2017 Sharp Advantage® Comprehensive Formulary

Drug Name Drug Tier Requirements/Limits ALREX OPHTHALMIC 3 ST DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % 2 dexamethasone sodium phosphate 2 ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % 2 DUREZOL OPHTHALMIC DROPS 0.05 3 % flunisolide nasal spray,non-aerosol 25 2 QL (50 per 25 days) mcg (0.025 %) fluocinolone acetonide oil otic drops 0.01 (DermOtic Oil) 2 % fluorometholone ophthalmic (FML Liquifilm) 2 drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops (Ocufen) 2 0.03 % fluticasone nasal spray,suspension 50 (24 Hour Allergy Relief) 1 mcg/actuation ILEVRO OPHTHALMIC 3 DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 % (Acular LS) 2 ketorolac ophthalmic drops 0.5 % (Acular) 2 LOTEMAX OPHTHALMIC 3 DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC 3 DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 3 0.5 % NEVANAC OPHTHALMIC 3 DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic (Omnipred) 2 drops,suspension 1 % prednisolone sodium phosphate 2 ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 3 0.07 % RESTASIS MULTIDOSE 3 QL (5.5 per 30 days) OPHTHALMIC DROPS 0.05 % RESTASIS OPHTHALMIC 3 QL (60 per 30 days) DROPPERETTE 0.05 % triamcinolone acetonide nasal (Nasal Allergy) 2 QL (16.5 per 30 days) aerosol,spray 55 mcg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 93

Drug Name Drug Tier Requirements/Limits XIIDRA OPHTHALMIC 4 PA; QL (60 per 30 days) DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral (Prevpac) 2 combo pack 500-500-30 mg CARAFATE ORAL SUSPENSION 100 3 MG/ML cimetidine hcl oral solution 300 mg/5 ml 2 cimetidine oral tablet 200 mg (Heartburn Relief 2 (cimetidine)) cimetidine oral tablet 300 mg, 400 mg, 2 800 mg DEXILANT ORAL CAPSULE,BIPHASE 3 ST DELAYED RELEAS 30 MG, 60 MG esomeprazole sodium intravenous recon 2 soln 20 mg esomeprazole sodium intravenous recon (Nexium IV) 2 soln 40 mg famotidine (pf) intravenous solution 20 2 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous 2 piggyback 20 mg/50 ml famotidine 20 mg/2 ml vial latex-free, p/f, 2 sdv 20 mg/2 ml famotidine 40 mg/4 ml vial 25's,outer 10 2 mg/ml famotidine oral suspension 40 mg/5 ml (8 (Pepcid) 2 mg/ml) famotidine oral tablet 20 mg (Acid Reducer 1 (famotidine)) famotidine oral tablet 40 mg (Pepcid) 1 lansoprazole oral capsule,delayed (Heartburn Treatment 24 2 release(dr/ec) 15 mg Hour) lansoprazole oral capsule,delayed (Prevacid) 2 release(dr/ec) 30 mg misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) 2 nizatidine oral capsule 150 mg, 300 mg 2 nizatidine oral solution 150 mg/10 ml 2 omeprazole oral capsule,delayed 1 release(dr/ec) 10 mg, 20 mg, 40 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 94

