Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

AMIKACIN 500 MG/2 ML 500 MG/2ML AA‐AMINOGLYCOSIDES 703903203 TEVA PARENTERAL IJ 2 GENTAMICIN 40 MG/ML VIAL 40 MG/M AA‐AMINOGLYCOSIDES 63323001002 APP PHARMACEUTI IJ 2 TOBRAMYCIN 40 MG/ML VIAL 40 MG/M AA‐AMINOGLYCOSIDES 63323030602 APP PHARMACEUTI IJ 2 GENTAMICIN 100MG IVPB 100MG AA‐AMINOGLYCOSIDES 338050548 BAXTER HEALTHCA IV 100 GENTAMICIN 120MG IVPB 120MG AA‐AMINOGLYCOSIDES 338050748 BAXTER HEALTHCA IV 100 GENTAMICIN 60 MG/NS 50 ML P 60 MG/5 AA‐AMINOGLYCOSIDES 409787913 IV 50 GENTAMICIN 80MG IVPB 80MG AA‐AMINOGLYCOSIDES 338050348 BAXTER HEALTHCA IV 100 VANCOMYCIN 500 MG VIAL 500 MG AA‐AMINOGLYCOSIDES 67457033950 INSTITUTI IV 1 VANCOMYCIN 500MG IVPB 500MG/0 AA‐AMINOGLYCOSIDES 338355148 BAXTER HEALTHCA IV 100 VANCOMYCIN 750MG IVPB 750MG AA‐AMINOGLYCOSIDES 338358048 BAXTER HEALTHCA IV 150 NEOMYCIN 500 MG TABLET 500 MG AA‐AMINOGLYCOSIDES 51991073801 BRECKENRIDGE PO 100 PLEASE USE OTHER OPTIONS FIRST VANCOCIN HCL 250 MG PULVULE 250 MG AA‐AMINOGLYCOSIDES 66593312602 VIROPHARMA INCO PO 20 USED ONLY WITH PRIOR APPROVAL VANCOMYCIN HCL 125 MG CAPSU 125 MG AA‐AMINOGLYCOSIDES 66993021019 PRASCO LABS PO 20 USED ONLY WITH PRIOR APPROVAL FLUCONAZOLE 100 MG TABLET 100 MG AA‐ANTIFUNGALS 16714069102 NORTHSTAR RX LL PO 100 FLUCONAZOLE 150 MG TABLET 150 MG AA‐ANTIFUNGALS 55111014512 DR.REDDY'S LAB PO 12 NYSTATIN 100000U/ML SUSP 100K U/ AA‐ANTIFUNGALS 60432053716 MORTON GROVE PH PO 473 TERBINAFINE HCL 250MG TABLE 250MG AA‐ANTIFUNGALS 60429022230 GSMS PO 30 METRONIDAZOLE 500 MG IV SOL 500MG AA‐ANTIMICROBIAL 338105548 BAXTER HEALTHCA IV 100 METRONIDAZOLE 500 MG/100 ML 500MG/0 AA‐ANTIMICROBIAL 409781124 HOSPIRA IV 100 METRONIDAZOLE 250 MG TABLET 250 MG AA‐ANTIMICROBIAL 50111033301 PLIVA, INC PO 100 METRONIDAZOLE 500 MG TABLET 500 MG AA‐ANTIMICROBIAL 50111033402 PLIVA, INC PO 500 NITROFURANTOIN MCR 50 MG CA 50MG AA‐ANTIMICROBIAL 378165001 MYLAN PO 100 NITROFURANTOIN‐MACRO 100 MG 100MG AA‐ANTIMICROBIAL 185012201 EON LABS PO 100 ZYVOX 600MG IVPB 600MG AA‐ANTIMICROBIAL/MAO INHIBITOR 9514001 PHARMACIA/UPJHN IV 300 USED ONLY IN EXTREME EMERGENCY WITH PRIOR APPROVAL RIFAMPIN 150MG CAP 150MG AA‐ANTIMICROBIAL/TB 61748001530 VERSA PHARMACEU PO 30 RIFAMPIN 300 MG CAPSULE 300 MG AA‐ANTIMICROBIAL/TB 61748001801 VERSA PHARMACEU PO 100 XIFAXAN 550 MG TABLET 550 MG AA‐ANTIMICROBIALS/DIARRHEA 65649030302 SALIX PHARMACEU PO 60 USED ONLY IN EXTREME EMERGENCY WITH PRIOR APPROVAL DAPSONE 100 MG TABLET 100 MG AA‐ANTIPARASITIC 49938010130 JACOBUS PHARM. PO 30 DAPSONE 25 MG TABLET 25 MG AA‐ANTIPARASITIC 49938010230 JACOBUS PHARM. PO 30 STROMECTOL 3MG 3MG AA‐ANTIPARASITIC 6003220 MERCK SHARP & DPO 20 ACYCLOVIR 200 MG CAPSULE 200 MG AA‐ANTIVIRAL 60429001201 GSMS, INC. PO 100 ACYCLOVIR 400 MG TABLET 400 MG AA‐ANTIVIRAL 60429030901 APOTEX PO 100 ACYCLOVIR 800 MG TABLET 800 MG AA‐ANTIVIRAL 60429031001 GSMS INC PO 100 FAMCICLOVIR 250 MG TABLET 250 MG AA‐ANTIVIRAL 60505324603 APOTEX CORP PO 30 FAMCICLOVIR 500 MG TABLET 500 MG AA‐ANTIVIRAL 60505324703 APOTEX CORP PO 30 TAMIFLU 75 MG GELCAP 75MG AA‐ANTIVIRAL 4080085 ROCHE LABS. PO 10 USED ONLY WITH PRIOR APPROVAL IF NEEDED FOR LARGE QUANTITIES ACETIC ACID 0.25% IRRIG SOL 0.25% AA‐BACTERICIDAL/FUNGICIDAL 409614309 HOSPIRA IR 1,000.00 INVANZ INJECTION 1 GM AA‐CARBAPENEMS 6384371 MERCK SHARP & D IM 1 USED ONLY WITH PRIOR APPROVAL CEFADROXIL 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS1 143994701 WEST‐WARD,INC. PO 100 CEPHALEXIN 250 MG CAPSULE 250 MG AA‐CEPHALOSPORINS1 65862001801 AUROBINDO PHARM PO 100 CEPHALEXIN 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS1 42291020950 AVKARE PO 500

Page 1 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

CEFACLOR 250 MG CAPSULE 250 MG AA‐CEPHALOSPORINS2 61442017130 CARLSBAD TECH PO 30 CEFACLOR 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS2 47781026703 ALVOGEN INC PO 30 CEFUROXIME AXETIL 250 MG TA 250 MG AA‐CEPHALOSPORINS2 16714040001 NORTHSTAR RX LL PO 20 CEFTRIAXONE 1 GM VIAL 1 GAA‐CEPHALOSPORINS3 25021010610 SAGENT PHARMACE IJ 1 CEFTRIAXONE 1GM IVPB 1G AA‐CEPHALOSPORINS3 338500241 BAXTER HEALTHCA IV 50 CEFEPIME HCL 1 GM VIAL 1G AA‐CEPHALOSPORINS4 32502112120 SAGENT PHARMACE IJ 1 CEFEPIME 1 GM IVPG 1 G/50 ML AA‐CEPHALOSPORINS4 338130141 BAXTER HEALTHCA IV 50 AVELOX 400MG IVPB 400MG AA‐FLUOROQUINOLONES 85173701 SCHERING CORP. IV 250 CIPROFLOXACN‐D5W 200 MG/100 200MG/0 AA‐FLUOROQUINOLONES 25021011482 SAGENT PHARMACE IV 100 CIPROFLOXACN‐D5W 400 MG/200 400MG/0.2L AA‐FLUOROQUINOLONES 409477702 HOSPIRA IV 200 LEVOFLOXACIN‐D5W 500 MG/100 500MG/0.1L AA‐FLUOROQUINOLONES 25021013282 SAGENT PHARMACE IV 100 LEVOFLOXACIN‐D5W 750 MG/150 750MG/.15L AA‐FLUOROQUINOLONES 63323035560 APP PHARMACEUTI IV 150 CIPROFLOXACIN HCL 250 MG TA 250 MG AA‐FLUOROQUINOLONES 42291021901 AVKARE PO 100 CIPROFLOXACIN HCL 500 MG TA 500 MG AA‐FLUOROQUINOLONES 24658025005 BLU PHARMACEUTI PO 500 LEVOFLOXACIN 250 MG TABLET 250 MG AA‐FLUOROQUINOLONES 904635161 MAJOR PHARMACEU PO 100 LEVOFLOXACIN 500 MG TABLET 500 MG AA‐FLUOROQUINOLONES 904635261 MAJOR PHARMACEU PO 100 LEVOFLOXACIN 750 MG TABLET 750 MG AA‐FLUOROQUINOLONES 904635361 MAJOR PHARMACEU PO 100 MOXIFLOXACIN HCL 400 MG TAB 400 MG AA‐FLUOROQUINOLONES 47781026830 ALVOGEN INC PO 30 EPIVIR HBV 100 MG TABLET 100MG AA‐HIV PROTEASE INH 173066200 GLAXOSMITHKLINE PO 60 USED ONLY WITH PRIOR APPROVAL ISENTRESS 400 MG TABLET 400 MG AA‐HIV PROTEASE INH 6022761 MERCK SHARP & D PO 60 USED ONLY WITH PRIOR APPROVAL NORVIR 100 MG TABLET 100 MG AA‐HIV PROTEASE INH 74333330 ABBVIE US LLC PO 30 USED ONLY WITH PRIOR APPROVAL TRUVADA TABLET 200‐300 AA‐HIV PROTEASE INH 61958070101 PO 30 USED ONLY WITH PRIOR APPROVAL TACROLIMUS 1 MG CAPSULE N/F 1 MG AA‐IMMUNOSUPPRESSANT 378204601 MYLAN PO 100 USED ONLY WITH PRIOR APPROVAL CLINDAMYCIN‐D5W 600 MG/50 M 600MG/50ML AA‐LINCOSAMIDES 17478012150 AKORN INC. IV 50 CLINDAMYCIN HCL 150 MG CAPS 150 MG AA‐LINCOSAMIDES 63304069205 RANBAXY PHARMAC PO 500 CLINDAMYCIN HCL 300 MG CAPS 300 MG AA‐LINCOSAMIDES 63304069301 RANBAXY PHARMAC PO 100 AZITHROMYCIN 250 MG TABLET 250MG AA‐MACROLIDES 781149631 SANDOZ PO 30 AZITHROMYCIN 250MGTABLET 250MG AA‐MACROLIDES 781149668 SANDOZ PO 6 CLARITHROMYCIN 250 MG TABLE 250 MG AA‐MACROLIDES 68382076114 ZYDUS PHARMACEU PO 60 CLARITHROMYCIN 500 MG TABLE 500 MG AA‐MACROLIDES 68382076214 ZYDUS PHARMACEU PO 60 ERY‐TAB 250 MG TABLET EC 250MG AA‐MACROLIDES 32433812213 ARBOR PHARMACEU PO 100 PENICILLIN G 1 MILL UNIT 1 MILL AA‐PENICILLIN 338102141 BAXTER HEALTHCA IV 50 AMOX TR‐K CLV 400‐57/5 SUSP 400‐57M AA‐PENICILLIN 66685101202 SANDOZ PO 100 AMOX TR‐K CLV 500‐125 MG TA 500‐125 MG AA‐PENICILLIN 16714029601 NORTHSTAR RX LL PO 20 AMOX TR‐K CLV 875‐125 MG TA 875‐125 MG AA‐PENICILLIN 65862050320 AUROBINDO PHARM PO 20 AMOXICILLIN 250 MG CAPSULE 250 MG AA‐PENICILLIN 781202001 SANDOZ PO 100 AMOXICILLIN 250 MG/5 ML SUS 250 MG/5ML AA‐PENICILLIN 781604158 SANDOZ PO 80 AMOXICILLIN 500 MG CAPSULE 500MG AA‐PENICILLIN 781261305 SANDOZ PO 500 AMPICILLIN 250 MG CAPSULE 250 MG AA‐PENICILLIN 67253018010 QUALITEST PO 100 AMPICILLIN TR 500 MG CAPSUL 500 MG AA‐PENICILLIN 67253018110 DAVA PHARMACEUT PO 100 DICLOXACILLIN 250MG CAPSULE 250MG AA‐PENICILLIN 93312301 TEVA USA PO 100

Page 2 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

PENICILLIN VK 250 MG TABLET 250 MG AA‐PENICILLIN 60429014701 GSMS, INC. PO 100 PENICILLIN VK 500 MG TABLET 500 MG AA‐PENICILLIN 16714023501 NORTHSTAR RX LL PO 100 ZOSYN 2.25 GM PRE MIX‐BAG 2.25 GM AA‐PENICILLIN/BROAD‐SPECTRUM 206886001 PHARM IV 50 ZOSYN 3.375 GM PRE MIX‐BAG 3.375G/ AA‐PENICILLIN/BROAD‐SPECTRUM 206886101 WYETH PHARM IV 50 ZOSYN 4.5 GM PRE‐MIX BAG 4.5G/10 AA‐PENICILLIN/BROAD‐SPECTRUM 206886202 WYETH PHARM IV 100 SULFAMIDE 10% EYE DROPS 10% AA‐SULFONAMIDES 904272835 MAJOR PHARMACEU OP 15 SULFAMETHOXAZOLE‐TMP DS TAB 800‐160 MG AA‐SULFONAMIDES 53489014605 MUTUAL PHARM CO PO 500 SULFAMETHOXAZOLE‐TMP SUSP 200‐40M AA‐SULFONAMIDES 50383082316 HI‐TECH PHARMAC PO 473 ISONIAZID 300MG TABLET 300MG AA‐TB 555007102 BARR PO 100 MYAMBUTOL 400 MG TABLET 400 MG AA‐TB 68850001202 X‐GEN PHARMACEU PO 100 DOXYCYCLINE MONO 100 MG CAP 100 MG AA‐TETRACYCLINES 591041150 WATSON LABS PO 50 DOXYCYCLINE MONO 50 MG CAP 50 MG AA‐TETRACYCLINES 591041001 PHARMA, PO 100 MINOCYCLINE 100 MG CAPSULE 100 MG AA‐TETRACYCLINES 93316753 TEVA USA PO 50 MINOCYCLINE 50MG CAPSULE 50MG AA‐TETRACYCLINES 93316501 TEVA USA PO 100 DONEPEZIL HCL 10 MG TABLET 10 MG ALZHEIMERS/DEMENTIA 33342002815 MACLEODS PHARMA PO 500 DONEPEZIL HCL 5 MG TABLET 5 MG ALZHEIMERS/DEMENTIA 33342002715 MACLEODS PHARMA PO 500 GALANTAMINE ER 16 MG CAPSUL 16 MG ALZHEIMERS/DEMENTIA 10147089203 PATRIOT PHARMAC PO 30 GALANTAMINE ER 24 MG CAPSUL 24 MG ALZHEIMERS/DEMENTIA 10147089303 PATRIOT PHARMAC PO 30 GALANTAMINE ER 8 MG CAPSULE 8 MG ALZHEIMERS/DEMENTIA 591349630 ACTAVIS PHARMA, PO 30 GALANTAMINE HBR 12 MG TABLE 12 MG ALZHEIMERS/DEMENTIA 10147088306 PATRIOT PHARMAC PO 60 GALANTAMINE HBR 4 MG TABLET 4 MG ALZHEIMERS/DEMENTIA 10147088106 PATRIOT PHARMAC PO 60 GALANTAMINE HBR 8 MG TABLET 8 MG ALZHEIMERS/DEMENTIA 10147088206 PATRIOT PHARMAC PO 60 MEMANTINE HCL 10 MG TABLET 10 MG ALZHEIMERS/DEMENTIA 47335032286 SUN PHARMACEUTI PO 60 MEMANTINE HCL 5 MG TABLET 5 MG ALZHEIMERS/DEMENTIA 53746017360 AMNEAL PHARMACE PO 60 PYRIDOSTIGMINE BR 60 MG TAB 60 MG ALZHEIMERS/DEMENTIA 68682030210 OCEANSIDE PHARM PO 100 EPIPEN 0.3 MG AUTO‐INJECTOR 0.3MG/0 ANAPHYLAXIS 49502050002 DEY LABS. IM 2 PROCRIT 20,000 UNITS/ML VIA 20000/ML ANEMIA 59676032004 JANSSEN PRODUCT IJ 1 MULTIDOSE VIAL ‐ CAN BE USED FOR VARIOUS STRENGTHS CLONAZEPAM 0.5 MG TABLET 0.5MG ANTIANXIETY/SEIZURES‐BENZO 603294821 QUALITEST PO 100 CLONAZEPAM 1 MG TABLET 1 MG ANTIANXIETY/SEIZURES‐BENZO 603294921 QUALITEST PO 100 CLONAZEPAM 2 MG TABLET 2 MG ANTIANXIETY/SEIZURES‐BENZO 228300511 ACTAVIS ELIZABE PO 100 LORAZEPAM 2 MG/ML VIAL 2 MG/ML ANTIANXIETY‐BENZO 641604401 WEST‐WARD,INC. IJ 1 CONTROLLED SUBSTANCE ALPRAZOLAM 0.25 MG TABLET 0.25 MG ANTIANXIETY‐BENZO 603212721 QUALITEST PO 100 CONTROLLED SUBSTANCE ALPRAZOLAM 0.5 MG TABLET 0.5 MG ANTIANXIETY‐BENZO 603212821 QUALITEST PO 100 CONTROLLED SUBSTANCE ALPRAZOLAM 1 MG TABLET 1 MG ANTIANXIETY‐BENZO 603212921 QUALITEST PO 100 CONTROLLED SUBSTANCE BUSPIRONE HCL 10 MG TABLET 10 MG ANTIANXIETY‐BENZO 591065810 ACTAVIS PHARMA, PO 1,000.00 BUSPIRONE HCL 15 MG TABLET 15 MG ANTIANXIETY‐BENZO 591071860 ACTAVIS PHARMA, PO 60 BUSPIRONE HCL 5 MG TABLET 5 MG ANTIANXIETY‐BENZO 591065701 ACTAVIS PHARMA, PO 100 DIAZEPAM 10 MG TABLET 10 MG ANTIANXIETY‐BENZO 603321521 QUALITEST PO 100 CONTROLLED SUBSTANCE DIAZEPAM 2MG TABLET 2MG ANTIANXIETY‐BENZO 591562101 WATSON LABS PO 100 CONTROLLED SUBSTANCE DIAZEPAM 5 MG TABLET 5 MG ANTIANXIETY‐BENZO 591561901 WATSON LABS PO 100 CONTROLLED SUBSTANCE LORAZEPAM 0.5 MG TABLET 0.5 MG ANTIANXIETY‐BENZO 603424621 QUALITEST PO 100 CONTROLLED SUBSTANCE

