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1 2018 COMPLETE DRUG LIST (FORMULARY)

Prescription drug list information

UnitedHealthcare® Group Medicare Advantage (PPO) CalPERS

Important Notes: This document has information about the drugs covered by this plan. For more up-to-date information or if you have any questions, please call Customer Service at:

Toll-Free 1-888-867-5581, TTY 711 7 a.m. - 8 p.m. local time, 7 days a week

www.UHCRetiree.com/calpers

Formulary ID Number 00018051, Version 10 Y0066_170613_155628 Last updated September 1, 2017 2 11 TABLE OF CONTENTS What is a drug list?...... 3 Note to existing members...... 3 How do I use the drug list?...... 4 What are generic drugs?...... 4 Drug payment stage and drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 40 Covered drugs with a quantity limit (QL)...... 143

Questions?

If you have questions, we’re here to help. Call Customer Service at: Toll-Free 1-888-867-5581, TTY 711 7 a.m. - 8 p.m. local time, 7 days a week 2 3 What is a drug list? A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of health care providers work together in selecting drugs that are needed for well-rounded care and treatment. Your plan will generally cover the drugs listed in our drug list as long as: · The drug is medically necessary · The prescription is filled at a network pharmacy · Other plan rules are followed For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members: This complete list of prescription drugs covered by your plan is current as of September 1, 2017. For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our contact information is on the cover. This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage (PPO). 4 3 How do I use the drug list? There are 2 ways to find your prescription drugs in this drug list: 1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–39 to see the ...... list of drug names in alphabetical order. Find the name of your drug. The page number where ...... you can find the drug will be next to it. 2. By medical condition. Turn to section “Covered drugs by medical condition” on pages ...... 40–142 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

What are generic drugs? Generic drugs have the same active ingredients as brand name drugs. They usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers both brand name and generic drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in plain type (for example, Simvastatin). 4 5 Drug payment stage and drug tiers The amount you pay for a covered prescription drug will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers. If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Customer Service. Our contact information is on the cover.

Drug Tier Includes Tier 1: All covered generic drugs. Preferred generic Tier 2: Many common brand name drugs, called preferred Preferred brand brands. Tier 3: Non-preferred brand name drugs. In addition, Part D Non-preferred drug eligible compound medications are covered in Tier 3. Tier 4: Unique and/or very high-cost brand drugs. Specialty tier

Getting Extra Help If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover. 1

6Dummy 5 Are there any rules or limits on my drug coverage? Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug has any coverage rules or limits, there will be a code(s) in the “Coverage rules or limits on use” column of the “Covered drugs by medical condition” chart starting on page 40. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call Customer Service. Our contact information is on the cover. Coverage Rules and Limits

PA - Prior authorization The plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used and covered correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on how it is used. If you don’t get prior approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for 1 copay/coinsurance or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try 1 or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. 6 7 Other Special Coverage Rules

B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. HRM - High-risk medication This drug is known as a high-risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. MED - Morphine equivalent dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative morphine equivalent dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

For Track Refered Purpose

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to learn more. If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules or limits, you may have to pay the full cost of the drug. 8 7 tRACK What if my drug is not on this list? If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s covered. Or go to www.UHCRetiree.com/calpers to look it up online. The information is updated on a regular basis. If you find out that your drug is not covered, you can do 1 of these things: 1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get the list, show it to your doctor and ask him or her to prescribe a covered drug. 2. Ask the plan to make an exception and cover your drug. Review the next section for more exception information.

How can I get an exception? Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This is called asking for an exception. When you do, the plan will review your request and give you a coverage decision known as a coverage determination. Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-sharing level. · Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For example, if your drug has a quantity limit, you can ask the plan to change the limit and cover more. · Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the specialty tier. The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as effective in treating your condition or would cause adverse medical effects. Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling Customer Service. Your doctor must give us a supporting statement with the reason for the exception. How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your expedited request is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting statement. 8 9 Can I get my drug while I wait for an exception? As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s not on our drug list or if it has rules or limits. For example, you may need a prior authorization from us before you can fill your prescription. During the time when you are getting a temporary supply, you should talk with your doctor to decide if there is a similar drug on the drug list you can take instead. If you and your doctor decide this is the only drug that will work for you, you will need to ask for an exception. We may cover your drug in certain cases during the first 90 days of your membership. The following chart shows how much of your drug we may cover while you ask for an exception.

If you... And you are… You can ask for… are a new member in the first 90 days of not in a nursing home or at least a 30-day your membership long-term care facility temporary supply OR were a member last year and it’s the in a nursing home or long- at least a 98-day first 90 days of your plan year term care facility temporary supply have been in the plan for more than 90 in a nursing home or at least a 31-day days long-term care facility and emergency supply need a supply right away are going through a change in your level not in a nursing home or at least a 30-day of care, such as being transferred from long-term care facility temporary supply a hospital to a long-term care facility, any time during the year in a nursing home or long- at least a 31-day term care facility temporary supply

The prescription must be filled at a network pharmacy. Also, if your prescription is written for fewer days, you can refill it multiple times. This is so you can get your full temporary supply. We will not pay for more of your drug after you get this temporary or emergency supply unless you receive authorization from the plan. 10 9 Can the drug list change? We try to change the drug list as little as possible during the plan year. Occasionally we may need to make changes for safety or other reasons. The drug list may change during the year if your plan: · Adds new drugs, including generic drugs, as they become available. · Removes a drug that has been found to be ineffective or unsafe. · Changes the coverage rules or limits for a drug. · Moves a drug into a different tier. If we remove a drug from the list

Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will not remove or reduce coverage during the year. If you are taking a drug that is removed because a generic version becomes available, we will tell you. If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe, we will take it off the drug list right away. If we change the coverage rules or limits

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking in the chart on pages 143-180. We’ll tell you about any changes

If a drug you are taking is removed from the drug list during the plan year we’ll include an update in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about any changes to our drug list at least 60 days before they go into effect or when you request a refill of the drug. If you find out when requesting a refill, you will receive a 60-day supply of the drug so you have time to talk with your doctor. To get updated information about the drugs covered by your plan, please call Customer Service or go to www.UHCRetiree.com/calpers to look it up online. 10 11 Drugs with dosages other than a 1-month supply Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription. For more information, please call Customer Service. Our contact information is on the cover. Daily cost-sharing for oral medications filled for less than a 1-month supply A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., or ) when dispensed for a supply of less than 1 month under applicable law. The daily cost-sharing requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.

For more information For more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan’s prescription drug coverage, we’re here to help. Call Customer Service toll-free at 1-888-867-5581, TTY 711, 7 a.m. - 8 p.m. local time, 7 days a week. Or visit us online at www.UHCRetiree.com/calpers. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week. Tracked 12

12 12 trackCovered drugs by name (Drug index)

A Actonel...... 131 Agrylin...... 88 Abacavir...... 81 Actoplus Met...... 84 Airduo Respiclick 113/14....140 Abacavir Sulfate/Lamivudine/ Actoplus Met XR...... 84 Airduo Respiclick 232/14....140 Zidovudine...... 81 Actos...... 84 Airduo Respiclick 55/14...... 140 Abacavir/Lamivudine...... 81 Acular...... 135 Ala Scalp...... 116 Abelcet...... 66 Acular LS...... 135 Ala-Cort...... 116 Abilify...... 76 Acuvail...... 135 Albenza...... 74 Abilify Maintena...... 76 Acyclovir...... 80 Albuterol Sulfate...... 138 Abraxane...... 71 Acyclovir Sodium...... 80 Albuterol Sulfate ER...... 138 Absorica...... 103 Aczone...... 103 Alclometasone Dipropionate Abstral...... 45 Adacel...... 129 ...... 116 Acamprosate Calcium DR.....47 Adagen...... 113 Alcohol Prep Pads...... 132 Acanya...... 103 Adalat CC...... 92 Aldactazide...... 94 Acarbose...... 84 Adapalene...... 103 Aldactone...... 97 Accolate...... 137 Adcirca...... 140 Aldara...... 103 Accupril...... 90 Adderall...... 100 Aldurazyme...... 113 Accuretic...... 94 Adderall XR...... 100 Alecensa...... 72 Acebutolol HCl...... 91 Adefovir Dipivoxil...... 79 Alendronate Sodium...... 131 Acetaminophen/Codeine...... 45 Adempas...... 140 Alfuzosin HCl ER...... 115 Acetasol HC...... 136 Adlyxin...... 84 Alimta...... 70 Acetazolamide...... 97 Adlyxin Starter Pack...... 84 Alinia...... 74 Acetazolamide ER...... 97 Adrenalin...... 138 Alkeran...... 70 Acetazolamide Sodium...... 97 Adriamycin...... 71 Allopurinol...... 68 Acetic Acid...... 136 Adrucil...... 70 Allopurinol Sodium...... 68 Acetylcysteine...... 140 Advair Diskus...... 140 Almotriptan Malate...... 68 Aciphex...... 112 Advair HFA...... 140 Alocril...... 133 Aciphex Sprinkle...... 112 Adzenys XR-ODT...... 100 Alogliptin...... 84 Acitretin...... 103 Aerospan...... 137 Alogliptin/Metformin HCl...... 84 Actemra...... 129 Afeditab CR...... 92 Alogliptin/Pioglitazone...... 84 ActHIB...... 129 Afinitor...... 72 Alomide...... 133 Actigall...... 110 Afinitor Disperz...... 72 Aloprim...... 68 Actimmune...... 129 Afrezza...... 86 Alora...... 121 Actiq...... 45 Aggrenox...... 89 Alosetron HCl...... 111 Tracked 13

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Aloxi...... 65 Amitiza...... 111 Anoro Ellipta...... 140 Alphagan P...... 134 Amitriptyline HCl...... 64 Antabuse...... 48 Alprazolam...... 83 Amlodipine Besylate...... 92 Antara...... 98 Alprazolam ER...... 83 Amlodipine Besylate/ Anusol-HC...... 130 Alprazolam Intensol...... 83 Atorvastatin Calcium...... 94 Anzemet...... 65 Alprazolam ODT...... 83 Amlodipine Besylate/ ApexiCon E...... 116 Benazepril HCl...... 94 Alrex...... 135 Apidra SoloStar...... 86 Amlodipine Besylate/Valsartan Altace...... 90 Apidra Vial...... 86 ...... 94 Altoprev...... 98 Aplenzin...... 62 Amlodipine/Olmesartan Alunbrig...... 72 Medoxomil...... 94 Apokyn...... 75 Alvesco...... 137 Amlodipine/Valsartan/ Apraclonidine...... 134 Alyacen 1/35...... 121 Hydrochlorothiazide...... 94 Aprepitant...... 65 Amantadine HCl...... 75 Ammonium Lactate...... 104 Apri...... 121 Amaryl...... 84 Amoxapine...... 64 Apriso...... 130 Ambien...... 141 Amoxicillin...... 52 Aptensio XR...... 101 AmBisome...... 66 Amoxicillin/Clavulanate Aptiom...... 60 Potassium...... 52 Amcinonide...... 116 Aptivus...... 82 Amoxicillin/Clavulanate Amerge...... 68 Aralast NP...... 113 Potassium ER...... 53 Amethia...... 121 Aranelle...... 121 Amphetamine/ Amethia Lo...... 121 Dextroamphetamine...... 100 Aranesp Albumin Free...... 88 Amikacin Sulfate...... 48 Amphotericin B...... 66 Arava...... 129 Amiloride HCl...... 97 Ampicillin...... 53 Arcalyst...... 129 Amiloride/Hydrochlorothiazide Ampicillin Sodium...... 53 Arcapta Neohaler...... 138 ...... 94 Ampicillin-Sulbactam...... 53 Argatroban...... 87 Aminophylline...... 139 Ampyra...... 103 Aricept...... 61 Aminosyn 7%/Electrolytes...106 Anadrol-50...... 120 Arimidex...... 72 Aminosyn 8.5%/Electrolytes Anafranil...... 64 Aripiprazole...... 76 ...... 106 Anagrelide HCl...... 88 Aripiprazole ODT...... 76 Aminosyn II...... 106 Anaprox DS...... 40 Aristada...... 76 Aminosyn II 8.5%/Electrolytes Arixtra...... 87 ...... 106 Anastrozole...... 72 Armodafinil...... 142 Aminosyn-HBC...... 106 Ancobon...... 66 Arnuity Ellipta...... 137 Aminosyn-PF...... 106 Androderm...... 120 Aromasin...... 72 Aminosyn-RF...... 106 AndroGel...... 120 Arranon...... 71 Amiodarone HCl...... 90 AndroGel Pump...... 120 Tracked 14

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Arthrotec 50...... 40 Avalide...... 94 Bacitracin/Polymyxin B...... 132 Arthrotec 75...... 40 Avandia...... 84 Baclofen...... 141 Asacol HD...... 130 Avapro...... 90 Bactocill in Dextrose...... 53 Ashlyna...... 121 Avastin...... 73 Bactrim...... 55 Asmanex HFA...... 137 AVC...... 66 Bactrim DS...... 55 Asmanex Twisthaler 120 Aveed...... 121 Bactroban...... 49 Metered Doses...... 137 Avelox...... 54 Bactroban Nasal...... 49 Asmanex Twisthaler 30 Aviane...... 121 Balsalazide Disodium...... 130 Metered Doses...... 137 Avita...... 104 Balziva...... 121 Asmanex Twisthaler 60 Avodart...... 115 Banzel...... 60 Metered Doses...... 137 Avonex...... 103 Baraclude...... 79 Aspirin/Dipyridamole...... 89 Avonex Pen...... 103 Basaglar KwikPen...... 86 Astagraf XL...... 127 Avycaz...... 51 Bavencio...... 73 Astepro...... 136 Axert...... 68 BCG Vaccine...... 129 Atacand...... 90 Axiron...... 121 Beconase AQ...... 137 Atacand HCT...... 94 Aygestin...... 125 Bekyree...... 121 Atelvia...... 131 Azacitidine...... 88 Belbuca...... 42 Atenolol...... 91 Azactam in Iso-Osmotic Beleodaq...... 72 Atenolol/Chlorthalidone...... 94 Dextrose...... 52 Belsomra...... 142 Atgam...... 128 Azasan...... 127 Benazepril HCl...... 90 Ativan...... 83 Azasite...... 53 Benazepril HCl/ Atomoxetine...... 101 Azathioprine...... 127 Hydrochlorothiazide...... 94 Atorvastatin Calcium...... 98 Azelastine HCl...... 133, 136 Benicar...... 90 Atovaquone...... 74 Azelex...... 104 Benicar HCT...... 95 Atovaquone/Proguanil HCl....74 Azilect...... 76 Benlysta...... 129 Atralin...... 104 Azithromycin...... 53 Bentyl...... 110 Atripla...... 80 Azopt...... 134 BenzaClin...... 104 Atropine Sulfate...... 110, 132 Azor...... 94 Benzamycin...... 104 Atrovent HFA...... 138 Aztreonam...... 52 Benztropine Mesylate...... 74 Aubagio...... 103 Azulfidine...... 131 Bepreve...... 133 Aubra...... 121 Azulfidine EN-Tabs...... 131 Berinert...... 127 Augmented Betamethasone B Besivance...... 54 Dipropionate...... 116 BACiiM...... 49 Betagan...... 134 Augmentin...... 53 Bacitracin...... 49 Auryxia...... 110 Tracked 15

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Betamethasone Dipropionate Boostrix...... 129 Bystolic...... 91 ...... 116 Bosulif...... 72 Byvalson...... 95 Betamethasone Valerate...... 116 Botox...... 132 C Betapace...... 90 Breo Ellipta...... 141 Cabergoline...... 126 Betaseron...... 103 Brevicon-28...... 121 Cabometyx...... 72 Betaxolol HCl...... 91, 134 Briellyn...... 121 Caduet...... 95 Bethanechol Chloride...... 116 Brilinta...... 89 Cafergot...... 68 Bethkis...... 139 Brimonidine Tartrate...... 134 Calan...... 92 Betimol...... 134 Brisdelle...... 62 Calan SR...... 92 Betoptic-S...... 134 BRIVIACT...... 57 Calcipotriene...... 104 Bevespi Aerosphere...... 141 Bromfenac...... 135 Calcipotriene/Betamethasone Bexarotene...... 73 Bromocriptine Mesylate...... 75 Dipropionate...... 104 Bexsero...... 129 Brovana...... 138 Calcitonin-Salmon...... 131 Beyaz...... 121 Budesonide...... 130, 137 Calcitriol...... 104, 131 Bicalutamide...... 70 Budesonide ...... 137 Calcium Acetate...... 110 Bicillin C-R...... 53 Bumetanide...... 97 Cambia...... 40 Bicillin L-A...... 53 Bunavail...... 48 Camila...... 125 BiCNU...... 70 Buphenyl...... 113 Camptosar...... 71 BiDil...... 95 Buprenex...... 48 Camrese Lo...... 121 Biltricide...... 74 Buprenorphine...... 42 Canasa...... 130 Bimatoprost...... 135 Buprenorphine HCl...... 48 Cancidas...... 66 Binosto...... 131 Buprenorphine HCl/Naloxone Candesartan Cilexetil...... 90 Bisoprolol Fumarate...... 91 HCl...... 48 Candesartan Cilexetil/ Bisoprolol Fumarate/ Bupropion HCl...... 62 Hydrochlorothiazide...... 95 Hydrochlorothiazide...... 95 Bupropion HCl SR...... 48, 62 Capastat Sulfate...... 69 BIVIGAM...... 128 Bupropion HCl XL...... 62 Capex...... 116 Bleomycin Sulfate...... 71 Buspirone HCl...... 83 Caprelsa...... 72 Bleph-10...... 55 Busulfan...... 70 Captopril...... 90 Blephamide...... 132 Busulfex...... 70 Captopril/Hydrochlorothiazide ...... 95 Blephamide S.O.P...... 132 Butorphanol Tartrate...... 45 Carac...... 104 Blisovi 24 Fe...... 121 Butrans...... 42 Carafate...... 112 Blisovi Fe 1.5/30...... 121 Bydureon...... 84 Carbaglu...... 106 Blisovi Fe 1/20...... 121 Bydureon Vial...... 84 Carbamazepine...... 60 Boniva...... 131 Byetta...... 84 Carbamazepine ER...... 60 Tracked 16

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Carbatrol...... 60 Cefotetan...... 51 Chlorothiazide Sodium...... 97 Carbidopa...... 75 Cefoxitin Sodium...... 51 Chlorpromazine HCl...... 76 Carbidopa/Levodopa...... 75 Cefpodoxime Proxetil...... 51 Chlorthalidone...... 97 Carbidopa/Levodopa ER...... 75 Cefprozil...... 51 Cholbam...... 114 Carbidopa/Levodopa ODT.... 75 Ceftazidime...... 51 Cholestyramine Light...... 98 Carbidopa/Levodopa/ Ceftin...... 51 Chorionic Gonadotropin...... 119 Entacapone...... 75 Ceftriaxone Sodium...... 51 Cialis...... 115 Carboplatin...... 71 Cefuroxime Axetil...... 51 Ciclopirox...... 66 Cardene IV...... 92 Cefuroxime Sodium...... 51 Ciclopirox Nail Lacquer...... 66 Cardizem...... 92 Celebrex...... 40 Ciclopirox Olamine...... 66 Cardizem CD...... 92 Celecoxib...... 40 Cidofovir...... 79 Cardizem LA...... 92 Celexa...... 62 Cilostazol...... 89 Cardura...... 89 Cellcept...... 127 Ciloxan...... 54 Cardura XL...... 115 Cellcept Intravenous...... 127 Cimetidine...... 111 Carimune Nanofiltered...... 128 Celontin...... 57 Cimetidine HCl...... 111 Carnitor...... 106 Cephalexin...... 51 Cimzia...... 127 Carteolol HCl...... 134 Cerdelga...... 113 Cinryze...... 127 Cartia XT...... 92 Cerebyx...... 60 Cipro...... 54 Carvedilol...... 91 Cerezyme...... 113 Cipro HC...... 136 Casodex...... 70 Cesamet...... 65 Cipro I.V. in D5W...... 54 Catapres...... 89 Cetirizine HCl...... 136 Ciprodex...... 136 Catapres-TTS-1...... 89 Cevimeline HCl...... 103 Ciprofloxacin...... 54 Catapres-TTS-2...... 89 Chantix...... 48 Ciprofloxacin ER...... 55 Catapres-TTS-3...... 89 Chantix Continuing Month Pak Ciprofloxacin HCl...... 55 Cayston...... 139 ...... 48 Ciprofloxacin I.V. in D5W...... 55 Caziant...... 121 Chantix Starting Month Pak...48 Cisplatin...... 71 Cefaclor...... 51 Chemet...... 109 Citalopram HBr...... 62 Cefaclor ER...... 51 Chenodal...... 110 Cladribine...... 70 Cefadroxil...... 51 Chloramphenicol Sodium Claravis...... 104 Succinate...... 49 Cefazolin Sodium...... 51 Clarinex...... 136 Chlordiazepoxide HCl...... 83 Cefdinir...... 51 Clarinex-D 12 Hour...... 141 Chlorhexidine Gluconate..... 103 Cefepime...... 51 Clarithromycin...... 53 Chloroquine Phosphate...... 74 Cefixime...... 51 Clarithromycin ER...... 54 Chlorothiazide...... 97 Cefotaxime Sodium...... 51 Cleocin...... 49 Tracked 17

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Cleocin in D5W...... 49 Clinimix E 2.75%/Dextrose 5% Codeine Sulfate...... 45 Cleocin Pediatric Granules.... 49 ...... 107 Cogentin...... 74 Cleocin Phosphate...... 49 Clinimix E 4.25%/Dextrose 10% Colazal...... 130 ...... 107 Cleocin-T...... 104 Colchicine...... 68 Clinimix E 4.25%/Dextrose 25% Climara Pro...... 121 Colcrys...... 68 ...... 107 Clindacin-P...... 104 Colestid...... 98 Clinimix E 4.25%/Dextrose 5% Clindagel...... 104 ...... 107 Colestipol HCl...... 98 Clindamax...... 104 Clinimix E 5%/Dextrose 15% Colistimethate Sodium...... 49 Clindamycin HCl...... 49 ...... 107 Colocort...... 130 Clindamycin Palmitate HCl.... 49 Clinimix E 5%/Dextrose 20% Coly-Mycin S...... 136 ...... 107 Clindamycin Phosphate...... 49, CoLyte-Flavor Packs...... 112 Clinimix E 5%/Dextrose 25% 104 Combigan...... 134 ...... 107 Clindamycin Phosphate in D5W Combivent Respimat...... 141 ...... 49 Clinisol SF 15%...... 107 Combivir...... 81 Clindamycin Phosphate/ Clobetasol Propionate...... 116 Cometriq...... 72 Tretinoin...... 104 Clobetasol Propionate E...... 116 Complera...... 80 Clindamycin/Benzoyl Peroxide Clobex...... 116 ...... 104 Compro...... 65 Clodan...... 117 Clindesse...... 49 Comtan...... 75 Cloderm Pump...... 117 Clinimix 2.75%/Dextrose 5% Concerta...... 101 Clofarabine...... 70 ...... 106 Condylox...... 104 Clolar...... 70 Clinimix 4.25%/Dextrose 10% Constulose...... 112 ...... 106 Clomipramine HCl...... 64 Conzip...... 42 Clinimix 4.25%/Dextrose 20% Clonazepam...... 83 Copaxone...... 103 ...... 106 Clonazepam ODT...... 83 Copegus...... 79 Clinimix 4.25%/Dextrose 25% Clonidine HCl...... 89 Cordran...... 117 ...... 106 Clonidine HCl ER...... 101 Coreg...... 91 Clinimix 4.25%/Dextrose 5% Clopidogrel...... 89 ...... 106 Coreg CR...... 91 Clorazepate Dipotassium...... 83 Clinimix 5%/Dextrose 15% Corgard...... 91 Clotrimazole...... 66 ...... 106 Corlanor...... 95 Clotrimazole/Betamethasone Clinimix 5%/Dextrose 20% Dipropionate...... 104 Cormax Scalp Application... 117 ...... 106 Clozapine...... 78 Cortef...... 117 Clinimix 5%/Dextrose 25% Cortisone Acetate...... 117 ...... 106 Clozapine ODT...... 78, 79 Cortisporin...... 104 Clinimix E 2.75%/Dextrose 10% Clozaril...... 79 ...... 106 Coartem...... 74 Corzide...... 95 Tracked 18

18 18

Cosentyx...... 104 Cytarabine Aqueous...... 70 Depakote...... 83 Cosentyx Sensoready Pen...104 Cytomel...... 125 Depakote ER...... 83 Cosmegen...... 71 Cytotec...... 112 Depakote Sprinkles...... 83 Cosopt...... 134 Cytovene...... 79 Depen Titratabs...... 116 Cosopt PF...... 134 D Depo-...... 121 Cotellic...... 72 Dacarbazine...... 70 Depo-Medrol...... 117 Coumadin...... 87 Dacogen...... 71 Depo-Provera...... 125 Cozaar...... 90 Daklinza...... 80 Depo-Provera Contraceptive Creon...... 114 Daliresp...... 139 ...... 125 Cresemba...... 66 Dalvance...... 49 Depo-SubQ Provera104...... 125 Crestor...... 98 Danazol...... 121 Depo-...... 121 Crinone...... 125 Dantrium...... 141 Dermatop...... 117 Crixivan...... 82 Dantrolene Sodium...... 141 Descovy...... 81 Cromolyn Sodium...... 110, 133, Dapsone...... 69 Desipramine HCl...... 64 139 Daptacel...... 129 Desloratadine...... 136 Cryselle-28...... 121 Daptomycin...... 49 Desloratadine ODT...... 136 Cubicin...... 49 DARAPRIM...... 74 Desmopressin Acetate...... 120 Cuprimine...... 116 Darifenacin HBr ER...... 115 Desogen...... 121 Cutivate...... 117 Darzalex...... 73 Desogestrel/Ethinyl Estradiol ...... 121 Cuvposa...... 110 Daunorubicin HCl...... 71 Desonate...... 117 Cyclafem...... 121 Daypro...... 40 Desonide...... 117 Cyclessa...... 121 Daytrana...... 101 DesOwen...... 117 Cyclobenzaprine HCl...... 141 DDAVP...... 119, 120 Desoximetasone...... 117 Cyclophosphamide...... 70 Deblitane...... 125 Desoxyn...... 100 Cycloset...... 84 Decitabine...... 71 Desvenlafaxine ER...... 63 Cyclosporine...... 127 Delestrogen...... 121 Detrol...... 115 Cyclosporine Modified...... 127 Delyla...... 121 Detrol LA...... 115 Cyklokapron...... 89 Delzicol...... 130 Dexamethasone...... 117 Cymbalta...... 102 Demadex...... 97 Dexamethasone Intensol..... 117 Cyproheptadine HCl...... 136 Demeclocycline HCl...... 56 Dexamethasone Sodium Cyramza...... 72 Demser...... 95 Phosphate...... 117, 135 Cystadane...... 114 Denavir...... 80 Dexedrine...... 100 Cystagon...... 114 Depacon...... 57 Dexilant...... 112 Cystaran...... 132 Depakene...... 57 Dexmethylphenidate HCl..... 101 Tracked 19

19 19

Dexmethylphenidate HCl ER Didanosine...... 81 Dofetilide...... 90 ...... 101 Differin...... 104 Dolophine...... 42 DexPak 13 Day...... 117 Dificid...... 54 Donepezil HCl...... 61 Dexrazoxane...... 71 Diflorasone Diacetate...... 117 Donepezil HCl ODT...... 61 Dextroamphetamine Sulfate Diflucan...... 66 Doribax...... 52 ...... 101 Diflunisal...... 40 Doryx...... 56 Dextroamphetamine Sulfate ER Digitek...... 95 Doryx MPC...... 56 ...... 101 Digoxin...... 95 Dorzolamide HCl...... 134 Dextrose 10%...... 107 Dihydroergotamine Mesylate Dorzolamide HCl/Timolol Dextrose 10%/NaCl 0.2%.... 107 ...... 68 Maleate...... 134 Dextrose 10%/NaCl 0.45% Dilantin...... 60 Dovonex...... 104 ...... 107 Dilantin INFATABS...... 60 Doxazosin Mesylate...... 89 Dextrose 2.5%/NaCl 0.45% ...... 107 Dilantin-125...... 60 Doxepin HCl...... 64, 104 Dextrose 5%...... 107 Dilaudid...... 45 Doxercalciferol...... 131 Dextrose 5%/NaCl 0.2%...... 107 Dilt-XR...... 93 Doxil...... 71 Dextrose 5%/NaCl 0.225% Diltiazem CD...... 93 Doxorubicin HCl...... 71 ...... 107 Diltiazem HCl...... 93 Doxorubicin HCl ....71 Dextrose 5%/NaCl 0.33%.... 107 Diltiazem HCl ER...... 93 Doxy 100...... 56 Dextrose 5%/NaCl 0.45%.... 107 Diovan...... 90 Doxycycline...... 56 Dextrose 5%/NaCl 0.9%...... 107 Diovan HCT...... 95 Doxycycline Hyclate...... 56 Diamox...... 97 Dipentum...... 130 Doxycycline Hyclate DR...... 56 Diastat AcuDial...... 57 Diphenhydramine HCl...... 136 Doxycycline Monohydrate...... 56 Diastat Pediatric...... 57 Diphenoxylate/Atropine...... 111 Dronabinol...... 65 Diazepam...... 83 Diphtheria/Tetanus Toxoids Drospirenone/Ethinyl Estradiol Diazepam Intensol...... 83 Adsorbed Pediatric...... 129 ...... 121 Dibenzyline...... 89 Diprolene...... 117 Drospirenone/Ethinyl Estradiol/ Levomefolate Calcium...... 122 Diclofenac Potassium...... 40 Diprolene AF...... 117 Droxia...... 70 Diclofenac Sodium...... 40, 104, Disulfiram...... 48 135 Ditropan XL...... 115 Duac...... 104 Diclofenac Sodium DR...... 40 Diuril...... 97 Duetact...... 84 Diclofenac Sodium ER...... 40 Divalproex Sodium...... 83 Duexis...... 40 Diclofenac Sodium/Misoprostol Divalproex Sodium DR...... 83 Dulera...... 141 ...... 40 Divalproex Sodium ER...... 84 Duloxetine HCl...... 102 Dicloxacillin Sodium...... 53 Docetaxel...... 71 Duopa...... 75 Dicyclomine HCl...... 110 Dupixent...... 104 Tracked 20

20 20

Duragesic...... 42 Eliquis...... 87 Epinastine HCl...... 133 Duramorph...... 45 Elitek...... 73 Epinephrine...... 138 Durezol...... 135 Ellence...... 71 EpiPen...... 138 Dutasteride...... 115 Elmiron...... 116 Epirubicin HCl...... 71 Dutasteride/Tamsulosin HCl Elocon...... 117 Epitol...... 60 ...... 116 Emadine...... 133 Epivir...... 81 DUTOPROL...... 95 Embeda...... 42 Epivir HBV...... 79 Dyazide...... 95 Emcyt...... 70 Eplerenone...... 97 Dymista...... 141 Emend...... 65 Epogen...... 88 Dyrenium...... 97 Emoquette...... 122 Eprosartan Mesylate...... 90 Dysport...... 132 Empliciti...... 73 Epzicom...... 81 E Emsam...... 62 Equetro...... 84 E.E.S. 400...... 54 Emtriva...... 81 Eraxis...... 66 E.E.S. Granules...... 54 Emverm...... 74 Erbitux...... 73 EC-Naprosyn...... 40 Enablex...... 115 Ergotamine Tartrate/Caffeine Econazole Nitrate...... 66 Enalapril Maleate...... 90 ...... 68 Edarbi...... 90 Enalapril Maleate/ Erivedge...... 72 Edarbyclor...... 95 Hydrochlorothiazide...... 95 Errin...... 125 Edecrin...... 97 Enbrel...... 127 Ertaczo...... 66 Edurant...... 80 Enbrel SureClick...... 127 Erwinaze...... 71 Effexor XR...... 63 Endocet...... 45 Ery...... 104 Effient...... 89 Engerix-B...... 129 Ery-Tab...... 54 Efudex...... 104 Enoxaparin Sodium...... 87 Erygel...... 105 Egrifta...... 126 Enpresse-28...... 122 EryPed 200...... 54 Elaprase...... 114 Enstilar...... 104 EryPed 400...... 54 Elavil...... 64 Entacapone...... 75 Erythrocin Lactobionate...... 54 Eldepryl...... 76 Entecavir...... 79 Erythrocin Stearate...... 54 Elelyso...... 114 Entocort EC...... 130 Erythromycin...... 54, 105 Elestat...... 133 Entresto...... 95 Erythromycin Base...... 54 Elestrin...... 122 Enulose...... 112 Erythromycin Ethylsuccinate Elidel...... 104 Envarsus XR...... 127 ...... 54 Eligard...... 126 Epclusa...... 80 Erythromycin/Benzoyl Peroxide ...... 105 Elimite...... 74 Epiduo...... 104 Esbriet...... 140 Eliphos...... 110 Epiduo Forte...... 104 Escitalopram Oxalate...... 63 Tracked 21

21 21

Esomeprazole Magnesium Extina...... 66 Fentanyl Citrate Oral ...... 112 Ezetimibe...... 99 Transmucosal...... 45 Esomeprazole Sodium...... 112 Ezetimibe/Simvastatin...... 99 Fentora...... 45 Estrace...... 122 F Ferriprox...... 109 Estradiol...... 122 Fabior...... 105 Fetzima...... 63 ...... 122 Fabrazyme...... 114 Fetzima Titration Pack...... 63 Estring...... 122 Falmina...... 122 Fexmid...... 141 Ethacrynate Sodium...... 97 Famciclovir...... 80 Fibricor...... 98 Ethacrynic Acid...... 97 Famotidine...... 111 Finacea...... 105 Ethambutol HCl...... 69 Famotidine Premixed...... 111 Finasteride...... 116 Ethosuximide...... 57 Fanapt...... 76, 77 Firazyr...... 127 Ethynodiol Diacetate/Ethinyl Fanapt Titration Pack...... 77 Firmagon...... 126 Estradiol...... 122 Fareston...... 70 Flagyl...... 49 Etidronate Disodium...... 131 Farxiga...... 84 Flarex...... 135 Etodolac...... 40 Farydak...... 72 Flavoxate HCl...... 115 Etodolac ER...... 40 Faslodex...... 70 Flebogamma DIF...... 128 Etopophos...... 72 Fayosim...... 122 Flecainide Acetate...... 90 Etoposide...... 72 Fazaclo...... 79 Flector...... 40 Eucrisa...... 105 Felbamate...... 58 Flomax...... 116 Eurax...... 74 Felbatol...... 58 Flovent Diskus...... 137 Evista...... 125 Feldene...... 40 Flovent HFA...... 137 Evoclin...... 105 Felodipine ER...... 93 Floxin Otic...... 55 Evotaz...... 82 Femara...... 72 Fluconazole...... 66 Evoxac...... 103 Femhrt Low Dose...... 122 Fluconazole in NaCl...... 66 Evzio...... 48 Femring...... 122 Flucytosine...... 66 Exalgo...... 42 Femynor...... 122 Fludarabine Phosphate...... 71 Exelderm...... 66 Fenofibrate...... 98 Fludrocortisone Acetate...... 117 Exelon...... 61 Fenofibrate Micronized...... 98 Flumadine...... 82 Exemestane...... 72 Fenofibric Acid...... 98 Flunisolide...... 137 Exforge...... 95 Fenofibric Acid DR...... 98 Fluocinolone Acetonide...... 117, Exforge HCT...... 95 136 Fenoglide...... 98 Exjade...... 109 Fluocinolone Acetonide Body Fenoprofen Calcium...... 40 Exondys 51...... 114 ...... 117 Fentanyl...... 42 Extavia...... 103 Fluocinonide...... 117 Fluocinonide-E...... 117 Tracked 22

22 22

Fluorometholone...... 135 Fosinopril Sodium/ GaviLyte-H...... 112 Fluorouracil...... 70, 105 Hydrochlorothiazide...... 95 GaviLyte-N/Flavor Pack...... 112 Fluoxetine DR...... 63 Fosphenytoin Sodium...... 60 Gelnique...... 115 Fluoxetine HCl...... 63 Fosrenol...... 110 Gemcitabine HCl...... 71 Decanoate...... 76 Fragmin...... 87 Gemfibrozil...... 98 Fluphenazine HCl...... 76 FreAmine HBC 6.9%...... 107 Gemzar...... 71 Flurandrenolide...... 118 Frova...... 68 Generess Fe...... 122 Flurbiprofen...... 40 Frovatriptan Succinate...... 68 Generlac...... 112 Flurbiprofen Sodium...... 135 Furadantin...... 49 Gengraf...... 127 Flutamide...... 70 Furosemide...... 97 Genotropin...... 120 Fluticasone Propionate...... 118, Fusilev...... 71 Genotropin Miniquick...... 120 137 Fuzeon...... 82 Gentak...... 48 Fluticasone Propionate/ Fyavolv...... 122 Gentamicin Sulfate...... 48 Salmeterol...... 141 Fycompa...... 58 Gentamicin Sulfate/0.9% Fluvastatin...... 98 G Sodium Chloride...... 48 Fluvastatin Sodium ER...... 98 Gabapentin...... 57 Genvoya...... 80 Fluvoxamine Maleate...... 63 Gabitril...... 57 Geodon...... 77 Fluvoxamine Maleate ER...... 63 Gablofen...... 141 Gianvi...... 122 FML...... 135 Galantamine HBr...... 61 Giazo...... 130 FML Forte...... 135 Gamastan S/D...... 128 Gildagia...... 122 FML Liquifilm...... 135 Gammagard ...... 128 Gilenya...... 103 Focalin...... 101 Gammagard S/D IGA Less Gilotrif...... 72 Focalin XR...... 101 Than 1 mcg/ml...... 129 Glassia...... 114 Folotyn...... 70 Gammaked...... 129 Glatopa...... 103 Fomepizole...... 132 Gammaplex...... 129 Gleevec...... 72 Fondaparinux Sodium...... 87 Gamunex-C...... 129 Gleostine...... 70 Forfivo XL...... 62 Ganciclovir...... 79 Glimepiride...... 84 Fortamet...... 84 Gardasil 9...... 129 Glipizide...... 84 Fortaz...... 51 Gastrocrom...... 111 Glipizide ER...... 84 Forteo...... 131 Gatifloxacin...... 55 Glipizide/Metformin HCl...... 84 Fortesta...... 121 Gattex...... 111 GlucaGen HypoKit...... 86 Fosamax...... 131 Gauze...... 132 Glucagon Emergency Kit...... 86 Fosamax Plus D...... 131 GaviLyte-C...... 112 Glucophage...... 84 Fosinopril Sodium...... 90 GaviLyte-G...... 112 Glucophage XR...... 84 Tracked 23

23 23

Glucotrol...... 84 HepatAmine...... 107 Hycet...... 45 Glucotrol XL...... 84 Hepsera...... 79 Hydralazine HCl...... 99 Glumetza...... 85 Herceptin...... 73 Hydrea...... 71 Glycopyrrolate...... 110 Hetlioz...... 142 Hydrochlorothiazide...... 97 Glyset...... 85 Hexalen...... 70 Hydrocodone Bitartrate/ Glyxambi...... 85 Hiberix...... 129 Acetaminophen...... 45 GoLYTELY...... 112 Hiprex...... 49 Hydrocodone/Ibuprofen...... 45 Gonitro...... 99 Horizant...... 102 Hydrocortisone...... 118, 130 Gralise...... 102 Humalog Cartridge...... 86 Hydrocortisone Butyrate...... 118 Gralise Starter Pack...... 102 Humalog KwikPen...... 86 Hydrocortisone Valerate...... 118 Granisetron HCl...... 65 Humalog Mix 50/50 KwikPen Hydrocortisone/Acetic Acid ...... 136 Granix...... 88 ...... 86 Hydromorphone HCl...... 45, 46 Grastek...... 141 Humalog Mix 50/50 Vial...... 86 Hydromorphone HCl ER...... 42 GRIS-PEG...... 66 Humalog Mix 75/25 KwikPen ...... 86 Hydroxychloroquine Sulfate Griseofulvin Microsize...... 67 Humalog Mix 75/25 Vial...... 86 ...... 74 Griseofulvin Ultramicrosize.... 67 Humalog Vial...... 86 Hydroxyprogesterone Caproate Guanidine HCl...... 69 ...... 125 Humatrope...... 120 Gynazole-1...... 67 Hydroxyurea...... 71 Humatrope Combo Pack..... 120 H Hydroxyzine HCl...... 83 Humira...... 127 H.P. Acthar...... 118 Hydroxyzine Pamoate...... 65 Humira Pediatric Crohns Halaven...... 71 Disease Starter Pack...... 127 Hyperrab S/D...... 129 Haldol...... 76 Humira Pen...... 127 Hysingla ER...... 42 Haldol Decanoate 100...... 76 Humira Pen Crohns Disease Hyzaar...... 95 Haldol Decanoate 50...... 76 Starter Pack...... 127 I Halobetasol Propionate...... 118 Humira Pen-Psoriasis Starter Ibandronate Sodium...... 131 Halog...... 118 ...... 127 Ibrance...... 72 ...... 76 Humulin 70/30 KwikPen...... 86 Ibudone...... 46 Haloperidol Decanoate...... 76 Humulin 70/30 Vial...... 86 Ibuprofen...... 41 Haloperidol Lactate...... 76 Humulin N KwikPen...... 86 Iclusig...... 72 Harvoni...... 80 Humulin N Vial...... 86 Idamycin PFS...... 71 Havrix...... 129 Humulin R U-500 KwikPen.....86 Idarubicin HCl...... 71 Hectorol...... 131 Humulin R U-500 Vial...... 86 Ifex...... 70 Heparin Sodium...... 87 Humulin R Vial...... 86 Ifosfamide...... 70 Heparin Sodium/D5W...... 87 Hycamtin...... 72 Ilaris...... 129 Tracked 24

24 24

Ilevro...... 135 Invokamet XR...... 85 Jalyn...... 116 Imatinib Mesylate...... 73 Invokana...... 85 Jantoven...... 87 Imbruvica...... 73 Ionosol-MB/Dextrose 5%..... 107 Janumet...... 85 Imfinzi...... 73 Iopidine...... 134 Janumet XR...... 85 Imipenem/Cilastatin...... 52 IPOL Inactivated IPV...... 129 Januvia...... 85 Imipramine HCl...... 64 Ipratropium Bromide...... 138 Jardiance...... 85 Imipramine Pamoate...... 64 Ipratropium Bromide/Albuterol Jentadueto...... 85 Imiquimod...... 105 Sulfate...... 141 Jentadueto XR...... 85 Imitrex...... 68 Irbesartan...... 90 Jevtana...... 73 Imitrex Statdose Refill...... 68 Irbesartan/Hydrochlorothiazide Jinteli...... 122 ...... 95 Imogam Rabies-HT...... 129 Jolivette...... 125 Iressa...... 73 Imovax Rabies...... 129 Jublia...... 67 Irinotecan...... 71 Imuran...... 127 Juleber...... 122 Isentress...... 80 Increlex...... 120 Junel 1.5/30...... 122 Isolyte-P/Dextrose 5%...... 107 Incruse Ellipta...... 138 Junel 1/20...... 122 Isolyte-S...... 107 Indapamide...... 97 Junel Fe 1.5/30...... 122 Isoniazid...... 69 Inderal LA...... 91 Junel Fe 1/20...... 122 Isopto Carpine...... 134 Infanrix...... 129 Junel Fe 24...... 122 Isordil Titradose...... 99 Inflectra...... 127 Juxtapid...... 99 Isosorbide Dinitrate...... 99 Ingrezza...... 102 K Isosorbide Dinitrate ER...... 99 Inlyta...... 73 K-Tab...... 107 Isosorbide Mononitrate...... 99 Innopran XL...... 91 Kadcyla...... 73 Isosorbide Mononitrate ER.... 99 Inspra...... 97 Kadian...... 42, 43 Isotonic Gentamicin...... 48 Syringes, Needles.....132 Kaitlib Fe...... 122 Isradipine...... 93 Intelence...... 81 Kaletra...... 82 Istalol...... 134 Intralipid...... 107 Kalydeco...... 139 Istodax...... 71 Intron A...... 79 Kanuma...... 114 Itraconazole...... 67 Introvale...... 122 Kapvay...... 101 Ivermectin...... 74 Invanz...... 52 Kariva...... 122 Ixiaro...... 129 Invega...... 77 Kayexalate...... 110 J Invega Sustenna...... 77 Kazano...... 85 Jadenu...... 109 Invega Trinza...... 77 KCl 0.075%/D5W/NaCl 0.45% Jadenu Sprinkle...... 110 Invirase...... 82 ...... 107 Jakafi...... 73 Invokamet...... 85 KCl 0.15%/D5W/LR...... 109 Tracked 25

25 25

KCl 0.15%/D5W/NaCl 0.2% Klor-Con M10...... 108 Lantus SoloStar...... 86 ...... 107 Klor-Con M15...... 108 Lantus Vial...... 86 KCl 0.15%/D5W/NaCl 0.9% Klor-Con M20...... 108 LARIN 1.5/30...... 122 ...... 107 Klor-Con Sprinkle...... 108 LARIN 1/20...... 122 KCl 0.3%/D5W/NaCl 0.45% Kombiglyze XR...... 85 LARIN Fe 1.5/30...... 122 ...... 108 Korlym...... 120 LARIN Fe 1/20...... 122 KCl 0.3%/D5W/NaCl 0.9%...108 Kristalose...... 112 Larissia...... 122 Kelnor 1/35...... 122 Kuvan...... 114 Lartruvo...... 73 Kenalog...... 118 Kynamro...... 99 Lasix...... 97 Kenalog-10...... 118 Kyprolis...... 72 Lastacaft...... 132 Kenalog-40...... 118 L Latanoprost...... 135 Kepivance...... 103 Labetalol HCl...... 91 Latuda...... 77 Keppra...... 57 Lacrisert...... 132 Layolis Fe...... 122 Keppra XR...... 57 Lactated Ringers Dextrose 5% Lazanda...... 46 Kerydin...... 67 Viaflex...... 107 Leena...... 122 Ketoconazole...... 67 Lactated Ringers Irrigation Leflunomide...... 129 Ketoprofen...... 41 ...... 108 Lenvima...... 73 Ketoprofen ER...... 41 Lactated Ringers Viaflex...... 108 Lescol XL...... 98 Ketorolac Tromethamine...... 41, Lactulose...... 112 135 Lessina...... 123 Lamictal...... 58 Keveyis...... 97 Letairis...... 140 Lamictal Chewable Dispersible Letrozole...... 72 Keytruda...... 73 ...... 58 Leucovorin Calcium...... 71 Khedezla...... 63 Lamictal ODT...... 58 Leukeran...... 70 Kimidess...... 122 Lamictal Starter...... 58 Leukine...... 88 Kineret...... 127 Lamictal XR...... 59 Leuprolide Acetate...... 126 Kinrix...... 129 Lamisil...... 67 Levalbuterol...... 138 Kionex...... 110 Lamivudine...... 79, 81 Levalbuterol Tartrate HFA....138 Kisqali...... 71 Lamivudine/Zidovudine...... 81 Levaquin...... 55 Kisqali Femara 200 Dose...... 71 Lamotrigine...... 59 Levemir FlexTouch...... 87 Kisqali Femara 400 Dose...... 71 Lamotrigine ER...... 59 Levemir Vial...... 87 Kisqali Femara 600 Dose...... 71 Lamotrigine ODT...... 59 Levetiracetam...... 57 Klaron...... 105 Lanoxin...... 95 Levetiracetam ER...... 57 Klonopin...... 83 Lansoprazole...... 112 Levobunolol HCl...... 134 Klor-Con 10...... 108 Lansoprazole/Amoxicillin/ Klor-Con 8...... 108 Clarithromycin...... 111 Levocarnitine...... 108 Tracked 26