Drug Name Drug Tier Requirements/Limits pantoprazole intravenous recon soln 40 (Protonix) 2 mg pantoprazole oral tablet,delayed release (Protonix) 1 (dr/ec) 20 mg, 40 mg ranitidine hcl injection solution 25 mg/ml, (Zantac) 2 50 mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 150 mg, 300 2 mg ranitidine hcl oral syrup 15 mg/ml 2 ranitidine hcl oral tablet 150 mg (Wal-Zan 150) 1 ranitidine hcl oral tablet 300 mg (Zantac) 1 sucralfate oral tablet 1 gram (Carafate) 2 Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 24 MCG, 8 3 QL (60 per 30 days) MCG BUPHENYL ORAL TABLET 500 MG 5 NDS CARBAGLU ORAL TABLET, 5 NDS DISPERSIBLE 200 MG constulose oral solution 10 gram/15 ml 2 cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) 2 dicyclomine oral capsule 10 mg (Bentyl) 2 dicyclomine oral solution 10 mg/5 ml 2 dicyclomine oral tablet 20 mg 2 diphenoxylate-atropine oral liquid 2.5- 2 0.025 mg/5 ml diphenoxylate-atropine oral tablet 2.5- (Lomotil) 2 0.025 mg enulose oral solution 10 gram/15 ml 2 GATTEX 5 MG 30-VIAL KIT 5 MG 5 PA; NDS GATTEX ONE-VIAL 5 PA; NDS SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml 2 glycopyrrolate injection solution 0.2 (Robinul) 2 mg/ml glycopyrrolate oral tablet 1 mg (Robinul) 2 glycopyrrolate oral tablet 2 mg (Robinul Forte) 2 kionex 15 gm/60 ml suspension 15-19.3 2 gram/60 ml kionex oral powder 2 lactulose oral solution 10 gram/15 ml (Generlac) 2 LINZESS ORAL CAPSULE 145 MCG, 3 QL (30 per 30 days) 290 MCG, 72 MCG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 95

Drug Name Drug Tier Requirements/Limits loperamide oral capsule 2 mg (Anti-Diarrheal 2 (loperamide)) methscopolamine oral tablet 2.5 mg, 5 mg 2 metoclopramide hcl injection solution 5 2 mg/ml metoclopramide hcl oral solution 5 mg/5 2 ml metoclopramide hcl oral tablet 10 mg, 5 (Reglan) 1 mg MOVANTIK ORAL TABLET 12.5 MG, 3 QL (30 per 30 days) 25 MG NUTRESTORE ORAL POWDER IN 4 PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 5 PA; NDS; QL (30 per 30 MG days) RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA; NDS RELISTOR ORAL TABLET 150 MG 5 PA; NDS; QL (90 per 30 days) RELISTOR SUBCUTANEOUS 5 PA; NDS; QL (28 per 28 SOLUTION 12 MG/0.6 ML days) RELISTOR SUBCUTANEOUS 5 PA; NDS; QL (28 per 28 SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML days) sodium polystyrene (sorb free) oral 2 suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 2 30 gram/120 ml sps (with sorbitol) oral suspension 15-20 2 gram/60 ml ursodiol oral capsule 300 mg (Actigall) 2 ursodiol oral tablet 250 mg (URSO 250) 2 ursodiol oral tablet 500 mg (URSO Forte) 2 VELTASSA ORAL POWDER IN 3 QL (30 per 30 days) PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 5 ST; NDS; QL (60 per 30 MG days) XERMELO ORAL TABLET 250 MG 5 PA; NDS; QL (90 per 30 days) Laxatives gavilyte-c oral recon soln 240-22.72-6.72 2 -5.84 gram gavilyte-g oral recon soln 236-22.74-6.74 2 -5.86 gram You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 96

Drug Name Drug Tier Requirements/Limits gavilyte-n oral recon soln 420 gram 2 MOVIPREP ORAL POWDER IN 3 PACKET 100-7.5-2.691 GRAM peg 3350-electrolytes oral recon soln 236- (Golytely) 2 22.74-6.74 -5.86 gram peg 3350-electrolytes oral recon soln 240- (Colyte with Flavor 2 22.72-6.72 -5.84 gram Packs) peg-electrolyte soln oral recon soln 420 (PEG-3350 with flavor 2 gram packs) polyethylene glycol 3350 oral powder 17 (Laxa Clear) 2 gram/dose polyethylene glycol 3350 oral powder in (SmoothLax) 2 packet 17 gram PREPOPIK ORAL POWDER IN 4 PACKET 10 MG-3.5 GRAM-12 GRAM SUPREP BOWEL PREP KIT ORAL 3 RECON SOLN 17.5-3.13-1.6 GRAM trilyte with flavor packets oral recon soln 2 420 gram Phosphate Binders AURYXIA ORAL TABLET 210 MG 4 IRON calcium acetate oral capsule 667 mg 2 calcium acetate oral tablet 667 mg (Eliphos) 2 eliphos oral tablet 667 mg 2 FOSRENOL ORAL POWDER IN 4 PACKET 1,000 MG, 750 MG FOSRENOL ORAL 5 NDS TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG magnebind 400 oral tablet 400-200-1 mg 1 PHOSLYRA ORAL SOLUTION 667 MG 4 (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 3 800 MG RENVELA ORAL POWDER IN 3 PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG 3 VELPHORO ORAL 3 TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 97

