QUALIFIED HEALTH PLAN FORMULARY Effective September 2021

Provided by Elixir

Introduction

The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.

Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC & Elixir, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature.

This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

i

Tier Guidelines

Generic Tier 1

Preferred Brand Tier 2

Non-Preferred Brand Tier 3 Non- Preferred Generic Specialty Tier 4

Preventive Tier 5 $0 co-pay at in-network pharmacies

The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, co- insurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines

Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include:

Prior Authorization Drug requires prior authorization through a specific physician request Required (PA) process.

Over the Counter Drug coverage is available for drugs that are available OTC with an Drugs (OTC) authorized prescription from your provider.

Specialty Drugs (SP) Drug requires processing through THC’s contracted specialty pharmacy, Elixir Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction Drug coverage may depend on patient gender. (GR) Step Therapy Drug coverage requires that an alternative or trial of another drug be used Required (ST) before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

ii

Saving on Out-Of-Pocket Costs

Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year.

Preventive Medications

Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations.

Prior Authorization (PA)

Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request.

Non-Formulary Agents

Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non- formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

• The patient has failed an appropriate trial of formulary or preferred agents. • The use of preferred or formulary agent is contraindicated in the patient.

iii

• The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety.

If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action.

Common Drug Exclusions

The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:

• OTC medications or their equivalents unless otherwise specified in the Formulary listing. • Drug products used for cosmetic purposes. • Drug products for sexual dysfunction. • Experimental drug products, or any drug product used in an experimental manner. • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

Mandated Generic Substitution

Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay.

Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.

Product Selection Criteria

The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies

Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, iv

and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin , alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Elixir Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Elixir Specialty Pharmacy.

A Specialty Drug Prior Authorization Request form must be completed and faxed to Elixir at 1-866-422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com.

Once the order is received, Elixir obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Elixir Specialty Pharmacy. Then, Elixir Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact Elixir at 1-844-222-5584 or Elixir Specialty Pharmacy at 1-877-437-9012.

Contact Information

The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862.

Medication Limitations

Quantity Limitations

Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy.

Age Limitations

Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

Gender Restrictions

Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage.

Step Therapy Criteria v

Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria Aminosalicylic Acid APRISO, PENTASA, Prior use of APRISO or Derivative Agents DELZICOL mesalamine DR mesalamine DR in the last 90 days.

Angiotensin Receptor amlodipine- amlodipine- Prior use of amlodipine-valsartan Blocker and Calcium valsartan olmesartan in the last 90 days. Channel Blocker

Antidiabetic Agents – alogliptin, JANUVIA, Prior use of alogliptin, alogliptin- DPP4 alogliptin-metformin JANUMET, metformin, or alogliptin- alogliptin- JANUMET XR, pioglitazone in the last 90 days. pioglitazone ONGLYZA, TRADJENTA

Antidiabetic Agents – INVOKANA, FARXIGA, Prior use of TWO of the SGLT-2 INVOKAMET, XIGDUO XR following: INVOKANA, INVOKAMET XR, INVOKAMET, JARDIANCE, JARDIANCE, SYNJARDY in the last 180 SYNJARDY, days. SYNJARDY XR Antiemetic Agents ondansetron, ANZEMET, Prior use of ondansetron AND granisetron aprepitant granisetron in the last 90 days.

Antiglaucoma Agents latanoprost, LUMIGAN, Prior use of TWO of the bimatoprost, TRAVATAN-Z, following: latanoprost, travoprost ZIOPTAN bimatoprost or travoprost in the last 90 days. Antimigraine sumatriptan, almotriptan, Prior use of TWO of the rizatriptan, eletriptan, following: sumatriptan, naratriptan, frovatriptan rizatriptan, zolmitriptan, zolmitriptan naratriptan in the last 90 days.

Anti-Parkinson's selegiline EMSAM Prior use of selegiline tablet in Agents – MAO-B the last 90 days. inhibitors Anti-Parkinson's ropinirole ropinirole Prior use of ropinirole Agents immediate-release, extended-release, immediate-release AND pramipexole pramipexole pramipexole immediate-release immediate-release extended-release in the last 90 days.

vi

Anti-platelet Agents clopidogrel prasugrel Prior use of clopidogrel in the last 90 days. Antipsychotics quetiapine IR, quetiapine ER Prior use for 30 days of quetiapine olanzapine, IR, olanzapine, risperidone, or risperidone, ziprasidone ziprasidone

Beta2 Agonist albuterol levalbuterol Prior use of albuterol nebulizer (nebulizer) nebulizer solution solution in the last 90 days.

Coreg CR carvedilol IR carvedilol ER Prior use of carvedilol IR in the last 90 days.

HMG-CoA Reductase atorvastatin, LIVALO, Prior use of TWO of the Inhibitor simvastatin, ezetimibe- following: atorvastatin, rosuvastatin simvastatin rosuvastatin, simvastatin in the last 90 days.

Hypnotic Agents temazepam, ramelteon, Prior use of TWO of the zaleplon, BELSOMRA following: temazepam, zaleplon, zolpidem IR, zolpidem, zolpidem ER, zolpidem ER, eszopiclone in the last 90 days. eszopiclone

Nasal Corticosteroids flunisolide azelastine, Prior use of TWO of the fluticasone, B ECONASE AQ, following: flunisolide, NASACORT OTC, mometasone, fluticasone , NASACORT OTC budesonide OTC QNASL or budesonide OTC nasal in the last 180 days. Pediculicides malathion 0.5% NATROBA Prior use of malathion 0.5% within the last 90 days. Pleuromutilin mupirocin ALTABAX Prior use of mupirocin in the last Antibiotic 90 days.

Propranolol ER propranolol IR propranolol ER Prior use of propranolol IR in the last 90 days.

Retinoic Acid tretinoin 0.025%, tretinoin 0.04% Prior use of tretinoin 0.025%, Derivatives tretinoin 0.05%, adapalene-benz tretinoin 0.05%, tretinoin 0.01%, tretinoin 0.1%, peroxide gel, tretinoin 0.1%, or DIFFERIN tretinoin 0.01%, clindamycin- OTC 0.1% GEL in the last 90 DIFFERIN OTC tretinoin days. 0.1% GEL Topical Scalp ketoconazole 2% CAPEX Prior use of ketoconazole 2% Corticosteroids SHAMPOO shampoo in the last 90 days.

Topical clobetasol, calcipotriene - Prior use of TWO of the Corticosteroids desonide, betamethasone following: clobetasol, desonide, betamethasone, betamethasone, flucinolone, vii

flucinolone, flucinonide, hydrocortisone, or flucinonide, triamcinolone in the last 90 days. hydrocortisone, triamcinolone Urinary oxybutynin, tolterodine, Prior use of OXYTROL OTC, Antispasmodics oxybutynin ER, tolterodine ER, oxybutynin, oxybutynin ER, or OXYTROL OTC, trospium, oxybutynin in the last 90 oxybutynin syrup trospium ER, days. darifenacin, solifenacin, TOVIAZ

Vascepa omega-3-acid icosapent ethyl Prior use of omega-3 acid in the last 90 days. Vyvanse amphetamine ER VYVANSE Prior use of amphetamine ER capsule in the last 90 days.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Elixir. The presence of a medication on this formulary list does not guarantee coverage.

viii

CURRENT AS OF 9/1/2021

Notes AL = Age Limit GR-F = Female Only GR-M = Male Only lowercase italics = Generic drugs PA = Prior Authorization UPPERCASE BOLD = Brand Status QL = Quantity Limit name drugs T1 = Covered ST = Step Therapy Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* amphetamine-dextroamphet er oral capsule QL (30 EA per 30 days); AL (Min T2 extended release 24 hour 10 mg, 15 mg, 5 mg 6 Years) amphetamine-dextroamphet er oral capsule QL (60 EA per 30 days); AL (Min T2 extended release 24 hour 20 mg, 25 mg, 30 mg 6 Years) amphetamine-dextroamphetamine oral tablet 10 QL (120 EA per 30 days); AL T1 mg, 12.5 mg, 15 mg (Min 6 Years) amphetamine-dextroamphetamine oral tablet 20 QL (90 EA per 30 days); AL (Min T1 mg, 5 mg, 7.5 mg 6 Years) amphetamine-dextroamphetamine oral tablet 30 QL (60 EA per 30 days); AL (Min T1 mg 6 Years) armodafinil oral tablet 150 mg, 200 mg, 250 mg, T1 QL (30 EA per 30 days) 50 mg atomoxetine hcl oral capsule 10 mg, 18 mg, 25 QL (60 EA per 30 days); AL (Min T1 mg, 40 mg 6 Years) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 QL (30 EA per 30 days); AL (Min T1 mg 6 Years) caffeine citrate solution 20 mg/ml oral 20 mg/ml T1 caffeine citrate solution 60 mg/3ml intravenous T1 60 mg/3ml caffeine-sodium benzoate solution 125-125 mg/ml T1 125-125 mg/ml DAYTRANA PATCH 10 MG/9HR PA; QL (30 EA per 30 days); AL T3 10 MG/9HR (Min 6 Years and Max 17 Years) DAYTRANA PATCH 15 MG/9HR PA; QL (30 EA per 30 days); AL T3 TRANSDERMAL 15 MG/9HR (Min 6 Years and Max 17 Years) DAYTRANA PATCH 20 MG/9HR PA; QL (30 EA per 30 days); AL T3 TRANSDERMAL 20 MG/9HR (Min 6 Years and Max 17 Years) DAYTRANA PATCH 30 MG/9HR PA; QL (30 EA per 30 days); AL T3 TRANSDERMAL 30 MG/9HR (Min 6 Years and Max 17 Years) dexmethylphenidate hcl er oral capsule extended QL (30 EA per 30 days); AL (Min release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 T1 4 Years) mg, 35 mg, 40 mg, 5 mg

1 Drug Status Notes QL (150 EA per 30 days); AL dexmethylphenidate hcl oral tablet 10 mg, 5 mg T1 (Min 6 Years) QL (90 EA per 30 days); AL (Min dexmethylphenidate hcl oral tablet 2.5 mg T1 6 Years) dextroamphetamine sulfate er oral capsule T1 extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg T1 QL (180 EA per 30 days) dextroamphetamine sulfate oral tablet 5 mg T1 QL (360 EA per 30 days) diethylpropion hcl er tablet extended release 24 T1 hour 75 mg oral 75 mg diethylpropion hcl tablet 25 mg oral 25 mg T1 DOPRAM INTRAVENOUS SOLUTION 20 T1 MG/ML guanfacine hcl er oral tablet extended release 24 T1 QL (60 EA per 30 days) hour 1 mg, 2 mg, 3 mg, 4 mg AL (Min 6 Years and Max 17 methamphetamine hcl tablet 5 mg oral 5 mg T1 Years) methylphenidate hcl er (cd) oral capsule extended QL (30 EA per 30 days); AL (Min release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 T1 4 Years) mg methylphenidate hcl er (la) oral capsule extended QL (30 EA per 30 days); AL (Min release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 T1 4 Years and Max 10 Years) mg methylphenidate hcl er oral tablet extended QL (300 EA per 30 days); AL T1 release 10 mg (Min 4 Years) methylphenidate hcl er oral tablet extended QL (150 EA per 30 days); AL T1 release 20 mg (Min 4 Years) methylphenidate hcl er oral tablet extended QL (30 EA per 30 days); AL (Min T1 release 24 hour 18 mg, 27 mg 4 Years and Max 10 Years) methylphenidate hcl er oral tablet extended QL (60 EA per 30 days); AL (Min T1 release 24 hour 36 mg, 54 mg 4 Years and Max 10 Years) QL (600 ML per 30 days); AL methylphenidate hcl oral solution 5 mg/5ml T1 (Min 4 Years and Max 10 Years) QL (300 EA per 30 days); AL methylphenidate hcl oral tablet 10 mg T1 (Min 4 Years) QL (150 EA per 30 days); AL methylphenidate hcl oral tablet 20 mg T1 (Min 4 Years) QL (600 EA per 30 days); AL methylphenidate hcl oral tablet 5 mg T1 (Min 4 Years) methylphenidate hcl solution 10 mg/5ml oral 10 PA; AL (Min 6 Years and Max 17 T1 mg/5ml Years) modafinil tablet 100 mg oral 100 mg T1 PA modafinil tablet 200 mg oral 200 mg T1 PA

2 Drug Status Notes phendimetrazine tartrate er capsule extended T1 release 24 hour 105 mg oral 105 mg phendimetrazine tartrate tablet 35 mg oral 35 mg T1 phentermine hcl capsule 15 mg oral 15 mg T1 phentermine hcl capsule 30 mg oral 30 mg T1 phentermine hcl capsule 37.5 mg oral 37.5 mg T1 phentermine hcl tablet 37.5 mg oral 37.5 mg T1 ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 10 MG ORAL 10 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 20 MG ORAL 20 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 30 MG ORAL 30 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 40 MG ORAL 40 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 50 MG ORAL 50 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 60 MG ORAL 60 MG T3 (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL VYVANSE CAPSULE 70 MG ORAL 70 MG T3 (Min 6 Years and Max 17 Years) *Aminoglycosides* neomycin sulfate tablet 500 mg oral 500 mg T1 paromomycin sulfate capsule 250 mg oral 250 mg T4 PA tobramycin nebulization solution 300 mg/5ml T4 PA 300 mg/5ml *Analgesics - Anti-Inflammatory* ARCALYST SOLUTION RECONSTITUTED T4 PA 220 MG SUBCUTANEOUS 220 MG celecoxib oral capsule 100 mg, 200 mg, 400 mg, T1 QL (60 EA per 30 days) 50 mg diclofenac potassium tablet 50 mg oral 50 mg T1 diclofenac sodium er tablet extended release 24 T1 hour 100 mg oral 100 mg diclofenac sodium tablet delayed release 25 mg T1 oral 25 mg diclofenac sodium tablet delayed release 50 mg T1 oral 50 mg diclofenac sodium tablet delayed release 75 mg T1 oral 75 mg diclofenac-misoprostol tablet delayed release 50- T3 0.2 mg oral 50-0.2 mg 3 Drug Status Notes diclofenac-misoprostol tablet delayed release 75- T3 0.2 mg oral 75-0.2 mg ENBREL SOLUTION PREFILLED 50 MG/ML SUBCUTANEOUS 50 T4 PA MG/ML ENBREL SOLUTION RECONSTITUTED 25 T4 PA MG SUBCUTANEOUS 25 MG ENBREL SUBCUTANEOUS SOLUTION T4 PA PREFILLED SYRINGE 25 MG/0.5ML ENBREL SURECLICK SOLUTION AUTO- INJECTOR 50 MG/ML SUBCUTANEOUS 50 T4 PA MG/ML etodolac capsule 200 mg oral 200 mg T1 etodolac capsule 300 mg oral 300 mg T1 etodolac er tablet extended release 24 hour 400 T1 mg oral 400 mg etodolac er tablet extended release 24 hour 500 T1 mg oral 500 mg etodolac er tablet extended release 24 hour 600 T1 mg oral 600 mg etodolac tablet 400 mg oral 400 mg T1 etodolac tablet 500 mg oral 500 mg T1 flurbiprofen tablet 100 mg oral 100 mg T1 flurbiprofen tablet 50 mg oral 50 mg T1 HUMIRA PEN PEN-INJECTOR KIT 40 T4 PA MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML HUMIRA PREFILLED SYRINGE KIT 20 T4 PA MG/0.4ML SUBCUTANEOUS 20 MG/0.4ML HUMIRA PREFILLED SYRINGE KIT 40 T4 PA MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED T4 PA SYRINGE KIT 10 MG/0.2ML IBU TABLET 400 MG ORAL 400 MG T1 ibuprofen oral 100 mg/5ml T1 ibuprofen tablet 600 mg oral 600 mg T1 ibuprofen tablet 800 mg oral 800 mg T1 indomethacin capsule 25 mg oral 25 mg T1 AL (Max 64 Years) indomethacin capsule 50 mg oral 50 mg T1 AL (Max 64 Years) indomethacin er capsule extended release 75 mg T1 AL (Max 64 Years) oral 75 mg ketoprofen er capsule extended release 24 hour T1 QL (30 EA per 30 days) 200 mg oral 200 mg

4 Drug Status Notes ketorolac tromethamine tablet 10 mg oral 10 mg T1 QL (20 EA per 5 days) KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML T4 PA SUBCUTANEOUS 100 MG/0.67ML leflunomide tablet 10 mg oral 10 mg T1 leflunomide tablet 20 mg oral 20 mg T1 meclofenamate sodium capsule 100 mg oral 100 T3 mg meclofenamate sodium capsule 50 mg oral 50 mg T3 meloxicam tablet 15 mg oral 15 mg T1 meloxicam tablet 7.5 mg oral 7.5 mg T1 nabumetone tablet 500 mg oral 500 mg T1 QL (120 EA per 30 days) nabumetone tablet 750 mg oral 750 mg T1 QL (60 EA per 30 days) naproxen sodium tablet 275 mg oral 275 mg T3 naproxen sodium tablet 550 mg oral 550 mg T3 naproxen suspension 125 mg/5ml oral 125 QL (300 ML per 30 days); AL T1 mg/5ml (Max 12 Years) naproxen tablet 250 mg oral 250 mg T1 naproxen tablet 375 mg oral 375 mg T1 naproxen tablet 500 mg oral 500 mg T1 naproxen tablet delayed release 375 mg oral 375 T1 mg naproxen tablet delayed release 500 mg oral 500 T1 mg oxaprozin tablet 600 mg oral 600 mg T3 piroxicam capsule 10 mg oral 10 mg T1 piroxicam capsule 20 mg oral 20 mg T1 RIDAURA CAPSULE 3 MG ORAL 3 MG T4 PA RINVOQ ORAL TABLET EXTENDED T4 PA RELEASE 24 HOUR 15 MG sulindac tablet 150 mg oral 150 mg T1 sulindac tablet 200 mg oral 200 mg T1 tolmetin sodium capsule 400 mg oral 400 mg T1 tolmetin sodium tablet 600 mg oral 600 mg T3 XELJANZ TABLET 5 MG ORAL 5 MG T4 PA XELJANZ XR ORAL TABLET EXTENDED T4 PA RELEASE 24 HOUR 11 MG *Analgesics - Nonnarcotic* QL (60 EA per 30 days); AL (Min aspirin 81 oral tablet chewable 81 mg T5 40 Years and Max 79 Years)

5 Drug Status Notes aspirin ec low dose oral tablet delayed release 81 QL (60 EA per 30 days); AL (Min T5 mg 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min aspirin ec oral tablet delayed release 325 mg T5 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min aspirin oral tablet 325 mg T5 40 Years and Max 79 Years) BAC TABLET 50-325-40 MG ORAL 50-325- T1 40 MG butalbital-acetaminophen oral tablet 50-325 mg T1 butalbital-apap-caffeine capsule 50-300-40 mg T1 oral 50-300-40 mg butalbital-apap-caffeine capsule 50-325-40 mg T3 oral 50-325-40 mg butalbital-aspirin-caffeine capsule 50-325-40 mg T1 oral 50-325-40 mg diflunisal tablet 500 mg oral 500 mg T1 salsalate tablet 500 mg oral 500 mg T1 salsalate tablet 750 mg oral 750 mg T1 *Analgesics - Opioid* acetaminophen- #2 tablet 300-15 mg oral T1 QL (390 EA per 30 days) 300-15 mg acetaminophen-codeine #3 tablet 300-30 mg oral T1 QL (390 EA per 30 days) 300-30 mg acetaminophen-codeine #4 tablet 300-60 mg oral T1 QL (390 EA per 30 days) 300-60 mg acetaminophen-codeine solution 120-12 mg/5ml T1 oral 120-12 mg/5ml buprenorphine hcl solution 0.3 mg/ml injection T3 PA 0.3 mg/ml buprenorphine hcl tablet sublingual 2 mg T3 PA sublingual 2 mg buprenorphine hcl tablet sublingual 8 mg T3 PA sublingual 8 mg buprenorphine hcl-naloxone hcl sublingual film T3 PA; QL (30 EA per 30 days) 12-3 mg buprenorphine hcl-naloxone hcl sublingual film T3 PA; QL (90 EA per 30 days) 2-0.5 mg, 4-1 mg buprenorphine hcl-naloxone hcl sublingual film T3 PA; QL (60 EA per 30 days) 8-2 mg buprenorphine hcl-naloxone hcl tablet sublingual T3 PA; QL (90 EA per 30 days) 2-0.5 mg sublingual 2-0.5 mg buprenorphine hcl-naloxone hcl tablet sublingual T3 PA; QL (90 EA per 30 days) 8-2 mg sublingual 8-2 mg 6 Drug Status Notes buprenorphine weekly 10 T3 PA mcg/hr, 20 mcg/hr, 5 mcg/hr butalbital-apap-caff-cod capsule 50-325-40-30 T1 mg oral 50-325-40-30 mg butalbital-asa-caff-codeine capsule 50-325-40-30 T1 mg oral 50-325-40-30 mg butorphanol tartrate solution 1 mg/ml injection 1 T3 mg/ml butorphanol tartrate solution 10 mg/ml nasal 10 T3 mg/ml butorphanol tartrate solution 2 mg/ml injection 2 T3 mg/ml codeine sulfate tablet 15 mg oral 15 mg T1 codeine sulfate tablet 30 mg oral 30 mg T1 EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, T3 PA 50-2 MG, 60-2.4 MG, 80-3.2 MG ENDOCET TABLET 5-325 MG ORAL 5-325 T1 QL (360 EA per 30 days) MG fentanyl transdermal patch 72 hour 100 mcg/hr, T1 QL (10 EA per 30 days) 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen solution 7.5-325 T1 mg/15ml oral 7.5-325 mg/15ml hydrocodone-acetaminophen tablet 10-325 mg T1 QL (180 EA per 30 days) oral 10-325 mg hydrocodone-acetaminophen tablet 5-325 mg oral T1 QL (180 EA per 30 days) 5-325 mg hydrocodone-acetaminophen tablet 7.5-325 mg T1 QL (180 EA per 30 days) oral 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg T3 PA hydrocodone-ibuprofen tablet 5-200 mg oral 5- T2 QL (180 EA per 30 days) 200 mg hydrocodone-ibuprofen tablet 7.5-200 mg oral T2 QL (180 EA per 30 days) 7.5-200 mg hydromorphone hcl er tablet extended release 24 T3 PA hour 12 mg oral 12 mg hydromorphone hcl er tablet extended release 24 T3 PA hour 16 mg oral 16 mg hydromorphone hcl er tablet extended release 24 T3 PA hour 32 mg oral 32 mg hydromorphone hcl er tablet extended release 24 T3 PA hour 8 mg oral 8 mg hydromorphone hcl 1 mg/ml oral 1 mg/ml T3

7 Drug Status Notes hydromorphone hcl 3 mg rectal 3 mg T3 hydromorphone hcl tablet 2 mg oral 2 mg T1 QL (240 EA per 30 days) hydromorphone hcl tablet 4 mg oral 4 mg T1 QL (240 EA per 30 days) hydromorphone hcl tablet 8 mg oral 8 mg T1 QL (240 EA per 30 days) levorphanol tartrate tablet 2 mg oral 2 mg T1 meperidine hcl solution 100 mg/ml injection 100 T3 mg/ml meperidine hcl solution 25 mg/ml injection 25 T3 mg/ml meperidine hcl solution 50 mg/5ml oral 50 T1 mg/5ml meperidine hcl solution 50 mg/ml injection 50 T3 mg/ml meperidine hcl tablet 100 mg oral 100 mg T1 meperidine hcl tablet 50 mg oral 50 mg T1 METHADONE HCL INTENSOL CONCENTRATE 10 MG/ML ORAL 10 T1 MG/ML methadone hcl solution 10 mg/5ml oral 10 T1 mg/5ml methadone hcl solution 10 mg/ml injection 10 T3 mg/ml methadone hcl solution 5 mg/5ml oral 5 mg/5ml T1 methadone hcl tablet 10 mg oral 10 mg T1 QL (240 EA per 30 days) methadone hcl tablet 5 mg oral 5 mg T1 METHADOSE TABLET SOLUBLE 40 MG T1 ORAL 40 MG morphine sulfate (concentrate) solution 100 T1 mg/5ml oral 100 mg/5ml morphine sulfate (pf) solution 0.5 mg/ml injection T3 0.5 mg/ml morphine sulfate (pf) solution 1 mg/ml injection 1 T3 mg/ml morphine sulfate (pf) solution 10 mg/ml T3 intravenous 10 mg/ml morphine sulfate (pf) solution 2 mg/ml T3 intravenous 2 mg/ml morphine sulfate (pf) solution 4 mg/ml T3 intravenous 4 mg/ml morphine sulfate (pf) solution 8 mg/ml T3 intravenous 8 mg/ml

8 Drug Status Notes morphine sulfate device 10 mg/0.7ml T3 intramuscular 10 mg/0.7ml morphine sulfate er tablet extended release 100 T1 QL (90 EA per 30 days) mg oral 100 mg morphine sulfate er tablet extended release 15 mg T1 QL (90 EA per 30 days) oral 15 mg morphine sulfate er tablet extended release 30 mg T1 QL (90 EA per 30 days) oral 30 mg morphine sulfate er tablet extended release 60 mg T1 QL (90 EA per 30 days) oral 60 mg morphine sulfate oral tablet 15 mg T1 QL (180 EA per 30 days) morphine sulfate solution 10 mg/5ml oral 10 T1 mg/5ml morphine sulfate solution 20 mg/5ml oral 20 T1 mg/5ml morphine sulfate suppository 10 mg rectal 10 mg T3 morphine sulfate suppository 20 mg rectal 20 mg T3 morphine sulfate suppository 30 mg rectal 30 mg T3 morphine sulfate suppository 5 mg rectal 5 mg T3 morphine sulfate tablet 30 mg oral 30 mg T1 QL (180 EA per 30 days) nalbuphine hcl solution 10 mg/ml injection 10 T3 mg/ml nalbuphine hcl solution 20 mg/ml injection 20 T3 mg/ml NUCYNTA ER TABLET EXTENDED T3 PA RELEASE 12 HOUR 100 MG ORAL 100 MG NUCYNTA ER TABLET EXTENDED T3 PA RELEASE 12 HOUR 150 MG ORAL 150 MG NUCYNTA ER TABLET EXTENDED T3 PA RELEASE 12 HOUR 200 MG ORAL 200 MG NUCYNTA ER TABLET EXTENDED T3 PA RELEASE 12 HOUR 250 MG ORAL 250 MG NUCYNTA ER TABLET EXTENDED T3 PA RELEASE 12 HOUR 50 MG ORAL 50 MG OXAYDO TABLET 7.5 MG ORAL 7.5 MG T3 PA; QL (180 EA per 30 days) oxycodone hcl capsule 5 mg oral 5 mg T3 QL (180 EA per 30 days) oxycodone hcl concentrate 100 mg/5ml oral 100 T3 mg/5ml oxycodone hcl oral tablet 5 mg T3 PA; QL (180 EA per 30 days) oxycodone hcl solution 5 mg/5ml oral 5 mg/5ml T1 oxycodone hcl tablet 10 mg oral 10 mg T1 QL (180 EA per 30 days) oxycodone hcl tablet 15 mg oral 15 mg T1 QL (180 EA per 30 days)

9 Drug Status Notes oxycodone hcl tablet 20 mg oral 20 mg T1 QL (180 EA per 30 days) oxycodone hcl tablet 30 mg oral 30 mg T1 QL (180 EA per 30 days) oxycodone-acetaminophen tablet 10-325 mg oral T1 QL (180 EA per 30 days) 10-325 mg oxycodone-acetaminophen tablet 2.5-325 mg oral T1 2.5-325 mg oxycodone-acetaminophen tablet 7.5-325 mg oral T1 QL (180 EA per 30 days) 7.5-325 mg oxycodone-aspirin tablet 4.8355-325 mg oral T1 4.8355-325 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 10 mg oral 10 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 15 mg oral 15 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 20 mg oral 20 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 30 mg oral 30 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 40 mg oral 40 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 5 mg oral 5 mg oxymorphone hcl er tablet extended release 12 T3 PA hour 7.5 mg oral 7.5 mg pentazocine-naloxone hcl tablet 50-0.5 mg oral T1 50-0.5 mg tramadol hcl er (biphasic) tablet extended release T3 QL (30 EA per 30 days) 24 hour 300 mg oral 300 mg tramadol hcl er capsule extended release 24 hour T3 QL (30 EA per 30 days) 150 mg oral 150 mg tramadol hcl er tablet extended release 24 hour T3 QL (30 EA per 30 days) 100 mg oral 100 mg tramadol hcl er tablet extended release 24 hour T3 QL (30 EA per 30 days) 200 mg oral 200 mg tramadol hcl tablet 50 mg oral 50 mg T1 QL (240 EA per 30 days) tramadol-acetaminophen tablet 37.5-325 mg oral T1 37.5-325 mg *Androgens-Anabolic* ANADROL-50 TABLET 50 MG ORAL 50 T4 PA MG ANDRODERM PATCH 24 HOUR 2 T3 PA MG/24HR TRANSDERMAL 2 MG/24HR

10 Drug Status Notes ANDRODERM PATCH 24 HOUR 4 T3 PA MG/24HR TRANSDERMAL 4 MG/24HR methitest tablet 10 mg oral 10 mg T3 oxandrolone tablet 10 mg oral 10 mg T3 PA oxandrolone tablet 2.5 mg oral 2.5 mg T3 PA testosterone cypionate solution 100 mg/ml T1 GR-M intramuscular 100 mg/ml testosterone cypionate solution 200 mg/ml T1 GR-M intramuscular 200 mg/ml testosterone enanthate intramuscular solution T1 GR-M 200 mg/ml testosterone gel 25 mg/2.5gm (1%) transdermal T3 PA 25 mg/2.5gm (1%) testosterone solution 30 mg/act transdermal 30 T3 PA mg/act testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm T3 PA (1.62%) testosterone transdermal gel 50 mg/5gm (1%) T3 *Anorectal And Related Products* ANALPRAM-HC 2.5-1 % T3 EXTERNAL 2.5-1 % COLOCORT 100 MG/60ML T1 RECTAL 100 MG/60ML CORTIFOAM FOAM 10 % EXTERNAL 10 T3 PA % lidocaine-hydrocortisone ace gel 2.8-0.55 % T3 rectal 2.8-0.55 % lidocaine-hydrocortisone ace kit 2-2 % rectal 2-2 T3 PA % lidocaine-hydrocortisone ace kit 3-0.5 % rectal 3- T1 0.5 % lidocaine-hydrocortisone ace kit 3-1 % rectal 3-1 T1 % lidocaine-hydrocortisone ace kit 3-2.5 % rectal 3- T1 2.5 % PROCTOFOAM HC FOAM 1-1 % T3 EXTERNAL 1-1 % PROCTOZONE-HC 2.5 % T1 EXTERNAL 2.5 % RECTIV OINTMENT 0.4 % RECTAL 0.4 % T3

11 Drug Status Notes *Antacids* magnesium oxide oral tablet 400 mg T1 sodium bicarbonate oral tablet 650 mg T1 *Anthelmintics* albendazole oral tablet 200 mg T3 PA ivermectin tablet 3 mg oral 3 mg T3 QL (10 EA per 30 days) reeses pinworm medicine suspension 144 (50 T1 base) mg/ml oral 144 (50 base) mg/ml *Antianginal Agents* DILATRATE-SR CAPSULE EXTENDED T3 RELEASE 40 MG ORAL 40 MG isosorbide dinitrate oral tablet 30 mg T1 isosorbide dinitrate tablet 10 mg oral 10 mg T1 isosorbide dinitrate tablet 20 mg oral 20 mg T1 isosorbide dinitrate tablet 5 mg oral 5 mg T1 isosorbide mononitrate er tablet extended release T1 24 hour 120 mg oral 120 mg isosorbide mononitrate er tablet extended release T1 24 hour 30 mg oral 30 mg isosorbide mononitrate er tablet extended release T1 24 hour 60 mg oral 60 mg isosorbide mononitrate tablet 10 mg oral 10 mg T1 isosorbide mononitrate tablet 20 mg oral 20 mg T1 NITRO-BID TRANSDERMAL OINTMENT 2 T2 % NITRO-DUR PATCH 24 HOUR 0.3 MG/HR T3 TRANSDERMAL 0.3 MG/HR NITRO-DUR PATCH 24 HOUR 0.8 MG/HR T3 TRANSDERMAL 0.8 MG/HR nitroglycerin er capsule extended release 2.5 mg T1 oral 2.5 mg nitroglycerin patch 24 hour 0.1 mg/hr T1 transdermal 0.1 mg/hr nitroglycerin patch 24 hour 0.2 mg/hr T1 transdermal 0.2 mg/hr nitroglycerin patch 24 hour 0.4 mg/hr T1 transdermal 0.4 mg/hr nitroglycerin patch 24 hour 0.6 mg/hr T1 transdermal 0.6 mg/hr nitroglycerin solution 0.4 mg/spray translingual T3 0.4 mg/spray

12 Drug Status Notes nitroglycerin sublingual tablet sublingual 0.3 mg, T1 0.4 mg, 0.6 mg NITRO-TIME CAPSULE EXTENDED T1 RELEASE 6.5 MG ORAL 6.5 MG NITRO-TIME CAPSULE EXTENDED T1 RELEASE 9 MG ORAL 9 MG ranolazine er oral tablet extended release 12 hour T3 1000 mg, 500 mg *Antianxiety Agents* alprazolam er tablet extended release 24 hour 1 T3 AL (Max 64 Years) mg oral 1 mg alprazolam er tablet extended release 24 hour 2 T3 AL (Max 64 Years) mg oral 2 mg alprazolam tablet 0.25 mg oral 0.25 mg T1 AL (Max 64 Years) alprazolam tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years) alprazolam tablet 1 mg oral 1 mg T1 AL (Max 64 Years) alprazolam tablet 2 mg oral 2 mg T1 AL (Max 64 Years) alprazolam tablet dispersible 0.25 mg oral 0.25 T3 AL (Max 64 Years) mg alprazolam tablet dispersible 0.5 mg oral 0.5 mg T3 AL (Max 64 Years) alprazolam tablet dispersible 1 mg oral 1 mg T3 AL (Max 64 Years) alprazolam tablet dispersible 2 mg oral 2 mg T3 AL (Max 64 Years) alprazolam xr tablet extended release 24 hour 0.5 T3 AL (Max 64 Years) mg oral 0.5 mg alprazolam xr tablet extended release 24 hour 3 T3 AL (Max 64 Years) mg oral 3 mg buspirone hcl tablet 10 mg oral 10 mg T1 buspirone hcl tablet 15 mg oral 15 mg T1 buspirone hcl tablet 30 mg oral 30 mg T1 buspirone hcl tablet 5 mg oral 5 mg T1 buspirone hcl tablet 7.5 mg oral 7.5 mg T1 chlordiazepoxide hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years) chlordiazepoxide hcl capsule 25 mg oral 25 mg T1 AL (Max 64 Years) chlordiazepoxide hcl capsule 5 mg oral 5 mg T1 AL (Max 64 Years) clorazepate dipotassium tablet 15 mg oral 15 mg T1 AL (Max 64 Years) clorazepate dipotassium tablet 3.75 mg oral 3.75 T1 AL (Max 64 Years) mg clorazepate dipotassium tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years) diazepam solution 5 mg/5ml oral 5 mg/5ml T1 AL (Max 64 Years) diazepam solution 5 mg/ml injection 5 mg/ml T1 AL (Max 64 Years)

13 Drug Status Notes diazepam tablet 10 mg oral 10 mg T1 AL (Max 64 Years) diazepam tablet 2 mg oral 2 mg T1 AL (Max 64 Years) diazepam tablet 5 mg oral 5 mg T1 AL (Max 64 Years) droperidol injection solution 2.5 mg/ml T1 hydroxyzine hcl solution 25 mg/ml intramuscular T1 AL (Max 64 Years) 25 mg/ml hydroxyzine hcl solution 50 mg/ml intramuscular T1 AL (Max 64 Years) 50 mg/ml hydroxyzine hcl syrup 10 mg/5ml oral 10 mg/5ml T1 AL (Max 64 Years) hydroxyzine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years) hydroxyzine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years) hydroxyzine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years) hydroxyzine pamoate capsule 100 mg oral 100 T1 AL (Max 64 Years) mg hydroxyzine pamoate capsule 25 mg oral 25 mg T1 AL (Max 64 Years) hydroxyzine pamoate capsule 50 mg oral 50 mg T1 AL (Max 64 Years) LORAZEPAM INTENSOL CONCENTRATE T1 2 MG/ML ORAL 2 MG/ML lorazepam solution 2 mg/ml injection 2 mg/ml T1 lorazepam solution 4 mg/ml injection 4 mg/ml T1 lorazepam tablet 0.5 mg oral 0.5 mg T1 lorazepam tablet 1 mg oral 1 mg T1 lorazepam tablet 2 mg oral 2 mg T1 meprobamate tablet 200 mg oral 200 mg T1 AL (Max 64 Years) meprobamate tablet 400 mg oral 400 mg T1 AL (Max 64 Years) oxazepam capsule 10 mg oral 10 mg T1 oxazepam oral capsule 15 mg, 30 mg T1 *Antiarrhythmics* amiodarone hcl tablet 200 mg oral 200 mg T1 disopyramide phosphate capsule 100 mg oral 100 T1 mg disopyramide phosphate capsule 150 mg oral 150 T1 mg dofetilide capsule 125 mcg oral 125 mcg T3 dofetilide capsule 250 mcg oral 250 mcg T3 dofetilide capsule 500 mcg oral 500 mcg T3 flecainide acetate tablet 100 mg oral 100 mg T1 flecainide acetate tablet 150 mg oral 150 mg T1 flecainide acetate tablet 50 mg oral 50 mg T1 mexiletine hcl capsule 150 mg oral 150 mg T1 14 Drug Status Notes mexiletine hcl capsule 200 mg oral 200 mg T1 mexiletine hcl capsule 250 mg oral 250 mg T1 MULTAQ TABLET 400 MG ORAL 400 MG T3 PA NORPACE CR CAPSULE EXTENDED T3 RELEASE 12 HOUR 100 MG ORAL 100 MG PACERONE TABLET 400 MG ORAL 400 T1 MG propafenone hcl er capsule extended release 12 T3 hour 225 mg oral 225 mg propafenone hcl er capsule extended release 12 T3 hour 325 mg oral 325 mg propafenone hcl er capsule extended release 12 T3 hour 425 mg oral 425 mg propafenone hcl tablet 150 mg oral 150 mg T1 propafenone hcl tablet 225 mg oral 225 mg T1 propafenone hcl tablet 300 mg oral 300 mg T1 quinidine gluconate er tablet extended release T1 324 mg oral 324 mg quinidine sulfate tablet 200 mg oral 200 mg T1 quinidine sulfate tablet 300 mg oral 300 mg T1 *Antiasthmatic And Bronchodilator Agents* ADVAIR HFA AEROSOL 115-21 MCG/ACT T2 QL (12 GM per 30 days) INHALATION 115-21 MCG/ACT ADVAIR HFA AEROSOL 230-21 MCG/ACT T2 QL (12 GM per 30 days) INHALATION 230-21 MCG/ACT ADVAIR HFA AEROSOL 45-21 MCG/ACT T2 QL (12 GM per 30 days) INHALATION 45-21 MCG/ACT albuterol sulfate er tablet extended release 12 T1 hour 4 mg oral 4 mg albuterol sulfate er tablet extended release 12 T1 hour 8 mg oral 8 mg albuterol sulfate nebulization solution (2.5 T1 mg/3ml) 0.083% inhalation (2.5 mg/3ml) 0.083% albuterol sulfate nebulization solution (5 mg/ml) T1 0.5% inhalation (5 mg/ml) 0.5% albuterol sulfate nebulization solution 0.63 T1 mg/3ml inhalation 0.63 mg/3ml albuterol sulfate nebulization solution 1.25 T1 mg/3ml inhalation 1.25 mg/3ml albuterol sulfate syrup 2 mg/5ml oral 2 mg/5ml T1