Page 3 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

LORAZEPAM 1 MG TABLET 1 MG ANTIANXIETY‐BENZO 603424721 QUALITEST PO 100 CONTROLLED SUBSTANCE LORAZEPAM 2 MG TABLET 2 MG ANTIANXIETY‐BENZO 603424821 QUALITEST PO 100 CONTROLLED SUBSTANCE LORAZEPAM 2 MG/ML ORAL CONC 2 MG/ML ANTIANXIETY‐BENZO 65162068784 AMNEAL PHARMACE PO 30 CONTROLLED SUBSTANCE TEMAZEPAM 15MG CAPSULE 15MG ANTIANXIETY‐BENZO 228207610 ACTAVIS ELIZABE PO 100 CONTROLLED SUBSTANCE GLYCOPYRROLATE 0.2MG/ML INJ 0.2MG/ML ANTICHOLINERGIC 517460125 AMERICAN REGENT INJ 25 GLYCOPYRROLATE 0.4MG/ML INJ 0.4MG/ML ANTICHOLINERGIC 517460225 AMERICAN REGENT INJ 25 GLYCOPYRROLATE 1 MG TABLET 1 MG ANTICHOLINERGIC 603318021 QUALITEST PO 100 GLYCOPYRROLATE 2 MG TABLET 2 MG ANTICHOLINERGIC 603318121 QUALITEST PO 100 PROPANTHELINE 15MG TABLET 15MG ANTICHOLINERGIC 54472125 ROXANE LABS. PO 100 TRANSDERM‐SCOP 1.5 MG/72HR 1.5MG/7 ANTICHOLINERGIC 10019055388 BAXTER HEALTHCA TD 10 ANASPAZ 0.125 MG TABLET ODT 0.125 M ANTICHOLINERGIC/SPASMS 225029515 B.F ASCHER & CO PO 100 HYOSCYAMINE 0.125 MG ODT 0.125 MG ANTICHOLINERGIC/SPASMS 43199001201 COUNTY LINE PHA PO 100 HEPARIN SOD 5,000 UNIT/ML V 5000/ML ANTICOAGULANT 409272301 HOSPIRA IJ 1 HEPARIN 300 UNIT/3 ML (100/ 300/3 ML ANTICOAGULANT 8881590123 /KENDAL IV 3 MONOJECT HEPARIN 100 UNITS/ 100/ML ANTICOAGULANT 8881590125 KENDALL HEALTH IV 5 CILOSTAZOL 100 MG TABLET 100 MG ANTICOAGULANT 185022360 SANDOZ PO 60 CILOSTAZOL 50 MG TABLET 50 MG ANTICOAGULANT 54002821 ROXANE LABS. PO 60 COUMADIN 10MG TABLET 10MG ANTICOAGULANT 56017475 BMS PO 100 COUMADIN 1MG TABLET 1MG ANTICOAGULANT 56016975 BMS PO 100 COUMADIN 2.5MG TABLET 2.5MG ANTICOAGULANT 56017675 BMS PO 100 COUMADIN 2MG TABLET 2MG ANTICOAGULANT 56017075 BMS PO 100 COUMADIN 3 MG TABLET 3 MG ANTICOAGULANT 56018875 BMS PO 100 COUMADIN 4MG TABLET 4MG ANTICOAGULANT 56016875 BMS PO 100 COUMADIN 5MG TABLET 5MG ANTICOAGULANT 56017275 BMS PO 100 COUMADIN 6MG TABLET 6MG ANTICOAGULANT 56018975 BMS PO 100 COUMADIN 7.5MG TABLET 7.5MG ANTICOAGULANT 56017375 BMS PO 100 PENTOXIFYLLINE ER 400 MG TA 400 MG ANTICOAGULANT 93511601 TEVA USA PO 100 ENOXAPARIN 100 MG/ML SYR 100 MG/ ANTICOAGULANT 548560500 AMPHASTAR PHARM SQ 1 ENOXAPARIN 120 MG/0.8 ML SY 120MG/.8ML ANTICOAGULANT 955101210 WINTHROP US SQ 0.8 ENOXAPARIN 30 MG/0.3 ML SYR 30MG/0.3ML ANTICOAGULANT 955100310 WINTHROP US SQ 0.3 ENOXAPARIN 40 MG/0.4 ML SYR 40MG/0. ANTICOAGULANT 548560200 AMPHASTAR PHARM SQ 0.4 ENOXAPARIN 60 MG/0.6 ML SYR 60MG/0. ANTICOAGULANT 548560300 AMPHASTAR PHARM SQ 0.6 ENOXAPARIN 80 MG/0.8 ML SYR 80MG/0. ANTICOAGULANT 548560400 AMPHASTAR PHARM SQ 0.8 AMITRIPTYLINE HCL 10 MG TAB 10 MG ANTIDEPRESSANT 603221221 QUALITEST PO 100 AMITRIPTYLINE HCL 100 MG TA 100 MG ANTIDEPRESSANT 51079056320 MYLAN INSTITUTI PO 100 AMITRIPTYLINE HCL 25 MG TAB 25 MG ANTIDEPRESSANT 51079010720 MYLAN INSTITUTI PO 100 AMITRIPTYLINE HCL 50 MG TAB 50 MG ANTIDEPRESSANT 51079013320 MYLAN INSTITUTI PO 100 AMITRIPTYLINE HCL 75 MG TAB 75 MG ANTIDEPRESSANT 51079014720 MYLAN INSTITUTI PO 100 BUPROPION 75MG HCL TABLET 75 MG ANTIDEPRESSANT 781105301 SANDOZ PO 100 BUPROPION HCL 100 MG TABLET 100 MG ANTIDEPRESSANT 781106401 SANDOZ PO 100 BUPROPION HCL SR 100 MG TAB 100 MG ANTIDEPRESSANT 591354060 ACTAVIS PHARMA, PO 60

Page 4 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

BUPROPION SR 150 MG TABLET 150 MG ANTIDEPRESSANT 591354125 WATSON LABS PO 250 BUPROPION SR 200 MG HCL TAB 200 MG ANTIDEPRESSANT 591354260 WATSON LABS PO 60 BUPROPION XL 150 MG TAB 150 MG ANTIDEPRESSANT PO 60 BUPROPION XL 300 MG TAB 300 MG ANTIDEPRESSANT PO 60 CITALOPRAM 10MG/5ML 10MG ANTIDEPRESSANT 54006258 ROXANE LABS. PO 240 CITALOPRAM 20 MG TABLET 20MG ANTIDEPRESSANT 24658014110 BLU PHARMACEUTI PO 1,000.00 CITALOPRAM 40 MG TABLET 40MG ANTIDEPRESSANT 24658014210 BLU PHARMACEUTI PO 1,000.00 CITALOPRAM HBR 10 MG TABLET 10 MG ANTIDEPRESSANT 24658014001 BLU PHARMACEUTI PO 100 DOXEPIN 10 MG CAPSULE 10 MG ANTIDEPRESSANT 378104901 MYLAN PO 100 DOXEPIN 100 MG CAPSULE 100 MG ANTIDEPRESSANT 378641001 MYLAN PO 100 DOXEPIN 150MG CAPSULE 150MG ANTIDEPRESSANT 49884022201 PAR PHARM. PO 100 DOXEPIN 25 MG CAPSULE 25 MG ANTIDEPRESSANT 378312501 MYLAN PO 100 DOXEPIN 50 MG CAPSULE 50 MG ANTIDEPRESSANT 51079043820 MYLAN INSTITUTI PO 100 DULOXETINE 30MG 30MG ANTIDEPRESSANT 60429016530 GSMS PO 30 DULOXETINE HCL 60 MG 60 MG ANTIDEPRESSANT 60429016630 GSMS PO 30 FLUOXETINE 10MG CAPSULE 10MG ANTIDEPRESSANT 406066105 MALLINCKRODT PH PO 1,000.00 FLUOXETINE 20MG CAPSULE 20MG ANTIDEPRESSANT 781282210 SANDOZ PO 1,000.00 FLUOXETINE HCL 10 MG CAPSUL 10 MG ANTIDEPRESSANT 50111064703 PLIVA, INC PO 1,000.00 FLUOXETINE HCL 20 MG CAPSUL 20 MG ANTIDEPRESSANT 50111064802 TEVA USA PO 500 IMIPRAMINE HCL 50 MG TABLET 50MG ANTIDEPRESSANT 49884005601 PAR PHARM. PO 100 MIRTAZAPINE 15 MG TABLET 15 MG ANTIDEPRESSANT 378351510 MYLAN PO 1,000.00 MIRTAZAPINE 30 MG TABLET 30 MG ANTIDEPRESSANT 378353005 MYLAN PO 500 MIRTAZAPINE 45 MG TABLET 45 MG ANTIDEPRESSANT 378354505 MYLAN PO 500 NORTRIPTYLINE HCL 10MG CAP 10MG ANTIDEPRESSANT 93081001 TEVA USA PO 100 NORTRIPTYLINE HCL 25 MG CAP 25MG ANTIDEPRESSANT 93081101 TEVA USA PO 100 NORTRIPTYLINE HCL 50 MG CAP 50 MG ANTIDEPRESSANT 93081201 TEVA USA PO 100 NORTRIPTYLINE HCL 75 MG CAP 75MG ANTIDEPRESSANT 93081301 TEVA USA PO 100 PAROXETINE 40 MG TABLET 40 MG ANTIDEPRESSANT 378700493 MYLAN PO 30 PAROXETINE HCL 10 MG TABLET 10 MG ANTIDEPRESSANT 378700193 MYLAN PO 30 PAROXETINE HCL 20 MG TABLET 20 MG ANTIDEPRESSANT 378700293 MYLAN PO 30 PAROXETINE HCL 30 MG TABLET 30 MG ANTIDEPRESSANT 378700393 MYLAN PO 30 SERTRALINE HCL 100 MG TABLE 100 MG ANTIDEPRESSANT 76282021405 EXELAN PHARMACE PO 500 SERTRALINE HCL 25 MG TABLET 25MG ANTIDEPRESSANT 31722021205 CAMBER PHARMACE PO 500 SERTRALINE HCL 50 MG TABLET 50 MG ANTIDEPRESSANT 76282021305 EXELAN PHARMACE PO 500 TRAZODONE 100 MG TABLET 100 MG ANTIDEPRESSANT 42291083410 AVKARE PO 1,000.00 TRAZODONE 150 MG TABLET 150 MG ANTIDEPRESSANT 53489051701 MUTUAL PHARM CO PO 100 TRAZODONE 50 MG TABLET 50 MG ANTIDEPRESSANT 42291083310 AVKARE PO 1,000.00 VENLAFAXINE HCL 100 MG TABL 100 MG ANTIDEPRESSANT 378488501 MYLAN PO 100 VENLAFAXINE HCL 75 MG TABLE 75 MG ANTIDEPRESSANT 42291089590 AVKARE PO 90 VENLAFAXINE HCL ER 150 MG C 150 MG ANTIDEPRESSANT 59762018202 GREENSTONE LLC. PO 100 VENLAFAXINE HCL ER 150 MG T 150 MG ANTIDEPRESSANT 131326746 UCB PHARMA PO 90

