 OMNITROPE... 127 ONCASPAR... 42 once daily... 160 oncovite... 160 ondansetron... 62 ondansetron hcl... 63 ondansetron hcl (pf)... 63 one daily... 160 one daily 50 plus... 160 one daily complete... 160 one daily energy... 160 one daily essential... 160 one daily gummy vites... 160 one daily maximum (with ca)... 160 one daily men's 50+... 160 one daily multi-vit w-mineral... 160 one daily multivitamin... 160 one daily multivit-iron(folic) 160 one daily plus iron... 160, 161 one daily plus minerals... 161 one daily with iron... 161 one-a-day essential... 161 one-a-day maximum formula161 one-a-day teen advantage... 161 ONFI... 28 opcicon one-step... 91 OPDIVO... 42 OPSUMIT... 148 opti-vitamins... 161 oral saline laxative... 121 oralyte... 141 ORAP... 67 ORENCIA... 129 ORENCIA (WITH MALTOSE)... 129 ORENITRAM... 148 ORFADIN... 109 ORKAMBI... 146 OTEZLA... 136 OTEZLA STARTER... 136 oxacillin... 35 oxacillin in dextrose(iso-osm) 35 oxaliplatin... 42 oxandrolone... 125 oxcarbazepine... 46 OXTELLAR XR... 46 oxybutynin chloride... 123 oxycodone... 19, 20 oxycodone hcl-acetaminophen... 19 oxycodone hcl-aspirin... 19 oxycodone-acetaminophen... 20 oxycodone-aspirin... 20 OXYCONTIN... 20 oxymorphone... 20 oysco 500/d... 141 oysco d... 141 oysco-500... 141 oyster shell calcium 500... 141 oyster shell calcium with d... 141 oyster shell calcium-vit d3... 141 oystercal-d... 142 P paclitaxel... 42 pain relief... 20 pain relief adult... 20 pain reliever... 20 pain reliever jr strength... 20 paliperidone... 67 PANRETIN... 103 pantoprazole... 116 papaverine... 84 paricalcitol... 133 paromomycin... 63 paroxetine hcl... 49 PASER... 61 PATADAY... 112 PATANOL... 112 PAXIL... 49 pecgen dmx... 98 pedi m.vit no.17 with fluoride... 159 pedia relief... 98 pedia relief infant... 98 pediacare multi-symptom cold98 PEDIARIX (PF)... 131 pediatric electrolyte... 142 pediatric freezer pops... 142 pediatric multivitamin... 161 PEDVAX HIB (PF)... 131 peg 3350-electrolytes... 121 PEG 3350-GRX... 122 peg 3350-na sulf,bicarb,cl-kcl... 122 PEGANONE... 46 PEGASYS... 70 PEGASYS PROCLICK... 71 I-17 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

peg-electrolyte soln... 122 PEGINTRON... 71 PEGINTRON REDIPEN... 71 PEN NEEDLE, DIABETIC. 109 penicillin g pot in dextrose... 35 penicillin g potassium... 35 penicillin g procaine... 35 penicillin v potassium... 35 PENTACEL (PF)... 131 PENTACEL ACTHIB COMPONENT (PF)... 131 PENTAM... 64 pentoxifylline... 74 pep-t-med... 119 peri-colace... 122 PERIKABIVEN... 78 perindopril erbumine... 80 PERJETA... 42 permethrin... 108 perphenazine... 67 perphenazine-amitriptyline... 49 persa-gel... 103 pharbetol... 20 pharmacist favorite multi-vit 161 phenelzine... 49 phenobarbital... 46 phenobarbital sodium... 46 phentolamine... 148 phenylephrine hcl... 79, 112 phenylephrine-chlorpheniramine... 59 phenylhistine dh... 98 phenytoin... 46 phenytoin sodium... 46 phenytoin sodium extended... 46 phillips... 119 phillips liqui-gels... 122 PHOS-FLUR... 101 PHOSLYRA... 123 PHOS-NAK... 142 phosphate laxative... 122 PHOSPHOLINE IODIDE... 138 phosphorus #1... 142 phytonadione... 161 PICATO... 103 pilocarpine hcl... 101, 138 pimozide... 67 pindolol... 81 pioglitazone... 51 pioglitazone-glimepiride... 