15 Drug Status Notes ANORO ELLIPTA AEROSOL BREATH ACTIVATED 62.5-25 MCG/INH T2 INHALATION 62.5-25 MCG/INH ARCAPTA NEOHALER CAPSULE 75 MCG T3 PA; QL (30 EA per 30 days) INHALATION 75 MCG arformoterol tartrate inhalation nebulization T3 PA; QL (120 ML per 30 days) solution 15 mcg/2ml ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH T2 QL (30 EA per 30 days) ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT ASMANEX (120 METERED DOSES) AEROSOL POWDER BREATH T2 QL (1 EA per 30 days) ACTIVATED 220 MCG/INH INHALATION 220 MCG/INH ASMANEX (7 METERED DOSES) AEROSOL POWDER BREATH T2 QL (1 EA per 30 days) ACTIVATED 110 MCG/INH INHALATION 110 MCG/INH ASMANEX HFA INHALATION AEROSOL T2 QL (13 GM per 1 day) 100 MCG/ACT ASMANEX HFA INHALATION AEROSOL T2 QL (13 GM per 30 days) 200 MCG/ACT ATROVENT HFA AEROSOL SOLUTION 17 T3 QL (12.9 GM per 30 days) MCG/ACT INHALATION 17 MCG/ACT BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH T2 QL (60 EA per 30 days) INHALATION 100-25 MCG/INH BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200-25 MCG/INH T2 QL (60 EA per 30 days) INHALATION 200-25 MCG/INH budesonide suspension 0.25 mg/2ml inhalation QL (120 ML per 30 days); AL T1 0.25 mg/2ml (Max 6 Years) budesonide suspension 0.5 mg/2ml inhalation 0.5 QL (120 ML per 30 days); AL T1 mg/2ml (Max 6 Years) budesonide suspension 1 mg/2ml inhalation 1 QL (120 ML per 30 days); AL T3 mg/2ml (Max 6 Years) COMBIVENT AEROSOL SOLUTION 20-100 MCG/ACT T3 QL (4 GM per 30 days) INHALATION 20-100 MCG/ACT DALIRESP TABLET 500 MCG ORAL 500 T2 QL (30 EA per 30 days) MCG DULERA AEROSOL 100-5 MCG/ACT T3 QL (13 GM per 30 days) INHALATION 100-5 MCG/ACT

16 Drug Status Notes DULERA AEROSOL 200-5 MCG/ACT T3 QL (13 GM per 30 days) INHALATION 200-5 MCG/ACT ELIXOPHYLLIN ELIXIR 80 MG/15ML T2 ORAL 80 MG/15ML FASENRA SUBCUTANEOUS SOLUTION T4 PA PREFILLED SYRINGE 30 MG/ML FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST T2 QL (60 EA per 30 days) INHALATION 100 MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST T2 QL (60 EA per 30 days) INHALATION 250 MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST T2 QL (60 EA per 30 days) INHALATION 50 MCG/BLIST FLOVENT HFA AEROSOL 110 MCG/ACT T2 QL (12 GM per 30 days) INHALATION 110 MCG/ACT FLOVENT HFA AEROSOL 220 MCG/ACT T2 QL (12 GM per 30 days) INHALATION 220 MCG/ACT FLOVENT HFA AEROSOL 44 MCG/ACT T2 QL (10.6 GM per 30 days) INHALATION 44 MCG/ACT fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 T1 QL (1 EA per 30 days) mcg/act fluticasone-salmeterol aerosol powder breath activated 232-14 mcg/act inhalation 232-14 T1 QL (1 EA per 30 days) mcg/act fluticasone-salmeterol aerosol powder breath T1 QL (1 EA per 30 days) activated 55-14 mcg/act inhalation 55-14 mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 T2 QL (60 EA per 30 days) mcg/dose, 500-50 mcg/dose formoterol fumarate inhalation nebulization T3 PA; QL (120 ML per 30 days) solution 20 mcg/2ml INCRUSE ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH T3 QL (30 EA per 30 days) INHALATION 62.5 MCG/INH ipratropium bromide solution 0.02 % inhalation T1 0.02 % ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml T1 inhalation 0.5-2.5 (3) mg/3ml levalbuterol hcl nebulization solution 0.31 T1 ST mg/3ml inhalation 0.31 mg/3ml levalbuterol hcl nebulization solution 0.63 T1 ST mg/3ml inhalation 0.63 mg/3ml 17 Drug Status Notes levalbuterol hcl nebulization solution 1.25 T1 ST mg/0.5ml inhalation 1.25 mg/0.5ml levalbuterol tartrate aerosol 45 mcg/act T3 QL (15 GM per 30 days) inhalation 45 mcg/act metaproterenol sulfate syrup 10 mg/5ml oral 10 T1 mg/5ml montelukast sodium packet 4 mg oral 4 mg T1 montelukast sodium tablet 10 mg oral 10 mg T1 montelukast sodium tablet chewable 4 mg oral 4 T1 mg montelukast sodium tablet chewable 5 mg oral 5 T1 mg PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108 (90 T3 QL (1 EA per 30 days) BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 180 T3 QL (1 EA per 30 days) MCG/ACT INHALATION 180 MCG/ACT PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 T3 QL (1 EA per 30 days) MCG/ACT INHALATION 90 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 T3 QL (10.6 GM per 30 days) MCG/ACT, 80 MCG/ACT SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE T2 QL (60 EA per 30 days) INHALATION 50 MCG/DOSE SPIRIVA HANDIHALER CAPSULE 18 MCG T2 QL (30 EA per 30 days) INHALATION 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 T2 QL (4 GM per 30 days) MCG/ACT STRIVERDI RESPIMAT AEROSOL SOLUTION 2.5 MCG/ACT INHALATION T2 QL (4 GM per 30 days) 2.5 MCG/ACT terbutaline sulfate solution 1 mg/ml injection 1 T1 mg/ml terbutaline sulfate tablet 2.5 mg oral 2.5 mg T1 terbutaline sulfate tablet 5 mg oral 5 mg T1 theophylline er tablet extended release 12 hour T1 300 mg oral 300 mg theophylline er tablet extended release 12 hour T1 450 mg oral 450 mg

18 Drug Status Notes theophylline er tablet extended release 24 hour T1 400 mg oral 400 mg theophylline er tablet extended release 24 hour T1 600 mg oral 600 mg theophylline solution 80 mg/15ml oral 80 T1 mg/15ml TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT T3 QL (1 EA per 30 days) INHALATION 400 MCG/ACT VENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 T2 QL (36 GM per 28 days) BASE) MCG/ACT WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 T2 QL (60 EA per 30 days) MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE XOLAIR SOLUTION RECONSTITUTED T4 PA 150 MG SUBCUTANEOUS 150 MG zafirlukast tablet 10 mg oral 10 mg T3 zafirlukast tablet 20 mg oral 20 mg T3 zileuton er tablet extended release 12 hour 600 T4 PA mg oral 600 mg ZYFLO TABLET 600 MG ORAL 600 MG T4 PA *Anticoagulants* ELIQUIS DVT/PE STARTER PACK ORAL T2 QL (60 EA per 30 days) TABLET 5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG T2 QL (60 EA per 30 days) enoxaparin sodium injection solution 300 mg/3ml T3 enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, T3 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium solution 10 mg/0.8ml T4 PA subcutaneous 10 mg/0.8ml fondaparinux sodium solution 2.5 mg/0.5ml T4 PA subcutaneous 2.5 mg/0.5ml fondaparinux sodium solution 5 mg/0.4ml T4 PA subcutaneous 5 mg/0.4ml fondaparinux sodium solution 7.5 mg/0.6ml T4 PA subcutaneous 7.5 mg/0.6ml FRAGMIN SOLUTION 10000 UNIT/ML T4 PA SUBCUTANEOUS 10000 UNIT/ML FRAGMIN SOLUTION 12500 UNIT/0.5ML T4 PA SUBCUTANEOUS 12500 UNIT/0.5ML

19 Drug Status Notes FRAGMIN SOLUTION 15000 UNIT/0.6ML T4 PA SUBCUTANEOUS 15000 UNIT/0.6ML FRAGMIN SOLUTION 18000 UNT/0.72ML T4 PA SUBCUTANEOUS 18000 UNT/0.72ML FRAGMIN SOLUTION 2500 UNIT/0.2ML T4 PA SUBCUTANEOUS 2500 UNIT/0.2ML FRAGMIN SOLUTION 5000 UNIT/0.2ML T4 PA SUBCUTANEOUS 5000 UNIT/0.2ML FRAGMIN SOLUTION 7500 UNIT/0.3ML T4 PA SUBCUTANEOUS 7500 UNIT/0.3ML heparin lock flush solution 10 unit/ml intravenous T1 10 unit/ml heparin sod (porcine) in d5w solution 100 unit/ml T1 intravenous 100 unit/ml heparin sodium (porcine) pf solution 5000 T1 unit/0.5ml injection 5000 unit/0.5ml heparin sodium (porcine) solution 1000 unit/ml T1 injection 1000 unit/ml heparin sodium (porcine) solution 10000 unit/ml T1 injection 10000 unit/ml heparin sodium (porcine) solution 20000 unit/ml T1 injection 20000 unit/ml heparin sodium (porcine) solution 5000 unit/ml T1 injection 5000 unit/ml heparin sodium lock flush solution 100 unit/ml T1 intravenous 100 unit/ml PRADAXA CAPSULE 150 MG ORAL 150 T3 PA MG PRADAXA CAPSULE 75 MG ORAL 75 MG T3 PA warfarin sodium tablet 1 mg oral 1 mg T1 warfarin sodium tablet 10 mg oral 10 mg T1 warfarin sodium tablet 2 mg oral 2 mg T1 warfarin sodium tablet 2.5 mg oral 2.5 mg T1 warfarin sodium tablet 3 mg oral 3 mg T1 warfarin sodium tablet 4 mg oral 4 mg T1 warfarin sodium tablet 5 mg oral 5 mg T1 warfarin sodium tablet 6 mg oral 6 mg T1 warfarin sodium tablet 7.5 mg oral 7.5 mg T1 XARELTO ORAL TABLET 2.5 MG T2 QL (60 EA per 30 days) XARELTO STARTER PACK ORAL T2 QL (51 EA per 365 days) TABLET THERAPY PACK 15 & 20 MG XARELTO TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days)

20 Drug Status Notes XARELTO TABLET 15 MG ORAL 15 MG T2 QL (60 EA per 30 days) XARELTO TABLET 20 MG ORAL 20 MG T2 QL (30 EA per 30 days) *Anticonvulsants* APTIOM TABLET 200 MG ORAL 200 MG T3 PA APTIOM TABLET 400 MG ORAL 400 MG T3 PA APTIOM TABLET 600 MG ORAL 600 MG T3 PA APTIOM TABLET 800 MG ORAL 800 MG T3 PA carbamazepine er capsule extended release 12 T1 hour 100 mg oral 100 mg carbamazepine er capsule extended release 12 T1 hour 200 mg oral 200 mg carbamazepine er capsule extended release 12 T1 hour 300 mg oral 300 mg carbamazepine er tablet extended release 12 hour T1 100 mg oral 100 mg carbamazepine er tablet extended release 12 hour T1 200 mg oral 200 mg carbamazepine er tablet extended release 12 hour T1 400 mg oral 400 mg carbamazepine suspension 100 mg/5ml oral 100 T1 mg/5ml carbamazepine tablet 200 mg oral 200 mg T1 carbamazepine tablet chewable 100 mg oral 100 T1 mg CELONTIN CAPSULE 300 MG ORAL 300 T2 MG clobazam oral suspension 2.5 mg/ml T3 PA clobazam oral tablet 10 mg, 20 mg T3 PA clonazepam tablet 0.5 mg oral 0.5 mg T1 clonazepam tablet 1 mg oral 1 mg T1 clonazepam tablet 2 mg oral 2 mg T1 clonazepam tablet dispersible 0.125 mg oral T1 0.125 mg clonazepam tablet dispersible 0.25 mg oral 0.25 T1 mg clonazepam tablet dispersible 0.5 mg oral 0.5 mg T1 clonazepam tablet dispersible 1 mg oral 1 mg T1 clonazepam tablet dispersible 2 mg oral 2 mg T1 DILANTIN ORAL CAPSULE 30 MG T2 divalproex sodium capsule delayed release T1 sprinkle 125 mg oral 125 mg

21 Drug Status Notes divalproex sodium er tablet extended release 24 T1 hour 250 mg oral 250 mg divalproex sodium er tablet extended release 24 T1 hour 500 mg oral 500 mg divalproex sodium tablet delayed release 125 mg T1 oral 125 mg divalproex sodium tablet delayed release 250 mg T1 oral 250 mg divalproex sodium tablet delayed release 500 mg T1 oral 500 mg ethosuximide capsule 250 mg oral 250 mg T1 ethosuximide solution 250 mg/5ml oral 250 T3 mg/5ml felbamate suspension 600 mg/5ml oral 600 T4 mg/5ml felbamate tablet 400 mg oral 400 mg T3 felbamate tablet 600 mg oral 600 mg T3 FYCOMPA TABLET 10 MG ORAL 10 MG T3 PA FYCOMPA TABLET 12 MG ORAL 12 MG T3 PA FYCOMPA TABLET 2 MG ORAL 2 MG T3 PA FYCOMPA TABLET 4 MG ORAL 4 MG T3 PA FYCOMPA TABLET 6 MG ORAL 6 MG T3 PA FYCOMPA TABLET 8 MG ORAL 8 MG T3 PA gabapentin capsule 100 mg oral 100 mg T1 gabapentin capsule 300 mg oral 300 mg T1 gabapentin capsule 400 mg oral 400 mg T1 gabapentin solution 250 mg/5ml oral 250 mg/5ml T1 gabapentin tablet 600 mg oral 600 mg T1 gabapentin tablet 800 mg oral 800 mg T1 GABITRIL ORAL TABLET 12 MG T3 LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & T3 14X100 MG lamotrigine er tablet extended release 24 hour T3 100 mg oral 100 mg lamotrigine er tablet extended release 24 hour T3 200 mg oral 200 mg lamotrigine er tablet extended release 24 hour 25 T3 mg oral 25 mg lamotrigine er tablet extended release 24 hour T3 250 mg oral 250 mg

22 Drug Status Notes lamotrigine er tablet extended release 24 hour T3 300 mg oral 300 mg lamotrigine er tablet extended release 24 hour 50 T3 mg oral 50 mg lamotrigine tablet 100 mg oral 100 mg T1 lamotrigine tablet 150 mg oral 150 mg T1 lamotrigine tablet 200 mg oral 200 mg T1 lamotrigine tablet 25 mg oral 25 mg T1 lamotrigine tablet chewable 25 mg oral 25 mg T1 lamotrigine tablet chewable 5 mg oral 5 mg T1 levetiracetam er tablet extended release 24 hour T3 500 mg oral 500 mg levetiracetam er tablet extended release 24 hour T3 750 mg oral 750 mg levetiracetam solution 100 mg/ml oral 100 mg/ml T1 levetiracetam solution 500 mg/5ml intravenous T1 500 mg/5ml levetiracetam tablet 1000 mg oral 1000 mg T1 QL (90 EA per 30 days) levetiracetam tablet 250 mg oral 250 mg T1 QL (360 EA per 30 days) levetiracetam tablet 500 mg oral 500 mg T1 QL (180 EA per 30 days) levetiracetam tablet 750 mg oral 750 mg T1 QL (120 EA per 30 days) LYRICA SOLUTION 20 MG/ML ORAL 20 T3 PA MG/ML oxcarbazepine suspension 300 mg/5ml oral 300 T1 mg/5ml oxcarbazepine tablet 150 mg oral 150 mg T1 oxcarbazepine tablet 300 mg oral 300 mg T1 oxcarbazepine tablet 600 mg oral 600 mg T1 PEGANONE TABLET 250 MG ORAL 250 T3 MG phenytoin sodium extended oral capsule 100 mg, T1 200 mg, 300 mg phenytoin sodium solution 50 mg/ml injection 50 T1 mg/ml phenytoin suspension 125 mg/5ml oral 125 T1 mg/5ml phenytoin tablet chewable 50 mg oral 50 mg T1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, T1 QL (90 EA per 30 days) 225 mg, 25 mg, 50 mg, 75 mg pregabalin oral capsule 300 mg T1 QL (60 EA per 30 days) primidone tablet 250 mg oral 250 mg T1

23 Drug Status Notes primidone tablet 50 mg oral 50 mg T1 rufinamide oral suspension 40 mg/ml T3 tiagabine hcl oral tablet 12 mg, 16 mg T3 tiagabine hcl tablet 2 mg oral 2 mg T3 tiagabine hcl tablet 4 mg oral 4 mg T3 topiramate capsule sprinkle 15 mg oral 15 mg T1 topiramate capsule sprinkle 25 mg oral 25 mg T1 topiramate tablet 100 mg oral 100 mg T1 topiramate tablet 200 mg oral 200 mg T1 topiramate tablet 25 mg oral 25 mg T1 topiramate tablet 50 mg oral 50 mg T1 valproic acid capsule 250 mg oral 250 mg T1 valproic acid solution 250 mg/5ml oral 250 T1 mg/5ml vigabatrin oral packet 500 mg T4 PA VIMPAT TABLET 100 MG ORAL 100 MG T3 PA VIMPAT TABLET 150 MG ORAL 150 MG T3 PA VIMPAT TABLET 200 MG ORAL 200 MG T3 PA VIMPAT TABLET 50 MG ORAL 50 MG T3 PA zonisamide capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days) zonisamide capsule 25 mg oral 25 mg T1 QL (360 EA per 30 days) zonisamide capsule 50 mg oral 50 mg T1 QL (360 EA per 30 days) *Antidepressants* amitriptyline hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years) amitriptyline hcl tablet 100 mg oral 100 mg T1 AL (Max 64 Years) amitriptyline hcl tablet 150 mg oral 150 mg T1 AL (Max 64 Years) amitriptyline hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years) amitriptyline hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years) amitriptyline hcl tablet 75 mg oral 75 mg T1 AL (Max 64 Years) amoxapine tablet 100 mg oral 100 mg T1 AL (Max 64 Years) amoxapine tablet 150 mg oral 150 mg T1 AL (Max 64 Years) amoxapine tablet 25 mg oral 25 mg T1 AL (Max 64 Years) amoxapine tablet 50 mg oral 50 mg T1 AL (Max 64 Years) bupropion hcl er (sr) tablet extended release 12 T1 hour 100 mg oral 100 mg bupropion hcl er (sr) tablet extended release 12 T1 hour 150 mg oral 150 mg bupropion hcl er (sr) tablet extended release 12 T1 hour 200 mg oral 200 mg

24 Drug Status Notes bupropion hcl er (xl) tablet extended release 24 T1 hour 150 mg oral 150 mg bupropion hcl er (xl) tablet extended release 24 T1 hour 300 mg oral 300 mg bupropion hcl tablet 100 mg oral 100 mg T1 bupropion hcl tablet 75 mg oral 75 mg T1 citalopram hydrobromide solution 10 mg/5ml T1 oral 10 mg/5ml citalopram hydrobromide tablet 10 mg oral 10 T1 mg citalopram hydrobromide tablet 20 mg oral 20 T1 mg citalopram hydrobromide tablet 40 mg oral 40 T1 QL (30 EA per 30 days) mg clomipramine hcl capsule 25 mg oral 25 mg T3 AL (Max 64 Years) clomipramine hcl capsule 50 mg oral 50 mg T3 AL (Max 64 Years) clomipramine hcl capsule 75 mg oral 75 mg T3 AL (Max 64 Years) desipramine hcl tablet 10 mg oral 10 mg T3 QL (60 EA per 30 days) desipramine hcl tablet 100 mg oral 100 mg T3 QL (60 EA per 30 days) desipramine hcl tablet 150 mg oral 150 mg T3 QL (60 EA per 30 days) desipramine hcl tablet 25 mg oral 25 mg T3 QL (60 EA per 30 days) desipramine hcl tablet 50 mg oral 50 mg T3 QL (60 EA per 30 days) desipramine hcl tablet 75 mg oral 75 mg T3 QL (60 EA per 30 days) desvenlafaxine er tablet extended release 24 hour T3 QL (30 EA per 30 days) 100 mg oral 100 mg desvenlafaxine er tablet extended release 24 hour T3 QL (30 EA per 30 days) 50 mg oral 50 mg desvenlafaxine succinate er oral tablet extended T3 QL (30 EA per 30 days) release 24 hour 25 mg desvenlafaxine succinate er tablet extended T3 QL (30 EA per 30 days) release 24 hour 100 mg oral 100 mg desvenlafaxine succinate er tablet extended T3 QL (30 EA per 30 days) release 24 hour 50 mg oral 50 mg doxepin hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years) doxepin hcl capsule 100 mg oral 100 mg T1 AL (Max 64 Years) doxepin hcl capsule 25 mg oral 25 mg T1 AL (Max 64 Years) doxepin hcl capsule 50 mg oral 50 mg T1 AL (Max 64 Years) doxepin hcl capsule 75 mg oral 75 mg T1 AL (Max 64 Years) doxepin hcl concentrate 10 mg/ml oral 10 mg/ml T1 AL (Max 64 Years) doxepin hcl oral capsule 150 mg T1

25 Drug Status Notes duloxetine hcl capsule delayed release particles T1 QL (60 EA per 30 days) 20 mg oral 20 mg duloxetine hcl capsule delayed release particles T1 QL (30 EA per 30 days) 30 mg oral 30 mg duloxetine hcl capsule delayed release particles T1 QL (30 EA per 30 days) 60 mg oral 60 mg EMSAM PATCH 24 HOUR 12 MG/24HR T3 ST; QL (30 EA per 30 days) TRANSDERMAL 12 MG/24HR EMSAM PATCH 24 HOUR 6 MG/24HR T3 ST; QL (30 EA per 30 days) TRANSDERMAL 6 MG/24HR EMSAM PATCH 24 HOUR 9 MG/24HR T3 ST; QL (30 EA per 30 days) TRANSDERMAL 9 MG/24HR escitalopram oxalate solution 5 mg/5ml oral 5 T1 mg/5ml escitalopram oxalate tablet 10 mg oral 10 mg T1 QL (45 EA per 30 days) escitalopram oxalate tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) escitalopram oxalate tablet 5 mg oral 5 mg T1 QL (45 EA per 30 days) FETZIMA CAPSULE EXTENDED T3 PA RELEASE 24 HOUR 120 MG ORAL 120 MG FETZIMA CAPSULE EXTENDED T3 PA RELEASE 24 HOUR 20 MG ORAL 20 MG FETZIMA CAPSULE EXTENDED T3 PA RELEASE 24 HOUR 40 MG ORAL 40 MG FETZIMA CAPSULE EXTENDED T3 PA RELEASE 24 HOUR 80 MG ORAL 80 MG fluoxetine hcl capsule 10 mg oral 10 mg T1 fluoxetine hcl capsule 20 mg oral 20 mg T1 fluoxetine hcl capsule 40 mg oral 40 mg T1 fluoxetine hcl capsule delayed release 90 mg oral T1 QL (4 EA per 28 days) 90 mg fluoxetine hcl solution 20 mg/5ml oral 20 mg/5ml T1 fluvoxamine maleate tablet 100 mg oral 100 mg T1 fluvoxamine maleate tablet 25 mg oral 25 mg T1 fluvoxamine maleate tablet 50 mg oral 50 mg T1 imipramine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years) imipramine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years) imipramine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years) imipramine pamoate capsule 100 mg oral 100 mg T3 AL (Max 64 Years) imipramine pamoate capsule 125 mg oral 125 mg T3 AL (Max 64 Years) imipramine pamoate capsule 150 mg oral 150 mg T3 AL (Max 64 Years) imipramine pamoate capsule 75 mg oral 75 mg T3 AL (Max 64 Years)

26 Drug Status Notes maprotiline hcl tablet 25 mg oral 25 mg T1 maprotiline hcl tablet 50 mg oral 50 mg T1 maprotiline hcl tablet 75 mg oral 75 mg T1 MARPLAN TABLET 10 MG ORAL 10 MG T3 mirtazapine tablet 15 mg oral 15 mg T1 AL (Max 64 Years) mirtazapine tablet 30 mg oral 30 mg T1 AL (Max 64 Years) mirtazapine tablet 45 mg oral 45 mg T1 AL (Max 64 Years) mirtazapine tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years) mirtazapine tablet dispersible 15 mg oral 15 mg T3 AL (Max 64 Years) mirtazapine tablet dispersible 30 mg oral 30 mg T3 AL (Max 64 Years) mirtazapine tablet dispersible 45 mg oral 45 mg T3 AL (Max 64 Years) nefazodone hcl tablet 100 mg oral 100 mg T1 nefazodone hcl tablet 150 mg oral 150 mg T1 nefazodone hcl tablet 200 mg oral 200 mg T1 nefazodone hcl tablet 250 mg oral 250 mg T1 nefazodone hcl tablet 50 mg oral 50 mg T1 nortriptyline hcl capsule 10 mg oral 10 mg T1 nortriptyline hcl capsule 25 mg oral 25 mg T1 nortriptyline hcl capsule 50 mg oral 50 mg T1 nortriptyline hcl capsule 75 mg oral 75 mg T1 nortriptyline hcl solution 10 mg/5ml oral 10 T1 mg/5ml paroxetine hcl er tablet extended release 24 hour T3 12.5 mg oral 12.5 mg paroxetine hcl er tablet extended release 24 hour T3 25 mg oral 25 mg paroxetine hcl er tablet extended release 24 hour T3 37.5 mg oral 37.5 mg paroxetine hcl tablet 10 mg oral 10 mg T1 paroxetine hcl tablet 20 mg oral 20 mg T1 paroxetine hcl tablet 30 mg oral 30 mg T1 paroxetine hcl tablet 40 mg oral 40 mg T1 phenelzine sulfate tablet 15 mg oral 15 mg T1 protriptyline hcl tablet 10 mg oral 10 mg T1 protriptyline hcl tablet 5 mg oral 5 mg T1 sertraline hcl concentrate 20 mg/ml oral 20 T1 mg/ml sertraline hcl tablet 100 mg oral 100 mg T1 sertraline hcl tablet 25 mg oral 25 mg T1

27 Drug Status Notes sertraline hcl tablet 50 mg oral 50 mg T1 tranylcypromine sulfate tablet 10 mg oral 10 mg T3 trazodone hcl tablet 100 mg oral 100 mg T1 trazodone hcl tablet 150 mg oral 150 mg T1 trazodone hcl tablet 50 mg oral 50 mg T1 trimipramine maleate capsule 100 mg oral 100 T1 mg trimipramine maleate capsule 25 mg oral 25 mg T1 trimipramine maleate capsule 50 mg oral 50 mg T1 venlafaxine hcl er capsule extended release 24 T1 hour 150 mg oral 150 mg venlafaxine hcl er capsule extended release 24 T1 hour 37.5 mg oral 37.5 mg venlafaxine hcl er capsule extended release 24 T1 hour 75 mg oral 75 mg venlafaxine hcl tablet 100 mg oral 100 mg T1 venlafaxine hcl tablet 25 mg oral 25 mg T1 venlafaxine hcl tablet 37.5 mg oral 37.5 mg T1 venlafaxine hcl tablet 50 mg oral 50 mg T1 venlafaxine hcl tablet 75 mg oral 75 mg T1 VIIBRYD TABLET 10 MG ORAL 10 MG T3 PA VIIBRYD TABLET 20 MG ORAL 20 MG T3 PA VIIBRYD TABLET 40 MG ORAL 40 MG T3 PA *Antidiabetics* acarbose tablet 100 mg oral 100 mg T1 acarbose tablet 25 mg oral 25 mg T1 acarbose tablet 50 mg oral 50 mg T1 alogliptin benzoate oral tablet 12.5 mg, 25 mg, T2 QL (30 EA per 30 days) 6.25 mg alogliptin-metformin hcl oral tablet 12.5-1000 mg T2 QL (60 EA per 30 days) alogliptin-metformin hcl oral tablet 12.5-500 mg T2 QL (30 EA per 30 days) alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25- T2 QL (30 EA per 30 days) 45 mg AVANDIA TABLET 2 MG ORAL 2 MG T3 BYETTA 10 MCG PEN SOLUTION PEN- INJECTOR 10 MCG/0.04ML T3 PA; QL (2.4 ML per 30 days) SUBCUTANEOUS 10 MCG/0.04ML BYETTA 5 MCG PEN SOLUTION PEN- INJECTOR 5 MCG/0.02ML T3 PA; QL (1.2 ML per 30 days) SUBCUTANEOUS 5 MCG/0.02ML 28 Drug Status Notes CYCLOSET TABLET 0.8 MG ORAL 0.8 MG T3 FARXIGA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days) FIASP FLEXTOUCH SUBCUTANEOUS T2 SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS 100 T2 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 T2 UNIT/ML glimepiride tablet 1 mg oral 1 mg T1 glimepiride tablet 2 mg oral 2 mg T1 glimepiride tablet 4 mg oral 4 mg T1 glipizide er tablet extended release 24 hour 10 mg T1 QL (60 EA per 30 days) oral 10 mg glipizide er tablet extended release 24 hour 2.5 T1 QL (60 EA per 30 days) mg oral 2.5 mg glipizide er tablet extended release 24 hour 5 mg T1 QL (60 EA per 30 days) oral 5 mg glipizide tablet 10 mg oral 10 mg T1 glipizide tablet 5 mg oral 5 mg T1 glipizide-metformin hcl tablet 2.5-250 mg oral T1 2.5-250 mg glipizide-metformin hcl tablet 2.5-500 mg oral T1 2.5-500 mg glipizide-metformin hcl tablet 5-500 mg oral 5- T1 500 mg GLUCAGEN HYPOKIT SOLUTION T2 QL (2 EA per 30 days) RECONSTITUTED 1 MG INJECTION 1 MG glucagon emergency kit 1 mg injection 1 mg T3 QL (2 EA per 30 days) glyburide micronized tablet 1.5 mg oral 1.5 mg T1 glyburide micronized tablet 3 mg oral 3 mg T1 glyburide micronized tablet 6 mg oral 6 mg T1 glyburide tablet 1.25 mg oral 1.25 mg T1 glyburide tablet 2.5 mg oral 2.5 mg T1 glyburide tablet 5 mg oral 5 mg T1 glyburide-metformin tablet 1.25-250 mg oral T1 1.25-250 mg glyburide-metformin tablet 2.5-500 mg oral 2.5- T1 500 mg glyburide-metformin tablet 5-500 mg oral 5-500 T1 mg

29 Drug Status Notes goodsense glucose tablet chewable 4-6 gm-mg T1 oral 4-6 gm-mg HUMULIN R U-500 (CONCENTRATED) T2 QL (20 ML per 30 days) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKAMET TABLET 150-1000 MG ORAL T2 QL (60 EA per 30 days) 150-1000 MG INVOKAMET TABLET 150-500 MG ORAL T2 QL (60 EA per 30 days) 150-500 MG INVOKAMET TABLET 50-1000 MG ORAL T2 QL (60 EA per 30 days) 50-1000 MG INVOKAMET TABLET 50-500 MG ORAL T2 QL (60 EA per 30 days) 50-500 MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG ORAL T2 QL (60 EA per 30 days) 150-1000 MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-500 MG ORAL 150- T2 QL (60 EA per 30 days) 500 MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG ORAL 50- T2 QL (60 EA per 30 days) 1000 MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 50-500 MG ORAL 50- T2 QL (60 EA per 30 days) 500 MG INVOKANA TABLET 100 MG ORAL 100 T2 QL (30 EA per 30 days) MG INVOKANA TABLET 300 MG ORAL 300 T2 QL (30 EA per 30 days) MG JANUMET ORAL TABLET 50-1000 MG, 50- T2 ST; QL (60 EA per 30 days) 500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 T2 ST; QL (30 EA per 30 days) MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, T2 ST; QL (30 EA per 30 days) 50 MG JARDIANCE TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days) JARDIANCE TABLET 25 MG ORAL 25 MG T2 QL (30 EA per 30 days) LANTUS SOLOSTAR SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS T2 100 UNIT/ML LANTUS SOLUTION 100 UNIT/ML T2 SUBCUTANEOUS 100 UNIT/ML

30 Drug Status Notes LEVEMIR FLEXTOUCH SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS T2 100 UNIT/ML LEVEMIR SOLUTION 100 UNIT/ML T2 SUBCUTANEOUS 100 UNIT/ML metformin hcl er tablet extended release 24 hour T1 500 mg oral 500 mg metformin hcl er tablet extended release 24 hour T1 750 mg oral 750 mg metformin hcl tablet 1000 mg oral 1000 mg T1 metformin hcl tablet 500 mg oral 500 mg T1 metformin hcl tablet 850 mg oral 850 mg T1 miglitol tablet 25 mg oral 25 mg T3 nateglinide tablet 120 mg oral 120 mg T1 nateglinide tablet 60 mg oral 60 mg T1 NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN- T2 INJECTOR (70-30) 100 UNIT/ML NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- T2 INJECTOR (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 T2 UNIT/ML NOVOLIN N FLEXPEN SUSPENSION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS T2 100 UNIT/ML NOVOLIN N RELION SUSPENSION 100 T2 UNIT/ML SUBCUTANEOUS 100 UNIT/ML NOVOLIN N SUSPENSION 100 UNIT/ML T2 SUBCUTANEOUS 100 UNIT/ML NOVOLIN R FLEXPEN SOLUTION PEN- INJECTOR 100 UNIT/ML INJECTION 100 T2 UNIT/ML NOVOLIN R RELION SOLUTION 100 T2 UNIT/ML INJECTION 100 UNIT/ML NOVOLIN R SOLUTION 100 UNIT/ML T2 INJECTION 100 UNIT/ML NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN- T2 INJECTOR (70-30) 100 UNIT/ML NOVOLOG FLEXPEN RELION SUBCUTANEOUS SOLUTION PEN- T2 INJECTOR 100 UNIT/ML 31 Drug Status Notes NOVOLOG FLEXPEN SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS T2 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 T2 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 T2 UNIT/ML NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 T2 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS T2 SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG RELION SUBCUTANEOUS T2 SOLUTION 100 UNIT/ML NOVOLOG SOLUTION 100 UNIT/ML T2 SUBCUTANEOUS 100 UNIT/ML ONGLYZA TABLET 2.5 MG ORAL 2.5 MG T3 ST; QL (30 EA per 30 days) ONGLYZA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- T2 QL (1.5 ML per 30 days) INJECTOR 2 MG/1.5ML OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML, 4 T2 QL (3 ML per 30 days) MG/3ML pioglitazone hcl tablet 15 mg oral 15 mg T1 QL (30 EA per 30 days) pioglitazone hcl tablet 30 mg oral 30 mg T1 QL (30 EA per 30 days) pioglitazone hcl tablet 45 mg oral 45 mg T1 QL (30 EA per 30 days) pioglitazone hcl-glimepiride tablet 30-2 mg oral T3 30-2 mg pioglitazone hcl-glimepiride tablet 30-4 mg oral T3 30-4 mg pioglitazone hcl-metformin hcl tablet 15-500 mg T3 oral 15-500 mg pioglitazone hcl-metformin hcl tablet 15-850 mg T3 oral 15-850 mg repaglinide tablet 0.5 mg oral 0.5 mg T1 repaglinide tablet 1 mg oral 1 mg T1 repaglinide tablet 2 mg oral 2 mg T1 RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 T2 QL (30 EA per 30 days) MG

32 Drug Status Notes SYMLINPEN 120 SOLUTION PEN- INJECTOR 2700 MCG/2.7ML T3 PA SUBCUTANEOUS 2700 MCG/2.7ML SYMLINPEN 60 SOLUTION PEN- INJECTOR 1500 MCG/1.5ML T3 PA SUBCUTANEOUS 1500 MCG/1.5ML SYNJARDY TABLET 12.5-1000 MG ORAL T2 QL (60 EA per 30 days) 12.5-1000 MG SYNJARDY TABLET 12.5-500 MG ORAL T2 QL (60 EA per 30 days) 12.5-500 MG SYNJARDY TABLET 5-1000 MG ORAL 5- T2 QL (60 EA per 30 days) 1000 MG SYNJARDY TABLET 5-500 MG ORAL 5-500 T2 QL (60 EA per 30 days) MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10- T2 QL (60 EA per 30 days) 1000 MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG ORAL T2 QL (60 EA per 30 days) 12.5-1000 MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG ORAL 25- T2 QL (60 EA per 30 days) 1000 MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL 5- T2 QL (60 EA per 30 days) 1000 MG tolbutamide tablet 500 mg oral 500 mg T1 TOUJEO SOLOSTAR SOLUTION PEN- INJECTOR 300 UNIT/ML SUBCUTANEOUS T2 300 UNIT/ML TRADJENTA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days) TRESIBA FLEXTOUCH SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS T2 100 UNIT/ML TRESIBA FLEXTOUCH SOLUTION PEN- INJECTOR 200 UNIT/ML SUBCUTANEOUS T2 200 UNIT/ML TRESIBA SOLUTION 100 UNIT/ML T2 SUBCUTANEOUS 100 UNIT/ML TRULICITY SOLUTION PEN-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS 0.75 T3 PA; QL (2 ML per 28 days) MG/0.5ML TRULICITY SOLUTION PEN-INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS 1.5 T3 PA; QL (2 ML per 28 days) MG/0.5ML 33 Drug Status Notes VICTOZA SOLUTION PEN-INJECTOR 18 T2 QL (9 ML per 30 days) MG/3ML SUBCUTANEOUS 18 MG/3ML XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10- T3 ST; QL (30 EA per 30 days) 1000 MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 10-500 MG ORAL 10- T3 ST; QL (30 EA per 30 days) 500 MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL 5- T3 ST; QL (30 EA per 30 days) 1000 MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 5-500 MG ORAL 5-500 T3 ST; QL (30 EA per 30 days) MG *Antidiarrheal/Probiotic Agents* diphenoxylate-atropine liquid 2.5-0.025 mg/5ml T1 oral 2.5-0.025 mg/5ml diphenoxylate-atropine tablet 2.5-0.025 mg oral T1 2.5-0.025 mg loperamide hcl oral capsule 2 mg T1 loperamide hcl oral liquid 1 mg/5ml T1 loperamide hcl oral tablet 2 mg T1 MOTOFEN TABLET 1-0.025 MG ORAL 1- T3 PA 0.025 MG *Antidotes And Specific Antagonists* acetylcysteine solution 200 mg/ml intravenous T1 200 mg/ml CHEMET CAPSULE 100 MG ORAL 100 MG T3 deferasirox oral tablet 180 mg T4 PA deferasirox oral tablet soluble 125 mg, 250 mg, T4 PA 500 mg deferiprone oral tablet 500 mg T4 PA deferoxamine mesylate solution reconstituted 2 T1 gm injection 2 gm JADENU TABLET 360 MG ORAL 360 MG T4 PA JADENU TABLET 90 MG ORAL 90 MG T4 PA KLOXXADO NASAL LIQUID 8 MG/0.1ML T1 naloxone hcl solution 0.4 mg/ml injection 0.4 T1 QL (2 ML per 90 days) mg/ml naloxone hcl solution prefilled syringe 2 mg/2ml T2 QL (2 ML per 90 days) injection 2 mg/2ml naltrexone hcl tablet 50 mg oral 50 mg T1