26 26

Levocetirizine Dihydrochloride Lithium...... 84 Losartan Potassium/ ...... 136 Lithium Carbonate...... 84 Hydrochlorothiazide...... 95 Levofloxacin...... 55 Lithium Carbonate ER...... 84 LoSeasonique...... 123 Levofloxacin in D5W...... 55 Lithobid...... 84 Lotemax...... 135 Levoleucovorin Calcium...... 72 Lithostat...... 116 Lotensin...... 90 Levonest...... 123 Livalo...... 98 Lotrel...... 96 Levonorgestrel and Ethinyl Lo Loestrin Fe...... 123 Lotrisone...... 105 Estradiol...... 123 Locoid...... 118 Lotronex...... 111 Levonorgestrel/Ethinyl Estradiol Lodine...... 41 Lovastatin...... 98 ...... 123 Lodosyn...... 75 Lovaza...... 99 Levora 0.15/30-28...... 123 Loestrin 1.5/30-21...... 123 Lovenox...... 88 Levorphanol Tartrate...... 43 Loestrin 1/20-21...... 123 Low-Ogestrel...... 123 Levothyroxine Sodium...... 125, Loxapine Succinate...... 76 126 Loestrin Fe 1.5/30...... 123 Lumigan...... 136 Levoxyl...... 126 Loestrin Fe 1/20...... 123 Lumizyme...... 114 Lexapro...... 63 LoKara...... 118 Lupaneta Pack...... 126 Lexiva...... 82 Lomedia 24 Fe...... 123 Lupron Depot...... 126 Lialda...... 130 Lomotil...... 111 Lupron Depot-Ped...... 126 Lidocaine...... 47 Lonsurf...... 72 Lutera...... 123 Lidocaine HCl...... 47 Loperamide HCl...... 111 Luzu...... 67 Lidocaine Viscous...... 47 Lopid...... 98 Lynparza...... 73 Lidocaine/Prilocaine...... 47 Lopinavir/Ritonavir...... 82 Lyrica...... 103 Lidoderm...... 47 Lopressor...... 91 Lysodren...... 126 Lincocin...... 49 Lopressor HCT...... 95 Lysteda...... 89 Lincomycin HCl...... 49 Loprox...... 67 Lyza...... 125 Lindane...... 74 Loprox ...... 67 M Linezolid...... 49 Lorazepam...... 83 M-M-R II...... 129 Linzess...... 111 Lorazepam Intensol...... 83 Macrobid...... 49 Lioresal Intrathecal...... 141 Lorcet...... 46 Macrodantin...... 49 Liothyronine Sodium...... 126 Lorcet HD...... 46 Magnesium Sulfate...... 108 Lipitor...... 98 Lorcet Plus...... 46 Makena...... 125 Lipofen...... 98 Lortab...... 46 Malarone...... 74 Lisinopril...... 90 Loryna...... 123 Malathion...... 74 Lisinopril/Hydrochlorothiazide Losartan Potassium...... 90 ...... 95 Maprotiline HCl...... 63 Tracked 27

27 27

Marinol...... 65 Mercaptopurine...... 71 Methylprednisolone Acetate Marlissa...... 123 Meropenem...... 52 ...... 118 Marplan...... 62 Merrem...... 52 Methylprednisolone Dose Pack ...... 118 Matulane...... 70 Mesalamine...... 130 Methylprednisolone Sodium Matzim LA...... 93 Mesalamine DR...... 130 Succinate...... 118 Maxalt...... 68 Mesna...... 73 Methyltestosterone...... 121 Maxalt-MLT...... 68 Mesnex...... 74 Metipranolol...... 134 Maxidex...... 135 Mestinon...... 69 Metoclopramide HCl...... 65 Maxipime...... 51 Mestinon Timespan...... 69 Metoclopramide ODT...... 65 Maxitrol...... 132 Metadate CD...... 101 Metolazone...... 97 Maxzide...... 96 Metadate ER...... 101 Metoprolol Succinate ER...... 91 Meclizine HCl...... 65 Metaproterenol Sulfate...... 139 Metoprolol Tartrate...... 92 Meclofenamate Sodium...... 41 Metformin HCl...... 85 Metoprolol/Hydrochlorothiazide Medrol...... 118 Metformin HCl ER...... 85 ...... 96 Medrol Dosepak...... 118 Methadone HCl...... 43 MetroCream...... 50 Medroxyprogesterone Acetate Methamphetamine HCl...... 101 MetroGel...... 50 ...... 125 Methazolamide...... 97 MetroGel-Vaginal...... 50 Mefenamic Acid...... 41 Methenamine Hippurate...... 50 MetroLotion...... 50 Mefloquine HCl...... 74 Methimazole...... 126 Metronidazole...... 50 Megace ES...... 125 Methitest...... 121 Metronidazole in NaCl 0.79% Megace Oral...... 125 Methotrexate...... 127 ...... 50 Megestrol Acetate...... 125 Methotrexate Sodium...... 127 Metronidazole Vaginal...... 50 Mekinist...... 73 Methoxsalen...... 105 Mexiletine HCl...... 90 Meloxicam...... 41 Methscopolamine Bromide Miacalcin...... 131 Melphalan HCl...... 70 ...... 110 Mibelas 24 Fe...... 123 Memantine HCl...... 61 Methyclothiazide...... 97 Micardis...... 90 Memantine HCl Titration Pak Methyldopa...... 89 Micardis HCT...... 96 ...... 62 Methyldopate HCl...... 89 Miconazole 3...... 67 Menactra...... 130 Methylin...... 101 Micort-HC...... 118 Menest...... 123 Methylphenidate HCl...... 101 Microgestin 1.5/30...... 123 Menomune-A/C/Y/W-135....130 Methylphenidate HCl CD..... 101 Microgestin 1/20...... 123 Mentax...... 67 Methylphenidate HCl ER...... 102 Microgestin Fe...... 123 Menveo...... 130 Methylprednisolone...... 118 Microgestin Fe 1.5/30...... 123 Mepron...... 74 Microzide...... 97 Tracked 28

28 28

Midodrine HCl...... 89 Monurol...... 50 Naloxone HCl...... 48 Migergot...... 68 Morgidox 1x50mg...... 56 HCl...... 48 Miglitol...... 85 Morphine Sulfate...... 46 Namenda...... 62 Migranal...... 68 Morphine Sulfate ER...... 44 Namenda Titration Pak...... 62 Millipred...... 118 Movantik...... 111 Namenda XR...... 62 Minastrin 24 Fe...... 123 MoviPrep...... 112 Namenda XR Titration Pack...62 Minipress...... 89 Moxeza...... 55 Namzaric...... 102 Minitran...... 99 Moxifloxacin HCl...... 55 Naprelan...... 41 Minivelle...... 123 Mozobil...... 88 Naprosyn...... 41 Minocin...... 56 MS Contin...... 44 Naproxen...... 41 Minocycline HCl...... 56 Multaq...... 90 Naproxen DR...... 41 Minocycline HCl ER...... 56 Mupirocin...... 50 Naproxen Sodium...... 41 Minoxidil...... 99 Mustargen...... 70 Naproxen Sodium ER...... 41 Mirapex...... 75 Myalept...... 111 Naratriptan HCl...... 68 Mirapex ER...... 75 Myambutol...... 69 Narcan...... 48 Mircera...... 88 Mycamine...... 67 Nardil...... 62 Mirtazapine...... 62 Mycobutin...... 69 Nasonex...... 137 Mirtazapine ODT...... 62 Mycophenolate Mofetil...... 127 Natacyn...... 67 Mirvaso...... 105 Mycophenolic Acid DR...... 127 Natazia...... 123 Misoprostol...... 112 Myfortic...... 128 Nateglinide...... 85 Mitigare...... 68 Myorisan...... 105 Natpara...... 131 Mitomycin...... 72 Myrbetriq...... 115 Nebupent...... 74 Mitoxantrone HCl...... 72 Mysoline...... 57 Necon 0.5/35-28...... 123 Mobic...... 41 Mytesi...... 111 Necon 1/50-28...... 123 Modafinil...... 142 N Necon 10/11-28...... 123 Moderiba...... 79 Nabumetone...... 41 Necon 7/7/7...... 123 Moderiba 1200 Dose Pack.... 79 Nadolol...... 92 Nefazodone HCl...... 63 Moderiba 800 Dose Pack...... 79 Nadolol/Bendroflumethiazide Neo-Synalar...... 105 Moexipril HCl...... 90 ...... 96 Neomycin Sulfate...... 48 Moexipril/Hydrochlorothiazide Nafcillin Sodium...... 53 Neomycin/Bacitracin/ ...... 96 Naftifine HCl...... 67 Polymyxin...... 133 Mometasone Furoate...118, 137 Naftin...... 67 Neomycin/Polymyxin B MonoNessa...... 123 Naglazyme...... 114 Sulfates...... 50 Montelukast Sodium...... 137 Nalbuphine HCl...... 46 Tracked 29

29 29

Neomycin/Polymyxin/ Nimodipine...... 93 Norinyl 1+35...... 124 Bacitracin/Hydrocortisone Ninlaro...... 72 Noritate...... 50 ...... 133 Nipent...... 71 Norlyroc...... 125 Neomycin/Polymyxin/ Nisoldipine...... 93 Normosol-M in D5W...... 108 Dexamethasone...... 133 Nitro-Bid...... 99 Normosol-R...... 108 Neomycin/Polymyxin/ Gramicidin...... 133 Nitro-Dur...... 99 Normosol-R in D5W...... 108 Neomycin/Polymyxin/ Nitrofurantoin...... 50 Norpramin...... 64 Hydrocortisone...... 133, 136 Nitrofurantoin Macrocrystals Northera...... 89 Neoral...... 128 ...... 50 Nortrel 0.5/35...... 124 Neosporin...... 133 Nitrofurantoin Monohydrate...50 Nortrel 1/35...... 124 Nephramine...... 108 Nitroglycerin...... 99 Nortrel 7/7/7...... 124 Nesina...... 85 Nitroglycerin Lingual...... 99 Nortriptyline HCl...... 64 Neuac...... 105 Nitroglycerin Transdermal... 100 Norvasc...... 93 Neulasta...... 89 NitroMist...... 100 Norvir...... 82 Neupogen...... 89 Nitrostat...... 100 Novarel...... 120 Neupro...... 75 Nizatidine...... 111 Novolin 70/30 Vial...... 87 Neurontin...... 58 Nizoral...... 67 Novolin N Vial...... 87 Nevanac...... 135 Nolix...... 118 Novolin R Vial...... 87 Nevirapine...... 81 Nora-BE...... 125 NovoLog FlexPen...... 87 Nevirapine ER...... 81 Norco...... 46 NovoLog Mix 70/30 Prefilled Nexavar...... 73 Norditropin FlexPro...... 120 FlexPen...... 87 Nexium...... 112, 113 Norethindrone...... 125 NovoLog Mix 70/30 Vial...... 87 Nexium I.V...... 113 Norethindrone & Ethinyl NovoLog PenFill...... 87 Estradiol Ferrous Fumarate Nexterone...... 90 NovoLog Vial...... 87 ...... 123 Niacin ER...... 99 Noxafil...... 67 Norethindrone Acetate...... 125 Niacor...... 99 Nucala...... 141 Norethindrone Acetate/Ethinyl Nucynta...... 46 Niaspan...... 99 Estradiol...... 123 Nucynta ER...... 44 Nicardipine HCl...... 93 Norethindrone Acetate/Ethinyl Nicotrol Inhaler...... 48 Estradiol/Ferrous Fumarate Nuedexta...... 102 Nicotrol NS...... 48 ...... 123 Nulojix...... 128 Nifedipine ER...... 93 Norethindrone/Ethinyl NuLYTELY/Flavor Packs...... 112 Estradiol/Ferrous Fumarate Nikki...... 123 Nuplazid...... 77 ...... 123 Nilandron...... 70 NutreStore...... 108 Norgestimate/Ethinyl Estradiol Nilutamide...... 70 ...... 124 Nutrilipid...... 108 Tracked 30

30 30

Nutropin AQ...... 120 Omeprazole...... 113 Ortho-Novum 1/35...... 124 NuvaRing...... 124 Omeprazole/Sodium Ortho-Novum 7/7/7...... 124 Nuvessa...... 50 Bicarbonate...... 113 Oseltamivir Phosphate...... 82 Nuvigil...... 142 Omnaris...... 137 Oseni...... 85 Nyamyc...... 67 Omnipred...... 135 OsmoPrep...... 112 Nyata...... 67 Omnitrope...... 120 Otezla...... 129 Nystatin...... 67 Ondansetron HCl...... 66 Otovel...... 136 Nystatin/Triamcinolone...... 67 Ondansetron ODT...... 66 Otrexup...... 128 Nystop...... 67 Onexton...... 105 Ovcon-35...... 124 O Onfi...... 58 Ovide...... 74 Ocaliva...... 114 Onglyza...... 85 Oxacillin Sodium...... 53 Ocella...... 124 ONMEL...... 67 Oxaliplatin...... 72 Octagam...... 129 Onzetra Xsail...... 68 Oxandrolone...... 121 Octreotide Acetate...... 126 Opana...... 46 Oxaprozin...... 41 Ocufen...... 135 Opana ER...... 44 Oxazepam...... 83 Ocuflox...... 55 Opdivo...... 73 Oxcarbazepine...... 61 Odefsey...... 81 Opsumit...... 140 Oxiconazole Nitrate...... 67 Odomzo...... 73 Oracea...... 56 Oxistat...... 67 Ofev...... 140 Oralair...... 141 Oxsoralen Ultra...... 105 Ofloxacin...... 55 Orap...... 76 Oxtellar XR...... 61 Ogestrel...... 124 Orapred ODT...... 118 Oxybutynin Chloride...... 115 Olanzapine...... 77 Oravig...... 67 Oxybutynin Chloride ER...... 115 Olanzapine ODT...... 77 Orbactiv...... 50 Oxycodone HCl...... 46 Olanzapine/Fluoxetine...... 62 Orencia...... 128 Oxycodone HCl ER...... 44 Olmesartan Medoxomil...... 90 Orencia Clickject...... 128 Oxycodone/Acetaminophen Olmesartan Medoxomil/ Orenitram...... 140 ...... 46 Amlodipine/ Orfadin...... 114 Oxycodone/Aspirin...... 46 Hydrochlorothiazide...... 96 Orkambi...... 139 Oxycodone/Ibuprofen...... 46 Olmesartan Medoxomil/ Orphenadrine Citrate...... 141 OxyContin...... 44 Hydrochlorothiazide...... 96 Orsythia...... 124 Oxymorphone HCl...... 47 Olopatadine HCl...... 133, 134, Ortho Micronor...... 125 Oxymorphone HCl ER...... 44 136 Ortho Tri-Cyclen...... 124 Oxytrol...... 115 Olux...... 118 Ortho Tri-Cyclen Lo...... 124 P Olysio...... 80 Ortho-Cyclen...... 124 Pacerone...... 90 Omega-3-Acid Ethyl Esters.....99 Tracked 31

31 31

Paclitaxel...... 72 Pennsaid...... 41 Pioglitazone HCl/Glimepiride Paliperidone ER...... 77 Pentam 300...... 74 ...... 85 Pamelor...... 64 Pentasa...... 130 Pioglitazone HCl/Metformin HCl...... 85 Pamidronate Disodium...... 131 Pentoxifylline ER...... 96 Piperacillin/Tazobactam...... 53 Pancreaze...... 114 Pepcid...... 111 Pirmella 1/35...... 124 Pandel...... 118 Percocet...... 47 Piroxicam...... 41 Panretin...... 73 Perforomist...... 139 Plaquenil...... 74 Pantoprazole Sodium...... 113 Perindopril Erbumine...... 90 Plasma-Lyte A...... 108 Paricalcitol...... 132 Periogard...... 103 Plasma-Lyte-148...... 108 Parlodel...... 75 Perjeta...... 73 Plavix...... 89 Parnate...... 62 Permethrin...... 74 Plegridy...... 103 Paromomycin Sulfate...... 48 Perphenazine...... 65 Plegridy Starter Pack...... 103 Paroxetine HCl...... 63 Pertzye...... 114 Plenamine...... 108 Paser...... 69 Phenadoz...... 136 Podofilox...... 105 Pataday...... 134 Phenelzine Sulfate...... 62 Polyethylene Glycol 3350 Patanase...... 136 Phenergan...... 136 ...... 112 Patanol...... 134 Phenobarbital...... 58 Polymyxin B Sulfate...... 50 Paxil...... 63 Phenoxybenzamine HCl...... 89 Polymyxin B Sulfate/ Pazeo...... 134 Phenytek...... 61 Trimethoprim Sulfate...... 133 PCE...... 54 Phenytoin...... 61 Polytrim...... 133 Pediarix...... 130 Phenytoin Sodium...... 61 Pomalyst...... 70 Pedvax HIB...... 130 Phenytoin Sodium Extended Ponstel...... 41 ...... 61 PEG-3350/Electrolytes...... 112 Portia-28...... 124 Phoslyra...... 110 PEG-3350/NaCl/Na Potassium Chloride...... 108 Bicarbonate/KCl...... 112 Phospholine Iodide...... 134 Potassium Chloride 0.15% Peganone...... 61 Physiolyte...... 108 D5W/NaCl 0.33%...... 108 Pegasys...... 79 Physiosol Irrigation...... 108 Potassium Chloride 0.15% Pegasys ProClick...... 79 Picato...... 105 D5W/NaCl 0.45%...... 108 Penicillin G Potassium...... 53 Pilocarpine HCl...... 103, 134 Potassium Chloride 0.22% D5W/NaCl 0.45%...... 108 Penicillin G Potassium in Iso- Pimozide...... 76 Potassium Chloride ER...... 109 Osmotic Dextrose...... 53 Pimtrea...... 124 Potassium Chloride/Dextrose Penicillin G Procaine...... 53 Pindolol...... 92 ...... 109 Penicillin G Sodium...... 53 Pioglitazone HCl...... 85 Potassium Chloride/Sodium Penicillin V Potassium...... 53 Chloride...... 109 Tracked 32

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Potassium Citrate ER...... 109 Prezista...... 82 Prolia...... 132 Pradaxa...... 88 Priftin...... 69 Promacta...... 89 Praluent...... 99 Prilosec...... 113 Promethazine HCl...... 136 Pramipexole Dihydrochloride Primaquine Phosphate...... 74 Prometrium...... 125 ...... 75 Primaxin IV...... 52 Propafenone HCl...... 91 Pramipexole Dihydrochloride Primidone...... 58 Propafenone HCl ER...... 91 ER...... 75 Primlev...... 47 Propantheline Bromide...... 110 Prandin...... 85 Primsol...... 50 Proparacaine HCl...... 133 Pravachol...... 98 Prinivil...... 90 Propranolol HCl...... 92 Pravastatin Sodium...... 98 Pristiq...... 63 Propranolol HCl ER...... 92 Prazosin HCl...... 89 Privigen...... 129 Propranolol/ Precose...... 85 ProAir HFA...... 139 Hydrochlorothiazide...... 96 Pred Forte...... 135 ProAir RespiClick...... 139 Propylthiouracil...... 126 Pred Mild...... 135 Probenecid...... 68 ProQuad...... 130 Pred-G...... 133 Probenecid/Colchicine...... 68 Proscar...... 116 Pred-G S.O.P...... 133 Procainamide HCl...... 90 Prosol...... 109 Prednicarbate...... 118, 119 Procalamine...... 109 Protonix...... 113 Prednisolone Acetate...... 135 Procardia XL...... 93 Protopic...... 105 Prednisolone Sodium ProCentra...... 101 Protriptyline HCl...... 65 Phosphate...... 119, 135 Prochlorperazine...... 65 Proventil HFA...... 139 Prednisolone Sodium Provera...... 125 Phosphate ODT...... 119 Prochlorperazine Edisylate.... 65 Provigil...... 142 Prednisone...... 119 Prochlorperazine Maleate...... 65 Prozac...... 64 Prednisone Intensol...... 119 Procrit...... 89 PRUDOXIN...... 105 Pregnyl w/Diluent Benzyl Procto-Med HC...... 130 Alcohol/NaCl...... 120 Procto-Pak...... 130 Psorcon...... 119 Premarin...... 124 Proctosol HC...... 130 Pulmicort...... 137 Premasol...... 109 Proctozone-HC...... 130 Pulmicort Flexhaler...... 137 Prepopik...... 112 Procysbi...... 114 Pulmozyme...... 141 Prevacid...... 113 Progesterone...... 125 Purixan...... 71 Prevacid SoluTab...... 113 Proglycem...... 86 Pylera...... 111 Prevalite...... 99 Prograf...... 128 Pyrazinamide...... 69 Previfem...... 124 Prolastin-C...... 114 Pyridostigmine Bromide...... 69 Prevpac...... 111 Prolensa...... 135 Pyridostigmine Bromide ER...69 Prezcobix...... 82 Proleukin...... 72 Tracked 33

33 33

Q Rasuvo...... 128 Rescriptor...... 81 Qbrelis...... 90 RAVICTI...... 114 Restasis...... 133 Qnasl...... 137 Rayos...... 119 Restoril...... 141 Qnasl Childrens...... 137 Razadyne...... 61 Retin-A...... 105 Quadracel...... 130 Razadyne ER...... 61 Retin-A Micro...... 105 Qualaquin...... 74 Rebetol...... 79 Retin-A Micro Pump...... 105 Quartette...... 124 Rebif...... 103 Retrovir...... 81 Quasense...... 124 Rebif Rebidose...... 103 Retrovir IV Infusion...... 81 Qudexy XR...... 59 Rebif Rebidose Titration Pack Revatio...... 140 Questran...... 99 ...... 103 Revlimid...... 70 Questran Light...... 99 Rebif Titration Pack...... 103 Rexulti...... 77 Quetiapine Fumarate...... 77 Reclast...... 132 Reyataz...... 82 Quetiapine Fumarate ER...... 77 Reclipsen...... 124 Ribasphere...... 79 QuilliChew ER...... 102 Recombivax HB...... 130 Ribasphere Ribapak...... 80 Quillivant XR...... 102 Rectiv...... 100 Ribavirin...... 80 Quinapril HCl...... 90 Reglan...... 65 Ridaura...... 129 Quinapril/Hydrochlorothiazide Regranex...... 105 Rifabutin...... 69 ...... 96 Relenza Diskhaler...... 82 Rifadin...... 69 Quinidine Gluconate...... 91 Relistor...... 111 Rifamate...... 69 Quinidine Gluconate CR...... 91 Relpax...... 68 Rifampin...... 70 Quinidine Sulfate...... 91 Remeron...... 62 Rifater...... 70 Quinine Sulfate...... 74 Remeron Soltab...... 62 Rilutek...... 102 QVAR...... 137 Remicade...... 128 Riluzole...... 102 R Remodulin...... 140 Rimantadine HCl...... 82 Rabavert...... 130 Renagel...... 110 Ringers ...... 109 Rabeprazole Sodium...... 113 Renvela...... 110 Ringers Irrigation...... 109 Ragwitek...... 141 Repaglinide...... 85 Riomet...... 86 Raloxifene HCl...... 125 Repaglinide/Metformin HCl...85 Risedronate Sodium...... 132 Ramipril...... 90 Repatha...... 99 Risedronate Sodium DR...... 132 Ranexa...... 96 Repatha Pushtronex System Risperdal...... 77 ...... 99 Ranitidine HCl...... 111 Risperdal Consta...... 77 Repatha SureClick...... 99 Rapaflo...... 116 Risperdal M-Tab...... 78 Requip...... 75 Rapamune...... 128 ...... 78 Requip XL...... 75 Rasagiline Mesylate...... 76 Risperidone ODT...... 78 Tracked 34

34 34

Ritalin...... 102 Sandostatin LAR Depot...... 126 Singulair...... 138 Ritalin LA...... 102 Santyl...... 105 Sirolimus...... 128 Rituxan...... 73 Saphris...... 78 Sirturo...... 70 Rivastigmine Tartrate...... 61 Sarafem...... 64 Sivextro...... 50 Rivastigmine Transdermal Savaysa...... 88 Sklice...... 74 System...... 61 Savella...... 103 Sodium Chloride...... 109 Rivelsa...... 124 Savella Titration Pack...... 103 Sodium Chloride 0.45%...... 109 Rizatriptan Benzoate...... 69 Seasonique...... 124 Sodium Chloride 0.9%...... 109 Rizatriptan Benzoate ODT..... 69 Selegiline HCl...... 76 Sodium Diuril...... 97 Robinul...... 110 Selenium Sulfide...... 105 Sodium Fluoride...... 109 Robinul Forte...... 110 Selzentry...... 82 Sodium Lactate...... 109 Rocaltrol...... 132 Semprex-D...... 141 Sodium Phenylbutyrate...... 114 Ropinirole ER...... 75 Sensipar...... 132 Sodium Polystyrene Sulfonate Ropinirole HCl...... 75 Serevent Diskus...... 139 ...... 110 Rosuvastatin Calcium...... 98 Seroquel...... 78 Sodium Sulfacetamide...... 55 Rotarix...... 130 Seroquel XR...... 78 Solaraze...... 105 RotaTeq...... 130 Serostim...... 111 Soliqua 100/33...... 86 Roweepra...... 57 Sertraline HCl...... 64 Solodyn...... 56 Roxicodone...... 47 Setlakin...... 124 Soltamox...... 70 Rozerem...... 142 sfRowasa...... 130 Solu-Cortef...... 119 Rubraca...... 72 Sharobel...... 125 Solu-Medrol...... 119 Ruconest...... 127 Signifor...... 126 Somatuline Depot...... 126 Rydapt...... 73 Signifor LAR...... 126 Somavert...... 126 Rytary...... 75 Sildenafil...... 140 Sonata...... 141 Rythmol SR...... 91 Siliq...... 105 Soolantra...... 105 S Silvadene...... 55 Soriatane...... 105 Sabril...... 58 Silver Sulfadiazine...... 55 Sorilux...... 105 Safyral...... 124 Simbrinza...... 134 Sorine...... 91 Saizen...... 120 Simponi...... 128 Sotalol HCl...... 91 Salagen...... 103 Simponi Aria...... 128 Sotylize...... 91 Samsca...... 110 Simulect...... 129 Sovaldi...... 80 Sancuso...... 66 Simvastatin...... 98 Spiriva HandiHaler...... 138 Sandimmune...... 128 Sinemet...... 75 Spiriva Respimat...... 138 Sandostatin...... 126 Sinemet CR...... 75 Spironolactone...... 97 Tracked 35

35 35

Spironolactone/ Sulfacetamide Sodium...55, 105 Synthroid...... 126 Hydrochlorothiazide...... 96 Sulfacetamide Sodium/ Syprine...... 110 Sporanox...... 67 Prednisolone Sodium T Phosphate...... 133 Sprintec 28...... 124 Tabloid...... 71 Sulfadiazine...... 55 Spritam...... 57 Taclonex...... 105 Sulfamethoxazole/ Sprycel...... 73 Tacrolimus...... 105, 128 Trimethoprim...... 55 SPS...... 110 Tafinlar...... 73 Sulfamethoxazole/ Sronyx...... 124 Trimethoprim DS...... 56 Tagrisso...... 73 SSD...... 55 Sulfamylon...... 50 Taltz...... 105 Stalevo 100...... 75 Sulfasalazine...... 131 Tamiflu...... 82 Stalevo 125...... 75 Sulindac...... 41 Tamoxifen Citrate...... 70 Stalevo 150...... 75 Sumatriptan...... 69 Tamsulosin HCl...... 116 Stalevo 200...... 75 Sumatriptan Succinate...... 69 Tanzeum...... 86 Stalevo 50...... 75 Sumatriptan Succinate Refill Tapazole...... 126 Stalevo 75...... 75 ...... 69 Tarceva...... 73 Starlix...... 86 Sumavel DosePro...... 69 Targadox...... 56 Stavudine...... 81 Suprax...... 52 Targretin...... 73 Stelara...... 105 Suprep Bowel Prep Kit...... 112 Tarina Fe 1/20...... 124 Sterile Water Irrigation...... 132 Surmontil...... 65 Tarka...... 96 Stimate...... 120 Sustiva...... 81 Tasigna...... 73 Stiolto Respimat...... 141 Sutent...... 73 Tasmar...... 75 Stivarga...... 73 Sylatron...... 80 Taxotere...... 72 Strattera...... 102 Sylvant...... 129 Tazarotene...... 105 Strensiq...... 114 Symbicort...... 141 Tazicef...... 52 Streptomycin Sulfate...... 48 Symbyax...... 62 Tazorac...... 106 Striant...... 121 SymlinPen 120...... 86 Taztia XT...... 94 Stribild...... 80 SymlinPen 60...... 86 Tecentriq...... 73 Striverdi Respimat...... 139 Synagis...... 129 Tecfidera...... 103 Stromectol...... 74 Synalar...... 119 Tecfidera Starter Pack...... 103 Suboxone...... 48 Synalgos-DC...... 47 Technivie...... 80 Subsys...... 47 Synarel...... 126 Teflaro...... 52 Sucraid...... 115 Synercid...... 50 Tegretol...... 61 Sucralfate...... 112 Synjardy...... 86 Tegretol-XR...... 61 Sular...... 93 Synribo...... 72 Tekturna...... 96 Tracked 36

36 36

Tekturna HCT...... 96 Thyrolar...... 126 Topamax Sprinkle...... 59 Telmisartan...... 90 Tiagabine HCl...... 58 Topicort...... 119 Telmisartan/Amlodipine...... 96 Tiazac...... 94 Topiramate...... 60 Telmisartan/ Tigan...... 65 Topiramate ER...... 60 Hydrochlorothiazide...... 96 Tigecycline...... 50 Toposar...... 72 Temazepam...... 141 Tikosyn...... 91 Topotecan HCl...... 72 Tenivac...... 130 Timolol Maleate...... 92, 134 Toprol XL...... 92 Tenoretic 100...... 96 Timolol Maleate Ophthalmic Torisel...... 128 Tenoretic 50...... 96 Gel Forming...... 134 Torsemide...... 97 Tenormin...... 92 Timoptic Ocudose...... 135 Toujeo SoloStar...... 87 Terazol 7...... 67 Timoptic-XE...... 135 Toviaz...... 115 Terazosin HCl...... 116 Tindamax...... 50 TPN Electrolytes...... 109 Terbinafine HCl...... 67 Tinidazole...... 50 Tracleer...... 140 Terbutaline Sulfate...... 139 Tirosint...... 126 Tradjenta...... 86 Terconazole...... 67 Tivicay...... 80 Tramadol HCl...... 47 Testim...... 121 Tizanidine HCl...... 141 Tramadol HCl ER...... 45 Testosterone...... 121 TOBI...... 139 Tramadol HCl/Acetaminophen ...... 121 TOBI Podhaler...... 139 ...... 47 ...... 121 Tobradex...... 133 Trandolapril...... 90 Testosterone Pump...... 121 Tobradex ST...... 133 Trandolapril/Verapamil HCl... 96 Tetanus/Diphtheria Toxoids- Tobramycin...... 139 Tranexamic Acid...... 89 Adsorbed Adult...... 130 Tobramycin Sulfate...... 49 Transderm-Scop...... 65 Tetrabenazine...... 102 Tobramycin/Dexamethasone Tranxene T...... 83 Tetracycline HCl...... 56 ...... 133 Tranylcypromine Sulfate...... 62 Thalomid...... 70 Tobrex...... 49 Travasol...... 109 Theo-24...... 139 Tofranil...... 65 Travatan Z...... 136 Theophylline...... 139 Tolak...... 106 Trazodone HCl...... 64 Theophylline CR...... 139 Tolazamide...... 86 Treanda...... 70 Theophylline ER...... 139 Tolbutamide...... 86 Trecator...... 70 Thiola...... 116 Tolcapone...... 75 Trelstar Mixject...... 126 Thioridazine HCl...... 76 Tolmetin Sodium...... 41 Tresiba FlexTouch...... 87 Thiotepa...... 72 Tolterodine Tartrate...... 115 Tretinoin...... 73, 106 Thiothixene...... 76 Tolterodine Tartrate ER...... 115 Tretinoin Microsphere...... 106 Thymoglobulin...... 129 Topamax...... 59 Trexall...... 128 Tracked 37

37 37

Treximet...... 69 Trizivir...... 81 Ursodiol...... 111 Trezix...... 47 Trokendi XR...... 60 V Tri-Legest Fe...... 124 Trophamine...... 109 Vagifem...... 124 Tri-Lo-Estarylla...... 124 Trospium Chloride...... 115 Valacyclovir HCl...... 80 Tri-Lo-Sprintec...... 124 Trospium Chloride ER...... 115 Valchlor...... 70 Tri-Norinyl 28...... 124 Trulicity...... 86 Valcyte...... 79 Tri-Previfem...... 124 Trumenba...... 130 Valganciclovir...... 79 Tri-Sprintec...... 124 Trusopt...... 135 Valganciclovir Hydrochlorde Triamcinolone Acetonide....119, Truvada...... 81 ...... 79 137 Tudorza Pressair...... 138 Valium...... 83 Triamcinolone in Orabase....103 Twinrix...... 130 Valproate Sodium...... 58 Triamterene/ Twynsta...... 96 Valproic Acid...... 58 Hydrochlorothiazide...... 96 Tybost...... 80 Valsartan...... 90 Trianex...... 119 Tygacil...... 50 Valsartan/Hydrochlorothiazide Tribenzor...... 96 ...... 96 Tykerb...... 73 Tricor...... 98 Valtrex...... 80 Tylenol/Codeine #3...... 47 Triderm...... 119 Vancocin HCl...... 50 Tylenol/Codeine #4...... 47 Tridesilon...... 119 Vancomycin HCl...... 50 Tymlos...... 132 Trifluoperazine HCl...... 76 Vandazole...... 50 Typhim Vi...... 130 Trifluridine...... 80 Vanos...... 119 Tysabri...... 103 Triglide...... 98 VAQTA...... 130 U Trihexyphenidyl HCl...... 74 Varivax...... 130 Uceris...... 131 Trileptal...... 61 Varizig...... 129 Uloric...... 68 Trilipix...... 98 Varubi...... 66 Ultracet...... 47 TriLyte...... 112 Vascepa...... 99 Ultram...... 47 Trimethobenzamide HCl...... 65 Vaseretic...... 96 Ultravate...... 119 Trimethoprim...... 50 Vasotec...... 90 Unasyn...... 53 Trimipramine Maleate...... 65 Vecamyl...... 96 Unasyn Bulk Pack...... 53 Trinessa...... 124 Vectibix...... 73 Unithroid...... 126 Trintellix...... 64 Vectical...... 106 Uptravi...... 140 Triostat...... 126 Velcade...... 72 Urecholine...... 116 Trisenox...... 72 Velivet...... 124 Urocit-K...... 109 Triumeq...... 80 Velphoro...... 110 Uroxatral...... 116 Trivora-28...... 124 Veltassa...... 110 Urso...... 111 Tracked 38

38 38

Vemlidy...... 79 Vimovo...... 41 X Venclexta...... 73 Vimpat...... 61 Xalatan...... 136 Venclexta Starting Pack...... 73 Vinblastine Sulfate...... 72 Xalkori...... 73 Venlafaxine HCl...... 64 Vincasar PFS...... 72 Xanax...... 83 Venlafaxine HCl ER...... 64 Vincristine Sulfate...... 72 Xanax XR...... 83 Ventavis...... 140 Vinorelbine Tartrate...... 72 Xarelto...... 88 Ventolin HFA...... 139 Viokace...... 115 Xarelto Starter Pack...... 88 Verapamil HCl...... 94 Viracept...... 82 Xeljanz...... 128 Verapamil HCl ER...... 94 Viramune...... 81 Xeljanz XR...... 128 Verapamil HCl SR...... 94 Viramune XR...... 81 Xenazine...... 102 Veregen...... 106 Viread...... 81 Xeomin...... 132 Verelan...... 94 Viroptic...... 80 Xerese...... 80 Verelan PM...... 94 Vistaril...... 65 Xermelo...... 111 Veripred 20...... 119 Vivelle-Dot...... 124 Xgeva...... 132 Versacloz...... 79 Vivitrol...... 48 Xifaxan...... 111 Vesicare...... 115 Vivlodex...... 41 Xigduo XR...... 86 Vestura...... 124 Vogelxo...... 121 Xiidra...... 133 Vfend...... 67 Vogelxo Pump...... 121 Xodol...... 47 Vfend IV...... 67 Voltaren...... 41 Xolair...... 129 Viberzi...... 111 Voriconazole...... 68 Xopenex...... 139 Vibramycin...... 56 Votrient...... 73 Xopenex Concentrate...... 139 Vicodin...... 47 VP-PNV-DHA...... 110 Xopenex HFA...... 139 Vicodin ES...... 47 VPRIV...... 115 Xtampza ER...... 45 Vicodin HP...... 47 Vraylar...... 78 Xtandi...... 70 Victoza...... 86 Vyfemla...... 124 Xulane...... 124 Vidaza...... 89 Vytorin...... 99 Xylocaine...... 47 Videx EC...... 81 Vyvanse...... 101 Xyrem...... 142 Videx Pediatric...... 81 W Xyzal...... 136, 137 Viekira Pak...... 80 Warfarin Sodium...... 88 Y Viekira XR...... 80 Welchol...... 99 Yasmin 28...... 124 Vienva...... 124 Wellbutrin SR...... 62 Yaz...... 124 Vigamox...... 55 Wellbutrin XL...... 62 Yervoy...... 73 Viibryd...... 64 WYMZYA Fe...... 124 YF-Vax...... 130 Viibryd Starter Pack...... 64 Yondelis...... 70 Tracked 39

39 39

Yosprala...... 113 Zetia...... 99 Zomig Nasal Spray...... 69 Yuvafem...... 124 Zetonna...... 137 Zomig ZMT...... 69 Z Ziac...... 97 Zonalon...... 106 Zafirlukast...... 138 Ziagen...... 82 Zonegran...... 57 Zaleplon...... 141 Ziana...... 106 Zonisamide...... 57 Zaltrap...... 72 Zidovudine...... 82 Zontivity...... 88 Zamicet...... 47 Zileuton ER...... 138 Zorbtive...... 111 Zanaflex...... 141 Zinacef...... 52 Zortress...... 128 Zanosar...... 70 Zinbryta...... 103 Zorvolex...... 42 Zantac...... 111 Zinecard...... 72 Zostavax...... 130 Zarah...... 124 Zinplava...... 129 Zosyn...... 53 Zarontin...... 57 Zioptan...... 136 Zovia 1/35E...... 125 Zarxio...... 89 Ziprasidone HCl...... 78 Zovia 1/50E...... 125 Zavesca...... 115 Zipsor...... 41 Zovirax...... 80 Zazole...... 68 Zirgan...... 79 Zubsolv...... 48 Zegerid...... 113 Zithromax...... 54 Zuplenz...... 66 Zejula...... 72 Zithromax Tri-Pak...... 54 Zurampic...... 68 Zelapar...... 76 Zithromax Z-Pak...... 54 Zyban...... 48 Zelboraf...... 73 Zmax...... 54 Zyclara...... 106 Zemaira...... 115 Zocor...... 98 Zyclara Pump...... 106 Zembrace Symtouch...... 69 Zofran...... 66 Zydelig...... 73 Zemplar...... 132 Zofran ODT...... 66 Zyflo...... 138 Zenatane...... 106 Zohydro ER...... 45 Zyflo CR...... 138 Zenchent...... 124 Zoledronic Acid...... 132 Zykadia...... 73 Zenchent Fe...... 125 Zolinza...... 72 Zylet...... 133 Zenpep...... 115 Zolmitriptan...... 69 Zyloprim...... 68 Zenzedi...... 101 Zolmitriptan ODT...... 69 Zymaxid...... 55 Zepatier...... 80 Zoloft...... 64 Zyprexa...... 78 Zerbaxa...... 52 Zolpidem Tartrate...... 142 Zyprexa Relprevv...... 78 Zerit...... 82 Zomacton...... 120 Zyprexa Zydis...... 78 Zestoretic...... 97 Zometa...... 132 Zytiga...... 70 Zestril...... 90 Zomig...... 69 Zyvox...... 50 39 40

40 tRACK Covered drugs by medical condition 1 The list below has information about the drugs covered by this plan. Find your medical condition to see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-39. The first column lists the drug name, which may include the and strength. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction

amountstRACK are shown in the chart on pages 143-180.

Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Analgesics Diclofenac Sodium/Misoprostol Sodium/

Nonsteroidal Anti-inflammatory Drugs Misoprostol (Tablet 1

Anaprox DS Anaprox DS (Tablet) 3 Delayed-Release) Diflunisal Arthrotec 50 50 (Tablet Diflunisal (Tablet) 1 3 Duexis Delayed-Release) Duexis (Tablet) 4 ST

EC-Naprosyn Arthrotec 75 75 (Tablet EC-Naprosyn (Tablet 3 3 Delayed-Release) Delayed-Release)

Etodolac Cambia Cambia (Packet) 3 Etodolac (200mg Celebrex (Capsule) 3 QL Capsule, 300mg

Celecoxib Capsule, 400mg Tablet 1 Celecoxib (Capsule) 1 QL Immediate-Release, Daypro Daypro (Tablet) 3 500mg Tablet Diclofenac Potassium Potassium Immediate-Release)

Etodolac ER (Tablet Immediate- 1 Etodolac ER (Tablet

Release) Extended-Release 24 1 Diclofenac Sodium Sodium Hour)

Feldene (1% Gel, 1.5% 1 PA Feldene (Capsule) 3 Transdermal ) Fenoprofen Calcium Calcium Diclofenac Sodium DR Sodium DR 1 (400mg Capsule) (Tablet Delayed- 1 Fenoprofen Calcium Calcium 1 Release) (600mg Tablet) Diclofenac Sodium ER

Diclofenac Sodium ER Flector Flector (Patch) 3 PA, QL

(Tablet Extended- 1 Flurbiprofen Release 24 Hour) Flurbiprofen (Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. 40 41

Last updatedtRACK September 1, 2017 41 2 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Ibuprofen (100mg/5ml Naproxen (125mg/5ml , 400mg Suspension, 250mg 1 Tablet, 600mg Tablet, Tablet Immediate-

800mg Tablet) Release, 375mg Tablet 1 Ketoprofen (Capsule Immediate-Release, 1 Immediate-Release) 500mg Tablet Ketoprofen ER ER Immediate-Release) Naproxen DR DR (Tablet (Capsule Extended- 1 Release 24 Hour) Delayed-Release) 1 Ketorolac Tromethamine (Generic EC-Naprosyn)

Naproxen Sodium Tromethamine (15mg/ Naproxen Sodium (275mg Tablet, 550mg ml Injection, 30mg/ml 1 PA, HRM Injection, 60mg/2ml Tablet, 500mg Tablet 1 Injection) Extended-Release 24

Lodine Lodine (Tablet) 4 Hour)

Naproxen Sodium ER Meclofenamate Sodium Naproxen Sodium ER 1 (Tablet Extended- Sodium (Capsule) 1

Mefenamic Acid Release 24 Hour) Mefenamic Acid 1 (Generic Naprelan)

(Capsule) Oxaprozin

Meloxicam Oxaprozin (Tablet) 1 Meloxicam (15mg 1 Pennsaid Tablet, 7.5mg Tablet) Pennsaid

Mobic (Transdermal 4 PA Mobic (Tablet) 3 Solution) Nabumetone

Nabumetone (Tablet) 1 Piroxicam Piroxicam (Capsule) 1 Naprelan

Naprelan (375mg Ponstel Ponstel (Capsule) 3 Tablet Extended- Sulindac Release 24 Hour, Sulindac (Tablet) 1 4 Tolmetin Sodium Tolmetin Sodium 500mg Tablet Extended-Release 24 (400mg Capsule, 1 Hour) 600mg Tablet)

Vimovo Naprelan (750mg Vimovo (Tablet 4 ST Tablet Extended- 3 Delayed-Release) Release 24 Hour) Vivlodex (Capsule) 3 QL

Naprosyn Naprosyn (Tablet) 3 Voltaren (Gel) 3 PA Zipsor (Capsule) 3 ST

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Exalgo Zorvolex (Capsule) 3 ST Exalgo (16mg Tablet Opioid Analgesics, Long-acting Extended-Release 24 Hour Abuse- Belbuca PA, QL, Belbuca (Film) 3 Deterrent, 32mg MED 4 QL, MED

Buprenorphine Tablet Extended- Buprenorphine (Patch 3 QL, MED Release 24 Hour Weekly) Abuse-Deterrent) Butrans

Butrans (Patch Fentanyl 2 QL, MED Fentanyl (Patch 72 Weekly) 1 QL, MED Hour) Conzip

Conzip (Capsule Hydromorphone HCl ER Hydromorphone HCl Extended-Release 24 3 QL, MED ER (Tablet Extended- Hour) 1 QL, MED Release 24 Hour Dolophine Dolophine (Tablet) 3 QL, MED Abuse-Deterrent)

Duragesic Duragesic (100mcg/ Hysingla ER ER (Tablet hr Patch 72 Hour, Extended-Release 24 4 QL, MED 2 QL, MED 75mcg/hr Patch 72 Hour Abuse- Hour) Deterrent)

Duragesic Duragesic (12mcg/hr Kadian (100mg Patch 72 Hour, Capsule Extended- 25mcg/hr Patch 72 3 QL, MED Release 24 Hour, Hour, 50mcg/hr 200mg Capsule Patch 72 Hour) Extended-Release 24 Embeda (Capsule Hour, 40mg Capsule 2 QL, MED Extended-Release) Extended-Release 24

Exalgo 4 QL, MED Exalgo (12mg Tablet Hour, 50mg Capsule Extended-Release 24 Extended-Release 24 Hour Abuse- Hour, 60mg Capsule Deterrent, 8mg Tablet 3 QL, MED Extended-Release 24 Extended-Release 24 Hour, 80mg Capsule Hour Abuse- Extended-Release 24 Deterrent) Hour)

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Kadian (10mg Capsule Extended- Release 24 Hour, 20mg Capsule 3 QL, MED Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour) Levorphanol Tartrate Tartrate 1 QL, MED (Tablet) Methadone HCl HCl (10mg Tablet, 5mg Tablet, 10mg/5ml Oral 1 QL, MED Solution, 5mg/5ml Oral Solution) Methadone HCl HCl 1 (10mg/ml Injection)

Bold type = Brand name drug Plain type = Generic drug 43 44

44 tRACK Last updated September 1, 2017 5 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use Morphine Sulfate ER Sulfate ER Hour)(Generic Avinza) (100mg Capsule MS Contin Contin (100mg Extended-Release 24 Tablet Extended- Hour, 10mg Capsule Release, 200mg 4 QL, MED Extended-Release 24 Tablet Extended- Hour, 20mg Capsule Release, 60mg Tablet Extended-Release 24 Extended-Release) Hour, 30mg Capsule MS Contin Contin (15mg Extended-Release 24 Tablet Extended- 3 QL, MED Hour, 50mg Capsule Release, 30mg Tablet Extended-Release 24 Extended-Release)

Hour, 60mg Capsule Nucynta ER Nucynta ER (Tablet Extended-Release 24 Extended-Release 12 2 QL, MED Hour, 80mg Capsule Hour) Extended-Release 24 Opana ER Hour)(Generic Kadian), Opana ER (Tablet Extended-Release 12 (100mg Tablet 3 QL, MED Extended-Release, Hour Abuse- 15mg Tablet Extended- 1 QL, MED Deterrent)

Oxycodone HCl ER Release, 200mg Tablet Oxycodone HCl ER (Tablet Extended- Extended-Release, 3 QL, MED 30mg Tablet Extended- Release 12 Hour Release, 60mg Tablet Abuse-Deterrent) Extended-Release) OxyContin (Tablet (Generic MS Contin), Extended-Release 12 2 QL, MED (120mg Capsule Hour Abuse- Extended-Release 24 Deterrent) Hour, 30mg Capsule Oxymorphone HCl ER HCl ER Extended-Release 24 (Tablet Extended- 1 QL, MED Hour, 45mg Capsule Release 12 Hour) Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Hour, 75mg Capsule Extended-Release 24 Hour, 90mg Capsule Extended-Release 24

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Tramadol HCl ER HCl ER Butorphanol Tartrate Tartrate (100mg Capsule (10mg/ml Nasal 1 QL, MED Extended-Release 24 Solution) Hour, 200mg Capsule Butorphanol Tartrate Tartrate 3 QL, MED Extended-Release 24 (1mg/ml Injection, 1 Hour, 300mg Capsule 2mg/ml Injection) Extended-Release 24 Codeine Sulfate Sulfate 1 QL, MED Hour) (Tablet)

Tramadol HCl ER Tramadol HCl ER Dilaudid (1mg/ml (100mg Tablet Liquid, 2mg Tablet, 3 QL, MED Extended-Release 24 4mg Tablet, 8mg Hour, 200mg Tablet Tablet)

Extended-Release 24 1 QL, MED Duramorph Duramorph (Injection) 1 Hour) (Generic Ultram Endocet ER), (300mg Tablet Endocet (Tablet) 1 QL, MED Extended-Release 24 Fentanyl Citrate Oral Transmucosal Citrate Oral Hour) (Generic Ryzolt) Transmucosal 1 PA, QL Xtampza ER ER (Capsule () Extended-Release 12 Fentora (Tablet) 4 PA, QL 3 QL, ST, MED Hour Abuse- Hycet (Oral Solution) 3 QL, MED

Deterrent) Hydrocodone Bitartrate/Acetaminophen Hydrocodone Zohydro ER Zohydro ER (Capsule Bitartrate/ Extended-Release 12 PA, QL, 3 Acetaminophen Hour Abuse- MED (10mg-300mg Tablet, Deterrent) 325mg-2.5mg Tablet, 1 QL, MED Opioid Analgesics, Short-acting 5mg-300mg Tablet, Abstral (Tablet 7.5mg-300mg Tablet, 4 PA, QL Sublingual) 7.5mg-325mg/15ml Acetaminophen/CodeineAcetaminophen/ Oral Solution) Codeine Hydrocodone/Hydrocodone/Ibuprofen 1 QL, MED (120mg-12mg/5ml Ibuprofen (Tablet) Oral Solution, 1 QL, MED Hydromorphone HCl HCl

300mg-15mg Tablet, (10mg/ml Injection, 1 300mg-30mg Tablet, 50mg/5ml Injection) 300mg-60mg Tablet) Actiq (Lollipop) 4 PA, QL

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Hydromorphone HCl HCl Nucynta (100mg 4 QL, MED (1mg/ml Liquid, 2mg Tablet) Tablet Immediate- Nucynta (50mg 3 QL, MED Release, 4mg Tablet 1 QL, MED Tablet, 75mg Tablet) Immediate-Release, Opana (10mg Tablet 4 QL, MED 8mg Tablet Immediate- Immediate-Release)

Release) Opana Opana (5mg Tablet Hydromorphone HCl HCl 3 QL, MED 1 Immediate-Release) (2mg/ml Injection) Oxycodone HCl Oxycodone HCl Ibudone Ibudone (Tablet) 1 QL, MED (100mg/5ml Lazanda (Nasal Concentrate, 10mg 4 PA, QL Solution) Tablet Immediate- Lorcet (Tablet) 1 QL, MED Release, 15mg Tablet Lorcet HD HD (Tablet) 1 QL, MED Immediate-Release,

Lorcet Plus 20mg Tablet Lorcet Plus (Tablet) 1 QL, MED Immediate-Release, 1 QL, MED Lortab (Tablet) 1 QL, MED 30mg Tablet Morphine Sulfate Sulfate Immediate-Release, (100mg/5ml Oral 5mg Tablet Immediate- Solution, 10mg/5ml 1 QL, MED Release, 5mg Capsule Oral Solution, 20mg/ Immediate-Release, 5ml Oral Solution) 5mg/5ml Oral Morphine Sulfate Sulfate Solution) (10mg/ml Injection, Oxycodone/Oxycodone/Acetaminophen 1 4mg/ml Injection, Acetaminophen 8mg/ml Injection) (10mg-325mg Tablet, Morphine Sulfate 2.5mg-325mg Tablet, Morphine Sulfate 1 QL, MED (15mg Tablet 5mg-325mg Tablet, Immediate-Release, 1 QL, MED 7.5mg-325mg Tablet, 30mg Tablet 325mg/5ml-5mg/5ml Immediate-Release) Oral Solution)

Oxycodone/Aspirin Morphine Sulfate Sulfate Oxycodone/Aspirin 1 1 QL, MED (2mg/ml Injection) (Tablet)

Oxycodone/Ibuprofen Nalbuphine HCl HCl Oxycodone/Ibuprofen 1 1 QL, MED (Injection) (Tablet) Norco (Tablet) 3 QL, MED

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Oxymorphone HCl Oxymorphone HCl Vicodin ES ES (Tablet) 1 QL, MED (Tablet Immediate- 1 QL, MED Vicodin HP HP (Tablet) 1 QL, MED

Release) Xodol

Percocet Xodol (10mg-300mg Percocet Tablet, 7.5mg-300mg 4 QL, MED (10mg-325mg Tablet, 4 QL, MED Tablet)

5mg-325mg Tablet, Xodol Xodol (5mg-300mg 7.5mg-325mg Tablet) 3 QL, MED

Percocet Tablet)

Percocet Zamicet 3 QL, MED Zamicet (Oral Solution) 1 QL, MED (2.5mg-325mg Tablet) Primlev (10mg-300mg Anesthetics 4 QL, MED Tablet) Local Anesthetics

Lidocaine Primlev Lidocaine (5% Primlev (5mg-300mg 1 Tablet, 7.5mg-300mg 3 QL, MED Ointment) Tablet) Lidocaine (5% Patch) 1 PA, QL Roxicodone (15mg Lidocaine HCl HCl (0.5% 3 QL, MED Tablet, 5mg Tablet) Injection, 1% Injection, 1 B/D, PA Roxicodone (30mg 2% Injection)

4 QL, MED Lidocaine HCl Tablet) Lidocaine HCl (4% 1 Subsys (Liquid) 4 PA, QL External Solution)

Lidocaine HCl Synalgos-DC Lidocaine HCl (Gel) 1

3 QL, MED Lidocaine Viscous (Capsule) Lidocaine Viscous

Tramadol HCl 1 Tramadol HCl (Tablet (Solution)

1 QL, MED Lidocaine/Prilocaine Immediate-Release) Lidocaine/Prilocaine

Tramadol HCl/Acetaminophen 1 Tramadol HCl/ () Acetaminophen 1 QL, MED Lidoderm (Patch) 3 PA, QL (Tablet) Xylocaine (2% Trezix 3 B/D, PA Trezix (Capsule) 1 QL, MED Injection) Tylenol/Codeine #3 #3 Xylocaine (4% 3 QL, MED 3 (Tablet) External Solution) Tylenol/Codeine #4 #4 Anti-Addiction/Substance Abuse Treatment 3 QL, MED (Tablet) Agents Ultracet (Tablet) 3 QL, MED Alcohol Deterrents/Anti-craving

Acamprosate Calcium DR Ultram Acamprosate Calcium Ultram (Tablet) 3 QL, MED Vicodin (Tablet) 1 QL, MED DR (Tablet Delayed- 1 Release)

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Chantix Starting Month Pak Antabuse Antabuse (Tablet) 3 Chantix Starting 2 Disulfiram Disulfiram (Tablet) 1 Month Pak (Tablet)

Nicotrol Inhaler Naltrexone HCl Naltrexone HCl Nicotrol Inhaler 1 3 (Tablet) (Inhaler) Nicotrol NS

Vivitrol Nicotrol NS (Nasal Vivitrol (Injection) 4 3 Solution)

Opioid Dependence Treatments Zyban Zyban (Tablet Bunavail Bunavail (Film) 3 QL, ST Extended-Release 12 3

Buprenex Buprenex (Injection) 4 Hour) Buprenorphine HCl HCl Antibacterials 1 (0.3mg/ml Injection) Aminoglycosides

Buprenorphine HCl Buprenorphine HCl Amikacin Sulfate Sulfate (2mg Tablet 1 1 QL (Injection) Sublingual, 8mg Tablet Gentak (Ophthalmic 1 Sublingual) Ointment)

Buprenorphine HCl/Naloxone HCl Buprenorphine HCl/ Gentamicin Sulfate Sulfate Naloxone HCl (Tablet 1 QL (0.1% Cream, 0.1% Sublingual) Ointment, 0.3% Suboxone 1 Suboxone (Film) 3 QL Ophthalmic Solution, Zubsolv (Tablet 10mg/ml Injection, 3 QL, ST Sublingual) 40mg/ml Injection) Gentamicin Sulfate/0.9% Sodium Chloride Sulfate/ Opioid Reversal Agents Evzio (Injection) 4 ST 0.9% Sodium Chloride 1

Naloxone HCl (Injection) Naloxone HCl 1 Isotonic Gentamicin Gentamicin (Injection) 1

Narcan (Injection)

Narcan (Liquid) 2 Neomycin Sulfate Neomycin Sulfate Smoking Cessation Agents 1 (Tablet) Bupropion HCl SR

Bupropion HCl SR Paromomycin Sulfate Paromomycin Sulfate (150mg Tablet 1 1 (Capsule)

Extended-Release 12 Streptomycin Sulfate Streptomycin Sulfate Hour) 3

Chantix (Injection) Chantix (Tablet) 2 Chantix Continuing Month Pak Continuing 2 Month Pak (Tablet)

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Tobramycin Sulfate Sulfate Clindamycin Palmitate HCl Palmitate 1 (0.3% Ophthalmic HCl (Oral Solution)

Solution, 10mg/ml 1 Clindamycin Phosphate Injection, 80mg/2ml Phosphate (2% Cream,

Injection) 300mg/2ml Solution, 1 Tobrex (0.3% 900mg/6ml Solution, 2 Ophthalmic Ointment) 600mg/4ml Injection) Tobrex (0.3% Clindamycin Phosphate in D5W 3 Ophthalmic Solution) Phosphate in D5W 1 Antibacterials, Other (Injection)

Clindesse BACiiM BACiiM (Injection) 1 Clindesse (Cream) 3

Colistimethate Sodium Bacitracin (50000unit Colistimethate Sodium 1 Injection, 500unit/gm 1 (Injection)

Cubicin Ophthalmic Ointment) Cubicin (Injection) 4

Bactroban Dalvance Bactroban (Cream) 3 Dalvance (Injection) 4 PA

Bactroban Nasal Bactroban Nasal Daptomycin 3 PA Daptomycin (Injection) 1 (Ointment) Flagyl (250mg Tablet, Chloramphenicol Sodium Succinate 500mg Tablet, 375mg 3 Sodium Succinate 1 Capsule) (Injection) Furadantin Cleocin 4 HRM Cleocin (100mg (Suspension)

Suppository, 150mg Hiprex Hiprex (Tablet) 3 Capsule, 300mg 3 Lincocin Capsule, 75mg Lincocin (Injection) 3 Lincomycin HCl HCl Capsule, 2% Cream) 1 Cleocin in D5W in D5W (Injection) 3 Linezolid (Injection) Linezolid (100mg/5ml Cleocin Pediatric Granules Pediatric Suspension, 600mg/ 1 PA

Granules (Oral 3 300ml Injection) Linezolid (600mg Solution) 1 PA, QL Cleocin Phosphate Phosphate Tablet) 3 Macrobid (Injection) Macrobid (Capsule) 3 HRM

Macrodantin Clindamycin HCl HCl Macrodantin 3 HRM (Capsule Immediate- 1 (Capsule) Release)

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Methenamine Hippurate Nuvessa Methenamine Nuvessa (Gel) 3 1 Orbactiv Hippurate (Tablet) Orbactiv (Injection) 4 MetroCream MetroCream (Cream) 3 Polymyxin B Sulfate B Sulfate MetroGel 1 MetroGel (Gel) 3 (Injection) MetroGel-Vaginal Primsol (Oral 3 3 (Gel) Solution)

MetroLotion Sivextro MetroLotion () 3 Sivextro (200mg Metronidazole (0.75% Injection, 200mg 4 PA Cream, 0.75% Gel, 1% Tablet) Sulfamylon (5% Gel, 0.75% Lotion, 4 250mg Tablet Packet)

Sulfamylon Immediate-Release, 1 Sulfamylon (85mg/ 3 500mg Tablet gm Cream)

Synercid Immediate-Release, Synercid (Injection) 4

375mg Capsule Tigecycline Tigecycline (Injection) 4 Immediate-Release) Tindamax Metronidazole in NaCl 0.79% in NaCl Tindamax (Tablet) 3 1 Tinidazole 0.79% (Injection) Tinidazole (Tablet) 1

Metronidazole Vaginal Trimethoprim Metronidazole Vaginal Trimethoprim (Tablet) 1 1 Tygacil (Gel) Tygacil (Injection) 4

Monurol Monurol (Packet) 3 Vancocin HCl HCl

Mupirocin 4 Mupirocin (2% Cream, (Capsule) 1 2% Ointment) Vancomycin HCl HCl Neomycin/Polymyxin B Sulfates B (1000mg Injection,

Sulfates (Irrigation 1 10gm Injection, 500mg 1 Solution) Injection, 125mg Nitrofurantoin Capsule, 250mg 1 HRM (Suspension) Capsule)

Vandazole Nitrofurantoin Macrocrystals Nitrofurantoin Vandazole (Gel) 1 Macrocrystals 1 HRM Zyvox (100mg/5ml (Capsule) Suspension, 600mg/ 4 PA Nitrofurantoin Monohydrate 300ml Injection) Monohydrate (100mg 1 HRM Zyvox (600mg Tablet) 4 PA, QL Capsule) Beta-lactam, Cephalosporins Noritate Noritate (Cream) 4

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Cefpodoxime Proxetil Avycaz (Injection) 4 PA Cefpodoxime Proxetil Cefaclor (125mg/5ml (100mg Tablet, 200mg

Suspension, 375mg/ 3 Tablet, 100mg/5ml 1 5ml Suspension) Suspension, 50mg/5ml Cefaclor (250mg Suspension) Cefprozil Capsule Immediate- Cefprozil (125mg/5ml Release, 500mg Suspension, 250mg/ 1 Capsule Immediate- 5ml Suspension, 1 Release, 250mg/5ml 250mg Tablet, 500mg Suspension) Tablet)

Ceftazidime Cefaclor ER ER (Tablet Ceftazidime (Injection) 1

Ceftin Extended-Release 12 1 Ceftin (Suspension) 3 Hour) Ceftriaxone Sodium Sodium Cefadroxil (1gm (10gm Injection, 1gm Tablet, 250mg/5ml Injection, 2gm 1 Suspension, 500mg/ 1 Injection, 250mg 5ml Suspension, Injection, 500mg 500mg Capsule) Injection)

Cefazolin Sodium Cefazolin Sodium Cefuroxime Axetil Axetil 1 1 (Injection) (Tablet)

Cefdinir Cefdinir (125mg/5ml Cefuroxime Sodium Sodium Suspension, 250mg/ 1 1 (Injection) 5ml Suspension, Cephalexin (125mg/ 300mg Capsule) 5ml Suspension,

Cefepime Cefepime (Injection) 1 250mg/5ml Cefixime Suspension, 250mg Cefixime (Suspension) 1 1 Cefotaxime Sodium Sodium Capsule, 500mg 1 (Injection) Capsule, 750mg

Cefotetan Capsule, 250mg Cefotetan (Injection) 1 Tablet, 500mg Tablet)

Cefoxitin Sodium Cefoxitin Sodium Fortaz (1gm Injection, (10gm Injection, 1gm 1 2gm Injection, 6gm 3 Injection, 2gm Injection)

Injection) Maxipime Maxipime (Injection) 3

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Suprax (100mg Tablet Amoxicillin (125mg

Chewable, 200mg 2 Tablet Chewable, Tablet Chewable) 250mg Tablet Suprax (100mg/5ml Chewable, 125mg/5ml

Suspension, 200mg/ 3 Suspension, 200mg/ 5ml Suspension, 5ml Suspension) Suprax (400mg 250mg/5ml 1 2 Capsule) Suspension, 400mg/

Suprax 5ml Suspension, Suprax (500mg/5ml 3 250mg Capsule, Suspension)

Tazicef 500mg Capsule, Tazicef (Injection) 1 500mg Tablet, 875mg Teflaro Teflaro (Injection) 4 Tablet) Zerbaxa (Injection) 4 PA Amoxicillin/Amoxicillin/Clavulanate Potassium

Zinacef Zinacef (Injection) 3 Clavulanate Potassium (200mg-28.5mg Tablet Beta-lactam, Other

Azactam in Iso-Osmotic Dextrose Chewable, Azactam in Iso- 400mg-57mg Tablet Osmotic Dextrose 3 Chewable, 200mg/ (Injection) 5ml-28.5mg/5ml Aztreonam Aztreonam (Injection) 1 Suspension, 250mg/

Doribax Doribax (Injection) 3 5ml-62.5mg/5ml Imipenem/Cilastatin Suspension, 400mg/ 1 (Injection) 5ml-57mg/5ml 1

Invanz Suspension, 600mg/ Invanz (Injection) 3 5ml-42.9mg/5ml Meropenem Meropenem (Injection) 1 Suspension,

Merrem Merrem (Injection) 3 250mg-125mg Tablet

Primaxin IV Primaxin IV (Injection) 3 Immediate-Release, Beta-lactam, Penicillins 500mg-125mg Tablet Immediate-Release, 875mg-125mg Tablet Immediate-Release) (Generic Augmentin)

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Amoxicillin/Amoxicillin/Clavulanate Potassium ER Penicillin G Procaine G Procaine 1 Clavulanate Potassium (Injection)

1 Penicillin G Sodium ER (Tablet Extended- Penicillin G Sodium 1 Release 12 Hour) (Injection)

Ampicillin Ampicillin (125mg/5ml Penicillin V Potassium V Potassium Suspension, 250mg/ (125mg/5ml Oral

5ml Suspension, 1 Solution, 250mg/5ml 1 250mg Capsule, Oral Solution, 250mg 500mg Capsule) Tablet, 500mg Tablet)

Ampicillin Sodium Ampicillin Sodium Piperacillin/Piperacillin/Tazobactam (10gm Injection, 1 1 Tazobactam (Injection) Unasyn 125mg Injection, 1gm Unasyn (Injection) 3

Injection) Unasyn Bulk Pack

Ampicillin-Sulbactam Unasyn Bulk Pack 3 Ampicillin-Sulbactam (Injection)

(10gm-5gm Injection, Zosyn 1 Zosyn (Injection) 1gm-0.5gm Injection, 3 2gm-1gm Injection) Macrolides

Azasite Augmentin Azasite (Ophthalmic 4 3 (Suspension) Solution)

Azithromycin Bactocill in Dextrose in Dextrose Azithromycin (100mg/ 3 (Injection) 5ml Suspension,

Bicillin C-R 200mg/5ml Bicillin C-R (Injection) 3

Bicillin L-A Suspension, 250mg 1 Bicillin L-A (Injection) 3 Tablet, 500mg Tablet, Dicloxacillin Sodium Sodium 1 600mg Tablet, 500mg (Capsule) Injection)

Nafcillin Sodium Nafcillin Sodium Azithromycin (1gm 1 1 (Injection) Packet)

Oxacillin Sodium Oxacillin Sodium Clarithromycin 1 Clarithromycin (Injection) (125mg/5ml Penicillin G Potassium G Potassium Suspension, 250mg/ 1 1 (Injection) 5ml Suspension, Penicillin G Potassium in Iso-Osmotic Dextrose G 250mg Tablet, 500mg Potassium in Iso- Tablet) 2 Osmotic Dextrose (Injection)

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Clarithromycin ER ER Zithromax (100mg/

(Tablet Extended- 1 5ml Suspension, Release 24 Hour) 200mg/5ml Dificid Suspension, 1gm Dificid (Tablet) 4 3 E.E.S. 400 Packet, 250mg E.E.S. 400 (Tablet) 3 Tablet, 500mg Tablet, E.E.S. Granules Granules 3 600mg Tablet, 500mg (Suspension) Injection)

Ery-Tab Ery-Tab (Tablet Zithromax Tri-Pak Tri-Pak 3 3 Delayed-Release) (Tablet)

EryPed 200 EryPed 200 Zithromax Z-Pak Z-Pak 3 3 (Suspension) (Tablet)

EryPed 400

EryPed 400 Zmax 4 Zmax (Suspension) 3 (Suspension)

Erythrocin Lactobionate Quinolones

Erythrocin Avelox Avelox (400mg Lactobionate 3 (Injection) Tablet, 400mg/ 3

Erythrocin Stearate 250ml-0.8% Injection)

Erythrocin Stearate Besivance 3 Besivance (Tablet) 3

Erythromycin (Suspension)

Erythromycin (250mg Ciloxan Ciloxan (0.3% Capsule Delayed- 1 Release, 5mg/gm Ointment, 0.3% 3 Ophthalmic Ointment) Ophthalmic Solution) Cipro Erythromycin Base Base Cipro (250mg Tablet, 1 500mg Tablet, (Tablet)

Erythromycin Ethylsuccinate 500mg/5ml 3 Erythromycin 1 Suspension, 5gm/ Ethylsuccinate (Tablet) 100ml Suspension) PCE

PCE (Tablet Delayed- Cipro I.V. in D5W 3 Cipro I.V. in D5W Release) 3 (Injection) Ciprofloxacin (250mg/ 5ml Suspension,

500mg/5ml 1 Suspension, 400mg/ 40ml Injection)

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Ciprofloxacin ER ER Ocuflox (Ophthalmic 3 (Tablet Extended- 1 Solution) Release 24 Hour) Ofloxacin (0.3% Ciprofloxacin HCl HCl Ophthalmic Solution,

(0.3% Ophthalmic 0.3% Otic Solution, 1 Solution, 100mg Tablet 300mg Tablet, 400mg Immediate-Release, Tablet) 250mg Tablet Vigamox (Ophthalmic 1 3 Immediate-Release, Solution) 500mg Tablet Zymaxid (Ophthalmic 3 Immediate-Release, Solution) 750mg Tablet Sulfonamides

Immediate-Release) Bactrim

Ciprofloxacin I.V. in D5W Bactrim (Tablet) 3 Ciprofloxacin I.V. in 1 Bactrim DS D5W (Injection) Bactrim DS (Tablet) 3

Bleph-10 Floxin Otic Otic (Otic Bleph-10 (Ophthalmic 3 3 Solution) Solution)

Silvadene Gatifloxacin Silvadene (Cream) 3

1 Silver Sulfadiazine (Ophthalmic Solution) Silver Sulfadiazine

Levaquin 1 Levaquin (Tablet) 3 (Cream)

Sodium Sulfacetamide Levofloxacin Sodium Sulfacetamide Levofloxacin (0.5% 1 Ophthalmic Solution, (Ophthalmic Solution)

SSD 250mg Tablet, 500mg SSD (Cream) 1

Tablet, 750mg Tablet, 1 Sulfacetamide Sodium Sodium

25mg/ml Injection, (10% Ophthalmic 1 25mg/ml Oral Ointment)

Sulfadiazine Solution) Sulfadiazine (Tablet) 1 Levofloxacin in D5W

Levofloxacin in D5W Sulfamethoxazole/Trimethoprim 1 Sulfamethoxazole/ (Injection) Trimethoprim Moxeza Moxeza (Ophthalmic (200mg-40mg/5ml 3 Solution) Suspension, 1 Moxifloxacin HCl HCl 1 400mg-80mg Tablet, (400mg Tablet) 400mg-80mg/5ml Moxifloxacin HCl HCl Injection)

(400mg/250ml 3 Injection)

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Sulfamethoxazole/Sulfamethoxazole/Trimethoprim DS Minocycline HCl HCl

Trimethoprim DS 1 (100mg Capsule (Tablet) Immediate-Release, Tetracyclines 50mg Capsule Demeclocycline HCl HCl Immediate-Release, 1 75mg Capsule (Tablet) Doryx Immediate-Release, 1 Doryx (Tablet 3 100mg Tablet Delayed-Release)

Doryx MPC Immediate-Release, Doryx MPC (Tablet 3 50mg Tablet Delayed-Release) Immediate-Release, Doxy 100 Doxy 100 (Injection) 1 75mg Tablet Doxycycline Immediate-Release) 1 (Suspension) Minocycline HCl ER HCl ER

Doxycycline Hyclate Doxycycline Hyclate (Tablet Extended- 1 (100mg Capsule, Release 24 Hour)

50mg Capsule, 100mg 1 Morgidox 1x50mg 1x50mg 1 Tablet, 20mg Tablet (Capsule) Immediate-Release) Oracea (Capsule Doxycycline Hyclate DR Hyclate 3 Delayed-Release) DR (Tablet Delayed- 1 Solodyn (Tablet

Release) Extended-Release 24 4

Doxycycline Monohydrate Doxycycline Hour)

Targadox Monohydrate (100mg Targadox (Tablet) 3

Capsule, 150mg Tetracycline HCl Tetracycline HCl Capsule, 50mg 1 (Capsule) Capsule, 75mg 1 Vibramycin Capsule, 100mg Vibramycin (100mg Capsule, 25mg/5ml Tablet, 150mg Tablet, 3 50mg Tablet, 75mg Suspension, 50mg/ Tablet) 5ml )

Minocin Minocin (Capsule) 4 Anticonvulsants Anticonvulsants, Other

You can find information on what the abbreviations in this table mean on pages 6 - 7. 56 57

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BRIVIACT (100mg Spritam (Tablet

Tablet, 10mg Tablet, Disintegrating 3 25mg Tablet, 50mg Soluble) 4 QL Tablet, 75mg Tablet, Calcium Channel Modifying Agents

Celontin 10mg/ml Oral Celontin (Capsule) 3

Solution) Ethosuximide

BRIVIACT Ethosuximide (250mg BRIVIACT (50mg/5ml 3 QL Capsule, 250mg/5ml 1 Injection) Oral Solution) Keppra Keppra (1000mg Zarontin (250mg Tablet, 500mg Tablet, 3 Capsule)

750mg Tablet, 4 Zarontin Zarontin (250mg/5ml 100mg/ml Oral 3 Oral Solution) Solution) Zonegran Keppra (250mg Zonegran (Capsule) 4 3 Zonisamide Tablet) Zonisamide (Capsule) 1 Keppra XR XR (Tablet Gamma-aminobutyric Acid (GABA)

Extended-Release 24 4 Augmenting Agents

Depacon Hour) Depacon (Injection) 3

Levetiracetam Levetiracetam Depakene (250mg 3 (1000mg Tablet Capsule) Immediate-Release, Depakene (250mg/ 4 250mg Tablet 5ml Syrup)

Immediate-Release, Diastat AcuDial Diastat AcuDial (Gel) 3 500mg Tablet 1 Diastat Pediatric Immediate-Release, Diastat Pediatric (Gel) 3 750mg Tablet Gabapentin (100mg Immediate-Release, Capsule, 300mg 100mg/ml Oral Capsule, 400mg 1 Solution, 500mg/5ml Capsule, 250mg/5ml Injection) Oral Solution, 600mg Levetiracetam ER ER Tablet, 800mg Tablet) Gabitril (Tablet Extended- 1 Gabitril (12mg Tablet, 3 QL Release 24 Hour) 16mg Tablet)

Gabitril Roweepra Gabitril (2mg Tablet, Roweepra (Tablet) 1 3 4mg Tablet)

Mysoline Mysoline (Tablet) 4

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Neurontin (100mg Felbatol (400mg Capsule, 300mg Tablet, 600mg Tablet, 4 Capsule, 400mg 3 600mg/5ml Capsule, 250mg/5ml Suspension) Oral Solution) Fycompa (0.5mg/ml Neurontin (600mg Suspension, 10mg 4 Tablet, 800mg Tablet) Tablet, 12mg Tablet,

Onfi 3 Onfi (10mg Tablet, 2mg Tablet, 4mg 4 QL 20mg Tablet) Tablet, 6mg Tablet, Onfi (2.5mg/ml 8mg Tablet) 4 Lamictal Suspension) Lamictal (Tablet) 4

Lamictal Chewable Dispersible Phenobarbital Lamictal Chewable Phenobarbital (100mg Tablet, 15mg Tablet, Dispersible (25mg 4 16.2mg Tablet, 30mg Tablet Chewable) Tablet, 32.4mg Tablet, 1 PA, HRM Lamictal Chewable Dispersible Chewable

60mg Tablet, 64.8mg Dispersible (5mg 3 Tablet, 97.2mg Tablet, Tablet Chewable) 20mg/5ml ) Lamictal ODT ODT (Tablet Primidone 3 Primidone (Tablet) 1 Dispersible) Sabril (500mg Packet, Lamictal Starter Starter (Blue 4 PA, QL, LA 3 500mg Tablet) Kit)

Lamictal Starter Tiagabine HCl Tiagabine HCl (Tablet) 1 Lamictal Starter 4 Valproate Sodium Sodium (Green Kit) 1 Lamictal Starter Starter (100mg/ml Injection) 3 Valproic Acid Acid (250mg (Orange Kit)

Capsule, 250mg/5ml 1 Syrup) Glutamate Reducing Agents Felbamate (400mg Tablet, 600mg Tablet, 1 600mg/5ml Suspension)

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Lamictal XR XR (100mg Qudexy XR XR (100mg Tablet Extended- Capsule Extended- Release 24 Hour, Release 24 Hour 200mg Tablet Sprinkle, 25mg Extended-Release 24 Capsule Extended- 3 PA Hour, 250mg Tablet Release 24 Hour Extended-Release 24 Sprinkle, 50mg 4 Hour, 25mg Tablet Capsule Extended- Extended-Release 24 Release 24 Hour Hour, 300mg Tablet Sprinkle) Extended-Release 24 Qudexy XR XR (150mg Hour, 50mg Tablet Capsule Extended- 4 PA Extended-Release 24 Release 24 Hour Hour) Sprinkle)

Lamictal XR Topamax Lamictal XR (Kit) 3 Topamax (100mg

Lamotrigine 4 Lamotrigine (100mg Tablet, 200mg Tablet) Tablet Immediate- Topamax (25mg 3 Release, 150mg Tablet Tablet, 50mg Tablet) Immediate-Release, Topamax Sprinkle Sprinkle 200mg Tablet (15mg Capsule 3 Immediate-Release, 1 Sprinkle) 25mg Tablet Topamax Sprinkle Sprinkle

Immediate-Release, (25mg Capsule 4 25mg Tablet Sprinkle) Chewable, 5mg Tablet Chewable) Lamotrigine ER ER (Tablet

Extended-Release 24 1 Hour) Lamotrigine ODT ODT 1 (Tablet Dispersible)

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Topiramate (100mg Carbamazepine Tablet Immediate- (100mg Tablet Release, 200mg Tablet Chewable, 100mg/5ml 1 Immediate-Release, Suspension, 200mg 25mg Tablet Tablet Immediate- Immediate-Release, Release)

50mg Tablet 1 Carbamazepine ER ER Immediate-Release, (100mg Capsule 15mg Capsule Extended-Release 12 Sprinkle Immediate- Hour, 200mg Capsule Release, 25mg Extended-Release 12 Capsule Sprinkle Hour, 300mg Capsule Immediate-Release) Extended-Release 12

Topiramate ER 1 Topiramate ER Hour, 100mg Tablet (Capsule Extended- Extended-Release 12 1 PA Release 24 Hour Hour, 200mg Tablet Sprinkle) Extended-Release 12 Trokendi XR XR (100mg Hour, 400mg Tablet Capsule Extended- Extended-Release 12 Release 24 Hour, Hour) 25mg Capsule Carbatrol (Capsule 3 PA, QL Extended-Release 24 Extended-Release 12 3 Hour, 50mg Capsule Hour)

Cerebyx Extended-Release 24 Cerebyx (Injection) 3

Hour) Dilantin Dilantin (Capsule) 2 Trokendi XR

Trokendi XR (200mg Dilantin INFATABS Dilantin INFATABS Capsule Extended- 4 PA, QL 2 (Tablet Chewable) Release 24 Hour) Dilantin-125 Sodium Channel Agents 3 (Suspension) Aptiom

Aptiom (Tablet) 4 QL Epitol Epitol (Tablet) 1 Banzel

Banzel (200mg Fosphenytoin Sodium Fosphenytoin Sodium Tablet, 400mg Tablet, 4 1 (Injection) 40mg/ml Suspension)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 60 61

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Oxcarbazepine Antidementia Agents (150mg Tablet, 300mg Cholinesterase Inhibitors Tablet, 600mg Tablet, 1 Aricept (Tablet) 3 QL

300mg/5ml Donepezil HCl Donepezil HCl (Tablet Suspension) 1 QL

Oxtellar XR Immediate-Release)

Oxtellar XR (Tablet Donepezil HCl ODT Donepezil HCl ODT Extended-Release 24 3 PA 1 QL (Tablet Dispersible) Hour) Exelon

Peganone Exelon (Patch 24 Peganone (Tablet) 3 3 QL Hour) Phenytek Phenytek (Capsule) 1 Galantamine HBr HBr Phenytoin (125mg/5ml (12mg Tablet, 4mg Suspension, 50mg 1 Tablet, 8mg Tablet, Tablet Chewable) 16mg Capsule Phenytoin Sodium Sodium Extended-Release 24 1 (Injection) Hour, 24mg Capsule 1 QL Phenytoin Sodium Extended Sodium Extended-Release 24 1 Extended (Capsule) Hour, 8mg Capsule Tegretol (100mg/5ml Extended-Release 24

Suspension, 200mg 3 Hour, 4mg/ml Oral Tablet) Solution)

Razadyne Tegretol-XR (Tablet Razadyne (Tablet) 3 QL

Razadyne ER Extended-Release 12 3 Razadyne ER Hour) (Capsule Extended- 3 QL Trileptal (150mg Release 24 Hour)

3 Rivastigmine Tartrate Tablet, 300mg Tablet) Rivastigmine Tartrate Trileptal (300mg/5ml (Capsule Immediate- 1 QL

Suspension, 600mg 4 Release) Tablet) Rivastigmine Transdermal System Vimpat (100mg Transdermal System 1 QL Tablet, 150mg Tablet, (Patch 24 Hour) 200mg Tablet, 50mg 3 QL N-methyl-D-aspartate (NMDA) Receptor Tablet, 10mg/ml Oral Antagonist Solution) Memantine HCl HCl (10mg Vimpat (200mg/20ml Tablet, 5mg Tablet, 1 PA, QL 3 Injection) 2mg/ml Oral Solution)

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Memantine HCl Titration Pak HCl Mirtazapine ODT ODT 1 PA 1 Titration Pak (Tablet) (Tablet Dispersible) Namenda (10mg Olanzapine/Fluoxetine 1 Tablet Immediate- (Capsule) Release, 5mg Tablet Remeron 3 PA, QL Remeron (Tablet) 3 Immediate-Release, Remeron Soltab Soltab 3 10mg/5ml Oral (Tablet Dispersible)

Solution) Symbyax

Namenda Titration Pak Symbyax (Capsule) 3 Namenda Titration 3 PA Wellbutrin SR SR (Tablet Pak (Tablet)

Namenda XR Extended-Release 12 3 Namenda XR Hour) (Capsule Extended- 2 PA, QL Wellbutrin XL Wellbutrin XL (Tablet Release 24 Hour)

Namenda XR Titration Pack Extended-Release 24 4 Namenda XR Titration Hour) Pack (Capsule 2 PA, QL Extended-Release 24 Monoamine Oxidase Inhibitors Emsam (Patch 24 Hour) 4 QL Antidepressants Hour) Marplan Antidepressants, Other Marplan (Tablet) 3

Nardil Aplenzin (Tablet Nardil (Tablet) 3

Parnate Extended-Release 24 4 Parnate (Tablet) 4 Hour) Phenelzine Sulfate Sulfate Bupropion HCl HCl (Tablet 1 1 (Tablet) Immediate-Release) Tranylcypromine Sulfate Bupropion HCl SR HCl SR 1 Sulfate (Tablet) (Tablet Extended- 1 SSRI/SNRI (Selective Serotonin Reuptake Release 12 Hour) Inhibitors/Serotonin and Norepinephrine Bupropion HCl XL HCl XL Reuptake Inhibitors) (Tablet Extended- 1 Brisdelle (Capsule) 3 HRM

Release 24 Hour) Celexa

Forfivo XL Celexa (Tablet) 3

Forfivo XL (Tablet Citalopram HBr

Extended-Release 24 3 Citalopram HBr (10mg Tablet, 20mg Tablet, Hour) 1

Mirtazapine 40mg Tablet, 10mg/ Mirtazapine (Tablet 1 5ml Oral Solution) Immediate-Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 62 63

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Desvenlafaxine ER ER Fluoxetine HCl HCl (10mg (100mg Tablet Capsule Immediate- Extended-Release 24 Release, 20mg Hour, 25mg Tablet Capsule Immediate- 1 QL Extended-Release 24 Release, 40mg 1 Hour, 50mg Tablet Capsule Immediate- Extended-Release 24 Release, 10mg Tablet, Hour) 20mg Tablet, 20mg/ Desvenlafaxine ER ER 5ml Oral Solution) (100mg Tablet Fluoxetine HCl HCl (60mg 1 Extended-Release 24 Tablet)

3 QL Fluvoxamine Maleate Hour, 50mg Tablet Fluvoxamine Maleate 1 Extended-Release 24 (Tablet) Hour) Fluvoxamine Maleate ER Maleate Effexor XR XR (Capsule ER (Capsule Extended- 1 Extended-Release 24 3 Release 24 Hour) Hour) Khedezla (Tablet

Escitalopram Oxalate Escitalopram Oxalate Extended-Release 24 3 QL (10mg Tablet, 20mg Hour) Lexapro Tablet, 5mg Tablet, 1 Lexapro (Tablet) 3

5mg/5ml Oral Maprotiline HCl Maprotiline HCl Solution) 1

Fetzima (Tablet)

Fetzima (Capsule Nefazodone HCl Nefazodone HCl Extended-Release 24 3 QL, ST 1 (Tablet) Hour) Paroxetine HCl

Fetzima Titration Pack Paroxetine HCl (Tablet Fetzima Titration 1 PA, HRM Immediate-Release) Pack (Capsule 3 ST Paxil Extended-Release 24 Paxil (10mg Tablet, Hour Therapy Pack) 20mg Tablet, 30mg

Fluoxetine DR Tablet, 40mg Tablet, 3 PA, HRM Fluoxetine DR 10mg/5ml (Capsule Delayed- 1 Suspension) Release) Pristiq (Tablet Extended-Release 24 3 QL Hour)

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Prozac (10mg Zoloft (100mg Tablet,

Capsule, 20mg 3 25mg Tablet, 50mg 3 Capsule) Tablet, 20mg/ml Prozac (40mg Concentrate) 4 Capsule) Tricyclics

Amitriptyline HCl Sarafem Sarafem (Tablet) 3 Amitriptyline HCl 1 PA, HRM Sertraline HCl HCl (100mg (Tablet) Tablet, 25mg Tablet, Amoxapine (Tablet) 1 PA, HRM 1 50mg Tablet, 20mg/ml Anafranil (Capsule) 4 PA, HRM Concentrate) Clomipramine HCl HCl Trazodone HCl 1 PA, HRM Trazodone HCl (Tablet) 1 (Capsule)

Trintellix Trintellix (Tablet) 3 QL Desipramine HCl HCl

Venlafaxine HCl 1 PA, HRM Venlafaxine HCl (Tablet)

Doxepin HCl (Tablet Immediate- 1 Doxepin HCl (100mg Release) Capsule, 10mg Venlafaxine HCl ER HCl ER Capsule, 150mg Capsule, 25mg (150mg Capsule 1 PA, HRM Extended-Release 24 Capsule, 50mg Hour, 37.5mg Capsule Capsule, 75mg Extended-Release 24 Capsule, 10mg/ml Hour, 75mg Capsule Concentrate) Extended-Release 24 Elavil (Tablet) 4 PA, HRM Hour, 150mg Tablet Imipramine HCl HCl 1 1 PA, HRM Extended-Release 24 (Tablet)

Hour, 225mg Tablet Imipramine Pamoate Imipramine Pamoate Extended-Release 24 1 PA, HRM (Capsule)

Hour, 37.5mg Tablet Norpramin Extended-Release 24 Norpramin (Tablet) 3 PA, HRM

Nortriptyline HCl Hour, 75mg Tablet Nortriptyline HCl Extended-Release 24 (10mg Capsule, 25mg Capsule, 50mg Hour) 1 PA, HRM Viibryd (Tablet) 3 QL Capsule, 75mg

Viibryd Starter Pack Capsule, 10mg/5ml Viibryd Starter Pack 3 QL Oral Solution)

(Kit) Pamelor Pamelor (Capsule) 4 PA, HRM

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Protriptyline HCl HCl Trimethobenzamide HCl 1 PA, HRM 1 B/D, PA (Tablet) HCl (Capsule) Surmontil (Capsule) 3 PA, HRM Vistaril (Capsule) 3 PA, HRM Tofranil (Tablet) 4 PA, HRM Emetogenic Therapy Adjuncts

Aloxi Trimipramine Maleate Trimipramine Maleate Aloxi (Injection) 4

1 PA, HRM Anzemet (Capsule) Anzemet (100mg 4 B/D, PA Antiemetics Tablet) Antiemetics, Other Anzemet (50mg 3 B/D, PA Compro Compro () 1 Tablet)

Aprepitant Hydroxyzine Pamoate Pamoate Aprepitant (Therapy 1 PA, HRM 1 PA (Capsule) Pack, Capsule)

Cesamet Meclizine HCl HCl (12.5mg Cesamet (Capsule) 4 PA

1 PA, HRM Dronabinol Tablet) Dronabinol (Capsule) 1 PA, QL

Metoclopramide HCl Metoclopramide HCl Emend (125mg (10mg Tablet, 5mg Capsule, 40mg Tablet, 5mg/5ml Oral 1 Capsule, 80mg 3 PA Solution, 5mg/ml Capsule, 125mg Injection) Suspension)

Metoclopramide ODT Metoclopramide ODT Emend (150mg 1 3 (Tablet Dispersible) Injection)

Perphenazine Emend Perphenazine (Tablet) 1 Emend (Pack, 125mg Prochlorperazine Capsule, 40mg 1 3 PA (Suppository) Capsule, 80mg Prochlorperazine Edisylate Capsule) 1 Granisetron HCl Edisylate (Injection) Granisetron HCl Prochlorperazine Maleate (0.1mg/ml Injection, 1 1 Maleate (Tablet) 1mg/ml Injection,

Reglan 4mg/4ml Injection) Reglan (Tablet) 3 Granisetron HCl

Tigan Granisetron HCl (1mg Tigan (100mg/ml 1 B/D, PA, QL 3 Tablet)

Injection) Marinol

Tigan Marinol (10mg Tigan (300mg 3 B/D, PA Capsule, 5mg 4 PA, QL Capsule) Capsule) Transderm-Scop

Transderm-Scop Marinol 3 PA, HRM Marinol (2.5mg (Patch 72 Hour) 3 PA, QL Capsule)

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Ondansetron HCl HCl Ciclopirox Olamine Olamine 1 (24mg Tablet, 4mg (Cream) Tablet, 8mg Tablet, 1 B/D, PA Clotrimazole (1% 4mg/5ml Oral Cream, 1% External 1 Solution) Solution, 10mg Ondansetron HCl HCl Lozenge)

1 Cresemba (4mg/2ml Injection) Cresemba (186mg Ondansetron ODT ODT Capsule, 372mg 4 PA 1 B/D, PA (Tablet Dispersible) Injection)

Diflucan Sancuso Sancuso (Patch) 4 Diflucan (100mg

Varubi Tablet, 150mg Tablet, Varubi (Tablet) 3 B/D, PA

Zofran 50mg Tablet, 10mg/ 3 Zofran (4mg Tablet) 3 B/D, PA ml Suspension, Zofran (4mg/5ml Oral 4 B/D, PA 40mg/ml Suspension) Solution, 8mg Tablet) Diflucan (200mg Zofran ODT ODT (Tablet 4 4 B/D, PA Tablet) Dispersible) Econazole Nitrate Nitrate Zuplenz 1 Zuplenz (4mg Film) 3 B/D, PA (Cream)

Zuplenz Eraxis Zuplenz (8mg Film) 4 B/D, PA Eraxis (Injection) 4

Ertaczo Antifungals Ertaczo (Cream) 4 Antifungals Exelderm (1% Cream, Abelcet 3 Abelcet (Injection) 4 B/D, PA 1% External Solution)