Page 5 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

VENLAFAXINE HCL ER 225 MG T 225 MG ANTIDEPRESSANT 131326832 UCB PHARMA PO 30 VENLAFAXINE HCL ER 37.5 MG 37.5 MG ANTIDEPRESSANT 59762018002 GREENSTONE LLC. PO 90 VENLAFAXINE HCL ER 75MG CAP 75 MG ANTIDEPRESSANT 59762018102 GREENSTONE LLC. PO 90 DIPHENHYDRAMINE 50 MG/ML VI 50MG/ML ANTIHISTAMINE 641037625 BAXTER HEALTHCA IJ 1 HYDROXYZINE 50 MG/ML VIAL 50 MG/M ANTIHISTAMINE 517560125 AMER. REGENT IM 1 BANOPHEN 12.5 MG/5 ML ELIXI 12.5MG/ ANTIHISTAMINE 904517416 MAJOR PHARMACEU PO 473 BANOPHEN 25 MG TABLET 25 MG ANTIHISTAMINE 904555159 MAJOR PHARMACEU PO 100 BANOPHEN 50 MG CAPSULE 50 MG ANTIHISTAMINE 904530780 MAJOR PHARMACEU PO 1,000.00 CETIRIZINE HCL 10 MG TABLET 10 MG ANTIHISTAMINE 45802091987 CO. PO 300 CETIRIZINE HCL 5 MG TABLET 5 MG ANTIHISTAMINE 378363501 MYLAN PO 100 DIPHENHIST 12.5 MG/5 ML SOL 12.5MG/ ANTIHISTAMINE 536077085 RUGBY PO 473 DIPHENHYDRAMINE 25 MG HCL 25MG ANTIHISTAMINE 603333932 QUALITEST PO 1,000.00 HYDROXYZINE 10 MG/5 ML SYRU 10MG/5M ANTIHISTAMINE 60432015016 MORTON GROVE PH PO 473 HYDROXYZINE HCL 10 MG TABLE 10 MG ANTIHISTAMINE 603396728 QUALITEST PO 100 HYDROXYZINE HCL 25 MG TABLE 25 MG ANTIHISTAMINE 16714008210 NORTHSTAR RX LL PO 100 LORATADINE 10 MG TABLET 10 MG ANTIHISTAMINE 45802065087 PERRIGO CO. PO 300 MECLIZINE 12.5MG TABLET 12.5MG ANTIHISTAMINE 536398510 RUGBY PO 1,000.00 HYDROXYZINE PAM 100 MG CAP 100MG ANTIHISTAMINE/PTSD 555032402 BARR PO 100 HYDROXYZINE PAM 25 MG CAP 25 MG ANTIHISTAMINE/PTSD 42291032250 AVKARE PO 500 HYDROXYZINE PAM 50 MG CAP 50 MG ANTIHISTAMINE/PTSD 42291032350 AVKARE PO 500 FLUPHENAZINE 2.5MG/ML VIAL 2.5MG/M ANTIPSYCHOTIC 63323028110 APP PHARMACEUTI IJ 10 FLUPHENAZINE DEC 125 MG/5 M 25 MG/ML ANTIPSYCHOTIC 42023012901 PAR PHARM. IJ 5 FLUPHENAZINE DEC 25 MG/ML V 25MG/ML ANTIPSYCHOTIC 63323027205 APP PHARMACEUTI IJ 5 HALOPERIDOL LAC 5 MG/ML VIA 5 MG/ML ANTIPSYCHOTIC 63323047401 APP PHARMACEUTI IJ 1 HALOPERIDOL DEC 100 MG/ML V 100 MG/ML ANTIPSYCHOTIC 63323047101 APP PHARMACEUTI IM 1 HALOPERIDOL DEC 50 MG/ML VI 50 MG/ML ANTIPSYCHOTIC 63323046901 APP PHARMACEUTI IM 1 ABILIFY 10 MG TABLET 10 MG ANTIPSYCHOTIC 59148000813 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST ABILIFY 15 MG TABLET 15 MG ANTIPSYCHOTIC 59148000913 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST ABILIFY 2 MG TABLET 2 MG ANTIPSYCHOTIC 59148000613 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST ABILIFY 20MG TABLET 20MG ANTIPSYCHOTIC 59148001013 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST ABILIFY 30MG TABLET 30MG ANTIPSYCHOTIC 59148001113 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST ABILIFY 5 MG TABLET 5 MG ANTIPSYCHOTIC 59148000713 OTSUKA AMERICA PO 30 PLEASE USE OTHER OPTIONS FIRST FLUPHENAZINE 1 MG TABLET 1 MG ANTIPSYCHOTIC 378600401 MYLAN PO 100 FLUPHENAZINE 2.5 MG TABLET 2.5 MG ANTIPSYCHOTIC 781143701 SANDOZ PO 100 FLUPHENAZINE 5 MG TABLET 5 MG ANTIPSYCHOTIC 781143801 SANDOZ PO 100 HALOPERIDOL 0.5MG TAB(AP) 0.5MG ANTIPSYCHOTIC 781139101 SANDOZ PO 100 HALOPERIDOL 1 MG TABLET 1 MG ANTIPSYCHOTIC 378025701 MYLAN PO 100 HALOPERIDOL 10MG TABLET 10MG ANTIPSYCHOTIC 781139701 SANDOZ PO 100 HALOPERIDOL 2MG TABLET 2MG ANTIPSYCHOTIC 378021401 MYLAN PO 100 HALOPERIDOL 5 MG TABLET 5MG ANTIPSYCHOTIC 781139610 SANDOZ PO 1,000.00 HALOPERIDOL LAC 2 MG/ML CON 2MG/ML ANTIPSYCHOTIC 121058104 PHARMACEU ASSOC PO 120

Page 6 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

OLANZAPINE 10 MG TABLET 10 MG ANTIPSYCHOTIC 52343004130 GEN‐SOURCE PO 30 OLANZAPINE 15MG TABLET 15 MG ANTIPSYCHOTIC 52343004230 GEN‐SOURCE PO 30 OLANZAPINE 2.5MG TABLET 2.5MG ANTIPSYCHOTIC 52343003830 GENSOURCE PO 30 OLANZAPINE 20 MG TABLET 20 MG ANTIPSYCHOTIC 52343004330 GEN SOURCE PO 30 OLANZAPINE 5 MG TABLET 5 MG ANTIPSYCHOTIC 52343003930 GEN SOURCE PO 30 OLANZAPINE 7.5 MG TABLET 7.5 MG ANTIPSYCHOTIC 52343004030 GEN SOURSE PO 30 QUETIAPINE FUMARATE 100 MG 100 MG ANTIPSYCHOTIC 54022125 ROXANE LABS. PO 100 QUETIAPINE FUMARATE 200 MG 200 MG ANTIPSYCHOTIC 54022225 ROXANE LABS. PO 100 QUETIAPINE FUMARATE 25 MG T 25 MG ANTIPSYCHOTIC 54022031 ROXANE LABS. PO 1,000.00 QUETIAPINE FUMARATE 300 MG 300 MG ANTIPSYCHOTIC 54022321 ROXANE LABS. PO 60 QUETIAPINE FUMARATE 400 MG 400 MG ANTIPSYCHOTIC 60429037601 GSMS INCORPORAT PO 100 QUETIAPINE FUMARATE 50 MG T 50 MG ANTIPSYCHOTIC 60429037210 GSMS INC. PO 1,000.00 RISPERIDONE 0.25 MG TABLET 0.25MG ANTIPSYCHOTIC 50458059050 PATRIOT PHARMAC PO 500 RISPERIDONE 0.5 MG TABLET 0.5MG ANTIPSYCHOTIC 50458059150 PATRIOT PHARMAC PO 500 RISPERIDONE 1 MG/ML SOLUTIO 1 MG/ML ANTIPSYCHOTIC 603942445 QUALITEST PO 30 RISPERIDONE 1MG TAB (AP) 1MG ANTIPSYCHOTIC 50458059250 PATRIOT PHARMAC PO 500 RISPERIDONE 2MG TABLETS (AP 2MG ANTIPSYCHOTIC 50458059360 PATRIOT PHARMAC PO 60 RISPERIDONE 3 MG TABLET 3 MG ANTIPSYCHOTIC 378351305 MYLAN PO 500 RISPERIDONE 4MG TABLET (AP) 4MG ANTIPSYCHOTIC 50458059560 PATRIOT PHARMAC PO 60 THIOTHIXENE 10 MG CAPSULE 10 MG ANTIPSYCHOTIC 378501001 MYLAN PO 100 ZIPRASIDONE HCL 40 MG CAPSU 40 MG ANTIPSYCHOTIC 59762200201 GREENSTONE LLC. PO 60 ZIPRASIDONE HCL 60 MG CAPSU 60 MG ANTIPSYCHOTIC 59762200301 GREENSTONE LLC. PO 60 ZIPRASIDONE HCL 80 MG CAPSU 80 MG ANTIPSYCHOTIC 59762200401 GREENSTONE LLC. PO 60 ZIPRASIDONE HCL 20 MG CAPSU 20 MG ANTIPSYCHOTIC 60429076560 GSMS INC 60 CHLORPROMAZINE 10MG TABLET 10MG ANTIPSYCHOTIC/NAUSEA/VOMITING 832030000 UPSHER SMITH PO 100 CHLORPROMAZINE 25 MG TABLET 25MG ANTIPSYCHOTIC/NAUSEA/VOMITING 832030100 UPSHER SMITH PO 100 CHLORPROMAZINE 50MG TABLET 50MG ANTIPSYCHOTIC/NAUSEA/VOMITING 832030200 UPSHER SMITH PO 100 PERPHENAZINE 2 MG TABLET 2 MG ANTIPSYCHOTIC/NAUSEA/VOMITING 603506021 QUALITEST PO 100 PERPHENAZINE 4 MG TABLET 4 MG ANTIPSYCHOTIC/NAUSEA/VOMITING 603506121 QUALITEST PO 100 PERPHENAZINE 8 MG TABLET 8MG ANTIPSYCHOTIC/NAUSEA/VOMITING 781104801 SANDOZ PO 100 PROCHLORPERAZINE 10 MG TAB 10 MG ANTIPSYCHOTIC/NAUSEA/VOMITING 378511001 MYLAN PO 100 MEGESTROL 40 MG TABLET 40 MG APPETITE STIMULANT/CANCER 49884029005 PAR PHARM. PO 500 MEGESTROL ACET 40 MG/ML SUS 400MG/1 APPETITE STIMULANT/CANCER 60432012608 MORTON GROVE PH PO 240 ALBUTEROL SULFATE 2 MG TAB 2 MG ASTHMA 378025501 MYLAN PO 100 AZO STANDARD 95 MG TABLET 95 MG BLADDER 87651030152 I‐HEALTH, INC PO 30 BETHANECHOL 10MG TABLET 10MG BLADDER 50111032401 PLIVA, INC PO 100 BETHANECHOL 25 MG TABLET 25MG BLADDER 832051200 UPSHER SMITH PO 100 FLAVOXATE 100 MG HCL TABLET 100MG BLADDER 574011501 PADDOCK LABS. PO 100 OXYBUTYNIN 5 MG TABLET 5 MG BLADDER 50111045602 PLIVA, INC PO 500 SOD CITRATE/CITRIC ACID SOL 334‐500 BLADDER 121059516 PHARMACEU ASSOC PO 473 TROSPIUM CHLORIDE 20 MG TAB 20 MG BLADDER 574014560 PADDOCK LABS. PO 60

Page 7 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

FINASTERIDE 5 MG TABLET 5 MG BPH 603363328 QUALITEST PO 500 TAMSULOSIN HCL 0.4 MG CAPSU 0.4 MG BPH 378250077 MYLAN PO 90 DOXAZOSIN 2 MG TAB 2 MG BPH/HTN 378402201 MYLAN PO 100 DOXAZOSIN MESYLATE 1 MG TAB 1 MG BPH/HTN 378402101 MYLAN PO 100 DOXAZOSIN MESYLATE 4 MG TAB 4 MG BPH/HTN 378402401 MYLAN PO 100 PRAZOSIN 1 MG CAPSULE 1 MG BPH/HTN 51079063020 UDL PO 100 PRAZOSIN 2 MG CAPSULE 2 MG BPH/HTN 93406801 TEVA USA PO 100 TERAZOSIN 1 MG CAPSULE 1 MG BPH/HTN 781205101 SANDOZ PO 100 TERAZOSIN 10 MG CAPSULE 10 MG BPH/HTN 781205401 SANDOZ PO 100 TERAZOSIN 2 MG CAPSULE 2MG BPH/HTN 781205205 SANDOZ PO 500 TERAZOSIN 5 MG CAPSULE 5MG BPH/HTN 781205305 SANDOZ PO 500 LETROZOLE 2.5 MG TABLET 2.5 MG BREAST CANCER 62756051183 SUN PHARMACEUTI PO 30 ATORVASTATIN 10 MG TABLET 10 MG CHOLESTEROL 59762015502 GREENSTONE LLC. PO 1,000.00 ATORVASTATIN 20 MG TABLET 20 MG CHOLESTEROL 59762015602 GREENSTONE LLC. PO 1,000.00 ATORVASTATIN 40 MG TABLET 40 MG CHOLESTEROL 59762015702 GREENSTONE LLC. PO 500 ATORVASTATIN 80 MG TABLET 80 MG CHOLESTEROL 59762015802 GREENSTONE LLC. PO 500 ROSUVASTATIN CALCIUM 5 MG TAB 5 MG CHOLESTEROL 16252061530 ACTAVIS PO 30 ROSUVASTATIN CALCIUM 10 MG TAB 10 MG CHOLESTEROL 16252061630 ACTAVIS PO 30 ROSUVASTATIN CALCIUM 20 MG TAB 20 MG CHOLESTEROL 16252061730 ACTAVIS PO 30 ROSUVASTATIN CALCIUM 40 MG TAB 40 MG CHOLESTEROL 16252061830 ACTAVIS PO 30 FENOFIBRATE 145 MG TABLET 145MG CHOLESTEROL 45802013275 PERRIGO CO. PO 90 FENOFIBRATE 48 MG TABLET 48 MG CHOLESTEROL 45802031575 PERRIGO CO. PO 90 FENOFIBRATE 54 MG TABLET 54 MG CHOLESTEROL 378710077 MYLAN PO 90 FISH OIL 1000MG 340‐100 CHOLESTEROL 904404360 MAJOR PHARMACEU PO 100 GEMFIBROZIL 600 MG TABLET 600 MG CHOLESTEROL 76282022505 EXELAN PHARMACE PO 500 NIACIN 250 MG ER CAPSULE 250MG CHOLESTEROL 536407401 RUGBY PO 100 NIACIN 500 MG SA TAB 500MG CHOLESTEROL 7985410078 NAT'L VIT. CO. PO 100 PRAVASTATIN SODIUM 10 MG TA 10 MG CHOLESTEROL 55111022990 DR.REDDY'S LAB PO 90 PRAVASTATIN SODIUM 20 MG TA 20MG CHOLESTEROL 93720198 TEVA USA PO 90 PRAVASTATIN SODIUM 40 MG TA 40MG CHOLESTEROL 93720298 TEVA USA PO 90 PRAVASTATIN SODIUM 80 MG TA 80 MG CHOLESTEROL 42291066910 AVKARE PO 1,000.00 PREVALITE PACKET 4 G CHOLESTEROL 245003660 UPSHER SMITH PO 60 SIMVASTATIN 10 MG TABLET 10 MG CHOLESTEROL 24658030110 BLU PHARMACEUTI PO 1,000.00 SIMVASTATIN 20 MG TABLET 20 MG CHOLESTEROL 68382006710 ZYDUS PHARMACEU PO 1,000.00 SIMVASTATIN 40 MG TABLET 40 MG CHOLESTEROL 68382006805 ZYDUS PHARMACEU PO 500 SIMVASTATIN 5MG TABLET 5MG CHOLESTEROL 52343002190 GEN SOURCE PO 90 SIMVASTATIN 80MG TABLET 80 MG CHOLESTEROL 52343002599 GENSOURCE PO 1,000.00 VITAMIN K 10 MG/ML AMPUL 10 MG/M CLOTTING AGENT 409915801 HOSPIRA IJ 1 SUDOGEST 30 MG TABLET 30 MG CONGESTION 904633860 MAJOR PHARMACEU PO 100 SUDOGEST 60MG TABLET 60MG CONGESTION 904512559 MAJOR PHARMACEU PO 100 DEXAMETHASONE 0.5MG TABLET 0.5MG CORTICOSTEROID 54417925 ROXANE LABS. PO 100