Drug Name Drug Tier Requirements/Limits bethanechol chloride oral tablet 10 mg, 25 (Urecholine) 2 mg, 5 mg, 50 mg flavoxate oral tablet 100 mg 2 MYRBETRIQ ORAL TABLET 3 EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml 2 oxybutynin chloride oral tablet 5 mg 2 oxybutynin chloride oral tablet extended (Ditropan XL) 2 release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release (Detrol LA) 2 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg (Detrol) 2 TOVIAZ ORAL TABLET EXTENDED 3 RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 2 24hr 60 mg trospium oral tablet 20 mg 2 VESICARE ORAL TABLET 10 MG, 5 3 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 (Uroxatral) 2 hr 10 mg dutasteride oral capsule 0.5 mg (Avodart) 2 dutasteride-tamsulosin oral capsule, er (Jalyn) 2 QL (30 per 30 days) multiphase 24 hr 0.5-0.4 mg finasteride oral tablet 5 mg (Proscar) 1 tamsulosin oral capsule,extended release (Flomax) 2 24hr 0.4 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 1 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG 5 NDS deferoxamine injection recon soln 2 gram, (Desferal) 2 PA BvD 500 mg DEPEN TITRATABS ORAL TABLET 5 NDS 250 MG EXJADE ORAL TABLET, 5 NDS DISPERSIBLE 125 MG, 250 MG, 500 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 98

Drug Name Drug Tier Requirements/Limits FERRIPROX ORAL SOLUTION 100 5 NDS MG/ML FERRIPROX ORAL TABLET 500 MG 5 NDS SYPRINE ORAL CAPSULE 250 MG 5 NDS Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG 5 PA; NDS ANDRODERM TRANSDERMAL 3 PA; QL (30 per 30 days) PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN 3 PA; QL (150 per 30 METERED-DOSE PUMP 20.25 MG/1.25 days) GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN 3 PA; QL (150 per 30 PACKET 1.62 % (20.25 MG/1.25 days) GRAM), 1.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 10 mg 2 AXIRON TRANSDERMAL SOLUTION 3 PA; QL (180 per 28 IN METERED PUMP W/APP 30 days) MG/ACTUATION (1.5 ML) danazol oral capsule 100 mg, 200 mg, 50 2 mg oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) 2 testosterone cypionate intramuscular oil (Depo-Testosterone) 2 PA 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 2 PA; QL (5 per 28 days) 200 mg/ml testosterone transdermal gel 50 mg/5 (Testim) 2 PA; QL (300 per 30 gram (1 %) days) testosterone transdermal gel in metered- (AndroGel) 2 PA; QL (300 per 30 dose pump 12.5 mg/ 1.25 gram (1 %) days) testosterone transdermal gel in packet 1 % (AndroGel) 2 PA; QL (300 per 30 (25 mg/2.5gram) days) testosterone transdermal gel in packet 1 % (Vogelxo) 2 PA; QL (300 per 30 (50 mg/5 gram) days) Estrogens And Antiestrogens amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 2 COMBIPATCH TRANSDERMAL 3 QL (8 per 28 days) PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DUAVEE ORAL TABLET 0.45-20 MG 3 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 99