51 pioglitazone-metformin... 51 piperacillin-tazobactam... 35 piroxicam... 23 PLAN B ONE-STEP... 91 PLASBUMIN 25 %... 75 PLASBUMIN 5 %... 75 PLASMA-LYTE 148... 142 PLASMA-LYTE A... 142 PLASMA-LYTE-56 IN 5 % DEXTROSE... 142 PLEGRIDY... 136 podactin... 56 podofilox... 103 podophyllum resin... 103 polyethylene glycol 3350... 122 poly-iron... 161 polymyxin b sulf-trimethoprim... 114 poly-tussin... 98 poly-vita... 161 poly-vita (iron)... 161 poly-vitamin... 161 poly-vitamin with iron... 161 polyvitamin/iron... 161 poly-vitamins... 161 POMALYST... 42 potassium acetate... 142 potassium bicarb and chloride... 142 potassium bicarb-citric acid. 142 potassium bicarbonate-cit ac 142 potassium chlorid-d5-0.45%nacl... 142 potassium chloride... 142, 143 potassium chloride in 0.9%nacl... 142 potassium chloride in 5 % dex... 142 potassium chloride in lr-d5... 78 potassium chloride-0.45 % nacl... 143 potassium chloride-d5-0.2%nacl... 143 potassium chloride-d5-0.3%nacl... 143 potassium chloride-d5-0.9%nacl... 143 potassium citrate-citric acid. 143 potassium hydroxide... 103 potassium phosphate m-/d-basic... 143 POTIGA... 46 PRADAXA... 73 PRALUENT PEN... 86 PRALUENT SYRINGE... 86 pramipexole... 64 PRANDIMET... 51 pravastatin... 86 prazosin... 79 prednicarbate... 107 prednisolone acetate... 115 prednisolone sodium phosphate... 115, 126 prednisone... 126 PREGNYL... 127 PREMARIN... 125 PREMASOL 10 %... 78 PREMASOL 6 %... 78 PREMPHASE... 125 PREMPRO... 125 I-18 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

prenatal... 161 prenatal formula... 161 prenatal vit#96-ferrous fum-fa... 162 prenatal vitamin with minerals... 162 prenatal vitamins... 162 PRENATAL VITAMINS... 162 prenatal vit-iron fumarate-fa 162 preparation h hydrocortisone 107 PREVIDENT 5000 SENSITIVE... 101 PREZCOBIX... 69 PREZISTA... 69 PRIFTIN... 61 PRILOSEC OTC... 116 PRIMAQUINE... 64 primidone... 46 PRISTIQ... 49 PRIVIGEN... 129 PROAIR HFA... 145 PROAIR RESPICLICK... 145 probenecid... 136 procainamide... 81 PROCALAMINE 3%... 78 prochlorperazine... 63 prochlorperazine edisylate... 63 prochlorperazine maleate... 63 PROCRIT... 74 PROCYSBI... 136 progesterone... 128 progesterone micronized capsules... 128 PROGLYCEM... 87 PROGRAF... 129 PROLENSA... 115 PROLEUKIN... 42 PROLIA... 133 PROMACTA... 74 promethazine... 59, 63 promethazine hcl... 63 promethazine-codeine... 98 promethazine-dm... 98 promethazine-phenylephcodeine... 98 promolaxin... 122 propafenone... 81 propantheline... 44 proparacaine... 112 proparacaine hcl... 112 proparacaine-fluorescein sod 112 propranolol... 81, 82 propranolol-hydrochlorothiazid... 82 propylthiouracil... 128 PROQUAD (PF)... 131 prosight... 162 PROSOL 20 %... 78 protamine... 74 protriptyline... 49 pseudoephedrine hcl... 98 PULMOZYME... 109 pure & gentle eye... 113 purelax... 122 PURIXAN... 42 pyrazinamide... 61 pyridostigmine bromide... 136 pyridoxine... 162 Q q-dryl... 59 q-pap... 20, 21 q-pap extra strength... 20 q-tapp... 59 q-tapp dm... 98 q-tussin... 98 q-tussin dm... 98 QUADRACEL (PF)... 131 QUDEXY XR... 46 quetiapine... 67 QUILLIVANT XR... 89 quinapril... 80 quinapril-hydrochlorothiazide 80 quinidine gluconate... 81 quinidine sulfate... 81 quinine sulfate... 