Page 8 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

DEXAMETHASONE 2 MG TABLET 2MG CORTICOSTEROID 54418325 ROXANE LABS. PO 100 DEXAMETHASONE 4MG TABLET 4MG CORTICOSTEROID 54418425 ROXANE LABS. PO 100 HYDROCORTISONE 5 MG TABLET 5 MG CORTICOSTEROID 603389919 QUALITEST PO 50 METHYLPREDNISOLONE 4 MG DOS 4 MG CORTICOSTEROID 51991018831 BRECKENRIDGE PO 21 METHYLPREDNISOLONE 4 MG TAB 4 MG CORTICOSTEROID 781502201 SANDOZ PO 100 PREDNISONE 10MG TABLET 10MG CORTICOSTEROID 54001729 ROXANE LABS. PO 500 PREDNISONE 2.5MG TABLET 2.5MG CORTICOSTEROID 54474225 ROXANE LABS. PO 100 PREDNISONE 20MG TABLET 20MG CORTICOSTEROID 54001829 ROXANE LABS. PO 500 PREDNISONE 5 MG TABLET 5 MG CORTICOSTEROID 591505210 ACTAVIS PHARMA, PO 1,000.00 PREDNISONE 50 MG TABLET 50 MG CORTICOSTEROID 54001925 ROXANE LABS. PO 100 PREDNISONE 5MG/5ML SOLUTI 5MG/5ML CORTICOSTEROID 54372263 ROXANE LABS. PO 500 HUMULIN R 100 UNITS/ML VIAL 100/ML DIABETES 2821501 ELI LILLY & CO. IJ 10 NOVOLIN R 100 UNITS/ML VIAL 100 U/M DIABETES 169183311 NOVO NORDISK IJ 10 NOVOFINE 30 NEEDLES (N/F) 30GX1/3 DIABETES 169185250 NOVO NORDISK MC 100 NOVOFINE AUTOCOVER 30G NEED 30GX1/3 DIABETES 169185275 NOVO NORDISK MC 100 USED ONLY WITH PRIOR APPROVAL GLIMEPIRIDE 1 MG TABLET 1 MG DIABETES 16729000101 ACCORD HEALTHCA PO 100 GLIMEPIRIDE 2 MG TABLET 2 MG DIABETES 378401201 MYLAN PO 100 GLIMEPIRIDE 4 MG TABLET 4 MG DIABETES 378401301 MYLAN PO 100 GLIPIZIDE 10MG TABLET (L) 10MG DIABETES 781145310 SANDOZ PO 1,000.00 GLIPIZIDE 5MG TABLET (L) 5MG DIABETES 781145210 SANDOZ PO 1,000.00 GLYBURIDE 1.25 MG TABLET 1.25 MG DIABETES 93947753 TEVA USA PO 50 GLYBURIDE 2.5 MG TABLET 2.5MG DIABETES 93943301 TEVA USA PO 100 GLYBURIDE 5 MG TABLET 5 MG DIABETES 93936401 TEVA USA PO 100 METFORMIN HCL 1,000 MG TABL 1000 MG DIABETES 57664047453 CARACO PHARM PO 500 METFORMIN HCL 500 MG TABLET 500MG DIABETES 60429011110 GSMS PO 1,000.00 METFORMIN HCL 850 MG TABLET 850 MG DIABETES 60429011205 GSMS INCOR PO 500 PIOGLITAZONE HCL 15 MG TABL 15 MG DIABETES 378004893 MYLAN PO 30 PIOGLITAZONE HCL 30 MG TABL 30 MG DIABETES 52343005430 GEN SOURCE PO 30 PIOGLITAZONE HCL 45 MG TABL 45 MG DIABETES 378031893 MYLAN PO 30 HUMALOG 100 UNITS/ML VIAL 100/ML DIABETES 2751017 ELI LILLY & CO. SQ 3 HUMALOG MIX 75‐25 VIAL 75‐25/ML DIABETES 2751101 ELI LILLY & CO. SQ 10 HUMULIN 70‐30 VIAL 70‐30/ML DIABETES 2871501 ELI LILLY & CO. SQ 10 HUMULIN N 100 UNITS/ML VIAL 100/ML DIABETES 2831501 ELI LILLY & CO. SQ 10 LANTUS 100U/ML VIAL 100 U/M DIABETES 88222033 SANOFI‐AVENTIS SQ 10 HYDROXYCHLOROQUINE 200 MG T 200 MG DMARDS/MALARIA 66993005702 PRASCO LABS PO 100 LEFLUNOMIDE 20 MG TABLET 20 MG DMARDS/RHEUMATOID ARTHRITIS 16714033101 NORTHSTAR RX LL PO 30 METHOTREXATE 2.5MG TABLET 2.5MG DMARDS/RHEUMATOID ARTHRITIS 378001401 MYLAN PO 100 SULFAZINE 500 MG TABLET 500 MG DMARDS/RHEUMATOID ARTHRITIS/UC 603580128 QUALITEST PO 500 SULFAZINE EC 500 MG TAB 500 MG DMARDS/RHEUMATOID ARTHRITIS/UC 603580325 QUALITEST PO 300 NEO/POLYMYXIN/HC EAR SUSP 3.5‐10K E‐ANTIMICROBIAL 24208063562 BAUSCH & LOMB POT 10 ACETIC ACID 2% EAR SOLUTION 2% E‐BACTERICIDAL/FUNGICIDAL 60432074115 MORTON GROVE PH OT 15

Page 9 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

EAR DROPS 6.5% 6.50% E‐WAX REMOVAL 904322035 MAJOR PHARMACEU OT 15 BISMATROL TABLET CHEW 262 MG GI‐ANTACID 904131546 MAJOR PHARMACEU PO 30 MINTOX SUSPENSION 200‐200 GI‐ANTACID 904572114 MAJOR PHARMACEU PO 355 MYTAB GAS 80 MG TABLET CHEW 80 MG GI‐ANTACID 603021021 QUALITEST PO 100 ANTI‐DIARRHEAL 2MG CAPLET 2MG GI‐ANTIDIARRHEAL 904772512 MAJOR PHARMACEU PO 12 DIPHENOXYLATE‐ATROPINE TABL 2.5‐.02 GI‐ANTIDIARRHEAL 378041501 MYLAN PO 100 LOPERAMIDE 2 MG CAPSULE 2 MG GI‐ANTIDIARRHEAL 51079069020 MYLAN INSTITUTI PO 100 METOCLOPRAMIDE 10 MG TABLET 10 MG GI‐GERD 93220301 TEVA USA PO 100 METOCLOPRAMIDE 5 MG TABLET 5 MG GI‐GERD 16714006111 NORTHSTAR RX LL PO 500 METOCLOPRAMIDE 5MG/5ML SYRP 5MG/5ML GI‐GERD 121057616 PHARMACEU ASSOC PO 473 CHLORDIAZEPOXIDE‐CLIDINIUM 5 MG‐2.5MG GI‐IBS 68682040910 OCEANSIDE PHARM PO 100 CONTROLLED SUBSTANCE DICYCLOMINE 10 MG CAPSULE 10MG GI‐IBS 378161005 MYLAN PO 500 DICYCLOMINE 20 MG TABLET 20 MG GI‐IBS 591079510 WATSON LABS PO 1,000.00 PROMETHAZINE 25 MG/ML VIAL 25 MG/ML GI‐NAUSEA/VOMITING 641092825 WEST‐WARD,INC. IJ 1 ONDANSETRON 4 MG/5 ML SOLUT 4 MG/5 ML GI‐NAUSEA/VOMITING 54838055550 SILARX PHARM PO 50 ONDANSETRON HCL 4 MG TABLET 4MG GI‐NAUSEA/VOMITING 378031593 MYLAN PO 30 ONDANSETRON HCL 8 MG TABLET 8 MG GI‐NAUSEA/VOMITING 378034493 MYLAN PO 30 PROMETHAZINE 12.5 MG TABLET 12.5 MG GI‐NAUSEA/VOMITING 603543721 QUALITEST PO 100 PROMETHAZINE 25 MG TABLET 25 MG GI‐NAUSEA/VOMITING 603543832 QUALITEST PO 1,000.00 PROMETHAZINE SYRUP 6.25MG/ GI‐NAUSEA/VOMITING 60432060816 MORTON GROVE PH PO 473 PROMETHAZINE 25 MG SUPPOSIT 25 MG GI‐NAUSEA/VOMITING 45802075930 PERRIGO CO. RC 12 ASACOL HD DR 800 MG TABLET 800 MG GI‐ULCER 430078327 WC PROF PRODS PO 180 PLEASE USE OTHER OPTIONS FIRST CARAFATE 1 GM/10 ML SUSPENS 1G/10ML GI‐ULCER 58914017014 AXCAN PHARMA US PO 420 OMEPRAZOLE DR 20 MG CAPSULE 20 MG GI‐ULCER 62175011843 KREMERS URBAN PO 1,000.00 PANTOPRAZOLE SOD DR 20 MG T 20 MG GI‐ULCER 8060601 WYETH PHARM PO 90 PANTOPRAZOLE SOD DR 40 MG T 40 MG GI‐ULCER 62175061743 KREMERS URBAN PO 1,000.00 RANITIDINE 15 MG/ML SYRUP 15 MG/ML GI‐ULCER 23155029151 HERITAGE PHARMA PO 480 RANITIDINE 150 MG TABLET 150 MG GI‐ULCER 42291072410 AVKARE PO 1,000.00 RANITIDINE 300 MG TABLET 300 MG GI‐ULCER 42291072525 AVKARE PO 250 SUCRALFATE 1 GM TABLET 1G GI‐ULCER 591078005 WATSON LABS PO 500 MISOPROSTOL 100 MCG TABLET 100 MCG GI‐ULCER PREVENTION 59762500701 GREENSTONE LLC. PO 60 MISOPROSTOL 200 MCG TABLET 200 MCG GI‐ULCER PREVENTION 59762500801 GREENSTONE LLC. PO 60 ALLOPURINOL 100 MG TABLET 100 MG GOUT 378013710 MYLAN PO 1,000.00 ALLOPURINOL 300 MG TABLET 300 MG GOUT 51079020620 MYLAN INSTITUTI PO 100 LISINOPRIL 10 MG TABLET 10 MG HA‐HYPERTENSION/CHF 603421132 QUALITEST PO 1,000.00 LISINOPRIL 2.5MG TAB 2.5MG HA‐HYPERTENSION/CHF 60429020605 GSMS PO 500 LISINOPRIL 20 MG TABLET 20 MG HA‐HYPERTENSION/CHF 603421234 QUALITEST PO 5,000.00 LISINOPRIL 30 MG TABLET 30 MG HA‐HYPERTENSION/CHF 64679095301 WOCKHARDT USA L PO 100 LISINOPRIL 40 MG TABLET 40 MG HA‐HYPERTENSION/CHF 603421428 QUALITEST PO 500 LISINOPRIL 5 MG TABLET 5 MG HA‐HYPERTENSION/CHF 603421028 QUALITEST PO 500 LOSARTAN POT 100MG TAB 100 HA‐HYPERTENSION/CHF 60429031890 GSMS PO 90

Page 10 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

LOSARTAN POTASSIUM 25 MG TA 25 MG HA‐HYPERTENSION/CHF 60429031610 GSMS PO 1,000.00 LOSARTAN POTASSIUM 50MG TAB 50MG HA‐HYPERTENSION/CHF 60429031710 GSMS PO 1,000.00 ATENOLOL 100 MG TABLET 100 MG HB‐HYPERTENSION 781522901 SANDOZ PO 100 ATENOLOL 25 MG TABLET 25 MG HB‐HYPERTENSION 42291014010 AVKARE PO 1,000.00 ATENOLOL 50 MG TABLET 50 MG HB‐HYPERTENSION 42291014110 AVKARE PO 1,000.00 CARVEDILOL 12.5 MG TABLET 12.5 MG HB‐HYPERTENSION 93729505 TEVA USA PO 500 CARVEDILOL 25 MG TABLET 25 MG HB‐HYPERTENSION 93729605 TEVA USA PO 500 CARVEDILOL 3.125 MG TABLET 3.125 MG HB‐HYPERTENSION 93005105 TEVA USA PO 500 CARVEDILOL 6.25 MG TABLET 6.25 MG HB‐HYPERTENSION 93013505 TEVA USA PO 500 METOPROLOL SUCC ER 100MG TA 100MG HB‐HYPERTENSION 60429014110 GSMS PO 1,000.00 METOPROLOL SUCC ER 200 MG T 200 HB‐HYPERTENSION 60429014201 GSMS PO 100 METOPROLOL SUCC ER 25 MG TA 25 MG HB‐HYPERTENSION 60429013910 PO 1,000.00 METOPROLOL SUCC ER 50MG TAB 50 MG HB‐HYPERTENSION 60429014010 PO 1,000.00 METOPROLOL TARTRATE 100 MG 100 MG HB‐HYPERTENSION 57664016758 CARACO PHARM PO 1,000.00 METOPROLOL TARTRATE 25 MG T 25 MG HB‐HYPERTENSION 57664050658 CARACO PHARM PO 1,000.00 METOPROLOL TARTRATE 50 MG T 50 MG HB‐HYPERTENSION 57664016658 CARACO PHARM PO 1,000.00 PROPRANOLOL 10 MG TABLET 10 MG HB‐HYPERTENSION 378018210 MYLAN PO 1,000.00 PROPRANOLOL 20MG TABLET 20MG HB‐HYPERTENSION 50111046803 PLIVA, INC PO 1,000.00 PROPRANOLOL 40 MG TABLET 40 MG HB‐HYPERTENSION 378018410 MYLAN PO 1,000.00 PROPRANOLOL ER 120 MG CAPSU 120 MG HB‐HYPERTENSION 228278011 ACTAVIS ELIZABE PO 100 PROPRANOLOL ER 60 MG CAPSUL 60MG HB‐HYPERTENSION 228277811 ACTAVIS ELIZABE PO 100 PROPRANOLOL ER 80 MG CAPSUL 80 MG HB‐HYPERTENSION 228277911 ACTAVIS ELIZABE PO 100 SOTALOL 120 MG TABLET 120MG HB‐HYPERTENSION 60429074901 GSMS PO 100 SOTALOL 80 MG TABLET 80MG HB‐HYPERTENSION 603576921 QUALITEST PO 100 AFEDITAB CR 30 MG TABLET 30MG HC‐HYPERTENSION/CHF 591319301 WATSON LABS PO 100 AMLODIPINE 10MG BESYLATE TA 10 MG HC‐HYPERTENSION/CHF 603211032 QUALITEST PO 1,000.00 AMLODIPINE 5 MG BESYLATE TA 5 MG HC‐HYPERTENSION/CHF 603210932 QUALITEST PO 1,000.00 AMLODIPINE BESYLATE 2.5 MG 2.5 MG HC‐HYPERTENSION/CHF 603210832 QUALITEST PO 1,000.00 DILTIAZEM 30 MG TABLET 30 MG HC‐HYPERTENSION/CHF 378002301 MYLAN PO 100 DILTIAZEM 60 MG TABLET 60 MG HC‐HYPERTENSION/CHF 378004501 MYLAN PO 100 DILTIAZEM HCL ER 120 MG CAP 120 MG HC‐HYPERTENSION/CHF 68682036790 OCEANSIDE PHARM PO 90 DILTIAZEM HCL ER 180 MG CAP 180 MG HC‐HYPERTENSION/CHF 68682036890 OCEANSIDE PHARM PO 90 DILTIAZEM HCL ER 240 MG CAP 240 MG HC‐HYPERTENSION/CHF 68682036990 OCEANSIDE PHARM PO 90 DILTIAZEM HCL ER 300 MG CAP 300 MG HC‐HYPERTENSION/CHF 258369090 INWOOD LABS. PO 90 FELODIPINE ER 10 MG TABLET 10 MG HC‐HYPERTENSION/CHF 603358321 QUALITEST PO 100 FELODIPINE ER 2.5 MG TABLET 2.5 MG HC‐HYPERTENSION/CHF 53489036801 MUTUAL PHARM CO PO 100 FELODIPINE ER 5 MG TABLET 5 MG HC‐HYPERTENSION/CHF 603358221 QUALITEST PO 100 NIFEDIPINE 10 MG CAPSULE 10 MG HC‐HYPERTENSION/CHF 59762100401 GREENSTONE LLC. PO 100 NIFEDIPINE ER 60 MG TABLET 60 MG HC‐HYPERTENSION/CHF 378036001 MYLAN PO 100 NIFEDIPINE ER 90 MG TABLET 90 MG HC‐HYPERTENSION/CHF 378039001 MYLAN PO 100 VERAPAMIL ER 120 MG TABLET 120 MG HC‐HYPERTENSION/CHF 378212001 MYLAN PO 100