Drug Name Drug Tier Requirements/Limits ESTRACE VAGINAL CREAM 0.01 % 3 (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) 2 estradiol transdermal patch semiweekly (Vivelle-Dot) 2 QL (8 per 28 days) 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch semiweekly (Alora) 2 QL (8 per 28 days) 0.075 mg/24 hr estradiol transdermal patch weekly 0.025 (Climara) 2 QL (4 per 28 days) mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 20 (Delestrogen) 2 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet (Mimvey Lo) 2 0.5-0.1 mg estradiol-norethindrone acet oral tablet 1- (Lopreeza) 2 0.5 mg ESTRING VAGINAL RING 2 MG (7.5 4 QL (1 per 84 days) MCG /24 HOUR) estropipate oral tablet 0.75 mg, 1.5 mg, 3 2 mg FEMRING VAGINAL RING 0.05 MG/24 4 QL (1 per 84 days) HR, 0.1 MG/24 HR fyavolv oral tablet 1-5 mg-mcg 2 jinteli oral tablet 1-5 mg-mcg 2 MENEST ORAL TABLET 0.3 MG, 0.625 4 MG, 1.25 MG, 2.5 MG mimvey lo oral tablet 0.5-0.1 mg 2 mimvey oral tablet 1-0.5 mg 2 norethindrone ac-eth estradiol oral tablet (Fyavolv) 2 1-5 mg-mcg PREMARIN INJECTION RECON SOLN 3 25 MG PREMARIN ORAL TABLET 0.3 MG, 3 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 0.625 3 MG/GRAM PREMPHASE ORAL TABLET 0.625 3 MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3-1.5 MG, 3 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG raloxifene oral tablet 60 mg (Evista) 2 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 100

Drug Name Drug Tier Requirements/Limits VAGIFEM VAGINAL TABLET 10 MCG 3 QL (18 per 28 days) yuvafem vaginal tablet 10 mcg 2 QL (18 per 28 days) Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 mg 2 betamethasone acet,sod phos injection (Celestone Soluspan) 2 suspension 6 mg/ml cortisone oral tablet 25 mg 2 PA BvD dexamethasone oral elixir 0.5 mg/5 ml 2 PA BvD dexamethasone oral tablet 0.5 mg, 0.75 1 PA BvD mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate 2 injection solution 10 mg/ml, 4 mg/ml EMFLAZA ORAL SUSPENSION 22.75 5 PA; NDS MG/ML EMFLAZA ORAL TABLET 18 MG 5 PA; NDS; QL (30 per 30 days) EMFLAZA ORAL TABLET 30 MG, 6 5 PA; NDS; QL (60 per 30 MG days) EMFLAZA ORAL TABLET 36 MG 5 PA; NDS fludrocortisone oral tablet 0.1 mg 2 hydrocortisone oral tablet 10 mg, 20 mg, 5 (Cortef) 2 PA BvD mg methylprednisolone acetate injection (Depo-Medrol) 2 suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 (Medrol) 2 PA BvD mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack (Medrol (Pak)) 2 4 mg methylprednisolone sodium succ injection 2 recon soln 125 mg, 40 mg methylprednisolone sodium succ (Solu-Medrol) 2 intravenous recon soln 1,000 mg prednisolone sodium phosphate oral 2 PA BvD solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral (Pediapred) 2 PA BvD solution 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml 2 PA BvD prednisone oral tablet 1 mg, 2.5 mg, 5 mg, 1 PA BvD 50 mg prednisone oral tablet 10 mg 1 PA BvD prednisone oral tablet 20 mg (Deltasone) 1 PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 101