64 QVAR... 144 R RABAVERT (PF)... 131 raloxifene... 125 ramipril... 80 RANEXA... 84 ranitidine hcl... 117 RAPAMUNE... 129 REBIF (WITH ALBUMIN). 136 REBIF REBIDOSE... 136 REBIF TITRATION PACK 136 RECOMBIVAX HB (PF)... 131 recort plus... 107 refenesen... 98 refenesen pe... 98 REFRESH CLASSIC (PF)... 113 REFRESH LACRI-LUBE... 113 REFRESH LIQUIGEL... 113 REFRESH OPTIVE... 113 REFRESH OPTIVE ADVANCED... 114 reguloid... 122 RELADOR PAK... 24 relcof c... 98 RELENZA DISKHALER... 70 RELISTOR... 119, 120 remedy phytoplex antifungal.. 56 REMICADE... 136 REMODULIN... 148 RENAGEL... 123 RENVELA... 123 repaglinide... 51 REPATHA SURECLICK... 86 REPATHA SYRINGE... 87 RESCRIPTOR... 69 I-19 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

RESTASIS... 115 retaine cmc... 113 RETROVIR... 69 REVLIMID... 42 REXULTI... 67 REYATAZ... 69 REZIRA... 98 ribavirin... 71 RIDAURA... 129 rifabutin... 61 rifampin... 62 RIFATER... 62 ri-gel ii... 120 riluzole... 89 rimantadine... 70 ri-mox... 120 ringers... 132, 143 risedronate... 133 RISPERDAL CONSTA... 67 risperidone... 67 RITUXAN... 42 rivastigmine tartrate... 48 rizatriptan... 61 robafen... 99 robafen cough... 99 robafen dm... 99 robitussin cough-chest-cong dm... 99 ROBITUSSIN LONG-ACTING... 99 robitussin pediatric... 99 ropinirole... 64 ROTARIX... 131 ROTATEQ VACCINE... 131 ROZEREM... 147 rydex... 99 S SABRIL... 46 safe tussin dm... 99 SAIZEN... 127 SAIZEN CLICK.EASY... 127 saline mist... 113 salsalate... 23 SANDOSTATIN LAR DEPOT... 127 SANTYL... 103 SAPHRIS (BLACK CHERRY)... 68 SAVELLA... 89 scooby-doo one a day... 162 scot-tussin dm... 99 scot-tussin expectorant... 99 sea soft nasal mist... 113 selegiline hcl... 64 selenium sulfide... 104 SELZENTRY... 69 senexon... 122 senior tabs... 162 senna... 122 senna lax... 122 senna laxative... 122 senna with docusate sodium. 122 senokot-s... 122 SENSIPAR... 136 sentry... 162 sentry senior... 162 SEREVENT DISKUS... 145 SEROQUEL XR... 68 SEROSTIM... 127 sertraline... 49 setlakin... 91 silace... 122 siladryl sa... 59 silapap... 21 sildenafil oral tablet 20 mg... 148 SILENOR... 49 siltussin dm das... 99 siltussin sa... 99 silver nitrate... 104 silver nitrate applicators... 103 silver sulfadiazine... 104 SIMBRINZA... 138 simethicone... 116 simply sleep... 59 SIMPONI... 136 SIMPONI ARIA... 136 simvastatin... 87 sinus & allergy (pseudoephed)... 59 sirolimus... 129 SIRTURO... 62 skin treatment... 103 sleep aid (diphenhydramine).. 59 sleep-tabs... 59 smoothlax... 122 sochlor... 113 sodium acetate... 143 sodium bicarbonate... 120, 143 sodium chloride... 113, 132, 144, 146 sodium chloride 0.45 %... 143 sodium chloride 0.9 %... 143 sodium chloride 3 %... 143 sodium chloride 5 %... 143 sodium chloride-nahco3-kcl-peg... 122 sodium citrate-citric acid... 144 sodium fluoride... 162 sodium lactate... 144 sodium phosphate... 144 sodium polystyrene sulfonate... 123 sodium thiosulfate... 124 sod-pot-k cit-sod cit-cit acid. 144 SOLIRIS... 136 SOLTAMOX... 42 SOLU-CORTEF (PF)... 126 SOMATULINE DEPOT... 127 SOMAVERT... 127 I-20 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