AmBisome Extina AmBisome (Injection) 4 B/D, PA Extina (Foam) 3 Amphotericin B B Fluconazole (100mg 1 B/D, PA (Injection) Tablet, 150mg Tablet, Ancobon 200mg Tablet, 50mg Ancobon (Capsule) 4 1 AVC Tablet, 10mg/ml AVC (Cream) 3 Suspension, 40mg/ml Cancidas Cancidas (Injection) 4 Suspension)

Ciclopirox Ciclopirox (0.77% Gel, Fluconazole in NaCl in NaCl 1 0.77% Suspension, 1% 1 (Injection)

Shampoo) Flucytosine Flucytosine (Capsule) 1 Ciclopirox Nail Lacquer

Ciclopirox Nail GRIS-PEG GRIS-PEG (Tablet) 3 Lacquer (External 1 Solution)

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Griseofulvin Microsize Microsize Noxafil (100mg Tablet 4 PA, QL (125mg/5ml Delayed-Release)

1 Noxafil Suspension, 500mg Noxafil (40mg/ml 4 QL Tablet) Suspension)

Griseofulvin Ultramicrosize Griseofulvin Nyamyc 1 Nyamyc (Powder) 1 Ultramicrosize (Tablet) Nyata Nyata (Powder) 1 Gynazole-1 Gynazole-1 (Cream) 3 Nystatin Nystatin (Cream, Itraconazole Itraconazole (Capsule) 1 PA, QL Ointment, Powder, 1 Jublia (External Suspension, Tablet)

3 Nystatin/Triamcinolone Solution) Nystatin/

Kerydin Kerydin (External Triamcinolone (0.1% 1 4 ST Solution) Cream, 0.1% Ointment)

Ketoconazole Nystop Ketoconazole (2% Nystop (Powder) 1

Cream, 2% Foam, 2% ONMEL 1 ONMEL (Tablet) 4 PA

Shampoo, 200mg Oravig Oravig (Tablet) 3 Tablet) Oxiconazole Nitrate

Lamisil Lamisil (250mg Oxiconazole Nitrate 4 1 Tablet) (Cream) Oxistat

Loprox Oxistat (1% Cream, Loprox (Cream) 3 3 1% Lotion) Loprox Shampoo Loprox Shampoo 4 Sporanox Sporanox (100mg Luzu 4 PA, QL Luzu (Cream) 3 Capsule)

Mentax Sporanox Mentax (Cream) 3 Sporanox (10mg/ml

Miconazole 3 4 PA Miconazole 3 Oral Solution)

1 Terazol 7 (Suppository) Terazol 7 (Cream) 3

Mycamine Terbinafine HCl Mycamine (Injection) 4 Terbinafine HCl

Naftifine HCl 1 Naftifine HCl (1% (Tablet)

1 Terconazole Cream) Terconazole (0.4%

Naftifine HCl Naftifine HCl (2% Cream, 0.8% Cream, 1 1 Cream) 80mg Suppository)

Vfend Naftin (1% Gel, 2% Vfend (200mg Tablet, 3 Gel, 2% Cream) 50mg Tablet, 40mg/ 4

Natacyn Natacyn (Suspension) 3 ml Suspension) Vfend IV

Nizoral Nizoral (Shampoo) 3 Vfend IV (Injection) 4

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Voriconazole Migergot Voriconazole (200mg Migergot (Suppository) 4 Injection, 200mg Migranal (Nasal 1 4 Tablet, 50mg Tablet, Solution) 40mg/ml Suspension) Serotonin (5-HT) 1b/1d Receptor Agonists Zazole Zazole (Cream) 1 Almotriptan Malate Malate 1 QL Antigout Agents (Tablet) Antigout Agents Amerge (Tablet) 3 QL

Allopurinol Allopurinol (Tablet) 1 Axert (12.5mg Tablet) 3 QL

Allopurinol Sodium Allopurinol Sodium Axert 1 Axert (6.25mg Tablet) 4 QL

(Injection) Frova

Aloprim Frova (Tablet) 3 QL

Aloprim (Injection) 3 Frovatriptan Succinate

Colchicine Frovatriptan Succinate 1 QL Colchicine (0.6mg (Tablet)

Capsule, 0.6mg 2 QL Imitrex Imitrex (100mg Tablet) Tablet, 25mg Tablet, Colcrys Colcrys (Tablet) 3 PA, QL 50mg Tablet, 20mg/ Mitigare 3 QL Mitigare (Capsule) 3 QL act Nasal Solution,

Probenecid Probenecid (Tablet) 1 5mg/act Nasal Probenecid/Colchicine Solution) 1 Imitrex (6mg/0.5ml (Tablet) 4 QL Uloric Injection) Uloric (Tablet) 2 ST Imitrex Statdose Refill

Zurampic Imitrex Statdose Refill Zurampic (Tablet) 3 PA 3 QL (4mg/0.5ml Injection) Zyloprim Zyloprim (Tablet) 3 Imitrex Statdose Refill Statdose Refill 4 QL Antimigraine Agents (6mg/0.5ml Injection) Ergot Alkaloids Maxalt (Tablet) 3 QL

Cafergot Cafergot (Tablet) 3 Maxalt-MLT (Tablet

Dihydroergotamine Mesylate 3 QL Dihydroergotamine Dispersible)

Mesylate (1mg/ml 1 Naratriptan HCl HCl 1 QL Injection) (Tablet)

Dihydroergotamine Mesylate Dihydroergotamine Onzetra Xsail Xsail (Exhaler 3 QL Mesylate (4mg/ml 1 Powder) Nasal Solution) Relpax (Tablet) 3 QL, ST Ergotamine Tartrate/Caffeine Tartrate/ 1 Caffeine (Tablet)

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Rizatriptan Benzoate Benzoate Mestinon (60mg

(Tablet Immediate- 1 QL Tablet, 60mg/5ml 4 Release) Syrup) Rizatriptan Benzoate ODT Benzoate Mestinon Timespan Timespan

ODT (Tablet 1 QL (Tablet Extended- 4 Dispersible) Release) Sumatriptan (Nasal Pyridostigmine Bromide 1 QL 1 Solution) Bromide (Tablet) Sumatriptan Succinate Succinate Pyridostigmine Bromide ER

(100mg Tablet, 25mg Bromide ER (Tablet 1 Tablet, 50mg Tablet, 1 QL Extended-Release) 4mg/0.5ml Injection, Antimycobacterials 6mg/0.5ml Injection) Antimycobacterials, Other

Sumatriptan Succinate Refill

Dapsone Sumatriptan Dapsone (Tablet) 1

Succinate Refill 1 QL Mycobutin (Injection) Mycobutin (Capsule) 3 Rifabutin Sumavel DosePro DosePro Rifabutin (Capsule) 1 4 QL (Injection) Antituberculars

Capastat Sulfate Treximet Capastat Sulfate Treximet (Tablet) 4 QL 3 Zembrace Symtouch Symtouch (Injection) 4 QL Ethambutol HCl HCl (Injection) 1 Zolmitriptan (Tablet) 1 QL (Tablet) Isoniazid

Zolmitriptan ODT Isoniazid (100mg Zolmitriptan ODT 1 QL Tablet, 300mg Tablet, (Tablet Dispersible) 1

Zomig Nasal Spray 100mg/ml Injection, Zomig Nasal Spray 50mg/5ml Syrup)

(2.5mg Solution, 5mg 3 QL Myambutol Solution) Myambutol (Tablet) 3 Paser Zomig (2.5mg Tablet, Paser (Packet) 3 4 QL Priftin 5mg Tablet) Priftin (Tablet) 3

Zomig ZMT Pyrazinamide Zomig ZMT (Tablet Pyrazinamide (Tablet) 1 4 QL Dispersible) Rifadin (150mg 3 Antimyasthenic Agents Capsule)

Rifamate Parasympathomimetics Rifamate (Capsule) 3 Guanidine HCl HCl 2 (Tablet)

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Rifampin Casodex Rifampin (150mg Casodex (Tablet) 3

Capsule, 300mg Flutamide 1 Flutamide (Capsule) 1

Capsule, 600mg Nilandron Nilandron (Tablet) 4 Injection) Nilutamide

Rifater Rifater (Tablet) 3 Nilutamide (Tablet) 1

Xtandi Sirturo (Tablet) 4 PA Xtandi (Capsule) 4 PA, QL

Zytiga

Trecator Trecator (Tablet) 3 Zytiga (Tablet) 4 PA, QL Antineoplastics Antiangiogenic Agents

Pomalyst Alkylating Agents Pomalyst (Capsule) 4 PA, QL

Revlimid

Alkeran Alkeran (Injection) 3 Revlimid (Capsule) 4 PA, QL, LA

Thalomid

BiCNU BiCNU (Injection) 4 Thalomid (Capsule) 4 PA, QL

Busulfan Busulfan (Injection) 1 Antiestrogens/Modifiers Emcyt

Busulfex Busulfex (Injection) 4 Emcyt (Capsule) 4 Fareston Cyclophosphamide Fareston (Tablet) 4 3 B/D, PA Faslodex (Capsule) Faslodex (Injection) 4

Soltamox Dacarbazine Dacarbazine (Injection) 1 Soltamox (Oral 3 Gleostine Gleostine (Capsule) 3 Solution)

Tamoxifen Citrate

Hexalen Tamoxifen Citrate Hexalen (Capsule) 4 PA 1 (Tablet) Ifex Ifex (Injection) 3 Antimetabolites Ifosfamide Ifosfamide (Injection) 1 Adrucil (Injection) 1 B/D, PA Leukeran Leukeran (Tablet) Alimta 3 Alimta (Injection) 4 PA

Matulane

Matulane (Capsule) Cladribine 4 LA Cladribine (Injection) 1 B/D, PA Melphalan HCl

Melphalan HCl Clofarabine 1 Clofarabine (Injection) 1 (Injection) Clolar

Mustargen Clolar (Injection) 4 Mustargen (Injection) 4 Cytarabine Aqueous

Treanda Cytarabine Aqueous Treanda (Injection) 4 PA 1 B/D, PA (Injection) Valchlor

Valchlor (Gel) Droxia 4 PA, LA Droxia (Capsule) 3

Yondelis Yondelis (Injection) 4 PA Fluorouracil (2.5gm/ Zanosar 1 B/D, PA Zanosar (Injection) 3 50ml Injection)

Folotyn Antiandrogens Folotyn (Injection) 4

Bicalutamide Bicalutamide (Tablet) 1

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Gemcitabine HCl HCl Doxorubicin HCl HCl 1 1 B/D, PA (Injection) (Injection)

Doxorubicin HCl Liposome Gemzar Gemzar (Injection) 4 Doxorubicin HCl 1 Hydrea Hydrea (Capsule) 3 Liposome (Injection) Ellence

Hydroxyurea Hydroxyurea (Capsule) 1 Ellence (Injection) 4

Epirubicin HCl Mercaptopurine Epirubicin HCl 1 1 (Tablet) (Injection) Erwinaze

Nipent Nipent (Injection) 4 Erwinaze (Injection) 4

Fludarabine Phosphate

Purixan Fludarabine Phosphate Purixan (Suspension) 4 PA 1

Tabloid (Injection)

Tabloid (Tablet) 4 PA Fusilev Fusilev (Injection) 4

Antineoplastics, Other Halaven

Abraxane Halaven (Injection) 4 PA

Abraxane (Injection) 4 PA Idamycin PFS Idamycin PFS Adriamycin 4 Adriamycin (Injection) 1 B/D, PA (Injection)

Arranon Arranon (Injection) 4 Idarubicin HCl HCl Bleomycin Sulfate 1 Bleomycin Sulfate (Injection) 1 B/D, PA Irinotecan (Injection) Irinotecan (Injection) 1

Camptosar Camptosar (Injection) 3 Istodax (Injection) 4 PA

Carboplatin Carboplatin (Injection) 1 Kisqali (Tablet) 4 PA, QL

Cisplatin Cisplatin (Injection) 1 Kisqali Femara 200 Dose Femara 200

Cosmegen Cosmegen (Injection) 4 Dose (Tablet Therapy 4 PA, QL

Dacogen Dacogen (Injection) 4 Pack)

Kisqali Femara 400 Dose Daunorubicin HCl HCl Kisqali Femara 400 1 (Injection) Dose (Tablet Therapy 4 PA, QL

Decitabine Pack)

Decitabine (Injection) 1 Kisqali Femara 600 Dose

Dexrazoxane Kisqali Femara 600 Dexrazoxane 1 PA Dose (Tablet Therapy 4 PA, QL (Injection) Pack) Docetaxel

Docetaxel (80mg/4ml Leucovorin Calcium 1 Leucovorin Calcium Injection) (100mg Injection, Docetaxel Docetaxel (80mg/8ml 350mg Injection, 10mg 1 1 Injection) Tablet, 15mg Tablet,

Doxil Doxil (Injection) 4 25mg Tablet, 5mg Tablet)

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Levoleucovorin Calcium Femara Levoleucovorin Femara (Tablet) 4 1 Letrozole Calcium (Injection) Letrozole (Tablet) 1

Lonsurf Lonsurf (Tablet) 4 PA, QL Enzyme Inhibitors

Mitomycin Etopophos Mitomycin (Injection) 1 Etopophos (Injection) 3

Mitoxantrone HCl Mitoxantrone HCl Etoposide 1 Etoposide (Injection) 1

(Injection) Hycamtin

Ninlaro Hycamtin (Injection) 4

Ninlaro (Capsule) 4 PA, QL Kyprolis

Oxaliplatin Kyprolis (Injection) 4 PA Oxaliplatin (IV Solution 1 Rubraca 100mg/20ml) Rubraca (Tablet) 4 PA, QL

Toposar Paclitaxel Paclitaxel (Injection) 1 Toposar (Injection) 1

Topotecan HCl Proleukin Topotecan HCl Proleukin (Injection) 4 PA 1

Synribo (Injection)

Synribo (Injection) 4 PA Zejula

Taxotere Zejula (Capsule) 4 PA, QL Taxotere (Injection) 4 Molecular Target Inhibitors Thiotepa

Thiotepa (Injection) 1 Afinitor Afinitor (Tablet) 4 PA Trisenox

Trisenox (Injection) 3 Afinitor Disperz Afinitor Disperz Velcade 4 PA Velcade (Injection) 4 PA (Tablet Soluble)

Vinblastine Sulfate Vinblastine Sulfate Alecensa 1 B/D, PA Alecensa (Capsule) 4 PA, QL (Injection) Alunbrig Alunbrig (Tablet) 4 PA, QL Vincasar PFS

Vincasar PFS Beleodaq 1 B/D, PA Beleodaq (Injection) 4 PA (Injection)

Bosulif Vincristine Sulfate Sulfate Bosulif (Tablet) 4 PA, QL 1 B/D, PA Cabometyx (Injection) Cabometyx (Tablet) 4 PA, QL Vinorelbine Tartrate Tartrate Caprelsa (Tablet) 4 PA, LA 1 (Injection) Cometriq (Kit) 4 PA

Zaltrap Zaltrap (Injection) 4 PA Cotellic (Tablet) 4 PA, QL, LA

Zinecard Zinecard (Injection) 4 PA Cyramza (Injection) 4 PA

Zolinza Zolinza (Capsule) 4 PA Erivedge (Capsule) 4 PA, QL Aromatase Inhibitors, 3rd Generation Farydak (Capsule) 4 PA Anastrozole Anastrozole (Tablet) 1 Gilotrif Gilotrif (Tablet) 4 PA Arimidex Arimidex (Tablet) 3 Gleevec Gleevec (Tablet) 4 PA, QL Aromasin Aromasin (Tablet) 4 Ibrance Ibrance (Capsule) 4 PA, QL Exemestane Exemestane (Tablet) 1 Iclusig Iclusig (45mg Tablet) 4 PA, QL, LA

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Imatinib Mesylate Imatinib Mesylate Zelboraf (Tablet) 4 PA, QL 1 PA, QL (Tablet) Zydelig (Tablet) 4 PA, QL

Imbruvica Imbruvica (Capsule) 4 PA, QL Zykadia (Capsule) 4 PA, QL

Inlyta Inlyta (Tablet) 4 PA, QL Monoclonal Antibody/Antibody-Drug Iressa (Tablet) 4 PA, QL Conjugate Jakafi (Tablet) 4 PA, QL, LA Avastin (Injection) 4 PA Jevtana (Injection) 4 PA Bavencio (Injection) 4 PA

Lenvima Lenvima (Capsule Darzalex (Injection) 4 PA, LA 4 PA Therapy Pack) Empliciti (Injection) 4 PA

Lynparza Lynparza (Capsule) 4 PA, QL Erbitux (Injection) 4 PA

Mekinist Mekinist (Tablet) 4 PA Herceptin (Injection) 4 PA

Nexavar Nexavar (Tablet) 4 PA Imfinzi (Injection) 4 PA

Odomzo Odomzo (Capsule) 4 PA, QL, LA Kadcyla (Injection) 4 PA

Rydapt Rydapt (Capsule) 4 PA, QL Keytruda (Injection) 4 PA

Sprycel Sprycel (Tablet) 4 PA, QL Lartruvo (Injection) 4 PA

Stivarga Stivarga (Tablet) 4 PA, QL Opdivo (Injection) 4 PA

Sutent Sutent (Capsule) 4 PA, QL Perjeta (Injection) 4 PA

Tafinlar Tafinlar (Capsule) 4 PA Rituxan (Injection) 4 PA

Tagrisso Tagrisso (Tablet) 4 PA, QL, LA Tecentriq (Injection) 4 PA

Tarceva Tarceva (Tablet) 4 PA, QL Vectibix (Injection) 4 PA

Tasigna Tasigna (Capsule) 4 PA, QL Yervoy (Injection) 4 PA

Tykerb Tykerb (Tablet) 4 PA Retinoids

Venclexta Venclexta (100mg Bexarotene 4 PA, QL Bexarotene (Capsule) 1 PA

Tablet, 50mg Tablet) Panretin

Venclexta Panretin (Gel) 4

Venclexta (10mg Targretin 2 PA, QL Targretin (1% Gel, Tablet) 4 PA

Venclexta Starting Pack 75mg Capsule)

Venclexta Starting Tretinoin Tretinoin (10mg Pack (Tablet Therapy 4 PA 1 Pack) Capsule)

Votrient Treatment Adjuncts Votrient (Tablet) 4 PA, QL Elitek

Xalkori Elitek (Injection) 4 Xalkori (Capsule) 4 PA, LA Mesna Mesna (Injection) 1

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Mesnex (100mg/ml Nebupent (Inhalation 3 3 B/D, PA, QL Injection) Solution) Mesnex (400mg Pentam 300 300 4 3 Tablet) (Injection)

Plaquenil Antiparasitics Plaquenil (Tablet) 3 Anthelmintics Primaquine Phosphate Phosphate

Albenza 1 Albenza (Tablet) 4 QL (Tablet)

Qualaquin Biltricide Biltricide (Tablet) 3 Qualaquin (Capsule) 3 PA

Quinine Sulfate Emverm (Tablet Quinine Sulfate 4 1 PA Chewable) (Capsule)

Ivermectin Ivermectin (Tablet) 1 Pediculicides/Scabicides

Elimite Sklice Sklice (Lotion) 3 Elimite (Cream) 3

Eurax Stromectol Eurax (10% Cream, Stromectol (Tablet) 3 3 10% Lotion) Antiprotozoals Lindane Alinia Lindane (Shampoo) 1 Alinia (100mg/5ml Malathion Suspension, 500mg 4 Malathion (Lotion) 1

Ovide Tablet) Ovide (Lotion) 3

Atovaquone Atovaquone Permethrin 1 Permethrin (Cream) 1 (Suspension) Antiparkinson Agents Atovaquone/Proguanil HCl Anticholinergics

HCl (Tablet) (Generic 1 Benztropine Mesylate Benztropine Mesylate Malarone)

Chloroquine Phosphate (0.5mg Tablet, 1mg 1 PA, HRM Chloroquine 1 Tablet, 2mg Tablet)

Phosphate (Tablet) Benztropine Mesylate Benztropine Mesylate Coartem 1 Coartem (Tablet) 3 (1mg/ml Injection)

DARAPRIM Cogentin DARAPRIM (Tablet) 4 Cogentin (Injection) 3

Hydroxychloroquine Sulfate Hydroxychloroquine Trihexyphenidyl HCl 1 Trihexyphenidyl HCl Sulfate (Tablet) (0.4mg/ml Elixir, 2mg 1 PA, HRM

Malarone Malarone (Tablet) 3 Tablet, 5mg Tablet) Mefloquine HCl HCl Antiparkinson Agents, Other 1 (Tablet)

Mepron Mepron (Suspension) 4

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Amantadine HCl HCl Ropinirole ER ER (Tablet

(100mg Capsule, Extended-Release 24 1 1 100mg Tablet, 50mg/ Hour) 5ml Syrup) Ropinirole HCl HCl (Tablet

Comtan 1 Comtan (Tablet) 3 Immediate-Release)

Entacapone Entacapone (Tablet) 1 Dopamine Precursors/L-Amino Acid Tasmar (Tablet) 4 QL Decarboxylase Inhibitors Carbidopa

Tolcapone Carbidopa (Tablet) 1 Tolcapone (Tablet) 1 QL Carbidopa/Levodopa Dopamine Agonists

Apokyn (Tablet Immediate- 1 Apokyn (Injection) 4 PA, QL Release)

Bromocriptine Mesylate Bromocriptine Carbidopa/Levodopa ER

Mesylate (2.5mg 1 ER (Tablet Extended- 1 Tablet, 5mg Capsule) Release)

Mirapex Mirapex (Tablet) 3 Carbidopa/Levodopa ODT

Mirapex ER Mirapex ER (Tablet ODT (Tablet 1 Extended-Release 24 3 Dispersible) Hour) Carbidopa/Levodopa/Carbidopa/Levodopa/Entacapone Neupro 1 Neupro (Patch 24 Entacapone (Tablet) 3 Hour) Duopa (Suspension) 4 PA

Parlodel Parlodel (2.5mg Lodosyn 3 Lodosyn (Tablet) 4

Tablet, 5mg Capsule) Rytary

Pramipexole Dihydrochloride Rytary (Capsule 3 ST Pramipexole Extended-Release)

Dihydrochloride Sinemet 1 Sinemet (Tablet) (Tablet Immediate- 3 Sinemet CR CR (Tablet Release) 3 Pramipexole Dihydrochloride ER Extended-Release) Stalevo 100 Dihydrochloride ER Stalevo 100 (Tablet) 4

1 Stalevo 125 (Tablet Extended- Stalevo 125 (Tablet) 3

Stalevo 150 Release 24 Hour) Stalevo 150 (Tablet) 4 Requip

Stalevo 200 Requip (Tablet) 3 Stalevo 200 (Tablet) 4

Requip XL

Requip XL (Tablet Stalevo 50 Stalevo 50 (Tablet) 3 Extended-Release 24 3 Stalevo 75 Hour) Stalevo 75 (Tablet) 3 Monoamine Oxidase B (MAO-B) Inhibitors

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Haloperidol Azilect Azilect (Tablet) 2 Haloperidol (0.5mg

Eldepryl Eldepryl (Capsule) 3 Tablet, 10mg Tablet,

Rasagiline Mesylate 1mg Tablet, 20mg Rasagiline Mesylate 1 1 Tablet, 2mg Tablet, (Tablet) 5mg Tablet, 2mg/ml Selegiline HCl HCl (5mg 1 Concentrate)

Capsule, 5mg Tablet) Haloperidol Decanoate Haloperidol Decanoate Zelapar (Tablet 1 4 (Injection)

Dispersible) Haloperidol Lactate Haloperidol Lactate 1 (Injection) 1st Generation/Typical Loxapine Succinate Succinate

Chlorpromazine HCl Chlorpromazine HCl (10mg Capsule, 5mg 1 QL (100mg Tablet, 10mg Capsule) Tablet, 200mg Tablet, Loxapine Succinate Succinate 1 25mg Tablet, 50mg (25mg Capsule, 50mg 1 Tablet, 50mg/2ml Capsule)

Injection) Orap

Fluphenazine Decanoate Orap (Tablet) 3

Fluphenazine Pimozide 1 Decanoate (Injection) Pimozide (Tablet) 1

Thioridazine HCl Fluphenazine HCl Thioridazine HCl Fluphenazine HCl 1 PA (10mg Tablet, 1mg (Tablet) Thiothixene Tablet, 2.5mg Tablet, Thiothixene (Capsule) 1

Trifluoperazine HCl 5mg Tablet, 2.5mg/ 1 Trifluoperazine HCl 1 5ml Elixir, 2.5mg/ml (Tablet) Injection, 5mg/ml 2nd Generation/Atypical

Concentrate) Abilify Abilify (Tablet) 4 QL Haldol Haldol (Injection) 3 Abilify Maintena Abilify Maintena Haldol Decanoate 100 Decanoate 100 4 3 (Injection) (Injection) Aripiprazole Aripiprazole (Tablet) 1 QL Haldol Decanoate 50

Haldol Decanoate 50 Aripiprazole ODT 3 Aripiprazole ODT (Injection) 1 QL (Tablet Dispersible)

Aristada Aristada (Injection) 4 Fanapt (10mg Tablet, 12mg Tablet, 6mg 4 QL, ST Tablet, 8mg Tablet)

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Fanapt (1mg Tablet, Olanzapine (10mg 2mg Tablet, 4mg 3 QL, ST Tablet Immediate- Tablet) Release, 15mg Tablet Fanapt Titration Pack Titration Pack Immediate-Release, 3 ST (Tablet) 2.5mg Tablet Geodon (20mg Immediate-Release, 1 QL Capsule, 40mg 20mg Tablet Capsule, 60mg 4 QL Immediate-Release, Capsule, 80mg 5mg Tablet Immediate- Capsule) Release, 7.5mg Tablet

Geodon Immediate-Release) Geodon (20mg 3 Olanzapine ODT ODT Injection) 1 QL Invega (Tablet Dispersible) Invega (Tablet Paliperidone ER Extended-Release 24 4 PA, QL Paliperidone ER Hour) (Tablet Extended- 1 QL

Invega Sustenna Release 24 Hour) Invega Sustenna Quetiapine Fumarate (117mg/0.75ml Quetiapine Fumarate Injection, 156mg/ml (Tablet Immediate- 1 QL

Injection, 234mg/ 4 Release) 1.5ml Injection, Quetiapine Fumarate ER Fumarate 78mg/0.5ml ER (Tablet Extended- 1 QL Injection) Release 24 Hour)

Rexulti Invega Sustenna Sustenna Rexulti (Tablet) 4 QL

Risperdal (39mg/0.25ml 3 Risperdal (0.25mg Injection) Tablet, 0.5mg Tablet,

Invega Trinza 3 Invega Trinza 1mg Tablet, 1mg/ml 4 PA (Injection) Oral Solution)

Risperdal Latuda Risperdal (2mg Latuda (Tablet) 4 QL Nuplazid (Tablet) 4 PA, QL Tablet, 3mg Tablet, 4

Olanzapine 4mg Tablet)

Olanzapine (10mg Risperdal Consta 1 Risperdal Consta Injection) 3 (12.5mg Injection) Risperdal Consta Consta (25mg Injection, 4 37.5mg Injection, 50mg Injection)

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Risperdal M-Tab M-Tab Vraylar (1.5mg (0.5mg Tablet Capsule, 3mg 3 Dispersible, 1mg Capsule, 4.5mg 4 QL, ST Tablet Dispersible) Capsule, 6mg Risperdal M-Tab M-Tab (2mg Capsule) Tablet Dispersible, Vraylar (Capsule 3 ST 3mg Tablet 4 Therapy Pack) Dispersible, 4mg Ziprasidone HCl HCl 1 QL Tablet Dispersible) (Capsule)

Risperidone Risperidone (0.25mg Zyprexa (10mg 3 Tablet Immediate- Injection) Release, 0.5mg Tablet Zyprexa (10mg Immediate-Release, Tablet, 2.5mg Tablet, 1mg Tablet Immediate- 3 QL 5mg Tablet, 7.5mg Release, 2mg Tablet 1 Tablet)

Immediate-Release, Zyprexa Zyprexa (15mg 3mg Tablet Immediate- 4 QL Tablet, 20mg Tablet)

Release, 4mg Tablet Zyprexa Relprevv Zyprexa Relprevv Immediate-Release, 4 (Injection) 1mg/ml Oral Solution) Zyprexa Zydis

Risperidone ODT Zyprexa Zydis (10mg Risperidone ODT 1 Tablet Dispersible, (Tablet Dispersible) 3 QL

Saphris 5mg Tablet Saphris (Tablet 3 QL Dispersible)

Sublingual) Zyprexa Zydis

Seroquel Zyprexa Zydis (15mg Seroquel (100mg Tablet Dispersible, Tablet, 200mg Tablet, 4 QL 3 QL 20mg Tablet 25mg Tablet, 50mg Dispersible) Tablet)

Seroquel Treatment-Resistant

Seroquel (300mg Clozapine 4 QL Clozapine (Tablet Tablet, 400mg Tablet) 1

Seroquel XR Immediate-Release)

Seroquel XR (Tablet Clozapine ODT Extended-Release 24 3 QL Clozapine ODT (100mg Tablet Hour) 1 QL Dispersible, 25mg Tablet Dispersible)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 78 79

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Clozapine ODT ODT Adefovir Dipivoxil Dipivoxil 1 (12.5mg Tablet (Tablet) Dispersible, 150mg Baraclude 1 QL Baraclude (0.05mg/ Tablet Dispersible, ml Oral Solution, 4 200mg Tablet 0.5mg Tablet, 1mg Dispersible) Tablet)

Clozaril Clozaril (100mg Entecavir 4 Entecavir (Tablet) 1 Tablet) Epivir HBV HBV (100mg Clozaril 3 Clozaril (25mg Tablet) 3 Tablet)

Fazaclo Fazaclo (100mg Epivir HBV HBV (5mg/ml 2 Tablet Dispersible, Oral Solution)

Hepsera 150mg Tablet 4 QL Hepsera (Tablet) 4

Dispersible, 200mg Lamivudine Lamivudine (100mg Tablet Dispersible) 1

Fazaclo Tablet)

Fazaclo (12.5mg Vemlidy Tablet Dispersible, Vemlidy (Tablet) 4 QL 3 QL 25mg Tablet Anti-hepatitis C (HCV) Agents, Other

Copegus Dispersible) Copegus (Tablet) 4

Versacloz Versacloz Intron A A (Injection) 4 4 PA (Suspension) Moderiba (200mg 1 Antivirals Tablet) Anti-cytomegalovirus (CMV) Agents Moderiba 1200 Dose Pack 1200 Dose

Cidofovir 1 Cidofovir (Injection) 1 Pack (Tablet)

Moderiba 800 Dose Pack Cytovene Moderiba 800 Dose Cytovene (Injection) 3 B/D, PA 1 Ganciclovir (Injection) 1 B/D, PA Pack (Tablet) Pegasys Valcyte (450mg Pegasys (Injection) 4 PA Pegasys ProClick ProClick Tablet, 50mg/ml Oral 4 QL 4 PA Solution) (Injection)

Rebetol Valganciclovir Rebetol (Oral Valganciclovir (Tablet) 1 QL 3 Valganciclovir Hydrochlorde Solution) Valganciclovir Ribasphere Hydrochlorde (Oral 1 QL Ribasphere (200mg Capsule, 200mg Solution) 1

Zirgan Tablet, 400mg Tablet, Zirgan (Gel) 3 600mg Tablet) Anti-hepatitis B (HBV) Agents

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Ribasphere Ribapak Ribapak Valacyclovir HCl HCl 1 1 QL (Tablet) (Tablet)

Ribavirin Ribavirin (200mg Valtrex Valtrex (Tablet) 3 QL Capsule, 200mg 1 Viroptic (Ophthalmic 3 Tablet) Solution)

Sylatron Sylatron (Injection) 4 PA Xerese (Cream) 4 PA, QL Anti-hepatitis C (HCV) Direct Acting Agents Zovirax (200mg

Daklinza Daklinza (Tablet) 4 PA, QL Capsule, 200mg/5ml 3 Epclusa (Tablet) 4 PA, QL Suspension)

Zovirax Harvoni Zovirax (5% Cream, Harvoni (Tablet) 4 PA, QL 4 QL

Olysio 5% Ointment)

Olysio (Capsule) 4 PA, QL Zovirax Zovirax (800mg Sovaldi 4 Sovaldi (Tablet) 4 PA, QL Tablet)

Technivie Technivie (Tablet) 4 PA, QL Anti-HIV Agents, Integrase Inhibitors (INSTI)

Viekira Pak Viekira Pak (Tablet Genvoya 4 PA, QL Genvoya (Tablet) 4 QL Therapy Pack) Isentress Isentress (100mg Viekira XR Viekira XR (Tablet Packet, 25mg Tablet 2 QL Extended-Release 24 4 PA, QL Chewable)

Hour) Isentress Isentress (100mg Zepatier Zepatier (Tablet) 4 PA, QL Tablet Chewable, 4 QL Antiherpetic Agents 400mg Tablet)

Acyclovir Acyclovir (200mg Stribild (Tablet) 4 QL

Capsule, 200mg/5ml Tivicay 1 Tivicay (10mg Tablet) 3 QL

Suspension, 400mg Tivicay Tivicay (25mg Tablet, Tablet, 800mg Tablet) 4 QL

Acyclovir 50mg Tablet)

Acyclovir (5% Triumeq 1 QL Triumeq (Tablet) Ointment) 4 QL

Tybost Acyclovir Sodium Sodium Tybost (Tablet) 3 QL 1 B/D, PA (Injection) Anti-HIV Agents, Non-nucleoside Reverse Denavir (Cream) 4 QL Transcriptase Inhibitors (NNRTI)

Atripla Famciclovir (Tablet) 1 QL Atripla (Tablet) 4 QL

Complera Trifluridine Complera (Tablet) 4 QL 1 Edurant (Ophthalmic Solution) Edurant (Tablet) 4 QL

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Intelence (100mg Abacavir/Lamivudine 4 QL 1 QL Tablet, 200mg Tablet) (Tablet)

Intelence Intelence (25mg Combivir (Tablet) 4 QL 3 QL Tablet) Descovy (Tablet) 4 QL

Nevirapine Nevirapine (200mg Didanosine (Capsule 1 QL Tablet Immediate- 1 QL Delayed-Release)

Release) Emtriva Emtriva (10mg/ml Nevirapine (50mg/ 1 QL Oral Solution, 200mg 3 QL 5ml Suspension) Capsule)

Nevirapine ER Nevirapine ER (Tablet Epivir (10mg/ml Oral Extended-Release 24 1 QL Solution, 150mg 3 QL Hour) Tablet, 300mg Tablet)

Odefsey Odefsey (Tablet) 4 QL Epzicom (Tablet) 4 QL

Rescriptor Rescriptor (Tablet) 3 QL Lamivudine (10mg/ml Sustiva (200mg Oral Solution, 150mg 1 QL Capsule, 600mg 4 QL Tablet, 300mg Tablet) Tablet) Lamivudine/Lamivudine/Zidovudine Sustiva (50mg 1 QL 3 QL Zidovudine (Tablet) Capsule) Retrovir (100mg Viramune (200mg 4 QL Capsule, 50mg/5ml 3 QL Tablet) Syrup)

Viramune Viramune (50mg/5ml Retrovir IV Infusion IV Infusion 3 QL 3 Suspension) (Injection)

Viramune XR Viramune XR (100mg Stavudine (Capsule) 1 QL

Tablet Extended- Trizivir 3 QL Trizivir (Tablet) 4 QL Release 24 Hour) Truvada

Viramune XR Truvada (Tablet) 4 QL Viramune XR (400mg Videx EC EC (Capsule Tablet Extended- 4 QL 3 QL Release 24 Hour) Delayed-Release) Videx Pediatric Pediatric (Oral Anti-HIV Agents, Nucleoside and Nucleotide 3 QL Reverse Transcriptase Inhibitors (NRTI) Solution)

Viread Abacavir (Tablet) 1 QL Viread (150mg Tablet,

Abacavir Sulfate/Lamivudine/Zidovudine 200mg Tablet, 250mg Abacavir Sulfate/ 4 QL Tablet, 300mg Tablet, Lamivudine/ 1 QL 40mg/gm Powder) Zidovudine (Tablet)

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Zerit (15mg Capsule, Lexiva (50mg/ml 3 QL 20mg Capsule, 30mg Suspension) Capsule, 40mg 3 QL Lexiva (700mg Tablet) 4 QL Capsule, 1mg/ml Oral Lopinavir/Ritonavir 1 QL Solution) (Oral Solution) Ziagen Ziagen (20mg/ml Oral Norvir (100mg Solution, 300mg 3 QL Capsule, 100mg 3 QL Tablet) Tablet, 80mg/ml Oral Zidovudine Zidovudine (100mg Solution)

Capsule, 300mg Prezcobix 1 QL Prezcobix (Tablet) 4 QL

Tablet, 50mg/5ml Prezista Syrup) Prezista (100mg/ml Suspension, 150mg Anti-HIV Agents, Other 4 QL Tablet, 600mg Tablet, Fuzeon Fuzeon (Injection) 4 QL 800mg Tablet)

Selzentry Selzentry (150mg Prezista (75mg 3 QL Tablet, 300mg Tablet, 4 QL Tablet) 75mg Tablet) Reyataz (150mg Selzentry (25mg 2 QL Capsule, 200mg Tablet) Capsule, 300mg 4 QL Anti-HIV Agents, Protease Inhibitors Capsule, 50mg Aptivus (100mg/ml Packet) Oral Solution, 250mg 4 QL Viracept (Tablet) 4 QL Capsule) Anti-influenza Agents

Crixivan

Flumadine Crixivan (Capsule) 2 QL Flumadine (Tablet) 3

Evotaz Evotaz (Tablet) 4 QL Oseltamivir Phosphate Phosphate Invirase 1 QL Invirase (200mg (Capsule) Capsule, 500mg 4 QL Relenza Diskhaler Diskhaler 2 QL Tablet) (Aerosol Powder)

Kaletra Kaletra (100mg-25mg Rimantadine HCl HCl Tablet, 1 3 QL (Tablet) 400mg-100mg/5ml Tamiflu (30mg Oral Solution) Capsule, 45mg Kaletra (200mg-50mg 4 QL Capsule, 75mg 3 QL Tablet) Capsule, 6mg/ml Suspension)

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Anxiolytics Lorazepam (Tablet) 1 QL Anxiolytics, Other Lorazepam Intensol Intensol

Buspirone HCl 1 QL Buspirone HCl (Tablet) 1 (2mg/ml Concentrate)

Oxazepam Hydroxyzine HCl Hydroxyzine HCl Oxazepam (Capsule) 1 (10mg/5ml Syrup, Tranxene T 1 PA, HRM Tranxene T (Tablet) 3 QL 25mg/ml Injection, Valium Valium (Tablet) 3 QL 50mg/ml Injection) Xanax (Tablet) 3 QL Benzodiazepines Xanax XR

Alprazolam Xanax XR (0.5mg Alprazolam (Tablet 1 QL Tablet Extended- Immediate-Release)

Alprazolam ER Release 24 Hour, Alprazolam ER (Tablet 1mg Tablet Extended- 3 PA, QL Extended-Release 24 1 PA, QL Release 24 Hour, Hour) 3mg Tablet Extended- Alprazolam Intensol Intensol 1 QL Release 24 Hour) (1mg/ml Concentrate) Xanax XR XR (2mg Tablet Alprazolam ODT ODT 1 QL Extended-Release 24 4 PA, QL (Tablet Dispersible) Hour)

Ativan Ativan (Tablet) 4 QL Bipolar Agents Chlordiazepoxide HCl HCl 1 Mood Stabilizers (Capsule) Depakote (Tablet Clonazepam (Tablet 3 1 QL Delayed-Release) Immediate-Release) Depakote ER ER (Tablet Clonazepam ODT ODT 1 QL Extended-Release 24 3 (Tablet Dispersible) Hour)

Clorazepate Dipotassium Clorazepate Depakote Sprinkles Sprinkles 1 QL Dipotassium (Tablet) (Capsule Sprinkle 3 Diazepam (10mg Delayed-Release) Tablet, 2mg Tablet, 1 QL Divalproex Sodium Sodium

5mg Tablet) (Capsule Sprinkle 1 Diazepam (1mg/ml Delayed-Release) 1 Oral Solution) Divalproex Sodium DR Sodium DR

Diazepam Intensol Diazepam Intensol (Tablet Delayed- 1 1 QL (5mg/ml Concentrate) Release) Klonopin (Tablet) 3 QL

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Divalproex Sodium ER Sodium ER Alogliptin/Metformin HCl 3 QL, ST (Tablet Extended- 1 HCl (Tablet) Release 24 Hour) Alogliptin/Alogliptin/Pioglitazone

Equetro 3 QL, ST Equetro (Capsule Pioglitazone (Tablet)

Extended-Release 12 3 Amaryl (Tablet) 3 QL

Hour) Avandia Avandia (Tablet) 3 PA, QL Lithium

Lithium (Oral Bydureon 1 Bydureon (Injection) 2 QL Solution) Bydureon Vial

Lithium Carbonate Bydureon Vial Lithium Carbonate 2 QL (150mg Capsule (Injection)

Byetta Immediate-Release, Byetta (Injection) 3 QL 300mg Capsule Cycloset Cycloset (Tablet) 3 PA, QL Immediate-Release, 1 Duetact (Tablet) 3 QL

600mg Capsule Farxiga Farxiga (Tablet) 3 QL, ST Immediate-Release, Fortamet 300mg Tablet Fortamet (Tablet Immediate-Release) Extended-Release 24 4 PA, QL Lithium Carbonate ER Carbonate ER Hour) Glimepiride (Tablet Extended- 1 Glimepiride (Tablet) 1 QL Release) Glipizide (Tablet

Lithobid 1 QL Lithobid (Tablet Immediate-Release)

3 Glipizide ER Extended-Release) Glipizide ER (Tablet Blood Glucose Regulators Extended-Release 24 1 QL Antidiabetic Agents Hour)

Glipizide/Metformin HCl Acarbose Glipizide/Metformin Acarbose (Tablet) 1 QL 1 QL

Actoplus Met HCl (Tablet)

Actoplus Met (Tablet) 3 QL Glucophage

Actoplus Met XR Glucophage (Tablet) 3 QL

Actoplus Met XR Glucophage XR (Tablet Extended- 3 QL Glucophage XR Release 24 Hour) (Tablet Extended- 3 QL

Actos Release 24 Hour)

Actos (Tablet) 3 QL Glucotrol Glucotrol (Tablet) Adlyxin 3 QL

Adlyxin (Injection) 3 QL, ST Glucotrol XL Glucotrol XL (Tablet Adlyxin Starter Pack Starter Pack 3 QL, ST Extended-Release 24 3 QL (Injection) Hour) Alogliptin (Tablet) 3 QL, ST

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Glumetza (Tablet Metformin HCl ER HCl ER Extended-Release 24 4 PA, QL (1000mg Tablet Hour) Extended-Release 24 Glyset (Tablet) 3 QL Hour Generic

Glyxambi Fortamet, 1000mg Glyxambi (Tablet) 3 QL, ST 1 PA, QL Tablet Extended- Invokamet Invokamet (Tablet) 2 QL Release 24 Hour, Invokamet XR XR (Tablet 500mg Tablet Extended-Release 24 2 QL Extended-Release 24 Hour) Hour)

Invokana Invokana (Tablet) 2 QL Metformin HCl ER HCl ER Janumet (Tablet (500mg Tablet 2 QL Immediate-Release) Extended-Release 24 Janumet XR XR (Tablet Hour, 750mg Tablet 1 QL Extended-Release 24 2 QL Extended-Release 24 Hour) Hour) (Generic

Januvia Glucophage XR) Januvia (Tablet) 2 QL Miglitol

Jardiance Miglitol (Tablet) 1 QL Jardiance (Tablet) 2 QL Nateglinide

Jentadueto Nateglinide (Tablet) 1 QL Jentadueto (Tablet) 3 QL Nesina

Jentadueto XR Nesina (Tablet) 3 QL, ST Jentadueto XR Onglyza (Tablet Extended- 3 QL Onglyza (Tablet) 2 QL Release 24 Hour) Oseni (Tablet) 3 QL, ST Kazano (Tablet) 3 QL, ST Pioglitazone HCl HCl 1 QL Kombiglyze XR XR (Tablet) (Tablet Extended- 2 QL Pioglitazone HCl/Glimepiride HCl/ 1 QL Release 24 Hour) Glimepiride (Tablet)

Pioglitazone HCl/Metformin HCl Metformin HCl HCl (Tablet Pioglitazone HCl/ 1 QL 1 QL Immediate-Release) Metformin HCl (Tablet) Prandin (1mg Tablet) 3 QL Prandin (2mg Tablet) 4 QL Precose (Tablet) 3 QL Repaglinide (Tablet) 1 QL Repaglinide/Metformin HCl 1 QL HCl (Tablet)

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Riomet (Oral Solution) 3 QL Apidra Vial Vial (Injection) 3 PA Soliqua 100/33 100/33 Basaglar KwikPen KwikPen 2 QL 3 ST (Injection) (Injection)

Humalog Cartridge Starlix (Tablet) 3 QL Humalog Cartridge 2 SymlinPen 120 120 (Injection) 4 PA Humalog KwikPen KwikPen (Injection) 2 SymlinPen 60 60 (Injection) 4 PA Humalog Mix 50/50 KwikPen Mix 50/50 (Injection) 2 Synjardy (Tablet) 2 QL KwikPen (Injection)

Humalog Mix 50/50 Vial

Tanzeum Humalog Mix 50/50 Tanzeum (Injection) 3 QL, ST 2 Vial (Injection) Tolazamide

Tolazamide (Tablet) 1 QL Humalog Mix 75/25 KwikPen Humalog Mix 75/25 Tolbutamide 2 Tolbutamide (Tablet) 1 QL KwikPen (Injection)

Tradjenta Tradjenta (Tablet) 3 QL Humalog Mix 75/25 Vial Mix 75/25

Trulicity 2 Trulicity (Injection) 2 QL Vial (Injection)

Humalog Vial Victoza Humalog Vial Victoza (Injection) 2 QL 2 Xigduo XR XR (Tablet (Injection) Humulin 70/30 KwikPen 70/30 Extended-Release 24 3 QL, ST 2 Hour) KwikPen (Injection) Humulin 70/30 Vial 70/30 Vial Glycemic Agents 2 GlucaGen HypoKit HypoKit (Injection) 3 Humulin N KwikPen N KwikPen (Injection) 2 Glucagon Emergency Kit Emergency (Injection) 2 Humulin N Vial N Vial Kit (Injection) 2 Proglycem (Injection) 4 Humulin R U-500 KwikPen R U-500 (Suspension) 2 KwikPen (Injection) Insulins Humulin R U-500 Vial