Drug Name Drug Tier Requirements/Limits prednisone oral tablets,dose pack 10 mg, 2 10 mg (48 pack), 5 mg, 5 mg (48 pack) SOLU-CORTEF (PF) INJECTION 4 RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML triamcinolone acetonide injection (Kenalog) 2 suspension 10 mg/ml, 40 mg/ml Pituitary desmopressin injection solution 4 mcg/ml (DDAVP) 2 desmopressin nasal solution 0.1 mg/ml (DDAVP) 2 QL (15 per 30 days) (refrigerate) desmopressin nasal spray,non-aerosol 10 2 QL (15 per 30 days) mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) 2 GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML GENOTROPIN MINIQUICK 5 PA; NDS SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS 5 PA; NDS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION 5 PA; NDS CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON 5 PA; NDS SOLN 5 (15 UNIT) MG INCRELEX SUBCUTANEOUS 5 NDS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) 5 NDS; QL (1 per 84 days) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED 5 NDS INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 102

Drug Name Drug Tier Requirements/Limits NORDITROPIN FLEXPRO 5 PA; NDS SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML) NORDITROPIN FLEXPRO 4 PA SUBCUTANEOUS PEN INJECTOR 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN 5 PA; NDS SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS 5 PA; NDS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML) octreotide acet 50 mcg/ml syr outer,single- 2 dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 (Sandostatin) 5 NDS mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 (Sandostatin) 2 mcg/ml, 200 mcg/ml octreotide acetate injection solution 50 (Sandostatin) 2 mcg/ml OMNITROPE SUBCUTANEOUS 5 PA; NDS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS 5 PA; NDS RECON SOLN 5.8 MG SAIZEN CLICK.EASY 5 PA; NDS SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON 5 PA; NDS SOLN 5 MG, 8.8 MG SANDOSTATIN LAR DEPOT 5 NDS INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON 5 PA; NDS SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT 5 NDS; QL (1 per 28 days) SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 103

Drug Name Drug Tier Requirements/Limits SOMAVERT SUBCUTANEOUS 5 NDS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL SPRAY,NON- 4 AEROSOL 150 MCG/SPRAY (0.1 ML) SUPPRELIN LA IMPLANT KIT 50 MG 5 NDS; QL (1 per 360 (65 MCG/DAY) days) ZOMACTON SUBCUTANEOUS 5 PA; NDS RECON SOLN 10 MG ZOMACTON SUBCUTANEOUS 4 PA RECON SOLN 5 MG ZORBTIVE SUBCUTANEOUS RECON 5 PA; NDS SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR 4 QL (10 per 28 days) SOLUTION 400 MG/ML hydroxyprogesterone caproate 2 PA NSO intramuscular oil 250 mg/ml medroxyprogesterone intramuscular (Depo-Provera) 2 QL (1 per 84 days) suspension 150 mg/ml medroxyprogesterone intramuscular (Depo-Provera) 2 QL (1 per 84 days) syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, (Provera) 1 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (Megace) 2 (40 mg/ml) megestrol oral suspension 625 mg/5 ml (Megace ES) 2 norethindrone acetate oral tablet 5 mg (Aygestin) 2 progesterone in oil intramuscular oil 50 2 mg/ml progesterone micronized oral capsule 100 (Prometrium) 2 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 5 NDS mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 (Levo-T) 1 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 137 mcg (Unithroid) 1 liothyronine intravenous solution 10 (Triostat) 2 mcg/ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 104

Drug Name Drug Tier Requirements/Limits liothyronine oral tablet 25 mcg, 5 mcg, 50 (Cytomel) 2 mcg methimazole oral tablet 10 mg, 5 mg (Tapazole) 2 propylthiouracil oral tablet 50 mg 2 Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS 5 PA; NDS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS 5 PA; NDS SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON 5 NDS SOLN 220 MG ASTAGRAF XL ORAL 4 PA BvD CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG azathioprine oral tablet 50 mg (Imuran) 2 PA BvD azathioprine sodium injection recon soln 2 PA BvD 100 mg CARIMUNE NF NANOFILTERED 5 PA BvD; NDS INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS 4 PA BvD INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR RECONST 5 PA; NDS SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE 5 PA; NDS KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 (Sandimmune) 2 PA BvD mg/5 ml cyclosporine modified oral capsule 100 (Gengraf) 2 PA BvD mg, 25 mg, 50 mg cyclosporine modified oral solution 100 (Neoral) 2 PA BvD mg/ml cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) 2 PA BvD ENBREL SUBCUTANEOUS RECON 5 PA; NDS SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 5 PA; NDS 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 105