Page 11 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

VERAPAMIL ER 240 MG TABLET 240 MG HC‐HYPERTENSION/CHF 57664011888 CARACO PHARM PO 100 FUROSEMIDE 10 MG/ML VIAL 10 MG/ML HD‐HYPERTENSION 409610204 HOSPIRA IJ 4 CHLORTHALIDONE 25 MG TABLET 25 MG HD‐HYPERTENSION 51079005820 MYLAN INSTITUTI PO 100 FUROSEMIDE 10 MG/ML SOLUTIO 10MG/ML HD‐HYPERTENSION 54329450 ROXANE LABS. PO 120 FUROSEMIDE 20 MG TABLET 20 MG HD‐HYPERTENSION 603373932 QUALITEST PO 1,000.00 FUROSEMIDE 40MG TABLET 40MG HD‐HYPERTENSION 603374032 QUALITEST PO 1,000.00 FUROSEMIDE 80 MG TABLET 80 MG HD‐HYPERTENSION 54430125 ROXANE LABS. PO 100 HYDROCHLOROTHIAZIDE 12.5MG 12.5MG HD‐HYPERTENSION 591034705 WATSON LABS PO 500 HYDROCHLOROTHIAZIDE 25 MG T 25 MG HD‐HYPERTENSION 172208380 IVAX PHARMACEUT PO 1,000.00 HYDROCHLOROTHIAZIDE 50MG TB 50MG HD‐HYPERTENSION 172208960 IVAX PHARMACEUT PO 100 METOLAZONE 10 MG TABLET 10 MG HD‐HYPERTENSION 378617401 MYLAN PO 100 METOLAZONE 2.5 MG TABLET 2.5MG HD‐HYPERTENSION 65580064371 UPSTATE PHARMA PO 100 METOLAZONE 5 MG TABLET 5 MG HD‐HYPERTENSION 378617301 MYLAN PO 100 SPIRONOLACTONE 25 MG TABLET 25 MG HD‐HYPERTENSION 603576332 QUALITEST PO 1,000.00 TRIAMTERENE‐HCTZ 37.5‐25 MG 37.5‐25 MG HD‐HYPERTENSION 378135201 MYLAN PO 100 TRIAMTERENE‐HCTZ 75‐50 MG T 75 MG‐5HD‐HYPERTENSION 378135501 MYLAN PO 100 CLONIDINE HCL 0.1 MG TABLET 0.1 MG HE‐HYPERTENSION 228212710 ACTAVIS PHARMA, PO 100 CLONIDINE HCL 0.2MG TABLET 0.2MG HE‐HYPERTENSION 228212850 ACTAVIS ELIZABE PO 500 CLONIDINE HCL 0.3 MG TABLET 0.3 MG HE‐HYPERTENSION 603295921 QUALITEST PO 100 HYDRALAZINE 10 MG TABLET 10 MG HE‐HYPERTENSION 50111039801 PLIVA, INC PO 100 HYDRALAZINE 25 MG TABLET 25 MG HE‐HYPERTENSION 50111032703 TEVA PO 1,000.00 HYDRALAZINE 50MG TABLET 50MG HE‐HYPERTENSION 50111032803 PLIVA, INC PO 1,000.00 CLONIDINE 0.1 MG/DAY PATCH 0.1MG/24HR HE‐HYPERTENSION 591350804 ACTAVIS PHARMA, TD 4 CLONIDINE 0.2 MG/DAY PATCH 0.2MG/24HR HE‐HYPERTENSION 591350904 ACTAVIS PHARMA, TD 4 CLONIDINE 0.3 MG/DAY PATCH 0.3MG/24HR HE‐HYPERTENSION 591351004 ACTAVIS PHARMA, TD 4 LANOXIN 125 MCG TABLET 125 MCG HF‐INOTROPES/PRESSORS 24987024276 COVIS PHARMACEU PO 1,000.00 LANOXIN 250 MCG TABLET 250 MCG HF‐INOTROPES/PRESSORS 24987024976 COVIS PHARMACEU PO 1,000.00 ISOSORBIDE DN 10 MG TABLET 10 MG HH‐ANGINA/DILATOR 143177101 WEST‐WARD,INC. PO 100 ISOSORBIDE DN 20 MG TABLET 20 MG HH‐ANGINA/DILATOR 143177201 WEST‐WARD,INC. PO 100 ISOSORBIDE MN ER 120 MG TAB 120 MG HH‐ANGINA/DILATOR 62175012937 KREMERS URBAN PO 100 ISOSORBIDE MN ER 30 MG TABL 30 MG HH‐ANGINA/DILATOR 62175012841 KREMERS URBAN PO 500 ISOSORBIDE MN ER 60 MG TABL 60 MG HH‐ANGINA/DILATOR 62175011941 KREMERS URBAN PO 500 NITROSTAT 0.4MG TABLET SL 0.4MG HH‐ANGINA/DILATOR 30071041813 PARKE,DAVIS CO. SL 100 NITROGLYCERIN 0.1 MG/HR PTC 0.1MG/H HH‐ANGINA/DILATOR 378910293 MYLAN TD 30 NITROGLYCERIN 0.2 MG/HR PTC 0.2MG/H HH‐ANGINA/DILATOR 378910493 MYLAN TD 30 NITROGLYCERIN 0.4 MG/HR PTC 0.4MG/H HH‐ANGINA/DILATOR 378911293 MYLAN TD 30 NITROGLYCERIN 0.6 MG/HR PTC 0.6MG/H HH‐ANGINA/DILATOR 378911693 MYLAN TD 30 FLECAINIDE ACETATE 50 MG TA 50 MG HH‐ANTIARRHYTHMIC 54001025 ROXANE LABS. PO 100 PACERONE 200 MG TABLET 200 MG HH‐ANTIARRHYTHMIC 245014715 UPSHER SMITH PO 500 PROPAFENONE HCL 150MG TAB 150MG HH‐ANTIARRHYTHMIC 603544825 QUALITEST PO 300 PROPAFENONE HCL 225 MG TAB 225MG HH‐ANTIARRHYTHMIC 603544921 QUALITEST PO 100

Page 12 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

ASPIRIN 325 MG TABLET 325 MG HHH‐ANTIPLATLETS 536105305 RUGBY PO 500 ASPIRIN 81 MG CHEWABLE TABL 81 MG HHH‐ANTIPLATLETS 904628889 MAJOR PHARMACEU PO 90 ASPIRIN 81 MG EC TABLET 81MG HHH‐ANTIPLATLETS 603002632 QUALITEST PO 1,000.00 ASPIRIN EC 325 MG TABLET 325 MG HHH‐ANTIPLATLETS 536331310 RUGBY PO 1,000.00 CLOPIDOGREL 75MG TABLET 75MG HHH‐ANTIPLATLETS 60429030110 GOLDEN STATE PO 1,000.00 DEPO‐TESTOSTERONE 100MG/ML 100MG/M HORMONE 9034702 PHARMACIA/UPJHN IM 10 CONTROLLED SUBSTANCE DEPO‐TESTOSTERONE 200 MG/ML 200MG/M HORMONE 9041701 PHARMACIA/UPJHN IM 1 CONTROLLED SUBSTANCE CABERGOLINE 0.5 MG TABLET 0.5MG HORMONE 49884067314 PAR PHARM. PO 8 MEDROXYPROGESTERONE 10MG TB 10MG HORMONE 59762374202 GREENSTONE LLC. PO 100 MEDROXYPROGESTERONE 5 MG TA 5 MG HORMONE 555087302 BARR PO 100 ANASTROZOLE 1MG TAB 1MG HORMONE/BREAST CANCER 60429028690 90 BROMOCRIPTINE 2.5 MG TABLET HORMONE/PARKINSONS 378204293 MYLAN PO 30 PROPYLTHIOURACIL 50 MG TABL 50 MG HYPERTHYROID 228234810 ACTAVIS ELIZABE PO 100 GLUCAGON 1 MG EMERGENCY KIT 1 MG HYPOGLYCEMIA 2803101 ELI LILLY & CO. IJ 1 MIDODRINE HCL 10 MG TABLET 10MG HYPOTENSION 378190301 MYLAN PO 100 MIDODRINE HCL 2.5 MG TABLET 2.5MG HYPOTENSION 378190101 MYLAN PO 100 MIDODRINE HCL 5 MG TABLET 5 MG HYPOTENSION 42291061690 AVKARE PO 90 FLUDROCORTISONE 0.1 MG TABL 0.1 MG HYPOTENSION/ADRENAL 42291052901 AVKARE PO 100 LEVOTHYROXINE 100 MCG TABLE 100 MCG HYPOTHYROID 781518410 SANDOZ PO 1,000.00 LEVOTHYROXINE 112 MCG TABLE 112 MCG HYPOTHYROID 781518592 SANDOZ PO 90 LEVOTHYROXINE 137 MCG TABLE 137 MCG HYPOTHYROID 781519192 SANDOZ PO 90 LEVOTHYROXINE 150MCG TABLET 150MCG HYPOTHYROID 781518710 SANDOZ PO 1,000.00 LEVOTHYROXINE 175 MCG TABLE 175MCG HYPOTHYROID 781518892 SANDOZ PO 90 LEVOTHYROXINE 200 MCG TABLE 200 MCG HYPOTHYROID 781518992 SANDOZ PO 90 LEVOTHYROXINE 25 MCG TABLET 25MCG HYPOTHYROID 781518010 SANDOZ PO 1,000.00 LEVOTHYROXINE 50 MCG TABLET 50 MCG HYPOTHYROID 781518192 SANDOZ PO 90 LEVOTHYROXINE 75 MCG TABLET 75MCG HYPOTHYROID 781518210 SANDOZ PO 1,000.00 LEVOTHYROXINE 88 MCG TABLET 88 MCG HYPOTHYROID 781518392 SANDOZ PO 90 MONTELUKAST SOD 10 MG TABLE 10 MG I‐ASTHMA 603465532 QUALITEST PO 1,000.00 THEOPHYLINE 300MG ER TAB (L 300MG I‐ASTHMA 50111045901 PLIVA, INC PO 100 VARIOUS STRENGTHS AVAILABLE IF NEEDED ASMANEX INH (120DOSE) 220MC 220MCG I‐ASTHMA/STEROIDS 85134101 SCHERING CORP. IH 1 ASMANEX INH(30DOSE) 220MCG 220MCG( I‐ASTHMA/STEROIDS 30085134107 SCHERING CORP. IH 0.24 ASMANEX INH(60DOSE) 220MCG 220MCG( I‐ASTHMA/STEROIDS 85134102 SCHERING CORP. IH 1 ALBUTEROL 0.083% INHAL SOLN 2.5 MG/3ML I‐COPD/ASTHMA 378827091 MYLAN IH 3 ATROVENT HFA INHALER (200) 17MCG I‐COPD/ASTHMA 597008717 BOEHRINGER ING. IH 12.9 COMBIVENT RESPIMAT (120) 20‐100 MCG I‐COPD/ASTHMA 597002402 BOEHRINGER ING. IH 4 IPRATROPIUM BR 0.02% SOLN 0.2 MG/ML I‐COPD/ASTHMA 378797091 MYLAN IH 2.5 PROVENTIL HFA (200) 90MCG I‐COPD/ASTHMA 85113201 SCHERING CORP. IH 6.7 SPIRIVA 18 MCG CP‐HANDIHALE 18MCG I‐COPD/ASTHMA 597007541 BOEHRINGER ING. IH 30 SYMBICORT 160‐4.5 MCG INHAL 160‐4.5MCG I‐COPD/ASTHMA 186037028 ASTRAZENECA IH 6 SYMBICORT 80‐4.5 MCG INHALE 80‐4.5 MCG I‐COPD/ASTHMA 186037228 ASTRAZENECA IH 6.9

Page 13 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

OPTICHAMBER DIAMOND VHC I‐COPD/ASTHMA 8373747800 PHILIPS RESPIRO MC 1 PULMICORT 0.5 MG/2 ML RESPU 0.5 MG/2ML I‐CORTICOSTEROID 186198904 ASTRAZENECA IH 2 PLEASE USE OTHER OPTIONS FIRST KENALOG‐40 40 MG/ML VIAL 40MG/ML INJ‐CORTICOSTEROID 3029305 BMS PRIMARYCARE IJ 1 SOLU‐CORTEF 100 MG VIAL 100MG INJ‐CORTICOSTEROID 9082501 PHARMACIA/UPJHN IJ 1 SOLU‐MEDROL (PF) 40 MG VIAL 40 MG/M INJ‐CORTICOSTEROID 9003928 US PHARM IJ 1 SOLU‐MEDROL 125 MG VIAL 125 MG/ INJ‐CORTICOSTEROID 9004722 PFIZER US PHARM IJ 1 NACL 0.9% FLUSH SYRINGE 0.90% IV‐FLUIDS 8290306546 BECTON DICKINSO IJ 10 D5/0.2%NACL 5%‐0.2% IV‐FLUIDS 338007704 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.2%NACL/KCL 20mEq 20MEQ/L IV‐FLUIDS 338066304 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.45%NACL 5%‐0.45 IV‐FLUIDS 338008504 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.45%NACL/KCL 10mEq 10MEQ/L IV‐FLUIDS 338066904 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.45%NACL/KCL 20mEq 20MEQ/L IV‐FLUIDS 338067104 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.45%NACL/KCL 40mEq 40MEQ/L IV‐FLUIDS 338067504 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.9%NACL 5%‐0.9% IV‐FLUIDS 338008904 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.9%NACL/KCL 20mEq 20MEQ/L IV‐FLUIDS 338080304 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY D5/0.9%NACL/KCL 40mEq 40MEQ/L IV‐FLUIDS 338080704 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY DEXTROSE 5%‐0.45% NACL IV S 5 %‐0.45 %IV‐FLUIDS 338008503 BAXTER HEALTHCA IV 500 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY DEXTROSE 5%‐WATER IV SOLN 5% IV‐FLUIDS 264751010 B.BRAUN IV 500 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY KCL 40 MEQ IN D5W‐NACL 0.9% 40 MEQ/L IV‐FLUIDS 409710909 HOSPIRA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.45% 0.45% IV‐FLUIDS 338004304 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.45%/KCL 20mEq 20MEQ/L IV‐FLUIDS 338070434 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.9% 1000ML 0.90% IV‐FLUIDS 338004904 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.9% 500ML 0.90% IV‐FLUIDS 338004903 BAXTER HEALTHCA IV 500 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.9%/ KCL 20mEq 20MEQ/L IV‐FLUIDS 338069104 BAXTER HEALTHCA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY NACL 0.9%/KCL 40mEq 40 MEQ/L IV‐FLUIDS 409711609 HOSPIRA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY SODIUM CHLORIDE 0.9% SOLUTI 0.90% IV‐FLUIDS 409798303 HOSPIRA IV 500 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY SODIUM CHLORIDE 0.9% SOLUTI 0.90% IV‐FLUIDS 409798309 HOSPIRA IV 1,000.00 AVAILABILITY SHOULD BE CHECKED WITH PHARMACY SODIUM CHLORIDE 1 GM TABLET IV‐FLUIDS 223176001 CONSOLIDATED MI PO 100 CALCITRIOL 0.25MCG CAPSULE 0.25MCG KIDNEY 63304023901 RANBAXY PHARMAC PO 100 CALCIUM ACETATE 667 MG GELC 667 MG KIDNEY 781208102 SANDOZ PO 200 K‐PHOS ORIGINAL TAB 500MG KIDNEY 486111101 BEACH PRODUCTS PO 100 PHOS‐NAK PACKET 280‐250 KIDNEY 60258000601 CYPRESS PHARM. PO 100 POTASSIUM CITRATE ER 10 MEQ 10 MEQ KIDNEY 245007111 UPSHER SMITH PO 100 RENAL CAPS SOFTGEL 1 MG KIDNEY 60258016201 CYPRESS PHARM. PO 100 RENVELA 800 MG TABLET 800MG KIDNEY 58468013001 GENZYME PO 270 SODIUM BICARB 325 MG TABLET 325 MG KIDNEY 536104610 RUGBY PO 1,000.00 SODIUM BICARB 650MG TABLET 650MG KIDNEY 536454410 RUGBY PO 1,000.00 SORBITOL 70% SOLUTION 70% LAXATIVE 603090058 QUALITEST MC 473 BISACODYL EC 5 MG TABLET 5 MG LAXATIVE 904792780 MAJOR PHARMACEU PO 1,000.00 BISACODYL EC 5 MG TABLET‐DO 5 MG LAXATIVE 904792760 MAJOR PHARMACEU PO 100 DIOCTO 50 MG/5 ML LIQUID 50 MG/5 ML LAXATIVE 536059085 RUGBY PO 473