Afrezza Humulin R U-500 Vial Afrezza (12unit 4 PA Powder) (Concentrated) 2

Afrezza (Injection)

Afrezza (4unit Humulin R Vial Humulin R Vial Powder, 8unit 3 PA 2 Powder) (Injection) Lantus SoloStar

Apidra SoloStar Apidra SoloStar Lantus SoloStar 3 PA 2 (Injection) (Injection) Lantus Vial Lantus Vial (Injection) 2

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Levemir FlexTouch FlexTouch Enoxaparin Sodium Sodium 2 (Injection) (100mg/ml Injection, Levemir Vial Vial 120mg/0.8ml Injection, 2 (Injection) 150mg/ml Injection, Novolin 70/30 Vial 70/30 Vial 30mg/0.3ml Injection, 1 QL 3 PA (Injection) 40mg/0.4ml Injection,

Novolin N Vial 60mg/0.6ml Injection, Novolin N Vial 3 PA 80mg/0.8ml Injection, (Injection)

Novolin R Vial 300mg/3ml Injection)

Novolin R Vial Fondaparinux Sodium 3 PA Fondaparinux Sodium (Injection) 1

NovoLog FlexPen (Injection)

NovoLog FlexPen Fragmin 3 PA Fragmin (10000unit/ (Injection)

NovoLog Mix 70/30 Prefilled FlexPen ml Injection, NovoLog Mix 70/30 12500unit/0.5ml Prefilled FlexPen 3 PA Injection, 15000unit/ (Injection) 0.6ml Injection, NovoLog Mix 70/30 Vial Mix 70/30 3 PA 18000unit/0.72ml 4 Vial (Injection) Injection, 5000unit/ NovoLog PenFill PenFill 3 PA 0.2ml Injection, (Injection) 7500unit/0.3ml NovoLog Vial Vial Injection, 95000unit/ 3 PA (Injection) 3.8ml Injection) Toujeo SoloStar SoloStar Fragmin (2500unit/ 2 3 (Injection) 0.2ml Injection) Tresiba FlexTouch FlexTouch Heparin Sodium Sodium 3 ST (Injection) (10000unit/ml

Blood Products/Modifiers/Volume Expanders Injection, 20000unit/ml 1 Anticoagulants Injection, 5000unit/ml

Argatroban Injection) Argatroban (125mg/ 1 B/D, PA Heparin Sodium Sodium 125ml-0.9% Injection) 1 B/D, PA Argatroban (1000unit/ml Injection) Argatroban (250mg/ 1 B/D, PA Heparin Sodium/D5W Sodium/D5W 2.5ml Injection) 1

Arixtra (Injection) Arixtra (Injection) 4 Jantoven

Coumadin Jantoven (Tablet) 1 Coumadin (Tablet) 2 Eliquis (Tablet) 2 QL

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Lovenox (100mg/ml Aranesp Albumin Free Albumin Injection, 120mg/ Free (100mcg/0.5ml 0.8ml Injection, Injection, 100mcg/ml 150mg/ml Injection, Injection, 150mcg/ 4 QL 60mg/0.6ml 0.3ml Injection, Injection, 80mg/ 200mcg/0.4ml 0.8ml Injection, Injection, 200mcg/ml 4 PA 300mg/3ml Injection) Injection, 300mcg/ Lovenox (30mg/0.3ml 0.6ml Injection, Injection, 40mg/ 3 QL 300mcg/ml Injection, 0.4ml Injection) 500mcg/ml Injection, Pradaxa (Capsule) 3 QL 60mcg/0.3ml

Savaysa Injection, 60mcg/ml Savaysa (Tablet) 3 PA, QL Injection)

Warfarin Sodium Warfarin Sodium Aranesp Albumin Free 1 Aranesp Albumin (Tablet) Free (10mcg/0.4ml

Xarelto Xarelto (Tablet) 2 QL Injection, 25mcg/ Xarelto Starter Pack Starter Pack 0.42ml Injection, 2 QL 3 PA (Tablet Therapy Pack) 25mcg/ml Injection, Zontivity (Tablet) 3 PA, QL 40mcg/0.4ml Injection, 40mcg/ml Blood Formation Modifiers

Agrylin Injection)

Agrylin (Capsule) 3 Azacitidine

Anagrelide HCl Azacitidine (Injection) 1 PA

Anagrelide HCl Epogen 1 Epogen (10000unit/ (Capsule) ml Injection, 2000unit/ml Injection, 3000unit/ 3 PA ml Injection, 4000unit/ml Injection) Epogen (20000unit/ 4 PA ml Injection) Granix (Injection) 4 ST Leukine (Injection) 4 PA Mircera (Injection) 3 PA Mozobil (Injection) 4 PA

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Neulasta (Injection) 4 PA Plavix (Tablet) 3 QL Neupogen (Injection) 4 ST Cardiovascular Agents Procrit (10000unit/ml Alpha-adrenergic Agonists

Catapres Injection, 2000unit/ Catapres (Tablet) 3 ml Injection, Catapres-TTS-1 3 PA 3 3000unit/ml (Patch Weekly)

Injection, 4000unit/ Catapres-TTS-2 Catapres-TTS-2 ml Injection) 3 (Patch Weekly) Procrit

Procrit (20000unit/ml Catapres-TTS-3 Catapres-TTS-3 Injection, 40000unit/ 4 PA 3 (Patch Weekly)

ml Injection) Clonidine HCl

Promacta Clonidine HCl (0.1mg Promacta (Tablet) 4 PA, QL Tablet Immediate-

Vidaza Vidaza (Injection) 4 PA Release, 0.2mg Tablet

Zarxio Zarxio (Injection) 4 Immediate-Release, 0.3mg Tablet Hemostasis Agents 1 Cyklokapron Immediate-Release, Cyklokapron 3 0.1mg/24hr Patch (Injection)

Lysteda Weekly, 0.2mg/24hr Lysteda (Tablet) 4 Patch Weekly, 0.3mg/

Tranexamic Acid Tranexamic Acid 24hr Patch Weekly)

(1000mg/10ml Methyldopa 1 Methyldopa (Tablet) 1 PA, HRM

Injection, 650mg Methyldopate HCl Methyldopate HCl Tablet) 1 HRM (Injection)

Platelet Modifying Agents Midodrine HCl

Aggrenox Midodrine HCl (Tablet) 1 Aggrenox (Capsule Northera Extended-Release 12 3 QL Northera (Capsule) 4 PA, QL Hour) Alpha-adrenergic Blocking Agents

Cardura Aspirin/Dipyridamole Aspirin/Dipyridamole Cardura (Tablet) 3

Dibenzyline (Capsule Extended- 1 QL Dibenzyline (Capsule) 4 Release 12 Hour) Doxazosin Mesylate Mesylate Brilinta 1 Brilinta (Tablet) 2 QL (Tablet)

Cilostazol Minipress Cilostazol (Tablet) 1 Minipress (Capsule) 3

Clopidogrel Clopidogrel (Tablet) 1 QL Phenoxybenzamine HCl

Effient 1 Effient (Tablet) 2 QL HCl (Capsule)

Prazosin HCl Prazosin HCl (Capsule) 1

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Angiotensin II Receptor Antagonists Perindopril Erbumine Erbumine 1 QL Atacand (Tablet) 3 QL (Tablet)

Prinivil Avapro (Tablet) 3 QL Prinivil (Tablet) 3 QL

Qbrelis Benicar (Tablet) 3 QL Qbrelis (Oral Solution) 3 QL

Quinapril HCl Candesartan Cilexetil Cilexetil Quinapril HCl (Tablet) 1 QL

1 QL Ramipril (Tablet) Ramipril (Capsule) 1 QL

Cozaar Cozaar (Tablet) 3 QL Trandolapril (Tablet) 1 QL

Diovan Diovan (Tablet) 3 QL Vasotec (10mg 4 QL Edarbi (Tablet) 3 QL Tablet, 20mg Tablet)

Vasotec Eprosartan Mesylate Mesylate Vasotec (2.5mg 1 QL 3 QL (Tablet) Tablet, 5mg Tablet)

Zestril Irbesartan (Tablet) 1 QL Zestril (Tablet) 3 QL Losartan Potassium Potassium Antiarrhythmics 1 QL Amiodarone HCl (Tablet) Amiodarone HCl

Micardis (100mg Tablet, 200mg Micardis (Tablet) 3 QL 1

Olmesartan Medoxomil Tablet, 400mg Tablet, Olmesartan Medoxomil 1 QL 50mg/ml Injection)

(Tablet) Betapace

Telmisartan Betapace (80mg Telmisartan (Tablet) 1 QL 4 Tablet)

Valsartan

Dofetilide Valsartan (Tablet) 1 QL Dofetilide (Capsule) 1 Angiotensin-converting Enzyme (ACE) Flecainide Acetate Acetate 1 Inhibitors (Tablet)

Accupril Accupril (Tablet) 3 QL Mexiletine HCl HCl Altace 1 Altace (Capsule) 3 QL (Capsule)

Benazepril HCl Benazepril HCl (Tablet) 1 QL Multaq (Tablet) 2 QL

Captopril Nexterone Captopril (Tablet) 1 QL Nexterone (Injection) 3

Enalapril Maleate Enalapril Maleate Pacerone (100mg 1 QL 3 (Tablet) Tablet, 400mg Tablet)

Fosinopril Sodium Fosinopril Sodium Pacerone (200mg 1 QL 1 (Tablet) Tablet) Lisinopril (Tablet) 1 QL Procainamide HCl HCl 1 Lotensin (Tablet) 3 QL (Injection) Moexipril HCl HCl (Tablet) 1 QL

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Propafenone HCl HCl Bisoprolol Fumarate Fumarate 1 1 (Tablet) (Tablet)

Propafenone HCl ER Propafenone HCl ER Bystolic Bystolic (Tablet) 2 QL (Capsule Extended- 1 Carvedilol (Tablet 1 Release 12 Hour) Immediate-Release)

Quinidine Gluconate Quinidine Gluconate Coreg 3 Coreg (Tablet) 3

(Injection) Coreg CR Coreg CR (Capsule Quinidine Gluconate CR Gluconate Extended-Release 24 3 CR (Tablet Extended- 1 Hour)

Release) Corgard

Quinidine Sulfate Corgard (Tablet) 3

Quinidine Sulfate Inderal LA 1 (Tablet) Inderal LA (120mg

Rythmol SR Capsule Extended- Rythmol SR (225mg Release 24 Hour, Capsule Extended- 3 4 160mg Capsule Release 12 Hour) Extended-Release 24 Rythmol SR Rythmol SR (325mg Hour)

Capsule Extended- Inderal LA Inderal LA (60mg Release 12 Hour, 4 Capsule Extended- 425mg Capsule Release 24 Hour, Extended-Release 12 3 80mg Capsule Hour) Extended-Release 24 Sorine Sorine (Tablet) 1 Hour)

Sotalol HCl Sotalol HCl (AF) Innopran XL XL (Capsule 1 (Tablet) Extended-Release 24 3

Sotalol HCl Sotalol HCl (Tablet) 1 Hour)

Labetalol HCl Sotylize (Oral Labetalol HCl (100mg 3 PA Solution) Tablet, 200mg Tablet, 1 Tikosyn Tikosyn (Capsule) 3 300mg Tablet, 5mg/ml Injection) Beta-adrenergic Blocking Agents Lopressor Acebutolol HCl HCl Lopressor (Tablet) 3 1 Metoprolol Succinate ER Succinate (Capsule)

Atenolol Atenolol (Tablet) 1 ER (Tablet Extended- 1

Betaxolol HCl Release 24 Hour) Betaxolol HCl (10mg 1 Tablet, 20mg Tablet)

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Metoprolol Tartrate Tartrate Adalat CC CC (Tablet (100mg Tablet Extended-Release 24 3 QL Immediate-Release, Hour) 25mg Tablet Afeditab CR 1 Afeditab CR (Tablet Immediate-Release, Extended-Release 24 1 QL 50mg Tablet Hour) Immediate-Release, Amlodipine Besylate Besylate 1 1mg/ml Injection) (Tablet)

Nadolol Calan Nadolol (Tablet) 1 Calan (Tablet) 3

Pindolol Pindolol (Tablet) 1 Calan SR SR (Tablet Propranolol HCl 3 Propranolol HCl (10mg Extended-Release)

Cardene IV Tablet Immediate- Cardene IV (Injection) 3

Release, 20mg Tablet Cardizem Cardizem (Tablet) 4 Immediate-Release, Cardizem CD CD 40mg Tablet Immediate-Release, (Capsule Extended- 4 60mg Tablet Release 24 Hour) 1 Cardizem LA Immediate-Release, Cardizem LA (120mg 80mg Tablet Tablet Extended- Immediate-Release, Release 24 Hour, 1mg/ml Injection, 180mg Tablet Extended-Release 24 20mg/5ml Oral 3 Solution, 40mg/5ml Hour, 240mg Tablet Oral Solution) Extended-Release 24 Propranolol HCl ER HCl ER Hour, 300mg Tablet

(Capsule Extended- 1 Extended-Release 24 Release 24 Hour) Hour)

Cardizem LA

Tenormin Tenormin (Tablet) 3 Cardizem LA (360mg

Timolol Maleate Tablet Extended- Timolol Maleate (10mg Release 24 Hour, Tablet, 20mg Tablet, 1 3 QL 420mg Tablet 5mg Tablet) Extended-Release 24 Toprol XL XL (Tablet Hour) Extended-Release 24 3 Cartia XT Cartia XT (Capsule Hour) Extended-Release 24 1 Calcium Channel Blocking Agents Hour)

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Dilt-XR Isradipine Dilt-XR (Capsule Isradipine (Capsule) 1 Extended-Release 24 1 Matzim LA LA (180mg Hour) Tablet Extended- Diltiazem CD CD (Capsule Release 24 Hour, Extended-Release 24 1 240mg Tablet 1 Hour) Extended-Release 24 Diltiazem HCl HCl (100mg Hour, 300mg Tablet Injection, 50mg/10ml Extended-Release 24 Injection, 120mg Hour) Tablet Immediate- Matzim LA LA (360mg Release, 30mg Tablet 1 Tablet Extended- Immediate-Release, Release 24 Hour, 1 QL 60mg Tablet 420mg Tablet Immediate-Release, Extended-Release 24 90mg Tablet Hour) Immediate-Release) Nicardipine HCl HCl Diltiazem HCl ER HCl ER (2.5mg/ml Injection, 1 (120mg Capsule 20mg Capsule, 30mg Extended-Release 12 Capsule) Hour, 60mg Capsule Nifedipine ER ER (Tablet Extended-Release 12 Extended-Release 24 1 QL Hour, 90mg Capsule Hour)

Extended-Release 12 Nimodipine Nimodipine (Capsule) 1 Hour, 120mg Capsule Nisoldipine Extended-Release 24 Nisoldipine (Tablet 1 Hour, 300mg Capsule Extended-Release 24 1 Extended-Release 24 Hour) Norvasc Hour, 180mg Capsule Norvasc (Tablet) 3 Extended-Release 24 Procardia XL XL (Tablet Hour, 360mg Capsule Extended-Release 24 3 QL Extended-Release 24 Hour) Hour, 420mg Capsule Sular (Tablet

Extended-Release 24 Extended-Release 24 3 Hour) Hour) Felodipine ER ER (Tablet

Extended-Release 24 1 Hour)

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Taztia XT XT (Capsule Verelan (Capsule

Extended-Release 24 1 Extended-Release 24 3 Hour) Hour) Tiazac (Capsule Verelan PM PM (Capsule

Extended-Release 24 3 Extended-Release 24 3 Hour) Hour) Verapamil HCl HCl (120mg Cardiovascular Agents, Other Tablet Immediate- Accuretic (Tablet) 3 QL

Release, 40mg Tablet Aldactazide Aldactazide (Tablet) 3

Immediate-Release, 1 Amiloride/Hydrochlorothiazide Amiloride/ 80mg Tablet Immediate-Release, Hydrochlorothiazide 1 2.5mg/ml Injection) (Tablet) Amlodipine Besylate/Atorvastatin Calcium Verapamil HCl ER HCl ER Amlodipine Besylate/ (100mg Capsule Atorvastatin Calcium 1 QL Extended-Release 24 (Tablet) Amlodipine Besylate/Benazepril HCl Hour, 120mg Capsule Amlodipine Besylate/ Extended-Release 24 Benazepril HCl 1 QL Hour, 180mg Capsule (Capsule) Extended-Release 24 Amlodipine Besylate/Valsartan Besylate/ 1 QL Hour, 200mg Capsule Valsartan (Tablet) Extended-Release 24 Amlodipine/Olmesartan Medoxomil Amlodipine/ Hour, 240mg Capsule 1 Olmesartan Medoxomil 1 QL Extended-Release 24 (Tablet) Hour, 300mg Capsule Amlodipine/Valsartan/Amlodipine/Valsartan/Hydrochlorothiazide Extended-Release 24 Hydrochlorothiazide 1 QL Hour, 120mg Tablet (Tablet)

Extended-Release, Atacand HCT Atacand HCT (Tablet) 3 QL

180mg Tablet Atenolol/Chlorthalidone Atenolol/ Extended-Release, 1 240mg Tablet Chlorthalidone (Tablet)

Avalide Extended-Release) Avalide (Tablet) 3 QL

Azor Verapamil HCl SR HCl SR Azor (Tablet) 3 QL

(Capsule Extended- 1 Benazepril HCl/Hydrochlorothiazide HCl/ Release 24 Hour) Hydrochlorothiazide 1 QL (Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 94 95

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DUTOPROL Benicar HCT DUTOPROL (Tablet Benicar HCT (Tablet) 3 QL BiDil (Tablet) 2 QL Extended-Release 24 3

Bisoprolol Fumarate/Hydrochlorothiazide Hour) Bisoprolol Fumarate/ Dyazide Hydrochlorothiazide 1 QL Dyazide (Capsule) 3 (Tablet) Edarbyclor (Tablet) 3 QL

Enalapril Maleate/Hydrochlorothiazide Byvalson (Tablet) 3 QL, ST Enalapril Maleate/ Caduet (Tablet) 3 QL Hydrochlorothiazide 1 QL

Candesartan Cilexetil/Hydrochlorothiazide (Tablet) Candesartan Cilexetil/ Entresto Hydrochlorothiazide 1 QL Entresto (Tablet) 2 QL (Tablet) Exforge (Tablet) 3 QL Captopril/Captopril/Hydrochlorothiazide Exforge HCT HCT (Tablet) 3 QL Hydrochlorothiazide 1 QL Fosinopril Sodium/Hydrochlorothiazide Sodium/ (Tablet) Hydrochlorothiazide 1 QL Corlanor (Tablet) 3 PA, QL (Tablet) Corzide (40mg-5mg Hyzaar (Tablet) 3 QL 3 QL Tablet) Irbesartan/Irbesartan/Hydrochlorothiazide Corzide (80mg-5mg 3 Hydrochlorothiazide 1 QL Tablet) (Tablet)

Demser Lanoxin Demser (Capsule) 4 Lanoxin (0.25mg/ml 3 HRM Digitek (0.125mg Injection)

1 QL, HRM Lanoxin Tablet) Lanoxin (125mcg Digitek (0.25mg Tablet, 62.5mcg 3 QL, HRM 1 PA, HRM Tablet) Tablet)

Lanoxin Digoxin (0.05mg/ml PA, QL, Lanoxin (187.5mcg 1 Oral Solution) HRM Tablet, 250mcg 3 PA, HRM Digoxin (0.25mg/ml Tablet) 1 HRM Lisinopril/Hydrochlorothiazide Injection) Lisinopril/ Digoxin (125mcg Hydrochlorothiazide 1 QL 1 QL, HRM Tablet) (Tablet)

Lopressor HCT Digoxin (250mcg Lopressor HCT 1 PA, HRM 3 Tablet) (Tablet)

Losartan Potassium/Hydrochlorothiazide Diovan HCT HCT (Tablet) 3 QL Losartan Potassium/ Hydrochlorothiazide 1 QL (Tablet)

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Ranexa Lotrel (Capsule) 3 QL Ranexa (Tablet

Maxzide Maxzide (Tablet) 3 Extended-Release 12 2 QL

Metoprolol/Hydrochlorothiazide Hour)

Metoprolol/ Spironolactone/Hydrochlorothiazide Spironolactone/ Hydrochlorothiazide 1 (Tablet) Hydrochlorothiazide 1

Micardis HCT (Tablet)

Micardis HCT (Tablet) 3 QL Tarka

Moexipril/Hydrochlorothiazide Tarka (Tablet 3 QL Moexipril/ Extended-Release)

Hydrochlorothiazide 1 QL Tekturna Tekturna (Tablet) 3 QL (Tablet)

Tekturna HCT Nadolol/Nadolol/Bendroflumethiazide Tekturna HCT (Tablet) 3 QL Telmisartan/Telmisartan/Amlodipine Bendroflumethiazide 1 QL 1 QL (40mg-5mg Tablet) Amlodipine (Tablet)

Telmisartan/Hydrochlorothiazide Nadolol/Nadolol/Bendroflumethiazide Telmisartan/

Bendroflumethiazide 1 Hydrochlorothiazide 1 QL (80mg-5mg Tablet) (Tablet)

Tenoretic 100 Olmesartan Medoxomil/Amlodipine/Hydrochlorothiazide Olmesartan Tenoretic 100 (Tablet) 3

Tenoretic 50 Medoxomil/ Tenoretic 50 (Tablet) 3 Amlodipine/ 1 QL Trandolapril/Verapamil HCl Hydrochlorothiazide HCl (Tablet Extended- 1 QL (Tablet) Release) Olmesartan Medoxomil/Hydrochlorothiazide Olmesartan Triamterene/Triamterene/Hydrochlorothiazide Medoxomil/ 1 QL Hydrochlorothiazide Hydrochlorothiazide (37.5mg-25mg

(Tablet) Capsule, 50mg-25mg 1 Pentoxifylline ER ER Capsule, 37.5mg-25mg (Tablet Extended- 1 Tablet, 75mg-50mg Release) Tablet)

Propranolol/Hydrochlorothiazide Propranolol/ Tribenzor Tribenzor (Tablet) 3 QL

Hydrochlorothiazide 1 Twynsta Twynsta (Tablet) 3 QL (Tablet) Valsartan/Hydrochlorothiazide Quinapril/Quinapril/Hydrochlorothiazide Valsartan/ Hydrochlorothiazide 1 QL Hydrochlorothiazide 1 QL (Tablet) (Tablet) Vaseretic (Tablet) 3 QL Vecamyl (Tablet) 4 PA

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Zestoretic Furosemide (10mg/ml (10mg-12.5mg Tablet, 3 QL Oral Solution, 8mg/ml

20mg-12.5mg Tablet) Oral Solution, 20mg 1 Ziac (Tablet) 3 QL Tablet, 40mg Tablet, Diuretics, Carbonic Anhydrase Inhibitors 80mg Tablet) Lasix Acetazolamide (Tablet Lasix (Tablet) 3 1 Torsemide Immediate-Release) Torsemide (Tablet) 1 Acetazolamide ER ER Diuretics, Potassium-sparing

Aldactone (Capsule Extended- 1 Aldactone (Tablet) 3

Amiloride HCl Release 12 Hour) Amiloride HCl (Tablet) 1 Acetazolamide Sodium

Acetazolamide Sodium Dyrenium 1 Dyrenium (Capsule) 3 (Injection) Eplerenone Diamox (Capsule Eplerenone (Tablet) 1 Inspra Extended-Release 12 3 Inspra (Tablet) 3 Hour) Spironolactone

Keveyis 1 Keveyis (Tablet) 4 PA, QL (Tablet) Methazolamide Diuretics, Thiazide

1 Chlorothiazide (Tablet) Chlorothiazide (Tablet) 1 Diuretics, Loop Chlorothiazide Sodium Sodium

Bumetanide 1 B/D, PA Bumetanide (0.25mg/ (Injection)

Chlorthalidone ml Injection, 0.5mg 1 Chlorthalidone (Tablet) 1 Diuril Tablet, 1mg Tablet, Diuril (Suspension) 3

2mg Tablet) Hydrochlorothiazide

Demadex Hydrochlorothiazide Demadex (Tablet) 3 (12.5mg Capsule, Edecrin 1 Edecrin (Tablet) 4 12.5mg Tablet, 25mg Ethacrynate Sodium Sodium Tablet, 50mg Tablet)

1 Indapamide (Injection) Indapamide (Tablet) 1

Ethacrynic Acid Ethacrynic Acid Methyclothiazide 1 1 (Tablet) (Tablet)

Furosemide Furosemide (10mg/ml Metolazone 1 B/D, PA Metolazone (Tablet) 1 Injection) Microzide Microzide (Capsule) 3 Sodium Diuril Diuril 3 B/D, PA (Injection) Dyslipidemics, Fibric Acid Derivatives

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Altoprev Antara Antara (Capsule) 2 Altoprev (Tablet Fenofibrate (120mg Extended-Release 24 3 QL Tablet, 145mg Tablet, Hour) 160mg Tablet, 40mg Atorvastatin Calcium Calcium 1 QL Tablet, 48mg Tablet, 1 (Tablet) 54mg Tablet, 130mg Crestor (Tablet) 3 QL Capsule, 43mg Fluvastatin (Capsule 1 QL Capsule) Immediate-Release)

Fenofibrate Fenofibrate (150mg Fluvastatin Sodium ER Fluvastatin Sodium ER Capsule, 50mg 1 (Tablet Extended- 1 QL Capsule) Release 24 Hour)

Fenofibrate Micronized Fenofibrate Micronized Lescol XL XL (Tablet (134mg Capsule, 1 Extended-Release 24 3 QL 200mg Capsule, 67mg Hour)

Capsule) Lipitor Lipitor (Tablet) 3 QL Fenofibric Acid

Fenofibric Acid Livalo 1 Livalo (Tablet) (Tablet) 2 QL Lovastatin Fenofibric Acid DR Acid DR Lovastatin (Tablet 1 QL (Capsule Delayed- 1 Immediate-Release)

Pravachol Release) Pravachol (Tablet) 3 QL

Pravastatin Sodium Fenoglide (120mg Pravastatin Sodium 4 1 QL Tablet) (Tablet)

Rosuvastatin Calcium Fenoglide (40mg Rosuvastatin Calcium 3 1 QL Tablet) (Tablet)

Simvastatin Fibricor Fibricor (Tablet) 3 Simvastatin (Tablet) 1 QL

Zocor Gemfibrozil Gemfibrozil (Tablet) 1 Zocor (Tablet) 3 QL

Lipofen Lipofen (Capsule) 3 Dyslipidemics, Other

Cholestyramine Light Lopid Cholestyramine Light Lopid (Tablet) 3 1

Tricor (Packet)

Tricor (Tablet) 3 Cholestyramine Light

Triglide Cholestyramine Light 1 Triglide (Tablet) 3 (Powder)

Trilipix Trilipix (Capsule Colestid (1gm Tablet, 3 3 Delayed-Release) 5gm Granules) Dyslipidemics, HMG CoA Reductase Colestipol HCl HCl (1gm 1 Inhibitors Tablet, 5gm Granules)

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Hydralazine HCl Ezetimibe (Tablet) 1 QL Hydralazine HCl Ezetimibe/Simvastatin (100mg Tablet, 10mg 1 QL (Tablet) Tablet, 25mg Tablet, 1

Juxtapid 50mg Tablet, 20mg/ml Juxtapid (Capsule) 4 PA, LA Injection) Kynamro

Kynamro (Injection) 4 PA, LA Minoxidil Minoxidil (Tablet) 1 Lovaza (Capsule) 3 QL Vasodilators, Direct-acting Arterial/Venous Niacin ER

Niacin ER (Tablet Gonitro 1 Gonitro (Packet) 3

Extended-Release) Isordil Titradose

Niacor Isordil Titradose Niacor (Tablet) 1 4 (Tablet) Niaspan

Isosorbide Dinitrate Niaspan (Tablet Isosorbide Dinitrate 3 Extended-Release) (Tablet Immediate- 1 Omega-3-Acid Ethyl Esters Omega-3-Acid Ethyl Release) Esters (Capsule) 1 QL Isosorbide Dinitrate ER Dinitrate ER

(Generic Lovaza) (Tablet Extended- 1

Praluent Praluent (Injection) 4 PA, QL Release)

Prevalite Isosorbide Mononitrate Prevalite (Powder) 1 Isosorbide Mononitrate

Questran Questran (Packet) 3 (Tablet Immediate- 1 Questran Light Light Release) 3 Isosorbide Mononitrate ER Mononitrate (Powder) Repatha ER (Tablet Extended- 1 Repatha (Injection) 4 PA, QL

Repatha Pushtronex System Release 24 Hour)

Repatha Pushtronex Minitran 4 PA, QL Minitran (Patch 24 System (Injection) 1

Repatha SureClick Hour)

Repatha SureClick Nitro-Bid 4 PA, QL (Injection) Nitro-Bid (Ointment) 3 Nitro-Dur

Vascepa Nitro-Dur (Patch 24 Vascepa (Capsule) 3 3 Hour) Vytorin

Vytorin (Tablet) 3 QL Nitroglycerin Nitroglycerin (0.3mg Welchol (3.75gm Tablet Sublingual, Packet, 625mg 2 0.4mg Tablet 1 Tablet) Sublingual, 0.6mg Zetia (Tablet) 3 QL Tablet Sublingual, Vasodilators, Direct-acting Arterial 5mg/ml Injection) Nitroglycerin Lingual Lingual 1 (Translingual Solution)

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Nitroglycerin Transdermal Amphetamine/Amphetamine/Dextroamphetamine

Transdermal (Patch 24 1 Dextroamphetamine Hour) (10mg Capsule NitroMist (Aerosol Extended-Release 24 3 Solution) Hour, 15mg Capsule Nitrostat (Tablet Extended-Release 24 3 Sublingual) Hour, 20mg Capsule

Rectiv Extended-Release 24 Rectiv (Ointment) 3 Hour, 25mg Capsule Central Nervous System Agents Extended-Release 24 Attention Deficit Hyperactivity Disorder Hour, 30mg Capsule Agents, Amphetamines Extended-Release 24 Adderall (Tablet) 3 QL Hour, 5mg Capsule Adderall XR XR (Capsule Extended-Release 24 1 QL Extended-Release 24 3 QL Hour, 10mg Tablet Hour) Immediate-Release, Adzenys XR-ODT XR-ODT 12.5mg Tablet (Tablet Extended- 3 QL Immediate-Release, Release Dispersible) 15mg Tablet Immediate-Release, 20mg Tablet Immediate-Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate- Release, 7.5mg Tablet Immediate-Release) Desoxyn (Tablet) 4 PA Dexedrine (10mg Capsule Extended- Release 24 Hour, 4 QL 15mg Capsule Extended-Release 24 Hour) Dexedrine (5mg Capsule Extended- 3 QL Release 24 Hour)

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Dextroamphetamine Sulfate Dexmethylphenidate HCl ER Sulfate (Tablet 1 QL HCl ER (Capsule 1 Immediate-Release) Extended-Release 24 Dextroamphetamine Sulfate ER Hour) Sulfate ER (Capsule Focalin (Tablet) 3 QL 1 QL Extended-Release 24 Focalin XR XR (Capsule

Hour) Extended-Release 24 3 Methamphetamine HCl HCl 1 PA Hour) (Tablet) Kapvay (Tablet ProCentra (Oral 3 Extended-Release 12 3 PA Solution) Hour)

Vyvanse Metadate CD Vyvanse (Capsule) 3 Metadate CD

Zenzedi (10mg Tablet, (Capsule Extended- 3 15mg Tablet, 2.5mg Release) Tablet, 20mg Tablet, 3 QL Metadate ER ER (Tablet 1 QL 30mg Tablet, 5mg Extended-Release) Tablet) Methylin (Oral

Zenzedi 3 QL Zenzedi (7.5mg Tablet) 4 QL Solution) Attention Deficit Hyperactivity Disorder Methylphenidate HCl HCl Agents, Non-amphetamines (10mg Tablet Aptensio XR XR (Capsule Chewable, 2.5mg Extended-Release 24 3 QL Tablet Chewable, 5mg Hour) Tablet Chewable),

Atomoxetine (10mg Tablet Atomoxetine (Capsule) 1 QL

Clonidine HCl ER Immediate-Release, 1 QL Clonidine HCl ER 20mg Tablet (Tablet Extended- 1 PA Immediate-Release, Release 12 Hour) 5mg Tablet Immediate- Concerta (Tablet 3 QL Release) (Generic Extended-Release) Ritalin), (10mg/5ml Daytrana (Patch) 3 QL Oral Solution, 5mg/5ml Dexmethylphenidate HCl Oral Solution) Methylphenidate HCl CD HCl HCl (Tablet Immediate- 1 QL Release) CD (Capsule Extended- 1 Release)

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Methylphenidate HCl ER HCl Ritalin LA LA (Capsule

ER (10mg Tablet Extended-Release 24 3 Extended-Release, Hour) 20mg Tablet Extended- Strattera (Capsule) 3 QL, ST Release, 18mg Tablet Central Nervous System, Other

Extended-Release 24 Gralise Gralise (Tablet) Hour, 27mg Tablet 1 QL 3 PA

Gralise Starter Pack Extended-Release 24 Gralise Starter Pack 3 PA Hour, 36mg Tablet Horizant (Tablet 3 PA Extended-Release 24 Extended-Release) Hour, 54mg Tablet Ingrezza (Capsule) 4 PA, QL

Extended-Release 24 Namzaric Namzaric (Therapy Hour) Pack, Capsule Methylphenidate HCl ER 2 PA, QL Methylphenidate HCl Extended-Release 24 ER (20mg Capsule Hour)

Extended-Release 24 Nuedexta Nuedexta (Capsule) 3 PA Hour, 40mg Capsule Rilutek Extended-Release 24 Rilutek (Tablet) 4

Riluzole Hour, 20mg Capsule 1 Riluzole (Tablet) 1 Extended-Release, Tetrabenazine (Tablet) 1 PA, QL

30mg Capsule Xenazine Xenazine (Tablet) 4 PA, QL, LA Extended-Release, 40mg Capsule Fibromyalgia Agents Cymbalta (Capsule Extended-Release) 3 QL Methylphenidate HCl ER HCl Delayed-Release)

Duloxetine HCl ER (La) (Capsule Duloxetine HCl (20mg 1 Extended-Release 24 Capsule Delayed- Hour) Release, 30mg QuilliChew ER ER (Tablet Capsule Delayed- 1 QL Chewable Extended- 3 QL Release, 60mg Release) Capsule Delayed-

Quillivant XR Release) Quillivant XR 3 Duloxetine HCl (Suspension) Duloxetine HCl (40mg

Ritalin Capsule Delayed- 3 QL Ritalin (Tablet) 3 QL Release)

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Lyrica (100mg Rebif Titration Pack Titration Pack 4 Capsule, 150mg (Injection) Capsule, 200mg Tecfidera (Capsule 4 QL Capsule, 225mg Delayed-Release) Capsule, 25mg Tecfidera Starter Pack Starter 2 QL 4 Capsule, 300mg Pack

Capsule, 50mg Tysabri Tysabri (Injection) 4 PA Capsule, 75mg Zinbryta Capsule, 20mg/ml Zinbryta (Injection) 4 PA Oral Solution) Dental and Oral Agents

Savella Savella (Tablet) 2 Dental and Oral Agents

Cevimeline HCl Savella Titration Pack Cevimeline HCl Savella Titration Pack 2 1 ST Multiple Sclerosis Agents (Capsule) Chlorhexidine Gluconate

Ampyra Chlorhexidine Ampyra (Tablet 1 Extended-Release 12 4 QL Gluconate (Solution) Evoxac Hour) Evoxac (Capsule) 3 ST

Kepivance Aubagio (Tablet) 4 QL Kepivance (Injection) 4

Periogard Avonex Avonex (Injection) 4 Periogard (Solution) 1

Pilocarpine HCl Avonex Pen Pen Pilocarpine HCl (5mg 4 1 (Injection) Tablet, 7.5mg Tablet)

Salagen Betaseron Betaseron (Injection) 4 Salagen (Tablet) 3

Triamcinolone in Orabase Copaxone Triamcinolone in Copaxone (Injection) 4 1 Extavia Orabase () Extavia (Injection) 4

Gilenya Dermatological Agents Gilenya (Capsule) 4 QL Dermatological Agents Glatopa

Glatopa (Injection) 1 Absorica Absorica (Capsule) 4 PA Plegridy

Plegridy (Injection) 4 Acanya Acanya (Gel) 3 ST Plegridy Starter Pack

Plegridy Starter Pack Acitretin 4 (Injection) Acitretin (Capsule) 1 Aczone

Rebif Rebif (Injection) 4 Aczone (Gel) 3

Adapalene Rebif Rebidose Adapalene (0.1% Rebif Rebidose 4 (Injection) Cream, 0.1% Gel, 0.3% 1

Rebif Rebidose Titration Pack Gel) Rebif Rebidose Aldara Titration Pack 4 Aldara (Cream) 4 (Injection)

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Ammonium Lactate Lactate Clindamycin Phosphate/Tretinoin

(12% Cream, 12% 1 Phosphate/Tretinoin 1 PA Lotion) (Gel)

Clindamycin/Benzoyl Peroxide Atralin Clindamycin/Benzoyl Atralin (Gel) 3 PA Avita (0.025% Cream, Peroxide (Gel) 1 1 PA 0.025% Gel) (Generic BenzaClin)

Clotrimazole/Betamethasone Dipropionate

Azelex Azelex (Cream) 3 Clotrimazole/

BenzaClin Betamethasone BenzaClin (Gel) 3 Dipropionate 1 Benzamycin Benzamycin (Gel) 3 (1%-0.05% Cream, Calcipotriene (0.005% 1%-0.05% Lotion) Cream, 0.005% Condylox 1 Condylox (Gel) 3 External Solution, Cortisporin

0.005% Ointment) (0.5%-0.5% Cream, 3 Calcipotriene/Betamethasone Dipropionate Calcipotriene/ 1%-0.5% Ointment)

Betamethasone Cosentyx 1 Cosentyx (Injection) 4 PA

Dipropionate Cosentyx Sensoready Pen Cosentyx Sensoready (Ointment) 4 PA

Calcitriol Pen (Injection) Calcitriol (3mcg/gm 1 Diclofenac Sodium Sodium Ointment) 1 PA

Carac (3% Gel)

Carac (Cream) 4 Differin Differin (0.1% Cream, Claravis Claravis (Capsule) 1 PA 0.1% Gel, 0.3% Gel, 3 Cleocin-T (1% 0.1% Lotion)

External Solution, 1% Dovonex 3 Dovonex (Cream) 4

Gel, 1% Lotion, 1% Doxepin HCl Swab) Doxepin HCl (Cream) 1 PA Duac

Clindacin-P Clindacin-P (Swab) 1 Duac (Gel) 3

Dupixent

Clindagel Clindagel (Gel) 4 Dupixent (Injection) 4 PA, QL Efudex

Clindamax Clindamax (Gel) 3 Efudex (Cream) 3

Elidel Clindamycin Phosphate Elidel (Cream) 3 ST Phosphate (1% Enstilar (Foam) 4 PA

External Solution, 1% 1 Epiduo (Gel) 3 ST

Foam, 1% Gel, 1% Epiduo Forte Epiduo Forte (Gel) 3 ST Lotion, 1% Swab) Ery Ery (2% Pad) 1

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Erygel PRUDOXIN Erygel (Gel) 3 PRUDOXIN (Cream) 1 PA

Erythromycin Erythromycin (2% Regranex Regranex (Gel) 4 PA External Solution, 2% 1 Retin-A (0.01% Gel, Gel) 0.025% Gel, 0.025% Erythromycin/Benzoyl Peroxide 3 PA 1 Cream, 0.05% Cream, Peroxide (Gel) 0.1% Cream)

Eucrisa Eucrisa (Ointment) 3 PA Retin-A Micro Micro (Gel) 3 PA

Evoclin Retin-A Micro Pump Evoclin (Foam) 3 Retin-A Micro Pump 4 PA Fabior (Foam) 3 PA (Gel)

Santyl Finacea (15% Foam, Santyl (Ointment) 3

2 Selenium Sulfide 15% Gel) Selenium Sulfide

Fluorouracil 1 Fluorouracil (0.5% (Lotion)

4 Siliq Cream) Siliq (Solution

Fluorouracil 4 PA Fluorouracil (2% Prefilled Syringe) External Solution, 5% Solaraze (Gel) 4 PA 1 Soolantra External Solution, 5% Soolantra (Cream) 3

Cream) Soriatane Soriatane (Capsule) Imiquimod 4

Imiquimod (Cream) 1 Sorilux Sorilux (Foam) Klaron 4

Klaron (Lotion) 3 PA Stelara Stelara (130mg/26ml Lotrisone Lotrisone (Cream) 3 Injection, 45mg/ Methoxsalen 4 PA Methoxsalen (Capsule) 1 0.5ml Injection,

Mirvaso Mirvaso (Gel) 3 90mg/ml Injection)

Sulfacetamide Sodium Myorisan Sulfacetamide Sodium Myorisan (Capsule) 1 PA 1 PA

Neo-Synalar (10% Lotion)

Neo-Synalar (Cream) 3 Taclonex Taclonex Neuac Neuac (Gel) 1 (0.064%-0.005% Onexton Onexton (Gel) 3 Ointment, 4 Oxsoralen Ultra Ultra 0.064%-0.005% 4 (Capsule) Suspension)

Tacrolimus Picato Tacrolimus (0.03% Picato (Gel) 2 Podofilox (External Ointment, 0.1% 1 1 Solution) Ointment)

Taltz

Protopic Protopic (Ointment) 3 Taltz (Injection) 4 PA Tazarotene (Cream) 1 PA

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Tazorac (0.05% Aminosyn-PF 3 B/D, PA Cream, 0.1% Cream, 3 PA (Injection) 0.05% Gel, 0.1% Gel) Aminosyn-RF

Tolak 3 B/D, PA Tolak (Cream) 3 (Injection)

Carbaglu Tretinoin (0.01% Gel, Carbaglu (Tablet) 4 LA 0.025% Gel, 0.05% Carnitor (1gm/10ml Gel, 0.025% Cream, 1 PA Oral Solution, 200mg/ 3 0.05% Cream, 0.1% ml Injection, 330mg Cream) Tablet)

Tretinoin Microsphere Tretinoin Microsphere Carnitor (200mg/ml 1 PA 3 B/D, PA (Gel) Injection)

Vectical Clinimix 2.75%/Dextrose 5% Vectical (Ointment) 4 Clinimix 2.75%/

Veregen Veregen (Ointment) 4 Dextrose 5% 3 B/D, PA

Zenatane (Injection) Zenatane (Capsule) 1 PA Clinimix 4.25%/Dextrose 10%

Ziana Clinimix 4.25%/ Ziana (Gel) 4 PA Dextrose 10% 3 B/D, PA Zonalon Zonalon (Cream) 4 PA (Injection)

Zyclara Zyclara (Cream) 4 PA Clinimix 4.25%/Dextrose 20% 4.25%/ Zyclara Pump Pump Dextrose 20% 3 B/D, PA 4 PA (Cream) (Injection) Electrolytes/Minerals/Metals/Vitamins Clinimix 4.25%/Dextrose 25% 4.25%/ Electrolyte/Mineral Replacement Dextrose 25% 3 B/D, PA Aminosyn 7%/Electrolytes 7%/ (Injection)

Clinimix 4.25%/Dextrose 5% Electrolytes 3 B/D, PA Clinimix 4.25%/ (Injection) Dextrose 5% 3 B/D, PA Aminosyn 8.5%/Electrolytes 8.5%/ (Injection) Clinimix 5%/Dextrose 15% 5%/Dextrose Electrolytes 1 B/D, PA 3 B/D, PA (Injection) 15% (Injection)

Clinimix 5%/Dextrose 20% Aminosyn II II Clinimix 5%/Dextrose 3 B/D, PA 3 B/D, PA (Injection) 20% (Injection)

Clinimix 5%/Dextrose 25% Aminosyn II 8.5%/Electrolytes Clinimix 5%/Dextrose Aminosyn II 8.5%/ 3 B/D, PA Electrolytes 1 B/D, PA 25% (Injection) (Injection) Clinimix E 2.75%/Dextrose 10% E 2.75%/ Aminosyn-HBC Dextrose 10% 3 B/D, PA 3 B/D, PA (Injection) (Injection)

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Clinimix E 2.75%/Dextrose 5% E 2.75%/ Lactated Ringers Dextrose 5% Viaflex Ringers

Dextrose 5% 3 B/D, PA Dextrose 5% Viaflex 1 (Injection) (Injection) Clinimix E 4.25%/Dextrose 10% E 4.25%/ Dextrose 5%/NaCl 0.2% 5%/NaCl 1 Dextrose 10% 3 B/D, PA 0.2% (Injection) (Injection) Dextrose 5%/NaCl 0.225% 5%/NaCl

Clinimix E 4.25%/Dextrose 25% 1 Clinimix E 4.25%/ 0.225% (Injection) Dextrose 25% 3 B/D, PA Dextrose 5%/NaCl 0.33% 5%/NaCl 1 (Injection) 0.33% (Injection)

Clinimix E 4.25%/Dextrose 5% Clinimix E 4.25%/ Dextrose 5%/NaCl 0.45% 5%/NaCl 1 Dextrose 5% 3 B/D, PA 0.45% (Injection) (Injection) Dextrose 5%/NaCl 0.9% 5%/NaCl Clinimix E 5%/Dextrose 15% 1 Clinimix E 5%/ 0.9% (Injection) Dextrose 15% 3 B/D, PA FreAmine HBC 6.9% HBC 6.9% 3 B/D, PA (Injection) (Injection)

Clinimix E 5%/Dextrose 20% Clinimix E 5%/ HepatAmine 1 B/D, PA Dextrose 20% 3 B/D, PA (Injection)

(Injection) Intralipid Intralipid (20gm/ Clinimix E 5%/Dextrose 25% 1 B/D, PA Clinimix E 5%/ 100ml Injection)

Dextrose 25% 3 B/D, PA Intralipid Intralipid (30gm/ (Injection) 3 B/D, PA 100ml Injection) Clinisol SF 15%

Clinisol SF 15% Ionosol-MB/Dextrose 5% 3 B/D, PA Ionosol-MB/Dextrose (Injection) 3 5% (Injection) Dextrose 10%

Dextrose 10% Isolyte-P/Dextrose 5% 1 Isolyte-P/Dextrose 5% (Injection) 3 (Injection) Dextrose 10%/NaCl 0.2%

Dextrose 10%/NaCl Isolyte-S 1 Isolyte-S (Injection) 3 0.2% (Injection) K-Tab

Dextrose 10%/NaCl 0.45% K-Tab (Tablet Dextrose 10%/NaCl 3 1 Extended-Release) 0.45% (Injection) KCl 0.075%/D5W/NaCl 0.45%