Drug Name Drug Tier Requirements/Limits ENBREL SURECLICK 5 PA; NDS SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET 4 PA BvD EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR 3 PA BvD SOLUTION 15-18 % RANGE, 15-18 % RANGE (10 ML), 15-18 % RANGE (2 ML) GAMMAGARD LIQUID INJECTION 5 PA BvD; NDS SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) 5 PA BvD; NDS INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) 5 PA BvD; NDS INTRAVENOUS SOLUTION 5 % GAMUNEX-C 20 GRAM/200 ML VIAL 5 PA BvD; NDS P/F,LTX-FR,SUV,OUTER 20 GRAM/200 ML (10 %) GAMUNEX-C INJECTION SOLUTION 5 PA BvD; NDS 1 GRAM/10 ML (10 %) gengraf oral capsule 100 mg, 25 mg, 50 2 PA BvD mg gengraf oral solution 100 mg/ml 2 PA BvD HUMIRA PEDIATRIC CROHN'S 5 PA; NDS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS 5 PA; NDS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NDS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN 5 PA; NDS INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE 5 PA; NDS KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 106

Drug Name Drug Tier Requirements/Limits HYPERRAB S/D (PF) 4 INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT 5 PA BvD; NDS SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS 5 PA BvD; NDS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON 5 PA; NDS SOLN 180 MG/1.2 ML (150 MG/ML) ILARIS (PF) SUBCUTANEOUS 5 PA; NDS SOLUTION 150 MG/ML IMOGAM RABIES-HT (PF) 4 INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 5 PA; NDS; QL (18.76 per 100 MG/0.67 ML 28 days) leflunomide oral tablet 10 mg, 20 mg (Arava) 2 mycophenolate mofetil hcl intravenous (CellCept Intravenous) 2 PA BvD recon soln 500 mg mycophenolate mofetil oral capsule 250 (CellCept) 2 PA BvD mg mycophenolate mofetil oral suspension for (CellCept) 5 PA BvD; NDS reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg (CellCept) 2 PA BvD mycophenolate sodium oral tablet,delayed (Myfortic) 2 PA BvD release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON 5 PA BvD; NDS SOLN 250 MG OCTAGAM INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) 5 PA; NDS INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS 5 PA; NDS SYRINGE 125 MG/ML OTEZLA ORAL TABLET 30 MG 5 PA; NDS; QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 107

Drug Name Drug Tier Requirements/Limits OTEZLA STARTER ORAL 5 PA; NDS; QL (60 per 30 TABLETS,DOSE PACK 10 MG (4)-20 days) MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS 3 AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PRIVIGEN INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 4 PA BvD 5 MG/ML RAPAMUNE ORAL SOLUTION 1 5 PA BvD; NDS MG/ML RASUVO (PF) SUBCUTANEOUS 3 AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 3 MG 5 NDS SIMPONI ARIA INTRAVENOUS 5 PA; NDS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN 5 PA; NDS INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 5 PA; NDS 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg (Rapamune) 2 PA BvD sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD; NDS STELARA INTRAVENOUS SOLUTION 5 PA; NDS 130 MG/26 ML STELARA SUBCUTANEOUS 5 PA; NDS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 mg, 5 (Prograf) 2 PA BvD mg TYSABRI INTRAVENOUS SOLUTION 5 PA; LA; NDS; QL (15 300 MG/15 ML per 28 days) XELJANZ ORAL TABLET 5 MG 5 PA; NDS; QL (60 per 30 days) XELJANZ XR ORAL TABLET 5 PA; NDS; QL (30 per 30 EXTENDED RELEASE 24 HR 11 MG days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 108