34 Drug Status Notes NARCAN NASAL LIQUID 4 MG/0.1ML T1 pentetate calcium trisodium solution 200 mg/ml T1 combination 200 mg/ml pentetate zinc trisodium solution 200 mg/ml T1 combination 200 mg/ml physostigmine salicylate solution 1 mg/ml T1 injection 1 mg/ml RADIOGARDASE CAPSULE 0.5 GM ORAL T3 PA 0.5 GM VIVITROL SUSPENSION RECONSTITUTED 380 MG T4 PA INTRAMUSCULAR 380 MG *Antiemetics* AKYNZEO CAPSULE 300-0.5 MG ORAL T4 PA 300-0.5 MG ANZEMET TABLET 100 MG ORAL 100 MG T3 ST ANZEMET TABLET 50 MG ORAL 50 MG T3 ST aprepitant capsule 125 mg oral 125 mg T3 ST aprepitant capsule 80 mg oral 80 mg T3 ST dimenhydrinate solution 50 mg/ml injection 50 T3 mg/ml dronabinol capsule 10 mg oral 10 mg T4 PA dronabinol capsule 2.5 mg oral 2.5 mg T3 PA dronabinol capsule 5 mg oral 5 mg T3 PA granisetron hcl tablet 1 mg oral 1 mg T3 QL (10 EA per 30 days) meclizine hcl oral tablet 25 mg T1 meclizine hcl tablet 12.5 mg oral (rx) 12.5 mg T1 ondansetron hcl solution 4 mg/5ml oral 4 mg/5ml T1 QL (50 ML per 30 days) ondansetron hcl tablet 24 mg oral 24 mg T1 QL (5 EA per 30 days) ondansetron hcl tablet 4 mg oral 4 mg T1 QL (15 EA per 30 days) ondansetron hcl tablet 8 mg oral 8 mg T1 QL (15 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (15 EA per 30 days) trimethobenzamide hcl capsule 300 mg oral 300 T1 mg *Antifungals* CRESEMBA CAPSULE 186 MG ORAL 186 T4 PA MG fluconazole suspension reconstituted 10 mg/ml T1 QL (105 ML per 30 days) oral 10 mg/ml fluconazole suspension reconstituted 40 mg/ml T1 QL (105 ML per 30 days) oral 40 mg/ml

35 Drug Status Notes fluconazole tablet 100 mg oral 100 mg T1 QL (30 EA per 30 days) fluconazole tablet 150 mg oral 150 mg T1 QL (30 EA per 30 days) fluconazole tablet 200 mg oral 200 mg T1 QL (30 EA per 30 days) fluconazole tablet 50 mg oral 50 mg T1 QL (30 EA per 30 days) flucytosine capsule 250 mg oral 250 mg T4 PA flucytosine capsule 500 mg oral 500 mg T4 PA griseofulvin microsize suspension 125 mg/5ml T3 oral 125 mg/5ml griseofulvin microsize tablet 500 mg oral 500 mg T3 griseofulvin ultramicrosize tablet 125 mg oral T3 125 mg griseofulvin ultramicrosize tablet 250 mg oral T3 250 mg itraconazole oral capsule 100 mg T3 ketoconazole tablet 200 mg oral 200 mg T1 nystatin tablet 500000 unit oral 500000 unit T1 terbinafine hcl tablet 250 mg oral 250 mg T1 voriconazole tablet 200 mg oral 200 mg T4 PA voriconazole tablet 50 mg oral 50 mg T4 PA ** carbinoxamine maleate tablet 4 mg oral 4 mg T1 AL (Max 64 Years) cetirizine hcl oral tablet 10 mg T1 QL (30 EA per 30 days) cetirizine hcl tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) cyproheptadine hcl syrup 2 mg/5ml oral 2 mg/5ml T1 AL (Max 64 Years) cyproheptadine hcl tablet 4 mg oral 4 mg T1 AL (Max 64 Years) hcl elixir 12.5 mg/5ml oral (rx) T1 AL (Max 64 Years) 12.5 mg/5ml diphenhydramine hcl solution 50 mg/ml injection T1 AL (Max 64 Years) 50 mg/ml fexofenadine hcl oral tablet 180 mg T1 QL (30 EA per 30 days) fexofenadine hcl oral tablet 60 mg T1 QL (60 EA per 30 days) kp diphenhydramine hcl capsule 50 mg oral 50 T1 AL (Max 64 Years) mg levocetirizine dihydrochloride tablet 5 mg oral T1 QL (30 EA per 30 days) (rx) 5 mg QL (300 ML per 30 days); AL loratadine childrens oral syrup 5 mg/5ml T1 (Max 12 Years) loratadine oral tablet 10 mg T1 QL (30 EA per 30 days) promethazine hcl solution 25 mg/ml injection 25 T1 AL (Max 64 Years) mg/ml

36 Drug Status Notes promethazine hcl solution 50 mg/ml injection 50 T1 AL (Max 64 Years) mg/ml promethazine hcl syrup 6.25 mg/5ml oral 6.25 T1 AL (Max 64 Years) mg/5ml promethazine hcl tablet 12.5 mg oral 12.5 mg T1 AL (Max 64 Years) promethazine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years) promethazine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years) PROMETHEGAN SUPPOSITORY 12.5 MG QL (12 EA per 30 days); AL (Max T1 RECTAL 12.5 MG 64 Years) PROMETHEGAN SUPPOSITORY 25 MG QL (12 EA per 30 days); AL (Max T1 RECTAL 25 MG 64 Years) PROMETHEGAN SUPPOSITORY 50 MG QL (12 EA per 30 days); AL (Max T1 RECTAL 50 MG 64 Years) *Antihyperlipidemics* atorvastatin calcium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days) atorvastatin calcium tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) atorvastatin calcium tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days) atorvastatin calcium tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days) colesevelam hcl oral packet 3.75 gm T3 PA colesevelam hcl oral tablet 625 mg T3 PA colestipol hcl granules 5 gm oral 5 gm T1 colestipol hcl tablet 1 gm oral 1 gm T1 ezetimibe tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days) ezetimibe-simvastatin tablet 10-10 mg oral 10-10 T3 ST; QL (30 EA per 30 days) mg ezetimibe-simvastatin tablet 10-20 mg oral 10-20 T3 ST; QL (30 EA per 30 days) mg ezetimibe-simvastatin tablet 10-40 mg oral 10-40 T3 ST; QL (30 EA per 30 days) mg ezetimibe-simvastatin tablet 10-80 mg oral 10-80 T3 ST; QL (30 EA per 30 days) mg fenofibrate micronized capsule 134 mg oral 134 T1 mg fenofibrate micronized capsule 200 mg oral 200 T1 mg fenofibrate micronized capsule 43 mg oral 43 mg T1 fenofibrate micronized capsule 67 mg oral 67 mg T1 fenofibrate tablet 145 mg oral 145 mg T1 fenofibrate tablet 160 mg oral 160 mg T1 fenofibrate tablet 48 mg oral 48 mg T1 fenofibrate tablet 54 mg oral 54 mg T1 37 Drug Status Notes fenofibric acid capsule delayed release 135 mg T3 oral 135 mg fenofibric acid capsule delayed release 45 mg T3 oral 45 mg FIBRICOR TABLET 105 MG ORAL 105 MG T1 FIBRICOR TABLET 35 MG ORAL 35 MG T1 fluvastatin sodium capsule 20 mg oral 20 mg T3 fluvastatin sodium capsule 40 mg oral 40 mg T3 gemfibrozil tablet 600 mg oral 600 mg T1 icosapent ethyl oral capsule 1 gm T3 ST; QL (120 EA per 30 days) LIVALO TABLET 1 MG ORAL 1 MG T3 ST; QL (30 EA per 30 days) LIVALO TABLET 2 MG ORAL 2 MG T3 ST; QL (30 EA per 30 days) LIVALO TABLET 4 MG ORAL 4 MG T3 ST; QL (30 EA per 30 days) lovastatin tablet 10 mg oral 10 mg T1 lovastatin tablet 20 mg oral 20 mg T1 lovastatin tablet 40 mg oral 40 mg T1 niacin er (antihyperlipidemic) tablet extended T3 release 1000 mg oral 1000 mg niacin er (antihyperlipidemic) tablet extended T3 release 500 mg oral 500 mg niacin er (antihyperlipidemic) tablet extended T3 release 750 mg oral 750 mg NIACOR TABLET 500 MG ORAL 500 MG T1 omega-3-acid ethyl esters capsule 1 gm oral 1 gm T3 QL (120 EA per 30 days) PRALUENT SUBCUTANEOUS SOLUTION T2 PA; QL (2 ML per 28 days) AUTO-INJECTOR 150 MG/ML, 75 MG/ML pravastatin sodium tablet 10 mg oral 10 mg T1 pravastatin sodium tablet 20 mg oral 20 mg T1 pravastatin sodium tablet 40 mg oral 40 mg T1 pravastatin sodium tablet 80 mg oral 80 mg T1 PREVALITE PACKET 4 GM ORAL 4 GM T1 QL (60 EA per 30 days) PREVALITE POWDER 4 GM/DOSE ORAL T1 QL (239.4 GM per 30 days) 4 GM/DOSE REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE T2 PA; QL (3.5 ML per 30 days) 420 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION T2 PA; QL (2 ML per 28 days) PREFILLED SYRINGE 140 MG/ML REPATHA SURECLICK SUBCUTANEOUS T2 PA; QL (2 ML per 28 days) SOLUTION AUTO-INJECTOR 140 MG/ML rosuvastatin calcium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)

38 Drug Status Notes rosuvastatin calcium tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) rosuvastatin calcium tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days) rosuvastatin calcium tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) simvastatin tablet 10 mg oral 10 mg T1 simvastatin tablet 20 mg oral 20 mg T1 simvastatin tablet 40 mg oral 40 mg T1 simvastatin tablet 5 mg oral 5 mg T1 simvastatin tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days) *Antihypertensives* aliskiren fumarate oral tablet 150 mg, 300 mg T3 amlodipine besy-benazepril hcl capsule 10-20 mg T1 oral 10-20 mg amlodipine besy-benazepril hcl capsule 10-40 mg T1 oral 10-40 mg amlodipine besy-benazepril hcl capsule 2.5-10 mg T1 oral 2.5-10 mg amlodipine besy-benazepril hcl capsule 5-10 mg T1 oral 5-10 mg amlodipine besy-benazepril hcl capsule 5-20 mg T1 oral 5-20 mg amlodipine besy-benazepril hcl capsule 5-40 mg T1 oral 5-40 mg amlodipine besylate-valsartan tablet 10-160 mg T1 oral 10-160 mg amlodipine besylate-valsartan tablet 10-320 mg T1 oral 10-320 mg amlodipine besylate-valsartan tablet 5-160 mg T1 oral 5-160 mg amlodipine besylate-valsartan tablet 5-320 mg T1 oral 5-320 mg amlodipine-olmesartan tablet 10-20 mg oral 10- T3 ST 20 mg amlodipine-olmesartan tablet 10-40 mg oral 10- T3 ST 40 mg amlodipine-olmesartan tablet 5-20 mg oral 5-20 T3 ST mg amlodipine-olmesartan tablet 5-40 mg oral 5-40 T3 ST mg atenolol-chlorthalidone tablet 100-25 mg oral T1 100-25 mg atenolol-chlorthalidone tablet 50-25 mg oral 50- T1 25 mg

39 Drug Status Notes benazepril hcl tablet 10 mg oral 10 mg T1 benazepril hcl tablet 20 mg oral 20 mg T1 benazepril hcl tablet 40 mg oral 40 mg T1 benazepril hcl tablet 5 mg oral 5 mg T1 benazepril-hydrochlorothiazide tablet 10-12.5 mg T1 oral 10-12.5 mg benazepril-hydrochlorothiazide tablet 20-12.5 mg T1 oral 20-12.5 mg benazepril-hydrochlorothiazide tablet 20-25 mg T1 oral 20-25 mg benazepril-hydrochlorothiazide tablet 5-6.25 mg T1 oral 5-6.25 mg bisoprolol-hydrochlorothiazide tablet 10-6.25 mg T1 oral 10-6.25 mg bisoprolol-hydrochlorothiazide tablet 2.5-6.25 mg T1 oral 2.5-6.25 mg bisoprolol-hydrochlorothiazide tablet 5-6.25 mg T1 oral 5-6.25 mg candesartan cilexetil oral tablet 4 mg, 8 mg T3 QL (30 EA per 30 days) candesartan cilexetil tablet 16 mg oral 16 mg T3 QL (30 EA per 30 days) candesartan cilexetil tablet 32 mg oral 32 mg T3 QL (30 EA per 30 days) candesartan cilexetil-hctz tablet 16-12.5 mg oral T3 QL (30 EA per 30 days) 16-12.5 mg candesartan cilexetil-hctz tablet 32-12.5 mg oral T3 QL (30 EA per 30 days) 32-12.5 mg candesartan cilexetil-hctz tablet 32-25 mg oral T3 QL (30 EA per 30 days) 32-25 mg captopril tablet 100 mg oral 100 mg T1 captopril tablet 12.5 mg oral 12.5 mg T1 captopril tablet 25 mg oral 25 mg T1 captopril tablet 50 mg oral 50 mg T1 captopril-hydrochlorothiazide tablet 25-15 mg T1 oral 25-15 mg captopril-hydrochlorothiazide tablet 25-25 mg T1 oral 25-25 mg captopril-hydrochlorothiazide tablet 50-15 mg T1 oral 50-15 mg captopril-hydrochlorothiazide tablet 50-25 mg T1 oral 50-25 mg clonidine hcl tablet 0.1 mg oral 0.1 mg T1 clonidine hcl tablet 0.2 mg oral 0.2 mg T1 clonidine hcl tablet 0.3 mg oral 0.3 mg T1 40 Drug Status Notes clonidine patch weekly 0.1 mg/24hr transdermal T3 0.1 mg/24hr clonidine patch weekly 0.2 mg/24hr transdermal T3 0.2 mg/24hr clonidine patch weekly 0.3 mg/24hr transdermal T3 0.3 mg/24hr doxazosin mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years) doxazosin mesylate tablet 2 mg oral 2 mg T1 AL (Max 64 Years) doxazosin mesylate tablet 4 mg oral 4 mg T1 AL (Max 64 Years) doxazosin mesylate tablet 8 mg oral 8 mg T1 AL (Max 64 Years) EDARBI TABLET 40 MG ORAL 40 MG T3 PA EDARBI TABLET 80 MG ORAL 80 MG T3 PA enalapril maleate tablet 10 mg oral 10 mg T1 enalapril maleate tablet 2.5 mg oral 2.5 mg T1 enalapril maleate tablet 20 mg oral 20 mg T1 enalapril maleate tablet 5 mg oral 5 mg T1 enalapril-hydrochlorothiazide tablet 10-25 mg T1 oral 10-25 mg enalapril-hydrochlorothiazide tablet 5-12.5 mg T1 oral 5-12.5 mg eplerenone tablet 25 mg oral 25 mg T3 eplerenone tablet 50 mg oral 50 mg T3 fosinopril sodium tablet 10 mg oral 10 mg T1 fosinopril sodium tablet 20 mg oral 20 mg T1 fosinopril sodium tablet 40 mg oral 40 mg T1 fosinopril sodium-hctz tablet 10-12.5 mg oral 10- T1 12.5 mg fosinopril sodium-hctz tablet 20-12.5 mg oral 20- T1 12.5 mg guanfacine hcl tablet 1 mg oral 1 mg T1 guanfacine hcl tablet 2 mg oral 2 mg T1 hydralazine hcl tablet 10 mg oral 10 mg T1 hydralazine hcl tablet 100 mg oral 100 mg T1 hydralazine hcl tablet 25 mg oral 25 mg T1 hydralazine hcl tablet 50 mg oral 50 mg T1 irbesartan tablet 150 mg oral 150 mg T1 QL (30 EA per 30 days) irbesartan tablet 300 mg oral 300 mg T1 QL (30 EA per 30 days) irbesartan tablet 75 mg oral 75 mg T1 QL (30 EA per 30 days) irbesartan-hydrochlorothiazide tablet 150-12.5 T1 mg oral 150-12.5 mg

41 Drug Status Notes irbesartan-hydrochlorothiazide tablet 300-12.5 T1 mg oral 300-12.5 mg lisinopril tablet 10 mg oral 10 mg T1 lisinopril tablet 2.5 mg oral 2.5 mg T1 lisinopril tablet 20 mg oral 20 mg T1 lisinopril tablet 30 mg oral 30 mg T1 lisinopril tablet 40 mg oral 40 mg T1 lisinopril tablet 5 mg oral 5 mg T1 lisinopril-hydrochlorothiazide tablet 10-12.5 mg T1 oral 10-12.5 mg lisinopril-hydrochlorothiazide tablet 20-12.5 mg T1 oral 20-12.5 mg lisinopril-hydrochlorothiazide tablet 20-25 mg T1 oral 20-25 mg losartan potassium tablet 100 mg oral 100 mg T1 losartan potassium tablet 25 mg oral 25 mg T1 QL (30 EA per 30 days) losartan potassium tablet 50 mg oral 50 mg T1 QL (30 EA per 30 days) losartan potassium-hctz tablet 100-12.5 mg oral T1 100-12.5 mg losartan potassium-hctz tablet 100-25 mg oral T1 100-25 mg losartan potassium-hctz tablet 50-12.5 mg oral T1 50-12.5 mg methyldopa tablet 250 mg oral 250 mg T1 methyldopa tablet 500 mg oral 500 mg T1 metoprolol-hydrochlorothiazide tablet 100-25 mg T1 oral 100-25 mg metoprolol-hydrochlorothiazide tablet 100-50 mg T1 oral 100-50 mg metoprolol-hydrochlorothiazide tablet 50-25 mg T1 oral 50-25 mg minoxidil tablet 10 mg oral 10 mg T1 minoxidil tablet 2.5 mg oral 2.5 mg T1 moexipril hcl tablet 15 mg oral 15 mg T1 moexipril hcl tablet 7.5 mg oral 7.5 mg T1 olmesartan medoxomil tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) olmesartan medoxomil tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days) olmesartan medoxomil tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) olmesartan medoxomil-hctz tablet 20-12.5 mg T1 QL (30 EA per 30 days) oral 20-12.5 mg

42 Drug Status Notes olmesartan medoxomil-hctz tablet 40-12.5 mg T1 QL (30 EA per 30 days) oral 40-12.5 mg olmesartan medoxomil-hctz tablet 40-25 mg oral T1 QL (30 EA per 30 days) 40-25 mg perindopril erbumine tablet 2 mg oral 2 mg T1 perindopril erbumine tablet 4 mg oral 4 mg T1 perindopril erbumine tablet 8 mg oral 8 mg T1 phenoxybenzamine hcl capsule 10 mg oral 10 mg T3 PA prazosin hcl capsule 1 mg oral 1 mg T1 prazosin hcl capsule 2 mg oral 2 mg T1 prazosin hcl capsule 5 mg oral 5 mg T1 propranolol-hctz tablet 40-25 mg oral 40-25 mg T1 propranolol-hctz tablet 80-25 mg oral 80-25 mg T1 quinapril hcl tablet 10 mg oral 10 mg T1 quinapril hcl tablet 20 mg oral 20 mg T1 quinapril hcl tablet 40 mg oral 40 mg T1 quinapril hcl tablet 5 mg oral 5 mg T1 quinapril-hydrochlorothiazide tablet 10-12.5 mg T1 oral 10-12.5 mg quinapril-hydrochlorothiazide tablet 20-12.5 mg T1 oral 20-12.5 mg quinapril-hydrochlorothiazide tablet 20-25 mg T1 oral 20-25 mg ramipril capsule 1.25 mg oral 1.25 mg T1 ramipril capsule 10 mg oral 10 mg T1 ramipril capsule 2.5 mg oral 2.5 mg T1 ramipril capsule 5 mg oral 5 mg T1 TEKTURNA HCT TABLET 150-12.5 MG T3 ORAL 150-12.5 MG TEKTURNA HCT TABLET 150-25 MG T3 ORAL 150-25 MG TEKTURNA HCT TABLET 300-12.5 MG T3 ORAL 300-12.5 MG TEKTURNA HCT TABLET 300-25 MG T3 ORAL 300-25 MG telmisartan tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) telmisartan tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days) telmisartan tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days) telmisartan-hctz tablet 40-12.5 mg oral 40-12.5 T3 QL (30 EA per 30 days) mg

43 Drug Status Notes telmisartan-hctz tablet 80-12.5 mg oral 80-12.5 T3 QL (30 EA per 30 days) mg telmisartan-hctz tablet 80-25 mg oral 80-25 mg T3 QL (30 EA per 30 days) terazosin hcl capsule 1 mg oral 1 mg T1 AL (Max 64 Years) terazosin hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years) terazosin hcl capsule 2 mg oral 2 mg T1 AL (Max 64 Years) terazosin hcl capsule 5 mg oral 5 mg T1 AL (Max 64 Years) trandolapril tablet 1 mg oral 1 mg T1 QL (30 EA per 30 days) trandolapril tablet 2 mg oral 2 mg T1 QL (30 EA per 30 days) trandolapril tablet 4 mg oral 4 mg T1 QL (30 EA per 30 days) trandolapril-verapamil hcl er tablet extended T3 QL (30 EA per 30 days) release 1-240 mg oral 1-240 mg trandolapril-verapamil hcl er tablet extended T3 QL (30 EA per 30 days) release 2-180 mg oral 2-180 mg trandolapril-verapamil hcl er tablet extended T3 QL (30 EA per 30 days) release 2-240 mg oral 2-240 mg trandolapril-verapamil hcl er tablet extended T3 QL (30 EA per 30 days) release 4-240 mg oral 4-240 mg valsartan tablet 160 mg oral 160 mg T1 QL (60 EA per 30 days) valsartan tablet 320 mg oral 320 mg T1 QL (30 EA per 30 days) valsartan tablet 40 mg oral 40 mg T1 QL (60 EA per 30 days) valsartan tablet 80 mg oral 80 mg T1 QL (60 EA per 30 days) valsartan-hydrochlorothiazide tablet 160-12.5 mg T1 oral 160-12.5 mg valsartan-hydrochlorothiazide tablet 160-25 mg T1 oral 160-25 mg valsartan-hydrochlorothiazide tablet 320-12.5 mg T1 oral 320-12.5 mg valsartan-hydrochlorothiazide tablet 320-25 mg T1 oral 320-25 mg valsartan-hydrochlorothiazide tablet 80-12.5 mg T1 oral 80-12.5 mg *Anti-Infective Agents - Misc.* ALINIA SUSPENSION RECONSTITUTED T4 PA 100 MG/5ML ORAL 100 MG/5ML ALINIA TABLET 500 MG ORAL 500 MG T4 PA atovaquone suspension 750 mg/5ml oral 750 T3 mg/5ml clindamycin hcl capsule 150 mg oral 150 mg T1 clindamycin hcl capsule 300 mg oral 300 mg T1 clindamycin hcl capsule 75 mg oral 75 mg T1

44 Drug Status Notes clindamycin palmitate hcl solution reconstituted T1 75 mg/5ml oral 75 mg/5ml dapsone tablet 100 mg oral 100 mg T1 dapsone tablet 25 mg oral 25 mg T1 FIRVANQ ORAL SOLUTION T2 RECONSTITUTED 25 MG/ML, 50 MG/ML HYOPHEN ORAL TABLET 81.6 MG T1 linezolid solution 600 mg/300ml intravenous 600 T3 mg/300ml linezolid suspension reconstituted 100 mg/5ml T3 AL (Max 12 Years) oral 100 mg/5ml linezolid tablet 600 mg oral 600 mg T3 QL (28 EA per 14 days) MACROBID ORAL CAPSULE 100 MG T1 methenamine hippurate oral tablet 1 gm T1 methenamine mandelate oral tablet 0.5 gm T1 metronidazole capsule 375 mg oral 375 mg T1 metronidazole tablet 250 mg oral 250 mg T1 metronidazole tablet 500 mg oral 500 mg T1 MONUROL ORAL PACKET 3 GM T3 nitrofurantoin macrocrystal oral capsule 100 mg, T1 50 mg nitrofurantoin monohyd macro capsule 100 mg T1 oral 100 mg nitrofurantoin oral suspension 25 mg/5ml T3 pentamidine isethionate injection solution T3 reconstituted 300 mg PHOSPHASAL ORAL TABLET 81.6 MG T1 SIVEXTRO TABLET 200 MG ORAL 200 MG T3 PA sulfamethoxazole-trimethoprim suspension 200- T1 40 mg/5ml oral 200-40 mg/5ml sulfamethoxazole-trimethoprim tablet 400-80 mg T1 oral 400-80 mg sulfamethoxazole-trimethoprim tablet 800-160 mg T1 oral 800-160 mg tinidazole tablet 250 mg oral 250 mg T3 tinidazole tablet 500 mg oral 500 mg T3 trimethoprim tablet 100 mg oral 100 mg T1 URIMAR-T ORAL TABLET 120 MG T1 USTELL ORAL CAPSULE 120 MG T1 vancomycin hcl in dextrose intravenous solution T1 1-5 gm/200ml-%

45 Drug Status Notes vancomycin hcl intravenous solution reconstituted T1 1 gm, 500 mg, 750 mg vancomycin hcl intravenous solution reconstituted T3 10 gm XIFAXAN TABLET 200 MG ORAL 200 MG T4 PA XIFAXAN TABLET 550 MG ORAL 550 MG T4 PA *Antimalarials* atovaquone-proguanil hcl tablet 250-100 mg oral T1 QL (30 EA per 30 days) 250-100 mg atovaquone-proguanil hcl tablet 62.5-25 mg oral T1 QL (30 EA per 30 days) 62.5-25 mg chloroquine phosphate tablet 250 mg oral 250 mg T1 chloroquine phosphate tablet 500 mg oral 500 mg T1 COARTEM ORAL TABLET 20-120 MG T3 DARAPRIM TABLET 25 MG ORAL 25 MG T4 PA hydroxychloroquine sulfate tablet 200 mg oral T1 200 mg mefloquine hcl tablet 250 mg oral 250 mg T1 primaquine phosphate tablet 26.3 (15 base) mg T1 oral 26.3 (15 base) mg quinine sulfate capsule 324 mg oral 324 mg T1 *Antimyasthenic/Cholinergic Agents* MESTINON SOLUTION 60 MG/5ML ORAL T2 PA 60 MG/5ML pyridostigmine bromide er tablet extended release T2 PA 180 mg oral 180 mg pyridostigmine bromide oral solution 60 mg/5ml T2 PA pyridostigmine bromide tablet 60 mg oral 60 mg T1 *Antimycobacterial Agents* cycloserine capsule 250 mg oral 250 mg T3 PA ethambutol hcl tablet 100 mg oral 100 mg T1 ethambutol hcl tablet 400 mg oral 400 mg T1 isoniazid syrup 50 mg/5ml oral 50 mg/5ml T1 isoniazid tablet 100 mg oral 100 mg T1 isoniazid tablet 300 mg oral 300 mg T1 PRIFTIN ORAL TABLET 150 MG T2 pyrazinamide tablet 500 mg oral 500 mg T3 rifabutin capsule 150 mg oral 150 mg T2 PA rifampin capsule 150 mg oral 150 mg T1 rifampin capsule 300 mg oral 300 mg T1 46 Drug Status Notes *Antineoplastics And Adjunctive Therapies* abiraterone acetate oral tablet 250 mg T4 PA ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML SUBCUTANEOUS 2000000 T4 PA UNIT/0.5ML AFINITOR TABLET 10 MG ORAL 10 MG T4 PA anastrozole tablet 1 mg oral 1 mg T1 bexarotene capsule 75 mg oral 75 mg T4 PA bicalutamide tablet 50 mg oral 50 mg T1 BOSULIF TABLET 100 MG ORAL 100 MG T4 PA BOSULIF TABLET 500 MG ORAL 500 MG T4 PA capecitabine tablet 150 mg oral 150 mg T4 PA capecitabine tablet 500 mg oral 500 mg T4 PA CAPRELSA TABLET 100 MG ORAL 100 T4 PA MG CAPRELSA TABLET 300 MG ORAL 300 T4 PA MG COMETRIQ (100 MG DAILY DOSE) KIT 80 T4 PA & 20 MG ORAL 80 & 20 MG COMETRIQ (140 MG DAILY DOSE) KIT 3 X 20 MG & 80 MG ORAL 3 X 20 MG & 80 T4 PA MG COMETRIQ (60 MG DAILY DOSE) KIT 20 T4 PA MG ORAL 20 MG cyclophosphamide oral capsule 25 mg, 50 mg T3 PA DEPO-PROVERA SUSPENSION 400 T3 MG/ML INTRAMUSCULAR 400 MG/ML ELIGARD KIT 22.5 MG SUBCUTANEOUS T4 PA 22.5 MG ELIGARD KIT 30 MG SUBCUTANEOUS 30 T4 PA MG ELIGARD KIT 45 MG SUBCUTANEOUS 45 T4 PA MG ELIGARD KIT 7.5 MG SUBCUTANEOUS T4 PA 7.5 MG EMCYT CAPSULE 140 MG ORAL 140 MG T3 ERIVEDGE CAPSULE 150 MG ORAL 150 T4 PA MG everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg T4 PA exemestane tablet 25 mg oral 25 mg T3 FARYDAK CAPSULE 10 MG ORAL 10 MG T4 PA 47 Drug Status Notes FARYDAK CAPSULE 20 MG ORAL 20 MG T4 PA FASLODEX SOLUTION 250 MG/5ML T4 PA INTRAMUSCULAR 250 MG/5ML FIRMAGON (240 MG DOSE) SOLUTION RECONSTITUTED 120 MG/VIAL T4 PA SUBCUTANEOUS 120 MG/VIAL FIRMAGON SOLUTION RECONSTITUTED T4 PA 80 MG SUBCUTANEOUS 80 MG flutamide capsule 125 mg oral 125 mg T3 GILOTRIF TABLET 20 MG ORAL 20 MG T4 PA GILOTRIF TABLET 30 MG ORAL 30 MG T4 PA GILOTRIF TABLET 40 MG ORAL 40 MG T4 PA GLEOSTINE CAPSULE 10 MG ORAL 10 T4 PA MG GLEOSTINE CAPSULE 100 MG ORAL 100 T4 PA MG GLEOSTINE CAPSULE 40 MG ORAL 40 T4 PA MG hydroxyprogesterone caproate solution 1.25 T4 PA; GR-F gm/5ml intramuscular 1.25 gm/5ml hydroxyurea capsule 500 mg oral 500 mg T1 IBRANCE CAPSULE 100 MG ORAL 100 MG T4 PA IBRANCE CAPSULE 125 MG ORAL 125 MG T4 PA IBRANCE CAPSULE 75 MG ORAL 75 MG T4 PA IBRANCE ORAL TABLET 100 MG, 125 MG, T4 PA 75 MG ICLUSIG TABLET 15 MG ORAL 15 MG T4 PA ICLUSIG TABLET 45 MG ORAL 45 MG T4 PA imatinib mesylate tablet 100 mg oral 100 mg T4 PA imatinib mesylate tablet 400 mg oral 400 mg T4 PA IMBRUVICA CAPSULE 140 MG ORAL 140 T4 PA MG INLYTA TABLET 1 MG ORAL 1 MG T4 PA INLYTA TABLET 5 MG ORAL 5 MG T4 PA INTRON A SOLUTION 6000000 UNIT/ML T4 PA INJECTION 6000000 UNIT/ML INTRON A SOLUTION RECONSTITUTED T4 PA 10000000 UNIT INJECTION 10000000 UNIT INTRON A SOLUTION RECONSTITUTED T4 PA 18000000 UNIT INJECTION 18000000 UNIT INTRON A SOLUTION RECONSTITUTED T4 PA 50000000 UNIT INJECTION 50000000 UNIT 48 Drug Status Notes JAKAFI TABLET 10 MG ORAL 10 MG T4 PA JAKAFI TABLET 15 MG ORAL 15 MG T4 PA JAKAFI TABLET 20 MG ORAL 20 MG T4 PA JAKAFI TABLET 25 MG ORAL 25 MG T4 PA JAKAFI TABLET 5 MG ORAL 5 MG T4 PA KYPROLIS SOLUTION RECONSTITUTED T4 PA 60 MG INTRAVENOUS 60 MG lapatinib ditosylate oral tablet 250 mg T4 PA GR-F; QL (30 EA per 30 days); letrozole tablet 2.5 mg oral 2.5 mg T1 AL (Min 18 Years) leucovorin calcium tablet 10 mg oral 10 mg T1 leucovorin calcium tablet 15 mg oral 15 mg T1 leucovorin calcium tablet 25 mg oral 25 mg T1 leucovorin calcium tablet 5 mg oral 5 mg T1 LEUKERAN TABLET 2 MG ORAL 2 MG T4 PA leuprolide acetate kit 1 mg/0.2ml injection 1 T4 PA mg/0.2ml LUPRON DEPOT (1-MONTH) KIT 3.75 MG T4 PA INTRAMUSCULAR 3.75 MG LUPRON DEPOT (1-MONTH) KIT 7.5 MG T4 PA INTRAMUSCULAR 7.5 MG LUPRON DEPOT (3-MONTH) KIT 11.25 MG T4 PA INTRAMUSCULAR 11.25 MG LUPRON DEPOT (3-MONTH) KIT 22.5 MG T4 PA INTRAMUSCULAR 22.5 MG LUPRON DEPOT (4-MONTH) KIT 30 MG T4 PA INTRAMUSCULAR 30 MG LUPRON DEPOT (6-MONTH) KIT 45 MG T4 PA INTRAMUSCULAR 45 MG LYSODREN ORAL TABLET 500 MG T3 PA MATULANE CAPSULE 50 MG ORAL 50 T4 PA MG megestrol acetate suspension 400 mg/10ml oral T1 400 mg/10ml megestrol acetate tablet 20 mg oral 20 mg T1 megestrol acetate tablet 40 mg oral 40 mg T1 MEKINIST TABLET 0.5 MG ORAL 0.5 MG T4 PA MEKINIST TABLET 2 MG ORAL 2 MG T4 PA mercaptopurine tablet 50 mg oral 50 mg T1 MESNEX TABLET 400 MG ORAL 400 MG T4 PA

49 Drug Status Notes methotrexate sodium (pf) injection solution 50 T1 mg/2ml methotrexate sodium injection solution 50 mg/2ml T1 methotrexate sodium solution reconstituted 1 gm T1 injection 1 gm methotrexate tablet 2.5 mg oral 2.5 mg T1 MYLERAN TABLET 2 MG ORAL 2 MG T4 PA NEXAVAR TABLET 200 MG ORAL 200 MG T4 PA ODOMZO CAPSULE 200 MG ORAL 200 T4 PA MG POMALYST CAPSULE 1 MG ORAL 1 MG T4 PA POMALYST CAPSULE 2 MG ORAL 2 MG T4 PA POMALYST CAPSULE 3 MG ORAL 3 MG T4 PA POMALYST CAPSULE 4 MG ORAL 4 MG T4 PA SPRYCEL TABLET 100 MG ORAL 100 MG T4 PA SPRYCEL TABLET 140 MG ORAL 140 MG T4 PA SPRYCEL TABLET 20 MG ORAL 20 MG T4 PA SPRYCEL TABLET 50 MG ORAL 50 MG T4 PA SPRYCEL TABLET 70 MG ORAL 70 MG T4 PA SPRYCEL TABLET 80 MG ORAL 80 MG T4 PA STIVARGA TABLET 40 MG ORAL 40 MG T4 PA sunitinib malate oral capsule 12.5 mg, 25 mg, T4 PA 37.5 mg, 50 mg TABLOID TABLET 40 MG ORAL 40 MG T4 PA TAFINLAR CAPSULE 50 MG ORAL 50 MG T4 PA TAFINLAR CAPSULE 75 MG ORAL 75 MG T4 PA tamoxifen citrate tablet 10 mg oral 10 mg T5 tamoxifen citrate tablet 20 mg oral 20 mg T5 TARCEVA TABLET 100 MG ORAL 100 MG T4 PA TARCEVA TABLET 150 MG ORAL 150 MG T4 PA TARCEVA TABLET 25 MG ORAL 25 MG T4 PA TASIGNA CAPSULE 150 MG ORAL 150 MG T4 PA TASIGNA CAPSULE 200 MG ORAL 200 MG T4 PA TASIGNA ORAL CAPSULE 50 MG T4 PA toremifene citrate oral tablet 60 mg T4 PA TRELSTAR MIXJECT SUSPENSION RECONSTITUTED 22.5 MG T4 PA INTRAMUSCULAR 22.5 MG tretinoin capsule 10 mg oral 10 mg T4 PA TREXALL TABLET 10 MG ORAL 10 MG T3 PA 50 Drug Status Notes TREXALL TABLET 15 MG ORAL 15 MG T3 PA TREXALL TABLET 5 MG ORAL 5 MG T3 PA TREXALL TABLET 7.5 MG ORAL 7.5 MG T3 PA VALSTAR SOLUTION 40 MG/ML T4 PA INTRAVESICAL 40 MG/ML VANTAS KIT 50 MG SUBCUTANEOUS 50 T4 PA MG VOTRIENT TABLET 200 MG ORAL 200 T4 PA MG XALKORI CAPSULE 200 MG ORAL 200 T4 PA MG XALKORI CAPSULE 250 MG ORAL 250 T4 PA MG ZOLADEX IMPLANT 10.8 MG T3 PA SUBCUTANEOUS 10.8 MG ZOLADEX IMPLANT 3.6 MG T3 PA SUBCUTANEOUS 3.6 MG ZOLINZA CAPSULE 100 MG ORAL 100 MG T4 PA ZYDELIG TABLET 100 MG ORAL 100 MG T4 PA ZYDELIG TABLET 150 MG ORAL 150 MG T4 PA *Antiparkinson And Related Therapy Agents* amantadine hcl capsule 100 mg oral 100 mg T1 amantadine hcl syrup 50 mg/5ml oral 50 mg/5ml T1 amantadine hcl tablet 100 mg oral 100 mg T1 benztropine mesylate solution 1 mg/ml injection 1 T3 mg/ml benztropine mesylate tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years) benztropine mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years) benztropine mesylate tablet 2 mg oral 2 mg T1 AL (Max 64 Years) bromocriptine mesylate capsule 5 mg oral 5 mg T3 bromocriptine mesylate tablet 2.5 mg oral 2.5 mg T1 carbidopa tablet 25 mg oral 25 mg T3 carbidopa-levodopa er tablet extended release T1 25-100 mg oral 25-100 mg carbidopa-levodopa er tablet extended release T1 50-200 mg oral 50-200 mg carbidopa-levodopa tablet 10-100 mg oral 10- T1 100 mg carbidopa-levodopa tablet 25-100 mg oral 25- T1 100 mg