Dextrose 2.5%/NaCl 0.45% KCl 0.075%/D5W/ Dextrose 2.5%/NaCl 1 NaCl 0.45% 1 0.45% (Injection)

Dextrose 5% (Injection)

Dextrose 5% KCl 0.15%/D5W/NaCl 0.2% 1 KCl 0.15%/D5W/NaCl (Injection) 1 0.2% (Injection) KCl 0.15%/D5W/NaCl 0.9% 0.15%/D5W/NaCl 1 0.9% (Injection)

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KCl 0.3%/D5W/NaCl 0.45% 0.3%/D5W/NaCl Normosol-R 1 1 0.45% (Injection) (Injection) KCl 0.3%/D5W/NaCl 0.9% 0.3%/D5W/NaCl Normosol-R in D5W in D5W 1 1 0.9% (Injection) (Injection)

Klor-Con 10 NutreStore Klor-Con 10 (Tablet NutreStore (Packet) 3 1 Extended-Release) Nutrilipid (Injection) 1 B/D, PA

Klor-Con 8 Klor-Con 8 (Tablet Physiolyte (Irrigation 1 3 Extended-Release) Solution)

Klor-Con M10 Klor-Con M10 (Tablet Physiosol Irrigation Irrigation 1 3 Extended-Release) (Solution)

Klor-Con M15 Klor-Con M15 (Tablet Plasma-Lyte A A 1 3 Extended-Release) (Injection)

Klor-Con M20 Klor-Con M20 (Tablet Plasma-Lyte-148 1 3 Extended-Release) (Injection)

Klor-Con Sprinkle

Klor-Con Sprinkle Plenamine Plenamine (Injection) 1 B/D, PA

(Capsule Extended- 1 Potassium Chloride Potassium Chloride Release)

Lactated Ringers Irrigation (10% Oral Solution, 1 Lactated Ringers 1 20% Oral Solution)

Irrigation (Solution) Potassium Chloride

Lactated Ringers Viaflex Potassium Chloride Lactated Ringers 1 (10meq/100ml Viaflex (Injection) Injection, 20meq/ Levocarnitine (1gm/ 1 B/D, PA 100ml Injection, 10ml Oral Solution, 1 40meq/100ml 330mg Tablet) Injection)

Magnesium Sulfate Magnesium Sulfate Potassium Chloride Chloride 1 B/D, PA (1gm/2ml-50% 1 (2meq/ml Injection)

Injection) Potassium Chloride 0.15% D5W/NaCl 0.33% Potassium Chloride Magnesium Sulfate Sulfate 0.15% D5W/NaCl 1 (5gm/10ml-50% 1 0.33% (Injection)

Injection) Potassium Chloride 0.15% D5W/NaCl 0.45% Potassium Chloride Nephramine 3 B/D, PA 0.15% D5W/NaCl 1 (Injection) 0.45% (Injection)

Normosol-M in D5W Normosol-M in D5W Potassium Chloride 0.22% D5W/NaCl 0.45% Chloride 1 (Injection) 0.22% D5W/NaCl 1 0.45% (Injection)

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Potassium Chloride ER Ringers Injection Potassium Chloride ER Ringers Injection 1 (10meq Capsule Ringers Irrigation Irrigation 1 Extended-Release, (Solution) 8meq Capsule Sodium Chloride Chloride

Extended-Release, 1 (0.9% Injection, 1 10meq Tablet 2.5meq/ml Injection)

Extended-Release, Sodium Chloride Sodium Chloride 8meq Tablet Extended- (2.5meq/ml Injection, Release) 1 B/D, PA

Potassium Chloride ER 3% Injection, 5% Potassium Chloride Injection)

ER (20meq Tablet 1 Sodium Chloride 0.45% Sodium Chloride Extended-Release) 1

Potassium Chloride/Dextrose 0.45% (Injection)

Potassium Chloride/ Sodium Chloride 0.9% 1 B/D, PA Sodium Chloride Dextrose (Injection)

KCl 0.15%/D5W/LR 0.9% (Irrigation 1 KCl 0.15%/D5W/LR 1 Solution)

(Injection) Sodium Fluoride

Potassium Chloride/Sodium Chloride Sodium Fluoride 1 Potassium Chloride/ (Tablet)

Sodium Chloride Sodium Lactate 1 B/D, PA Sodium Lactate (20meq/L-0.45% 1 (Injection) Injection) TPN Electrolytes

Potassium Chloride/Sodium Chloride TPN Electrolytes Potassium Chloride/ 1 (Injection) Sodium Chloride Travasol (20meq/L-0.9% 1 B/D, PA Travasol (Injection) 3 B/D, PA Injection, 40meq/ Trophamine 3 B/D, PA L-0.9% Injection) (Injection)

Urocit-K Potassium Citrate ER Citrate ER Urocit-K (Tablet 3 (Tablet Extended- 1 Extended-Release) Release) Electrolyte/Mineral/Metal Modifiers

Premasol Premasol (10% Chemet 3 B/D, PA Chemet (Capsule) 4 Injection) Exjade (Tablet Premasol (6% 4 PA 1 B/D, PA Soluble) Injection) Ferriprox (100mg/ml Procalamine 3 B/D, PA Oral Solution, 500mg 4 PA (Injection) Tablet)

Prosol Prosol (Injection) 3 B/D, PA Jadenu (Tablet) 4 PA

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Jadenu Sprinkle Sprinkle Gastrointestinal Agents 4 PA (Packet) Antispasmodics, Gastrointestinal

Kayexalate Atropine Sulfate Kayexalate (Powder) 3 Atropine Sulfate

Kionex Kionex (Powder) 1 (0.25mg/5ml 1 PA, HRM

Samsca Injection) Samsca (Tablet) 4 PA, QL Bentyl

Sodium Polystyrene Sulfonate Bentyl (10mg Sodium Polystyrene 3 QL, HRM 1 Capsule) Sulfonate (Suspension) Cuvposa

SPS Cuvposa (Oral SPS (Suspension) 1 3 Solution) Syprine Syprine (Capsule) 4 PA, QL Dicyclomine HCl HCl

Veltassa Veltassa (Packet) 3 QL (10mg Capsule, 10mg/ Phosphate Binders 5ml Oral Solution, 1 HRM

Auryxia Auryxia (Tablet) 4 10mg/ml Injection,

Calcium Acetate 20mg Tablet) Calcium Acetate Glycopyrrolate (1mg (667mg Capsule, 1 1 PA 667mg Tablet) Tablet, 2mg Tablet)

Glycopyrrolate Eliphos Glycopyrrolate (4mg/ Eliphos (Tablet) 1 1

Fosrenol 20ml Injection)

Fosrenol (1000mg Methscopolamine Bromide Methscopolamine Packet, 750mg 1 Packet, 1000mg Bromide (Tablet) Propantheline Bromide Bromide Tablet Chewable, 4 1 PA, HRM 500mg Tablet (Tablet) Chewable, 750mg Robinul (1mg Tablet) 3 PA Tablet Chewable) Robinul Forte Forte (Tablet) 3 PA Phoslyra (Oral 2 Gastrointestinal Agents, Other Solution) Actigall Actigall (Capsule) 4 Renagel

Renagel (Tablet) 2 ST Chenodal Chenodal (Tablet) 4 Renvela

Renvela (0.8gm Cromolyn Sodium Cromolyn Sodium Packet, 2.4gm 2 (100mg/5ml 1 Packet, 800mg Concentrate) Tablet) Velphoro (Tablet 4 Chewable) Vitamins

VP-PNV-DHA VP-PNV-DHA (Capsule) 1

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Diphenoxylate/Atropine Cimetidine Diphenoxylate/ Cimetidine (Tablet) 1 Atropine Cimetidine HCl HCl (Oral (2.5mg-0.025mg 1 1 PA, HRM Solution) Tablet, Famotidine (20mg 2.5mg-0.025mg/5ml Tablet, 40mg Tablet,

Liquid) 20mg/2ml Injection, 1 Gastrocrom 4 40mg/5ml (Concentrate) Suspension)

Gattex Gattex (Injection) 4 PA Famotidine Premixed Premixed

Lansoprazole/Amoxicillin/Clarithromycin 1 Lansoprazole/ (Injection) Amoxicillin/ Nizatidine 1 Nizatidine (150mg Clarithromycin Capsule, 300mg 1 (Therapy Pack) Capsule, 15mg/ml Oral Lomotil (Tablet) 3 PA, HRM Solution)

Loperamide HCl Pepcid Loperamide HCl Pepcid (20mg Tablet) 3 1 Pepcid (Capsule) Pepcid (40mg Tablet) 4

Movantik

Pepcid Movantik (Tablet) 3 PA, QL Pepcid (Suspension) 3

Myalept Myalept (Injection) 4 PA Ranitidine HCl HCl (150mg Mytesi (Tablet Capsule, 300mg 3 PA Delayed-Release) Capsule, 150mg

Prevpac 1 Prevpac (Therapy Tablet, 300mg Tablet, 4 Pack) 50mg/2ml Injection,

Pylera Pylera (Capsule) 4 75mg/5ml Syrup)

Zantac

Relistor Zantac (150mg Relistor (Injection) 4 PA

Relistor Tablet, 300mg Tablet, 3 Relistor (150mg 4 PA, QL 25mg/ml Injection) Tablet) Irritable Bowel Syndrome Agents Serostim

Serostim (Injection) 4 PA Alosetron HCl Alosetron HCl (Tablet) 1 PA Urso

Urso (Tablet) 3 Amitiza Amitiza (Capsule) 2 QL Ursodiol

Ursodiol (250mg Linzess Linzess (Capsule) 2 QL Tablet, 500mg Tablet, 1

Lotronex 300mg Capsule) Lotronex (Tablet) 4 PA

Viberzi Xermelo (Tablet) 4 PA, QL Viberzi (Tablet) 4 PA, QL

Xifaxan Zorbtive (Injection) 4 PA Xifaxan (Tablet) 4 PA Histamine2 (H2) Receptor Antagonists Laxatives

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CoLyte-Flavor Packs Packs Polyethylene Glycol 3350 Powder Glycol 3 (Oral Solution) 3350 Powder (Generic 1 Constulose (Oral MiraLAX)

1 Prepopik Solution) Prepopik (Packet) 3

Enulose Suprep Bowel Prep Kit Enulose (Oral Solution) 1 Suprep Bowel Prep

GaviLyte-C 2 GaviLyte-C (Oral Kit (Oral Solution)

1 TriLyte Solution) TriLyte (Oral Solution) 1 GaviLyte-G (Oral 1 Protectants Solution) Carafate (1gm Tablet,

GaviLyte-H GaviLyte-H (Kit) 1 1gm/10ml 3 GaviLyte-N/Flavor Pack Suspension)

1 Cytotec Pack (Oral Solution) Cytotec (Tablet) 3

Generlac Generlac (Oral Misoprostol 1 Misoprostol (Tablet) 1

Sucralfate Solution) Sucralfate (Tablet) 1 GoLYTELY (Oral 3 Proton Pump Inhibitors

Solution) Aciphex

Kristalose Aciphex (Tablet 3 Kristalose (Packet) 3 Delayed-Release)

Lactulose Lactulose (Oral Aciphex Sprinkle Sprinkle 1 3 ST Solution) (Capsule Sprinkle)

MoviPrep MoviPrep (Oral Dexilant (Capsule 3 3 QL Solution) Delayed-Release)

NuLYTELY/Flavor Packs NuLYTELY/Flavor Esomeprazole Magnesium 3 Esomeprazole Packs (Oral Solution) Magnesium (Capsule OsmoPrep 1 QL OsmoPrep (Tablet) 3 Delayed-Release) PEG-3350/PEG-3350/Electrolytes (Generic Nexium) Electrolytes (Oral Esomeprazole Sodium Sodium 1 1 Solution) (Generic (Injection) GoLYTELY) Lansoprazole (Capsule PEG-3350/NaCl/Na Bicarbonate/KCl 1 QL PEG-3350/NaCl/Na Delayed-Release) Bicarbonate/KCl (Oral Nexium 1 Nexium (10mg Solution) (Generic Packet, 2.5mg

NuLYTELY) Packet, 20mg Packet, 2 40mg Packet, 5mg Packet)

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Nexium (20mg Protonix (20mg Capsule Delayed- Tablet Delayed- 3 QL Release, 40mg 2 QL Release, 40mg Tablet Capsule Delayed- Delayed-Release) Release) Protonix (40mg

Nexium I.V. 3 Nexium I.V. (Injection) 3 Injection)

Protonix Omeprazole Protonix (40mg Omeprazole (10mg 3 ST Capsule Delayed- Packet) Release, 40mg 1 QL Rabeprazole Sodium Sodium

Capsule Delayed- (Tablet Delayed- 1 Release) Release)

Omeprazole Omeprazole (20mg Yosprala (Tablet 3 QL Capsule Delayed- 1 Delayed-Release) Release) Zegerid Omeprazole/Sodium Bicarbonate (20mg-1100mg Bicarbonate Capsule, (20mg-1100mg 40mg-1100mg

Capsule, Capsule, 4 1 40mg-1100mg 20mg-1680mg Capsule, Packet, 20mg-1680mg Packet, 40mg-1680mg 40mg-1680mg Packet) Packet) Pantoprazole Sodium Sodium Genetic or Enzyme Disorder: Replacement, (20mg Tablet Delayed- Modifiers, Treatment 1 QL Release, 40mg Tablet Genetic or Enzyme Disorder: Replacement, Delayed-Release) Modifiers, Treatment

Pantoprazole Sodium Pantoprazole Sodium Adagen 1 Adagen (Injection) 4 LA (40mg Injection) Aldurazyme Aldurazyme Prevacid (Capsule 4 3 QL (Injection)

Delayed-Release) Aralast NP Aralast NP (Injection) Prevacid SoluTab 4 PA, LA

Prevacid SoluTab Buphenyl 3 ST Buphenyl (3gm/tsp (Tablet Dispersible) Powder, 500mg Prilosec 4 Prilosec (Packet) 3 PA Tablet) Cerdelga (Capsule) 4 PA, QL Cerezyme (Injection) 4 PA

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Pancreaze Cholbam (Capsule) 4 PA Pancreaze Creon (Capsule (10850unit-2600unit- 2 Delayed-Release) 6200unit Capsule

Cystadane Delayed-Release, Cystadane (Powder) 4 24600unit-4200unit-1 Cystagon Cystagon (Capsule) 3 LA 4200unit Capsule

Elaprase Elaprase (Injection) 4 Delayed-Release, 3 ST Elelyso (Injection) 4 PA, LA 61500unit-10500unit- Exondys 51 51 35500unit Capsule 4 PA, LA (Injection) Delayed-Release,

Fabrazyme 98400unit-16800unit- Fabrazyme (Injection) 4 56800unit Capsule Glassia (Injection) 4 PA, LA Delayed-Release) Kanuma (Injection) 4 PA Pancreaze Kuvan (83900unit-21000unit Kuvan (100mg 4 ST Packet, 500mg -54700unit Capsule 4 Packet, 100mg Tablet Delayed-Release) Soluble) Pertzye

Lumizyme Lumizyme (Injection) 4 (15125unit-4000unit-

Naglazyme 14375unit Capsule Naglazyme (Injection) 4 Delayed-Release, 3 ST Ocaliva Ocaliva (Tablet) 4 PA, QL 30250unit-8000unit-2 Orfadin (10mg 8750unit Capsule Capsule, 2mg Delayed-Release) Capsule, 5mg 4 LA Pertzye Capsule, 4mg/ml (60500unit-16000unit 4 ST Suspension) -57500unit Capsule Delayed-Release) Procysbi (Capsule 4 Delayed-Release) Prolastin-C (Injection) 4 PA, LA RAVICTI (Liquid) 4 QL Sodium Phenylbutyrate Phenylbutyrate 1 (Powder) Strensiq (Injection) 4 PA, LA

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Sucraid (Oral Oxybutynin Chloride Chloride 4 LA Solution) (5mg Tablet

Viokace 1 Viokace Immediate-Release, (39150unit-10440unit 3 ST 5mg/5ml Syrup) -39150unit Tablet) Oxybutynin Chloride ER Chloride Viokace ER (Tablet Extended- 1 QL (78300unit-20880unit 4 ST Release 24 Hour) -78300unit Tablet) Oxytrol (Patch Twice 3 VPRIV (Injection) 4 PA Weekly)

Tolterodine Tartrate Zavesca Tolterodine Tartrate Zavesca (Capsule) 4 PA, LA 1

Zemaira (Tablet)

Zemaira (Injection) 4 PA, LA Tolterodine Tartrate ER

Zenpep Tolterodine Tartrate Zenpep (Capsule 2 ER (Capsule Extended- 1 Delayed-Release) Release 24 Hour) Genitourinary Agents Toviaz (Tablet Antispasmodics, Urinary Extended-Release 24 3 QL, ST Darifenacin HBr ER HBr ER Hour) (Tablet Extended- 1 QL Trospium Chloride Chloride 1 Release 24 Hour) (Tablet)

Detrol Detrol (Tablet) 3 Trospium Chloride ER Chloride ER

Detrol LA Detrol LA (Capsule (Capsule Extended- 1

Extended-Release 24 3 Release 24 Hour) Hour) Vesicare (Tablet) 2 QL

Ditropan XL Ditropan XL (Tablet Benign Prostatic Hypertrophy Agents Extended-Release 24 3 QL Alfuzosin HCl ER HCl ER

Hour) (Tablet Extended- 1 Enablex Enablex (Tablet Release 24 Hour)

Extended-Release 24 3 QL Avodart Avodart (Capsule) 3 Hour) Cardura XL

Flavoxate HCl Cardura XL (Tablet Flavoxate HCl (Tablet) 1 Extended-Release 24 3 QL

Gelnique Gelnique (10% Gel) 3 QL Hour)

Myrbetriq Myrbetriq (Tablet Cialis (2.5mg Tablet, 3 PA, QL Extended-Release 24 2 5mg Tablet)

Dutasteride Hour) Dutasteride (Capsule) 1

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Dutasteride/Dutasteride/Tamsulosin HCl Alclometasone Dipropionate

Tamsulosin HCl 1 Dipropionate (0.05% 1 (Capsule) Cream, 0.05% Finasteride (5mg Ointment)

Amcinonide Tablet) (Generic 1 Amcinonide (0.1%

Proscar) Cream, 0.1% Lotion, 1

Flomax Flomax (Capsule) 3 0.1% Ointment)

ApexiCon E Jalyn Jalyn (Capsule) 3 ApexiCon E (Cream) 4

Augmented Betamethasone Dipropionate

Proscar Proscar (Tablet) 3 Augmented

Rapaflo Betamethasone Rapaflo (Capsule) 2 QL Dipropionate (0.05% Tamsulosin HCl HCl 1 1 Cream, 0.05% Gel, (Capsule) 0.05% Lotion, 0.05% Terazosin HCl HCl 1 Ointment) (Capsule) Betamethasone Dipropionate Uroxatral (Tablet Dipropionate (0.05% 1 Extended-Release 24 3 Cream, 0.05% Lotion, Hour) 0.05% Ointment) Genitourinary Agents, Other Betamethasone Valerate Bethanechol Chloride Chloride Valerate (0.1% Cream, 1 (Tablet) 0.1% Lotion, 0.1% 1 Cuprimine (Capsule) 4 PA Ointment, 0.12%

Depen Titratabs Foam) Depen Titratabs 4 Capex (Tablet) Capex (Shampoo) 3

Clobetasol Propionate Elmiron Elmiron (Capsule) 3 Clobetasol Propionate

Lithostat (0.05% External Lithostat (Tablet) 4 Solution, 0.05% Foam, Thiola Thiola (Tablet) 4 0.05% Gel, 0.05% 1

Urecholine Urecholine (Tablet) 3 Liquid, 0.05% Lotion, Hormonal Agents, Stimulant/Replacement/ 0.05% Ointment, Modifying (Adrenal) 0.05% Shampoo) Clobetasol Propionate E Propionate Hormonal Agents, Stimulant/Replacement/ 1 Modifying (Adrenal) E (Cream)

Clobex Ala Scalp Clobex (0.05% Liquid, Ala Scalp (Lotion) 3

Ala-Cort 0.05% Lotion, 0.05% 4 Ala-Cort (Cream) 1 Shampoo)

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Dexamethasone Intensol Clodan Dexamethasone Clodan (Shampoo) 1 Cloderm Pump Pump Intensol (1mg/ml 1 3 (Cream) Concentrate)

Dexamethasone Sodium Phosphate

Cordran Cordran (Tape) 3 Dexamethasone

Cormax Scalp Application Sodium Phosphate Cormax Scalp 1 (10mg/ml Injection, Application (External 1 120mg/30ml Injection)

Solution) DexPak 13 Day

Cortef DexPak 13 Day (Tablet Cortef (Tablet) 3 3 Therapy Pack) Cortisone Acetate

Diflorasone Diacetate Cortisone Acetate Diflorasone Diacetate 1 (Tablet) (0.05% Cream, 0.05% 1 Cutivate Cutivate (Lotion) 4 Ointment)

Depo-Medrol Depo-Medrol Diprolene (0.05% 3 (Injection) Lotion, 0.05% 3

Dermatop Dermatop (Cream) 3 Ointment)

Diprolene AF Desonate Desonate (Gel) 3 Diprolene AF (Cream) 3

Elocon Desonide (0.05% Elocon (0.1% Cream,

Cream, 0.05% Lotion, 1 0.1% Lotion, 0.1% 3 0.05% Ointment) Ointment)

Fludrocortisone Acetate DesOwen (0.05% Fludrocortisone 3 1 Cream) Acetate (Tablet)

Fluocinolone Acetonide DesOwen (0.05% Fluocinolone 3 Lotion) Acetonide (0.01% Desoximetasone Cream, 0.025% Cream, Desoximetasone 1 (0.05% Cream, 0.25% 0.01% External

Cream, 0.05% Gel, 1 Solution, 0.025% 0.05% Ointment, Ointment) Fluocinolone Acetonide Body 0.25% Ointment) 1 Dexamethasone Acetonide Body (Oil) (0.5mg Tablet, 0.75mg Fluocinonide (0.05% Tablet, 1.5mg Tablet, External Solution, 1 1mg Tablet, 2mg 1 0.05% Gel, 0.05% Tablet, 4mg Tablet, Ointment, 0.1% Cream) 6mg Tablet, 0.5mg/ Fluocinonide-E 1 5ml Elixir) (Cream)

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Flurandrenolide (0.05% Locoid (0.1% Cream,

Cream, 0.05% Lotion, 1 0.1% External 3 0.05% Ointment) Solution, 0.1% Lotion, Fluticasone Propionate Propionate 0.1% Ointment)

LoKara (0.005% Ointment, LoKara (Lotion) 1 1 Medrol 0.05% Cream, 0.05% Medrol (Tablet) 3

Lotion) Medrol Dosepak Medrol Dosepak H.P. Acthar 3 H.P. Acthar (Injection) 4 PA (Tablet Therapy Pack)

Halobetasol Propionate Halobetasol Methylprednisolone Propionate (0.05% 1 1 (Tablet) Cream, 0.05% Methylprednisolone Acetate 1 Ointment) Acetate (Injection) Halog

Methylprednisolone Dose Pack Halog (0.1% Cream, Methylprednisolone 4 0.1% Ointment) Dose Pack (Tablet 1 Hydrocortisone Hydrocortisone (1% Therapy Pack) Cream, 2.5% Cream, Methylprednisolone Sodium Succinate 1% Ointment, 2.5% Sodium Succinate 1 Ointment, 10mg 1 (Injection)

Tablet, 20mg Tablet, Micort-HC 5mg Tablet, 2.5% Micort-HC (Cream) 3 Millipred (10mg/5ml Lotion) Hydrocortisone Butyrate Oral Solution, 5mg 3 Butyrate (0.1% External Tablet) 1 Mometasone Furoate Solution, 0.1% Mometasone Furoate (0.1% Cream, 0.1% Ointment) 1 Hydrocortisone Butyrate External Solution, 0.1%

Butyrate (Lipophilic) 1 Ointment) Nolix (Cream) Nolix (Lotion) 1

Olux Hydrocortisone Valerate Hydrocortisone Olux (Foam) 4

Valerate (0.2% Cream, 1 Orapred ODT ODT (Tablet 3 0.2% Ointment) Dispersible)

Kenalog Kenalog (Aerosol Pandel 3 Pandel (Cream) 3 Solution) Prednicarbate (0.1% Kenalog-10 1 Kenalog-10 (Injection) 3 Cream)

Kenalog-40 Kenalog-40 (Injection) 3

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Prednicarbate (0.1% Topicort (0.05% 1 Ointment) Ointment, 0.25% 3 Prednisolone Sodium Phosphate Sodium Liquid) Phosphate (10mg/5ml Triamcinolone Acetonide Oral Solution, 15mg/ Acetonide (0.025% 5ml Oral Solution, Cream, 0.1% Cream, 1 20mg/5ml Oral 0.5% Cream, 0.025% Solution, 25mg/5ml Lotion, 0.1% Lotion,

Oral Solution, 5mg/5ml 0.025% Ointment, 1 Oral Solution) 0.1% Ointment, 0.5% Prednisolone Sodium Phosphate ODT Sodium Ointment, 0.147mg/

Phosphate ODT 1 gm Aerosol Solution (Tablet Dispersible) Generic Kenalog Prednisone (10mg Spray)

Trianex Tablet Therapy Pack, Trianex (Ointment) 4

Triderm 5mg Tablet Therapy Triderm (Cream) 1

Pack, 10mg Tablet, Tridesilon Tridesilon (Cream) 1

1mg Tablet, 2.5mg 1 Ultravate Ultravate (0.05% Tablet, 20mg Tablet, 50mg Tablet, 5mg Cream, 0.05% 3 Tablet, 5mg/5ml Oral Ointment) Ultravate (0.05% Solution) 4 Prednisone Intensol Intensol Lotion) 1 Vanos (5mg/ml Concentrate) Vanos (Cream) 4

Veripred 20 Psorcon Veripred 20 (Oral Psorcon (Cream) 1 3 Rayos (Tablet Solution) 4 PA Delayed-Release) Hormonal Agents, Stimulant/Replacement/

Solu-Cortef Modifying (Pituitary) Solu-Cortef (Injection) 3

Solu-Medrol Hormonal Agents, Stimulant/Replacement/ Solu-Medrol 3 Modifying (Pituitary) (Injection) Chorionic Gonadotropin

Synalar Chorionic Synalar (Cream) 3 Gonadotropin 1 PA Topicort Topicort (0.05% (Injection)

DDAVP Cream, 0.25% Cream, DDAVP (0.01% Nasal 3 0.05% Gel, 0.25% Rhinal Tube Solution, 3 Ointment) 0.1mg Tablet)

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DDAVP (0.01% Nasal Nutropin AQ AQ 4 PA Spray Solution, 0.2mg (Injection)

4 Omnitrope Tablet, 4mcg/ml Omnitrope (10mg/ Injection) 1.5ml Injection, 5mg/ 4 PA Desmopressin Acetate 1.5ml Injection)

Acetate (0.01% Nasal 1 Omnitrope (5.8mg 3 PA Rhinal Tube Solution) Injection)

Desmopressin Acetate Desmopressin Acetate Pregnyl w/Diluent Benzyl Alcohol/NaCl w/Diluent (0.01% Nasal Spray Benzyl Alcohol/NaCl 1 PA Solution, 0.1mg Tablet, 1 (Injection) 0.2mg Tablet, 4mcg/ Saizen (Injection) 4 PA

ml Injection) Stimate

Genotropin Stimate (Nasal 4 Genotropin (12mg Solution)

Injection, 5mg 4 PA Zomacton Zomacton (10mg Injection) 4 PA

Genotropin Miniquick Injection)

Genotropin Miniquick Zomacton 3 PA Zomacton (5mg (0.2mg Injection) 3 PA

Genotropin Miniquick Injection) Genotropin Miniquick Hormonal Agents, Stimulant/Replacement/ (0.4mg Injection, Modifying (Prostaglandins) 0.6mg Injection, 0.8mg Injection, Hormonal Agents, Stimulant/Replacement/ 1.2mg Injection, Modifying (Prostaglandins) 4 PA Korlym 1.4mg Injection, Korlym (Tablet) 4 PA, QL 1.6mg Injection, Hormonal Agents, Stimulant/Replacement/ 1.8mg Injection, 1mg Modifying (Sex /Modifiers) Injection, 2mg Androgens

Injection) Anadrol-50 Anadrol-50 (Tablet) 4 PA Humatrope

Humatrope (Injection) 4 PA Androderm Androderm (Patch 24 Humatrope Combo Pack Combo 2 QL 4 PA Hour) Pack (Injection) AndroGel (1% Packet Increlex 3 Increlex (Injection) 4 PA Gel)

Norditropin FlexPro Norditropin FlexPro AndroGel (1.62% 4 PA 2 (Injection) Packet Gel)

Novarel Novarel (Injection) 1 PA AndroGel Pump Pump 2 (1.62% Gel)

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Aveed Aranelle Aveed (Injection) 3 Aranelle (Tablet) 1

Axiron Ashlyna Axiron (Transdermal Ashlyna (Tablet) 1 3 PA, QL Aubra Solution) Aubra (Tablet) 1 Danazol

Aviane Danazol (Capsule) 1 Aviane (Tablet) 1

Depo-Testosterone

Depo-Testosterone Balziva 3 Balziva (Tablet) 1

(Injection) Bekyree

Fortesta Bekyree (Tablet) 1 Fortesta (Gel) 3 PA Beyaz

Methitest Beyaz (Tablet) 3 Methitest (Tablet) 3 PA Blisovi 24 Fe

Methyltestosterone Blisovi 24 Fe (Tablet) 1 Methyltestosterone 1 PA Blisovi Fe 1.5/30 Fe 1.5/30 (Capsule) 1

Oxandrolone (Tablet) Oxandrolone (Tablet) 1 PA, QL Blisovi Fe 1/20

Striant Blisovi Fe 1/20 (Tablet) 1 Striant 3 PA Brevicon-28

Testim Brevicon-28 (Tablet) 3 Testim (Gel) 3 PA Briellyn

Testosterone Briellyn (Tablet) 1 Testosterone (10mg/ 3 PA Camrese Lo act Gel) Camrese Lo (Tablet) 1

Caziant Testosterone (25mg/ Caziant (Tablet) 1

Climara Pro 2.5gm Gel, 50mg/5gm 1 Climara Pro (Patch 3 PA, HRM Gel) Weekly)

Testosterone Cypionate Cryselle-28 Testosterone 1 Cryselle-28 (Tablet) 1 Cyclafem Cypionate (Injection) Cyclafem (Tablet) 1 Testosterone Enanthate

Testosterone Cyclessa 1 Cyclessa (Tablet) 3 Enanthate (Injection) Delestrogen

Testosterone Pump Delestrogen Testosterone Pump 3 1 (Injection) (Gel) Delyla

Vogelxo Delyla (Tablet) 1 Vogelxo (Gel) 3 PA Depo-Estradiol

Vogelxo Pump Depo-Estradiol Vogelxo Pump (Gel) 3 PA 3 (Injection)

Estrogens Desogen Desogen (Tablet) 3 Alora

Alora (Patch Twice PA, QL, Desogestrel/Ethinyl Estradiol 3 Desogestrel/Ethinyl Weekly) HRM 1 Estradiol (Tablet) Alyacen 1/35

Alyacen 1/35 (Tablet) 1 Drospirenone/Ethinyl Estradiol Drospirenone/Ethinyl Amethia 1 Amethia (Tablet) 1 Estradiol (Tablet)

Amethia Lo Amethia Lo (Tablet) 1

Apri Apri (Tablet) 1

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Drospirenone/Ethinyl Estradiol/Levomefolate Calcium Femhrt Low Dose Low Dose 3 PA, HRM Estradiol/ (Tablet) 1 Femring Levomefolate Femring (Ring) 3

Calcium (Tablet) Femynor Femynor (Tablet) 1 Elestrin

Elestrin (Gel) 3 PA, HRM Fyavolv Fyavolv (Tablet) 1 PA, HRM Emoquette Emoquette (Tablet) 1 Generess Fe Generess Fe (Tablet Enpresse-28 3 Enpresse-28 (Tablet) 1 Chewable)

Estrace Estrace (0.1mg/gm Gianvi 3 Gianvi (Tablet) 1 Cream) Gildagia Gildagia (Tablet) 1 Estrace

Estrace (0.5mg Tablet, Introvale Introvale (Tablet) 1 1mg Tablet, 2mg 3 PA, HRM

Jinteli Tablet) Jinteli (Tablet) 1 HRM

Juleber Estradiol Estradiol (0.025mg/ Juleber (Tablet) 1

Junel 1.5/30 24hr Patch Twice Junel 1.5/30 (Tablet) 1

Junel 1/20 Weekly, 0.0375mg/ Junel 1/20 (Tablet) 1

24hr Patch Twice Junel Fe 1.5/30

Weekly, 0.05mg/24hr PA, QL, Junel Fe 1.5/30 1 1 Patch Twice Weekly, HRM (Tablet) Junel Fe 1/20 0.075mg/24hr Patch Junel Fe 1/20 (Tablet) 1

Junel Fe 24 Twice Weekly, 0.1mg/ Junel Fe 24 (Tablet) 1 24hr Patch Twice Kaitlib Fe Fe (Tablet 1 Weekly) Chewable)

Estradiol

Kariva Estradiol (0.5mg Kariva (Tablet) 1

Tablet, 1mg Tablet, Kelnor 1/35 1 PA, HRM Kelnor 1/35 (Tablet) 1 2mg Tablet) (Generic Kimidess Estrace) Kimidess (Tablet) 1

LARIN 1.5/30 Estradiol Valerate Estradiol Valerate LARIN 1.5/30 (Tablet) 1

1 LARIN 1/20 (Injection) LARIN 1/20 (Tablet) 1

Estring Estring (Ring) 3 LARIN Fe 1.5/30 Fe 1.5/30

Ethynodiol Diacetate/Ethinyl Estradiol 1 Ethynodiol Diacetate/ (Tablet)

LARIN Fe 1/20 Ethinyl Estradiol 1 LARIN Fe 1/20 (Tablet) 1

Larissia (Tablet) Larissia (Tablet) 1 Falmina Falmina (Tablet) 1 Layolis Fe Fe (Tablet Fayosim 1 Fayosim (Tablet) 1 Chewable)

Leena Leena (Tablet) 1

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Microgestin Fe Lessina Lessina (Tablet) 1 Microgestin Fe 1 Levonest Levonest (Tablet) 1 (Tablet)

Microgestin Fe 1.5/30 Levonorgestrel and Ethinyl Estradiol Levonorgestrel and Microgestin Fe 1.5/30 1 Ethinyl Estradiol 1 (Tablet) Minastrin 24 Fe 24 Fe (Tablet) 3 Levonorgestrel/Ethinyl Estradiol (Tablet Chewable) 1 Minivelle (Patch PA, QL, Estradiol (Tablet) 3 Levora 0.15/30-28 0.15/30-28 Twice Weekly) HRM 1 MonoNessa (Tablet) MonoNessa (Tablet) 1

Natazia Lo Loestrin Fe Lo Loestrin Fe Natazia (Tablet) 3

3 Necon 0.5/35-28 (Tablet) Necon 0.5/35-28

Loestrin 1.5/30-21 1 Loestrin 1.5/30-21 (Tablet)

3 Necon 1/50-28 (Tablet) Necon 1/50-28

Loestrin 1/20-21 1 Loestrin 1/20-21 (Tablet)

3 Necon 10/11-28 (Tablet) Necon 10/11-28

Loestrin Fe 1.5/30 1 Loestrin Fe 1.5/30 (Tablet) 3 Necon 7/7/7 (Tablet) Necon 7/7/7 (Tablet) 1

Loestrin Fe 1/20 Loestrin Fe 1/20 Nikki 3 Nikki (Tablet) 1

(Tablet) Norethindrone & Ethinyl Estradiol Ferrous Fumarate Norethindrone & Lomedia 24 Fe Lomedia 24 Fe (Tablet) 1 Ethinyl Estradiol Loryna 1 Loryna (Tablet) 1 Ferrous Fumarate LoSeasonique (Tablet Chewable)

3 Norethindrone Acetate/Ethinyl Estradiol (Tablet) Norethindrone

Low-Ogestrel Low-Ogestrel (Tablet) 1 Acetate/Ethinyl 1 PA, HRM

Lutera Estradiol (Tablet) Lutera (Tablet) 1 Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Marlissa Norethindrone Marlissa (Tablet) 1 Acetate/Ethinyl

Menest Menest (Tablet) 3 PA, HRM Estradiol/Ferrous

Mibelas 24 Fe 1 Mibelas 24 Fe (Tablet Fumarate 1 Chewable) (20mcg-75mg-1mg Microgestin 1.5/30 1.5/30 Tablet)

1 Norethindrone/Ethinyl Estradiol/Ferrous Fumarate (Tablet) Norethindrone/Ethinyl Microgestin 1/20 1/20 Estradiol/Ferrous 1 1 (Tablet) Fumarate (Tablet Chewable)

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Norgestimate/Ethinyl Estradiol Rivelsa Norgestimate/Ethinyl Rivelsa (Tablet) 1 1 Safyral Estradiol (Tablet) Safyral (Tablet) 3 Norinyl 1+35

Seasonique Norinyl 1+35 (Tablet) 3 Seasonique (Tablet) 3

Nortrel 0.5/35

Nortrel 0.5/35 (28) Setlakin 1 Setlakin (Tablet) 1 (Tablet) Sprintec 28

Nortrel 1/35 Sprintec 28 (Tablet) 1 Nortrel 1/35 (Tablet) 1 Sronyx

Nortrel 7/7/7 Sronyx (Tablet) 1 Nortrel 7/7/7 (Tablet) 1 Tarina Fe 1/20

NuvaRing Tarina Fe 1/20 (Tablet) 1 NuvaRing (Ring) 3 Tri-Legest Fe

Ocella Tri-Legest Fe (Tablet) 1 Ocella (Tablet) 1 Tri-Lo-Estarylla

Ogestrel Tri-Lo-Estarylla (Tablet) 1 Ogestrel (Tablet) 1 Tri-Lo-Sprintec

Orsythia Tri-Lo-Sprintec (Tablet) 1 Orsythia (Tablet) 1 Tri-Norinyl 28

Ortho Tri-Cyclen Tri-Norinyl 28 (Tablet) 3 Ortho Tri-Cyclen 3 Tri-Previfem (Tablet) Tri-Previfem (Tablet) 1

Tri-Sprintec Ortho Tri-Cyclen Lo Tri-Cyclen Lo Tri-Sprintec (Tablet) 1

3 Trinessa (Tablet) Trinessa (Tablet) 1

Ortho-Cyclen Trivora-28 Ortho-Cyclen (Tablet) 3 Trivora-28 (Tablet) 1

Ortho-Novum 1/35 Ortho-Novum 1/35 Vagifem 3 Vagifem (Tablet) 3 QL

(Tablet) Velivet Velivet (Tablet) 1 Ortho-Novum 7/7/7

Ortho-Novum 7/7/7 Vestura 3 (Tablet) Vestura (Tablet) 1 Vienva

Ovcon-35 Ovcon-35 (Tablet) 3 Vienva (Tablet) 1

Vivelle-Dot

Pimtrea Vivelle-Dot (Patch PA, QL, Pimtrea (Tablet) 1 3 Twice Weekly) HRM Pirmella 1/35

Pirmella 1/35 (Tablet) 1 Vyfemla Vyfemla (Tablet) 1 Portia-28

Portia-28 (Tablet) 1 WYMZYA Fe WYMZYA Fe (Tablet Premarin (25mg 1 3 Chewable)

Injection) Xulane Xulane (Patch Weekly) 1 Premarin

Premarin (Vaginal Yasmin 28 2 Cream) Yasmin 28 (Tablet) 3 Yaz

Previfem Previfem (Tablet) 1 Yaz (Tablet) 3

Yuvafem

Quartette Quartette (Tablet) 3 Yuvafem (Tablet) 1 QL Zarah

Quasense Quasense (Tablet) 1 Zarah (Tablet) 1 Zenchent

Reclipsen Reclipsen (Tablet) 1 Zenchent (Tablet) 1

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Zenchent Fe Fe (Tablet Megestrol Acetate Acetate 1 Chewable) (20mg Tablet, 40mg

Zovia 1/35E Zovia 1/35E (Tablet) 1 Tablet, 40mg/ml 1 PA, HRM

Zovia 1/50E Suspension, 625mg/ Zovia 1/50E (Tablet) 1 5ml Suspension)

Progestins Nora-BE Nora-BE (Tablet) Aygestin 1

Aygestin (Tablet) 3 Norethindrone

Camila Norethindrone (Tablet) 1

Camila (Tablet) 1 Norethindrone Acetate Norethindrone Acetate Crinone 1 Crinone (Gel) 3 PA (Tablet)

Deblitane Norlyroc Deblitane (Tablet) 1 Norlyroc (Tablet) 1

Depo-Provera Depo-Provera Ortho Micronor Micronor 3 3 (Injection) (Tablet)

Depo-Provera Contraceptive Depo-Provera Progesterone 1 Contraceptive 3 (Capsule)

(Injection) Prometrium Prometrium (Capsule) 3 Depo-SubQ Provera104

Depo-SubQ Provera Provera (Tablet) 3 Provera104 3 Sharobel (Injection) Sharobel (Tablet) 1

Errin Errin (Tablet) 1 Selective Estrogen Receptor Modifying Hydroxyprogesterone Caproate Agents 1 PA Evista Caproate (Injection) Evista (Tablet) 3 QL

Raloxifene HCl Jolivette Jolivette (Tablet) 1 Raloxifene HCl (Tablet) 1 QL

Lyza Lyza (Tablet) 1 Hormonal Agents, Stimulant/Replacement/

Makena Modifying (Thyroid) Makena (Injection) 4 PA

Medroxyprogesterone Acetate Hormonal Agents, Stimulant/Replacement/ Medroxyprogesterone Modifying (Thyroid) Acetate (10mg Tablet, Cytomel 2.5mg Tablet, 5mg 1 Cytomel (Tablet) 3 Levothyroxine Sodium Tablet, 150mg/ml Injection) Sodium (100mcg 1 Megace ES ES Injection) 4 PA, HRM (Suspension) Megace Oral Oral 3 PA, HRM (Suspension)

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Levothyroxine Sodium Sodium Firmagon (80mg 3 PA (100mcg Tablet, Injection) 112mcg Tablet, Leuprolide Acetate Acetate 1 PA 125mcg Tablet, (Injection)

137mcg Tablet, Lupaneta Pack Lupaneta Pack (Kit) 4 PA

150mcg Tablet, 1 Lupron Depot Lupron Depot 175mcg Tablet, 4 PA (Injection) 200mcg Tablet, 25mcg Lupron Depot-Ped Depot-Ped (1- Tablet, 300mcg Tablet, 4 PA 50mcg Tablet, 75mcg Month) (Injection) Octreotide Acetate Acetate Tablet, 88mcg Tablet) 1 PA Levoxyl Levoxyl (Tablet) 1 (Injection) Sandostatin

Liothyronine Sodium Sandostatin Liothyronine Sodium (100mcg/ml Injection, (10mcg/ml Injection, 4 PA 1 500mcg/ml Injection) 25mcg Tablet, 50mcg Sandostatin (50mcg/ Tablet, 5mcg Tablet) 3 PA Synthroid ml Injection) Synthroid (Tablet) 2 Sandostatin LAR Depot

Thyrolar Sandostatin LAR Thyrolar (Tablet) 2 4 PA Depot (Injection) Tirosint Tirosint (Capsule) 3 Signifor (Injection) 4 PA Triostat Triostat (Injection) 3 Signifor LAR LAR Unithroid 4 PA Unithroid (Tablet) 1 (Injection) Hormonal Agents, Suppressant (Adrenal) Somatuline Depot Depot 4 PA Hormonal Agents, Suppressant (Adrenal) (Injection)

Somavert Lysodren Lysodren (Tablet) 4 Somavert (Injection) 4 PA, QL Synarel (Nasal Hormonal Agents, Suppressant (Pituitary) 4 Hormonal Agents, Suppressant (Pituitary) Solution)

Trelstar Mixject Cabergoline Trelstar Mixject Cabergoline (Tablet) 1 4 PA

Egrifta (Injection) Egrifta (Injection) 4 PA

Eligard Hormonal Agents, Suppressant (Thyroid) Eligard (22.5mg Antithyroid Agents Injection, 30mg 3 PA Methimazole Injection, 7.5mg Methimazole (Tablet) 1 Injection) Propylthiouracil 1 Firmagon (120mg (Tablet)

4 PA Tapazole Injection) Tapazole (Tablet) 3

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Immunological Agents Envarsus XR XR (Tablet Angioedema Agents Extended-Release 24 3 PA Berinert (Injection) 4 PA, LA Hour)

Gengraf

Cinryze Gengraf (100mg Cinryze (Injection) 4 PA, LA Capsule, 25mg Firazyr Firazyr (Injection) 4 PA, QL Capsule, 50mg 1 B/D, PA Ruconest (Injection) 4 PA Capsule, 100mg/ml Immune Suppressants Oral Solution)

Humira Astagraf XL XL (Capsule Humira (Injection) 4 PA Extended-Release 24 3 PA Humira Pediatric Crohns Disease Starter Pack Pediatric Hour) Crohns Disease

Azasan 4 PA Azasan (Tablet) 3 B/D, PA Starter Pack Azathioprine (100mg (Injection) 1 B/D, PA Humira Pen Pen Injection, 50mg Tablet) 4 PA Cellcept (200mg/ml (Injection) Suspension, 250mg Humira Pen Crohns Disease Starter Pack Pen Crohns 4 PA Capsule, 500mg Disease Starter Pack 4 PA Tablet) (Injection)

Humira Pen-Psoriasis Starter Cellcept Intravenous Intravenous Humira Pen-Psoriasis 3 PA 4 PA (Injection) Starter (Injection)

Imuran Cimzia (Injection) 4 PA Imuran (Tablet) 3 B/D, PA

Inflectra Cyclosporine (100mg Inflectra (Injection) 4 PA Capsule, 25mg 1 B/D, PA Kineret (Injection) 4 PA

Methotrexate Capsule) Methotrexate (Tablet) 1 Cyclosporine

Cyclosporine (50mg/ Methotrexate Sodium 1 Methotrexate Sodium ml Injection) 1 (Injection) Cyclosporine Modified

Cyclosporine Modified Mycophenolate Mofetil Mycophenolate Mofetil (100mg Capsule, (200mg/ml 25mg Capsule, 50mg 1 B/D, PA Suspension, 250mg Capsule, 100mg/ml 1 PA Capsule, 500mg Oral Solution) Injection, 500mg Enbrel Enbrel (Injection) 4 PA Tablet)