Drug Name Drug Tier Requirements/Limits ZORTRESS ORAL TABLET 0.25 MG, 5 PA BvD; NDS 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR 3 RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP 3 ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP 3 ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF- (2.5-5-3-5 MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) 3 PA BvD PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR 3 SYRINGE 50-50-50-25 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR 3 SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR 3 SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) 3 INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR 3 SUSPENSION 5-7.5-125 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) 3 INTRAMUSCULAR SUSPENSION 15- 10-5 LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR 3 PA BvD SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR 3 PA BvD SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) 3 PA BvD INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) 3 PA BvD INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SUSPENSION 20-40-40-20 MCG/0.5 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 109

Drug Name Drug Tier Requirements/Limits GARDASIL (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SYRINGE 20-40-40-20 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR 3 SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR 3 SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR 3 RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) 3 PA BvD INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) 3 INTRAMUSCULAR SUSPENSION 25- 58-10 LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 40-8- 3 32 UNIT/0.5 ML IPOL INJECTION SYRINGE 40-8-32 3 UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR 3 SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR 3 SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR 3 SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR 3 SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR 3 RECON SOLN 5-2.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) 3 SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 3 SUBCUTANEOUS RECON SOLN 50 MCG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 110

Drug Name Drug Tier Requirements/Limits MENVEO A-C-Y-W-135-DIP (PF) 3 INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS 3 QL (2 per 365 days) RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR 3 SYRINGE 10 MCG-25LF-25 MCG- 10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR 3 SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR 3 KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS 3 QL (2 per 365 days) SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR 3 SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR 3 PA BvD SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) 3 PA BvD INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) 3 PA BvD INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL 3 PA BvD OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR 3 RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL 3 SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR 3 SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) 3 INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD 3 INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 111

Drug Name Drug Tier Requirements/Limits TICE BCG INTRAVESICAL 3 PA BvD SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR 3 SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR 3 SUSPENSION 720 ELISA UNIT -20 MCG/ML TWINRIX (PF) INTRAMUSCULAR 3 SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR 3 SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR 3 SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR 3 SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR 3 SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, 3 OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS 3 QL (2 per 365 days) SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS 3 QL (1 per 365 days) SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) 5 NDS APRISO ORAL CAPSULE,EXTENDED 3 RELEASE 24HR 0.375 GRAM ASACOL HD ORAL 3 TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) 2 budesonide oral (Entocort EC) 5 NDS capsule,delayed,extend.release 3 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 112

Drug Name Drug Tier Requirements/Limits colocort rectal enema 100 mg/60 ml 2 DELZICOL ORAL CAPSULE (WITH 3 DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG 5 ST; NDS hydrocortisone rectal enema 100 mg/60 ml (Colocort) 2 LIALDA ORAL TABLET,DELAYED 3 RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (Asacol HD) 2 (dr/ec) 800 mg UCERIS RECTAL FOAM 2 3 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % 2 LACTATED RINGERS IRRIGATION 3 SOLUTION ringers irrigation solution 2 sodium chloride irrigation solution 0.9 % (Sterile Saline) 2 sorbitol irrigation solution 3 %, 3.3 % 2 sorbitol-mannitol urethral solution 2.7- 2 0.54 g/100 ml water for irrigation, sterile irrigation (Curity Sterile Water) 2 solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml 2 QL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg 1 alendronate oral tablet 35 mg 1 QL (4 per 28 days) alendronate oral tablet 40 mg 2 alendronate oral tablet 70 mg (Fosamax) 1 QL (4 per 28 days) calcitonin (salmon) nasal spray,non- (Miacalcin) 2 QL (3.7 per 28 days) aerosol 200 unit/actuation calcitriol intravenous solution 1 mcg/ml 2 calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) 2 calcitriol oral solution 1 mcg/ml (Rocaltrol) 2 doxercalciferol intravenous solution 4 (Hectorol) 2 mcg/2 ml doxercalciferol oral capsule 0.5 mcg, 1 (Hectorol) 2 mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, 2 400 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 113