51 Drug Status Notes carbidopa-levodopa tablet 25-250 mg oral 25- T1 250 mg carbidopa-levodopa tablet dispersible 10-100 mg T1 oral 10-100 mg carbidopa-levodopa tablet dispersible 25-100 mg T1 oral 25-100 mg carbidopa-levodopa tablet dispersible 25-250 mg T1 oral 25-250 mg entacapone tablet 200 mg oral 200 mg T3 NEUPRO PATCH 24 HOUR 1 MG/24HR T3 PA TRANSDERMAL 1 MG/24HR NEUPRO PATCH 24 HOUR 2 MG/24HR T3 PA TRANSDERMAL 2 MG/24HR NEUPRO PATCH 24 HOUR 3 MG/24HR T3 PA TRANSDERMAL 3 MG/24HR NEUPRO PATCH 24 HOUR 4 MG/24HR T3 PA TRANSDERMAL 4 MG/24HR NEUPRO PATCH 24 HOUR 6 MG/24HR T3 PA TRANSDERMAL 6 MG/24HR NEUPRO PATCH 24 HOUR 8 MG/24HR T3 PA TRANSDERMAL 8 MG/24HR pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 0.375 mg oral 0.375 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 0.75 mg oral 0.75 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 1.5 mg oral 1.5 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 2.25 mg oral 2.25 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 3 mg oral 3 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 3.75 mg oral 3.75 mg pramipexole dihydrochloride er tablet extended T3 ST; QL (30 EA per 30 days) release 24 hour 4.5 mg oral 4.5 mg pramipexole dihydrochloride tablet 0.125 mg oral T1 0.125 mg pramipexole dihydrochloride tablet 0.25 mg oral T1 0.25 mg pramipexole dihydrochloride tablet 0.5 mg oral T1 0.5 mg pramipexole dihydrochloride tablet 0.75 mg oral T1 0.75 mg

52 Drug Status Notes pramipexole dihydrochloride tablet 1 mg oral 1 T1 mg pramipexole dihydrochloride tablet 1.5 mg oral T1 1.5 mg rasagiline mesylate tablet 0.5 mg oral 0.5 mg T3 rasagiline mesylate tablet 1 mg oral 1 mg T3 ropinirole hcl er tablet extended release 24 hour T2 ST; QL (30 EA per 30 days) 12 mg oral 12 mg ropinirole hcl er tablet extended release 24 hour T2 ST; QL (30 EA per 30 days) 2 mg oral 2 mg ropinirole hcl er tablet extended release 24 hour T2 ST; QL (30 EA per 30 days) 4 mg oral 4 mg ropinirole hcl er tablet extended release 24 hour T2 ST; QL (30 EA per 30 days) 6 mg oral 6 mg ropinirole hcl er tablet extended release 24 hour T2 ST; QL (30 EA per 30 days) 8 mg oral 8 mg ropinirole hcl tablet 0.25 mg oral 0.25 mg T1 ropinirole hcl tablet 0.5 mg oral 0.5 mg T1 ropinirole hcl tablet 1 mg oral 1 mg T1 ropinirole hcl tablet 2 mg oral 2 mg T1 ropinirole hcl tablet 3 mg oral 3 mg T1 ropinirole hcl tablet 4 mg oral 4 mg T1 ropinirole hcl tablet 5 mg oral 5 mg T1 selegiline hcl capsule 5 mg oral 5 mg T1 selegiline hcl tablet 5 mg oral 5 mg T1 tolcapone tablet 100 mg oral 100 mg T4 PA trihexyphenidyl hcl oral tablet 5 mg T1 *Antipsychotics/Antimanic Agents* ABILIFY MAINTENA INTRAMUSCULAR T4 PA PREFILLED SYRINGE 300 MG aripiprazole solution 1 mg/ml oral 1 mg/ml T3 PA aripiprazole tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days) aripiprazole tablet 15 mg oral 15 mg T1 QL (30 EA per 30 days) aripiprazole tablet 2 mg oral 2 mg T1 QL (30 EA per 30 days) aripiprazole tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days) aripiprazole tablet 30 mg oral 30 mg T1 QL (30 EA per 30 days) aripiprazole tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) aripiprazole tablet dispersible 10 mg oral 10 mg T3 PA aripiprazole tablet dispersible 15 mg oral 15 mg T3 PA chlorpromazine hcl tablet 10 mg oral 10 mg T1

53 Drug Status Notes chlorpromazine hcl tablet 100 mg oral 100 mg T1 chlorpromazine hcl tablet 200 mg oral 200 mg T1 chlorpromazine hcl tablet 25 mg oral 25 mg T1 chlorpromazine hcl tablet 50 mg oral 50 mg T1 clozapine oral tablet dispersible 12.5 mg T3 clozapine tablet 100 mg oral 100 mg T1 clozapine tablet 200 mg oral 200 mg T1 clozapine tablet 25 mg oral 25 mg T1 clozapine tablet 50 mg oral 50 mg T1 clozapine tablet dispersible 100 mg oral 100 mg T3 clozapine tablet dispersible 25 mg oral 25 mg T3 FANAPT TABLET 1 MG ORAL 1 MG T4 PA FANAPT TABLET 10 MG ORAL 10 MG T4 PA FANAPT TABLET 12 MG ORAL 12 MG T4 PA FANAPT TABLET 2 MG ORAL 2 MG T4 PA FANAPT TABLET 4 MG ORAL 4 MG T4 PA FANAPT TABLET 6 MG ORAL 6 MG T4 PA FANAPT TABLET 8 MG ORAL 8 MG T4 PA fluphenazine decanoate solution 25 mg/ml T3 injection 25 mg/ml fluphenazine hcl concentrate 5 mg/ml oral 5 T3 mg/ml fluphenazine hcl elixir 2.5 mg/5ml oral 2.5 T1 mg/5ml fluphenazine hcl solution 2.5 mg/ml injection 2.5 T3 mg/ml fluphenazine hcl tablet 1 mg oral 1 mg T1 fluphenazine hcl tablet 10 mg oral 10 mg T1 fluphenazine hcl tablet 2.5 mg oral 2.5 mg T1 fluphenazine hcl tablet 5 mg oral 5 mg T1 haloperidol decanoate solution 100 mg/ml T1 intramuscular 100 mg/ml haloperidol decanoate solution 50 mg/ml T1 intramuscular 50 mg/ml haloperidol lactate concentrate 2 mg/ml oral 2 T1 mg/ml haloperidol lactate solution 5 mg/ml injection 5 T1 mg/ml haloperidol tablet 0.5 mg oral 0.5 mg T1 haloperidol tablet 1 mg oral 1 mg T1

54 Drug Status Notes haloperidol tablet 10 mg oral 10 mg T1 haloperidol tablet 2 mg oral 2 mg T1 haloperidol tablet 20 mg oral 20 mg T1 haloperidol tablet 5 mg oral 5 mg T1 LATUDA TABLET 120 MG ORAL 120 MG T3 PA LATUDA TABLET 20 MG ORAL 20 MG T3 PA LATUDA TABLET 40 MG ORAL 40 MG T3 PA LATUDA TABLET 80 MG ORAL 80 MG T3 PA lithium carbonate capsule 150 mg oral 150 mg T1 lithium carbonate capsule 300 mg oral 300 mg T1 lithium carbonate capsule 600 mg oral 600 mg T1 lithium carbonate er tablet extended release 300 T1 mg oral 300 mg lithium carbonate er tablet extended release 450 T1 mg oral 450 mg lithium carbonate tablet 300 mg oral 300 mg T1 lithium solution 8 meq/5ml oral 8 meq/5ml T1 loxapine succinate capsule 10 mg oral 10 mg T1 loxapine succinate capsule 25 mg oral 25 mg T1 loxapine succinate capsule 5 mg oral 5 mg T1 loxapine succinate capsule 50 mg oral 50 mg T1 olanzapine solution reconstituted 10 mg T2 intramuscular 10 mg olanzapine tablet 10 mg oral 10 mg T1 olanzapine tablet 15 mg oral 15 mg T1 olanzapine tablet 2.5 mg oral 2.5 mg T1 olanzapine tablet 20 mg oral 20 mg T1 olanzapine tablet 5 mg oral 5 mg T1 olanzapine tablet 7.5 mg oral 7.5 mg T1 olanzapine tablet dispersible 10 mg oral 10 mg T2 olanzapine tablet dispersible 15 mg oral 15 mg T2 olanzapine tablet dispersible 20 mg oral 20 mg T2 olanzapine tablet dispersible 5 mg oral 5 mg T2 paliperidone er tablet extended release 24 hour T4 PA 1.5 mg oral 1.5 mg paliperidone er tablet extended release 24 hour 3 T4 PA mg oral 3 mg paliperidone er tablet extended release 24 hour 6 T4 PA mg oral 6 mg

55 Drug Status Notes paliperidone er tablet extended release 24 hour 9 T4 PA mg oral 9 mg perphenazine tablet 16 mg oral 16 mg T1 perphenazine tablet 2 mg oral 2 mg T1 perphenazine tablet 4 mg oral 4 mg T1 perphenazine tablet 8 mg oral 8 mg T1 prochlorperazine maleate tablet 10 mg oral 10 T1 mg prochlorperazine maleate tablet 5 mg oral 5 mg T1 prochlorperazine suppository 25 mg rectal 25 mg T1 quetiapine fumarate er oral tablet extended T2 ST; QL (30 EA per 30 days) release 24 hour 150 mg, 200 mg, 50 mg quetiapine fumarate er oral tablet extended T2 ST; QL (60 EA per 30 days) release 24 hour 300 mg, 400 mg quetiapine fumarate tablet 100 mg oral 100 mg T1 quetiapine fumarate tablet 200 mg oral 200 mg T1 quetiapine fumarate tablet 25 mg oral 25 mg T1 quetiapine fumarate tablet 300 mg oral 300 mg T1 quetiapine fumarate tablet 400 mg oral 400 mg T1 quetiapine fumarate tablet 50 mg oral 50 mg T1 REXULTI TABLET 0.25 MG ORAL 0.25 MG T4 PA REXULTI TABLET 0.5 MG ORAL 0.5 MG T4 PA REXULTI TABLET 1 MG ORAL 1 MG T4 PA REXULTI TABLET 2 MG ORAL 2 MG T4 PA REXULTI TABLET 3 MG ORAL 3 MG T4 PA REXULTI TABLET 4 MG ORAL 4 MG T4 PA risperidone solution 1 mg/ml oral 1 mg/ml T3 risperidone tablet 0.25 mg oral 0.25 mg T1 risperidone tablet 0.5 mg oral 0.5 mg T1 risperidone tablet 1 mg oral 1 mg T1 risperidone tablet 2 mg oral 2 mg T1 risperidone tablet 3 mg oral 3 mg T1 risperidone tablet 4 mg oral 4 mg T1 risperidone tablet dispersible 0.25 mg oral 0.25 T3 mg risperidone tablet dispersible 1 mg oral 1 mg T3 risperidone tablet dispersible 2 mg oral 2 mg T3 risperidone tablet dispersible 4 mg oral 4 mg T3 SAPHRIS TABLET SUBLINGUAL 10 MG T3 PA SUBLINGUAL 10 MG 56 Drug Status Notes SAPHRIS TABLET SUBLINGUAL 5 MG T3 PA SUBLINGUAL 5 MG thioridazine hcl tablet 10 mg oral 10 mg T2 thioridazine hcl tablet 100 mg oral 100 mg T2 thioridazine hcl tablet 25 mg oral 25 mg T2 thioridazine hcl tablet 50 mg oral 50 mg T2 thiothixene capsule 1 mg oral 1 mg T1 thiothixene capsule 10 mg oral 10 mg T1 thiothixene capsule 2 mg oral 2 mg T1 thiothixene capsule 5 mg oral 5 mg T1 trifluoperazine hcl tablet 1 mg oral 1 mg T1 trifluoperazine hcl tablet 10 mg oral 10 mg T1 trifluoperazine hcl tablet 2 mg oral 2 mg T1 trifluoperazine hcl tablet 5 mg oral 5 mg T1 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 T1 mg, 80 mg *Antiseptics & Disinfectants* chlorhexidine gluconate solution 20 % 20 % T3 *Antivirals* abacavir sulfate oral solution 20 mg/ml T4 QL (900 ML per 30 days) abacavir sulfate tablet 300 mg oral 300 mg T3 QL (60 EA per 30 days) abacavir sulfate-lamivudine tablet 600-300 mg T4 QL (30 EA per 30 days) oral 600-300 mg abacavir-lamivudine-zidovudine tablet 300-150- T4 QL (60 EA per 30 days) 300 mg oral 300-150-300 mg acyclovir capsule 200 mg oral 200 mg T1 acyclovir suspension 200 mg/5ml oral 200 T1 AL (Max 12 Years) mg/5ml acyclovir tablet 400 mg oral 400 mg T1 acyclovir tablet 800 mg oral 800 mg T1 adefovir dipivoxil tablet 10 mg oral 10 mg T4 PA APTIVUS CAPSULE 250 MG ORAL 250 MG T4 QL (120 EA per 30 days) APTIVUS SOLUTION 100 MG/ML ORAL T4 QL (300 ML per 30 days) 100 MG/ML atazanavir sulfate oral capsule 300 mg T4 QL (30 EA per 30 days) BARACLUDE SOLUTION 0.05 MG/ML T4 PA ORAL 0.05 MG/ML BIKTARVY ORAL TABLET 50-200-25 MG T4 QL (30 EA per 30 days) COMPLERA TABLET 200-25-300 MG T4 QL (30 EA per 30 days) ORAL 200-25-300 MG

57 Drug Status Notes CRIXIVAN CAPSULE 200 MG ORAL 200 T4 QL (360 EA per 30 days) MG CRIXIVAN CAPSULE 400 MG ORAL 400 T4 QL (180 EA per 30 days) MG DESCOVY ORAL TABLET 200-25 MG T4 QL (30 EA per 30 days) didanosine capsule delayed release 200 mg oral T3 QL (60 EA per 30 days) 200 mg didanosine capsule delayed release 250 mg oral T3 QL (30 EA per 30 days) 250 mg didanosine capsule delayed release 400 mg oral T3 QL (30 EA per 30 days) 400 mg EDURANT TABLET 25 MG ORAL 25 MG T4 QL (30 EA per 30 days) efavirenz oral capsule 200 mg T4 QL (90 EA per 30 days) efavirenz oral capsule 50 mg T4 QL (360 EA per 30 days) efavirenz oral tablet 600 mg T4 QL (30 EA per 30 days) efavirenz-emtricitab-tenofovir oral tablet 600- T4 QL (30 EA per 30 days) 200-300 mg efavirenz-lamivudine-tenofovir oral tablet 400- T1 QL (30 EA per 30 days) 300-300 mg efavirenz-lamivudine-tenofovir oral tablet 600- T4 300-300 mg emtricitabine oral capsule 200 mg T4 emtricitabine-tenofovir df oral tablet 100-150 mg, T4 QL (30 EA per 30 days) 133-200 mg, 167-250 mg, 200-300 mg EMTRIVA SOLUTION 10 MG/ML ORAL 10 T4 MG/ML EPIVIR HBV SOLUTION 5 MG/ML ORAL 5 T3 QL (1800 ML per 30 days) MG/ML etravirine oral tablet 100 mg T4 QL (120 EA per 30 days) etravirine oral tablet 200 mg T4 QL (60 EA per 30 days) EVOTAZ TABLET 300-150 MG ORAL 300- T4 QL (30 EA per 30 days) 150 MG famciclovir tablet 125 mg oral 125 mg T3 QL (90 EA per 30 days) famciclovir tablet 250 mg oral 250 mg T3 QL (90 EA per 30 days) famciclovir tablet 500 mg oral 500 mg T3 QL (90 EA per 30 days) fosamprenavir calcium oral tablet 700 mg T4 QL (120 EA per 30 days) FUZEON SOLUTION RECONSTITUTED 90 T4 QL (60 EA per 30 days) MG SUBCUTANEOUS 90 MG GENVOYA ORAL TABLET 150-150-200-10 T4 QL (30 EA per 30 days) MG INTELENCE TABLET 25 MG ORAL 25 MG T4 QL (480 EA per 30 days) INVIRASE TABLET 500 MG ORAL 500 MG T4 QL (120 EA per 30 days) 58 Drug Status Notes ISENTRESS TABLET 400 MG ORAL 400 T4 QL (60 EA per 30 days) MG ISENTRESS TABLET CHEWABLE 100 MG T4 QL (60 EA per 30 days) ORAL 100 MG ISENTRESS TABLET CHEWABLE 25 MG T4 QL (60 EA per 30 days) ORAL 25 MG JULUCA ORAL TABLET 50-25 MG T4 QL (30 EA per 30 days) lamivudine solution 10 mg/ml oral 10 mg/ml T3 QL (900 ML per 30 days) lamivudine tablet 100 mg oral 100 mg T2 QL (90 EA per 30 days) lamivudine tablet 150 mg oral 150 mg T3 QL (60 EA per 30 days) lamivudine tablet 300 mg oral 300 mg T3 QL (30 EA per 30 days) lamivudine-zidovudine tablet 150-300 mg oral T4 QL (60 EA per 30 days) 150-300 mg LEXIVA SUSPENSION 50 MG/ML ORAL 50 T4 QL (180 ML per 30 days) MG/ML lopinavir-ritonavir oral tablet 100-25 mg, 200-50 T4 mg lopinavir-ritonavir solution 400-100 mg/5ml oral T4 QL (450 ML per 30 days) 400-100 mg/5ml MAVYRET ORAL TABLET 100-40 MG T4 PA nevirapine er tablet extended release 24 hour 400 T2 QL (30 EA per 30 days) mg oral 400 mg nevirapine tablet 200 mg oral 200 mg T1 QL (60 EA per 30 days) NORVIR SOLUTION 80 MG/ML ORAL 80 T4 QL (450 ML per 30 days) MG/ML ODEFSEY ORAL TABLET 200-25-25 MG T4 QL (30 EA per 30 days) oseltamivir phosphate capsule 30 mg oral 30 mg T1 QL (10 EA per 10 days) oseltamivir phosphate capsule 45 mg oral 45 mg T1 QL (10 EA per 10 days) oseltamivir phosphate capsule 75 mg oral 75 mg T1 QL (10 EA per 10 days) oseltamivir phosphate oral suspension T1 QL (120 ML per 10 days) reconstituted 6 mg/ml PEGASYS SOLUTION 180 MCG/ML T4 PA SUBCUTANEOUS 180 MCG/ML PEGINTRON KIT 50 MCG/0.5ML T4 PA SUBCUTANEOUS 50 MCG/0.5ML PREZCOBIX TABLET 800-150 MG ORAL T4 QL (30 EA per 30 days) 800-150 MG PREZISTA SUSPENSION 100 MG/ML T4 QL (480 ML per 30 days) ORAL 100 MG/ML PREZISTA TABLET 150 MG ORAL 150 MG T4 QL (240 EA per 30 days) PREZISTA TABLET 600 MG ORAL 600 MG T4 QL (60 EA per 30 days) PREZISTA TABLET 75 MG ORAL 75 MG T4 QL (480 EA per 30 days) 59 Drug Status Notes PREZISTA TABLET 800 MG ORAL 800 MG T4 QL (30 EA per 30 days) RELENZA DISKHALER AEROSOL POWDER BREATH ACTIVATED 5 T2 PA; QL (20 EA per 5 days) MG/BLISTER INHALATION 5 MG/BLISTER REYATAZ CAPSULE 150 MG ORAL 150 T4 QL (60 EA per 30 days) MG REYATAZ CAPSULE 200 MG ORAL 200 T4 QL (60 EA per 30 days) MG REYATAZ CAPSULE 300 MG ORAL 300 T4 QL (30 EA per 30 days) MG ribavirin capsule 200 mg oral 200 mg T4 PA rimantadine hcl tablet 100 mg oral 100 mg T1 ritonavir oral tablet 100 mg T4 QL (360 EA per 30 days) SELZENTRY TABLET 150 MG ORAL 150 T4 QL (120 EA per 30 days) MG SELZENTRY TABLET 300 MG ORAL 300 T4 QL (120 EA per 30 days) MG sofosbuvir-velpatasvir tablet 400-100 mg oral T4 PA; QL (28 EA per 28 days) 400-100 mg stavudine capsule 15 mg oral 15 mg T1 QL (60 EA per 30 days) stavudine capsule 20 mg oral 20 mg T1 QL (60 EA per 30 days) stavudine capsule 30 mg oral 30 mg T1 QL (60 EA per 30 days) stavudine capsule 40 mg oral 40 mg T1 QL (60 EA per 30 days) STRIBILD TABLET 150-150-200-300 MG T4 QL (30 EA per 30 days) ORAL 150-150-200-300 MG tenofovir disoproxil fumarate oral tablet 300 mg T4 QL (30 EA per 30 days) TIVICAY TABLET 50 MG ORAL 50 MG T4 QL (30 EA per 30 days) TRIUMEQ TABLET 600-50-300 MG ORAL T4 QL (30 EA per 30 days) 600-50-300 MG valacyclovir hcl tablet 1 gm oral 1 gm T1 valacyclovir hcl tablet 500 mg oral 500 mg T1 valganciclovir hcl solution reconstituted 50 T4 PA mg/ml oral 50 mg/ml valganciclovir hcl tablet 450 mg oral 450 mg T4 PA VIRACEPT TABLET 250 MG ORAL 250 MG T4 QL (300 EA per 30 days) VIRACEPT TABLET 625 MG ORAL 625 MG T4 QL (120 EA per 30 days) VIRAMUNE SUSPENSION 50 MG/5ML T2 QL (1200 ML per 30 days) ORAL 50 MG/5ML VIREAD TABLET 150 MG ORAL 150 MG T4 QL (30 EA per 30 days) VIREAD TABLET 200 MG ORAL 200 MG T4 QL (30 EA per 30 days)

60 Drug Status Notes VIREAD TABLET 250 MG ORAL 250 MG T4 QL (30 EA per 30 days) ZEPATIER TABLET 50-100 MG ORAL 50- T4 PA 100 MG zidovudine capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days) zidovudine syrup 50 mg/5ml oral 50 mg/5ml T1 QL (1800 ML per 30 days) zidovudine tablet 300 mg oral 300 mg T1 QL (60 EA per 30 days) *Beta Blockers* acebutolol hcl capsule 200 mg oral 200 mg T1 acebutolol hcl capsule 400 mg oral 400 mg T1 atenolol tablet 100 mg oral 100 mg T1 atenolol tablet 25 mg oral 25 mg T1 atenolol tablet 50 mg oral 50 mg T1 betaxolol hcl tablet 10 mg oral 10 mg T1 betaxolol hcl tablet 20 mg oral 20 mg T1 bisoprolol fumarate tablet 10 mg oral 10 mg T1 bisoprolol fumarate tablet 5 mg oral 5 mg T1 BYSTOLIC TABLET 10 MG ORAL 10 MG T3 BYSTOLIC TABLET 2.5 MG ORAL 2.5 MG T3 BYSTOLIC TABLET 20 MG ORAL 20 MG T3 BYSTOLIC TABLET 5 MG ORAL 5 MG T3 carvedilol phosphate er oral capsule extended T3 ST release 24 hour 10 mg, 20 mg, 40 mg, 80 mg carvedilol tablet 12.5 mg oral 12.5 mg T1 carvedilol tablet 25 mg oral 25 mg T1 carvedilol tablet 3.125 mg oral 3.125 mg T1 carvedilol tablet 6.25 mg oral 6.25 mg T1 labetalol hcl tablet 100 mg oral 100 mg T1 labetalol hcl tablet 200 mg oral 200 mg T1 labetalol hcl tablet 300 mg oral 300 mg T1 metoprolol succinate er tablet extended release T1 QL (45 EA per 30 days) 24 hour 100 mg oral 100 mg metoprolol succinate er tablet extended release T1 QL (60 EA per 30 days) 24 hour 200 mg oral 200 mg metoprolol succinate er tablet extended release T1 QL (45 EA per 30 days) 24 hour 25 mg oral 25 mg metoprolol succinate er tablet extended release T1 QL (45 EA per 30 days) 24 hour 50 mg oral 50 mg metoprolol tartrate tablet 100 mg oral 100 mg T1 metoprolol tartrate tablet 25 mg oral 25 mg T1 metoprolol tartrate tablet 50 mg oral 50 mg T1 61 Drug Status Notes nadolol tablet 20 mg oral 20 mg T1 nadolol tablet 40 mg oral 40 mg T1 nadolol tablet 80 mg oral 80 mg T1 pindolol tablet 10 mg oral 10 mg T1 pindolol tablet 5 mg oral 5 mg T1 propranolol hcl er capsule extended release 24 T1 ST hour 120 mg oral 120 mg propranolol hcl er capsule extended release 24 T1 ST hour 160 mg oral 160 mg propranolol hcl er capsule extended release 24 T1 ST hour 60 mg oral 60 mg propranolol hcl er capsule extended release 24 T1 ST hour 80 mg oral 80 mg propranolol hcl solution 20 mg/5ml oral 20 T1 mg/5ml propranolol hcl solution 40 mg/5ml oral 40 T1 mg/5ml propranolol hcl tablet 10 mg oral 10 mg T1 propranolol hcl tablet 20 mg oral 20 mg T1 propranolol hcl tablet 40 mg oral 40 mg T1 propranolol hcl tablet 60 mg oral 60 mg T1 propranolol hcl tablet 80 mg oral 80 mg T1 sotalol hcl (af) tablet 120 mg oral 120 mg T1 sotalol hcl (af) tablet 160 mg oral 160 mg T1 sotalol hcl (af) tablet 80 mg oral 80 mg T1 sotalol hcl tablet 120 mg oral 120 mg T1 sotalol hcl tablet 160 mg oral 160 mg T1 sotalol hcl tablet 240 mg oral 240 mg T1 sotalol hcl tablet 80 mg oral 80 mg T1 timolol maleate tablet 10 mg oral 10 mg T1 timolol maleate tablet 20 mg oral 20 mg T1 timolol maleate tablet 5 mg oral 5 mg T1 *Calcium Channel Blockers* AFEDITAB CR TABLET EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 30 MG ORAL 30 MG amlodipine besylate tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days) amlodipine besylate tablet 2.5 mg oral 2.5 mg T1 QL (30 EA per 30 days) amlodipine besylate tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) CARTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 120 MG ORAL 120 MG

62 Drug Status Notes CARTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 180 MG ORAL 180 MG CARTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 240 MG ORAL 240 MG CARTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 300 MG ORAL 300 MG diltiazem hcl er beads capsule extended release T1 QL (30 EA per 30 days) 24 hour 420 mg oral 420 mg diltiazem hcl er beads oral capsule extended T1 QL (30 EA per 30 days) release 24 hour 360 mg diltiazem hcl er capsule extended release 12 hour T1 QL (60 EA per 30 days) 120 mg oral 120 mg diltiazem hcl er capsule extended release 12 hour T1 QL (60 EA per 30 days) 60 mg oral 60 mg diltiazem hcl er capsule extended release 12 hour T1 QL (60 EA per 30 days) 90 mg oral 90 mg diltiazem hcl er capsule extended release 24 hour T1 QL (120 EA per 30 days) 120 mg oral 120 mg diltiazem hcl tablet 120 mg oral 120 mg T1 diltiazem hcl tablet 30 mg oral 30 mg T1 diltiazem hcl tablet 60 mg oral 60 mg T1 diltiazem hcl tablet 90 mg oral 90 mg T1 dilt-xr capsule extended release 24 hour 240 mg T1 QL (30 EA per 30 days) oral 240 mg felodipine er tablet extended release 24 hour 10 T1 QL (30 EA per 30 days) mg oral 10 mg felodipine er tablet extended release 24 hour 2.5 T1 QL (30 EA per 30 days) mg oral 2.5 mg felodipine er tablet extended release 24 hour 5 mg T1 QL (30 EA per 30 days) oral 5 mg isradipine capsule 2.5 mg oral 2.5 mg T1 isradipine capsule 5 mg oral 5 mg T1 nicardipine hcl capsule 20 mg oral 20 mg T1 nicardipine hcl capsule 30 mg oral 30 mg T1 nifedipine capsule 10 mg oral 10 mg T1 nifedipine capsule 20 mg oral 20 mg T1 nifedipine er osmotic release tablet extended T1 QL (30 EA per 30 days) release 24 hour 30 mg oral 30 mg nifedipine er osmotic release tablet extended T1 QL (30 EA per 30 days) release 24 hour 60 mg oral 60 mg nifedipine er osmotic release tablet extended T1 QL (30 EA per 30 days) release 24 hour 90 mg oral 90 mg

63 Drug Status Notes nifedipine er tablet extended release 24 hour 60 T1 QL (30 EA per 30 days) mg oral 60 mg nimodipine capsule 30 mg oral 30 mg T3 nisoldipine er tablet extended release 24 hour 17 T3 mg oral 17 mg nisoldipine er tablet extended release 24 hour 20 T1 mg oral 20 mg nisoldipine er tablet extended release 24 hour T1 25.5 mg oral 25.5 mg nisoldipine er tablet extended release 24 hour 30 T1 mg oral 30 mg nisoldipine er tablet extended release 24 hour 34 T3 mg oral 34 mg nisoldipine er tablet extended release 24 hour 40 T1 mg oral 40 mg nisoldipine er tablet extended release 24 hour 8.5 T3 mg oral 8.5 mg TAZTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 120 MG ORAL 120 MG TAZTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 180 MG ORAL 180 MG TAZTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 240 MG ORAL 240 MG TAZTIA XT CAPSULE EXTENDED T1 QL (30 EA per 30 days) RELEASE 24 HOUR 300 MG ORAL 300 MG verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 100 mg oral 100 mg verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 120 mg oral 120 mg verapamil hcl er capsule extended release 24 T1 QL (60 EA per 30 days) hour 180 mg oral 180 mg verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 200 mg oral 200 mg verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 240 mg oral 240 mg verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 300 mg oral 300 mg verapamil hcl er capsule extended release 24 T1 QL (30 EA per 30 days) hour 360 mg oral 360 mg verapamil hcl er tablet extended release 120 mg T1 QL (30 EA per 30 days) oral 120 mg verapamil hcl er tablet extended release 180 mg T1 QL (30 EA per 30 days) oral 180 mg

64 Drug Status Notes verapamil hcl er tablet extended release 240 mg T1 QL (30 EA per 30 days) oral 240 mg verapamil hcl tablet 120 mg oral 120 mg T1 verapamil hcl tablet 40 mg oral 40 mg T1 verapamil hcl tablet 80 mg oral 80 mg T1 *Cardiotonics* digoxin solution 0.05 mg/ml oral 0.05 mg/ml T1 digoxin tablet 125 mcg oral 125 mcg T1 digoxin tablet 250 mcg oral 250 mcg T1 *Cardiovascular Agents - Misc.* ADEMPAS TABLET 0.5 MG ORAL 0.5 MG T4 PA ADEMPAS TABLET 1 MG ORAL 1 MG T4 PA ADEMPAS TABLET 1.5 MG ORAL 1.5 MG T4 PA ADEMPAS TABLET 2 MG ORAL 2 MG T4 PA ADEMPAS TABLET 2.5 MG ORAL 2.5 MG T4 PA ambrisentan oral tablet 10 mg, 5 mg T4 PA CORLANOR ORAL TABLET 5 MG, 7.5 MG T3 PA ENTRESTO ORAL TABLET 24-26 MG, 49- T3 PA; QL (60 EA per 30 days) 51 MG, 97-103 MG OPSUMIT TABLET 10 MG ORAL 10 MG T4 PA sildenafil citrate tablet 20 mg oral 20 mg T1 PA tadalafil (pah) oral tablet 20 mg T4 PA tadalafil oral tablet 2.5 mg, 5 mg T3 PA TRACLEER TABLET 125 MG ORAL 125 T4 PA MG TRACLEER TABLET 62.5 MG ORAL 62.5 T4 PA MG TYVASO STARTER SOLUTION 0.6 MG/ML T4 PA INHALATION 0.6 MG/ML UPTRAVI TABLET 1000 MCG ORAL 1000 T4 PA MCG UPTRAVI TABLET 1200 MCG ORAL 1200 T4 PA MCG UPTRAVI TABLET 1400 MCG ORAL 1400 T4 PA MCG UPTRAVI TABLET 1600 MCG ORAL 1600 T4 PA MCG UPTRAVI TABLET 200 MCG ORAL 200 T4 PA MCG UPTRAVI TABLET 400 MCG ORAL 400 T4 PA MCG 65 Drug Status Notes UPTRAVI TABLET 600 MCG ORAL 600 T4 PA MCG UPTRAVI TABLET 800 MCG ORAL 800 T4 PA MCG VENTAVIS SOLUTION 10 MCG/ML T4 PA INHALATION 10 MCG/ML VENTAVIS SOLUTION 20 MCG/ML T4 PA INHALATION 20 MCG/ML *Cephalosporins* cefaclor capsule 250 mg oral 250 mg T1 cefaclor capsule 500 mg oral 500 mg T1 cefaclor suspension reconstituted 125 mg/5ml T1 oral 125 mg/5ml cefaclor suspension reconstituted 250 mg/5ml T1 oral 250 mg/5ml cefaclor suspension reconstituted 375 mg/5ml T1 oral 375 mg/5ml cefadroxil capsule 500 mg oral 500 mg T1 cefadroxil suspension reconstituted 250 mg/5ml T1 oral 250 mg/5ml cefadroxil suspension reconstituted 500 mg/5ml T1 oral 500 mg/5ml cefadroxil tablet 1 gm oral 1 gm T1 cefdinir capsule 300 mg oral 300 mg T1 cefdinir oral suspension reconstituted 125 T1 mg/5ml, 250 mg/5ml cefditoren pivoxil tablet 400 mg oral 400 mg T2 cefpodoxime proxetil suspension reconstituted T1 100 mg/5ml oral 100 mg/5ml cefpodoxime proxetil suspension reconstituted 50 T1 mg/5ml oral 50 mg/5ml cefpodoxime proxetil tablet 100 mg oral 100 mg T1 cefpodoxime proxetil tablet 200 mg oral 200 mg T1 cefprozil suspension reconstituted 125 mg/5ml T1 oral 125 mg/5ml cefprozil suspension reconstituted 250 mg/5ml T1 oral 250 mg/5ml cefprozil tablet 250 mg oral 250 mg T1 cefprozil tablet 500 mg oral 500 mg T1 cefuroxime axetil tablet 250 mg oral 250 mg T1 cefuroxime axetil tablet 500 mg oral 500 mg T1

66 Drug Status Notes cephalexin capsule 250 mg oral 250 mg T1 cephalexin capsule 500 mg oral 500 mg T1 cephalexin suspension reconstituted 125 mg/5ml T1 oral 125 mg/5ml cephalexin suspension reconstituted 250 mg/5ml T1 oral 250 mg/5ml cephalexin tablet 250 mg oral 250 mg T1 cephalexin tablet 500 mg oral 500 mg T1 SUPRAX SUSPENSION RECONSTITUTED T3 500 MG/5ML ORAL 500 MG/5ML *Chemicals* coal tar solution T1 iodine strong (lugol's) solution (otc) T1 *Contraceptives* ARANELLE ORAL TABLET 0.5/1/0.5-35 T5 QL (28 EA per 28 days) MG-MCG BALCOLTRA ORAL TABLET 0.1-20 MG- T5 PA; QL (28 EA per 21 days) MCG(21) BALZIVA ORAL TABLET 0.4-35 MG-MCG T5 GR-F; QL (28 EA per 21 days) DEPO-SUBQ PROVERA 104 SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML T3 GR-F; QL (1 ML per 90 days) SUBCUTANEOUS 104 MG/0.65ML desogestrel-ethinyl estradiol oral tablet 0.15- T5 PA; QL (28 EA per 21 days) 0.02/0.01 mg (21/5) desogestrel-ethinyl estradiol oral tablet 0.15-30 T5 QL (28 EA per 21 days) mg-mcg drospiren-eth estrad-levomefol oral tablet 3-0.02- T5 PA; QL (28 EA per 21 days) 0.451 mg, 3-0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 T5 QL (28 EA per 21 days) mg, 3-0.03 mg ELLA TABLET 30 MG ORAL 30 MG T5 GR-F; QL (1 EA per 30 days) ethynodiol diac-eth estradiol oral tablet 1-50 mg- T5 QL (28 EA per 21 days) mcg etonogestrel-ethinyl estradiol vaginal ring 0.12- T5 PA; GR-F 0.015 mg/24hr GIANVI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days) HAILEY 24 FE ORAL TABLET 1-20 MG- T5 PA; QL (28 EA per 21 days) MCG(24) JASMIEL ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days) JUNEL 1.5/30 TABLET 1.5-30 MG-MCG T5 GR-F; QL (21 EA per 21 days) ORAL 1.5-30 MG-MCG