soothe (bismuth subsalicylate)... 120 soothe regular strength... 120 sorbitol... 132 sorbitol-mannitol... 132 sotalol... 82 sotalol hcl... 82 SOVALDI... 70 spectravite... 162 spectravite adult 50+... 162 spectravite advanced formula... 162 spectravite senior... 162 spectravite senior w-lycopene... 163 spectravite ultra women... 163 SPIRIVA RESPIMAT... 145 SPIRIVA WITH HANDIHALER... 145 spironolactone... 87 spironolacton-hydrochlorothiaz... 87 SPRYCEL... 42 st joseph aspirin... 23 st. joseph aspirin... 23 stavudine... 69 STELARA... 136 STERILE LUBRICANT... 113 STERILE PADS... 136 STIOLTO RESPIMAT... 145 STIVARGA... 42 stomach relief... 120 stool softener... 122 STRATTERA... 89 streptomycin... 29 stress 500 plus zinc... 163 stress b with zinc... 163 stress b-biotin... 163 stress formula... 163 stress formula plus iron... 163 stress formula with iron... 163 stress formula with zinc... 163 STRIBILD... 69 STRIVERDI RESPIMAT... 145 stuart prenatal... 163 sucralfate... 117 sudogest... 99 sudogest cold & allergy... 59 sudogest pe... 79 sulfacetamide sodium... 114 sulfacetamide sodium (acne) 104 sulfacetamide-prednisolone. 114 sulfadiazine... 35 sulfamethoxazole-trimethoprim... 35, 36 sulfasalazine... 36 sulfatrim... 36 sulfazine... 36 sulfazine ec... 36 sulindac... 23 sumatriptan nasal spray... 61 sumatriptan succinate... 61 summer's eve disposable douche... 136 summers eve extra cleansing 137 sunvite... 163 super b complex-vitamin c... 163 super b/c... 163 super b-50 complex... 163 super b-50 complex plus... 163 super multiple... 163 super multivitamin... 163 super quints b-50... 163 super thera vite m... 164 superior 35... 164 superplex-t... 164 suphedrin... 99 suphedrine pe day-night... 99 suphedrine severe cold max str... 99 support... 164 support-500... 164 SUPPRELIN LA... 127 SUPRAX... 33 SURE COMFORT INS. SYR. U-100... 109 SURMONTIL... 49 SUSPENDOL-S... 137 SUSTIVA... 69 SUTENT... 42 SYLATRON... 71 SYLVANT... 42 SYMLINPEN 120... 51 SYMLINPEN 60... 51 SYNAGIS... 70 SYNAREL... 137 SYNERCID... 30 SYNRIBO... 42 SYPRINE... 124 T tab-a-vite... 164 tab-a-vite/iron... 164 tab-a-vite-minerals... 164 TABLOID... 42 tacrolimus... 107, 129 tactinal... 21 tactinal extra strength... 21 TAFINLAR... 42 TAMIFLU... 70 tamoxifen... 42 tamsulosin... 124 TARCEVA... 42, 43 TARGRETIN... 43 tarina fe... 91 TASIGNA... 43 TAZORAC... 108 taztia xt... 82 tears again... 113 TEARS NATURALE II... 113 TECFIDERA... 137 I-21 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

TECHNIVIE... 70 TEFLARO... 33 telmisartan... 79 telmisartan-hydrochlorothiazid... 79 temazepam... 28 TEMODAR... 43 TENIVAC (PF)... 131 terazosin... 124 terbinafine hcl... 56 terbutaline... 145 terconazole... 61 testosterone... 125 testosterone cypionate... 125 testosterone enanthate... 125 TETANUS TOXOID,ADSORBED (PF)... 131 TETANUS,DIPHTHERIA TOX PED(PF)... 131 TETANUS-DIPHTHERIA TOXOIDS-TD... 131 tetrabenazine... 89 tetracaine hcl... 113 tetracycline... 36 TEV-TROPIN... 127 THALOMID... 137 the magic bullet... 123 theophylline... 145, 146 theophylline anhydrous... 145 theophylline in dextrose 5 % 145 thera m plus (ferrous fumarat)... 164 thera vitamin... 164 theradex m... 164 THERAFLU DAYTIME COLD-COUGH... 99 THERAFLU NIGHTTIME SEVERE COLD... 99 THERAFLU SEVERE COLD- COUGH... 100 thera-m... 164 theramill forte... 164 therapeutic liquid... 164 therapeutic m + beta-carotene... 