Enbrel SureClick Enbrel SureClick Mycophenolic Acid DR 4 PA Mycophenolic Acid DR (Injection) (Tablet Delayed- 1 B/D, PA Release)

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Myfortic (180mg Sandimmune Tablet Delayed- 3 B/D, PA (100mg/ml Oral 3 B/D, PA Release) Solution, 25mg Myfortic (360mg Capsule) Tablet Delayed- 4 B/D, PA Sandimmune (50mg/ 3 Release) ml Injection)

Neoral Neoral (100mg Simponi (Injection) 4 PA Capsule, 25mg Simponi Aria Aria 3 B/D, PA 4 PA Capsule, 100mg/ml (Injection)

Oral Solution) Sirolimus Sirolimus (Tablet) 1 B/D, PA Nulojix

Nulojix (Injection) 4 PA Tacrolimus Tacrolimus (0.5mg Orencia Orencia (125mg/ml Capsule, 1mg Capsule, 1 PA Injection, 250mg 4 PA 5mg Capsule)

Injection) Torisel Torisel (Injection) 4 Orencia Clickject

Orencia Clickject Trexall 4 PA Trexall (Tablet) 3 (Injection)

Xeljanz Otrexup (Injection) 3 PA Xeljanz (Tablet) 4 PA, QL

Xeljanz XR Prograf (0.5mg Xeljanz XR (Tablet Capsule, 1mg Extended-Release 24 4 PA, QL 3 PA Capsule, 5mg/ml Hour)

Zortress Injection) Zortress (Tablet) 4 PA Prograf (5mg Immunizing Agents, Passive

4 PA Atgam Capsule) Atgam (Injection) 4

Rapamune Rapamune (0.5mg BIVIGAM 3 B/D, PA BIVIGAM (Injection) 4 PA Tablet) Carimune Nanofiltered

Rapamune Rapamune (1mg Nanofiltered 4 PA Tablet, 2mg Tablet, 4 B/D, PA (Injection) 1mg/ml Oral Solution) Flebogamma DIF DIF Rasuvo 4 PA Rasuvo (Injection) 3 PA (Injection)

Remicade Remicade (Injection) 4 PA Gamastan S/D S/D

Sandimmune 2 PA Sandimmune (100mg (Injection)

4 B/D, PA Gammagard Liquid Capsule) Gammagard Liquid 4 PA (Injection)

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Gammagard S/D IGA Less Than 1 mcg/ml S/D IGA Otezla (Tablet Less Than 1 mcg/ml 4 PA Therapy Pack, 30mg 4 PA (Injection) Tablet)

Gammaked Ridaura Gammaked (Injection) 4 PA Ridaura (Capsule) 4

Gammaplex Simulect Gammaplex Simulect (Injection) 4 4 PA (Injection) Sylvant (Injection) 4 PA

Gamunex-C

Gamunex-C Synagis 4 PA Synagis (Injection) 4 PA (Injection) Xolair

Hyperrab S/D Xolair (Injection) 4 PA Hyperrab S/D 3 B/D, PA Zinplava (Injection) Zinplava (Injection) 4 PA Imogam Rabies-HT Rabies-HT Vaccines

3 B/D, PA ActHIB (Injection) ActHIB (Injection) 2

Octagam Adacel Octagam (Injection) 4 PA Adacel (Injection) 2 Privigen (Injection) 4 PA BCG Vaccine Vaccine 2 Thymoglobulin (Injection)

4 Bexsero (Injection) Bexsero (Injection) 2

Varizig Boostrix Varizig (Injection) 2 Boostrix (Injection) 2

Daptacel Immunomodulators Daptacel (Injection) 2

Actemra Actemra (162mg/ Diphtheria/Tetanus Toxoids Adsorbed Pediatric

0.9ml Injection, Toxoids Adsorbed 1 200mg/10ml 4 PA Pediatric (Injection) Injection, 400mg/ Engerix-B (Injection) 2 B/D, PA

20ml Injection) Gardasil 9

Actemra Gardasil 9 (Injection) 2 Actemra (80mg/4ml 3 PA Havrix Injection) Havrix (Injection) 2

Hiberix Actimmune Actimmune (Injection) 4 Hiberix (Injection) 2

Imovax Rabies Arava Imovax Rabies Arava (Tablet) 4 2 B/D, PA

Arcalyst (H.D.C.V.) (Injection) Arcalyst (Injection) 4 PA, LA Infanrix

Benlysta Infanrix (Injection) 2

Benlysta (Injection) 4 PA IPOL Inactivated IPV

Ilaris IPOL Inactivated IPV 2 Ilaris (Injection) 4 PA, QL, LA (Injection) Leflunomide Ixiaro Leflunomide (Tablet) 1 Ixiaro (Injection) 2

Kinrix Kinrix (Injection) 2

M-M-R II M-M-R II (Injection) 2

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Balsalazide Disodium Menactra Menactra (Injection) 2 Balsalazide Disodium 1 Menomune-A/C/Y/Menomune-A/C/Y/W-135 (Capsule) 2 Canasa W-135 (Injection) Canasa (Suppository) 4

Menveo Colazal Menveo (Injection) 2 Colazal (Capsule) 4

Delzicol Pediarix Pediarix (Injection) 2 Delzicol (Capsule 3 ST Pedvax HIB Pedvax HIB (Injection) 2 Delayed-Release) Dipentum

ProQuad ProQuad (Injection) 2 Dipentum (Capsule) 4 Giazo

Quadracel Quadracel (Injection) 2 Giazo (Tablet) 3

Lialda

Rabavert Lialda (Tablet Rabavert (Injection) 2 B/D, PA 2 QL

Recombivax HB Delayed-Release)

Recombivax HB Mesalamine 2 B/D, PA (Injection) Mesalamine (Kit) 1 Mesalamine DR

Rotarix Mesalamine DR Rotarix (Suspension) 2

RotaTeq (Tablet Delayed- 3 QL, ST RotaTeq (Oral 2 Release)

Solution) Pentasa Pentasa (Capsule Tenivac 3 QL Tenivac (Injection) 2 Extended-Release)

Tetanus/Diphtheria Toxoids-Adsorbed Adult Tetanus/Diphtheria sfRowasa sfRowasa () 4 QL Toxoids-Adsorbed 1 Glucocorticoids Adult (Injection) Anusol-HC

Trumenba Anusol-HC (Cream) 3 Trumenba (Injection) 2 Budesonide

Twinrix Budesonide (3mg Twinrix (Injection) 2 Capsule Delayed- 1 Typhim Vi Typhim Vi (Injection) 2 Release)

VAQTA Colocort VAQTA (Injection) 2 Colocort (Enema) 1

Varivax Varivax (Injection) 2 Entocort EC EC (Capsule

YF-Vax 4 YF-Vax (Injection) 2 Delayed-Release)

Hydrocortisone Zostavax Hydrocortisone Zostavax (Injection) 2 PA 1 (100mg/60ml Enema) Inflammatory Bowel Disease Agents Procto-Med HC HC Aminosalicylates 1

Apriso (Cream)

Apriso (Capsule Procto-Pak Extended-Release 24 2 QL Procto-Pak (Cream) 1 Proctosol HC Hour) Proctosol HC (Cream) 1

Proctozone-HC Asacol HD HD (Tablet Proctozone-HC 3 QL, ST 1 Delayed-Release) (Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 130 131

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Uceris (2mg/act Calcitriol (0.25mcg 3 Foam) Capsule, 0.5mcg Uceris (9mg Tablet Capsule, 1mcg/ml 1 B/D, PA Extended-Release 24 4 ST Injection, 1mcg/ml Hour) Oral Solution)

Doxercalciferol Sulfonamides Doxercalciferol

Azulfidine (0.5mcg Capsule, Azulfidine (Tablet) 3 1 B/D, PA, QL

Azulfidine EN-Tabs 1mcg Capsule, 2.5mcg Azulfidine EN-Tabs Capsule)

(Tablet Delayed- 3 Doxercalciferol Doxercalciferol (4mcg/ Release) 1 B/D, PA

Sulfasalazine 2ml Injection)

Sulfasalazine (500mg Etidronate Disodium

Tablet Delayed- Etidronate Disodium 1 1 Release, 500mg Tablet (Tablet)

Forteo Immediate-Release) Forteo (Injection) 4 PA, QL Metabolic Bone Disease Agents Fosamax (Tablet) 3 QL Metabolic Bone Disease Agents Fosamax Plus D Plus D 3 QL Actonel (Tablet) 3 QL (Tablet)

Hectorol Alendronate Sodium Sodium Hectorol (0.5mcg (10mg Tablet, 35mg Capsule, 1mcg 3 B/D, PA, QL Tablet, 40mg Tablet, 1 QL Capsule) Hectorol (2.5mcg 5mg Tablet, 70mg 4 B/D, PA, QL Tablet) Capsule)

Hectorol Alendronate Sodium Sodium Hectorol (4mcg/2ml 3 B/D, PA (70mg/75ml Oral 1 Injection) Solution) Ibandronate Sodium Sodium

Atelvia 1 QL Atelvia (Tablet (150mg Tablet)

3 QL Ibandronate Sodium Delayed-Release) Ibandronate Sodium

Binosto 1 B/D, PA Binosto (Tablet (3mg/3ml Injection)

3 QL Miacalcin Effervescent) Miacalcin (200unit/ml

Boniva 4 PA Boniva (150mg Injection)

3 QL Natpara Tablet) Natpara (Injection) 4 PA

Boniva Boniva (3mg/3ml Pamidronate Disodium Disodium 3 B/D, PA 1 B/D, PA Injection) (Injection) Calcitonin-Salmon 1 QL (Nasal Solution)

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Paricalcitol Paricalcitol (1mcg Zometa (Injection) 4 B/D, PA Capsule, 2mcg 1 B/D, PA, QL Miscellaneous Therapeutic Agents Capsule) Miscellaneous Therapeutic Agents Paricalcitol

Paricalcitol (2mcg/ml Alcohol Prep Pads Alcohol Prep Pads 2 Injection, 5mcg/ml 1 B/D, PA Botox Injection, 4mcg Botox (Injection) 3 PA, QL Capsule) Dysport (Injection) 3 PA

Prolia Fomepizole Prolia (Injection) 3 Fomepizole (Injection) 1 Reclast (Injection) 3 PA Gauze (Non-medicated 2 Risedronate Sodium Sodium 2X2) 1 QL Insulin Syringes, Needles Syringes, (Tablet) 2 Risedronate Sodium DR Sodium Needles Sterile Water Irrigation Water DR (Tablet Delayed- 1 QL 1 Release) Irrigation (Solution) Rocaltrol (0.25mcg Xeomin (Injection) 3 PA Capsule, 0.5mcg 3 B/D, PA Ophthalmic Agents Capsule, 1mcg/ml Ophthalmic Agents, Other

Oral Solution) Atropine Sulfate Atropine Sulfate (1% Sensipar (30mg 1 2 B/D, PA, QL Ophthalmic Solution) Tablet) Bacitracin/Polymyxin B Bacitracin/Polymyxin B Sensipar (60mg 1 4 B/D, PA, QL (Ophthalmic Ointment) Tablet, 90mg Tablet) Blephamide Blephamide Tymlos 3 Tymlos (Injection) 4 PA, QL (Suspension)

Xgeva Xgeva (Injection) 4 PA Blephamide S.O.P. S.O.P.

Zemplar 3 Zemplar (1mcg (Ointment) Capsule, 2mcg 3 B/D, PA, QL Cystaran (Ophthalmic 4 Capsule) Solution)

Zemplar Zemplar (2mcg/ml Lacrisert 3 B/D, PA Lacrisert (Insert) 3 Injection) Lastacaft (Ophthalmic Zemplar (5mcg/ml 2 4 B/D, PA Solution) Injection) Maxitrol (0.1% Zoledronic Acid Acid (4mg/ 1 B/D, PA Ointment, 0.1% 3 5ml Injection) Suspension) Zoledronic Acid Acid (5mg/ 1 PA 100ml Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 132 133

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Neomycin/Bacitracin/Neomycin/Bacitracin/Polymyxin Tobradex (0.3%-0.1% 1 2 Polymyxin (Ointment) Ophthalmic Ointment) Neomycin/Polymyxin/Neomycin/Polymyxin/Bacitracin/Hydrocortisone Tobradex (0.3%-0.1%

Bacitracin/ Ophthalmic 3 1 Hydrocortisone Suspension) (Ophthalmic Ointment) Tobradex ST ST

Neomycin/Polymyxin/Dexamethasone Neomycin/Polymyxin/ (Ophthalmic 3 Dexamethasone (0.1% Suspension)

Ophthalmic Ointment, 1 Tobramycin/Tobramycin/Dexamethasone 0.1% Ophthalmic Dexamethasone 1 Suspension) (Ophthalmic Neomycin/Polymyxin/Neomycin/Polymyxin/Gramicidin Suspension)

Gramicidin 1 Xiidra (Ophthalmic 3 QL (Ophthalmic Solution) Solution)

Neomycin/Polymyxin/Hydrocortisone Zylet Neomycin/Polymyxin/ Zylet (Suspension) 3 Hydrocortisone (1% 1 Ophthalmic Anti-allergy Agents

Ophthalmic Alocril Alocril (Ophthalmic Suspension) 3

Neosporin Solution)

Neosporin (Ophthalmic Alomide 3 Alomide (Ophthalmic Solution) 3

Polymyxin B Sulfate/Trimethoprim Sulfate Solution)

Polymyxin B Sulfate/ Azelastine HCl Azelastine HCl (0.05% Trimethoprim Sulfate 1 1 Ophthalmic Solution) (Ophthalmic Solution) Bepreve

Polytrim Bepreve (Ophthalmic Polytrim (Ophthalmic 3 3 Solution) Solution) Cromolyn Sodium

Pred-G Cromolyn Sodium (4% Pred-G (Suspension) 3 1 Ophthalmic Solution) Pred-G S.O.P.

Pred-G S.O.P. Elestat 3 Elestat (Ophthalmic (Ointment) 3 Solution) Proparacaine HCl

Proparacaine HCl Emadine 1 Emadine (Ophthalmic (Ophthalmic Solution) 3 Solution) Restasis Restasis () 2 QL Epinastine HCl HCl Sulfacetamide Sodium/Prednisolone Sodium Phosphate 1 Sulfacetamide (Ophthalmic Solution) Sodium/Prednisolone Olopatadine HCl HCl (0.1% 1 1 Sodium Phosphate Ophthalmic Solution) (Ophthalmic Solution)

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Olopatadine HCl HCl Cosopt (Ophthalmic 1 3 (Ophthalmic Solution) Solution) Pataday (Ophthalmic Cosopt PF PF 3 3 Solution) (Ophthalmic Solution) Patanol (Ophthalmic Dorzolamide HCl HCl 2 1 Solution) (Ophthalmic Solution) Pazeo (Ophthalmic Dorzolamide HCl/Timolol Maleate HCl/ 2 Solution) Timolol Maleate 1 Ophthalmic Antiglaucoma Agents (Ophthalmic Solution)

Iopidine Alphagan P P (0.1% Iopidine (Ophthalmic 2 3 Ophthalmic Solution) Solution)

Isopto Carpine Alphagan P P (0.15% Isopto Carpine 3 3 Ophthalmic Solution) (Ophthalmic Solution)

Istalol Apraclonidine Istalol (Ophthalmic 1 3 (Ophthalmic Solution) Solution)

Levobunolol HCl Azopt Levobunolol HCl Azopt (Suspension) 2 1 Betagan (Ophthalmic (Ophthalmic Solution) 3 Metipranolol Solution) 1 Betaxolol HCl HCl (0.5% (Ophthalmic Solution) 1 Phospholine Iodide Iodide Ophthalmic Solution) 3 Betimol (Ophthalmic (Ophthalmic Solution) 3 Pilocarpine HCl Solution) Pilocarpine HCl (1%

Betoptic-S Ophthalmic Solution, Betoptic-S 3 (Suspension) 2% Ophthalmic 1

Brimonidine Tartrate Solution, 4% Brimonidine Tartrate Ophthalmic Solution)

(0.15% Ophthalmic 1 Simbrinza Simbrinza Solution) 2

Brimonidine Tartrate (Suspension)

Brimonidine Tartrate Timolol Maleate

(0.2% Ophthalmic 1 Timolol Maleate (0.25% Ophthalmic Solution) 1

Carteolol HCl Solution, 0.5% Carteolol HCl 1 Ophthalmic Solution)

(Ophthalmic Solution) Timolol Maleate Ophthalmic Gel Forming

Combigan Timolol Maleate Combigan 2 Ophthalmic Gel 1 (Ophthalmic Solution) Forming (Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 134 135

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Timoptic Ocudose Ocudose FML Liquifilm Liquifilm 3 3 (Ophthalmic Solution) (Suspension)

Timoptic-XE Ilevro Timoptic-XE (Gel Ilevro (Suspension) 2 3 Form Solution) Ketorolac Tromethamine Trusopt (Ophthalmic Tromethamine (0.4% 3 Solution) Ophthalmic Solution, 1 Ophthalmic Anti-inflammatories 0.5% Ophthalmic Acular (Ophthalmic Solution) 3 Lotemax Lotemax (0.5% Gel, Solution) Acular LS LS 0.5% Ointment, 0.5% 3 3 (Ophthalmic Solution) Suspension)

Maxidex Acuvail (Ophthalmic Maxidex (Suspension) 3

3 ST Nevanac Solution) Nevanac

Alrex 2 Alrex (Suspension) 3 (Suspension)

Ocufen Bromfenac Ocufen (Ophthalmic 1 3 (Ophthalmic Solution) Solution)

Omnipred Dexamethasone Sodium Phosphate Omnipred Dexamethasone 3 Sodium Phosphate (Suspension) 1 Pred Forte (0.1% Ophthalmic Pred Forte 3 Solution) (Suspension)

Pred Mild Diclofenac Sodium Sodium Pred Mild 3 (0.1% Ophthalmic 1 (Suspension) Solution) Prednisolone Acetate Acetate

Durezol 1 Durezol (Emulsion) 2 (Suspension)

Prednisolone Sodium Phosphate Flarex Prednisolone Sodium Flarex (Suspension) 3 Fluorometholone Phosphate (1% 1

(Ophthalmic 1 Ophthalmic Solution) Prolensa (Ophthalmic Suspension) 3 Flurbiprofen Sodium Sodium Solution) 1 (Ophthalmic Solution) Ophthalmic Prostaglandin and Prostamide

FML Analogs FML (Ointment) 3 Bimatoprost

FML Forte Bimatoprost FML Forte 1 3 (Ophthalmic Solution) (Suspension) Latanoprost 1 (Ophthalmic Solution)

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Lumigan (Ophthalmic Azelastine HCl HCl (0.1% 2 1 QL Solution) Nasal Solution) Travatan Z Z Azelastine HCl HCl (0.15% 2 1 (Ophthalmic Solution) Nasal Solution)

Xalatan Cetirizine HCl Xalatan (Ophthalmic Cetirizine HCl (Syrup) 1 3 Solution) Clarinex (0.5mg/ml Zioptan (Ophthalmic 3 3 ST Syrup, 5mg Tablet) Solution) Cyproheptadine HCl HCl 1 PA, HRM Otic Agents (4mg Tablet)

Desloratadine Otic Agents Desloratadine (Tablet) 1

Acetasol HC Acetasol HC (Otic Desloratadine ODT ODT 3 1 Solution) (Tablet Dispersible)

Acetic Acid Acetic Acid (Otic Diphenhydramine HCl HCl 1 1 B/D, PA Solution) (50mg/ml Injection)

Cipro HC Cipro HC Levocetirizine Dihydrochloride 3 Levocetirizine (Suspension) Dihydrochloride Ciprodex 1 Ciprodex (Otic (2.5mg/5ml Oral 2 Suspension) Solution)

Coly-Mycin S Coly-Mycin S Levocetirizine Dihydrochloride 3 (Suspension) Dihydrochloride (5mg 1 QL Fluocinolone Acetonide Tablet)

Olopatadine HCl Acetonide (0.01% Otic 1 Olopatadine HCl (0.6% 1 Oil) Nasal Solution)

Hydrocortisone/Acetic Acid Hydrocortisone/Acetic Patanase (Nasal 1 3 Acid (Otic Solution) Solution)

Neomycin/Polymyxin/Hydrocortisone Neomycin/Polymyxin/ Phenadoz (12.5mg 1 PA, HRM Hydrocortisone (1% Suppository) 1 Otic Solution, 1% Otic Phenergan (12.5mg 1 PA, HRM Suspension) Suppository)

Otovel Otovel (Otic Solution) 3 ST Promethazine HCl HCl Respiratory Tract/Pulmonary Agents (12.5mg Suppository, 1 PA, HRM Antihistamines 12.5mg Tablet, 25mg Astepro (Nasal Tablet, 50mg Tablet) 3 Xyzal (2.5mg/5ml Solution) 3 Oral Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 136 137

Last updatedtRACK September 1, 2017 137 98 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Fluticasone Propionate Xyzal Fluticasone Propionate Xyzal (5mg Tablet) 3 QL Anti-inflammatories, Inhaled Corticosteroids (50mcg/act 1 Aerospan (Aerosol Suspension) 3 QL, ST Mometasone Furoate Furoate Solution) Alvesco (Aerosol (50mcg/act 1 3 QL, ST Solution) Suspension) Nasonex

Arnuity Ellipta Arnuity Ellipta Nasonex 2 QL 3 (Aerosol Powder) (Suspension) Omnaris Asmanex HFA HFA Omnaris (Suspension) 3 ST 3 QL, ST Pulmicort (Aerosol) 3 B/D, PA Asmanex Twisthaler 120 Metered Doses Twisthaler (Suspension) Pulmicort Flexhaler Flexhaler 120 Metered Doses 3 QL, ST 3 QL, ST (Aerosol Powder) (Aerosol Powder)

Qnasl Asmanex Twisthaler 30 Metered Doses Qnasl (Aerosol Asmanex Twisthaler 3 ST 30 Metered Doses 3 QL, ST Solution) (Aerosol Powder) Qnasl Childrens Childrens 3 ST Asmanex Twisthaler 60 Metered Doses Twisthaler (Aerosol Solution) 60 Metered Doses 3 QL, ST QVAR (Aerosol 3 QL, ST (Aerosol Powder) Solution) Beconase AQ AQ Triamcinolone Acetonide 3 ST (Suspension) Acetonide (55mcg/ 1 Budesonide (0.25mg/ act Aerosol) 2ml Suspension, Zetonna (Aerosol 3 ST 0.5mg/2ml 1 B/D, PA Solution) Suspension, 1mg/2ml Antileukotrienes Suspension) Accolate (Tablet) 3 QL

Budesonide Nasal Spray Budesonide Nasal Montelukast Sodium 1 Montelukast Sodium Spray (Suspension) (10mg Tablet, 4mg Flovent Diskus Diskus 2 QL Packet, 4mg Tablet 1 QL (Aerosol Powder) Chewable, 5mg Tablet Flovent HFA HFA (Aerosol) 2 QL Chewable) Flunisolide (Nasal 1 Solution)

Bold type = Brand name drug Plain type = Generic drug 137 138

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Singulair (10mg Albuterol Sulfate Sulfate Tablet, 4mg Packet, (0.083% Nebulized 4mg Tablet 3 QL Solution, 0.5% Chewable, 5mg Nebulized Solution, 1 B/D, PA Tablet Chewable) 0.63mg/3ml Nebulized Zafirlukast (Tablet) 1 QL Solution, 1.25mg/3ml Zileuton ER ER (Tablet Nebulized Solution) Albuterol Sulfate Extended-Release 12 1 ST Albuterol Sulfate (2mg Tablet Immediate- Hour) Zyflo Release, 4mg Tablet 1 Zyflo (Tablet) 4 ST

Zyflo CR Immediate-Release, Zyflo CR (Tablet 2mg/5ml Syrup)

Extended-Release 12 4 ST Albuterol Sulfate ER Albuterol Sulfate ER Hour) (Tablet Extended- 1 Bronchodilators, Anticholinergic Release 12 Hour) Atrovent HFA Atrovent HFA Arcapta Neohaler Neohaler 3 3 QL, ST (Aerosol Solution) (Capsule)

Incruse Ellipta Incruse Ellipta Brovana (Nebulized 2 QL 3 B/D, PA, QL (Aerosol Powder) Solution)

Ipratropium Bromide Ipratropium Bromide Epinephrine (0.15mg/ (0.02% Inhalation 1 B/D, PA 0.15ml Injection, Solution) 0.3mg/0.3ml 3 QL, ST Ipratropium Bromide Bromide Injection) (Generic (0.03% Nasal Solution, 1 Adrenaclick) 0.06% Nasal Solution) Epinephrine (0.15mg/ Spiriva HandiHaler HandiHaler 2 QL 0.3ml Injection, (Capsule) 0.3mg/0.3ml 2 QL Spiriva Respimat Respimat Injection) (Generic 2 QL (Aerosol Solution) EpiPen)

Tudorza Pressair Tudorza Pressair EpiPen 3 ST EpiPen (Injection) 3 QL, ST (Aerosol Powder) Levalbuterol 1 B/D, PA Bronchodilators, Sympathomimetic (Nebulized Solution)

Adrenalin Adrenalin (Injection) 3 Levalbuterol Tartrate HFA Tartrate 3 ST HFA (Aerosol)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 138 139

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Metaproterenol Sulfate Sulfate Kalydeco (150mg (10mg Tablet, 20mg Tablet, 50mg Packet, 4 PA, QL 1 Tablet, 10mg/5ml 75mg Packet) Syrup) Orkambi (Tablet) 4 PA, QL, LA

Perforomist Perforomist TOBI (Nebulized 3 B/D, PA, QL 4 B/D, PA, QL (Nebulized Solution) Solution)

ProAir HFA ProAir HFA (Aerosol TOBI Podhaler Podhaler 2 4 PA, QL Solution) (Capsule)

ProAir RespiClick ProAir RespiClick Tobramycin (Nebulized 2 1 B/D, PA, QL (Aerosol Powder) Solution) Proventil HFA HFA 3 ST Mast Cell Stabilizers (Aerosol Solution) Cromolyn Sodium Sodium Serevent Diskus Diskus 2 QL (20mg/2ml Nebulized 1 B/D, PA (Aerosol Powder) Solution) Striverdi Respimat Respimat 3 QL, ST Phosphodiesterase Inhibitors, Airways (Aerosol Solution) Disease

Terbutaline Sulfate Terbutaline Sulfate Aminophylline (1mg/ml Injection, 1 1 (Injection) 2.5mg Tablet, 5mg Daliresp Daliresp (Tablet) 3 PA, QL

Tablet) Theo-24

Ventolin HFA Theo-24 (Capsule Ventolin HFA (Aerosol 3 ST Extended-Release 24 3 Solution)

Xopenex Hour)

Xopenex (Nebulized Theophylline 3 B/D, PA Theophylline (Oral Solution) 1

Xopenex Concentrate Solution)

Xopenex Concentrate Theophylline CR 3 B/D, PA Theophylline CR (Nebulized Solution)

Xopenex HFA (Tablet Extended- 1 Xopenex HFA 3 ST Release 12 Hour)

(Aerosol) Theophylline ER Theophylline ER Cystic Fibrosis Agents (300mg Tablet Bethkis (Nebulized 4 B/D, PA, QL Extended-Release 12 Solution) Hour, 400mg Tablet Cayston 1 Cayston (Inhalation Extended-Release 24 4 PA, LA Solution) Hour, 600mg Tablet Extended-Release 24 Hour)

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Pulmonary Antihypertensives Uptravi (1000mcg Adcirca (Tablet) 4 PA, QL Tablet, 1200mcg

Adempas Tablet, 1400mcg Adempas (Tablet) 4 PA Tablet, 1600mcg Letairis Letairis (Tablet) 4 PA, QL, LA Tablet, 200mcg 4 PA, QL Opsumit (Tablet) 4 PA, LA Tablet, 400mcg Orenitram (0.125mg Tablet, 600mcg Tablet Extended- 3 PA, QL Tablet, 800mcg Release) Tablet)

Uptravi Orenitram Uptravi (Tablet Orenitram (0.25mg 4 PA Tablet Extended- Therapy Pack)

4 PA, QL Ventavis Release, 1mg Tablet Ventavis (Inhalation 4 PA, QL, LA Extended-Release) Solution) Orenitram (2.5mg Pulmonary Fibrosis Agents Tablet Extended- Esbriet 4 PA Esbriet (267mg Release, 5mg Tablet Capsule, 267mg 4 PA, QL, LA Extended-Release) Tablet, 801mg Tablet)

Remodulin Remodulin (Injection) 4 PA, LA Ofev (Capsule) 4 PA, QL, LA Revatio (10mg/ 4 PA Respiratory Tract Agents, Other 12.5ml Injection) Acetylcysteine Revatio 1 B/D, PA Revatio (10mg/ml (Inhalation Solution) Suspension, 20mg 4 PA, QL Advair Diskus Diskus 2 QL Tablet) (Aerosol Powder)

Sildenafil Sildenafil (10mg/ Advair HFA 1 PA Advair HFA (Aerosol) 2 QL

12.5ml Injection) Airduo Respiclick 113/14

Sildenafil Airduo Respiclick Sildenafil (20mg 113/14 (Aerosol 3 QL, ST Tablet) (Generic 1 PA, QL Powder)

Revatio) Airduo Respiclick 232/14 Airduo Respiclick Tracleer Tracleer (Tablet) 4 PA, QL 232/14 (Aerosol 3 QL, ST Powder) Airduo Respiclick 55/14 Respiclick 55/14 (Aerosol 3 QL, ST Powder) Anoro Ellipta Ellipta (Aerosol 2 QL Powder)

You can find information on what the abbreviations in this table mean on pages 6 - 7. 140 141

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Bevespi Aerosphere Aerosphere Cyclobenzaprine HCl HCl 2 QL 1 PA, HRM (Aerosol) (7.5mg Tablet)

Breo Ellipta Dantrium Breo Ellipta (Aerosol Dantrium (Capsule) 3 2 QL Powder) Dantrolene Sodium Sodium Clarinex-D 12 Hour 12 Hour 1 (Capsule) (Tablet Extended- 3 Fexmid (Tablet) 3 PA, HRM

Release) Gablofen Gablofen (40000mcg/ Combivent Respimat Respimat 4 B/D, PA 2 20ml Injection)

(Aerosol Solution) Lioresal Intrathecal Lioresal Intrathecal Dulera Dulera (Aerosol) 3 PA, QL (0.05mg/ml Injection, 3 B/D, PA

Dymista Dymista (Suspension) 3 10mg/20ml Injection) Fluticasone Propionate/Salmeterol Lioresal Intrathecal Intrathecal 4 B/D, PA Propionate/ (10mg/5ml Injection)

2 QL Orphenadrine Citrate Salmeterol (Aerosol Orphenadrine Citrate 1 PA, HRM Powder) (Injection)

Grastek Grastek (Tablet Tizanidine HCl 3 PA, QL Tizanidine HCl (2mg Sublingual) Capsule, 4mg Capsule,

Ipratropium Bromide/Albuterol Sulfate 1 Ipratropium Bromide/ 6mg Capsule, 2mg Albuterol Sulfate 1 B/D, PA Tablet, 4mg Tablet) (Inhalation Solution) Zanaflex (2mg Nucala (Injection) 4 PA, QL, LA Capsule, 4mg 3 Oralair (Tablet Capsule, 6mg 3 PA, QL Sublingual) Capsule, 4mg Tablet) Pulmozyme Sleep Disorder Agents 4 B/D, PA, QL (Inhalation Solution) GABA Receptor Modulators

Ragwitek

Ragwitek (Tablet Ambien PA, QL, 3 PA, QL Ambien (Tablet) 3 Sublingual) HRM

Restoril Semprex-D Restoril (22.5mg Semprex-D (Capsule) 3 3 QL, HRM Stiolto Respimat Respimat Capsule) 2 QL Sonata PA, QL, (Aerosol Solution) Sonata (Capsule) 3 Symbicort (Aerosol) 2 QL HRM Temazepam (22.5mg Skeletal Muscle Relaxants 1 QL, HRM Capsule) Skeletal Muscle Relaxants

Zaleplon

Baclofen PA, QL, Zaleplon (Capsule) 1 Baclofen (Tablet) 1 HRM

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Zolpidem Tartrate Zolpidem Tartrate Hetlioz (Capsule) 4 PA, QL

(10mg Tablet Modafinil PA, QL, Modafinil (Tablet) 1 PA, QL

Immediate-Release, 1 Nuvigil HRM Nuvigil (Tablet) 3 PA, QL 5mg Tablet Immediate-

Provigil Release) Provigil (Tablet) 4 PA, QL Sleep Disorders, Other Rozerem (Tablet) 3 QL Armodafinil (Tablet) 1 PA, QL Xyrem (Oral Solution) 4 PA, QL, LA Belsomra (Tablet) 2 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. 1 track

143 143 Covered drugs with a quantity limit (QL)1 This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety. Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover. Drugs are listed in alphabetical order in the chart below. track

Drug Name Quantity Limit Abacavir (Tablet) Maximum of 3 tablets per day Abacavir Sulfate/Lamivudine/Zidovudine Maximum of 3 tablets per day (Tablet) Abacavir/Lamivudine (Tablet) Maximum of 2 tablets per day Abilify (Tablet) Maximum of 1 tablet per day Abstral (Tablet Sublingual) Maximum of 4 tablets per day Acarbose (100mg Tablet) Maximum of 3 tablets per day Acarbose (25mg Tablet) Maximum of 12 tablets per day Acarbose (50mg Tablet) Maximum of 6 tablets per day Accolate (Tablet) Maximum of 2 tablets per day Accupril (Tablet) Maximum of 2 tablets per day Accuretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Accuretic (20mg-12.5mg Tablet, 20mg-25mg Maximum of 2 tablets per day Tablet) Acetaminophen/Codeine (120mg/5ml-12mg/ Maximum of 150 ml per day 5ml Oral Solution) Acetaminophen/Codeine (300mg-15mg Tablet, Maximum of 13 tablets per day 300mg-30mg Tablet, 300mg-60mg Tablet) Actiq (Lollipop) Maximum of 4 lozenges per day Actonel (150mg Tablet) Maximum of 1 tablet per 30 days Actonel (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Actonel (35mg Tablet) Maximum of 4 tablets per 28 days Actoplus Met (Tablet) Maximum of 3 tablets per day Actoplus Met XR (15mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Actoplus Met XR (30mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Actos (15mg Tablet) Maximum of 3 tablets per day Actos (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day

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144144 Last updated September 1, 2017 2 Drug Name Quantity Limit Acyclovir (5% Ointment) Maximum of 1 tube (30 grams) per 30 days Adalat CC (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Adcirca (Tablet) Maximum of 2 tablets per day Adderall (20mg Tablet) Maximum of 3 tablets per day Adderall (5mg Tablet, 7.5mg Tablet) Maximum of 2 tablets per day Adderall XR (Capsule Extended-Release 24 Maximum of 2 capsules per day Hour) Adlyxin (Injection) Maximum of 6 ml (2 pens) per 28 days Adlyxin Starter Pack (Injection) Maximum of 6 ml (1 kit) per 28 days Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Advair HFA (Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Adzenys XR-ODT (Tablet Extended-Release Maximum of 1 tablet per day Dispersible) Maximum of 2 inhalers (17.8 grams) per 30 Aerospan (Aerosol Solution) days Afeditab CR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Aggrenox (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour) Airduo Respiclick 113/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Airduo Respiclick 232/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Airduo Respiclick 55/14 (Aerosol Powder) Maximum of 1 inhaler per 30 days Albenza (Tablet) Maximum of 16 tablets per day Alecensa (Capsule) Maximum of 8 capsules per day Alendronate Sodium (10mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 5mg Tablet) Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days Almotriptan Malate (Tablet) Maximum of 12 tablets per 30 days Alogliptin (Tablet) Maximum of 1 tablet per day Alogliptin/Metformin HCl (Tablet) Maximum of 2 tablets per day Alogliptin/Pioglitazone (Tablet) Maximum of 1 tablet per day Alora (Patch Twice Weekly) Maximum of 8 patches per 28 days Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg Tablet Immediate-Release, 1mg Tablet Maximum of 4 tablets per day Immediate-Release) Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day

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Last145 updated September 1, 2017 145 3 Drug Name Quantity Limit Alprazolam ER (0.5mg Tablet Extended-Release 24 Hour, 1mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Alprazolam ER (2mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Alprazolam ER (3mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Alprazolam Intensol (1mg/ml Concentrate) Maximum of 10 ml per day Alprazolam ODT (0.25mg Tablet Dispersible, 0.5mg Tablet Dispersible, 1mg Tablet Maximum of 4 tablets per day Dispersible) Alprazolam ODT (2mg Tablet Dispersible) Maximum of 5 tablets per day Altace (Capsule) Maximum of 2 capsules per day Altoprev (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Alunbrig (Tablet) Maximum of 6 tablets per day Maximum of 2 inhalers (12.2 grams) per 30 Alvesco (160mcg/act Aerosol Solution) days Alvesco (80mcg/act Aerosol Solution) Maximum of 1 inhaler (6.1 grams) per 30 days Amaryl (1mg Tablet) Maximum of 8 tablets per day Amaryl (2mg Tablet) Maximum of 4 tablets per day Amaryl (4mg Tablet) Maximum of 2 tablets per day Ambien (Tablet) Maximum of 90 days of use per year Amerge (Tablet) Maximum of 12 tablets per 30 days Amitiza (Capsule) Maximum of 2 capsules per day Amlodipine Besylate/Atorvastatin Calcium Maximum of 1 tablet per day (Tablet) Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day Amlodipine/Olmesartan Medoxomil (Tablet) Maximum of 1 tablet per day Amlodipine/Valsartan/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Amphetamine/Dextroamphetamine (10mg Capsule Extended-Release 24 Hour, 15mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour)

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146146 Last updated September 1, 2017 4 Drug Name Quantity Limit Amphetamine/Dextroamphetamine (10mg Tablet Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate- Maximum of 2 tablets per day Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Amphetamine/Dextroamphetamine (20mg Maximum of 3 tablets per day Tablet Immediate-Release) Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Androderm (Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 3 ml per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptensio XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Aptiom (200mg Tablet, 400mg Tablet) Maximum of 1 tablet per day Aptiom (600mg Tablet, 800mg Tablet) Maximum of 2 tablets per day Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day Aptivus (250mg Capsule) Maximum of 6 capsules per day Arcapta Neohaler (Capsule) Maximum of 1 capsule per day Aricept (10mg Tablet) Maximum of 2 tablets per day Aricept (23mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Aripiprazole (Tablet) Maximum of 1 tablet per day Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day Armodafinil (150mg Tablet, 200mg Tablet, Maximum of 1 tablet per day 250mg Tablet) Armodafinil (50mg Tablet) Maximum of 2 tablets per day Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Asacol HD (Tablet Delayed-Release) Maximum of 6 tablets per day Asmanex HFA (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Asmanex Twisthaler 120 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 2 inhalers per 30 days (110mcg/INH Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 1 inhaler per 30 days (220mcg/INH Aerosol Powder) Asmanex Twisthaler 60 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder)

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Last147 updated September 1, 2017 147 5 Drug Name Quantity Limit Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atacand (16mg Tablet, 32mg Tablet, 4mg Maximum of 1 tablet per day Tablet) Atacand (8mg Tablet) Maximum of 3 tablets per day Atacand HCT (Tablet) Maximum of 1 tablet per day Atelvia (Tablet Delayed-Release) Maximum of 4 tablets per 28 days Ativan (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Ativan (2mg Tablet) Maximum of 5 tablets per day Atomoxetine (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Atomoxetine (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day Atripla (Tablet) Maximum of 2 tablets per day Aubagio (Tablet) Maximum of 1 tablet per day Avalide (Tablet) Maximum of 1 tablet per day Avandia (2mg Tablet) Maximum of 4 tablets per day Avandia (4mg Tablet) Maximum of 2 tablets per day Avapro (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Avapro (75mg Tablet) Maximum of 3 tablets per day Axert (12.5mg Tablet, 6.25mg Tablet) Maximum of 12 tablets per 30 days Axiron (Transdermal Solution) Maximum of 2 bottles (180 ml) per 30 days Azelastine HCl (0.1% Nasal Solution) Maximum of 2 bottles (60 ml) per 30 days Azor (Tablet) Maximum of 1 tablet per day Belbuca (Film) Maximum of 2 films per day Belsomra (Tablet) Maximum of 1 tablet per day Benazepril HCl (Tablet) Maximum of 2 tablets per day Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day Benicar (5mg Tablet) Maximum of 2 tablets per day Benicar HCT (Tablet) Maximum of 1 tablet per day Bentyl (10mg Capsule) Maximum of 16 capsules per 30 days Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day Bevespi Aerosphere (Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days BiDil (Tablet) Maximum of 6 tablets per day Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days

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148148 Last updated September 1, 2017 6 Drug Name Quantity Limit Bisoprolol Fumarate/Hydrochlorothiazide Maximum of 2 tablets per day (Tablet) Boniva (150mg Tablet) Maximum of 1 tablet per 28 days Bosulif (100mg Tablet) Maximum of 6 tablets per day Bosulif (500mg Tablet) Maximum of 1 tablet per day Botox (Injection) Maximum of 9 vials per 30 days Breo Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Brilinta (Tablet) Maximum of 2 tablets per day BRIVIACT (100mg Tablet, 10mg Tablet, Maximum of 2 tablets per day 25mg Tablet, 50mg Tablet, 75mg Tablet) BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day BRIVIACT (50mg/5ml Intravenous Solution) Maximum of 20 ml per day Brovana (Nebulized Solution) Maximum of 2 vials (4 ml) per day Bunavail (Film) Maximum of 2 films per day Buprenorphine (Patch Weekly) Maximum of 4 patches per 28 days Buprenorphine HCl (2mg Tablet Sublingual, Maximum of 3 tablets per day 8mg Tablet Sublingual) Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Butrans (Patch Weekly) Maximum of 4 patches per 28 days Bydureon (2mg Pen injector) Maximum of 4 pens per 28 days Bydureon (2mg Suspension Extended- Maximum of 4 vials per 28 days Release) Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 1 tablet per day Tablet) Bystolic (20mg Tablet) Maximum of 2 tablets per day Byvalson (Tablet) Maximum of 1 tablet per day Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day Cabometyx (40mg Tablet) Maximum of 2 tablets per day Caduet (Tablet) Maximum of 1 tablet per day Calcitonin-Salmon (Nasal Solution) Maximum of 1 bottle per 28 days Candesartan Cilexetil (16mg Tablet, 32mg Maximum of 1 tablet per day Tablet, 4mg Tablet) Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day

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Last149 updated September 1, 2017 149 7 Drug Name Quantity Limit Candesartan Cilexetil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Captopril (100mg Tablet) Maximum of 4 tablets per day Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day Captopril (50mg Tablet) Maximum of 9 tablets per day Captopril/Hydrochlorothiazide (25mg-15mg Maximum of 3 tablets per day Tablet, 50mg-15mg Tablet) Captopril/Hydrochlorothiazide (25mg-25mg Maximum of 2 tablets per day Tablet, 50mg-25mg Tablet) Cardizem LA (360mg Tablet Extended- Release 24 Hour, 420mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Cardura XL (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Celebrex (Capsule) Maximum of 2 capsules per day Celecoxib (Capsule) Maximum of 2 capsules per day Cerdelga (Capsule) Maximum of 2 capsules per day Cialis (2.5mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Clonazepam (0.5mg Tablet Immediate-Release, Maximum of 4 tablets per day 1mg Tablet Immediate-Release) Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day Clonazepam ODT (0.125mg Tablet Dispersible, 0.25mg Tablet Dispersible, 0.5mg Tablet Maximum of 4 tablets per day Dispersible, 1mg Tablet Dispersible) Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel (300mg Tablet) Maximum of 1 tablet per day Clopidogrel (75mg Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Capsule) (Generic Maximum of 4 capsules per day Mitigare)

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150150 Last updated September 1, 2017 8 Drug Name Quantity Limit Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Colcrys (Tablet) Maximum of 4 tablets per day Combivir (Tablet) Maximum of 3 tablets per day Complera (Tablet) Maximum of 2 tablets per day Concerta (18mg Tablet Extended-Release) Maximum of 3 tablets per day Concerta (27mg Tablet Extended-Release, Maximum of 2 tablets per day 36mg Tablet Extended-Release) Concerta (54mg Tablet Extended-Release) Maximum of 1 tablet per day Conzip (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Corlanor (Tablet) Maximum of 2 tablets per day Corzide (40mg-5mg Tablet) Maximum of 1 tablet per day Cotellic (Tablet) Maximum of 3 tablets per day Cozaar (100mg Tablet) Maximum of 1 tablet per day Cozaar (25mg Tablet, 50mg Tablet) Maximum of 2 tablets per day Crestor (Tablet) Maximum of 1 tablet per day Crixivan (Capsule) Maximum of 9 capsules per day Cycloset (Tablet) Maximum of 6 tablets per day Cymbalta (Capsule Delayed-Release) Maximum of 2 capsules per day Daklinza (Tablet) Maximum of 1 tablet per day Daliresp (Tablet) Maximum of 1 tablet per day Darifenacin HBr ER (Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Daytrana (Patch) Maximum of 1 patch per day Denavir (Cream) Maximum of 1 tube (5 grams) per 30 days Descovy (Tablet) Maximum of 2 tablets per day Desvenlafaxine ER (100mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Pristiq) Desvenlafaxine ER (25mg Tablet Extended- Release 24 Hour, 50mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Pristiq) Desvenlafaxine ER (50mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Khedezla) Dexedrine (10mg Capsule Extended-Release Maximum of 6 capsules per day 24 Hour) Dexedrine (15mg Capsule Extended-Release Maximum of 4 capsules per day 24 Hour) Dexedrine (5mg Capsule Extended-Release Maximum of 3 capsules per day 24 Hour)

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Last151 updated September 1, 2017 151 9 Drug Name Quantity Limit Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Tablet Immediate- Maximum of 2 tablets per day Release) Dextroamphetamine Sulfate (10mg Tablet) Maximum of 6 tablets per day Dextroamphetamine Sulfate (5mg Tablet Maximum of 6 tablets per day Immediate-Release) Dextroamphetamine Sulfate ER (10mg Capsule Maximum of 6 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (15mg Capsule Maximum of 4 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (5mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) Diazepam (10mg Tablet, 2mg Tablet, 5mg Maximum of 4 tablets per day Tablet) Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day Digitek (0.125mg Tablet) Maximum of 1 tablet per day Digoxin (0.05mg/ml Oral Solution) Maximum of 5 ml per day Digoxin (125mcg Tablet) Maximum of 1 tablet per day Dilaudid (1mg/ml Liquid) Maximum of 90 ml per day Dilaudid (2mg Tablet, 4mg Tablet) Maximum of 8 tablets per day Dilaudid (8mg Tablet) Maximum of 11 tablets per day Diovan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Diovan (320mg Tablet) Maximum of 1 tablet per day Diovan HCT (Tablet) Maximum of 1 tablet per day Ditropan XL (10mg Tablet Extended-Release 24 Hour, 15mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Ditropan XL (5mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Dolophine (10mg Tablet) Maximum of 12 tablets per day Dolophine (5mg Tablet) Maximum of 8 tablets per day Donepezil HCl (10mg Tablet Immediate- Maximum of 2 tablets per day Release) Donepezil HCl (23mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day