67 Drug Status Notes JUNEL FE 1.5/30 TABLET 1.5-30 MG-MCG T5 GR-F; QL (28 EA per 21 days) ORAL 1.5-30 MG-MCG LEVONEST ORAL TABLET 50-30/75-40/ T5 QL (28 EA per 21 days) 125-30 MCG levonorgest-eth est & eth est oral tablet 42-21-21- T5 PA; QL (91 EA per 91 days) 7 days levonorgest-eth estrad 91-day oral tablet 0.15- T5 PA; QL (91 EA per 91 days) 0.03 &0.01 mg levonorgest-eth estrad 91-day oral tablet 0.15- T5 QL (91 EA per 91 days) 0.03 mg levonorgest-eth estrad 91-day tablet 0.1-0.02 & T5 GR-F; QL (91 EA per 91 days) 0.01 mg oral 0.1-0.02 & 0.01 mg levonorgestrel tablet 1.5 mg oral (otc) 1.5 mg T5 GR-F; QL (1 EA per 30 days) levonorgestrel-ethinyl estrad oral tablet 0.1-20 T5 QL (28 EA per 21 days) mg-mcg, 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet 90-20 T5 QL (60 EA per 30 days) mcg LO LOESTRIN FE ORAL TABLET 1 MG-10 T5 PA; QL (28 EA per 21 days) MCG / 10 MCG LORYNA ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days) LOW-OGESTREL TABLET 0.3-30 MG- T5 GR-F; QL (28 EA per 21 days) MCG ORAL 0.3-30 MG-MCG LO-ZUMANDIMINE ORAL TABLET 3-0.02 T5 PA; QL (28 EA per 21 days) MG medroxyprogesterone acetate intramuscular T5 QL (1 ML per 90 days) suspension prefilled syringe 150 mg/ml medroxyprogesterone acetate suspension 150 T5 GR-F; QL (1 ML per 90 days) mg/ml intramuscular 150 mg/ml NIKKI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days) norethin ace-eth estrad-fe oral tablet 1-20 mg- T5 QL (28 EA per 21 days) mcg norethin ace-eth estrad-fe oral tablet chewable 1- T5 PA; QL (28 EA per 21 days) 20 mg-mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 T5 QL (21 EA per 21 days) mg-mcg norethindrone oral tablet 0.35 mg T5 GR-F; QL (28 EA per 21 days) norethin-eth estradiol-fe oral tablet chewable 0.4- T5 PA; QL (28 EA per 21 days) 35 mg-mcg, 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg- T5 QL (28 EA per 21 days) mcg norgestim-eth estrad triphasic oral tablet T5 QL (28 EA per 21 days) 0.18/0.215/0.25 mg-35 mcg

68 Drug Status Notes NORTREL 0.5/35 (28) TABLET 0.5-35 MG- T5 GR-F; QL (28 EA per 21 days) MCG ORAL 0.5-35 MG-MCG NORTREL 1/35 (28) TABLET 1-35 MG-MCG T5 GR-F; QL (28 EA per 21 days) ORAL 1-35 MG-MCG NORTREL 7/7/7 TABLET 0.5/0.75/1-35 MG- T5 GR-F; QL (28 EA per 21 days) MCG ORAL 0.5/0.75/1-35 MG-MCG OCELLA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days) SLYND ORAL TABLET 4 MG T5 PA; QL (28 EA per 21 days) SYEDA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days) TAYTULLA ORAL CAPSULE 1-20 MG- T5 PA; QL (28 EA per 21 days) MCG(24) TRI-LEGEST FE ORAL TABLET 1-20/1- T5 PA; QL (28 EA per 21 days) 30/1-35 MG-MCG TRI-LO-SPRINTEC ORAL TABLET T5 GR-F; QL (28 EA per 21 days) 0.18/0.215/0.25 MG-25 MCG TWIRLA TRANSDERMAL PATCH T5 PA; QL (3 EA per 28 days) WEEKLY 120-30 MCG/24HR VELIVET TABLET 0.1/0.125/0.15 -0.025 MG T5 GR-F; QL (28 EA per 21 days) ORAL 0.1/0.125/0.15 -0.025 MG XULANE PATCH WEEKLY 150-35 MCG/24HR TRANSDERMAL 150-35 T5 PA; GR-F MCG/24HR ZARAH ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days) ZOVIA 1/35E (28) TABLET 1-35 MG-MCG T5 GR-F; QL (28 EA per 28 days) ORAL 1-35 MG-MCG ZUMANDIMINE ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days) *Corticosteroids* betamethasone sod phos & acet suspension 6 (3- T1 3) mg/ml injection 6 (3-3) mg/ml budesonide oral capsule delayed release particles T3 3 mg cortisone acetate tablet 25 mg oral 25 mg T1 DEPO-MEDROL SUSPENSION 20 MG/ML T3 INJECTION 20 MG/ML DEXAMETHASONE INTENSOL T3 CONCENTRATE 1 MG/ML ORAL 1 MG/ML dexamethasone oral solution 0.5 mg/5ml T1 dexamethasone oral tablet therapy pack 1.5 mg T3 (21), 1.5 mg (35), 1.5 mg (51) dexamethasone sodium phosphate solution 10 T1 mg/ml injection 10 mg/ml

69 Drug Status Notes dexamethasone sodium phosphate solution 120 T1 mg/30ml injection 120 mg/30ml dexamethasone tablet 0.5 mg oral 0.5 mg T1 dexamethasone tablet 0.75 mg oral 0.75 mg T1 dexamethasone tablet 1 mg oral 1 mg T1 dexamethasone tablet 1.5 mg oral 1.5 mg T1 dexamethasone tablet 2 mg oral 2 mg T1 dexamethasone tablet 4 mg oral 4 mg T1 dexamethasone tablet 6 mg oral 6 mg T1 fludrocortisone acetate tablet 0.1 mg oral 0.1 mg T1 hydrocortisone tablet 10 mg oral 10 mg T1 hydrocortisone tablet 20 mg oral 20 mg T1 hydrocortisone tablet 5 mg oral 5 mg T1 methylprednisolone tablet 16 mg oral 16 mg T1 methylprednisolone tablet 32 mg oral 32 mg T1 methylprednisolone tablet 4 mg oral 4 mg T1 methylprednisolone tablet 8 mg oral 8 mg T1 methylprednisolone tablet therapy pack 4 mg oral T1 4 mg MILLIPRED TABLET 5 MG ORAL 5 MG T3 prednisolone sodium phosphate solution 15 T1 mg/5ml oral 15 mg/5ml prednisolone sodium phosphate solution 25 T1 mg/5ml oral 25 mg/5ml prednisolone sodium phosphate solution 6.7 (5 T1 base) mg/5ml oral 6.7 (5 base) mg/5ml PREDNISONE INTENSOL CONCENTRATE T3 5 MG/ML ORAL 5 MG/ML prednisone solution 5 mg/5ml oral 5 mg/5ml T1 prednisone tablet 1 mg oral 1 mg T1 prednisone tablet 10 mg oral 10 mg T1 prednisone tablet 2.5 mg oral 2.5 mg T1 prednisone tablet 20 mg oral 20 mg T1 prednisone tablet 5 mg oral 5 mg T1 prednisone tablet 50 mg oral 50 mg T1 prednisone tablet therapy pack 5 mg (48) oral 5 T1 mg (48) *Cough/Cold/* acetylcysteine solution 10 % inhalation 10 % T1 acetylcysteine solution 20 % inhalation 20 % T1 70 Drug Status Notes benzonatate capsule 100 mg oral 100 mg T1 benzonatate capsule 200 mg oral 200 mg T1 BROMFED DM SYRUP 30-2-10 MG/5ML T1 ORAL 30-2-10 MG/5ML hydrocod polst-cpm polst er suspension extended T1 release 10-8 mg/5ml oral 10-8 mg/5ml hydrocodone-homatropine syrup 5-1.5 mg/5ml T1 oral 5-1.5 mg/5ml promethazine vc/codeine syrup 6.25-5-10 mg/5ml T1 oral 6.25-5-10 mg/5ml promethazine-codeine solution 6.25-10 mg/5ml T1 oral 6.25-10 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml oral T1 6.25-15 mg/5ml sodium chloride nebulization solution 0.9 % T1 inhalation (rx) 0.9 % sodium chloride nebulization solution 10 % T1 inhalation 10 % sodium chloride nebulization solution 3 % T1 inhalation 3 % sodium chloride nebulization solution 7 % T1 inhalation 7 % *Dermatologicals* acitretin oral capsule 10 mg, 17.5 mg, 25 mg T3 PA acne treatment gel 10 % external 10 % T1 acyclovir external ointment 5 % T3 PA adapalene external gel 0.1 % T1 QL (45 GM per 30 days) adapalene-benzoyl peroxide gel 0.1-2.5 % ST; QL (45 GM per 30 days); AL T3 external 0.1-2.5 % (Max 28 Years) alclometasone dipropionate cream 0.05 % T1 external 0.05 % alclometasone dipropionate ointment 0.05 % T1 external 0.05 % ALTABAX OINTMENT 1 % EXTERNAL 1 T3 ST % amcinonide cream 0.1 % external 0.1 % T3 amcinonide lotion 0.1 % external 0.1 % T3 amcinonide ointment 0.1 % external 0.1 % T3 ammonium lactate external cream 12 % T1 QL (385 GM per 30 days) ammonium lactate external lotion 12 % T1 QL (500 G4M per 30 days) ANECREAM CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

71 Drug Status Notes ASPERCREME LIDOCAINE EXTERNAL T1 QL (30 EA per 30 days) PATCH 4 % ASPERCREME W/LIDOCAINE CREAM 4 T1 QL (90 GM per 30 days) % EXTERNAL 4 % QL (45 GM per 30 days); AL AVITA GEL 0.025 % EXTERNAL 0.025 % T1 (Max 28 Years) BASIS OVERNIGHT EXTERNAL CREAM T1 BENZEPRO FOAM 5.3 % EXTERNAL 5.3 % T3 BENZEPRO SHORT CONTACT FOAM 9.8 T3 % EXTERNAL 9.8 % benzoyl peroxide-erythromycin gel 5-3 % external T1 5-3 % betamethasone dipropionate aug cream 0.05 % T1 QL (100 GM per 30 days) external 0.05 % betamethasone dipropionate aug external gel 0.05 T1 QL (100 GM per 30 days) % betamethasone dipropionate aug lotion 0.05 % T1 QL (120 ML per 30 days) external 0.05 % betamethasone dipropionate aug ointment 0.05 % T1 QL (100 GM per 30 days) external 0.05 % betamethasone dipropionate cream 0.05 % T1 QL (90 GM per 30 days) external 0.05 % betamethasone dipropionate lotion 0.05 % T1 QL (120 ML per 30 days) external 0.05 % betamethasone dipropionate ointment 0.05 % T1 QL (90 GM per 30 days) external 0.05 % betamethasone valerate cream 0.1 % external 0.1 T1 QL (90 GM per 30 days) % betamethasone valerate foam 0.12 % external T3 0.12 % betamethasone valerate lotion 0.1 % external 0.1 T1 QL (120 ML per 30 days) % betamethasone valerate ointment 0.1 % external T1 QL (90 GM per 30 days) 0.1 % calcipotriene cream 0.005 % external 0.005 % T3 calcipotriene solution 0.005 % external 0.005 % T3 calcipotriene-betameth diprop ointment 0.005- T3 ST; QL (60 GM per 30 days) 0.064 % external 0.005-0.064 % CALCITRENE OINTMENT 0.005 % T3 EXTERNAL 0.005 % CAPEX SHAMPOO 0.01 % EXTERNAL 0.01 T3 ST; QL (120 ML per 30 days) %

72 Drug Status Notes CEM-UREA SOLUTION 45 % EXTERNAL T3 45 % ciclopirox solution 8 % external 8 % T1 CLINDACIN PAC KIT 1 % EXTERNAL 1 % T1 clindamycin phos-benzoyl perox external gel 1.2- T1 QL (45 GM per 30 days) 5 % clindamycin phos-benzoyl perox gel 1-5 % T3 external 1-5 % clindamycin phosphate external swab 1 % T1 QL (60 EA per 30 days) clindamycin phosphate foam 1 % external 1 % T3 clindamycin phosphate lotion 1 % external 1 % T1 clindamycin phosphate solution 1 % external 1 % T1 ST; QL (30 GM per 30 days); AL clindamycin-tretinoin external gel 1.2-0.025 % T3 (Max 28 Years) clobetasol propionate e cream 0.05 % external T1 QL (120 GM per 30 days) 0.05 % clobetasol propionate external cream 0.05 % T1 clobetasol propionate gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days) clobetasol propionate lotion 0.05 % external 0.05 T3 % clobetasol propionate ointment 0.05 % external T3 QL (120 GM per 30 days) 0.05 % clobetasol propionate shampoo 0.05 % external T3 0.05 % clobetasol propionate solution 0.05 % external T1 QL (100 ML per 30 days) 0.05 % CLODERM CREAM 0.1 % EXTERNAL 0.1 T3 % clotrimazole external cream 1 % T1 QL (50 GM per 30 days) clotrimazole external solution 1 % T1 clotrimazole-betamethasone cream 1-0.05 % T1 QL (90 GM per 30 days) external 1-0.05 % clotrimazole-betamethasone lotion 1-0.05 % T3 QL (60 ML per 30 days) external 1-0.05 % CONDYLOX GEL 0.5 % EXTERNAL 0.5 % T3 PA CORDRAN LOTION 0.05 % EXTERNAL T3 PA 0.05 % CORTISPORIN CREAM 3.5-10000-0.5 T1 EXTERNAL 3.5-10000-0.5 CORTISPORIN OINTMENT 1 % T3 EXTERNAL 1 %

73 Drug Status Notes COSENTYX (300 MG DOSE) SOLUTION PREFILLED SYRINGE 150 MG/ML T4 PA SUBCUTANEOUS 150 MG/ML COSENTYX SENSOREADY PEN SOLUTION AUTO-INJECTOR 150 MG/ML T4 PA SUBCUTANEOUS 150 MG/ML CROTAN EXTERNAL LOTION 10 % T2 PA DENAVIR EXTERNAL CREAM 1 % T3 PA desonide cream 0.05 % external 0.05 % T3 QL (120 GM per 30 days) desonide lotion 0.05 % external 0.05 % T3 desonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days) desoximetasone cream 0.05 % external 0.05 % T1 QL (200 GM per 30 days) desoximetasone cream 0.25 % external 0.25 % T1 QL (200 GM per 30 days) desoximetasone gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days) desoximetasone ointment 0.05 % external 0.05 % T3 QL (120 GM per 30 days) desoximetasone ointment 0.25 % external 0.25 % T1 QL (200 GM per 30 days) diclofenac sodium gel 1 % external (rx) 1 % T1 QL (200 GM per 30 days) DIFFERIN EXTERNAL GEL 0.1 % T1 QL (45 GM per 30 days) diflorasone diacetate external cream 0.05 % T3 PA; QL (120 GM per 30 days) diflorasone diacetate external ointment 0.05 % T3 PA; QL (120 GM per 30 days) docosanol external cream 10 % T1 DRITHO-CREME HP EXTERNAL CREAM T3 PA 1 % DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML, 300 T4 PA MG/2ML DUPIXENT SUBCUTANEOUS SOLUTION T4 PA PREFILLED SYRINGE 300 MG/2ML econazole nitrate cream 1 % external 1 % T1 QL (85 GM per 30 days) ERTACZO CREAM 2 % EXTERNAL 2 % T3 erythromycin gel 2 % external 2 % T1 erythromycin solution 2 % external 2 % T1 ethyl chloride aerosol external T1 EUCERIN EXTERNAL CREAM T1 EXELDERM CREAM 1 % EXTERNAL 1 % T3 QL (30 GM per 30 days) EXELDERM SOLUTION 1 % EXTERNAL 1 T3 QL (30 ML per 30 days) % EXODERM LOTION 25-1 % EXTERNAL T1 25-1 % FINACEA GEL 15 % EXTERNAL 15 % T3 PA finasteride tablet 1 mg oral 1 mg T1 74 Drug Status Notes fluocinolone acetonide body external oil 0.01 % T1 QL (128.28 ML per 30 days) fluocinolone acetonide cream 0.01 % external T1 QL (120 GM per 30 days) 0.01 % fluocinolone acetonide cream 0.025 % external T1 QL (120 GM per 30 days) 0.025 % fluocinolone acetonide ointment 0.025 % external T1 QL (120 GM per 30 days) 0.025 % fluocinolone acetonide scalp external oil 0.01 % T1 QL (128.28 ML per 30 days) fluocinolone acetonide solution 0.01 % external T3 QL (120 ML per 30 days) 0.01 % fluocinonide emulsified base cream 0.05 % T1 QL (120 GM per 30 days) external 0.05 % fluocinonide gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days) fluocinonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days) fluocinonide solution 0.05 % external 0.05 % T1 QL (120 ML per 30 days) fluorouracil cream 5 % external 5 % T3 fluorouracil solution 2 % external 2 % T1 fluorouracil solution 5 % external 5 % T1 flurandrenolide cream 0.05 % external 0.05 % T3 PA flurandrenolide lotion 0.05 % external 0.05 % T3 PA fluticasone propionate cream 0.05 % external T1 QL (120 GM per 30 days) 0.05 % fluticasone propionate lotion 0.05 % external T3 0.05 % fluticasone propionate ointment 0.005 % external T1 QL (120 GM per 30 days) 0.005 % gentamicin sulfate cream 0.1 % external 0.1 % T1 gentamicin sulfate ointment 0.1 % external 0.1 % T1 halobetasol propionate cream 0.05 % external T1 QL (100 GM per 30 days) 0.05 % halobetasol propionate ointment 0.05 % external T1 QL (100 GM per 30 days) 0.05 % HALOG CREAM 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days) HALOG OINTMENT 0.1 % EXTERNAL 0.1 T3 QL (100 GM per 30 days) % hydrocortisone butyr lipo base cream 0.1 % T1 external 0.1 % hydrocortisone butyrate ointment 0.1 % external T1 0.1 % hydrocortisone butyrate solution 0.1 % external T1 0.1 % hydrocortisone cream 1 % external (otc) 1 % T1 QL (120 GM per 30 days) 75 Drug Status Notes hydrocortisone cream 2.5 % external 2.5 % T3 QL (90 GM per 30 days) hydrocortisone external lotion 1 % T1 QL (240 GM per 30 days) hydrocortisone external ointment 1 % T1 QL (90 GM per 30 days) hydrocortisone lotion 2.5 % external 2.5 % T1 QL (120 ML per 30 days) hydrocortisone ointment 2.5 % external 2.5 % T1 QL (90 GM per 30 days) hydrocortisone valerate cream 0.2 % external 0.2 T1 QL (120 GM per 30 days) % hydrocortisone valerate ointment 0.2 % external T1 QL (120 GM per 30 days) 0.2 % hydroquinone external cream 4 % T1 imiquimod cream 5 % external 5 % T3 QL (12 EA per 28 days) ketoconazole cream 2 % external 2 % T1 ketoconazole shampoo 2 % external 2 % T1 lactic acid e cream 10-3500 %-unt/30gm external T1 PA (rx) 10-3500 %-unt/30gm lactic acid external lotion 10 % T1 lidocaine cream 4 % external 4 % T1 QL (90 GM per 30 days) lidocaine hcl external cream 3 % T1 QL (85 GM per 30 days) lidocaine hcl lotion 3 % external 3 % T1 QL (100 ML per 30 days) lidocaine hcl solution 4 % external 4 % T1 QL (100 ML per 30 days) lidocaine patch 5 % external 5 % T3 PA lidocaine-prilocaine cream 2.5-2.5 % external T1 2.5-2.5 % lindane shampoo 1 % external 1 % T3 LMX 4 CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days) mafenide acetate packet 5 % external 5 % T3 malathion external lotion 0.5 % T2 MENTAX CREAM 1 % EXTERNAL 1 % T3 methoxsalen rapid capsule 10 mg oral 10 mg T3 PA metronidazole external cream 0.75 % T1 metronidazole external gel 0.75 % T1 metronidazole lotion 0.75 % external 0.75 % T1 miconazole nitrate external cream 2 % T1 MIRVASO GEL 0.33 % EXTERNAL 0.33 % T3 PA mometasone furoate cream 0.1 % external 0.1 % T1 mometasone furoate ointment 0.1 % external 0.1 T1 % mometasone furoate solution 0.1 % external 0.1 T1 % mupirocin ointment 2 % external 2 % T1 76 Drug Status Notes naftifine hcl external gel 1 % T3 PA; QL (60 GM per 30 days) NATROBA SUSPENSION 0.9 % EXTERNAL T3 ST; QL (120 ML per 30 days) 0.9 % NYAMYC EXTERNAL POWDER 100000 T1 UNIT/GM nystatin cream 100000 unit/gm external 100000 T1 unit/gm nystatin external powder 100000 unit/gm T1 nystatin ointment 100000 unit/gm external T1 100000 unit/gm nystatin-triamcinolone cream 100000-0.1 T3 unit/gm-% external 100000-0.1 unit/gm-% nystatin-triamcinolone ointment 100000-0.1 T1 unit/gm-% external 100000-0.1 unit/gm-% NYSTOP EXTERNAL POWDER 100000 T1 UNIT/GM oxiconazole nitrate external cream 1 % T3 PA permethrin cream 5 % external 5 % T1 QL (120 GM per 30 days) pimecrolimus external cream 1 % T3 PA; QL (100 GM per 30 days) podocon solution 25 % external 25 % T3 podofilox solution 0.5 % external 0.5 % T1 PR BENZOYL PEROXIDE WASH LIQUID 7 T3 % EXTERNAL 7 % prednicarbate cream 0.1 % external 0.1 % T1 QL (120 GM per 30 days) prednicarbate ointment 0.1 % external 0.1 % T1 QL (120 GM per 30 days) pyrogallic acid ointment 25-2 % external 25-2 % T1 REGRANEX GEL 0.01 % EXTERNAL 0.01 T4 PA % ROSADAN KIT 0.75 % (CREAM) T3 EXTERNAL 0.75 % (CREAM) ROSADAN KIT 0.75 % (GEL) EXTERNAL T3 0.75 % (GEL) salicylic acid external solution 26 % T1 salicylic acid foam 6 % external 6 % T3 salicylic acid gel 6 % external 6 % T1 salicylic acid lotion 6 % external 6 % T1 salicylic acid shampoo 6 % external 6 % T1 salicylic acid wart remover liquid 27.5 % external T1 27.5 % SANTYL OINTMENT 250 UNIT/GM T3 EXTERNAL 250 UNIT/GM

77 Drug Status Notes selenium sulfide lotion 2.5 % external 2.5 % T1 silver nitrate solution 0.5 % external 0.5 % T1 silver nitrate solution 10 % external 10 % T1 silver nitrate solution 25 % external 25 % T1 silver nitrate solution 50 % external 50 % T1 SKLICE LOTION 0.5 % EXTERNAL 0.5 % T3 PA SKYRIZI (150 MG DOSE) SUBCUTANEOUS T4 PA PREFILLED SYRINGE KIT 75 MG/0.83ML SSD CREAM 1 % EXTERNAL 1 % T1 QL (85 GM per 30 days) STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML SUBCUTANEOUS T4 PA 45 MG/0.5ML sulfacetamide sodium (acne) lotion 10 % external T3 10 % sulfacetamide sodium liquid 10 % external 10 % T3 sulfacetamide sodium-sulfur external lotion 10-5 T3 % SULFAMYLON CREAM 85 MG/GM T3 QL (56.7 GM per 30 days) EXTERNAL 85 MG/GM SYNALAR (CREAM) KIT 0.025 % T3 EXTERNAL 0.025 % SYNALAR (OINTMENT) KIT 0.025 % T3 EXTERNAL 0.025 % TACLONEX SUSPENSION 0.005-0.064 % T3 ST; QL (60 GM per 30 days) EXTERNAL 0.005-0.064 % tacrolimus ointment 0.03 % external 0.03 % T3 tacrolimus ointment 0.1 % external 0.1 % T3 tazarotene external cream 0.1 % T3 PA TAZORAC EXTERNAL CREAM 0.05 % T3 PA TAZORAC EXTERNAL GEL 0.05 %, 0.1 % T3 PA QL (45 GM per 30 days); AL tretinoin cream 0.025 % external 0.025 % T1 (Max 28 Years) QL (45 GM per 30 days); AL tretinoin cream 0.05 % external 0.05 % T1 (Max 28 Years) QL (45 GM per 30 days); AL tretinoin cream 0.1 % external 0.1 % T1 (Max 28 Years) QL (45 GM per 30 days); AL tretinoin gel 0.01 % external 0.01 % T1 (Max 28 Years) ST; QL (20 GM per 30 days); AL tretinoin microsphere gel 0.04 % external 0.04 % T3 (Max 28 Years) triamcinolone acetonide aerosol solution 0.147 T3 PA mg/gm external 0.147 mg/gm

78 Drug Status Notes triamcinolone acetonide cream 0.025 % external T1 QL (160 GM per 30 days) 0.025 % triamcinolone acetonide cream 0.1 % external 0.1 T1 QL (160 GM per 30 days) % triamcinolone acetonide cream 0.5 % external 0.5 T1 QL (60 GM per 30 days) % triamcinolone acetonide lotion 0.025 % external T1 QL (120 ML per 30 days) 0.025 % triamcinolone acetonide lotion 0.1 % external 0.1 T1 QL (120 ML per 30 days) % triamcinolone acetonide ointment 0.025 % T1 QL (160 GM per 30 days) external 0.025 % triamcinolone acetonide ointment 0.1 % external T1 QL (160 GM per 30 days) 0.1 % triamcinolone acetonide ointment 0.5 % external T1 QL (60 GM per 30 days) 0.5 % UMECTA MOUSSE FOAM 40 % T3 EXTERNAL 40 % urea cream 39 % external 39 % T3 urea cream 40 % external 40 % T1 urea cream 45 % external 45 % T3 urea external lotion 40 % T3 urea nail gel 45 % external 45 % T3 VECTICAL OINTMENT 3 MCG/GM T3 PA EXTERNAL 3 MCG/GM VEREGEN OINTMENT 15 % EXTERNAL T3 PA 15 % *Diagnostic Products* GLUCOCARD EXPRESSION TEST IN T1 VITRO STRIP GLUCOCARD VITAL TEST IN VITRO T1 STRIP ketone test in vitro strip T1 *Digestive Aids* CREON CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT ORAL T2 12000-38000 UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 24000-76000 UNIT ORAL T2 24000-76000 UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 3000-9500 UNIT ORAL 3000- T2 9500 UNIT 79 Drug Status Notes CREON CAPSULE DELAYED RELEASE PARTICLES 36000-114000 UNIT ORAL T2 36000-114000 UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 6000-19000 UNIT ORAL 6000- T2 19000 UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES 25000-79000 UNIT ORAL T2 25000-79000 UNIT *Diuretics* acetazolamide er capsule extended release 12 T1 QL (60 EA per 30 days) hour 500 mg oral 500 mg acetazolamide tablet 125 mg oral 125 mg T1 acetazolamide tablet 250 mg oral 250 mg T1 amiloride hcl tablet 5 mg oral 5 mg T1 amiloride-hydrochlorothiazide tablet 5-50 mg T1 oral 5-50 mg bumetanide solution 0.25 mg/ml injection 0.25 T1 mg/ml bumetanide tablet 0.5 mg oral 0.5 mg T1 bumetanide tablet 1 mg oral 1 mg T1 bumetanide tablet 2 mg oral 2 mg T1 CAROSPIR ORAL SUSPENSION 25 T1 AL (Max 12 Years) MG/5ML chlorothiazide tablet 250 mg oral 250 mg T1 chlorothiazide tablet 500 mg oral 500 mg T1 chlorthalidone tablet 25 mg oral 25 mg T1 chlorthalidone tablet 50 mg oral 50 mg T1 ethacrynic acid tablet 25 mg oral 25 mg T3 furosemide solution 10 mg/ml oral 10 mg/ml T1 furosemide solution 8 mg/ml oral 8 mg/ml T1 furosemide tablet 20 mg oral 20 mg T1 furosemide tablet 40 mg oral 40 mg T1 furosemide tablet 80 mg oral 80 mg T1 hydrochlorothiazide capsule 12.5 mg oral 12.5 T1 mg hydrochlorothiazide tablet 12.5 mg oral 12.5 mg T1 hydrochlorothiazide tablet 25 mg oral 25 mg T1 hydrochlorothiazide tablet 50 mg oral 50 mg T1 indapamide tablet 1.25 mg oral 1.25 mg T1 indapamide tablet 2.5 mg oral 2.5 mg T1 80 Drug Status Notes methazolamide tablet 25 mg oral 25 mg T3 methazolamide tablet 50 mg oral 50 mg T3 metolazone tablet 10 mg oral 10 mg T1 metolazone tablet 2.5 mg oral 2.5 mg T1 metolazone tablet 5 mg oral 5 mg T1 spironolactone tablet 100 mg oral 100 mg T1 spironolactone tablet 25 mg oral 25 mg T1 spironolactone tablet 50 mg oral 50 mg T1 spironolactone-hctz tablet 25-25 mg oral 25-25 T1 mg torsemide tablet 10 mg oral 10 mg T1 torsemide tablet 100 mg oral 100 mg T1 torsemide tablet 20 mg oral 20 mg T1 torsemide tablet 5 mg oral 5 mg T1 triamterene oral capsule 100 mg T3 triamterene-hctz capsule 37.5-25 mg oral 37.5-25 T1 mg triamterene-hctz tablet 37.5-25 mg oral 37.5-25 T1 mg triamterene-hctz tablet 75-50 mg oral 75-50 mg T1 *Endocrine And Metabolic Agents - Misc.* alendronate sodium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days) alendronate sodium tablet 35 mg oral 35 mg T1 QL (4 EA per 28 days) alendronate sodium tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days) alendronate sodium tablet 70 mg oral 70 mg T1 QL (4 EA per 28 days) cabergoline tablet 0.5 mg oral 0.5 mg T1 calcitonin (salmon) injection solution 200 unit/ml T4 calcitonin (salmon) solution 200 unit/act nasal T1 200 unit/act calcitriol capsule 0.25 mcg oral 0.25 mcg T1 calcitriol capsule 0.5 mcg oral 0.5 mcg T1 calcitriol solution 1 mcg/ml oral 1 mcg/ml T3 chorionic gonadotropin solution reconstituted T4 PA 10000 unit intramuscular 10000 unit CYSTADANE POWDER ORAL T4 PA DDAVP RHINAL TUBE NASAL SOLUTION T1 0.01 % desmopressin ace spray refrig solution 0.01 % T3 nasal 0.01 %

81 Drug Status Notes desmopressin acetate solution 4 mcg/ml injection T4 PA 4 mcg/ml desmopressin acetate spray nasal solution 0.01 % T1 desmopressin acetate tablet 0.1 mg oral 0.1 mg T1 desmopressin acetate tablet 0.2 mg oral 0.2 mg T1 doxercalciferol capsule 0.5 mcg oral 0.5 mcg T3 PA doxercalciferol capsule 1 mcg oral 1 mcg T3 PA doxercalciferol capsule 2.5 mcg oral 2.5 mcg T3 PA FORTEO SOLUTION PEN-INJECTOR 620 MCG/2.48ML SUBCUTANEOUS 620 T4 PA MCG/2.48ML FOSAMAX PLUS D TABLET 70-2800 MG- T3 PA UNIT ORAL 70-2800 MG-UNIT FOSAMAX PLUS D TABLET 70-5600 MG- T3 PA UNIT ORAL 70-5600 MG-UNIT ganirelix acetate solution prefilled syringe 250 T4 PA mcg/0.5ml subcutaneous 250 mcg/0.5ml GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.2 MG T4 PA SUBCUTANEOUS 0.2 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.4 MG T4 PA SUBCUTANEOUS 0.4 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.6 MG T4 PA SUBCUTANEOUS 0.6 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.8 MG T4 PA SUBCUTANEOUS 0.8 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1 MG SUBCUTANEOUS T4 PA 1 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.2 MG T4 PA SUBCUTANEOUS 1.2 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.4 MG T4 PA SUBCUTANEOUS 1.4 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.6 MG T4 PA SUBCUTANEOUS 1.6 MG GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.8 MG T4 PA SUBCUTANEOUS 1.8 MG

82 Drug Status Notes GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 2 MG SUBCUTANEOUS T4 PA 2 MG GENOTROPIN SOLUTION RECONSTITUTED 12 MG T4 PA SUBCUTANEOUS 12 MG GENOTROPIN SOLUTION RECONSTITUTED 5 MG SUBCUTANEOUS T4 PA 5 MG GONAL-F RFF REDIJECT SOLUTION 300 UNIT/0.5ML SUBCUTANEOUS 300 T4 PA UNIT/0.5ML GONAL-F RFF REDIJECT SOLUTION 450 UNT/0.75ML SUBCUTANEOUS 450 T4 PA UNT/0.75ML GONAL-F RFF REDIJECT SOLUTION 900 UNIT/1.5ML SUBCUTANEOUS 900 T4 PA UNIT/1.5ML ibandronate sodium tablet 150 mg oral 150 mg T1 QL (1 EA per 28 days) INCRELEX SOLUTION 40 MG/4ML T4 PA SUBCUTANEOUS 40 MG/4ML levocarnitine oral tablet 330 mg T3 levocarnitine solution 1 gm/10ml oral 1 gm/10ml T3 nitisinone oral capsule 10 mg, 2 mg, 5 mg T4 PA octreotide acetate solution 100 mcg/ml injection T4 PA 100 mcg/ml octreotide acetate solution 1000 mcg/ml injection T4 PA 1000 mcg/ml octreotide acetate solution 200 mcg/ml injection T4 PA 200 mcg/ml octreotide acetate solution 50 mcg/ml injection 50 T4 PA mcg/ml octreotide acetate solution 500 mcg/ml injection T4 PA 500 mcg/ml OSPHENA TABLET 60 MG ORAL 60 MG T3 QL (30 EA per 30 days) paricalcitol capsule 1 mcg oral 1 mcg T3 PA paricalcitol capsule 2 mcg oral 2 mcg T3 PA paricalcitol capsule 4 mcg oral 4 mcg T3 PA raloxifene hcl tablet 60 mg oral 60 mg T5 PA risedronate sodium tablet 150 mg oral 150 mg T3 QL (1 EA per 28 days) risedronate sodium tablet 30 mg oral 30 mg T3 QL (30 EA per 30 days) risedronate sodium tablet 35 mg oral 35 mg T3 QL (4 EA per 28 days) risedronate sodium tablet 5 mg oral 5 mg T3 QL (30 EA per 30 days) 83 Drug Status Notes SAMSCA TABLET 15 MG ORAL 15 MG T4 PA SANDOSTATIN LAR DEPOT KIT 10 MG T4 PA INTRAMUSCULAR 10 MG SANDOSTATIN LAR DEPOT KIT 20 MG T4 PA INTRAMUSCULAR 20 MG SANDOSTATIN LAR DEPOT KIT 30 MG T4 PA INTRAMUSCULAR 30 MG sapropterin dihydrochloride oral tablet soluble T4 PA 100 mg SENSIPAR TABLET 30 MG ORAL 30 MG T4 PA SENSIPAR TABLET 60 MG ORAL 60 MG T4 PA SENSIPAR TABLET 90 MG ORAL 90 MG T4 PA SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 20 MG T4 PA INTRAMUSCULAR 20 MG SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 40 MG T4 PA INTRAMUSCULAR 40 MG SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 60 MG T4 PA INTRAMUSCULAR 60 MG SIGNIFOR SOLUTION 0.3 MG/ML T4 PA SUBCUTANEOUS 0.3 MG/ML SIGNIFOR SOLUTION 0.6 MG/ML T4 PA SUBCUTANEOUS 0.6 MG/ML SIGNIFOR SOLUTION 0.9 MG/ML T4 PA SUBCUTANEOUS 0.9 MG/ML SOMATULINE DEPOT SOLUTION 120 MG/0.5ML SUBCUTANEOUS 120 T4 PA MG/0.5ML SOMATULINE DEPOT SOLUTION 60 T4 PA MG/0.2ML SUBCUTANEOUS 60 MG/0.2ML SOMATULINE DEPOT SOLUTION 90 T4 PA MG/0.3ML SUBCUTANEOUS 90 MG/0.3ML SOMAVERT SOLUTION RECONSTITUTED 10 MG T4 PA SUBCUTANEOUS 10 MG SOMAVERT SOLUTION RECONSTITUTED 15 MG T4 PA SUBCUTANEOUS 15 MG SOMAVERT SOLUTION RECONSTITUTED 20 MG T4 PA SUBCUTANEOUS 20 MG

84 Drug Status Notes STIMATE SOLUTION 1.5 MG/ML NASAL T4 PA 1.5 MG/ML tolvaptan oral tablet 30 mg T4 PA *Estrogens* COMBIPATCH PATCH TWICE WEEKLY 0.05-0.14 MG/DAY TRANSDERMAL 0.05- T3 0.14 MG/DAY COMBIPATCH PATCH TWICE WEEKLY 0.05-0.25 MG/DAY TRANSDERMAL 0.05- T3 0.25 MG/DAY DUAVEE TABLET 0.45-20 MG ORAL 0.45- T3 GR-F; QL (30 EA per 30 days) 20 MG estradiol patch twice weekly 0.025 mg/24hr T2 GR-F; QL (8 EA per 28 days) transdermal 0.025 mg/24hr estradiol patch twice weekly 0.0375 mg/24hr T2 GR-F; QL (8 EA per 28 days) transdermal 0.0375 mg/24hr estradiol patch twice weekly 0.05 mg/24hr T2 GR-F; QL (8 EA per 28 days) transdermal 0.05 mg/24hr estradiol patch twice weekly 0.075 mg/24hr T2 GR-F; QL (8 EA per 28 days) transdermal 0.075 mg/24hr estradiol patch twice weekly 0.1 mg/24hr T2 GR-F; QL (8 EA per 28 days) transdermal 0.1 mg/24hr estradiol patch weekly 0.025 mg/24hr T1 GR-F; QL (4 EA per 28 days) transdermal 0.025 mg/24hr estradiol patch weekly 0.0375 mg/24hr T1 GR-F; QL (4 EA per 28 days) transdermal 0.0375 mg/24hr estradiol patch weekly 0.05 mg/24hr transdermal T1 GR-F; QL (4 EA per 28 days) 0.05 mg/24hr estradiol patch weekly 0.06 mg/24hr transdermal T1 GR-F; QL (4 EA per 28 days) 0.06 mg/24hr estradiol patch weekly 0.075 mg/24hr T1 GR-F; QL (4 EA per 28 days) transdermal 0.075 mg/24hr estradiol patch weekly 0.1 mg/24hr transdermal T1 GR-F; QL (4 EA per 28 days) 0.1 mg/24hr estradiol tablet 0.5 mg oral 0.5 mg T1 GR-F estradiol tablet 1 mg oral 1 mg T1 GR-F estradiol tablet 2 mg oral 2 mg T1 GR-F estradiol valerate oil 20 mg/ml intramuscular 20 T1 GR-F mg/ml estradiol valerate oil 40 mg/ml intramuscular 40 T1 GR-F mg/ml estradiol-norethindrone acet tablet 0.5-0.1 mg T1 oral 0.5-0.1 mg