164 therapeutic vitamin & mineral... 164 therapeutic vitamins/minerals... 165 therapeutic-m... 165 therapeutic-m vitamin/minerals... 165 thera-tabs... 165 theratrum complete 50 plus.. 165 theratrum complete 50 plus/lut... 165 therems... 165 therems-h... 165 therems-m... 165 thiamine hcl... 165 thioridazine... 68 thiothixene... 68 tiagabine... 46 TICE BCG... 131 TIKOSYN... 81 timolol maleate... 82, 138 TIVICAY... 69 tizanidine... 147 TOBI PODHALER... 29 TOBRADEX ST... 114 tobramycin... 114 tobramycin in 0.225 % nacl... 29 tobramycin in 0.9 % nacl... 29 tobramycin sulfate... 29 tolazamide... 53 tolbutamide... 53 tolmetin... 23 tolnaftate... 56 tolterodine... 123 topiramate... 47 toposar intravenous... 43 topotecan... 43 TORISEL... 43 torsemide... 85 total b/c... 165 totalday multiple... 165 TOUJEO SOLOSTAR... 52 TOVIAZ... 123 TPN ELECTROLYTES... 144 TPN ELECTROLYTES II... 144 TRACLEER... 148 TRADJENTA... 51 tramadol... 21 tramadol-acetaminophen... 21 trandolapril... 80 tranexamic acid... 74 TRANSDERM-SCOP... 63 tranylcypromine... 49 TRAVASOL 10 %... 78 TRAVATAN Z... 138 travel sickness (meclizine)... 63 travoprost (benzalkonium)... 138 trazodone... 49 TREANDA... 43 TRECATOR... 62 TRELSTAR... 43 tretinoin... 108 tretinoin (chemotherapy)... 43 tretinoin microspheres... 108 TREXALL... 43 triacting m-sym cold/cough.. 100 triamcinolone acetonide... 101, 107, 126 triaminic cold & cough (pe). 100 TRIAMINIC COLD & COUGH NT (PE)... 59 triaminic cough-nasal congesti... 100 I-22 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

TRIAMINIC COUGH-SORE THROAT... 100 triamterene-hydrochlorothiazid... 85 triazolam... 28, 29 TRIBENZOR... 79 tri-buffered aspirin... 23 triderm... 108 tri-dex pe... 100 trifluoperazine... 68 trifluridine... 114 trigofen dm... 100 trihexyphenidyl... 64 TRILEPTAL... 47 trimethoprim... 30 triple paste af... 56 TRIUMEQ... 69 tri-vi-sol... 165 tri-vita... 165 tri-vitamin... 165 TROKENDI XR... 47 TROPHAMINE 10 %... 78 TROPHAMINE 6%... 78 trospium... 123, 124 TRULICITY... 51 TRUMENBA... 131 TRUVADA... 69 trymine cg... 100 TUDORZA PRESSAIR... 146 tusnel diabetic... 100 TUSNEL PEDIATRIC... 100 tussin cf... 100 tussin cf cough-cold... 100 tussin cold-congestion... 100 tussin cough (dm only)... 100 tussin dm... 100 tussin dm cough & chest... 100 tussin maximum strength cough... 100 tussin pe... 100 TWINRIX (PF)... 131 TYBOST... 137 TYGACIL... 36 TYKERB... 43 TYPHIM VI... 131 TYSABRI... 129 TYVASO... 148 TYVASO REFILL KIT... 148 TYVASO STARTER KIT... 149 TYZEKA... 71 U ULORIC... 137 ultra b-100 complex... 165 ultra fresh pm... 113 ultra sleep (doxylamine succ) 59 ultra strength antacid... 120 unicomplex-m... 166 unisom sleepgels... 59 UNITUXIN... 43 ursodiol... 120 V VAGIFEM... 126 valacyclovir... 71 VALCHLOR... 103 valganciclovir... 71 valproate sodium... 47 valproic acid... 47 valproic acid (as sodium salt). 47 valsartan... 79 valsartan-hydrochlorothiazide 79 VALSTAR... 43 valu-tapp dm... 100 vancomycin... 31 vancomycin in d5w... 30 VAQTA (PF)... 131 VARIVAX (PF)... 131 VASCEPA... 87 vasopressin... 127 VECTIBIX... 43 VELCADE... 43 venlafaxine... 50 VENTAVIS... 149 verapamil... 82 VERSACLOZ... 68 vicks dayquil cough... 101 vicks nature fusion cough... 