Page 14 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

DOK 100 MG CAPSULE DOM 100MG LAXATIVE 904788960 MAJOR PHARMACEU PO 100 DOK 100 MG SOFTGEL 100 MG LAXATIVE 904645780 MAJOR PHARMACEU PO 1,000.00 FIBER‐LAX CAPTABS 625 MG LAXATIVE 536430605 RUGBY PO 500 GOLYTELY SOLUTION LAXATIVE 52268010001 BRAINTREE LABS. PO 4,000.00 MILK OF MAGNESIA SUSPENSION 400 MG/5ML LAXATIVE 904078816 MAJOR PHARMACEU PO 473 POLYETHYLENE GLYCOL 3350 PO 17G/CAP LAXATIVE 45802086803 PERRIGO CO. PO 510 POLYETHYLENE GLYCOL 3350 PO 17G/DOSE LAXATIVE 45802086802 PERRIGO CO. PO 238 REGULOID LAXATIVE POWDER LAXATIVE 536187579 RUGBY PO 284 SENNA 8.8 MG/5 ML SYRUP 8.8MG/5 LAXATIVE 904628909 MAJOR PHARMACEU PO 237 SENNA‐LAX 8.6 MG TABLET 8.6 MG LAXATIVE 603028232 QUALITEST PO 1,000.00 SENNALAX‐S TABLET 8.6MG‐50MG LAXATIVE 603028332 QUALITEST PO 1,000.00 BISAC‐EVAC 10 MG SUPPOSITOR 10 MG LAXATIVE 30713010901 G & W LABS. RC 8 LACTULOSE 10 GM/15 ML SOLUT 10 G/15 ML LAXATIVE/LIVER 121057716 PHARMACEU ASSOC PO 473 LITHIUM CAPSULE 150MG 150MG MIND‐BIPOLAR 143318801 WEST‐WARD,INC. PO 100 LITHIUM CAPSULE 300MG 300MG MIND‐BIPOLAR 54252731 ROXANE LABS. PO 1,000.00 LITHIUM CARBONATE 150 MG CA 150 MG MIND‐BIPOLAR 54252625 ROXANE LABS. PO 100 LITHIUM CARBONATE 300 MG TA 300 MG MIND‐BIPOLAR 54452725 ROXANE LABS. PO 100 LITHIUM CARBONATE 600 MG CA 600MG MIND‐BIPOLAR 54253125 ROXANE LABS. PO 100 LITHIUM ER TABLET 300MG 300MG MIND‐BIPOLAR 54002125 ROXANE LABS. PO 100 LITHIUM ER TABLET 450MG 450MG MIND‐BIPOLAR 54002025 ROXANE LABS. PO 100 WATER FOR INJECTION VIAL MIX AGENT 409488720 HOSPIRA IJ 20 SM PEDIATRIC ELECTROLYTE SO MIX AGENT 1093920833 SUNMARK PO 960 LIDOCAINE HCL 1% VIAL 10 MG/M MIX AGENT/NUMBING AGENT 409427601 HOSPIRA IJ 20 BIOTENE DRY MOUTH ORAL RINS M‐MOISTURIZER 48582080220 GSK CONSUMER HE MM 237 CHLORHEXIDINE 0.12% RINSE 1.2MG/M M‐MOUTHWASH 116200116 XTTRIUM LABS. PO 473 ORABASE‐B 20% PASTE 20% M‐NUMBING AGENT 38341006545 COLGATE ORAL PH DT 6 SORE THROAT 1.4% SPRAY 1.40% M‐NUMBING AGENT 904630521 MAJOR PHARMACEU MM 177 LIDOCAINE 2% VISCOUS SOLN 20MG/ML M‐NUMBING AGENT 603139364 QUALITEST PO 100 BACLOFEN 10 MG TABLET 10 MG MUSCLE RELAXANT 603240628 QUALITEST PO 500 CYCLOBENZAPRINE 10MG TABLET 10MG MUSCLE RELAXANT 60429005210 PO 1,000.00 METHOCARBAMOL 500 MG TABLET 500 MG MUSCLE RELAXANT 60429011801 GSMS INC. PO 100 METHOCARBAMOL 750 MG TABLE 750 MG MUSCLE RELAXANT 60429011901 GSMS PO 100 TIZANIDINE 4 MG TABLET 4 MG MUSCLE RELAXANT 378072419 MYLAN PO 150 FLUTICASONE 50 MCG NS (120) 50MCG N‐ALLERGY 54327099 ROXANE LABS. NS 16 IPRATROPIUM 0.03% SPR (345) 21MCG N‐ALLERGY 54004544 ROXANE LABS. NS 30 IPRATROPIUM 0.06% SPR (165) 42MCG N‐ALLERGY 54004641 ROXANE LABS. NS 15 AZELASTINE 137 MCG NASAL SP 137 MCG N‐ALLERGY 51525029403 WALLACE PHARMAC NS 30 NASAL DECONGESTANT SPRAY 0.05% N‐DECONGESTANT 904571135 MAJOR PHARMACEU NS 15 DEEP SEA 0.65% NOSE SPRAY 0.65% N‐MOISTURIZER 904386575 MAJOR PHARMACEU NS 44 AYR SALINE NASAL GEL N‐MOISTURIZER 225052547 B.F ASCHER & CO TP 14.1 LIDOCAINE HCL 2% JEL (URO‐J 2% NUMBING AGENT 76329301305 INTERNATIONAL MMM 10

Page 15 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

KETOTIFEN FUM 0.025% EYE DR 0.03% O‐ALLERGIES 17478071710 AKORN INC. OP 5 VISINE‐A EYE ALLERGY DROPS 0.025‐0.3% O‐ALLERGIES 42002020005 J&J CONS PROD OP 15 TOBRAMYCIN‐DEXAMETHASONE OP 0.3‐0.1 O‐AMINOGLYCOSIDE/STEROID 61314064705 FALCON PHARMACE OP 5 GENTAK 3MG/GM EYE OINTMENT 0.30% O‐AMINOGLYCOSIDES 17478028435 AKORN INC. OP 3.5 GENTAMICIN 3 MG/ML EYE DROP 0.30% O‐AMINOGLYCOSIDES 61314063305 FALCON PHARMACE OP 5 TOBRAMYCIN 0.3% EYE DROPS 0.30% O‐AMINOGLYCOSIDES 61314064305 FALCON PHARMACE OP 5 GENTAMICIN 0.1% OINTMENT 0.10% O‐AMINOGLYCOSIDES 45802004635 PERRIGO CO. TP 15 ATROPINE 1% EYE DROPS 1% O‐ANTICHOLINERGIC 24208075060 BAUSCH & LOMB POP 5 ISOPTO HYOSCINE 0.25% DRO 0.25% O‐ANTICHOLINERGIC 998033105 (P.R.) OP 5 AK‐POLY‐BAC EYE OINTMENT 500‐10K O‐ANTIMICROBIAL 17478023835 AKORN INC. OP 3.5 BACITRACIN‐POLYMYXIN EYE OI 500‐10K O‐ANTIMICROBIAL 24208055555 BAUSCH & LOMB P OP 3.5 NEO/BACIT/POLY EYE OINTMENT 3.5MG‐4O‐ANTIMICROBIAL 24208078055 BAUSCH & LOMB P OP 3.5 POLYMYXIN B‐TMP EYE DROPS 10K/ML‐ O‐ANTIMICROBIAL 24208031510 BAUSCH & LOMB POP 10 NEOMYC‐POLYM‐DEXAMET EYE OI 3.5‐10K O‐ANTIMICROBIAL/STEROID 61314063136 FALCON PHARMACE OP 3.5 NEOMYC‐POLYM‐DEXAMETH EYE D 0.10% O‐ANTIMICROBIAL/STEROID 61314063006 FALCON PHARMACE OP 5 FLUOROMETHOLONE 0.1% DROPS 0.10% O‐CORTICOSTEROID 60758088005 PACIFIC PHARMA OP 5 PREDNISOLONE AC 1%EYE DR 1% O‐CORTICOSTEROID 61314063705 FALCON PHARMACE OP 5 PHENYLEPHRINE 2.5% EYE DROP 2.50% O‐DILATION 24208074006 BAUSCH & LOMB POP 15 MURO‐128 2% EYE DROPS 2% O‐EDEMA 24208027615 BAUSCH & LOMB POP 15 SODIUM CHLORIDE 5% EYE DROP 5% O‐EDEMA 17478062312 AKORN INC. OP 15 SODIUM CHLORIDE 5% EYE OINT 5% O‐EDEMA 17478062235 AKORN INC. OP 3.5 SODIUM CHLORIDE 5% EYE OINT 5% O‐EDEMA 904531538 MAJOR PHARMACEU OP 3.5 CIPROFLOXACIN 0.3% EYE DROP 0.30% O‐FLUOROQUINOLONES 61314065605 SANDOZ OP 5 OFLOXACIN 0.3% EYE DROPS 0.30% O‐FLUOROQUINOLONES 17478071310 AKORN INC. OP 5 BRIMONIDINE 0.2% EYE DROP 0.20% O‐GLAUCOMA 24208041115 VALEANT OP 15 DORZOLAMIDE HCL 2% EYE DROP 2% O‐GLAUCOMA 61314001910 SANDOZ OP 10 DORZOLAMIDE‐TIMOLOL EYE DRO 2 %‐0.5 %O‐GLAUCOMA 61314003002 SANDOZ OP 10 LATANOPROST 0.005% EYE DROP 0.01% O‐GLAUCOMA 59762033302 GREENSTONE LLC. OP 2.5 PILOCARPINE 2% EYE DROPS 2% O‐GLAUCOMA 61314020415 FALCON PHARMACE OP 15 TIMOLOL 0.25% EYE DROPS 0.25% O‐GLAUCOMA 61314022615 FALCON PHARMACE OP 15 TIMOLOL 0.5% EYE DROPS 0.50% O‐GLAUCOMA 61314022710 FALCON PHARMACE OP 10 ACETAZOLAMIDE 250 MG TABLET 250 MG O‐GLAUCOMA 60429003401 GSMS, INC. PO 100 ACETAZOLAMIDE ER 500 MG CAP 500 MG O‐GLAUCOMA 555051302 BARR PO 100 ARTIFICIAL TEARS EYE OINT O‐LUBRICANT 536655091 RUGBY OP 3.5 LIQUITEARS 1.4 % DROPS 1.40% O‐LUBRICANT 904501735 MAJOR PHARMACEU OP 15 REFRESH LIQUIGEL 1% EYE DRO 1% O‐LUBRICANT 23920502 INC. OP 15 REFRESH PLUS 0.5% EYE DROPS 0.50% O‐LUBRICANT 23040370 ALLERGAN INC. OP 70 REFRESH TEARS 0.5% DROPS 0.50% O‐LUBRICANT 23079830 ALLERGAN INC. OP 30 ERYTHROMYCIN EYE OINTMENT 5MG/G O‐MACROLIDES 17478007035 AKORN INC. OP 3.5 DICLOFENAC 0.1% EYE DROPS 0.10% O‐NSAID 61314001405 FALCON PHARMACE OP 5 KETOROLAC 0.5% OPHTH SOLUTI 0.50% O‐NSAID 17478020910 AKORN INC. OP 5

Page 16 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

ALENDRONATE 70MG TABLET 70MG OSTEOPOROSIS 378356999 MYLAN PO 4 ALENDRONATE SODIUM 35 MG TA 35MG OSTEOPOROSIS 378356899 MYLAN PO 4 SULFACETAMIDE 10% EYE DROPS 10% O‐SULFONAMIDES 61314070101 FALCON PHARMACE OP 15 MAPAP 325 MG TABLET 325 MG PAIN 904198280 MAJOR PHARMACEU PO 1,000.00 MAPAP 325 MG TABLET (DOM) 325 MG PAIN 904198260 MAJOR PHARMACEU PO 100 MAPAP 325 MG TABLET U/D 325MG PAIN 904198261 MAJOR PHARMACEU PO 100 MAPAP 500 MG TABLET 500 MG PAIN 904198880 MAJOR PHARMACEU PO 1,000.00 MAPAP 500 MG TABLET (DOM) 500 MG PAIN 904198860 MAJOR PHARMACEU PO 100 Q‐PAP 160 MG/5 ML LIQUID 160 MG/ PAIN 603083958 QUALITEST PO 480 CELECOXIB 100 MG CAPSULE 100 MG PAIN‐NSAID 591282001 ACTAVIS PHARMA, PO 100 CELECOXIB 200 MG CAPSULE 200 MG PAIN‐NSAID 591282501 ACTAVIS PHARMA, PO 100 DICLOFENAC 75 MG EC SODIUM 75 MG PAIN‐NSAID 228255196 ACTAVIS ELIZABE PO 1,000.00 DICLOFENAC SOD 50MG TAB EC 50MG PAIN‐NSAID 228255011 ACTAVIS ELIZABE PO 100 ETODOLAC 300MG CAPSULE 300MG PAIN‐NSAID 60429244001 GSMS INC PO 100 IBUPROFEN 100 MG/5 ML SUSP 100 MG/ PAIN‐NSAID 45802095243 PERRIGO CO. PO 473 IBUPROFEN 200 MG TABLET 200 MG PAIN‐NSAID 904791559 MAJOR PHARMACEU PO 100 IBUPROFEN 400 MG TABLET 400 MG PAIN‐NSAID 904585340 MAJOR PHARMACEU PO 500 IBUPROFEN 600 MG TABLET 600 MG PAIN‐NSAID 904585440 MAJOR PHARMACEU PO 500 IBUPROFEN 800 MG TABLET 800 MG PAIN‐NSAID 904585540 MAJOR PHARMACEU PO 500 INDOMETHACIN 25 MG CAPSULE 25 MG PAIN‐NSAID 378014301 MYLAN PO 100 INDOMETHACIN 50 MG CAPSULE 50MG PAIN‐NSAID 781235001 SANDOZ PO 100 MELOXICAM 15 MG TABLET 15 MG PAIN‐NSAID 76282015301 EXELAN PHARMACE PO 100 MELOXICAM 7.5 MG TABLET 7.5 MG PAIN‐NSAID 61442012610 CARLSBAD TECH PO 1,000.00 NAPROXEN 250 MG TABLET 250MG PAIN‐NSAID 53746018801 AMNEAL PHARMACE PO 100 NAPROXEN 375 MG TABLET 375MG PAIN‐NSAID 53746018910 AMNEAL PHARMACE PO 1,000.00 NAPROXEN 500 MG TABLET 500MG PAIN‐NSAID 53746019010 AMNEAL PHARMACE PO 1,000.00 ETODOLAC 400MG TABLET 400MG PAIN‐NSAID 60429031101 GSMS 100 NALOXONE 2 MG/2 ML SYRINGE 1 MG/ML PAIN‐OPIOD OVERDOSE 76329336901 INTERNATIONAL MIJ 2 NALTREXONE 50MG TAB 50MG PAIN‐OPIOD OVERDOSE 406117003 MALLINCKRODT PH PO 30 HYDROMORPHONE 2 MG/ML VIAL 2MG/ML PAIN‐OPIODS 641012125 BAXTER HEALTHCA IJ 1 CONTROLLED SUBSTANCE HYDROMORPHONE INJ 10MG/ML 10MG/ML PAIN‐OPIODS 409263401 HOSPIRA IJ 1 CONTROLLED SUBSTANCE ACETAMIN/COD #3 TABLET 30‐300M PAIN‐OPIODS 406048401 MALLINCKRODT PH PO 100 CONTROLLED SUBSTANCE ACETAMINOPHEN/COD ELIXIR 12‐120M PAIN‐OPIODS 60432024516 MORTON GROVE PH PO 473 CONTROLLED SUBSTANCE HYDROCOD/APAP 7.5‐325 TAB 7.5‐325MG PAIN‐OPIODS 57664017088 SUN PHARMA PO 100 CONTROLLED SUBSTANCE HYDROCODON‐ACETAMINOPHN 10‐ 10MG‐325MG PAIN‐OPIODS 406012501 MALLINCKRODT PH PO 100 CONTROLLED SUBSTANCE HYDROCODON‐APAP 5‐325 5MG‐325MG PAIN‐OPIODS 406012301 MALLINCKRODT PH PO 100 CONTROLLED SUBSTANCE HYDROCODONE/APAP SOLUTION 2.5/167 PAIN‐OPIODS 121065516 PHARMACEU ASSOC PO 473 CONTROLLED SUBSTANCE HYDROMORPHONE 4 MG TABLET 4 MG PAIN‐OPIODS 42858030201 RHODES PHARMACE PO 100 CONTROLLED SUBSTANCE HYDROMORPHONE 5 MG/5 ML SOL 1 MG/ML PAIN‐OPIODS 42858030416 RHODES PHARMACE PO 473 CONTROLLED SUBSTANCE METHADONE HCL 10 MG TABLET 10 MG PAIN‐OPIODS 54457125 ROXANE LABS. PO 100 CONTROLLED SUBSTANCE METHADONE HCL 5 MG TABLET 5 MG PAIN‐OPIODS 54457025 ROXANE LABS. PO 100 CONTROLLED SUBSTANCE