85 Drug Status Notes estradiol-norethindrone acet tablet 1-0.5 mg oral T1 1-0.5 mg ESTROGEL GEL 0.75 MG/1.25 GM (0.06%) T3 GR-F TRANSDERMAL 0.75 MG/1.25 GM (0.06%) EVAMIST SOLUTION 1.53 MG/SPRAY T3 GR-F TRANSDERMAL 1.53 MG/SPRAY JINTELI TABLET 1-5 MG-MCG ORAL 1-5 T1 GR-F; QL (28 EA per 28 days) MG-MCG MENEST TABLET 0.3 MG ORAL 0.3 MG T3 GR-F MENEST TABLET 0.625 MG ORAL 0.625 T3 GR-F MG MENEST TABLET 1.25 MG ORAL 1.25 MG T3 GR-F norethindrone-eth estradiol tablet 0.5-2.5 mg-mcg T1 GR-F; QL (28 EA per 28 days) oral 0.5-2.5 mg-mcg PREMARIN TABLET 0.3 MG ORAL 0.3 MG T3 GR-F PREMARIN TABLET 0.45 MG ORAL 0.45 T3 GR-F MG PREMARIN TABLET 0.625 MG ORAL 0.625 T3 GR-F MG PREMARIN TABLET 0.9 MG ORAL 0.9 MG T3 GR-F PREMARIN TABLET 1.25 MG ORAL 1.25 T3 GR-F MG PREMPHASE TABLET 0.625-5 MG ORAL T3 GR-F 0.625-5 MG PREMPRO TABLET 0.3-1.5 MG ORAL 0.3- T3 GR-F 1.5 MG PREMPRO TABLET 0.45-1.5 MG ORAL T3 GR-F 0.45-1.5 MG PREMPRO TABLET 0.625-2.5 MG ORAL T3 GR-F 0.625-2.5 MG PREMPRO TABLET 0.625-5 MG ORAL T3 GR-F 0.625-5 MG *Fluoroquinolones* CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 T3 MG/5ML (10%) ciprofloxacin hcl tablet 100 mg oral 100 mg T1 ciprofloxacin hcl tablet 250 mg oral 250 mg T1 ciprofloxacin hcl tablet 500 mg oral 500 mg T1 ciprofloxacin hcl tablet 750 mg oral 750 mg T1 levofloxacin tablet 250 mg oral 250 mg T1 levofloxacin tablet 500 mg oral 500 mg T1

86 Drug Status Notes levofloxacin tablet 750 mg oral 750 mg T1 moxifloxacin hcl tablet 400 mg oral 400 mg T1 ofloxacin tablet 400 mg oral 400 mg T1 *Gastrointestinal Agents - Misc.* alosetron hcl oral tablet 0.5 mg, 1 mg T3 PA AMITIZA CAPSULE 24 MCG ORAL 24 T3 PA MCG AMITIZA CAPSULE 8 MCG ORAL 8 MCG T3 PA APRISO CAPSULE EXTENDED RELEASE T3 QL (120 EA per 30 days) 24 HOUR 0.375 GM ORAL 0.375 GM balsalazide disodium capsule 750 mg oral 750 mg T1 calcium acetate (phos binder) capsule 667 mg T1 oral 667 mg CALPHRON TABLET 667 MG ORAL 667 T1 MG cromolyn sodium oral concentrate 100 mg/5ml T3 DIPENTUM CAPSULE 250 MG ORAL 250 T3 PA MG generlac solution 10 gm/15ml oral 10 gm/15ml T1 lanthanum carbonate oral tablet chewable 1000 T3 PA mg, 500 mg, 750 mg LINZESS CAPSULE 145 MCG ORAL 145 T3 PA MCG LINZESS CAPSULE 290 MCG ORAL 290 T3 PA MCG mesalamine enema 4 gm rectal 4 gm T3 QL (1680 ML per 28 days) mesalamine oral capsule delayed release 400 mg T3 QL (180 EA per 30 days) mesalamine oral tablet delayed release 1.2 gm T3 QL (60 EA per 30 days) mesalamine rectal suppository 1000 mg T4 PA mesalamine tablet delayed release 800 mg oral T3 ST; QL (180 EA per 30 days) 800 mg metoclopramide hcl solution 10 mg/10ml oral 10 T1 mg/10ml metoclopramide hcl tablet 10 mg oral 10 mg T1 metoclopramide hcl tablet 5 mg oral 5 mg T1 PENTASA CAPSULE EXTENDED T3 ST; QL (240 EA per 30 days) RELEASE 250 MG ORAL 250 MG PENTASA CAPSULE EXTENDED T3 ST; QL (240 EA per 30 days) RELEASE 500 MG ORAL 500 MG PHOSLYRA SOLUTION 667 MG/5ML T3 PA ORAL 667 MG/5ML

87 Drug Status Notes RENVELA PACKET 0.8 GM ORAL 0.8 GM T3 PA sevelamer carbonate oral tablet 800 mg T3 PA sevelamer carbonate packet 2.4 gm oral 2.4 gm T3 PA sevelamer hcl oral tablet 800 mg T3 PA sulfasalazine tablet 500 mg oral 500 mg T1 sulfasalazine tablet delayed release 500 mg oral T1 500 mg ursodiol capsule 300 mg oral 300 mg T3 ursodiol tablet 250 mg oral 250 mg T3 ursodiol tablet 500 mg oral 500 mg T3 VELPHORO TABLET CHEWABLE 500 MG T3 PA ORAL 500 MG *Genitourinary Agents - Miscellaneous* acetic acid solution 0.25 % irrigation 0.25 % T1 alfuzosin hcl er tablet extended release 24 hour T3 10 mg oral 10 mg aminoacetic acid solution 1.5 % irrigation 1.5 % T1 ARGYLE STERILE SALINE SOLUTION 0.9 T1 % IRRIGATION 0.9 % CARDURA XL TABLET EXTENDED T3 RELEASE 24 HOUR 4 MG ORAL 4 MG CYTRA-3 SYRUP 550-500-334 MG/5ML T1 ORAL 550-500-334 MG/5ML ELMIRON ORAL CAPSULE 100 MG T3 finasteride tablet 5 mg oral 5 mg T1 neomycin-polymyxin b gu solution 40-200000 T1 irrigation 40-200000 phenazopyridine hcl oral tablet 200 mg T1 phenazopyridine hcl tablet 100 mg oral 100 mg T1 potassium citrate er tablet extended release 10 T1 meq (1080 mg) oral 10 meq (1080 mg) potassium citrate er tablet extended release 15 T3 meq (1620 mg) oral 15 meq (1620 mg) potassium citrate er tablet extended release 5 meq T1 (540 mg) oral 5 meq (540 mg) potassium citrate-citric acid solution 1100-334 T1 mg/5ml oral 1100-334 mg/5ml silodosin oral capsule 4 mg, 8 mg T3 sod citrate-citric acid solution 500-334 mg/5ml T1 oral 500-334 mg/5ml solution 3 % irrigation 3 % T1

88 Drug Status Notes sorbitol solution 3.3 % irrigation 3.3 % T1 sorbitol-mannitol solution 2.7-0.54 gm/100ml T1 irrigation 2.7-0.54 gm/100ml tamsulosin hcl capsule 0.4 mg oral 0.4 mg T1 QL (60 EA per 30 days) *Gout Agents* allopurinol tablet 100 mg oral 100 mg T1 allopurinol tablet 300 mg oral 300 mg T1 colchicine oral capsule 0.6 mg T3 QL (60 EA per 30 days) colchicine oral tablet 0.6 mg T2 QL (60 EA per 30 days) colchicine-probenecid oral tablet 0.5-500 mg T1 probenecid tablet 500 mg oral 500 mg T1 ULORIC TABLET 40 MG ORAL 40 MG T3 PA ULORIC TABLET 80 MG ORAL 80 MG T3 PA *Hematological Agents - Misc.* anagrelide hcl capsule 0.5 mg oral 0.5 mg T1 anagrelide hcl capsule 1 mg oral 1 mg T1 aspirin-dipyridamole er capsule extended release T3 12 hour 25-200 mg oral 25-200 mg BERINERT KIT 500 UNIT INTRAVENOUS T4 PA 500 UNIT BRILINTA TABLET 60 MG ORAL 60 MG T2 QL (60 EA per 30 days) BRILINTA TABLET 90 MG ORAL 90 MG T2 QL (60 EA per 30 days) CEPROTIN SOLUTION RECONSTITUTED T4 PA 1000 UNIT INTRAVENOUS 1000 UNIT cilostazol tablet 100 mg oral 100 mg T1 cilostazol tablet 50 mg oral 50 mg T1 clopidogrel bisulfate tablet 300 mg oral 300 mg T1 QL (30 EA per 30 days) clopidogrel bisulfate tablet 75 mg oral 75 mg T1 QL (30 EA per 30 days) dipyridamole tablet 25 mg oral 25 mg T1 dipyridamole tablet 50 mg oral 50 mg T1 dipyridamole tablet 75 mg oral 75 mg T1 FIRAZYR SOLUTION 30 MG/3ML T4 PA SUBCUTANEOUS 30 MG/3ML KALBITOR SOLUTION 10 MG/ML T4 PA SUBCUTANEOUS 10 MG/ML pentoxifylline er tablet extended release 400 mg T1 QL (90 EA per 30 days) oral 400 mg prasugrel hcl oral tablet 10 mg, 5 mg T3 ST; QL (30 EA per 30 days) ZONTIVITY TABLET 2.08 MG ORAL 2.08 T3 QL (30 EA per 30 days) MG

89 Drug Status Notes *Hematopoietic Agents* ARANESP (ALBUMIN FREE) SOLUTION T4 PA 100 MCG/ML INJECTION 100 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION T4 PA 200 MCG/ML INJECTION 200 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION T4 PA 25 MCG/ML INJECTION 25 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION T4 PA 300 MCG/ML INJECTION 300 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION T4 PA 40 MCG/ML INJECTION 40 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION T4 PA 60 MCG/ML INJECTION 60 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML T4 PA INJECTION 100 MCG/0.5ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML T4 PA INJECTION 150 MCG/0.3ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 200 MCG/0.4ML T4 PA INJECTION 200 MCG/0.4ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 25 MCG/0.42ML T4 PA INJECTION 25 MCG/0.42ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 300 MCG/0.6ML T4 PA INJECTION 300 MCG/0.6ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 40 MCG/0.4ML T4 PA INJECTION 40 MCG/0.4ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 500 MCG/ML T4 PA INJECTION 500 MCG/ML ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 60 MCG/0.3ML T4 PA INJECTION 60 MCG/0.3ML b-6 folic acid capsule 8.333-100-1 mg oral 8.333- T1 100-1 mg cyanocobalamin solution 1000 mcg/ml injection T1 1000 mcg/ml DROXIA CAPSULE 200 MG ORAL 200 MG T2 DROXIA CAPSULE 300 MG ORAL 300 MG T2 DROXIA CAPSULE 400 MG ORAL 400 MG T2

90 Drug Status Notes EPOGEN SOLUTION 10000 UNIT/ML T4 PA INJECTION 10000 UNIT/ML EPOGEN SOLUTION 2000 UNIT/ML T4 PA INJECTION 2000 UNIT/ML EPOGEN SOLUTION 20000 UNIT/ML T4 PA INJECTION 20000 UNIT/ML EPOGEN SOLUTION 3000 UNIT/ML T4 PA INJECTION 3000 UNIT/ML EPOGEN SOLUTION 4000 UNIT/ML T4 PA INJECTION 4000 UNIT/ML fe tabs tablet delayed release 325 (65 fe) mg oral T5 325 (65 fe) mg ferotrinsic capsule oral T1 ferraplus 90 tablet 90-1 mg oral 90-1 mg T1 ferrous sulfate elixir 220 (44 fe) mg/5ml oral 220 T5 (44 fe) mg/5ml folic acid injection solution 5 mg/ml T1 folic acid oral tablet 1 mg, 800 mcg T5 QL (30 EA per 30 days) folic acid tablet 400 mcg oral 400 mcg T5 QL (30 EA per 30 days) hematinic/folic acid tablet 324-1 mg oral 324-1 T1 mg HEMATOGEN FA CAPSULE 200-250-0.01-1 T1 MG ORAL 200-250-0.01-1 MG iron 27 tablet 240 (27 fe) mg oral 240 (27 fe) mg T5 iron tablet 325 (65 fe) mg oral 325 (65 fe) mg T5 LEUKINE SOLUTION RECONSTITUTED T4 PA 250 MCG INJECTION 250 MCG NEULASTA SOLUTION PREFILLED SYRINGE 6 MG/0.6ML SUBCUTANEOUS 6 T4 PA MG/0.6ML poly-iron 150 forte capsule 150-25-1 mg-mcg-mg T1 oral 150-25-1 mg-mcg-mg PROCRIT SOLUTION 10000 UNIT/ML T4 PA INJECTION 10000 UNIT/ML PROCRIT SOLUTION 2000 UNIT/ML T4 PA INJECTION 2000 UNIT/ML PROCRIT SOLUTION 20000 UNIT/ML T4 PA INJECTION 20000 UNIT/ML PROCRIT SOLUTION 3000 UNIT/ML T4 PA INJECTION 3000 UNIT/ML PROCRIT SOLUTION 4000 UNIT/ML T4 PA INJECTION 4000 UNIT/ML

91 Drug Status Notes PROCRIT SOLUTION 40000 UNIT/ML T4 PA INJECTION 40000 UNIT/ML PROMACTA TABLET 12.5 MG ORAL 12.5 T3 PA MG PROMACTA TABLET 25 MG ORAL 25 MG T3 PA PROMACTA TABLET 50 MG ORAL 50 MG T3 PA PROMACTA TABLET 75 MG ORAL 75 MG T3 PA RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, T4 PA 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML ZARXIO SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION 300 T4 PA MCG/0.5ML ZARXIO SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION 480 T4 PA MCG/0.8ML *Hemostatics* aminocaproic acid oral tablet 1000 mg, 500 mg T3 tranexamic acid oral tablet 650 mg T1 *//Sleep Disorder Agents* BELSOMRA TABLET 10 MG ORAL 10 MG T3 ST; QL (30 EA per 30 days) BELSOMRA TABLET 15 MG ORAL 15 MG T3 ST; QL (30 EA per 30 days) BELSOMRA TABLET 20 MG ORAL 20 MG T3 ST; QL (30 EA per 30 days) BELSOMRA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days) estazolam tablet 1 mg oral 1 mg T1 estazolam tablet 2 mg oral 2 mg T1 QL (30 EA per 30 days); AL (Max eszopiclone tablet 1 mg oral 1 mg T1 64 Years) QL (30 EA per 30 days); AL (Max eszopiclone tablet 2 mg oral 2 mg T1 64 Years) QL (30 EA per 30 days); AL (Max eszopiclone tablet 3 mg oral 3 mg T1 64 Years) flurazepam hcl capsule 15 mg oral 15 mg T1 AL (Max 64 Years) flurazepam hcl capsule 30 mg oral 30 mg T1 AL (Max 64 Years) HETLIOZ CAPSULE 20 MG ORAL 20 MG T4 PA phenobarbital elixir 20 mg/5ml oral 20 mg/5ml T1 phenobarbital tablet 100 mg oral 100 mg T1 phenobarbital tablet 15 mg oral 15 mg T1 phenobarbital tablet 16.2 mg oral 16.2 mg T1

92 Drug Status Notes phenobarbital tablet 30 mg oral 30 mg T1 phenobarbital tablet 32.4 mg oral 32.4 mg T1 phenobarbital tablet 60 mg oral 60 mg T1 phenobarbital tablet 64.8 mg oral 64.8 mg T1 phenobarbital tablet 97.2 mg oral 97.2 mg T1 ROZEREM TABLET 8 MG ORAL 8 MG T3 ST; QL (30 EA per 30 days) temazepam capsule 15 mg oral 15 mg T1 temazepam capsule 22.5 mg oral 22.5 mg T3 temazepam capsule 30 mg oral 30 mg T1 temazepam capsule 7.5 mg oral 7.5 mg T3 QL (30 EA per 30 days); AL (Max zaleplon capsule 10 mg oral 10 mg T1 64 Years) QL (30 EA per 30 days); AL (Max zaleplon capsule 5 mg oral 5 mg T1 64 Years) zolpidem tartrate er oral tablet extended release QL (30 EA per 30 days); AL (Min T1 12.5 mg, 6.25 mg 18 Years) QL (30 EA per 30 days); AL (Max zolpidem tartrate tablet 10 mg oral 10 mg T1 64 Years) QL (30 EA per 30 days); AL (Max zolpidem tartrate tablet 5 mg oral 5 mg T1 64 Years) *Laxatives* GAVILYTE-C ORAL SOLUTION T5 QL (4000 ML per 365 days) RECONSTITUTED 240 GM GAVILYTE-G SOLUTION T1 RECONSTITUTED 236 GM ORAL 236 GM GAVILYTE-N WITH PACK SOLUTION RECONSTITUTED 420 GM T1 ORAL 420 GM GOLYTELY SOLUTION RECONSTITUTED T1 QL (1 EA per 365 days) 227.1 GM ORAL 227.1 GM KRISTALOSE PACKET 20 GM ORAL 20 T3 PA GM lactulose oral packet 10 gm T3 PA lactulose solution 10 gm/15ml oral 10 gm/15ml T1 OSMOPREP TABLET 1.102-0.398 GM T3 ORAL 1.102-0.398 GM peg-3350/electrolytes/ascorbat oral solution T3 reconstituted 100 gm polyethylene glycol 3350 oral powder 17 T1 gm/scoop

93 Drug Status Notes SUPREP BOWEL PREP KIT SOLUTION 17.5-3.13-1.6 GM/177ML ORAL 17.5-3.13-1.6 T3 GM/177ML *Macrolides* azithromycin oral tablet 500 mg T1 QL (6 EA per 30 days) azithromycin packet 1 gm oral 1 gm T1 QL (2 EA per 30 days) azithromycin suspension reconstituted 100 T1 mg/5ml oral 100 mg/5ml azithromycin suspension reconstituted 200 T1 mg/5ml oral 200 mg/5ml azithromycin tablet 250 mg oral 250 mg T1 QL (12 EA per 30 days) azithromycin tablet 600 mg oral 600 mg T1 QL (60 EA per 30 days) clarithromycin er tablet extended release 24 hour T1 500 mg oral 500 mg clarithromycin suspension reconstituted 125 T1 mg/5ml oral 125 mg/5ml clarithromycin suspension reconstituted 250 T1 mg/5ml oral 250 mg/5ml clarithromycin tablet 250 mg oral 250 mg T1 clarithromycin tablet 500 mg oral 500 mg T1 DIFICID TABLET 200 MG ORAL 200 MG T3 PA ERYTHROCIN STEARATE TABLET 250 T3 MG ORAL 250 MG erythromycin base capsule delayed release T3 particles 250 mg oral 250 mg erythromycin base oral tablet delayed release 333 T3 mg erythromycin base tablet 250 mg oral 250 mg T3 erythromycin base tablet 500 mg oral 500 mg T3 erythromycin ethylsuccinate tablet 400 mg oral T3 400 mg *Medical Devices And Supplies* BD INSULIN SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days) BD PEN NEEDLE ORIGINAL U/F 29G X T1 QL (200 EA per 30 days) 12.7MM BD SAFETYGLIDE INSULIN SYRINGE 31G T1 QL (200 EA per 30 days) X 15/64" 0.5 ML BD VEO INSULIN SYRINGE U/F 31G X T1 QL (200 EA per 30 days) 15/64" 0.3 ML, 31G X 15/64" 1 ML COMFORT EZ PEN NEEDLES 32G X 5 MM T1 QL (200 EA per 30 days) FREESTYLE LIBRE SENSOR SYSTEM T1

94 Drug Status Notes insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 T1 QL (200 EA per 30 days) ml insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml T1 QL (200 EA per 30 days) insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 T1 QL (200 EA per 30 days) ml insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml T1 QL (200 EA per 30 days) insupen pen needles 29g x 12mm 29g x 12mm T1 QL (200 EA per 30 days) MAGELLAN INSULIN SAFETY SYR 29G X T1 QL (200 EA per 30 days) 1/2" 0.3 ML 29G X 1/2" 0.3 ML OMNIFLEX DIAPHRAGM VAGINAL T5 DIAPHRAGM ONETOUCH VERIO SOLUTION IN VITRO T1 QL (1 EA per 365 days) pen needles 31g x 6 mm 31g x 6 mm T1 QL (200 EA per 30 days) pen needles 31g x 8 mm 31g x 8 mm T1 QL (200 EA per 30 days) pen needles 32g x 4 mm 32g x 4 mm T1 QL (200 EA per 30 days) pen needles 32g x 6 mm 32g x 6 mm T1 QL (200 EA per 30 days) TECHLITE PEN NEEDLES 31G X 5 MM T1 QL (200 EA per 30 days) 31G X 5 MM ULTILET INSULIN SYRINGE 30G X 1/2" T1 QL (200 EA per 30 days) 0.5 ML 30G X 1/2" 0.5 ML ULTILET INSULIN SYRINGE 30G X 1/2" 1 T1 QL (200 EA per 30 days) ML 30G X 1/2" 1 ML ULTILET INSULIN SYRINGE 30G X 5/16" T1 QL (200 EA per 30 days) 0.3 ML 30G X 5/16" 0.3 ML ULTILET INSULIN SYRINGE 30G X 5/16" T1 QL (200 EA per 30 days) 0.5 ML 30G X 5/16" 0.5 ML ULTILET INSULIN SYRINGE 30G X 5/16" 1 T1 QL (200 EA per 30 days) ML 30G X 5/16" 1 ML ULTILET INSULIN SYRINGE 31G X 5/16" T1 QL (200 EA per 30 days) 0.3 ML 31G X 5/16" 0.3 ML ULTILET INSULIN SYRINGE 31G X 5/16" 1 T1 QL (200 EA per 30 days) ML 31G X 5/16" 1 ML ULTILET INSULIN SYRINGE SHORT 30G T1 QL (200 EA per 30 days) X 1/2" 0.3 ML 30G X 1/2" 0.3 ML ULTILET INSULIN SYRINGE SHORT 31G T1 QL (200 EA per 30 days) X 5/16" 0.5 ML 31G X 5/16" 0.5 ML *Migraine Products* almotriptan malate tablet 12.5 mg oral 12.5 mg T3 ST; QL (9 EA per 30 days) almotriptan malate tablet 6.25 mg oral 6.25 mg T3 ST; QL (9 EA per 30 days) eletriptan hydrobromide tablet 20 mg oral 20 mg T3 ST; QL (9 EA per 30 days) eletriptan hydrobromide tablet 40 mg oral 40 mg T3 ST; QL (9 EA per 30 days)

95 Drug Status Notes ergotamine-caffeine oral tablet 1-100 mg T3 QL (40 EA per 28 days) frovatriptan succinate tablet 2.5 mg oral 2.5 mg T3 ST; QL (9 EA per 30 days) naratriptan hcl tablet 1 mg oral 1 mg T2 QL (9 EA per 30 days) naratriptan hcl tablet 2.5 mg oral 2.5 mg T2 QL (9 EA per 30 days) RELPAX TABLET 20 MG ORAL 20 MG T3 ST; QL (9 EA per 30 days) rizatriptan benzoate tablet 10 mg oral 10 mg T1 QL (12 EA per 30 days) rizatriptan benzoate tablet 5 mg oral 5 mg T1 QL (12 EA per 30 days) rizatriptan benzoate tablet dispersible 10 mg oral T1 QL (12 EA per 30 days) 10 mg rizatriptan benzoate tablet dispersible 5 mg oral 5 T1 QL (12 EA per 30 days) mg sumatriptan solution 20 mg/act nasal 20 mg/act T3 sumatriptan solution 5 mg/act nasal 5 mg/act T3 sumatriptan succinate solution 6 mg/0.5ml T3 PA; QL (10 ML per 30 days) subcutaneous 6 mg/0.5ml sumatriptan succinate solution auto-injector 6 T3 PA; QL (10 ML per 30 days) mg/0.5ml subcutaneous 6 mg/0.5ml sumatriptan succinate subcutaneous solution T4 PA auto-injector 4 mg/0.5ml sumatriptan succinate tablet 100 mg oral 100 mg T1 QL (9 EA per 30 days) sumatriptan succinate tablet 25 mg oral 25 mg T1 QL (9 EA per 30 days) sumatriptan succinate tablet 50 mg oral 50 mg T1 QL (9 EA per 30 days) zolmitriptan tablet 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days) zolmitriptan tablet 5 mg oral 5 mg T1 QL (6 EA per 30 days) zolmitriptan tablet dispersible 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days) zolmitriptan tablet dispersible 5 mg oral 5 mg T1 QL (6 EA per 30 days) *Minerals & Electrolytes* EFFER-K TABLET EFFERVESCENT 10 T3 MEQ ORAL 10 MEQ EFFER-K TABLET EFFERVESCENT 20 T3 MEQ ORAL 20 MEQ fluoritab tablet chewable 1.1 (0.5 f) mg oral 1.1 T5 (0.5 f) mg iodine strong solution 5 % oral 5 % T1 KLOR-CON M15 TABLET EXTENDED T3 RELEASE 15 MEQ ORAL 15 MEQ K-PRIME TABLET EFFERVESCENT 25 T1 MEQ ORAL 25 MEQ MONOJECT SODIUM CHLORIDE FLUSH T3 SOLUTION 0.9 % INTRAVENOUS 0.9 %

96 Drug Status Notes PHOSPHO-TRIN 250 NEUTRAL TABLET T1 155-852-130 MG ORAL 155-852-130 MG pot bicarb-pot chloride oral tablet effervescent 25 T1 meq potassium chloride crys er oral tablet extended T3 release 15 meq potassium chloride crys er tablet extended release T1 10 meq oral 10 meq potassium chloride crys er tablet extended release T1 20 meq oral 20 meq potassium chloride er capsule extended release T1 10 meq oral 10 meq potassium chloride er capsule extended release 8 T1 meq oral 8 meq potassium chloride er oral tablet extended release T1 20 meq potassium chloride er tablet extended release 10 T1 meq oral 10 meq potassium chloride er tablet extended release 8 T1 meq oral 8 meq potassium chloride packet 20 meq oral 20 meq T3 sodium chloride solution 0.9 % intravenous 0.9 % T3 sodium fluoride solution 1.1 (0.5 f) mg/ml oral 1.1 T5 (0.5 f) mg/ml sodium fluoride tablet chewable 2.2 (1 f) mg oral T5 2.2 (1 f) mg zinc sulfate capsule 220 (50 zn) mg oral (otc) 220 T1 (50 zn) mg *Miscellaneous Therapeutic Classes* alprostadil solution 500 mcg/ml injection 500 T1 mcg/ml AZASAN TABLET 100 MG ORAL 100 MG T3 PA AZASAN TABLET 75 MG ORAL 75 MG T3 PA azathioprine tablet 50 mg oral 50 mg T1 CUPRIMINE CAPSULE 250 MG ORAL 250 T4 PA MG cyclosporine capsule 100 mg oral 100 mg T3 cyclosporine capsule 25 mg oral 25 mg T3 cyclosporine modified capsule 100 mg oral 100 T3 mg cyclosporine modified capsule 25 mg oral 25 mg T1 everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg T4 PA

97 Drug Status Notes GENGRAF SOLUTION 100 MG/ML ORAL T3 100 MG/ML mycophenolate mofetil capsule 250 mg oral 250 T1 mg mycophenolate mofetil suspension reconstituted T4 200 mg/ml oral 200 mg/ml mycophenolate mofetil tablet 500 mg oral 500 mg T1 mycophenolate sodium tablet delayed release 180 T3 PA mg oral 180 mg mycophenolate sodium tablet delayed release 360 T3 PA mg oral 360 mg penicillamine oral tablet 250 mg T4 RAPAMUNE SOLUTION 1 MG/ML ORAL 1 T4 PA MG/ML REVLIMID CAPSULE 10 MG ORAL 10 MG T4 PA REVLIMID CAPSULE 15 MG ORAL 15 MG T4 PA REVLIMID CAPSULE 2.5 MG ORAL 2.5 T4 PA MG REVLIMID CAPSULE 20 MG ORAL 20 MG T4 PA REVLIMID CAPSULE 25 MG ORAL 25 MG T4 PA REVLIMID CAPSULE 5 MG ORAL 5 MG T4 PA SANDIMMUNE SOLUTION 100 MG/ML T4 PA ORAL 100 MG/ML sirolimus tablet 0.5 mg oral 0.5 mg T4 PA sodium polystyrene sulfonate powder oral T1 SPS ORAL SUSPENSION 15 GM/60ML T1 sterile for irrigation irrigation solution T1 SYPRINE CAPSULE 250 MG ORAL 250 MG T4 tacrolimus capsule 0.5 mg oral 0.5 mg T1 tacrolimus capsule 1 mg oral 1 mg T1 tacrolimus capsule 5 mg oral 5 mg T3 THALOMID CAPSULE 100 MG ORAL 100 T4 PA MG THALOMID CAPSULE 150 MG ORAL 150 T4 PA MG THALOMID CAPSULE 200 MG ORAL 200 T4 PA MG THALOMID CAPSULE 50 MG ORAL 50 T4 PA MG ZORTRESS TABLET 0.75 MG ORAL 0.75 T4 PA MG

98 Drug Status Notes *Mouth/Throat/Dental Agents* cevimeline hcl capsule 30 mg oral 30 mg T3 PA chlorhexidine gluconate solution 0.12 % T1 mouth/throat 0.12 % FLUORIDEX DAILY RENEWAL CONCENTRATE 0.63 % MOUTH/THROAT T1 0.63 % FLUORIDEX 1.1 % DENTAL 1.1 % T1 lidocaine hcl solution 4 % mouth/throat 4 % T1 QL (100 ML per 30 days) nystatin suspension 100000 unit/ml mouth/throat T1 100000 unit/ml ORAVIG TABLET 50 MG BUCCAL 50 MG T4 PA pilocarpine hcl tablet 5 mg oral 5 mg T1 pilocarpine hcl tablet 7.5 mg oral 7.5 mg T1 sf 5000 plus cream 1.1 % dental 1.1 % T1 sf dental gel 1.1 % T1 triamcinolone acetonide paste 0.1 % mouth/throat T3 QL (5 GM per 30 days) 0.1 % *Multivitamins* multivitamin/fluoride solution 0.25 mg/ml oral T1 (rx) 0.25 mg/ml prenatal tablet 27-0.8 mg oral (otc) 27-0.8 mg T5 TARON-PREX CAPSULE 30-1.2-265 MG T1 ORAL 30-1.2-265 MG thrivite 19 tablet 1 mg oral 1 mg T5 vitamins acd-fluoride solution 0.25 mg/ml oral T1 0.25 mg/ml *Musculoskeletal Therapy Agents* baclofen tablet 10 mg oral 10 mg T1 baclofen tablet 20 mg oral 20 mg T1 carisoprodol tablet 350 mg oral 350 mg T1 chlorzoxazone oral tablet 375 mg T3 chlorzoxazone tablet 500 mg oral 500 mg T1 AL (Max 64 Years) cyclobenzaprine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years) cyclobenzaprine hcl tablet 5 mg oral 5 mg T1 AL (Max 64 Years) dantrolene sodium capsule 100 mg oral 100 mg T1 dantrolene sodium capsule 25 mg oral 25 mg T1 dantrolene sodium capsule 50 mg oral 50 mg T1 metaxalone tablet 800 mg oral 800 mg T3 PA; AL (Max 64 Years) methocarbamol tablet 500 mg oral 500 mg T1 AL (Max 64 Years) 99 Drug Status Notes methocarbamol tablet 750 mg oral 750 mg T1 AL (Max 64 Years) orphenadrine citrate er tablet extended release 12 T1 AL (Max 64 Years) hour 100 mg oral 100 mg tizanidine hcl capsule 2 mg oral 2 mg T3 QL (90 EA per 30 days) tizanidine hcl capsule 4 mg oral 4 mg T3 QL (90 EA per 30 days) tizanidine hcl capsule 6 mg oral 6 mg T3 QL (90 EA per 30 days) tizanidine hcl tablet 2 mg oral 2 mg T1 QL (90 EA per 30 days) tizanidine hcl tablet 4 mg oral 4 mg T1 QL (90 EA per 30 days) *Nasal Agents - Systemic And Topical* allergy spray 24 hour aerosol 55 mcg/act nasal T1 QL (16.9 ML per 30 days) 55 mcg/act azelastine hcl solution 0.1 % nasal 0.1 % T1 azelastine hcl solution 0.15 % nasal 0.15 % T3 ST BECONASE AQ SUSPENSION 42 T3 ST MCG/SPRAY NASAL 42 MCG/SPRAY cvs nasal allergy spray aerosol 55 mcg/act nasal T1 QL (16.9 ML per 30 days) 55 mcg/act eq nasal allergy aerosol 55 mcg/act nasal 55 T1 QL (16.9 ML per 30 days) mcg/act FLONASE SENSIMIST SUSPENSION 27.5 T1 QL (15.8 ML per 30 days) MCG/SPRAY NASAL 27.5 MCG/SPRAY flunisolide solution 25 mcg/act (0.025%) nasal 25 T1 QL (50 ML per 30 days) mcg/act (0.025%) fluticasone propionate nasal suspension 50 T1 QL (16 GM per 30 days) mcg/act gnp 24 hour nasal allergy aerosol 55 mcg/act T1 QL (16.9 ML per 30 days) nasal 55 mcg/act goodsense nasal allergy spray aerosol 55 mcg/act T1 QL (16.9 ML per 30 days) nasal 55 mcg/act ipratropium bromide solution 0.03 % nasal 0.03 T1 QL (30 ML per 30 days) % ipratropium bromide solution 0.06 % nasal 0.06 T1 QL (15 ML per 30 days) % mometasone furoate suspension 50 mcg/act nasal T3 ST 50 mcg/act nasal allergy 24 hour aerosol 55 mcg/act nasal T1 QL (16.9 ML per 30 days) 55 mcg/act QNASL AEROSOL SOLUTION 80 T3 ST MCG/ACT NASAL 80 MCG/ACT ra nasal allergy aerosol 55 mcg/act nasal 55 T1 QL (16.9 ML per 30 days) mcg/act

100 Drug Status Notes triamcinolone acetonide aerosol 55 mcg/act nasal T1 QL (16.9 GM per 30 days) (otc) 55 mcg/act triamcinolone acetonide aerosol 55 mcg/act nasal T1 QL (16.9 GM per 30 days) (rx) 55 mcg/act *Neuromuscular Agents* riluzole oral tablet 50 mg T1 *Nutrients* nac capsule 600 mg oral 600 mg T1 *Ophthalmic Agents* ACUVAIL SOLUTION 0.45 % T3 OPHTHALMIC 0.45 % ALOCRIL SOLUTION 2 % OPHTHALMIC T3 PA 2 % ALOMIDE SOLUTION 0.1 % T3 PA OPHTHALMIC 0.1 % ALPHAGAN P SOLUTION 0.1 % T3 OPHTHALMIC 0.1 % ALTACAINE SOLUTION 0.5 % T1 OPHTHALMIC 0.5 % apraclonidine hcl solution 0.5 % ophthalmic 0.5 T3 % atropine sulfate ointment 1 % ophthalmic 1 % T1 atropine sulfate solution 1 % ophthalmic 1 % T1 AZASITE SOLUTION 1 % OPHTHALMIC 1 T3 PA % azelastine hcl solution 0.05 % ophthalmic 0.05 % T1 QL (6 ML per 30 days) bacitracin ointment 500 unit/gm ophthalmic 500 T1 unit/gm bacitracin-polymyxin b ointment 500-10000 T1 unit/gm ophthalmic 500-10000 unit/gm bacitra-neomycin-polymyxin-hc ointment 1 % T1 ophthalmic 1 % balanced salt solution intraocular T1 bepotastine besilate ophthalmic solution 1.5 % T3 PA BESIVANCE SUSPENSION 0.6 % T3 OPHTHALMIC 0.6 % betaxolol hcl solution 0.5 % ophthalmic 0.5 % T1 BETOPTIC-S SUSPENSION 0.25 % T2 PA OPHTHALMIC 0.25 % bimatoprost ophthalmic solution 0.03 % T1 QL (5 ML per 30 days)

101 Drug Status Notes BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % T2 OPHTHALMIC 10-0.2 % brimonidine tartrate solution 0.15 % ophthalmic T3 0.15 % brimonidine tartrate solution 0.2 % ophthalmic T1 0.2 % brinzolamide ophthalmic suspension 1 % T3 QL (15 ML per 30 days) bromfenac sodium (once-daily) solution 0.09 % T3 ophthalmic 0.09 % carteolol hcl solution 1 % ophthalmic 1 % T1 CILOXAN OINTMENT 0.3 % T3 OPHTHALMIC 0.3 % ciprofloxacin hcl solution 0.3 % ophthalmic 0.3 T1 % COMBIGAN SOLUTION 0.2-0.5 % T3 OPHTHALMIC 0.2-0.5 % cromolyn sodium solution 4 % ophthalmic 4 % T1 cvs sodium chloride ointment 5 % ophthalmic 5 % T1 cyclopentolate hcl solution 1 % ophthalmic 1 % T1 cyclopentolate hcl solution 2 % ophthalmic 2 % T1 CYSTARAN SOLUTION 0.44 % T4 OPHTHALMIC 0.44 % dexamethasone sodium phosphate solution 0.1 % T1 ophthalmic 0.1 % diclofenac sodium solution 0.1 % ophthalmic 0.1 T1 % dorzolamide hcl solution 2 % ophthalmic 2 % T1 dorzolamide hcl-timolol mal solution 22.3-6.8 T1 mg/ml ophthalmic 22.3-6.8 mg/ml DUREZOL 0.05 % T3 OPHTHALMIC 0.05 % epinastine hcl solution 0.05 % ophthalmic 0.05 % T3 erythromycin ointment 5 mg/gm ophthalmic 5 T1 mg/gm eye allergy relief ophthalmic solution 0.025-0.3 % T1 FLAREX SUSPENSION 0.1 % T3 OPHTHALMIC 0.1 % FLUCAINE SOLUTION 0.25-0.5 % T1 OPHTHALMIC 0.25-0.5 % fluorometholone suspension 0.1 % ophthalmic 0.1 T1 %