101 vicks qlearquil(oxymetazoline)... 113 vicks sinex 12-hour... 113 VICTOZA... 51 VIDEX 2 GRAM PEDIATRIC... 69 VIDEX 4 GRAM PEDIATRIC... 69 VIEKIRA PAK... 70 VIGAMOX... 114 VIIBRYD... 50 VIMIZIM... 110 VIMPAT... 47 vinblastine... 43 vincristine... 43 vincristine sulfate... 44 vinorelbine... 44 VIRACEPT... 69 VIRAMUNE XR... 69 VIRAZOLE... 71 virdec dm... 101 VIREAD... 70 vision... 166 vision formula... 166 vision formula (with lutein). 166 vision plus lutein... 166 vit b cmplx 3-fa-vit c-biotin. 166 vit b cmplx no3-fa-c-biot-zinc... 166 vitabee/c... 166 vitalets... 166 vitamin a... 166 vitamin b complex... 166 vitamin b complex with c... 166 I-23 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

vitamin b-1... 166 vitamin b-100 complex... 166 vitamin b12-folic acid... 166 vitamin b-6... 166 vitamin c... 166, 167 vitamins & minerals... 167 vitamins b complex... 167 vitamins for hair... 167 VITEKTA... 70 vitrum senior... 167 VOLTAREN... 23 voriconazole... 56 VOTRIENT... 44 VPRIV... 110 W wal-act d cold & allergy... 59 wal-dram... 63 wal-dryl allergy... 59, 60 wal-finate... 60 wal-finate-d... 60 wal-itin... 60 wal-itin d... 60 wal-itin d 12 hour... 60 wal-phed... 60, 101 wal-phed pe... 79 wal-phed pe day-night... 101 wal-phed pe sinus & allergy.. 60 wal-profen... 23 wal-sleep z... 60 wal-som (diphenhydramine).. 60 wal-tap... 60 wal-tussin cough... 101 wal-tussin cough & cold cf.. 101 wal-tussin dm... 101 wal-zan 75... 117 wal-zyr (cetirizine)... 60 wal-zyr (ketotifen)... 113 wal-zyr d... 60 warfarin... 73 water for irrigation, sterile... 132 WELCHOL... 87 womens daily gummies... 167 women's daily multivitamin. 167 X XALKORI... 44 XARELTO... 73 XELJANZ... 137 XENAZINE... 89 XGEVA... 133 XIFAXAN... 31 XOLAIR... 146 XTANDI... 44 xylon 10... 21 XYREM... 147 Y yelets... 167 YERVOY... 44 YF-VAX (PF)... 131 Z zafirlukast... 145 zaleplon... 147 ZALTRAP... 44 zantac 75... 117 ZARXIO... 74 ZAVESCA... 110 ZELBORAF... 44 ZEMAIRA... 146 ZEMPLAR... 133 ZENPEP... 110 zephrex-d... 101 ZETIA... 87 ZIAGEN... 70 zidovudine... 70 zinc oxide... 103 ziprasidone hcl... 68 ZOLADEX... 44 zoledronic acid... 133 zoledronic acid-mannitol-water... 133 ZOLINZA... 44 zolmitriptan... 61 zolpidem... 147, 148 ZOMACTON... 127 ZOMETA... 133 ZONATUSS... 101 zonisamide... 47 zoo chews... 167 ZORTRESS... 129 ZOSTAVAX (PF)... 131 ZOVIRAX... 103 z-sleep... 60 ZUBSOLV... 25 ZYDELIG... 44 ZYKADIA... 44 ZYLET... 114 zyncof... 101 ZYPREXA RELPREVV... 68 ZYRTEC... 60 zyrtec itchy eye drops (keto) 113 ZYTIGA... 44 ZYVOX... 31 I-24 ICS Formulario Community ICS Community Care Plus 2015 Care FIDA-MMP Plus FIDA-MMP Formulary per il 2015 Formulary ID del formulario: ID: 15412.000, Version: Versione: 14 16 In vigore da: 1 nov 2015

Questo formulario è stato aggiornato in data 27 Ottobre 2015. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, da lunedì a venerdì, dalle 8:00 alle 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito www.icsny.org/care-plus.

1.877.ICS.2525 www.icsny.org Ufficio amministrativo Independence Care System 257 Park Ave. South 2nd Floor New York, NY 10010 Centri di assistenza per gli iscritti 400 East Fordham Road 10th floor Bronx, New York 10458 25 Elm Place 5th Floor Brooklyn, NY 11201