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152152 Last updated September 1, 2017 10 Drug Name Quantity Limit Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day Doxercalciferol (1mcg Capsule, 2.5mcg Maximum of 4 capsules per day Capsule) Dronabinol (Capsule) Maximum of 4 capsules per day Duetact (Tablet) Maximum of 1 tablet per day Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) Duloxetine HCl (40mg Capsule Delayed- Maximum of 3 capsules per day Release) Dupixent (Injection) Maximum of 8 ml (4 syringes) per 28 days Duragesic (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Maximum of 15 patches per 30 days Hour, 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Edarbi (Tablet) Maximum of 1 tablet per day Edarbyclor (Tablet) Maximum of 1 tablet per day Edurant (Tablet) Maximum of 2 tablets per day Effient (Tablet) Maximum of 1 tablet per day Eliquis (Tablet) Maximum of 2 tablets per day Embeda (100mg-4mg Capsule Extended- Maximum of 3 capsules per day Release) Embeda (20mg-0.8mg Capsule Extended- Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day Release) Embeda (30mg-1.2mg Capsule Extended- Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day Release) Embeda (60mg-2.4mg Capsule Extended- Maximum of 6 capsules per day Release) Emsam (Patch 24 Hour) Maximum of 1 patch per day Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enablex (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide Maximum of 2 tablets per day (10mg-25mg Tablet)

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Last153 updated September 1, 2017 153 11 Drug Name Quantity Limit Enalapril Maleate/Hydrochlorothiazide Maximum of 1 tablet per day (5mg-12.5mg Tablet) Endocet (Tablet) Maximum of 12 tablets per day Enoxaparin Sodium (100mg/ml Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150mg/ml Subcutaneous Solution) Enoxaparin Sodium (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day Enoxaparin Sodium (30mg/0.3ml Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40mg/0.4ml Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60mg/0.6ml Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Tablet) Maximum of 2 tablets per day Epclusa (Tablet) Maximum of 1 tablet per day Epinephrine (Injection) (Generic EpiPen) Maxiumum of 4 pens (2 boxes) per 30 days EpiPen (Injection) Maxiumum of 4 pens (2 boxes) per 30 days Epivir (10mg/ml Oral Solution) Maximum of 48 ml per day Epivir (150mg Tablet) Maximum of 3 tablets per day Epivir (300mg Tablet) Maximum of 2 tablets per day Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day Epzicom (Tablet) Maximum of 2 tablets per day Erivedge (Capsule) Maximum of 1 capsule per day Esbriet (267mg Capsule) Maximum of 9 capsules per day Esbriet (267mg Tablet) Maximum of 6 tablets per day Esbriet (801mg Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20mg Capsule Maximum of 3 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Magnesium (40mg Capsule Maximum of 2 capsules per day Delayed-Release) (Generic Nexium) Estradiol (0.025mg/24hr Patch Twice Weekly, 0.0375mg/24hr Patch Twice Weekly, 0.05mg/ Maximum of 8 patches per 28 days 24hr Patch Twice Weekly, 0.075mg/24hr Patch Twice Weekly, 0.1mg/24hr Patch Twice Weekly) Evista (Tablet) Maximum of 1 tablet per day Evotaz (Tablet) Maximum of 2 tablets per day

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154154 Last updated September 1, 2017 12 Drug Name Quantity Limit Exalgo (12mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 16mg Tablet Extended-Release 24 Hour Abuse-Deterrent, Maximum of 2 tablets per day 32mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 8mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Exelon (Patch 24 Hour) Maximum of 1 patch per day Exforge (Tablet) Maximum of 1 tablet per day Exforge HCT (Tablet) Maximum of 1 tablet per day Ezetimibe (Tablet) Maximum of 1 tablet per day Ezetimibe/Simvastatin (Tablet) Maximum of 1 tablet per day Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famciclovir (500mg Tablet) Maximum of 3 tablets per day Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Farxiga (Tablet) Maximum of 1 tablet per day Fazaclo (100mg Tablet Dispersible) Maximum of 9 tablets per day Fazaclo (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Fazaclo (150mg Tablet Dispersible) Maximum of 6 tablets per day Fazaclo (200mg Tablet Dispersible) Maximum of 4 tablets per day Fazaclo (25mg Tablet Dispersible) Maximum of 3 tablets per day Fentanyl (Patch 72 Hour) Maximum of 15 patches per 30 days Fentanyl Citrate Oral Transmucosal (Lollipop) Maximum of 4 lozenges per day Fentora (Tablet) Maximum of 4 tablets per day Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Firazyr (Injection) Maximum of 9 ml per day Flector (Patch) Maximum of 2 patches per day Maximum of 2 inhalers (120 blisters) per 30 Flovent Diskus (Aerosol Powder) days Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluticasone Propionate/Salmeterol (Aerosol Maximum of 1 inhaler per 30 days Powder) Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day

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Last155 updated September 1, 2017 155 13 Drug Name Quantity Limit Fluvastatin Sodium ER (Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Focalin (Tablet) Maximum of 2 tablets per day Fortamet (1000mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Fortamet (500mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days Fosamax (Tablet) Maximum of 4 tablets per 28 days Fosamax Plus D (Tablet) Maximum of 4 tablets per 28 days Fosinopril Sodium (Tablet) Maximum of 2 tablets per day Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day Frova (Tablet) Maximum of 12 tablets per 30 days Frovatriptan Succinate (Tablet) Maximum of 12 tablets per 30 days Fuzeon (Injection) Maximum of 3 vials per day Gabitril (12mg Tablet) Maximum of 4 tablets per day Gabitril (16mg Tablet) Maximum of 3 tablets per day Galantamine HBr (12mg Tablet, 4mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days Galantamine HBr ER (Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Gelnique (10% Gel) Maximum of 1 packet per day Genvoya (Tablet) Maximum of 2 tablets per day Geodon (20mg Capsule, 40mg Capsule, Maximum of 2 capsules per day 60mg Capsule, 80mg Capsule) Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days Gleevec (Tablet) Maximum of 3 tablets per day Glimepiride (1mg Tablet) Maximum of 8 tablets per day Glimepiride (2mg Tablet) Maximum of 4 tablets per day Glimepiride (4mg Tablet) Maximum of 2 tablets per day Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day Glipizide ER (10mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Glipizide ER (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour)

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156156 Last updated September 1, 2017 14 Drug Name Quantity Limit Glipizide ER (5mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day Glipizide/Metformin HCl (2.5mg-500mg Tablet, Maximum of 4 tablets per day 5mg-500mg Tablet) Glucophage (1000mg Tablet) Maximum of 2.5 tablets per day Glucophage (500mg Tablet) Maximum of 5 tablets per day Glucophage (850mg Tablet) Maximum of 3 tablets per day Glucophage XR (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Glucophage XR (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Glucotrol (10mg Tablet) Maximum of 4 tablets per day Glucotrol (5mg Tablet) Maximum of 8 tablets per day Glucotrol XL (10mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Glucotrol XL (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour) Glucotrol XL (5mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glumetza (1000mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Glumetza (500mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glyset (100mg Tablet) Maximum of 3 tablets per day Glyset (25mg Tablet) Maximum of 12 tablets per day Glyset (50mg Tablet) Maximum of 6 tablets per day Glyxambi (Tablet) Maximum of 1 tablet per day Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day Grastek (Tablet Sublingual) Maximum of 1 tablet per day Harvoni (Tablet) Maximum of 1 tablet per day Hectorol (0.5mcg Capsule) Maximum of 3 capsules per day Hectorol (1mcg Capsule, 2.5mcg Capsule) Maximum of 4 capsules per day Hetlioz (Capsule) Maximum of 1 capsule per day Hycet (Oral Solution) Maximum of 180 ml per day Hydrocodone Bitartrate/Acetaminophen (10mg-300mg Tablet, 5mg-300mg Tablet, Maximum of 13 tablets per day 7.5mg-300mg Tablet)

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Last157 updated September 1, 2017 157 15 Drug Name Quantity Limit Hydrocodone Bitartrate/Acetaminophen Maximum of 12 tablets per day (325mg-2.5mg Tablet) Hydrocodone Bitartrate/Acetaminophen Maximum of 180 ml per day (7.5mg-325mg/15ml Oral Solution) Hydrocodone/Acetaminophen (Tablet) Maximum of 12 tablets per day Hydrocodone/Ibuprofen (Tablet) Maximum of 5 tablets per day Hydromorphone HCl (1mg/ml Liquid) Maximum of 90 ml per day Hydromorphone HCl (2mg Tablet Immediate- Maximum of 8 tablets per day Release, 4mg Tablet Immediate-Release) Hydromorphone HCl (8mg Tablet Immediate- Maximum of 11 tablets per day Release) Hydromorphone HCl ER (Tablet Extended- Maximum of 2 tablets per day Release 24 Hour Abuse-Deterrent) Hysingla ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour Abuse-Deterrent) Hyzaar (100mg-12.5mg Tablet, 100mg-25mg Maximum of 1 tablet per day Tablet) Hyzaar (50mg-12.5mg Tablet) Maximum of 2 tablets per day Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days Ibrance (Capsule) Maximum of 1 capsule per day Ibudone (Tablet) Maximum of 5 tablets per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Ilaris (Injection) Maximum of 2 vials per 28 days Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (Capsule) Maximum of 4 capsules per day Imitrex (100mg Tablet, 25mg Tablet, 50mg Maximum of 12 tablets per 30 days Tablet) Imitrex (20mg/act Nasal Solution, 5mg/act Maximum of 12 devices per 30 days Nasal Solution) Imitrex (6mg/0.5ml Subcutaneous Solution) Maximum of 12 injections (6 ml) per 30 days Imitrex Statdose Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Incruse Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Ingrezza (Capsule) Maximum of 2 capsules per day Inlyta (Tablet) Maximum of 4 tablets per day Intelence (100mg Tablet) Maximum of 2 tablets per day Intelence (200mg Tablet) Maximum of 3 tablets per day Intelence (25mg Tablet) Maximum of 6 tablets per day

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158158 Last updated September 1, 2017 16 Drug Name Quantity Limit Invega (1.5mg Tablet Extended-Release 24 Hour, 3mg Tablet Extended-Release 24 Hour, Maximum of 1 tablet per day 9mg Tablet Extended-Release 24 Hour) Invega (6mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets per day Invokamet (Tablet) Maximum of 2 tablets per day Invokamet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invokana (Tablet) Maximum of 1 tablet per day Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Irbesartan (75mg Tablet) Maximum of 3 tablets per day Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Iressa (Tablet) Maximum of 2 tablets per day Isentress (100mg Packet) Maximum of 4 packets per day Isentress (100mg Tablet Chewable, 25mg Maximum of 9 tablets per day Tablet Chewable) Isentress (400mg Tablet) Maximum of 6 tablets per day Itraconazole (Capsule) Maximum of 4 capsules per day Jakafi (Tablet) Maximum of 2 tablets per day Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day Janumet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Januvia (Tablet) Maximum of 1 tablet per day Jardiance (Tablet) Maximum of 1 tablet per day Jentadueto (Tablet) Maximum of 2 tablets per day Jentadueto XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Jentadueto XR (5mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Kadian (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Maximum of 3 capsules per day Hour, 80mg Capsule Extended-Release 24 Hour)

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Last159 updated September 1, 2017 159 17 Drug Name Quantity Limit Kadian (10mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Maximum of 2 capsules per day Hour, 40mg Capsule Extended-Release 24 Hour, 50mg Capsule Extended-Release 24 Hour) Kadian (200mg Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day Kalydeco (150mg Tablet) Maximum of 2 tablets per day Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day Kazano (Tablet) Maximum of 2 tablets per day Keveyis (Tablet) Maximum of 4 tablets per day Khedezla (100mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Khedezla (50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Kisqali (Tablet) Maximum of 3 tablets per day Kisqali Femara 200 Dose (Tablet Therapy Maximum of 91 tablets (1 pack) per 28 days Pack) Kisqali Femara 400 Dose (Tablet Therapy Maximum of 91 tablets (1 pack) per 28 days Pack) Kisqali Femara 600 Dose (Tablet Therapy Maximum of 91 tablets (1 pack) per 28 days Pack) Klonopin (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Klonopin (2mg Tablet) Maximum of 10 tablets per day Kombiglyze XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Kombiglyze XR (5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day Tablet Extended-Release 24 Hour) Korlym (Tablet) Maximum of 4 tablets per day Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day Lamivudine (150mg Tablet) Maximum of 3 tablets per day Lamivudine (300mg Tablet) Maximum of 2 tablets per day Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day Lanoxin (125mcg Tablet) Maximum of 1 tablet per day

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160160 Last updated September 1, 2017 18 Drug Name Quantity Limit Lanoxin (62.5mcg Tablet) Maximum of 2 tablets per day Lansoprazole (Capsule Delayed-Release) Maximum of 2 capsules per day Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Lazanda (Nasal Solution) Maximum of 15 bottles (79.5 ml) per 30 days Lescol XL (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Letairis (Tablet) Maximum of 1 tablet per day Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day Lexiva (50mg/ml Suspension) Maximum of 90 ml per day Lexiva (700mg Tablet) Maximum of 6 tablets per day Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day Lidocaine (5% Patch) Maximum of 3 patches per day Lidoderm (Patch) Maximum of 3 patches per day Linezolid (600mg Tablet) Maximum of 2 tablets per day Linzess (Capsule) Maximum of 1 capsule per day Lipitor (Tablet) Maximum of 1 tablet per day Lisinopril (Tablet) Maximum of 2 tablets per day Lisinopril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-12.5mg Maximum of 4 tablets per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-25mg Maximum of 2 tablets per day Tablet) Livalo (Tablet) Maximum of 1 tablet per day Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day Lopinavir/Ritonavir (Oral Solution) Maximum of 16 ml per day Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Lorazepam (2mg Tablet) Maximum of 5 tablets per day Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet HD (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Lortab (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day

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Last161 updated September 1, 2017 161 19 Drug Name Quantity Limit Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 1 tablet per day (100mg-12.5mg Tablet, 100mg-25mg Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 2 tablets per day (50mg-12.5mg Tablet) Lotensin (Tablet) Maximum of 2 tablets per day Lotrel (Capsule) Maximum of 1 capsule per day Lovastatin (10mg Tablet Immediate-Release, Maximum of 1 tablet per day 20mg Tablet Immediate-Release) Lovastatin (40mg Tablet Immediate-Release) Maximum of 2 tablets per day Lovaza (Capsule) Maximum of 4 capsules per day Lovenox (100mg/ml Subcutaneous Solution, Maximum of 2 syringes (2 ml) per day 150mg/ml Subcutaneous Solution) Lovenox (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Subcutaneous Maximum of 2 syringes (1.6 ml) per day Solution) Lovenox (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day Lovenox (30mg/0.3ml Subcutaneous Maximum of 2 syringes (0.6 ml) per day Solution) Lovenox (40mg/0.4ml Subcutaneous Maximum of 2 syringes (0.8 ml) per day Solution) Lovenox (60mg/0.6ml Subcutaneous Maximum of 2 syringes (1.2 ml) per day Solution) Loxapine Succinate (10mg Capsule, 5mg Maximum of 4 capsules per day Capsule) Lynparza (Capsule) Maximum of 16 capsules per day Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day Capsule, 75mg Capsule) Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Marinol (10mg Capsule, 2.5mg Capsule, 5mg Maximum of 4 capsules per day Capsule) Matzim LA (360mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour, 420mg Tablet Extended-Release 24 Hour) Maxalt (Tablet) Maximum of 12 tablets per 30 days Maxalt-MLT (Tablet Dispersible) Maximum of 12 tablets per 30 days Memantine HCl (10mg Tablet) Maximum of 2 tablets per day

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162162 Last updated September 1, 2017 20 Drug Name Quantity Limit Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Mesalamine DR (Tablet Delayed-Release) Maximum of 6 tablets per day Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day Metformin HCl (1000mg Tablet Immediate- Maximum of 2.5 tablets per day Release) Metformin HCl (500mg Tablet Immediate- Maximum of 5 tablets per day Release) Metformin HCl (850mg Tablet Immediate- Maximum of 3 tablets per day Release) Metformin HCl ER (1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Fortamet) Metformin HCl ER (1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Glucophage XR) Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500mg Tablet Extended- Maximum of 5 tablets per day Release 24 Hour) (Generic Glumetza) Metformin HCl ER (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Glucophage XR) Methadone HCl (10mg Tablet) Maximum of 12 tablets per day Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day Methadone HCl (5mg Tablet) Maximum of 8 tablets per day Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day Methylin (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylin (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (10mg Tablet Chewable) Maximum of 6 tablets per day Methylphenidate HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 3 tablets per day Tablet Immediate-Release) (Generic Ritalin) Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylphenidate HCl (2.5mg Tablet Chewable, Maximum of 3 tablets per day 5mg Tablet Chewable) Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl ER (10mg Tablet Maximum of 4 tablets per day Extended-Release)

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Last163 updated September 1, 2017 163 21 Drug Name Quantity Limit Methylphenidate HCl ER (18mg Tablet Maximum of 3 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (20mg Tablet Maximum of 3 tablets per day Extended-Release) Methylphenidate HCl ER (27mg Tablet Extended-Release 24 Hour, 36mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (54mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Micardis (Tablet) Maximum of 1 tablet per day Micardis HCT (12.5mg-40mg Tablet, Maximum of 1 tablet per day 25mg-80mg Tablet) Micardis HCT (12.5mg-80mg Tablet) Maximum of 2 tablets per day Miglitol (100mg Tablet) Maximum of 3 tablets per day Miglitol (25mg Tablet) Maximum of 12 tablets per day Miglitol (50mg Tablet) Maximum of 6 tablets per day Minivelle (Patch Twice Weekly) Maximum of 8 patches per 28 days Mitigare (Capsule) Maximum of 4 capsules per day Modafinil (100mg Tablet) Maximum of 1 tablet per day Modafinil (200mg Tablet) Maximum of 2 tablets per day Moexipril HCl (7.5mg Tablet) Maximum of 2 tablets per day Moexipril/Hydrochlorothiazide (15mg-12.5mg Maximum of 2 tablets per day Tablet, 15mg-25mg Tablet) Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Maximum of 1 tablet per day Tablet) Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day Montelukast Sodium (4mg Tablet Chewable, Maximum of 1 tablet per day 5mg Tablet Chewable) Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 18 ml per day Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 120 ml per day Morphine Sulfate (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day Morphine Sulfate (30mg Tablet Immediate- Maximum of 12 tablets per day Release)

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164164 Last updated September 1, 2017 22 Drug Name Quantity Limit Morphine Sulfate ER (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour, 80mg Capsule Extended-Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (100mg Tablet Extended- Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day (Generic MS Contin) Morphine Sulfate ER (10mg Capsule Extended- Release 24 Hour, 20mg Capsule Extended- Release 24 Hour, 30mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 50mg Capsule Extended- Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (120mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (200mg Tablet Extended- Maximum of 2 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (30mg Capsule Extended- Release 24 Hour, 45mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 60mg Capsule Extended- Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (30mg Tablet Extended- Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day (Generic MS Contin) Morphine Sulfate ER (75mg Capsule Extended- Release 24 Hour, 90mg Capsule Extended- Maximum of 4 capsules per day Release 24 Hour) (Generic Avinza) Movantik (Tablet) Maximum of 1 tablet per day MS Contin (100mg Tablet Extended-Release, Maximum of 3 tablets per day 15mg Tablet Extended-Release) MS Contin (200mg Tablet Extended-Release) Maximum of 2 tablets per day MS Contin (30mg Tablet Extended-Release, Maximum of 4 tablets per day 60mg Tablet Extended-Release) Multaq (Tablet) Maximum of 2 tablets per day Nadolol/Bendroflumethiazide (40mg-5mg Maximum of 1 tablet per day Tablet) Namenda (10mg Tablet Immediate-Release) Maximum of 2 tablets per day Namenda (10mg/5ml Oral Solution) Maximum of 10 ml per day Namenda (5mg Tablet Immediate-Release) Maximum of 3 tablets per day Namenda XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour)

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Last165 updated September 1, 2017 165 23 Drug Name Quantity Limit Namenda XR Titration Pack (Capsule Maximum of 1 capsule per day Extended-Release 24 Hour) Namzaric (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namzaric (Therapy Pack, Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Naratriptan HCl (Tablet) Maximum of 12 tablets per 30 days Nateglinide (120mg Tablet) Maximum of 3 tablets per day Nateglinide (60mg Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days Nesina (Tablet) Maximum of 1 tablet per day Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day Nevirapine (50mg/5ml Suspension) Maximum of 60 ml per day Nevirapine ER (100mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Nevirapine ER (400mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Nifedipine ER (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Ninlaro (Capsule) Maximum of 3 capsules per 28 days Norco (Tablet) Maximum of 12 tablets per day Northera (100mg Capsule) Maximum of 3 capsules per day Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day Norvir (100mg Capsule) Maximum of 18 capsules per day Norvir (100mg Tablet) Maximum of 18 tablets per day Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day Noxafil (100mg Tablet Delayed-Release) Maximum of 8 tablets per day Noxafil (40mg/ml Suspension) Maximum of 20 ml per day Nucala (Injection) Maximum of 1 vial per 28 days Nucynta (100mg Tablet, 50mg Tablet, 75mg Maximum of 6 tablets per day Tablet) Nucynta ER (Tablet Extended-Release 12 Maximum of 2 tablets per day Hour) Nuplazid (Tablet) Maximum of 2 tablets per day Nuvigil (150mg Tablet, 200mg Tablet, 250mg Maximum of 1 tablet per day Tablet)

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166166 Last updated September 1, 2017 24 Drug Name Quantity Limit Nuvigil (50mg Tablet) Maximum of 2 tablets per day Ocaliva (Tablet) Maximum of 1 tablet per day Odefsey (Tablet) Maximum of 2 tablets per day Odomzo (Capsule) Maximum of 1 capsule per day Ofev (Capsule) Maximum of 2 capsules per day Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 2.5mg Tablet Immediate-Release, 20mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day Olmesartan Medoxomil (20mg Tablet, 40mg Maximum of 1 tablet per day Tablet) Olmesartan Medoxomil (5mg Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil/Amlodipine/ Maximum of 1 tablet per day Hydrochlorothiazide (Tablet) Olmesartan Medoxomil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Olysio (Capsule) Maximum of 1 capsule per day Omega-3-Acid Ethyl Esters (Capsule) (Generic Maximum of 4 capsules per day Lovaza) Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day Onglyza (Tablet) Maximum of 1 tablet per day Onzetra Xsail (Exhaler Powder) Maximum of 1 kit (16 exhalers) per 30 days Opana (10mg Tablet Immediate-Release, Maximum of 6 tablets per day 5mg Tablet Immediate-Release) Opana ER (10mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 15mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 20mg Tablet Extended-Release 12 Hour Maximum of 2 tablets per day Abuse-Deterrent, 5mg Tablet Extended- Release 12 Hour Abuse-Deterrent, 7.5mg Tablet Extended-Release 12 Hour Abuse- Deterrent) Opana ER (30mg Tablet Extended-Release 12 Maximum of 4 tablets per day Hour Abuse-Deterrent)

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Last167 updated September 1, 2017 167 25 Drug Name Quantity Limit Opana ER (40mg Tablet Extended-Release 12 Maximum of 3 tablets per day Hour Abuse-Deterrent) Oralair (Tablet Sublingual) Maximum of 1 tablet per day Orenitram (0.125mg Tablet Extended- Release, 0.25mg Tablet Extended-Release, Maximum of 6 tablets per day 1mg Tablet Extended-Release) Orkambi (Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (Capsule) Maximum of 2 capsules per day Oseni (Tablet) Maximum of 1 tablet per day Oxandrolone (10mg Tablet) Maximum of 2 tablets per day Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10mg Tablet Extended-Release 24 Hour, 15mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (5mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day Oxycodone HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 12 tablets per day Tablet Immediate-Release) Oxycodone HCl (15mg Tablet Immediate- Maximum of 16 tablets per day Release) Oxycodone HCl (30mg Tablet Immediate- Maximum of 8 tablets per day Release) Oxycodone HCl (5mg Capsule Immediate- Maximum of 12 capsules per day Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day Oxycodone HCl ER (Tablet Extended-Release Maximum of 3 tablets per day 12 Hour Abuse-Deterrent) Oxycodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet) Oxycodone/Acetaminophen (325mg/5ml-5mg/ Maximum of 60 ml per day 5ml Oral Solution) Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day OxyContin (Tablet Extended-Release 12 Hour Maximum of 3 tablets per day Abuse-Deterrent) Oxymorphone HCl (Tablet Immediate-Release) Maximum of 6 tablets per day

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168168 Last updated September 1, 2017 26 Drug Name Quantity Limit Oxymorphone HCl ER (10mg Tablet Extended- Release 12 Hour, 15mg Tablet Extended- Release 12 Hour, 20mg Tablet Extended- Maximum of 2 tablets per day Release 12 Hour, 5mg Tablet Extended-Release 12 Hour, 7.5mg Tablet Extended-Release 12 Hour) Oxymorphone HCl ER (30mg Tablet Extended- Maximum of 4 tablets per day Release 12 Hour) Oxymorphone HCl ER (40mg Tablet Extended- Maximum of 3 tablets per day Release 12 Hour) Paliperidone ER (1.5mg Tablet Extended- Release 24 Hour, 3mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour, 9mg Tablet Extended-Release 24 Hour) Paliperidone ER (6mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Pantoprazole Sodium (20mg Tablet Delayed- Maximum of 3 tablets per day Release) Pantoprazole Sodium (40mg Tablet Delayed- Maximum of 2 tablets per day Release) Paricalcitol (1mcg Capsule) Maximum of 1 capsule per day Paricalcitol (2mcg Capsule) Maximum of 2 capsules per day Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day Percocet (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Maximum of 12 tablets per day Tablet) Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day Perindopril Erbumine (Tablet) Maximum of 2 tablets per day Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day Plavix (300mg Tablet) Maximum of 1 tablet per day Plavix (75mg Tablet) Maximum of 4 tablets per day Pomalyst (Capsule) Maximum of 1 capsule per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (150mg/ml Solution Pen injector, Maximum of 2 pens (2 ml) per 28 days 75mg/ml Solution Pen injector)

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Last169 updated September 1, 2017 169 27 Drug Name Quantity Limit Prandin (1mg Tablet) Maximum of 16 tablets per day Prandin (2mg Tablet) Maximum of 8 tablets per day Pravachol (Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Tablet) Maximum of 1 tablet per day Precose (100mg Tablet) Maximum of 3 tablets per day Precose (25mg Tablet) Maximum of 12 tablets per day Precose (50mg Tablet) Maximum of 6 tablets per day Prevacid (Capsule Delayed-Release) Maximum of 2 capsules per day Prezcobix (Tablet) Maximum of 2 tablets per day Prezista (100mg/ml Suspension) Maximum of 60 ml per day Prezista (150mg Tablet) Maximum of 6 tablets per day Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day Prezista (75mg Tablet) Maximum of 7 tablets per day Primlev (10mg-300mg Tablet, 5mg-300mg Maximum of 13 tablets per day Tablet, 7.5mg-300mg Tablet) Prinivil (Tablet) Maximum of 2 tablets per day Pristiq (100mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Pristiq (25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Procardia XL (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Promacta (12.5mg Tablet, 25mg Tablet) Maximum of 1 tablet per day Promacta (50mg Tablet, 75mg Tablet) Maximum of 2 tablets per day Protonix (20mg Tablet Delayed-Release) Maximum of 3 tablets per day Protonix (40mg Tablet Delayed-Release) Maximum of 2 tablets per day Provigil (100mg Tablet) Maximum of 1 tablet per day Provigil (200mg Tablet) Maximum of 2 tablets per day Pulmicort Flexhaler (Aerosol Powder) Maximum of 2 inhalers per 30 days Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day Qbrelis (Oral Solution) Maximum of 80 ml per day Quetiapine Fumarate (100mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, Maximum of 3 tablets per day 50mg Tablet Immediate-Release) Quetiapine Fumarate (25mg Tablet Immediate- Maximum of 4 tablets per day Release)

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170170 Last updated September 1, 2017 28 Drug Name Quantity Limit Quetiapine Fumarate (300mg Tablet Immediate- Maximum of 2 tablets per day Release, 400mg Tablet Immediate-Release) Quetiapine Fumarate ER (150mg Tablet Extended-Release 24 Hour, 200mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Quetiapine Fumarate ER (300mg Tablet Extended-Release 24 Hour, 400mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) QuilliChew ER (20mg Tablet Chewable Extended-Release, 40mg Tablet Chewable Maximum of 1 tablet per day Extended-Release) QuilliChew ER (30mg Tablet Chewable Maximum of 2 tablets per day Extended-Release) Quinapril HCl (Tablet) Maximum of 2 tablets per day Quinapril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Quinapril/Hydrochlorothiazide (20mg-12.5mg Maximum of 2 tablets per day Tablet, 20mg-25mg Tablet) Maximum of 2 inhalers (17.4 grams) per 30 QVAR (Aerosol Solution) days Ragwitek (Tablet Sublingual) Maximum of 1 tablet per day Raloxifene HCl (Tablet) Maximum of 1 tablet per day Ramipril (Capsule) Maximum of 2 capsules per day Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Rapaflo (Capsule) Maximum of 1 capsule per day RAVICTI (Liquid) Maximum of 17.5 ml per day Razadyne (Tablet) Maximum of 2 tablets per day Razadyne ER (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days Relistor (150mg Tablet) Maximum of 3 tablets per day Relpax (Tablet) Maximum of 12 tablets per 30 days Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day Repaglinide (1mg Tablet) Maximum of 16 tablets per day Repaglinide (2mg Tablet) Maximum of 8 tablets per day Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days Repatha Pushtronex System (Injection) Maximum of 1 cartridge (3.5 ml) per 28 days

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Last171 updated September 1, 2017 171 29 Drug Name Quantity Limit Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days Rescriptor (Tablet) Maximum of 9 tablets per day Restasis (Emulsion) Maximum of 2 vials per day Restoril (22.5mg Capsule) Maximum of 1 capsule per day Retrovir (100mg Capsule) Maximum of 8 capsules per day Retrovir (50mg/5ml Syrup) Maximum of 96 ml per day Revatio (10mg/ml Suspension) Maximum of 6 ml per day Revatio (20mg Tablet) Maximum of 3 tablets per day Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Reyataz (200mg Capsule) Maximum of 3 capsules per day Reyataz (50mg Packet) Maximum of 8 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days Risedronate Sodium DR (Tablet Delayed- Maximum of 4 tablets per 28 days Release) Ritalin (Tablet) Maximum of 3 tablets per day Rivastigmine Tartrate (Capsule Immediate- Maximum of 2 capsules per day Release) Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet Immediate- Maximum of 12 tablets per 30 days Release) Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Roxicodone (15mg Tablet) Maximum of 16 tablets per day Roxicodone (30mg Tablet) Maximum of 8 tablets per day Roxicodone (5mg Tablet) Maximum of 12 tablets per day Rozerem (Tablet) Maximum of 1 tablet per day Rubraca (Tablet) Maximum of 4 tablets per day Rydapt (Capsule) Maximum of 8 capsules per day Sabril (500mg Packet) Maximum of 6 packets per day Sabril (500mg Tablet) Maximum of 6 tablets per day Samsca (Tablet) Maximum of 2 tablets per day

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172172 Last updated September 1, 2017 30 Drug Name Quantity Limit Saphris (Tablet Sublingual) Maximum of 2 tablets per day Savaysa (Tablet) Maximum of 1 tablet per day Selzentry (150mg Tablet, 75mg Tablet) Maximum of 3 tablets per day Selzentry (25mg Tablet, 300mg Tablet) Maximum of 6 tablets per day Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day Sensipar (90mg Tablet) Maximum of 4 tablets per day Maximum of 1 inhaler (60 inhalations) per 30 Serevent Diskus (Aerosol Powder) days Seroquel (100mg Tablet, 200mg Tablet, Maximum of 3 tablets per day 50mg Tablet) Seroquel (25mg Tablet) Maximum of 4 tablets per day Seroquel (300mg Tablet, 400mg Tablet) Maximum of 2 tablets per day Seroquel XR (150mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Seroquel XR (300mg Tablet Extended- Release 24 Hour, 400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour, 50mg Tablet Extended- Release 24 Hour) sfRowasa (Enema) Maximum of 1 bottle (60 ml) per day Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day Simvastatin (Tablet) Maximum of 1 tablet per day Singulair (10mg Tablet) Maximum of 1 tablet per day Singulair (4mg Packet) Maximum of 1 packet per day Singulair (4mg Tablet Chewable, 5mg Tablet Maximum of 1 tablet per day Chewable) Soliqua 100/33 (Injection) Maximum of 18 ml (6 pens) per 30 days Somavert (Injection) Maximum of 1 vial per day Sonata (Capsule) Maximum of 90 days of use per year Sovaldi (Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Sporanox (100mg Capsule) Maximum of 4 capsules per day Sprycel (100mg Tablet, 140mg Tablet, 70mg Maximum of 1 tablet per day Tablet) Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day Sprycel (80mg Tablet) Maximum of 2 tablets per day Starlix (120mg Tablet) Maximum of 3 tablets per day

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Last173 updated September 1, 2017 173 31 Drug Name Quantity Limit Starlix (60mg Tablet) Maximum of 6 tablets per day Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (20mg Capsule) Maximum of 2 capsules per day Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Tablet) Maximum of 4 tablets per day Strattera (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Strattera (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Stribild (Tablet) Maximum of 2 tablets per day Striverdi Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 films per day Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 films per day Subsys (Liquid) Maximum of 4 sprays per day Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100mg Tablet, 25mg Maximum of 12 tablets per 30 days Tablet, 50mg Tablet) Sumatriptan Succinate (4mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector, 6mg/0.5ml Solution Auto injector) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Prefilled Syringe) Sumatriptan Succinate (6mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Sumavel DosePro (Injection) Maximum of 12 injections (6 ml) per 30 days Sustiva (200mg Capsule) Maximum of 3 capsules per day Sustiva (50mg Capsule) Maximum of 9 capsules per day Sustiva (600mg Tablet) Maximum of 2 tablets per day Sutent (12.5mg Capsule, 25mg Capsule, Maximum of 1 capsule per day 50mg Capsule) Sutent (37.5mg Capsule) Maximum of 2 tablets per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Synalgos-DC (Capsule) Maximum of 8 capsules per day Synjardy (Tablet) Maximum of 2 tablets per day Syprine (Capsule) Maximum of 8 capsules per day Tagrisso (Tablet) Maximum of 1 tablet per day

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174174 Last updated September 1, 2017 32 Drug Name Quantity Limit Tamiflu (30mg Capsule, 45mg Capsule, Maximum of 2 capsules per day 75mg Capsule) Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day Tanzeum (Injection) Maximum of 4 pens per 28 days Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day Tarka (Tablet Extended-Release) Maximum of 1 tablet per day Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 capsules per day Tasmar (Tablet) Maximum of 6 tablets per day Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day Technivie (Tablet) Maximum of 2 tablets per day Tekturna (Tablet) Maximum of 1 tablet per day Tekturna HCT (150mg-12.5mg Tablet, Maximum of 1 tablet per day 150mg-25mg Tablet, 300mg-12.5mg Tablet) Tekturna HCT (Tablet) Maximum of 1 tablet per day Telmisartan (Tablet) Maximum of 1 tablet per day Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day Telmisartan/Hydrochlorothiazide (40mg-12.5mg Maximum of 1 tablet per day Tablet, 80mg-25mg Tablet) Telmisartan/Hydrochlorothiazide (80mg-12.5mg Maximum of 2 tablets per day Tablet) Temazepam (22.5mg Capsule) Maximum of 1 capsule per day Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 tablets per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI (Nebulized Solution) Maximum of 10 ml (2 ampules) per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day Tolazamide (250mg Tablet) Maximum of 4 tablets per day Tolazamide (500mg Tablet) Maximum of 2 tablets per day Tolbutamide (Tablet) Maximum of 6 tablets per day Tolcapone (Tablet) Maximum of 6 tablets per day Toviaz (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day

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Last175 updated September 1, 2017 175 33 Drug Name Quantity Limit Tracleer (Tablet) Maximum of 2 tablets per day Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day Tramadol HCl ER (100mg Capsule Extended- Release 24 Hour, 200mg Capsule Extended- Maximum of 1 capsule per day Release 24 Hour, 300mg Capsule Extended- Release 24 Hour) Tramadol HCl ER (100mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour, 300mg Tablet Extended- Release 24 Hour) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Trandolapril (4mg Tablet) Maximum of 2 tablets per day Trandolapril/Verapamil HCl (Tablet Extended- Maximum of 1 tablet per day Release) Tranxene T (7.5mg Tablet) Maximum of 12 tablets per day Treximet (Tablet) Maximum of 9 tablets per 30 days Trezix (Capsule) Maximum of 10 capsules per day Tribenzor (Tablet) Maximum of 1 tablet per day Trintellix (Tablet) Maximum of 1 tablet per day Triumeq (Tablet) Maximum of 2 tablets per day Trizivir (Tablet) Maximum of 3 tablets per day Trokendi XR (100mg Capsule Extended- Release 24 Hour, 50mg Capsule Extended- Maximum of 3 capsules per day Release 24 Hour) Trokendi XR (200mg Capsule Extended- Release 24 Hour, 25mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour) Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days Truvada (Tablet) Maximum of 2 tablets per day Twynsta (Tablet) Maximum of 1 tablet per day Tybost (Tablet) Maximum of 2 tablets per day Tylenol/Codeine #3 (Tablet) Maximum of 13 tablets per day Tylenol/Codeine #4 (Tablet) Maximum of 13 tablets per day Tymlos (Injection) Maximum of 1.56 ml per 30 days Ultracet (Tablet) Maximum of 12 tablets per day Ultram (Tablet) Maximum of 8 tablets per day

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176176 Last updated September 1, 2017 34 Drug Name Quantity Limit Uptravi (1000mcg Tablet, 1200mcg Tablet, 1400mcg Tablet, 1600mcg Tablet, 400mcg Maximum of 2 tablets per day Tablet, 600mcg Tablet, 800mcg Tablet) Uptravi (200mcg Tablet) Maximum of 5 tablets per day Vagifem (Tablet) Maximum of 1 tablet per day Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valcyte (450mg Tablet) Maximum of 4 tablets per day Valcyte (50mg/ml Oral Solution) Maximum of 36 ml per day Valganciclovir (Tablet) Maximum of 4 tablets per day Valganciclovir Hydrochlorde (Oral Solution) Maximum of 36 ml per day Valium (Tablet) Maximum of 4 tablets per day Valsartan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Valsartan (320mg Tablet) Maximum of 1 tablet per day Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Valtrex (1gm Tablet) Maximum of 4 tablets per day Valtrex (500mg Tablet) Maximum of 2 tablets per day Vaseretic (Tablet) Maximum of 2 tablets per day Vasotec (10mg Tablet, 2.5mg Tablet, 20mg Maximum of 2 tablets per day Tablet, 5mg Tablet) Veltassa (Packet) Maximum of 1 packet per day Vemlidy (Tablet) Maximum of 1 tablet per day Venclexta (100mg Tablet) Maximum of 4 tablets per day Venclexta (10mg Tablet) Maximum of 2 tablets per day Venclexta (50mg Tablet) Maximum of 1 tablet per day Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day Vesicare (Tablet) Maximum of 1 tablet per day Viberzi (Tablet) Maximum of 2 tablets per day Vicodin (Tablet) Maximum of 13 tablets per day Vicodin ES (Tablet) Maximum of 13 tablets per day Vicodin HP (Tablet) Maximum of 13 tablets per day Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days Videx EC (Capsule Delayed-Release) Maximum of 2 capsules per day Videx Pediatric (Oral Solution) Maximum of 30 ml per day Viekira Pak (Tablet Therapy Pack) Maximum of 1 pack (112 tablets) per 28 days

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Last177 updated September 1, 2017 177 35 Drug Name Quantity Limit Viekira XR (Tablet Extended-Release 24 Maximum of 1 pack (84 tablets) per 28 days Hour) Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 tablet per day Vimpat (100mg Tablet, 150mg Tablet, 200mg Maximum of 2 tablets per day Tablet, 50mg Tablet) Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viramune (200mg Tablet) Maximum of 3 tablets per day Viramune (50mg/5ml Suspension) Maximum of 60 ml per day Viramune XR (100mg Tablet Extended- Maximum of 3 tablets per day Release 24 Hour) Viramune XR (400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet, 300mg Maximum of 2 tablets per day Tablet) Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days Vivelle-Dot (Patch Twice Weekly) Maximum of 8 patches per 28 days Vivlodex (Capsule) Maximum of 1 capsule per day Votrient (Tablet) Maximum of 4 tablets per day Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 1 capsule per day Capsule, 6mg Capsule) Vytorin (Tablet) Maximum of 1 tablet per day Xanax (0.25mg Tablet, 0.5mg Tablet, 1mg Maximum of 4 tablets per day Tablet) Xanax (2mg Tablet) Maximum of 5 tablets per day Xanax XR (0.5mg Tablet Extended-Release 24 Hour, 1mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xanax XR (2mg Tablet Extended-Release 24 Maximum of 5 tablets per day Hour) Xanax XR (3mg Tablet Extended-Release 24 Maximum of 3 tablets per day Hour) Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Xarelto (15mg Tablet) Maximum of 2 tablets per day Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days Xeljanz (Tablet) Maximum of 2 tablets per day

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178178 Last updated September 1, 2017 36 Drug Name Quantity Limit Xeljanz XR (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xenazine (12.5mg Tablet) Maximum of 3 tablets per day Xenazine (25mg Tablet) Maximum of 4 tablets per day Xerese (Cream) Maximum of 1 tube (5 grams) per 30 days Xermelo (Tablet) Maximum of 3 tablets per day Xigduo XR (10mg-1000mg Tablet Extended- Release 24 Hour, 10mg-500mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour, 5mg-500mg Tablet Extended-Release 24 Hour) Xigduo XR (5mg-1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Xodol (10mg-300mg Tablet, 5mg-300mg Tablet, Maximum of 13 tablets per day 7.5mg-300mg Tablet) Xtampza ER (Capsule Extended-Release 12 Maximum of 3 capsules per day Hour Abuse-Deterrent) Xtandi (Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Xyzal (5mg Tablet) Maximum of 1 tablet per day Yosprala (Tablet Delayed-Release) Maximum of 1 tablet per day Yuvafem (Tablet) Maximum of 1 tablet per day Zafirlukast (Tablet) Maximum of 2 tablets per day Zaleplon (Capsule) Maximum of 90 days of use per year Zamicet (Oral Solution) Maximum of 180 ml per day Zejula (Capsule) Maximum of 3 capsules per day Zelboraf (Tablet) Maximum of 8 tablets per day Zembrace Symtouch (Injection) Maximum of 8 ml (16 syringes) per 30 days Zemplar (1mcg Capsule) Maximum of 1 capsule per day Zemplar (2mcg Capsule) Maximum of 2 capsules per day Zenzedi (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 6 tablets per day Tablet, 7.5mg Tablet) Zenzedi (15mg Tablet) Maximum of 4 tablets per day Zenzedi (20mg Tablet) Maximum of 3 tablets per day Zenzedi (30mg Tablet) Maximum of 2 tablets per day Zepatier (Tablet) Maximum of 1 tablet per day Zerit (15mg Capsule, 30mg Capsule, 40mg Maximum of 3 capsules per day Capsule)

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Last179 updated September 1, 2017 179 37 Drug Name Quantity Limit Zerit (1mg/ml Oral Solution) Maximum of 120 ml per day Zerit (20mg Capsule) Maximum of 2 capsules per day Zestoretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Zestoretic (20mg-12.5mg Tablet) Maximum of 4 tablets per day Zestoretic (20mg-25mg Tablet) Maximum of 2 tablets per day Zestril (Tablet) Maximum of 2 tablets per day Zetia (Tablet) Maximum of 1 tablet per day Ziac (Tablet) Maximum of 2 tablets per day Ziagen (20mg/ml Oral Solution) Maximum of 48 ml per day Ziagen (300mg Tablet) Maximum of 3 tablets per day Zidovudine (100mg Capsule) Maximum of 8 capsules per day Zidovudine (300mg Tablet) Maximum of 3 tablets per day Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zocor (Tablet) Maximum of 1 tablet per day Zohydro ER (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour Abuse-Deterrent) Zolmitriptan (Tablet) Maximum of 12 tablets per 30 days Zolmitriptan ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 90 days of use per year Release, 5mg Tablet Immediate-Release) Zomig Nasal Spray (2.5mg Solution) Maximum of 18 devices per 30 days Zomig (2.5mg Tablet, 5mg Tablet) Maximum of 12 tablets per 30 days Zomig Nasal Spray (5mg Solution) Maximum of 12 devices per 30 days Zomig ZMT (Tablet Dispersible) Maximum of 12 tablets per 30 days Zontivity (Tablet) Maximum of 1 tablet per day Zovirax (5% Cream) Maximum of 1 tube (5 grams) per 30 days Zovirax (5% Ointment) Maximum of 1 tube (30 grams) per 30 days Zubsolv (1.4mg-0.36mg Tablet Sublingual, Maximum of 3 tablets per day 5.7mg-1.4mg Tablet Sublingual) Zubsolv (11.4mg-2.9mg Tablet Sublingual) Maximum of 1 tablet per day Zubsolv (2.9mg-0.71mg Tablet Sublingual) Maximum of 5 tablets per day Zubsolv (8.6mg-2.1mg Tablet Sublingual) Maximum of 2 tablets per day Zydelig (Tablet) Maximum of 2 tablets per day Zykadia (Capsule) Maximum of 5 capsules per day

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180180 Last updated September 1, 2017 38 Drug Name Quantity Limit Zyprexa (10mg Tablet, 15mg Tablet, 2.5mg Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Maximum of 1 tablet per day Tablet) Zyprexa Zydis (10mg Tablet Dispersible, 15mg Tablet Dispersible, 20mg Tablet Maximum of 1 tablet per day Dispersible, 5mg Tablet Dispersible) Zytiga (Tablet) Maximum of 4 tablets per day Zyvox (600mg Tablet) Maximum of 2 tablets per day track

Bold type = Brand name drug Plain type = Generic drug 181 181 Required information Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change from time to time during each plan year. You will receive notice when necessary. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Please call Customer Service. Our contact information is on the cover. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. For more up-to-date information or if you have other questions, please call Customer Service at:

Toll-Free 1-888-867-5581, TTY 711 7 a.m. - 8 p.m. local time, 7 days a week

www.UHCRetiree.com/calpers

UHEX18PP4082656_001 Last updated September 1, 2017