102 Drug Status Notes flurbiprofen sodium solution 0.03 % ophthalmic T1 0.03 % FML OINTMENT 0.1 % OPHTHALMIC 0.1 T2 % gatifloxacin solution 0.5 % ophthalmic 0.5 % T3 GENTAK OPHTHALMIC OINTMENT 0.3 T1 % gentamicin sulfate solution 0.3 % ophthalmic 0.3 T1 % HOMATROPAIRE OPHTHALMIC T1 SOLUTION 5 % IOPIDINE SOLUTION 1 % OPHTHALMIC T3 1 % ketorolac tromethamine solution 0.4 % T1 ophthalmic 0.4 % ketorolac tromethamine solution 0.5 % T1 ophthalmic 0.5 % LACRISERT INSERT 5 MG OPHTHALMIC T3 PA 5 MG LASTACAFT SOLUTION 0.25 % T3 PA OPHTHALMIC 0.25 % latanoprost solution 0.005 % ophthalmic 0.005 % T1 QL (5 ML per 30 days) levobunolol hcl solution 0.5 % ophthalmic 0.5 % T1 levofloxacin ophthalmic solution 0.5 % T1 LOTEMAX OINTMENT 0.5 % T3 OPHTHALMIC 0.5 % LOTEMAX SUSPENSION 0.5 % T3 OPHTHALMIC 0.5 % LUMIGAN SOLUTION 0.01 % T3 ST; QL (7.5 ML per 30 days) OPHTHALMIC 0.01 % moxifloxacin hcl (2x day) ophthalmic solution 0.5 T3 % moxifloxacin hcl ophthalmic solution 0.5 % T1 NATACYN SUSPENSION 5 % T3 PA OPHTHALMIC 5 % neomycin-bacitracin zn-polymyx ointment 5-400- T1 10000 ophthalmic 5-400-10000 neomycin-polymyxin-dexameth ointment 3.5- T1 10000-0.1 ophthalmic 3.5-10000-0.1 neomycin-polymyxin-dexameth suspension 3.5- T1 10000-0.1 ophthalmic 3.5-10000-0.1 neomycin-polymyxin-gramicidin solution 1.75- T1 10000-.025 ophthalmic 1.75-10000-.025 103 Drug Status Notes neomycin-polymyxin-hc suspension 3.5-10000-1 T1 ophthalmic 3.5-10000-1 NEVANAC SUSPENSION 0.1 % T3 OPHTHALMIC 0.1 % ofloxacin solution 0.3 % ophthalmic 0.3 % T1 olopatadine hcl solution 0.1 % ophthalmic (rx) T1 0.1 % olopatadine hcl solution 0.2 % ophthalmic (rx) T3 PA 0.2 % PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED 0.125 % OPHTHALMIC T2 PA 0.125 % pilocarpine hcl solution 1 % ophthalmic 1 % T1 pilocarpine hcl solution 2 % ophthalmic 2 % T1 pilocarpine hcl solution 4 % ophthalmic 4 % T1 polymyxin b-trimethoprim solution 10000-0.1 T1 unit/ml-% ophthalmic 10000-0.1 unit/ml-% PRED MILD SUSPENSION 0.12 % T2 OPHTHALMIC 0.12 % prednisolone acetate ophthalmic suspension 1 % T1 prednisolone sodium phosphate solution 1 % T1 ophthalmic 1 % proparacaine hcl solution 0.5 % ophthalmic 0.5 T1 % SIMBRINZA SUSPENSION 1-0.2 % T3 QL (8 ML per 30 days) OPHTHALMIC 1-0.2 % sodium chloride (hypertonic) ophthalmic solution T1 5 % sulfacetamide sodium solution 10 % ophthalmic T1 10 % sulfacetamide-prednisolone solution 10-0.23 % T1 ophthalmic 10-0.23 % timolol maleate gel forming solution 0.25 % T3 ophthalmic 0.25 % timolol maleate gel forming solution 0.5 % T3 ophthalmic 0.5 % timolol maleate solution 0.25 % ophthalmic 0.25 T1 % timolol maleate solution 0.5 % ophthalmic 0.5 % T1 TOBRADEX OINTMENT 0.3-0.1 % T3 QL (3.5 GM per 30 days) OPHTHALMIC 0.3-0.1 % TOBRADEX ST SUSPENSION 0.3-0.05 % T2 QL (5 ML per 30 days) OPHTHALMIC 0.3-0.05 % 104 Drug Status Notes tobramycin solution 0.3 % ophthalmic 0.3 % T1 tobramycin-dexamethasone suspension 0.3-0.1 % T1 QL (5 ML per 30 days) ophthalmic 0.3-0.1 % TOBREX OINTMENT 0.3 % OPHTHALMIC T2 0.3 % travoprost (bak free) ophthalmic solution 0.004 % T3 ST; QL (5 ML per 30 days) trifluridine solution 1 % ophthalmic 1 % T3 tropicamide solution 0.5 % ophthalmic 0.5 % T1 tropicamide solution 1 % ophthalmic 1 % T1 ZIOPTAN SOLUTION 0.0015 % T3 ST; QL (30 EA per 30 days) OPHTHALMIC 0.0015 % ZIRGAN GEL 0.15 % OPHTHALMIC 0.15 T3 % *Otic Agents* ACETASOL HC SOLUTION 2-1 % OTIC 2-1 T3 % acetic acid solution 2 % otic 2 % T1 CIPRO HC SUSPENSION 0.2-1 % OTIC 0.2- T3 PA 1 % ciprofloxacin-dexamethasone otic suspension 0.3- T3 0.1 % fluocinolone acetonide oil 0.01 % otic 0.01 % T3 neomycin-polymyxin-hc solution 3.5-10000-1 otic T1 3.5-10000-1 neomycin-polymyxin-hc suspension 3.5-10000-1 T1 otic 3.5-10000-1 ofloxacin solution 0.3 % otic 0.3 % T1 *Oxytocics* methylergonovine maleate oral tablet 0.2 mg T2 *Passive Immunizing And Treatment Agents* HYPERRHO S/D SOLUTION PREFILLED SYRINGE 1500 UNIT INTRAMUSCULAR T2 GR-F 1500 UNIT HYQVIA KIT 2.5 GM/25ML T4 PA SUBCUTANEOUS 2.5 GM/25ML HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 20 GM/200ML, 30 GM/300ML, 5 T4 PA GM/50ML SYNAGIS SOLUTION 100 MG/ML T4 PA INTRAMUSCULAR 100 MG/ML

105 Drug Status Notes SYNAGIS SOLUTION 50 MG/0.5ML T4 PA INTRAMUSCULAR 50 MG/0.5ML *Penicillins* amoxicillin capsule 250 mg oral 250 mg T1 amoxicillin capsule 500 mg oral 500 mg T1 amoxicillin suspension reconstituted 125 mg/5ml T1 oral 125 mg/5ml amoxicillin suspension reconstituted 200 mg/5ml T1 oral 200 mg/5ml amoxicillin suspension reconstituted 250 mg/5ml T1 oral 250 mg/5ml amoxicillin suspension reconstituted 400 mg/5ml T1 oral 400 mg/5ml amoxicillin tablet 500 mg oral 500 mg T1 amoxicillin tablet 875 mg oral 875 mg T1 amoxicillin tablet chewable 125 mg oral 125 mg T1 amoxicillin tablet chewable 250 mg oral 250 mg T1 amoxicillin-pot clavulanate er tablet extended T3 release 12 hour 1000-62.5 mg oral 1000-62.5 mg amoxicillin-pot clavulanate suspension reconstituted 200-28.5 mg/5ml oral 200-28.5 T1 mg/5ml amoxicillin-pot clavulanate suspension T1 reconstituted 400-57 mg/5ml oral 400-57 mg/5ml amoxicillin-pot clavulanate suspension reconstituted 600-42.9 mg/5ml oral 600-42.9 T1 mg/5ml amoxicillin-pot clavulanate tablet 250-125 mg T1 QL (28 EA per 14 days) oral 250-125 mg amoxicillin-pot clavulanate tablet 500-125 mg T1 QL (28 EA per 14 days) oral 500-125 mg amoxicillin-pot clavulanate tablet 875-125 mg T1 QL (28 EA per 14 days) oral 875-125 mg amoxicillin-pot clavulanate tablet chewable 200- T1 28.5 mg oral 200-28.5 mg amoxicillin-pot clavulanate tablet chewable 400- T1 57 mg oral 400-57 mg ampicillin capsule 500 mg oral 500 mg T1 BICILLIN L-A SUSPENSION 1200000 UNIT/2ML INTRAMUSCULAR 1200000 T4 PA UNIT/2ML

106 Drug Status Notes BICILLIN L-A SUSPENSION 600000 UNIT/ML INTRAMUSCULAR 600000 T4 PA UNIT/ML dicloxacillin sodium capsule 250 mg oral 250 mg T1 dicloxacillin sodium capsule 500 mg oral 500 mg T1 penicillin v potassium solution reconstituted 125 T1 mg/5ml oral 125 mg/5ml penicillin v potassium solution reconstituted 250 T1 mg/5ml oral 250 mg/5ml penicillin v potassium tablet 250 mg oral 250 mg T1 penicillin v potassium tablet 500 mg oral 500 mg T1 *Pharmaceutical Adjuvants* cherry oral syrup T1 flavor sweet oral syrup T1 ORA-BLEND ORAL SUSPENSION T1 ORA-PLUS ORAL LIQUID T1 ORA-SWEET ORAL SYRUP T1 simple syrup oral syrup T1 *Progestins* hydroxyprogesterone caproate intramuscular oil T4 PA; GR-F 250 mg/ml medroxyprogesterone acetate tablet 10 mg oral T1 10 mg medroxyprogesterone acetate tablet 2.5 mg oral T1 2.5 mg medroxyprogesterone acetate tablet 5 mg oral 5 T1 mg norethindrone acetate tablet 5 mg oral 5 mg T1 progesterone micronized oral capsule 100 mg, T2 GR-F 200 mg *Psychotherapeutic And Neurological Agents - Misc.* acamprosate calcium oral tablet delayed release T1 333 mg AMPYRA ORAL TABLET EXTENDED T4 PA RELEASE 12 HOUR 10 MG apo-varenicline oral tablet 0.5 mg, 1 mg T5 QL (60 EA per 30 days) AUBAGIO TABLET 14 MG ORAL 14 MG T4 PA AUBAGIO TABLET 7 MG ORAL 7 MG T4 PA

107 Drug Status Notes AVONEX PEN AUTO-INJECTOR KIT 30 MCG/0.5ML INTRAMUSCULAR 30 T4 PA MCG/0.5ML AVONEX PREFILLED PREFILLED SYRINGE KIT 30 MCG/0.5ML T4 PA INTRAMUSCULAR 30 MCG/0.5ML bupropion hcl er (smoking det) tablet extended T5 release 12 hour 150 mg oral 150 mg CHANTIX CONTINUING MONTH PAK T5 QL (60 EA per 30 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG T5 QL (60 EA per 30 days) CHANTIX STARTING MONTH PAK ORAL T5 QL (60 EA per 30 days) TABLET 0.5 MG X 11 & 1 MG X 42 chlordiazepoxide-amitriptyline tablet 10-25 mg T1 oral 10-25 mg chlordiazepoxide-amitriptyline tablet 5-12.5 mg T1 oral 5-12.5 mg dalfampridine er oral tablet extended release 12 T4 PA hour 10 mg dimethyl fumarate oral capsule delayed release T4 PA 120 mg, 240 mg disulfiram tablet 250 mg oral 250 mg T1 disulfiram tablet 500 mg oral 500 mg T1 donepezil hcl tablet 10 mg oral 10 mg T1 donepezil hcl tablet 23 mg oral 23 mg T3 donepezil hcl tablet 5 mg oral 5 mg T1 donepezil hcl tablet dispersible 10 mg oral 10 mg T1 donepezil hcl tablet dispersible 5 mg oral 5 mg T1 ergoloid mesylates tablet 1 mg oral 1 mg T3 PA galantamine hydrobromide er capsule extended T3 release 24 hour 16 mg oral 16 mg galantamine hydrobromide er capsule extended T3 release 24 hour 24 mg oral 24 mg galantamine hydrobromide er capsule extended T3 release 24 hour 8 mg oral 8 mg galantamine hydrobromide tablet 12 mg oral 12 T1 mg galantamine hydrobromide tablet 4 mg oral 4 mg T1 galantamine hydrobromide tablet 8 mg oral 8 mg T1 GILENYA CAPSULE 0.5 MG ORAL 0.5 MG T4 PA glatiramer acetate subcutaneous solution T4 PA prefilled syringe 40 mg/ml

108 Drug Status Notes GLATOPA SOLUTION PREFILLED SYRINGE 20 MG/ML SUBCUTANEOUS 20 T4 PA MG/ML MAYZENT ORAL TABLET 0.25 MG, 2 MG T4 PA memantine hcl solution 2 mg/ml oral 2 mg/ml T3 PA memantine hcl tablet 10 mg oral 10 mg T1 QL (60 EA per 30 days) memantine hcl tablet 28 x 5 mg & 21 x 10 mg oral T1 QL (49 EA per 365 days) 28 x 5 mg & 21 x 10 mg memantine hcl tablet 5 mg oral 5 mg T1 QL (60 EA per 30 days) NICORETTE MOUTH/ T5 QL (270 EA per 30 days) 4 MG nicotine mini mouth/throat lozenge 2 mg T5 QL (270 EA per 30 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg T5 QL (810 EA per 365 days) nicotine transdermal patch 24 hour 14 mg/24hr, T5 QL (90 EA per 365 days) 21 mg/24hr, 7 mg/24hr NICOTROL INHALATION 10 T5 QL (168 EA per 30 days) MG NUEDEXTA CAPSULE 20-10 MG ORAL 20- T4 PA 10 MG olanzapine-fluoxetine hcl oral capsule 12-25 mg, T3 PA 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg perphenazine-amitriptyline tablet 2-10 mg oral 2- T1 10 mg perphenazine-amitriptyline tablet 2-25 mg oral 2- T1 25 mg perphenazine-amitriptyline tablet 4-10 mg oral 4- T1 10 mg perphenazine-amitriptyline tablet 4-25 mg oral 4- T1 25 mg perphenazine-amitriptyline tablet 4-50 mg oral 4- T1 50 mg pimozide tablet 1 mg oral 1 mg T3 PA pimozide tablet 2 mg oral 2 mg T3 PA rivastigmine patch 24 hour 13.3 mg/24hr T3 PA transdermal 13.3 mg/24hr rivastigmine patch 24 hour 4.6 mg/24hr T3 PA transdermal 4.6 mg/24hr rivastigmine patch 24 hour 9.5 mg/24hr T3 PA transdermal 9.5 mg/24hr rivastigmine tartrate capsule 1.5 mg oral 1.5 mg T3 rivastigmine tartrate capsule 3 mg oral 3 mg T3 rivastigmine tartrate capsule 4.5 mg oral 4.5 mg T3

109 Drug Status Notes rivastigmine tartrate capsule 6 mg oral 6 mg T3 SAVELLA TABLET 100 MG ORAL 100 MG T3 PA SAVELLA TABLET 12.5 MG ORAL 12.5 MG T3 PA SAVELLA TABLET 25 MG ORAL 25 MG T3 PA SAVELLA TABLET 50 MG ORAL 50 MG T3 PA tetrabenazine tablet 12.5 mg oral 12.5 mg T4 PA tetrabenazine tablet 25 mg oral 25 mg T4 PA XYREM SOLUTION 500 MG/ML ORAL 500 T4 PA MG/ML *Respiratory Agents - Misc.* ESBRIET CAPSULE 267 MG ORAL 267 MG T4 PA KALYDECO TABLET 150 MG ORAL 150 T4 PA MG OFEV CAPSULE 100 MG ORAL 100 MG T4 PA OFEV CAPSULE 150 MG ORAL 150 MG T4 PA PULMOZYME SOLUTION 1 MG/ML T4 PA; QL (60 ML per 30 days) INHALATION 1 MG/ML *Sulfonamides* sulfadiazine tablet 500 mg oral 500 mg T3 *Tetracyclines* demeclocycline hcl tablet 150 mg oral 150 mg T3 demeclocycline hcl tablet 300 mg oral 300 mg T3 doxycycline hyclate capsule 100 mg oral 100 mg T1 doxycycline hyclate capsule 50 mg oral 50 mg T1 doxycycline hyclate tablet 100 mg oral 100 mg T1 doxycycline hyclate tablet 20 mg oral 20 mg T1 doxycycline monohydrate capsule 150 mg oral T3 150 mg doxycycline monohydrate oral capsule 75 mg T3 PA doxycycline monohydrate suspension T1 reconstituted 25 mg/5ml oral 25 mg/5ml doxycycline monohydrate tablet 100 mg oral 100 T1 mg doxycycline monohydrate tablet 150 mg oral 150 T3 mg doxycycline monohydrate tablet 50 mg oral 50 mg T1 doxycycline monohydrate tablet 75 mg oral 75 mg T1 minocycline hcl capsule 100 mg oral 100 mg T1 minocycline hcl capsule 50 mg oral 50 mg T1

110 Drug Status Notes minocycline hcl capsule 75 mg oral 75 mg T1 tetracycline hcl capsule 250 mg oral 250 mg T3 tetracycline hcl capsule 500 mg oral 500 mg T3 *Thyroid Agents* ARMOUR THYROID ORAL TABLET 180 T1 MG, 240 MG, 300 MG, 90 MG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 T1 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium tablet 25 mcg oral 25 mcg T1 liothyronine sodium tablet 5 mcg oral 5 mcg T1 liothyronine sodium tablet 50 mcg oral 50 mcg T1 methimazole tablet 10 mg oral 10 mg T1 methimazole tablet 5 mg oral 5 mg T1 NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 16.25 MG, 162.5 MG, 260 T1 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG NATURE-THROID TABLET 130 MG ORAL T1 130 MG NATURE-THROID TABLET 195 MG ORAL T1 195 MG NATURE-THROID TABLET 32.5 MG ORAL T1 32.5 MG np thyroid oral tablet 120 mg, 15 mg, 30 mg T1 propylthiouracil tablet 50 mg oral 50 mg T1 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 T2 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG WESTHROID TABLET 65 MG ORAL 65 T1 MG *Ulcer Drugs/Antispasmodics/Anticholinergics * belladonna alkaloids-opium suppository 16.2-30 QL (12 EA per 30 days); AL (Max T3 mg rectal 16.2-30 mg 64 Years) belladonna alkaloids-opium suppository 16.2-60 QL (12 EA per 30 days); AL (Max T3 mg rectal 16.2-60 mg 64 Years) CARAFATE ORAL SUSPENSION 1 T3 GM/10ML cimetidine hcl solution 300 mg/5ml oral 300 T1 mg/5ml

111 Drug Status Notes cimetidine oral tablet 200 mg T1 cimetidine tablet 300 mg oral 300 mg T1 cimetidine tablet 400 mg oral 400 mg T1 cimetidine tablet 800 mg oral 800 mg T1 dicyclomine hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years) dicyclomine hcl solution 10 mg/5ml oral 10 T1 AL (Max 64 Years) mg/5ml dicyclomine hcl tablet 20 mg oral 20 mg T1 AL (Max 64 Years) famotidine oral tablet 20 mg T1 famotidine suspension reconstituted 40 mg/5ml T1 AL (Max 12 Years) oral 40 mg/5ml famotidine tablet 40 mg oral 40 mg T1 FIRST-LANSOPRAZOLE SUSPENSION 3 T1 QL (150 ML per 30 days) MG/ML ORAL 3 MG/ML glycopyrrolate tablet 1 mg oral 1 mg T1 glycopyrrolate tablet 2 mg oral 2 mg T1 hyoscyamine sulfate sl tablet sublingual 0.125 mg T1 AL (Max 64 Years) sublingual 0.125 mg hyoscyamine sulfate tablet 0.125 mg oral 0.125 T1 AL (Max 64 Years) mg hyoscyamine sulfate tablet dispersible 0.125 mg T1 AL (Max 64 Years) oral 0.125 mg hyosyne elixir 0.125 mg/5ml oral 0.125 mg/5ml T1 AL (Max 64 Years) hyosyne solution 0.125 mg/ml oral 0.125 mg/ml T1 AL (Max 64 Years) lansoprazole capsule delayed release 30 mg oral T2 QL (30 EA per 30 days) 30 mg lansoprazole oral capsule delayed release 15 mg T1 QL (60 EA per 30 days) methscopolamine bromide oral tablet 2.5 mg, 5 T3 AL (Max 64 Years) mg misoprostol tablet 100 mcg oral 100 mcg T1 misoprostol tablet 200 mcg oral 200 mcg T1 nizatidine capsule 150 mg oral 150 mg T1 nizatidine capsule 300 mg oral 300 mg T1 nizatidine solution 15 mg/ml oral 15 mg/ml T1 omeprazole capsule delayed release 10 mg oral T1 QL (60 EA per 30 days) 10 mg omeprazole capsule delayed release 20 mg oral T1 QL (60 EA per 30 days) (rx) 20 mg omeprazole capsule delayed release 40 mg oral T1 QL (60 EA per 30 days) 40 mg

112 Drug Status Notes pantoprazole sodium tablet delayed release 20 mg T1 QL (60 EA per 30 days) oral 20 mg pantoprazole sodium tablet delayed release 40 mg T1 QL (60 EA per 30 days) oral 40 mg propantheline bromide tablet 15 mg oral 15 mg T1 rabeprazole sodium oral tablet delayed release 20 T1 QL (30 EA per 30 days) mg sucralfate tablet 1 gm oral 1 gm T1 SYMAX DUOTAB TABLET EXTENDED T1 AL (Max 64 Years) RELEASE 0.375 MG ORAL 0.375 MG SYMAX-SR TABLET EXTENDED RELEASE 12 HOUR 0.375 MG ORAL 0.375 T1 AL (Max 64 Years) MG *Urinary Anti-Infectives* urin ds oral tablet T1 *Urinary Antispasmodics* bethanechol chloride tablet 10 mg oral 10 mg T1 bethanechol chloride tablet 25 mg oral 25 mg T1 bethanechol chloride tablet 5 mg oral 5 mg T1 bethanechol chloride tablet 50 mg oral 50 mg T1 darifenacin hydrobromide er tablet extended T2 ST release 24 hour 15 mg oral 15 mg darifenacin hydrobromide er tablet extended T2 ST release 24 hour 7.5 mg oral 7.5 mg flavoxate hcl tablet 100 mg oral 100 mg T1 oxybutynin chloride er oral tablet extended T1 release 24 hour 5 mg oxybutynin chloride er tablet extended release 24 T1 hour 10 mg oral 10 mg oxybutynin chloride er tablet extended release 24 T1 hour 15 mg oral 15 mg oxybutynin chloride oral syrup 5 mg/5ml T1 oxybutynin chloride tablet 5 mg oral 5 mg T1 OXYTROL FOR WOMEN PATCH TWICE WEEKLY 3.9 MG/24HR TRANSDERMAL T1 3.9 MG/24HR solifenacin succinate oral tablet 10 mg, 5 mg T3 ST tolterodine tartrate er capsule extended release T2 ST 24 hour 2 mg oral 2 mg tolterodine tartrate er capsule extended release T2 ST 24 hour 4 mg oral 4 mg tolterodine tartrate tablet 1 mg oral 1 mg T1 ST 113 Drug Status Notes tolterodine tartrate tablet 2 mg oral 2 mg T1 ST TOVIAZ TABLET EXTENDED RELEASE T2 ST 24 HOUR 4 MG ORAL 4 MG TOVIAZ TABLET EXTENDED RELEASE T2 ST 24 HOUR 8 MG ORAL 8 MG trospium chloride er capsule extended release 24 T1 ST hour 60 mg oral 60 mg trospium chloride tablet 20 mg oral 20 mg T1 ST VESICARE TABLET 10 MG ORAL 10 MG T3 ST VESICARE TABLET 5 MG ORAL 5 MG T3 ST *Vaccines* AFLURIA QUADRIVALENT QL (0.5 ML per 365 days); AL T5 INTRAMUSCULAR SUSPENSION (Min 6 Months) AFLURIA QUADRIVALENT QL (0.25 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 6 Months and Max 35 PREFILLED SYRINGE 0.25 ML Months) AFLURIA QUADRIVALENT QL (0.5 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 6 Months) PREFILLED SYRINGE 0.5 ML FLUAD INTRAMUSCULAR SUSPENSION QL (0.5 ML per 365 days); AL T5 PREFILLED SYRINGE 0.5 ML (Min 65 Years) FLUAD QUADRIVALENT QL (0.5 ML per 365 days); AL INTRAMUSCULAR PREFILLED SYRINGE T5 (Min 65 Years) 0.5 ML FLUARIX QUADRIVALENT QL (0.5 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 6 Months) PREFILLED SYRINGE 0.5 ML FLULAVAL QUADRIVALENT QL (0.5 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 6 Months) PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE QUADRIVALENT QL (0.7 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 65 Years) PREFILLED SYRINGE 0.7 ML FLUZONE QUADRIVALENT QL (0.5 ML per 365 days); AL T5 INTRAMUSCULAR SUSPENSION , 0.5 ML (Min 6 Months) FLUZONE QUADRIVALENT QL (0.5 ML per 365 days); AL INTRAMUSCULAR SUSPENSION T5 (Min 6 Months) PREFILLED SYRINGE 0.5 ML SHINGRIX INTRAMUSCULAR QL (2 EA per 1 lifetime); AL (Min SUSPENSION RECONSTITUTED 50 T5 50 Years) MCG/0.5ML *Vaginal And Related Products* CLEOCIN SUPPOSITORY 100 MG T3 VAGINAL 100 MG 114 Drug Status Notes clindamycin phosphate cream 2 % vaginal 2 % T1 clotrimazole vaginal cream 1 % T1 QL (50 GM per 30 days) CRINONE GEL 4 % VAGINAL 4 % T4 PA CRINONE GEL 8 % VAGINAL 8 % T4 PA ENDOMETRIN INSERT 100 MG VAGINAL T3 PA 100 MG estradiol tablet 10 mcg vaginal 10 mcg T3 GR-F estradiol vaginal cream 0.1 mg/gm T2 ESTRING RING 2 MG VAGINAL 2 MG T3 FIRST-PROGESTERONE VGS T2 GR-F; QL (30 EA per 30 days) SUPPOSITORY 100 MG VAGINAL 100 MG FIRST-PROGESTERONE VGS T2 GR-F; QL (30 EA per 30 days) SUPPOSITORY 200 MG VAGINAL 200 MG GYNAZOLE-1 CREAM 2 % VAGINAL 2 % T3 metronidazole vaginal gel 0.75 % T1 miconazole 3 applicator vaginal kit 200 & 2 mg- T1 % (9gm) miconazole 3 combo pack vaginal kit 200 & 2 T1 mg-% (9gm) terconazole cream 0.4 % vaginal 0.4 % T1 terconazole vaginal cream 0.8 % T1 terconazole vaginal suppository 80 mg T1 *Vasopressors* ADRENALIN SOLUTION 1 MG/ML T1 QL (2 ML per 90 days) INJECTION 1 MG/ML epinephrine solution auto-injector 0.15 T1 QL (2 EA per 30 days) mg/0.15ml injection 0.15 mg/0.15ml epinephrine solution auto-injector 0.15 mg/0.3ml T1 QL (2 EA per 30 days) injection 0.15 mg/0.3ml epinephrine solution auto-injector 0.3 mg/0.3ml T1 QL (2 EA per 30 days) injection 0.3 mg/0.3ml midodrine hcl tablet 10 mg oral 10 mg T1 midodrine hcl tablet 2.5 mg oral 2.5 mg T1 midodrine hcl tablet 5 mg oral 5 mg T1 SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 T1 QL (2 EA per 30 days) MG/0.3ML *Vitamins* ascorbic acid solution 500 mg/ml injection 500 T1 mg/ml niacin oral tablet 500 mg T1

115 Drug Status Notes phytonadione oral tablet 5 mg T2 PA pyridoxine hcl solution 100 mg/ml injection 100 T3 mg/ml REPLESTA CHILDRENS WAFER 350 MCG T5 (14000 UT) ORAL 350 MCG (14000 UT) THERA-D 4000 TABLET 100 MCG (4000 T5 UT) ORAL 100 MCG (4000 UT) vitamin d (cholecalciferol) oral capsule 25 mcg T5 QL (60 EA per 30 days) (1000 ut) vitamin d (ergocalciferol) capsule 1.25 mg T1 (50000 ut) oral 1.25 mg (50000 ut) vitamin d oral capsule 50 mcg (2000 ut) T5 QL (60 EA per 30 days) vitamin d3 capsule 250 mcg (10000 ut) oral 250 T5 QL (60 EA per 30 days) mcg (10000 ut) vitamin d3 oral capsule 1.25 mg (50000 ut) T2 QL (4 EA per 28 days) vitamin d3 oral capsule 10 mcg (400 unit), 125 T5 QL (60 EA per 30 days) mcg (5000 ut) vitamin d3 tablet 10 mcg (400 unit) oral 10 mcg T5 (400 unit) vitamin d3 tablet 125 mcg (5000 ut) oral 125 mcg T5 (5000 ut) vitamin d3 tablet 25 mcg (1000 ut) oral 25 mcg T5 (1000 ut) vitamin d3 tablet 50 mcg (2000 ut) oral 50 mcg T5 (2000 ut) vitamin d3 tablet chewable 25 mcg (1000 ut) oral T5 25 mcg (1000 ut)

116 Index abacavir sulfate...... 57 alprazolam...... 13 aripiprazole...... 53 abacavir sulfate-lamivudine...... 57 alprazolam er...... 13 armodafinil...... 1 abacavir-lamivudine-zidovudine 57 alprazolam xr...... 13 ARMOUR THYROID...... 111 ABILIFY MAINTENA...... 53 alprostadil...... 97 ARNUITY ELLIPTA...... 16 abiraterone acetate...... 47 ALTABAX...... 71 ascorbic acid...... 115 acamprosate calcium...... 107 ALTACAINE...... 101 ASMANEX (120 METERED acarbose...... 28 amantadine hcl...... 51 DOSES)...... 16 acebutolol hcl...... 61 ambrisentan...... 65 ASMANEX (7 METERED acetaminophen-codeine...... 6 amcinonide...... 71 DOSES)...... 16 acetaminophen-codeine #2...... 6 amiloride hcl...... 80 ASMANEX HFA...... 16 acetaminophen-codeine #3...... 6 amiloride-hydrochlorothiazide... 80 ASPERCREME LIDOCAINE 72 acetaminophen-codeine #4...... 6 aminoacetic acid...... 88 ASPERCREME ACETASOL HC...... 105 aminocaproic acid...... 92 W/LIDOCAINE...... 72 acetazolamide...... 80 amiodarone hcl...... 14 aspirin...... 6 acetazolamide er...... 80 AMITIZA...... 87 aspirin 81...... 5 acetic acid...... 88, 105 amitriptyline hcl...... 24 aspirin ec...... 6 acetylcysteine...... 34, 70 amlodipine besy-benazepril hcl.. 39 aspirin ec low dose...... 6 acitretin...... 71 amlodipine besylate...... 62 aspirin-dipyridamole er...... 89 acne treatment...... 71 amlodipine besylate-valsartan....39 atazanavir sulfate...... 57 ACTIMMUNE...... 47 amlodipine-olmesartan...... 39 atenolol...... 61 ACUVAIL...... 101 ammonium lactate...... 71 atenolol-chlorthalidone...... 39 acyclovir...... 57, 71 amoxapine...... 24 atomoxetine hcl...... 1 adapalene...... 71 amoxicillin...... 106 atorvastatin calcium...... 37 adapalene-benzoyl peroxide...... 71 amoxicillin-pot clavulanate...... 106 atovaquone...... 44 adefovir dipivoxil...... 57 amoxicillin-pot clavulanate er..106 atovaquone-proguanil hcl...... 46 ADEMPAS...... 65 amphetamine-dextroamphet er..... 1 atropine sulfate...... 101 ADRENALIN...... 115 amphetamine- ATROVENT HFA...... 16 ADVAIR HFA...... 15 dextroamphetamine...... 1 AUBAGIO...... 107 AFEDITAB CR...... 62 ampicillin...... 106 AVANDIA...... 28 AFINITOR...... 47 AMPYRA...... 107 AVITA...... 72 AFLURIA QUADRIVALENT ANADROL-50...... 10 AVONEX PEN...... 108 ...... 114 anagrelide hcl...... 89 AVONEX PREFILLED...... 108 AKYNZEO...... 35 ANALPRAM-HC...... 11 AZASAN...... 97 albendazole...... 12 anastrozole...... 47 AZASITE...... 101 albuterol sulfate...... 15 ANDRODERM...... 10, 11 azathioprine...... 97 albuterol sulfate er...... 15 ANECREAM...... 71 azelastine hcl...... 100, 101 alclometasone dipropionate...... 71 ANORO ELLIPTA...... 16 azithromycin...... 94 alendronate sodium...... 81 ANZEMET...... 35 b-6 folic acid...... 90 alfuzosin hcl er...... 88 apo-varenicline...... 107 BAC...... 6 ALINIA...... 44 apraclonidine hcl...... 101 bacitracin...... 101 aliskiren fumarate...... 39 aprepitant...... 35 bacitracin-polymyxin b...... 101 allergy spray 24 hour...... 100 APRISO...... 87 bacitra-neomycin-polymyxin-hc101 allopurinol...... 89 APTIOM...... 21 baclofen...... 99 almotriptan malate...... 95 APTIVUS...... 57 balanced salt...... 101 ALOCRIL...... 101 ARANELLE...... 67 BALCOLTRA...... 67 alogliptin benzoate...... 28 ARANESP (ALBUMIN balsalazide disodium...... 87 alogliptin-metformin hcl...... 28 FREE)...... 90 BALZIVA...... 67 alogliptin-pioglitazone...... 28 ARCALYST...... 3 BARACLUDE...... 57 ALOMIDE...... 101 ARCAPTA NEOHALER...... 16 BASIS OVERNIGHT...... 72 alosetron hcl...... 87 arformoterol tartrate...... 16 BD INSULIN SYRINGE...... 94 ALPHAGAN P...... 101 ARGYLE STERILE SALINE. 88 117 BD PEN NEEDLE bupropion hcl er (xl)...... 25 cephalexin...... 67 ORIGINAL U/F...... 94 buspirone hcl...... 13 CEPROTIN...... 89 BD SAFETYGLIDE butalbital-acetaminophen...... 6 cetirizine hcl...... 36 INSULIN SYRINGE...... 94 butalbital-apap-caff-cod...... 7 cevimeline hcl...... 99 BD VEO INSULIN SYRINGE butalbital-apap-caffeine...... 6 CHANTIX...... 108 U/F...... 94 butalbital-asa-caff-codeine...... 7 CHANTIX CONTINUING BECONASE AQ...... 100 butalbital-aspirin-caffeine...... 6 MONTH PAK...... 108 belladonna alkaloids-opium..... 111 butorphanol tartrate...... 7 CHANTIX STARTING BELSOMRA...... 92 BYETTA 10 MCG PEN...... 28 MONTH PAK...... 108 benazepril hcl...... 40 BYETTA 5 MCG PEN...... 28 CHEMET...... 34 benazepril-hydrochlorothiazide..40 BYSTOLIC...... 61 cherry...... 107 BENZEPRO...... 72 cabergoline...... 81 chlordiazepoxide hcl...... 13 BENZEPRO SHORT caffeine citrate...... 1 chlordiazepoxide-amitriptyline.108 CONTACT...... 72 caffeine-sodium benzoate...... 1 chlorhexidine gluconate...... 57, 99 benzonatate...... 71 calcipotriene...... 72 chloroquine phosphate...... 46 benzoyl peroxide-erythromycin...72 calcipotriene-betameth diprop....72 chlorothiazide...... 80 benztropine mesylate...... 51 calcitonin (salmon)...... 81 chlorpromazine hcl...... 53, 54 bepotastine besilate...... 101 CALCITRENE...... 72 chlorthalidone...... 80 BERINERT...... 89 calcitriol...... 81 chlorzoxazone...... 99 BESIVANCE...... 101 calcium acetate (phos binder).....87 chorionic gonadotropin...... 81 betamethasone dipropionate...... 72 CALPHRON...... 87 ciclopirox...... 73 betamethasone dipropionate candesartan cilexetil...... 40 cilostazol...... 89 aug...... 72 candesartan cilexetil-hctz...... 40 CILOXAN...... 102 betamethasone sod phos & acet..69 capecitabine...... 47 cimetidine...... 112 betamethasone valerate...... 72 CAPEX...... 72 cimetidine hcl...... 111 betaxolol hcl...... 61, 101 CAPRELSA...... 47 CIPRO...... 86 bethanechol chloride...... 113 captopril...... 40 CIPRO HC...... 105 BETOPTIC-S...... 101 captopril-hydrochlorothiazide....40 ciprofloxacin hcl...... 86, 102 bexarotene...... 47 CARAFATE...... 111 ciprofloxacin-dexamethasone... 105 bicalutamide...... 47 carbamazepine...... 21 citalopram hydrobromide...... 25 BICILLIN L-A...... 106, 107 carbamazepine er...... 21 clarithromycin...... 94 BIKTARVY...... 57 carbidopa...... 51 clarithromycin er...... 94 bimatoprost...... 101 carbidopa-levodopa...... 51, 52 CLEOCIN...... 114 bisoprolol fumarate...... 61 carbidopa-levodopa er...... 51 CLINDACIN PAC...... 73 bisoprolol-hydrochlorothiazide.. 40 carbinoxamine maleate...... 36 clindamycin hcl...... 44 BLEPHAMIDE S.O.P...... 102 CARDURA XL...... 88 clindamycin palmitate hcl...... 45 BOSULIF...... 47 carisoprodol...... 99 clindamycin phos-benzoyl perox.73 BREO ELLIPTA...... 16 CAROSPIR...... 80 clindamycin phosphate...... 73, 115 BRILINTA...... 89 carteolol hcl...... 102 clindamycin-tretinoin...... 73 brimonidine tartrate...... 102 CARTIA XT...... 62, 63 clobazam...... 21 brinzolamide...... 102 carvedilol...... 61 clobetasol propionate...... 73 BROMFED DM...... 71 carvedilol phosphate er...... 61 clobetasol propionate e...... 73 bromfenac sodium (once-daily) 102 cefaclor...... 66 CLODERM...... 73 bromocriptine mesylate...... 51 cefadroxil...... 66 clomipramine hcl...... 25 budesonide...... 16, 69 cefdinir...... 66 clonazepam...... 21 bumetanide...... 80 cefditoren pivoxil...... 66 clonidine...... 41 buprenorphine...... 7 cefpodoxime proxetil...... 66 clonidine hcl...... 40 buprenorphine hcl...... 6 cefprozil...... 66 clopidogrel bisulfate...... 89 buprenorphine hcl-naloxone hcl...6 cefuroxime axetil...... 66 clorazepate dipotassium...... 13 bupropion hcl...... 25 celecoxib...... 3 clotrimazole...... 73, 115 bupropion hcl er (smoking det).108 CELONTIN...... 21 clotrimazole-betamethasone...... 73 bupropion hcl er (sr)...... 24 CEM-UREA...... 73 clozapine...... 54