Page 17 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

MORPHINE SULF 100 MG/5 ML S 100 MG/5ML PAIN‐OPIODS 406800330 MALLINCKRODT PH PO 30 CONTROLLED SUBSTANCE MORPHINE SULF ER 15 MG TABL 15 MG PAIN‐OPIODS 378265801 MYLAN PO 100 CONTROLLED SUBSTANCE MORPHINE SULF ER 30 MG TABL 30 MG PAIN‐OPIODS 378265901 MYLAN PO 100 CONTROLLED SUBSTANCE MORPHINE SULF ER 60 MG TABL 60 MG PAIN‐OPIODS 378266001 MYLAN PO 100 CONTROLLED SUBSTANCE OXYCODON‐ACETAMINOPHEN 7.5‐ 7.5‐325MG PAIN‐OPIODS 47781022905 ALVOGEN INC PO 500 CONTROLLED SUBSTANCE OXYCODONE HCL 10 MG TABLET 10 MG PAIN‐OPIODS 57664037088 CARACO PHARM PO 100 CONTROLLED SUBSTANCE OXYCODONE HCL 15 MG TABLET 15 MG PAIN‐OPIODS 57664018788 CARACO PHARM PO 100 CONTROLLED SUBSTANCE OXYCODONE HCL 30 MG TABLET 30 MG PAIN‐OPIODS 603499221 QUALITEST PO 100 CONTROLLED SUBSTANCE OXYCODONE HCL 5 MG TABLET 5 MG PAIN‐OPIODS 603499021 QUALITEST PO 100 CONTROLLED SUBSTANCE OXYCODONE HCL ER 10 MG TABL 10 MG PAIN‐OPIODS 49884013601 PAR PHARM. PO 100 CONTROLLED SUBSTANCE OXYCODONE HCL ER 20 MG TABL 20 MG PAIN‐OPIODS 781572601 SANDOZ PO 100 CONTROLLED SUBSTANCE OXYCODONE W/APAP 5/325 TAB 5‐325MG PAIN‐OPIODS 406051201 MALLINCKRODT PH PO 100 CONTROLLED SUBSTANCE OXYCONTIN 15MG TABLET SA 15MG PAIN‐OPIODS 59011041510 L PO 100 CONTROLLED SUBSTANCE OXYCONTIN 30MG TABLET SA 30MG PAIN‐OPIODS 59011043010 PURDUE PHARMA L PO 100 CONTROLLED SUBSTANCE OXYCONTIN 40MG TABLET SA 40MG PAIN‐OPIODS 59011044010 PURDUE PHARMA L PO 100 CONTROLLED SUBSTANCE OXYCONTIN 60MG TABLET SA 60MG PAIN‐OPIODS 59011046010 PURDUE PHARMA L PO 100 CONTROLLED SUBSTANCE OXYCONTIN 80MG TABLET SA 80MG PAIN‐OPIODS 59011048010 PURDUE PHARMA L PO 100 CONTROLLED SUBSTANCE TRAMADOL HCL 50 MG TABLET 50 MG PAIN‐OPIODS 65162062710 AMNEAL PHARMACE PO 100 CONTROLLED SUBSTANCE ACETAMINOPHEN 650 MG SUPPOS 650 MG PAIN‐OPIODS 45802073033 PERRIGO CO. RC 100 FENTANYL 100 MCG/HR PATCH 100 MCG PAIN‐OPIODS 406900076 MALLINCKRODT PH TD 5 CONTROLLED SUBSTANCE FENTANYL 12 MCG/HR PATCH 12 MCG/ PAIN‐OPIODS 781724055 SANDOZ TD 5 CONTROLLED SUBSTANCE FENTANYL 25 MCG/HR PATCH 25MCG/H PAIN‐OPIODS 406902576 MALLINCKRODT PH TD 5 CONTROLLED SUBSTANCE FENTANYL 50 MCG/HR PATCH 50MCG/HR PAIN‐OPIODS 781724255 SANDOZ TD 5 CONTROLLED SUBSTANCE FENTANYL 75 MCG/HR PATCH 75MCG/H PAIN‐OPIODS 781724355 SANDOZ TD 5 CONTROLLED SUBSTANCE PANCRELIPASE DR 5,000 UNIT 5K‐17K‐27K PANCREATIC ENZYMES 39822020501 X‐GEN PHARMACEU PO 100 DIFFERENT STRENGTHS AVAILABLE AS NEEDED AMANTADINE 100 MG TABLET 100 MG PARKINSONS 832011150 UPSHER SMITH PO 500 BENZTROPINE MES 0.5 MG TAB 0.5 MG PARKINSONS 603243321 QUALITEST PO 100 BENZTROPINE MES 1 MG TABLET 1 MG PARKINSONS 603243432 QUALITEST PO 1,000.00 BENZTROPINE MES 2 MG TABLET 2 MG PARKINSONS 603243532 QUALITEST PO 1,000.00 CARBIDOPA/LEVO SA 25/100MG 25/100 PARKINSONS 378008801 MYLAN PO 100 CARBIDOPA‐LEVO ER 50‐200 TA 50MG‐200MG PARKINSONS 62756045788 SUN PHARMACEUTI PO 100 CARBIDOPA‐LEVODOPA 25‐100 T 25MG‐100MG PARKINSONS 378008501 MYLAN PO 100 CARBIDOPA‐LEVODOPA 25‐250 T 25MG‐250MG PARKINSONS 378113301 MYLAN PO 100 ENTACAPONE 200 MG TABLET 200 MG PARKINSONS 378908001 MYLAN PO 100 SELEGILINE HCL 5 MG CAPSULE 5 MG PARKINSONS 60429001960 GSMS, INC. PO 60 TRIHEXYPHENIDYL 2MG TABLET 2MG PARKINSONS 603624021 QUALITEST PO 100 TRIHEXYPHENIDYL 5MG TABLET 5MG PARKINSONS 603624121 QUALITEST PO 100 ROPINIROLE 0.25 MG TAB 0.25 MG PARKINSONS/RLS 54011625 ROXANE LABS. PO 100 ROPINIROLE 1MG HCL TABLET 1 MG PARKINSONS/RLS 54011825 ROXANE LABS. PO 100 ROPINIROLE 2MG HCL TABLET 2 MG PARKINSONS/RLS 54011925 ROXANE LABS. PO 100 ROPINIROLE 3MG TABLET 3MG PARKINSONS/RLS 30378550302 MYLAN PO 100

Page 18 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

ROPINIROLE HCL 0.5 MG TABLE 0.5 MG PARKINSONS/RLS 54011725 ROXANE LABS. PO 100 ROPINIROLE HCL 3 MG TABLET 3 MG PARKINSONS/RLS 54012025 ROXANE LABS. PO 100 ROPINIROLE HCL 4 MG TABLET 4 MG PARKINSONS/RLS 54012125 ROXANE LABS. PO 100 KLOR‐CON M10 TABLET 10 MEQ POTASSIUM 66758017010 SANDOZ PO 1,000.00 KLOR‐CON M20 TABLET 20 MEQ POTASSIUM 66758019005 SANDOZ PO 500 POTASSIUM CL ER 10 MEQ CAPS 10 MEQ POTASSIUM 904606861 MAJOR PHARMACEU PO 100 USED ONLY WITH PRIOR APPROVAL SPS 15 GM/60 ML SUSPENSION 15G/60M POTASSIUM LOWER 46287000601 CAROLINA MED. PO 473 SPS SUSP 15GM/60ML (60ML) 15/60 POTASSIUM LOWER 46287000660 60 ACIDOPHILUS CAPLET 25MM‐100MG PROBIOTIC 536718001 RUGBY PO 100 FLORANEX TABLET 1MM CELL PROBIOTIC 42291040305 AVKARE PO 50 BICALUTAMIDE 50 MG TABLET 50 MG PROSTATE CANCER 60429017701 GSMS PO 100 CARBAMAZEPE 400 ER TABLET 400 MG ER SEIZURES/PTSD 781598801 SANDOZ PO 100 CARBAMAZEPINE 100 MG/5 ML S 100MG/5 SEIZURES/PTSD 51672404709 TARO PHARM USA PO 450 CARBAMAZEPINE 100MG TAB CHW 100MG SEIZURES/PTSD 51672404101 TARO PHARM USA PO 100 CARBAMAZEPINE 200 MG TABLET 200 MG SEIZURES/PTSD 60429003210 GSMS, INC. PO 1,000.00 CARBAMAZEPINE XR 200MG 200MG SEIZURES/PTSD 781598701 SANDOZ PO 100 PHENOBARBITAL 32.4 MG TABLE 32.4MG SEIZURES 603516621 QUALITEST PO 100 CONTROLLED SUBSTANCE PHENOBARBITAL 97.2 MG TABLE 97.2MG SEIZURES 603516821 QUALITEST PO 100 CONTROLLED SUBSTANCE DEPAKOTE SPR125MG CAP 125MG SEIZURES/NEUROPATHY/PTSD 74611413 ABBOTT LABS. PO 100 DIVALPROEX DR 500MG (12HR) 500MG SEIZURES/NEUROPATHY/PTSD 378104501 MYLAN PO 100 DIVALPROEX SOD DR 250MG 250MG SEIZURES/NEUROPATHY/PTSD 378104401 MYLAN PO 100 DIVALPROEX SOD ER 250 MG TA 250 MG SEIZURES/NEUROPATHY/PTSD 378047201 MYLAN PO 100 DIVALPROEX SOD ER 500 MG TA 500 MG SEIZURES/NEUROPATHY/PTSD 51079076701 MYLAN INSTITUTI PO 80 GABAPENTIN 100 MG CAPSULE 100 MG SEIZURES/NEUROPATHY/PTSD 45963055550 ACTAVIS PHARMA, PO 500 GABAPENTIN 250 MG/5 ML SOLN 250 MG/5ML SEIZURES/NEUROPATHY/PTSD 65162069890 AMNEAL PHARMACE PO 473 GABAPENTIN 300 MG CAPSULE 300 MG SEIZURES/NEUROPATHY/PTSD 45963055611 ACTAVIS PHARMA, PO 100 GABAPENTIN 400 MG CAPSULE 400 MG SEIZURES/NEUROPATHY/PTSD 45963055750 ACTAVIS PHARMA, PO 500 GABAPENTIN 600 MG TABLET 600 MG SEIZURES/NEUROPATHY/PTSD 76282040505 EXELAN PHARMACE PO 500 GABAPENTIN 800 MG TABLET 800 MG SEIZURES/NEUROPATHY/PTSD 76282040601 EXELAN PHARMACE PO 100 LAMOTRIGINE 100MG TABS 100MG SEIZURES/NEUROPATHY/PTSD 59746024601 CADISTA PHARMAC PO 100 LAMOTRIGINE 150 MG TABLET 150 MG SEIZURES/NEUROPATHY/PTSD 59746024760 CADISTA PHARMAC PO 60 LAMOTRIGINE 200 MG TABLET 200 MG SEIZURES/NEUROPATHY/PTSD 51672413304 TARO PHARM USA PO 60 LAMOTRIGINE 25 MG TABLET 25 MG SEIZURES/NEUROPATHY/PTSD 59746024501 CADISTA PHARMAC PO 100 LEVETIRACETAM 1,000 MG TABL 1000 MG SEIZURES/NEUROPATHY 52343007260 GENSOURSE PO 60 LEVETIRACETAM 100MG/ML SOLN 100MG/M SEIZURES/NEUROPATHY 472023516 ACTAVIS MID ATL PO 473 LEVETIRACETAM 250MG TAB 250MG SEIZURES/NEUROPATHY 52343006912 GEN SOURCE PO 120 LEVETIRACETAM 500 MG TABLET 500 MG SEIZURES/NEUROPATHY 13668001512 TORRENT PHARMAC PO 120 LEVETIRACETAM 750 MG TABLET 750 MG SEIZURES/NEUROPATHY 378561707 MYLAN PO 500 LYRICA 100 MG CAPSULE 100MG SEIZURES/NEUROPATHY 71101568 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE LYRICA 150 MG CAPSULE 150 MG SEIZURES/NEUROPATHY 71101668 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE LYRICA 200 MG CAPSULE 200 MG SEIZURES/NEUROPATHY 71101768 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE

Page 19 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

LYRICA 25 MG CAPSULE 25MG SEIZURES/NEUROPATHY 71101268 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE LYRICA 300 MG CAPSULE 300MG SEIZURES/NEUROPATHY 71101868 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE LYRICA 50 MG CAPSULE 50 MG SEIZURES/NEUROPATHY 71101368 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE LYRICA 75MG CAPSULE 75MG SEIZURES/NEUROPATHY 71101468 PFIZER US PHARM PO 90 CONTROLLED SUBSTANCE OXCARBAZEPINE 150 MG TABLET 150MG SEIZURES/NEUROPATHY 54009725 ROXANE LABS. PO 100 OXCARBAZEPINE 300 MG TABLET 300MG SEIZURES/NEUROPATHY 54009825 ROXANE LABS. PO 100 PHENYTOIN 125 MG/5 ML SUSP 125 MG/5ML SEIZURES/NEUROPATHY 60432013108 MORTON GROVE PH PO 237 PHENYTOIN 50 MG TABLET CHEW 50 MG SEIZURES/NEUROPATHY 378385001 MYLAN PO 100 PHENYTOIN SOD. 100 MG CAP 100 MG SEIZURES/NEUROPATHY 378156010 MYLAN PO 1,000.00 PRIMIDONE 250 MG TABLET 250 MG SEIZURES/NEUROPATHY 603537221 QUALITEST PO 100 PRIMIDONE 50 MG TABLET 50 MG SEIZURES/NEUROPATHY 42291050950 AVKARE PO 500 TOPIRAMATE 100 MG TABLET 100 MG SEIZURES/NEUROPATHY/PTSD 60429077110 GSMS, INC. PO 1,000.00 TOPIRAMATE 25 MG TABLET 25 MG SEIZURES/NEUROPATHY/PTSD 60429076910 GSMS, INC. PO 1,000.00 TOPIRAMATE 50 MG TABLET 50 MG SEIZURES/NEUROPATHY/PTSD 60429077010 GSMS, INC. PO 1,000.00 VALPROIC ACID 250 MG/5 ML S 250 MG/ SEIZURES/NEUROPATHY/PTSD 603184158 QUALITEST PO 473 VALPROIC ACID 250MG CAPSULE 250MG SEIZURES/NEUROPATHY/PTSD 50111085201 PLIVA, INC PO 100 ZONISAMIDE 25 MG CAPSULE 25 MG SEIZURES/NEUROPATHY 378672501 MYLAN PO 100 MELATONIN TABLETS VARIETY SLEEPING AGENT 904518252 MAJOR PHARMACEU PO 100 ZOLPIDEM TARTRATE 10 MG TAB 10MG SLEEPING AGENT 603646921 QUALITEST PO 100 CONTROLLED SUBSTANCE ZOLPIDEM TARTRATE 5 MG TABL 5 MG SLEEPING AGENT 603646821 QUALITEST PO 100 CONTROLLED SUBSTANCE NICORETTE 2 MG CHEWING GUM 2 MG SMOKE CESSATION 135015707 GSK CONSUMER HE BC 110 VARIOUS STRENGTHS AVAILABLE IF NEEDED NICODERM CQ 7 MG/24HR PATCH 7MG/24H SMOKE CESSATION 766144028 GSK CONSUMER HE TD 14 VARIOUS STRENGTHS AVAILABLE IF NEEDED NICOTINE 14 MG/24HR PATCH 14MG/24HR SMOKE CESSATION 536589588 RUGBY TD 14 VARIOUS STRENGTHS AVAILABLE IF NEEDED NICOTINE 21 MG/24HR PATCH 21 MG/24HR SMOKE CESSATION 536589688 RUGBY TD 14 VARIOUS STRENGTHS AVAILABLE IF NEEDED METHLYPHENIDATE 5MG TABLET 5MG STIMULANT 406114201 MALLINKRT PHARM PO 100 CONTROLLED SUBSTANCE METHYLPHENIDATE 10 MG TABLE 10 MG STIMULANT 406114401 MALLINCKRODT PH PO 100 CONTROLLED SUBSTANCE CYANOCOBALAMIN 1,000 MCG/ML 1000MCG SUPPLEMENT 63323004401 APP PHARMACEUTI IJ 1 ANTACID 500MG TABLET CHEW 500MG SUPPLEMENT 904125792 MAJOR PHARMACEU PO 150 CAL‐GEST 500 MG TABLET CHEW 200(500)MG SUPPLEMENT 536100715 RUGBY PO 150 CEROVITE LIQUID SUPPLEMENT 536279059 RUGBY PO 237 FERREX FORTE PLUS 150 CAPSU 150 SUPPLEMENT 51991079890 BRECKENRIDGE PO 90 FERROUS SULF 220MG/5ML ELIX 220MG/5 SUPPLEMENT 603076358 QUALITEST PO 473 FERROUS SULFATE 325 MG TABL 325(65) MG SUPPLEMENT 904759080 MAJOR PHARMACEU PO 1,000.00 FOLIC ACID 0.4MG TABLET 0.4 MG SUPPLEMENT 904319760 MAJOR PHARMACEU PO 100 FOLIC ACID 1 MG TABLET 1 MG SUPPLEMENT 603316232 QUALITEST PO 1,000.00 MAGNESIUM OXIDE 400MG TAB 400MG SUPPLEMENT 603020922 QUALITEST PO 120 OYSTER SHEL CAL 500 MG TAB 500MG SUPPLEMENT 904188380 MAJOR PHARMACEU PO 1,000.00 OYSTER SHELL CALCIUM‐VIT D 500 MG‐200 SUPPLEMENT 904546080 MAJOR PHARMACEU PO 1,000.00 PROSIGHT TABLET SUPPLEMENT 904773518 MAJOR PHARMACEU PO 120 PYRIDOXINE 50MG TABLET 50MG SUPPLEMENT 10135013910 MARLEX PHARM. PO 1,000.00 STRESS FORMULA/ZINC TABLET SUPPLEMENT 904272752 MAJOR PHARMACEU PO 60