118 coal tar...... 67 dantrolene sodium...... 99 diltiazem hcl er beads...... 63 COARTEM...... 46 dapsone...... 45 dilt-xr...... 63 codeine sulfate...... 7 DARAPRIM...... 46 dimenhydrinate...... 35 colchicine...... 89 darifenacin hydrobromide er....113 dimethyl fumarate...... 108 colchicine-probenecid...... 89 DAYTRANA...... 1 DIPENTUM...... 87 colesevelam hcl...... 37 DDAVP RHINAL TUBE...... 81 diphenhydramine hcl...... 36 colestipol hcl...... 37 deferasirox...... 34 diphenoxylate-atropine...... 34 COLOCORT...... 11 deferiprone...... 34 dipyridamole...... 89 COMBIGAN...... 102 deferoxamine mesylate...... 34 disopyramide phosphate...... 14 COMBIPATCH...... 85 demeclocycline hcl...... 110 disulfiram...... 108 COMBIVENT RESPIMAT..... 16 DENAVIR...... 74 divalproex sodium...... 21, 22 COMETRIQ (100 MG DEPO-MEDROL...... 69 divalproex sodium er...... 22 DAILY DOSE)...... 47 DEPO-PROVERA...... 47 docosanol...... 74 COMETRIQ (140 MG DEPO-SUBQ PROVERA 104. 67 dofetilide...... 14 DAILY DOSE)...... 47 DESCOVY...... 58 donepezil hcl...... 108 COMETRIQ (60 MG DAILY desipramine hcl...... 25 DOPRAM...... 2 DOSE)...... 47 desmopressin ace spray refrig.... 81 dorzolamide hcl...... 102 COMFORT EZ PEN desmopressin acetate...... 82 dorzolamide hcl-timolol mal.....102 NEEDLES...... 94 desmopressin acetate spray...... 82 doxazosin mesylate...... 41 COMPLERA...... 57 desogestrel-ethinyl estradiol...... 67 doxepin hcl...... 25 CONDYLOX...... 73 desonide...... 74 doxercalciferol...... 82 CORDRAN...... 73 desoximetasone...... 74 doxycycline hyclate...... 110 CORLANOR...... 65 desvenlafaxine er...... 25 doxycycline monohydrate...... 110 CORTIFOAM...... 11 desvenlafaxine succinate er...... 25 DRITHO-CREME HP...... 74 cortisone acetate...... 69 dexamethasone...... 69, 70 dronabinol...... 35 CORTISPORIN...... 73 DEXAMETHASONE droperidol...... 14 COSENTYX (300 MG DOSE).74 INTENSOL...... 69 drospiren-eth estrad-levomefol...67 COSENTYX SENSOREADY dexamethasone sodium drospirenone-ethinyl estradiol....67 PEN...... 74 phosphate...... 69, 70, 102 DROXIA...... 90 CREON...... 79, 80 dexmethylphenidate hcl...... 2 DUAVEE...... 85 CRESEMBA...... 35 dexmethylphenidate hcl er...... 1 DULERA...... 16, 17 CRINONE...... 115 dextroamphetamine sulfate...... 2 duloxetine hcl...... 26 CRIXIVAN...... 58 dextroamphetamine sulfate er...... 2 DUPIXENT...... 74 cromolyn sodium...... 87, 102 diazepam...... 13, 14 DUREZOL...... 102 CROTAN...... 74 diclofenac potassium...... 3 econazole nitrate...... 74 CUPRIMINE...... 97 diclofenac sodium...... 3, 74, 102 EDARBI...... 41 cvs nasal allergy spray...... 100 diclofenac sodium er...... 3 EDURANT...... 58 cvs sodium chloride...... 102 diclofenac-misoprostol...... 3, 4 efavirenz...... 58 cyanocobalamin...... 90 dicloxacillin sodium...... 107 efavirenz-emtricitab-tenofovir.... 58 cyclobenzaprine hcl...... 99 dicyclomine hcl...... 112 efavirenz-lamivudine-tenofovir...58 cyclopentolate hcl...... 102 didanosine...... 58 EFFER-K...... 96 cyclophosphamide...... 47 diethylpropion hcl...... 2 eletriptan hydrobromide...... 95 cycloserine...... 46 diethylpropion hcl er...... 2 ELIGARD...... 47 CYCLOSET...... 29 DIFFERIN...... 74 ELIQUIS...... 19 cyclosporine...... 97 DIFICID...... 94 ELIQUIS DVT/PE cyclosporine modified...... 97 diflorasone diacetate...... 74 STARTER PACK...... 19 cyproheptadine hcl...... 36 diflunisal...... 6 ELIXOPHYLLIN...... 17 CYSTADANE...... 81 digoxin...... 65 ELLA...... 67 CYSTARAN...... 102 DILANTIN...... 21 ELMIRON...... 88 CYTRA-3...... 88 DILATRATE-SR...... 12 EMBEDA...... 7 dalfampridine er...... 108 diltiazem hcl...... 63 EMCYT...... 47 DALIRESP...... 16 diltiazem hcl er...... 63 EMSAM...... 26

119 emtricitabine...... 58 ezetimibe...... 37 fluocinolone acetonide...... 75, 105 emtricitabine-tenofovir df...... 58 ezetimibe-simvastatin...... 37 fluocinolone acetonide body...... 75 EMTRIVA...... 58 famciclovir...... 58 fluocinolone acetonide scalp...... 75 enalapril maleate...... 41 famotidine...... 112 fluocinonide...... 75 enalapril-hydrochlorothiazide....41 FANAPT...... 54 fluocinonide emulsified base...... 75 ENBREL...... 4 FARXIGA...... 29 FLUORIDEX...... 99 ENBREL SURECLICK...... 4 FARYDAK...... 47, 48 FLUORIDEX DAILY ENDOCET...... 7 FASENRA...... 17 RENEWAL...... 99 ENDOMETRIN...... 115 FASLODEX...... 48 fluoritab...... 96 enoxaparin sodium...... 19 fe tabs...... 91 fluorometholone...... 102 entacapone...... 52 felbamate...... 22 fluorouracil...... 75 ENTRESTO...... 65 felodipine er...... 63 fluoxetine hcl...... 26 epinastine hcl...... 102 fenofibrate...... 37 fluphenazine decanoate...... 54 epinephrine...... 115 fenofibrate micronized...... 37 fluphenazine hcl...... 54 EPIVIR HBV...... 58 fenofibric acid...... 38 flurandrenolide...... 75 eplerenone...... 41 fentanyl...... 7 flurazepam hcl...... 92 EPOGEN...... 91 ferotrinsic...... 91 flurbiprofen...... 4 eq nasal allergy...... 100 ferraplus 90...... 91 flurbiprofen sodium...... 103 ergoloid mesylates...... 108 ferrous sulfate...... 91 flutamide...... 48 ergotamine-caffeine...... 96 FETZIMA...... 26 fluticasone propionate...... 75, 100 ERIVEDGE...... 47 fexofenadine hcl...... 36 fluticasone-salmeterol...... 17 ERTACZO...... 74 FIASP...... 29 fluvastatin sodium...... 38 ERYTHROCIN STEARATE.. 94 FIASP FLEXTOUCH...... 29 fluvoxamine maleate...... 26 erythromycin...... 74, 102 FIASP PENFILL...... 29 FLUZONE HIGH-DOSE erythromycin base...... 94 FIBRICOR...... 38 QUADRIVALENT...... 114 erythromycin ethylsuccinate...... 94 FINACEA...... 74 FLUZONE ESBRIET...... 110 finasteride...... 74, 88 QUADRIVALENT...... 114 escitalopram oxalate...... 26 FIRAZYR...... 89 FML...... 103 estazolam...... 92 FIRMAGON...... 48 folic acid...... 91 estradiol...... 85, 115 FIRMAGON (240 MG DOSE) 48 fondaparinux sodium...... 19 estradiol valerate...... 85 FIRST-LANSOPRAZOLE.... 112 formoterol fumarate...... 17 estradiol-norethindrone acet 85, 86 FIRST-PROGESTERONE FORTEO...... 82 ESTRING...... 115 VGS...... 115 FOSAMAX PLUS D...... 82 ESTROGEL...... 86 FIRVANQ...... 45 fosamprenavir calcium...... 58 eszopiclone...... 92 FLAREX...... 102 fosinopril sodium...... 41 ethacrynic acid...... 80 flavor sweet...... 107 fosinopril sodium-hctz...... 41 ethambutol hcl...... 46 flavoxate hcl...... 113 FRAGMIN...... 19, 20 ethosuximide...... 22 flecainide acetate...... 14 FREESTYLE LIBRE ethyl chloride...... 74 FLONASE SENSIMIST...... 100 SENSOR SYSTEM...... 94 ethynodiol diac-eth estradiol...... 67 FLOVENT DISKUS...... 17 frovatriptan succinate...... 96 etodolac...... 4 FLOVENT HFA...... 17 furosemide...... 80 etodolac er...... 4 FLUAD...... 114 FUZEON...... 58 etonogestrel-ethinyl estradiol..... 67 FLUAD QUADRIVALENT...114 FYCOMPA...... 22 etravirine...... 58 FLUARIX QUADRIVALENT gabapentin...... 22 EUCERIN...... 74 ...... 114 GABITRIL...... 22 EVAMIST...... 86 FLUCAINE...... 102 galantamine hydrobromide...... 108 everolimus...... 47, 97 fluconazole...... 35, 36 galantamine hydrobromide er.. 108 EVOTAZ...... 58 flucytosine...... 36 ganirelix acetate...... 82 EXELDERM...... 74 fludrocortisone acetate...... 70 gatifloxacin...... 103 exemestane...... 47 FLULAVAL GAVILYTE-C...... 93 EXODERM...... 74 QUADRIVALENT...... 114 GAVILYTE-G...... 93 eye allergy relief...... 102 flunisolide...... 100

120 GAVILYTE-N WITH heparin sodium (porcine) pf...... 20 INTELENCE...... 58 FLAVOR PACK...... 93 heparin sodium lock flush...... 20 INTRON A...... 48 gemfibrozil...... 38 HETLIOZ...... 92 INVIRASE...... 58 generlac...... 87 HOMATROPAIRE...... 103 INVOKAMET...... 30 GENGRAF...... 98 HUMIRA...... 4 INVOKAMET XR...... 30 GENOTROPIN...... 83 HUMIRA PEN...... 4 INVOKANA...... 30 GENOTROPIN MINIQUICK HUMULIN R U-500 iodine strong...... 96 ...... 82, 83 (CONCENTRATED)...... 30 iodine strong (lugol's)...... 67 GENTAK...... 103 hydralazine hcl...... 41 IOPIDINE...... 103 gentamicin sulfate...... 75, 103 hydrochlorothiazide...... 80 ipratropium bromide...... 17, 100 GENVOYA...... 58 hydrocod polst-cpm polst er...... 71 ipratropium-albuterol...... 17 GIANVI...... 67 hydrocodone-acetaminophen...... 7 irbesartan...... 41 GILENYA...... 108 hydrocodone-homatropine...... 71 irbesartan-hydrochlorothiazide GILOTRIF...... 48 hydrocodone-ibuprofen...... 7 ...... 41, 42 glatiramer acetate...... 108 hydrocortisone...... 70, 75, 76 iron...... 91 GLATOPA...... 109 hydrocortisone butyr lipo base... 75 iron 27...... 91 GLEOSTINE...... 48 hydrocortisone butyrate...... 75 ISENTRESS...... 59 glimepiride...... 29 hydrocortisone valerate...... 76 isoniazid...... 46 glipizide...... 29 hydromorphone hcl...... 7, 8 isosorbide dinitrate...... 12 glipizide er...... 29 hydromorphone hcl er...... 7 isosorbide mononitrate...... 12 glipizide-metformin hcl...... 29 hydroquinone...... 76 isosorbide mononitrate er...... 12 GLUCAGEN HYPOKIT...... 29 hydroxychloroquine sulfate...... 46 isradipine...... 63 glucagon emergency...... 29 hydroxyprogesterone caproate itraconazole...... 36 GLUCOCARD ...... 48, 107 ivermectin...... 12 EXPRESSION TEST...... 79 hydroxyurea...... 48 JADENU...... 34 GLUCOCARD VITAL TEST. 79 hydroxyzine hcl...... 14 JAKAFI...... 49 glyburide...... 29 hydroxyzine pamoate...... 14 JANUMET...... 30 glyburide micronized...... 29 HYOPHEN...... 45 JANUMET XR...... 30 glyburide-metformin...... 29 hyoscyamine sulfate...... 112 JANUVIA...... 30 glycopyrrolate...... 112 hyoscyamine sulfate sl...... 112 JARDIANCE...... 30 gnp 24 hour nasal allergy...... 100 hyosyne...... 112 JASMIEL...... 67 GOLYTELY...... 93 HYPERRHO S/D...... 105 JINTELI...... 86 GONAL-F RFF REDIJECT....83 HYQVIA...... 105 JULUCA...... 59 goodsense glucose...... 30 ibandronate sodium...... 83 JUNEL 1.5/30...... 67 goodsense nasal allergy spray..100 IBRANCE...... 48 JUNEL FE 1.5/30...... 68 granisetron hcl...... 35 IBU...... 4 KALBITOR...... 89 griseofulvin microsize...... 36 ibuprofen...... 4 KALYDECO...... 110 griseofulvin ultramicrosize...... 36 ICLUSIG...... 48 ketoconazole...... 36, 76 guanfacine hcl...... 41 icosapent ethyl...... 38 ketone test...... 79 guanfacine hcl er...... 2 imatinib mesylate...... 48 ketoprofen er...... 4 GYNAZOLE-1...... 115 IMBRUVICA...... 48 ketorolac tromethamine...... 5, 103 HAILEY 24 FE...... 67 imipramine hcl...... 26 KINERET...... 5 halobetasol propionate...... 75 imipramine pamoate...... 26 KLOR-CON M15...... 96 HALOG...... 75 imiquimod...... 76 KLOXXADO...... 34 haloperidol...... 54, 55 INCRELEX...... 83 kp diphenhydramine hcl...... 36 haloperidol decanoate...... 54 INCRUSE ELLIPTA...... 17 K-PRIME...... 96 haloperidol lactate...... 54 indapamide...... 80 KRISTALOSE...... 93 hematinic/folic acid...... 91 indomethacin...... 4 KYPROLIS...... 49 HEMATOGEN FA...... 91 indomethacin er...... 4 labetalol hcl...... 61 heparin lock flush...... 20 INLYTA...... 48 LACRISERT...... 103 heparin sod (porcine) in d5w...... 20 insulin syringe...... 95 lactic acid...... 76 heparin sodium (porcine)...... 20 insupen pen needles...... 95 lactic acid e...... 76

121 lactulose...... 93 LMX 4...... 76 mesalamine...... 87 LAMICTAL ODT...... 22 LO LOESTRIN FE...... 68 MESNEX...... 49 lamivudine...... 59 loperamide hcl...... 34 MESTINON...... 46 lamivudine-zidovudine...... 59 lopinavir-ritonavir...... 59 metaproterenol sulfate...... 18 lamotrigine...... 23 loratadine...... 36 metaxalone...... 99 lamotrigine er...... 22, 23 loratadine childrens...... 36 metformin hcl...... 31 lansoprazole...... 112 lorazepam...... 14 metformin hcl er...... 31 lanthanum carbonate...... 87 LORAZEPAM INTENSOL.....14 methadone hcl...... 8 LANTUS...... 30 LORYNA...... 68 METHADONE HCL LANTUS SOLOSTAR...... 30 losartan potassium...... 42 INTENSOL...... 8 lapatinib ditosylate...... 49 losartan potassium-hctz...... 42 METHADOSE...... 8 LASTACAFT...... 103 LOTEMAX...... 103 methamphetamine hcl...... 2 latanoprost...... 103 lovastatin...... 38 methazolamide...... 81 LATUDA...... 55 LOW-OGESTREL...... 68 methenamine hippurate...... 45 leflunomide...... 5 loxapine succinate...... 55 methenamine mandelate...... 45 letrozole...... 49 LO-ZUMANDIMINE...... 68 methimazole...... 111 leucovorin calcium...... 49 LUMIGAN...... 103 methitest...... 11 LEUKERAN...... 49 LUPRON DEPOT (1- methocarbamol...... 99, 100 LEUKINE...... 91 MONTH)...... 49 methotrexate...... 50 leuprolide acetate...... 49 LUPRON DEPOT (3- methotrexate sodium...... 50 levalbuterol hcl...... 17, 18 MONTH)...... 49 methotrexate sodium (pf)...... 50 levalbuterol tartrate...... 18 LUPRON DEPOT (4- methoxsalen rapid...... 76 LEVEMIR...... 31 MONTH)...... 49 methscopolamine bromide...... 112 LEVEMIR FLEXTOUCH...... 31 LUPRON DEPOT (6- methyldopa...... 42 levetiracetam...... 23 MONTH)...... 49 methylergonovine maleate...... 105 levetiracetam er...... 23 LYRICA...... 23 methylphenidate hcl...... 2 levobunolol hcl...... 103 LYSODREN...... 49 methylphenidate hcl er...... 2 levocarnitine...... 83 MACROBID...... 45 methylphenidate hcl er (cd)...... 2 levocetirizine dihydrochloride.... 36 mafenide acetate...... 76 methylphenidate hcl er (la)...... 2 levofloxacin...... 86, 87, 103 MAGELLAN INSULIN methylprednisolone...... 70 LEVONEST...... 68 SAFETY SYR...... 95 metoclopramide hcl...... 87 levonorgest-eth est & eth est...... 68 magnesium oxide...... 12 metolazone...... 81 levonorgest-eth estrad 91-day.... 68 malathion...... 76 metoprolol succinate er...... 61 levonorgestrel...... 68 maprotiline hcl...... 27 metoprolol tartrate...... 61 levonorgestrel-ethinyl estrad...... 68 MARPLAN...... 27 metoprolol-hydrochlorothiazide. 42 levorphanol tartrate...... 8 MATULANE...... 49 metronidazole...... 45, 76, 115 levothyroxine sodium...... 111 MAVYRET...... 59 mexiletine hcl...... 14, 15 LEXIVA...... 59 MAYZENT...... 109 miconazole 3 applicator...... 115 lidocaine...... 76 meclizine hcl...... 35 miconazole 3 combo pack...... 115 lidocaine hcl...... 76, 99 meclofenamate sodium...... 5 miconazole nitrate...... 76 lidocaine-hydrocortisone ace..... 11 medroxyprogesterone acetate midodrine hcl...... 115 lidocaine-prilocaine...... 76 ...... 68, 107 miglitol...... 31 lindane...... 76 mefloquine hcl...... 46 MILLIPRED...... 70 linezolid...... 45 megestrol acetate...... 49 minocycline hcl...... 110, 111 LINZESS...... 87 MEKINIST...... 49 minoxidil...... 42 liothyronine sodium...... 111 meloxicam...... 5 mirtazapine...... 27 lisinopril...... 42 memantine hcl...... 109 MIRVASO...... 76 lisinopril-hydrochlorothiazide....42 MENEST...... 86 misoprostol...... 112 lithium...... 55 MENTAX...... 76 modafinil...... 2 lithium carbonate...... 55 meperidine hcl...... 8 moexipril hcl...... 42 lithium carbonate er...... 55 meprobamate...... 14 mometasone furoate...... 76, 100 LIVALO...... 38 mercaptopurine...... 49

122 MONOJECT SODIUM NICORETTE...... 109 NOVOLOG MIX 70/30 CHLORIDE FLUSH...... 96 nicotine...... 109 FLEXPEN...... 32 montelukast sodium...... 18 nicotine mini...... 109 NOVOLOG MIX 70/30 MONUROL...... 45 nicotine polacrilex...... 109 RELION...... 32 morphine sulfate...... 9 NICOTROL...... 109 NOVOLOG PENFILL...... 32 morphine sulfate (concentrate).....8 nifedipine...... 63 NOVOLOG RELION...... 32 morphine sulfate (pf)...... 8 nifedipine er...... 64 np thyroid...... 111 morphine sulfate er...... 9 nifedipine er osmotic release...... 63 NUCYNTA ER...... 9 MOTOFEN...... 34 NIKKI...... 68 NUEDEXTA...... 109 moxifloxacin hcl...... 87, 103 nimodipine...... 64 NYAMYC...... 77 moxifloxacin hcl (2x day)...... 103 nisoldipine er...... 64 nystatin...... 36, 77, 99 MULTAQ...... 15 nitisinone...... 83 nystatin-triamcinolone...... 77 multivitamin/fluoride...... 99 NITRO-BID...... 12 NYSTOP...... 77 mupirocin...... 76 NITRO-DUR...... 12 OCELLA...... 69 mycophenolate mofetil...... 98 nitrofurantoin...... 45 octreotide acetate...... 83 mycophenolate sodium...... 98 nitrofurantoin macrocrystal...... 45 ODEFSEY...... 59 MYLERAN...... 50 nitrofurantoin monohyd macro...45 ODOMZO...... 50 nabumetone...... 5 nitroglycerin...... 12, 13 OFEV...... 110 nac...... 101 nitroglycerin er...... 12 ofloxacin...... 87, 104, 105 nadolol...... 62 NITRO-TIME...... 13 olanzapine...... 55 naftifine hcl...... 77 nizatidine...... 112 olanzapine-fluoxetine hcl...... 109 nalbuphine hcl...... 9 norethin ace-eth estrad-fe...... 68 olmesartan medoxomil...... 42 naloxone hcl...... 34 norethindrone...... 68 olmesartan medoxomil-hctz.. 42, 43 naltrexone hcl...... 34 norethindrone acetate...... 107 olopatadine hcl...... 104 naproxen...... 5 norethindrone acet-ethinyl est.... 68 omega-3-acid ethyl esters...... 38 naproxen sodium...... 5 norethindrone-eth estradiol...... 86 omeprazole...... 112 naratriptan hcl...... 96 norethin-eth estradiol-fe...... 68 OMNIFLEX DIAPHRAGM....95 NARCAN...... 35 norgestimate-eth estradiol...... 68 ondansetron...... 35 nasal allergy 24 hour...... 100 norgestim-eth estrad triphasic....68 ondansetron hcl...... 35 NATACYN...... 103 NORPACE CR...... 15 ONETOUCH VERIO...... 95 nateglinide...... 31 NORTREL 0.5/35 (28)...... 69 ONGLYZA...... 32 NATROBA...... 77 NORTREL 1/35 (28)...... 69 OPSUMIT...... 65 NATURE-THROID...... 111 NORTREL 7/7/7...... 69 ORA-BLEND...... 107 nefazodone hcl...... 27 nortriptyline hcl...... 27 ORA-PLUS...... 107 neomycin sulfate...... 3 NORVIR...... 59 ORA-SWEET...... 107 neomycin-bacitracin zn- NOVOLIN 70/30...... 31 ORAVIG...... 99 polymyx...... 103 NOVOLIN 70/30 FLEXPEN... 31 orphenadrine citrate er...... 100 neomycin-polymyxin b gu...... 88 NOVOLIN 70/30 FLEXPEN oseltamivir phosphate...... 59 neomycin-polymyxin-dexameth.103 RELION...... 31 OSMOPREP...... 93 neomycin-polymyxin-gramicidin NOVOLIN N...... 31 OSPHENA...... 83 ...... 103 NOVOLIN N FLEXPEN...... 31 oxandrolone...... 11 neomycin-polymyxin-hc.... 104, 105 NOVOLIN N RELION...... 31 oxaprozin...... 5 NEULASTA...... 91 NOVOLIN R...... 31 OXAYDO...... 9 NEUPRO...... 52 NOVOLIN R FLEXPEN...... 31 oxazepam...... 14 NEVANAC...... 104 NOVOLIN R RELION...... 31 oxcarbazepine...... 23 nevirapine...... 59 NOVOLOG...... 32 oxiconazole nitrate...... 77 nevirapine er...... 59 NOVOLOG 70/30 FLEXPEN oxybutynin chloride...... 113 NEXAVAR...... 50 RELION...... 31 oxybutynin chloride er...... 113 niacin...... 115 NOVOLOG FLEXPEN...... 32 oxycodone hcl...... 9, 10 niacin er (antihyperlipidemic).... 38 NOVOLOG FLEXPEN oxycodone-acetaminophen...... 10 NIACOR...... 38 RELION...... 31 oxycodone-aspirin...... 10 nicardipine hcl...... 63 NOVOLOG MIX 70/30...... 32 oxymorphone hcl er...... 10

123 OXYTROL FOR WOMEN... 113 piroxicam...... 5 promethazine-dm...... 71 OZEMPIC (0.25 OR 0.5 podocon...... 77 PROMETHEGAN...... 37 MG/DOSE)...... 32 podofilox...... 77 propafenone hcl...... 15 OZEMPIC (1 MG/DOSE)...... 32 polyethylene glycol 3350...... 93 propafenone hcl er...... 15 PACERONE...... 15 poly-iron 150 forte...... 91 propantheline bromide...... 113 paliperidone er...... 55, 56 polymyxin b-trimethoprim...... 104 proparacaine hcl...... 104 pantoprazole sodium...... 113 POMALYST...... 50 propranolol hcl...... 62 paricalcitol...... 83 pot bicarb-pot chloride...... 97 propranolol hcl er...... 62 paromomycin sulfate...... 3 potassium chloride...... 97 propranolol-hctz...... 43 paroxetine hcl...... 27 potassium chloride crys er...... 97 propylthiouracil...... 111 paroxetine hcl er...... 27 potassium chloride er...... 97 protriptyline hcl...... 27 peg-3350/electrolytes/ascorbat...93 potassium citrate er...... 88 PULMICORT FLEXHALER..18 PEGANONE...... 23 potassium citrate-citric acid...... 88 PULMOZYME...... 110 PEGASYS...... 59 PR BENZOYL PEROXIDE pyrazinamide...... 46 PEGINTRON...... 59 WASH...... 77 pyridostigmine bromide...... 46 pen needles...... 95 PRADAXA...... 20 pyridostigmine bromide er...... 46 penicillamine...... 98 PRALUENT...... 38 pyridoxine hcl...... 116 penicillin v potassium...... 107 pramipexole dihydrochloride52, 53 pyrogallic acid...... 77 pentamidine isethionate...... 45 pramipexole dihydrochloride er. 52 QNASL...... 100 PENTASA...... 87 prasugrel hcl...... 89 quetiapine fumarate...... 56 pentazocine-naloxone hcl...... 10 pravastatin sodium...... 38 quetiapine fumarate er...... 56 pentetate calcium trisodium...... 35 prazosin hcl...... 43 quinapril hcl...... 43 pentetate zinc trisodium...... 35 PRED MILD...... 104 quinapril-hydrochlorothiazide....43 pentoxifylline er...... 89 prednicarbate...... 77 quinidine gluconate er...... 15 perindopril erbumine...... 43 prednisolone acetate...... 104 quinidine sulfate...... 15 permethrin...... 77 prednisolone sodium phosphate quinine sulfate...... 46 perphenazine...... 56 ...... 70, 104 QVAR REDIHALER...... 18 perphenazine-amitriptyline...... 109 prednisone...... 70 ra nasal allergy...... 100 phenazopyridine hcl...... 88 PREDNISONE INTENSOL.... 70 rabeprazole sodium...... 113 phendimetrazine tartrate...... 3 pregabalin...... 23 RADIOGARDASE...... 35 phendimetrazine tartrate er...... 3 PREMARIN...... 86 raloxifene hcl...... 83 phenelzine sulfate...... 27 PREMPHASE...... 86 ramipril...... 43 phenobarbital...... 92, 93 PREMPRO...... 86 ranolazine er...... 13 phenoxybenzamine hcl...... 43 prenatal...... 99 RAPAMUNE...... 98 phentermine hcl...... 3 PREVALITE...... 38 rasagiline mesylate...... 53 phenytoin...... 23 PREZCOBIX...... 59 RECTIV...... 11 phenytoin sodium...... 23 PREZISTA...... 59, 60 reeses pinworm medicine...... 12 phenytoin sodium extended...... 23 PRIFTIN...... 46 REGRANEX...... 77 PHOSLYRA...... 87 primaquine phosphate...... 46 RELENZA DISKHALER...... 60 PHOSPHASAL...... 45 primidone...... 23, 24 RELPAX...... 96 PHOSPHOLINE IODIDE..... 104 PROAIR RESPICLICK...... 18 RENVELA...... 88 PHOSPHO-TRIN 250 probenecid...... 89 repaglinide...... 32 NEUTRAL...... 97 prochlorperazine...... 56 REPATHA...... 38 physostigmine salicylate...... 35 prochlorperazine maleate...... 56 REPATHA PUSHTRONEX phytonadione...... 116 PROCRIT...... 91, 92 SYSTEM...... 38 pilocarpine hcl...... 99, 104 PROCTOFOAM HC...... 11 REPATHA SURECLICK...... 38 pimecrolimus...... 77 PROCTOZONE-HC...... 11 REPLESTA CHILDRENS.... 116 pimozide...... 109 progesterone micronized...... 107 RETACRIT...... 92 pindolol...... 62 PROMACTA...... 92 REVLIMID...... 98 pioglitazone hcl...... 32 promethazine hcl...... 36, 37 REXULTI...... 56 pioglitazone hcl-glimepiride...... 32 promethazine vc/codeine...... 71 REYATAZ...... 60 pioglitazone hcl-metformin hcl... 32 promethazine-codeine...... 71 ribavirin...... 60

124 RIDAURA...... 5 SKYRIZI (150 MG DOSE)...... 78 SYNALAR (CREAM)...... 78 rifabutin...... 46 SLYND...... 69 SYNALAR (OINTMENT)...... 78 rifampin...... 46 sod citrate-citric acid...... 88 SYNJARDY...... 33 riluzole...... 101 sodium bicarbonate...... 12 SYNJARDY XR...... 33 rimantadine hcl...... 60 sodium chloride...... 71, 97 SYNTHROID...... 111 RINVOQ...... 5 sodium chloride (hypertonic)....104 SYPRINE...... 98 risedronate sodium...... 83 sodium fluoride...... 97 TABLOID...... 50 risperidone...... 56 sodium polystyrene sulfonate...... 98 TACLONEX...... 78 ritonavir...... 60 sofosbuvir-velpatasvir...... 60 tacrolimus...... 78, 98 rivastigmine...... 109 solifenacin succinate...... 113 tadalafil...... 65 rivastigmine tartrate...... 109, 110 SOMATULINE DEPOT...... 84 tadalafil (pah)...... 65 rizatriptan benzoate...... 96 SOMAVERT...... 84 TAFINLAR...... 50 ropinirole hcl...... 53 sorbitol...... 88, 89 tamoxifen citrate...... 50 ropinirole hcl er...... 53 sorbitol-mannitol...... 89 tamsulosin hcl...... 89 ROSADAN...... 77 sotalol hcl...... 62 TARCEVA...... 50 rosuvastatin calcium...... 38, 39 sotalol hcl (af)...... 62 TARON-PREX...... 99 ROZEREM...... 93 SPIRIVA HANDIHALER...... 18 TASIGNA...... 50 rufinamide...... 24 SPIRIVA RESPIMAT...... 18 TAYTULLA...... 69 RYBELSUS...... 32 spironolactone...... 81 tazarotene...... 78 salicylic acid...... 77 spironolactone-hctz...... 81 TAZORAC...... 78 salicylic acid wart remover...... 77 SPRYCEL...... 50 TAZTIA XT...... 64 salsalate...... 6 SPS...... 98 TECHLITE PEN NEEDLES...95 SAMSCA...... 84 SSD...... 78 TEKTURNA HCT...... 43 SANDIMMUNE...... 98 stavudine...... 60 telmisartan...... 43 SANDOSTATIN LAR STELARA...... 78 telmisartan-hctz...... 43, 44 DEPOT...... 84 sterile water for irrigation...... 98 temazepam...... 93 SANTYL...... 77 STIMATE...... 85 tenofovir disoproxil fumarate..... 60 SAPHRIS...... 56, 57 STIVARGA...... 50 terazosin hcl...... 44 sapropterin dihydrochloride...... 84 STRIBILD...... 60 terbinafine hcl...... 36 SAVELLA...... 110 STRIVERDI RESPIMAT...... 18 terbutaline sulfate...... 18 selegiline hcl...... 53 sucralfate...... 113 terconazole...... 115 selenium sulfide...... 78 sulfacetamide sodium...... 78, 104 testosterone...... 11 SELZENTRY...... 60 sulfacetamide sodium (acne)...... 78 testosterone cypionate...... 11 SENSIPAR...... 84 sulfacetamide sodium-sulfur...... 78 testosterone enanthate...... 11 SEREVENT DISKUS...... 18 sulfacetamide-prednisolone...... 104 tetrabenazine...... 110 sertraline hcl...... 27, 28 sulfadiazine...... 110 tetracycline hcl...... 111 sevelamer carbonate...... 88 sulfamethoxazole-trimethoprim.. 45 THALOMID...... 98 sevelamer hcl...... 88 SULFAMYLON...... 78 theophylline...... 19 sf...... 99 sulfasalazine...... 88 theophylline er...... 18, 19 sf 5000 plus...... 99 sulindac...... 5 THERA-D 4000...... 116 SHINGRIX...... 114 sumatriptan...... 96 thioridazine hcl...... 57 SIGNIFOR...... 84 sumatriptan succinate...... 96 thiothixene...... 57 SIGNIFOR LAR...... 84 sunitinib malate...... 50 thrivite 19...... 99 sildenafil citrate...... 65 SUPRAX...... 67 tiagabine hcl...... 24 silodosin...... 88 SUPREP BOWEL PREP KIT.94 timolol maleate...... 62, 104 silver nitrate...... 78 SYEDA...... 69 tinidazole...... 45 SIMBRINZA...... 104 SYMAX DUOTAB...... 113 TIVICAY...... 60 simple syrup...... 107 SYMAX-SR...... 113 tizanidine hcl...... 100 simvastatin...... 39 SYMJEPI...... 115 TOBRADEX...... 104 sirolimus...... 98 SYMLINPEN 120...... 33 TOBRADEX ST...... 104 SIVEXTRO...... 45 SYMLINPEN 60...... 33 tobramycin...... 3, 105 SKLICE...... 78 SYNAGIS...... 105, 106 tobramycin-dexamethasone...... 105

125 TOBREX...... 105 ULTILET INSULIN XARELTO...... 20, 21 tolbutamide...... 33 SYRINGE...... 95 XARELTO STARTER PACK 20 tolcapone...... 53 ULTILET INSULIN XELJANZ...... 5 tolmetin sodium...... 5 SYRINGE SHORT...... 95 XELJANZ XR...... 5 tolterodine tartrate...... 113, 114 UMECTA MOUSSE...... 79 XIFAXAN...... 46 tolterodine tartrate er...... 113 UPTRAVI...... 65, 66 XIGDUO XR...... 34 tolvaptan...... 85 urea...... 79 XOLAIR...... 19 topiramate...... 24 urea nail...... 79 XULANE...... 69 toremifene citrate...... 50 URIMAR-T...... 45 XYREM...... 110 torsemide...... 81 urin ds...... 113 zafirlukast...... 19 TOUJEO SOLOSTAR...... 33 ursodiol...... 88 zaleplon...... 93 TOVIAZ...... 114 USTELL...... 45 ZARAH...... 69 TRACLEER...... 65 valacyclovir hcl...... 60 ZARXIO...... 92 TRADJENTA...... 33 valganciclovir hcl...... 60 ZENPEP...... 80 tramadol hcl...... 10 valproic acid...... 24 ZEPATIER...... 61 tramadol hcl er...... 10 valsartan...... 44 zidovudine...... 61 tramadol hcl er (biphasic)...... 10 valsartan-hydrochlorothiazide... 44 zileuton er...... 19 tramadol-acetaminophen...... 10 VALSTAR...... 51 zinc sulfate...... 97 trandolapril...... 44 vancomycin hcl...... 46 ZIOPTAN...... 105 trandolapril-verapamil hcl er..... 44 vancomycin hcl in dextrose...... 45 ziprasidone hcl...... 57 tranexamic acid...... 92 VANTAS...... 51 ZIRGAN...... 105 tranylcypromine sulfate...... 28 VECTICAL...... 79 ZOLADEX...... 51 travoprost (bak free)...... 105 VELIVET...... 69 ZOLINZA...... 51 trazodone hcl...... 28 VELPHORO...... 88 zolmitriptan...... 96 TRELSTAR MIXJECT...... 50 venlafaxine hcl...... 28 zolpidem tartrate...... 93 TRESIBA...... 33 venlafaxine hcl er...... 28 zolpidem tartrate er...... 93 TRESIBA FLEXTOUCH...... 33 VENTAVIS...... 66 zonisamide...... 24 tretinoin...... 50, 78 VENTOLIN HFA...... 19 ZONTIVITY...... 89 tretinoin microsphere...... 78 verapamil hcl...... 65 ZORTRESS...... 98 TREXALL...... 50, 51 verapamil hcl er...... 64, 65 ZOVIA 1/35E (28)...... 69 triamcinolone acetonide VEREGEN...... 79 ZUMANDIMINE...... 69 ...... 78, 79, 99, 101 VESICARE...... 114 ZYDELIG...... 51 triamterene...... 81 VICTOZA...... 34 ZYFLO...... 19 triamterene-hctz...... 81 vigabatrin...... 24 trifluoperazine hcl...... 57 VIIBRYD...... 28 trifluridine...... 105 VIMPAT...... 24 trihexyphenidyl hcl...... 53 VIRACEPT...... 60 TRI-LEGEST FE...... 69 VIRAMUNE...... 60 TRI-LO-SPRINTEC...... 69 VIREAD...... 60, 61 trimethobenzamide hcl...... 35 vitamin d...... 116 trimethoprim...... 45 vitamin d (cholecalciferol)...... 116 trimipramine maleate...... 28 vitamin d (ergocalciferol)...... 116 TRIUMEQ...... 60 vitamin d3...... 116 tropicamide...... 105 vitamins acd-fluoride...... 99 trospium chloride...... 114 VIVITROL...... 35 trospium chloride er...... 114 voriconazole...... 36 TRULICITY...... 33 VOTRIENT...... 51 TUDORZA PRESSAIR...... 19 VYVANSE...... 3 TWIRLA...... 69 warfarin sodium...... 20 TYVASO STARTER...... 65 WESTHROID...... 111 ULORIC...... 89 WIXELA INHUB...... 19 XALKORI...... 51

126