Page 20 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

TAB‐A‐VITE TABLET SUPPLEMENT 904053080 MAJOR PHARMACEU PO 1,000.00 UNICOMPLEX‐M TABLET SUPPLEMENT 536475011 RUGBY PO 90 VIT D(50,000)1.25MG CAPS 50000 UNIT SUPPLEMENT 50111099001 BARR PO 100 VITAMIN B COMPLEX CAPSULE SUPPLEMENT 536478701 RUGBY PO 100 VITAMIN B‐1 100 MG TABLET 100 MG SUPPLEMENT 536468010 RUGBY PO 1,000.00 VITAMIN B‐12 1,000 MCG TABL 1000 MCG SUPPLEMENT 536355601 RUGBY PO 100 VITAMIN B‐12 100 MCG TABLET 100 MCG SUPPLEMENT 904113213 MAJOR PHARMACEU PO 130 VITAMIN B‐12 500 MCG TABLET 500MCG SUPPLEMENT 904320713 MAJOR PHARMACEU PO 130 VITAMIN B‐6 100MG TABLET 100MG SUPPLEMENT 904051860 MAJOR PHARMACEU PO 100 VITAMIN B‐6 50 MG TABLET 50 MG SUPPLEMENT 536440801 RUGBY PO 100 VITAMIN C 250MG TABLET 250MG SUPPLEMENT 904052260 MAJOR PHARMACEU PO 100 VITAMIN C 500 MG TABLET 500MG SUPPLEMENT 904052372 MAJOR PHARMACEU PO 300 VITAMIN D 400 UNIT TABLET 400 UNI SUPPLEMENT 7985401162 NAT'L VIT. CO. PO 100 VITAMIN D 5000 IU CAPSULE 5000IU SUPPLEMENT 904598660 MAJOR PHARMACEU PO 100 VITAMIN D3 1,000 UNIT TABLE 1000 UNIT SUPPLEMENT 904582460 MAJOR PHARMACEU PO 100 VITAMIN E 1,000 UNITS CAPSU 1000 UNIT SUPPLEMENT 904027760 MAJOR PHARMACEU PO 100 VITAMIN E 400 UNIT CAPSULE 400 UNI SUPPLEMENT 904027472 MAJOR PHARMACEU PO 300 ZINC SULFATE 220 MG CAPSULE 220(50) SUPPLEMENT 904533260 MAJOR PHARMACEU PO 100 SM CENTURY COMPLETE MATURE W/VITK SUPPLEMENT 1093955344 300 BENZONATATE 100 MG CAPSULE 100 MG T‐COUGH SUPPRESSANT 65162053610 AMNEAL PHARMACE PO 100 BENZONATATE 200 MG CAPSULE 200 MG T‐COUGH SUPPRESSANT 65162053750 AMNEAL PHARMACE PO 500 DIABETIC TUSSIN DM LIQUID 100‐10M T‐COUGH SUPPRESSANT 61787006204 HI‐TECH CARE PO 118 GUAIFENESIN ER 600 MG TABLE 600 MG T‐COUGH SUPPRESSANT 45802049878 PERRIGO CO. PO 100 GUAIFENESIN W/CODEINE SYRUP 100‐10M T‐COUGH SUPPRESSANT 121077504 PHARMACEU ASSOC PO 118 CONTROLLED SUBSTANCE MUCINEX DM ER 600‐30 MG TAB 600/30M T‐COUGH SUPPRESSANT 63824005640 RECKITT BENCKIS PO 40 MUCUS RELIEF 400 MG TABLET 400 MG T‐COUGH SUPPRESSANT 904623252 MAJOR PHARMACEU PO 60 N'ICE LOZENGE T‐COUGH SUPPRESSANT 63736086004 INSIGHT PHARMAC PO 24 PROMETHAZINE W/CODEINE SYRU 10‐6.25 T‐COUGH SUPPRESSANT 603158558 QUALITEST PO 473 CONTROLLED SUBSTANCE PROMETHAZINE‐DM SYRUP 15‐6.25 T‐COUGH SUPPRESSANT 603158658 QUALITEST PO 473 SILTUSSIN DM DAS LIQUID 100‐10MG/5 T‐COUGH SUPPRESSANT 54838013340 SILARX PHARM PO 118 SILTUSSIN SA 100 MG/5 ML SY 100 MG/5ML T‐COUGH SUPPRESSANT 54838011740 SILARX PHARM PO 118 MULTISTIX 10 SG URINE STRIP TEST STRIPS 8620216121 SIEMENS HEALTHC MC 100 GENTAMICIN 0.1% CREAM 0.10% TPA‐AMINOGLYCOSIDES 45802005635 PERRIGO CO. TP 15 BETASEPT 4% SURGICAL SCRUB 4% TPA‐ANTIBACTERIAL 67618020008 PURDUE PROD LP TP 237 POVIDONE‐IODINE 10% SOLN 10% TPA‐ANTIBACTERIAL 52380190504 APLICARE, INC TP 118 SSD 1% CREAM 1% TPA‐ANTIBACTERIAL 43598021050 DR.REDDY'S LAB TP 50 ANTIFUNGAL 2% CREAM 2% TPA‐ANTIFUNGALS 472073514 ACTAVIS PHARMA, TP 14 CICLOPIROX 0.77% CREAM 0.77% TPA‐ANTIFUNGALS 45802013811 PERRIGO CO. TP 30 CICLOPIROX 8% SOLUTION 8% TPA‐ANTIFUNGALS 713031788 G & W LABS. TP 6.6 CLOTRIMAZOLE 1% CREAM 1% TPA‐ANTIFUNGALS 904782231 MAJOR PHARMACEU TP 28.35 CLOTRIMAZOLE 1% SOLUTION 1% TPA‐ANTIFUNGALS 93024831 TEVA USA TP 30

Page 21 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

ECONAZOLE NITRATE 1% CREAM 1% TPA‐ANTIFUNGALS 51672130308 TARO PHARM USA TP 85 FUNGOID 2% TINCTURE 2% TPA‐ANTIFUNGALS 884029301 PEDINOL PHARM. TP 29.57 KETOCONAZOLE 2% CREAM 2% TPA‐ANTIFUNGALS 168009915 FOUGERA TP 15 KETOCONAZOLE 2% CREAM 2% TPA‐ANTIFUNGALS 168009930 FOUGERA TP 30 KETOCONAZOLE 2% SHAMPOO 2% TPA‐ANTIFUNGALS 10147075004 PATRIOT PHARMAC TP 120 MICONAZOLE NITRATE 2% CREAM 2% TPA‐ANTIFUNGALS 603780550 QUALITEST TP 28.4 NYSTATIN 100,000 UNIT/GM CR 100000/G TPA‐ANTIFUNGALS 45802005911 PERRIGO CO. TP 30 NYSTATIN 100K U/GM OINT 100000/ TPA‐ANTIFUNGALS 45802004811 PERRIGO CO. TP 30 NYSTATIN‐TRIAMCINOLONE CREA ‐100000 TPA‐ANTIFUNGALS 51672126303 TARO PHARM USA TP 60 NYSTATIN‐TRIAMCINOLONE OINT 100000‐0.1 TPA‐ANTIFUNGALS 51672127202 TARO PHARM USA TP 30 NYSTOP 100,000 UNITS/GM POW 100000/ TPA‐ANTIFUNGALS 574200802 PADDOCK LABS. TP 60 TERBINAFINE 1% CREAM 1% TPA‐ANTIFUNGALS 35167220802 TARO PHARM USA TP 30 CLOTRIMAZOLE‐BETAMETHASONE 1 %‐0.05 % TPA‐ANTIFUNGALS/STEROID 168025846 FOUGERA TP 45 BACITRACIN 500 UNIT/GM OINT 500 UNI TPA‐ANTIMICROBIAL 713028031 G & W LABS. TP 28.4 BACTROBAN 2% CREAM 2% TPA‐ANTIMICROBIAL 29152725 GLAXOSMITHKLINE TP 30 USED ONLY WITH PRIOR APPROVAL METRONIDAZOLE 0.75% CREAM 0.75% TPA‐ANTIMICROBIAL 168032346 FOUGERA TP 45 MUPIROCIN 2% OINTMENT 2% TPA‐ANTIMICROBIAL 45802011222 PERRIGO CO. TP 22 TRIPLE ANTIBIOTIC OINTMENT 3.5‐400 TPA‐ANTIMICROBIAL 34580214303 PERRIGO CO. TP 28 METROGEL‐VAGINAL 0.75% GEL 0.75% TPA‐ANTIMICROBIAL 99207013070 VALEANT VG 70 PERMETHRIN 5% CREAM 5% TPA‐ANTIPARASITIC 45802026937 PERRIGO CO. TP 60 ACYCLOVIR 5% OINTMENT 5% TPA‐ANTIVIRAL 378870006 MYLAN TP 15 CLINDAMYCIN PH 1% SOLUTION 1% TPA‐LINCOSAMIDES 45802056202 PERRIGO CO. TP 60 CLINDAMYCIN PHOSP 1% LOTION 1% TPA‐LINCOSAMIDES 168020360 FOUGERA TP 60 DAKIN'S 0.125% SOLUTION 0.13% TP‐ANTISEPTIC 436067216 CENTURY PHARM. MC 473 DAKIN'S 0.25% SOLUTION 0.25% TP‐ANTISEPTIC 436093616 CENTURY PHARM. MC 473 SOD SULFACET‐SULFUR LOT 10% 10‐5%(W/W) TPA‐SULFONAMIDES 44523060702 BIOCOMP PHARMA, TP 60 UREA 20% CREAM 20% TP‐CALLUS/BUNIONS 58980061030 STRATUS PHARM TP 85 X‐VIATE 40% CREAM 40% TP‐CALLUS/BUNIONS 58980062570 STRATUS PHARM TP 199 SILVER NITRATE APPLICATOR 75%‐25% TP‐CLOTTING AGENT 12870000102 ARZOL CHEMICAL TP 100 TRIAMCINOLONE 0.1% PASTE 0.10% TP‐CORTICOSTEROID 51672126705 TARO PHARM USA DT 5 BETAMETHASONE DP 0.05% CRM 0.05% TP‐CORTICOSTEROID 168005546 FOUGERA TP 45 BETAMETHASONE DP 0.05% OINT 0.05% TP‐CORTICOSTEROID 472038115 ACTAVIS MID ATL TP 15 BETAMETHASONE VA 0.1% CREAM 0.10% TP‐CORTICOSTEROID 168004046 FOUGERA TP 45 BETAMETHASONE VA 0.1% CREAM 0.10% TP‐CORTICOSTEROID 168004015 FOUGERA TP 15 CLOBETASOL 0.05% CREAM 0.05% TP‐CORTICOSTEROID 60429090230 GSMS, INC. TP 30 CLOBETASOL 0.05% OINTMENT 0.05% TP‐CORTICOSTEROID 60429090130 GSMS, INC. TP 30 CLOBETASOL 0.05% SOLUTION 0.05% TP‐CORTICOSTEROID 60432013325 MORTON GROVE PH TP 25 DESOXIMETASONE 0.25% CREAM 0.25% TP‐CORTICOSTEROID 45802049537 PERRIGO CO. TP 60 DESOXIMETASONE 0.25% OINT 0.25% TP‐CORTICOSTEROID 35167212623 TARO PHARM USA TP 60 FLUOCINONIDE 0.05% CREAM 0.05% TP‐CORTICOSTEROID 60429090460 GSMS, INC. TP 60 FLUOCINONIDE 0.05% OINT 0.05% TP‐CORTICOSTEROID 60429090760 GSMS, INC. TP 60

Page 22 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home

Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes

FLUOCINONIDE 0.05% SOLUTION 0.05% TP‐CORTICOSTEROID 60429090860 GSMS, INC. TP 60 HYDROCORTISONE 1% CREAM 1% TP‐CORTICOSTEROID 472034356 ACTAVIS MID ATL TP 28 HYDROCORTISONE 1% OINTMENT 1% TP‐CORTICOSTEROID 168002016 FOUGERA TP 453.6 HYDROCORTISONE 1% OINTMENT 1% TP‐CORTICOSTEROID 51672020182 TARO PHARM USA TP 28.4 HYDROCORTISONE 2.5% CREAM 2.50% TP‐CORTICOSTEROID 45802000403 PERRIGO CO. TP 28 TRIAMCINOLONE 0.025% CREAM 0.03% TP‐CORTICOSTEROID 603786190 QUALITEST TP 80 TRIAMCINOLONE 0.025% LOTION 0.03% TP‐CORTICOSTEROID 60432056060 MORTON GROVE PH TP 60 TRIAMCINOLONE 0.025% OINT 0.03% TP‐CORTICOSTEROID 45802005435 PERRIGO CO. TP 15 TRIAMCINOLONE 0.1% CREAM 0.10% TP‐CORTICOSTEROID 45802006436 PERRIGO CO. TP 80 TRIAMCINOLONE 0.1% LOTION 0.10% TP‐CORTICOSTEROID 60432056160 MORTON GROVE PH TP 60 TRIAMCINOLONE 0.1% OINTMENT 0.10% TP‐CORTICOSTEROID 45802005505 PERRIGO CO. TP 454 TRIAMCINOLONE 0.5% CREAM 0.50% TP‐CORTICOSTEROID 168000215 SANDOZ TP 15 TRIAMCINOLONE 0.5% OINTMENT 0.50% TP‐CORTICOSTEROID 45802004935 PERRIGO CO. TP 15 SELENIUM 2.5% LOTION/SHAMPO 2.50% TP‐DANDRUFF/ANTIFUNGAL 45802004064 PERRIGO CO. TP 120 ANUCORT‐HC 25 MG SUPPOSITOR 25 MG TP‐HEMORRHOIDS 713050324 G & W LABS. RC 24 PROCTOSOL‐HC 2.5% CREAM 2.50% TP‐HEMORRHOIDS 10631040701 RANBAXY LABORAT RC 28.35 MEDI PADS TP‐HEMORRHOIDS 904505960 MAJOR PHARMACEU TP 100 AMMONIUM LACTATE 12% CREAM 12% TP‐MOISTURIZER 45802051377 PERRIGO CO. TP 140 GERI‐HYDROLAC 12% LOTION 12% TP‐MOISTURIZER 92771061208 GERITREX CORP. TP 240 MUSCLE RUB CREAM 15%‐10% TP‐MUSCLE PAIN/COUNTERIRRITANT 45802017453 PERRIGO CO. TP 85 TRIXAICIN 0.025% CREAM 0.03% TP‐MUSCLE PAIN/COUNTERIRRITANT 603064888 QUALITEST TP 60 TRIXAICIN HP 0.075% CREAM 0.08% TP‐MUSCLE PAIN/COUNTERIRRITANT 603064988 QUALITEST TP 60 DIBUCAINE 1% OINTMENT 1% TP‐NUMBING AGENT 45802005003 PERRIGO CO. RC 28 LIDOCAINE 5% PATCH 5%(700MG) TP‐NUMBING AGENT 591352530 ACTAVIS PHARMA, TP 30 LIDOCAINE HCL 2% JELLY 2% TP‐NUMBING AGENT 17478071130 AKORN INC. TP 30 LIDOCAINE‐PRILOCAINE CREAM 2.5%‐2. TP‐NUMBING AGENT 168035755 FOUGERA TP 5 CALCIPOTRIENE 0.005% CREAM 0.01% TP‐VITAMIN D 66993087761 PRASCO LABS TP 60 USED ONLY WITH PRIOR APPROVAL GRANULEX SPRAY 0.12‐87 TP‐WOUND 51079062182 MYLAN INSTITUTI TP 113.4 SANTYL OINTMENT 250 UNI TP‐WOUND 64501030 HEALTHPOINT MED TP 30 VENELEX OINTMENT 87‐788MG/G TP‐WOUND 58980078021 STRATUS PHARM TP 60 ZINC OXIDE 20% OINTMENT 20% TP‐WOUND/BARRIER 536570098 RUGBY TP 454

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