Drug Name Drug Tier Requirements/Limits FORTEO SUBCUTANEOUS PEN 4 QL (2.4 per 28 days) INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML FORTICAL NASAL SPRAY,NON- 4 QL (3.7 per 28 days) AEROSOL 200 UNIT/ACTUATION ibandronate intravenous solution 3 mg/3 2 QL (3 per 84 days) ml ibandronate intravenous syringe 3 mg/3 (Boniva) 2 QL (3 per 84 days) ml ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 3 200 UNIT/ML NATPARA SUBCUTANEOUS 5 PA; NDS; QL (2 per 28 CARTRIDGE 100 MCG/DOSE, 25 days) MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 2 mg, 90 mg pamidronate intravenous solution 30 2 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) 2 paricalcitol oral capsule 4 mcg 2 PROLIA SUBCUTANEOUS SYRINGE 3 QL (1 per 180 days) 60 MG/ML RAYALDEE ORAL 5 NDS; QL (60 per 30 CAPSULE,EXTENDED RELEASE 24 days) HR 30 MCG risedronate oral tablet 150 mg (Actonel) 2 QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) 2 QL (30 per 30 days) risedronate oral tablet 35 mg (Actonel) 2 QL (4 per 28 days) risedronate oral tablet 35 mg (12 pack), 2 QL (4 per 28 days) 35 mg (4 pack) XGEVA SUBCUTANEOUS SOLUTION 5 PA; NDS 120 MG/1.7 ML (70 MG/ML) ZEMPLAR INTRAVENOUS 3 SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 (Zometa) 2 mg/5 ml zoledronic acid-mannitol-water 2 intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water (Reclast) 2 QL (100 per 300 days) intravenous solution 5 mg/100 ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 114

Drug Name Drug Tier Requirements/Limits ZOMETA INTRAVENOUS SOLUTION 5 NDS 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS 5 NDS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon (Ethyol) 2 soln 500 mg BENLYSTA INTRAVENOUS RECON 5 PA; NDS SOLN 120 MG, 400 MG BOTOX INJECTION RECON SOLN 100 4 PA; QL (4 per 90 days) UNIT BOTOX INJECTION RECON SOLN 200 4 PA; QL (1 per 90 days) UNIT buspirone oral tablet 10 mg, 15 mg, 30 2 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG 5 PA; NDS CETYLEV ORAL TABLET, 4 EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER 1 5 NDS GRAM/1.7 ML dexrazoxane hcl intravenous recon soln (Zinecard (as HCl)) 2 250 mg, 500 mg droperidol injection solution 2.5 mg/ml 2 ELMIRON ORAL CAPSULE 100 MG 4 ergoloid oral tablet 1 mg 2 EXONDYS 51 INTRAVENOUS 5 PA; LA; NDS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) fomepizole intravenous solution 1 gram/ml 5 NDS FUSILEV INTRAVENOUS RECON 5 NDS SOLN 50 MG GLUCAGEN HYPOKIT INJECTION 3 RECON SOLN 1 MG GLUCAGON EMERGENCY KIT 4 (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg 2 hydroxyzine pamoate oral capsule 100 mg 2 hydroxyzine pamoate oral capsule 25 mg, (Vistaril) 2 50 mg INFLECTRA INTRAVENOUS RECON 5 PA; NDS SOLN 100 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 115

Drug Name Drug Tier Requirements/Limits KEVEYIS ORAL TABLET 50 MG 5 PA; NDS; QL (120 per 30 days) leucovorin calcium 200 mg vial sdv, p/f, 2 latex-free 200 mg leucovorin calcium injection recon soln 2 100 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 2 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution (Carnitor) 2 100 mg/ml levocarnitine intravenous solution 200 (Carnitor) 2 mg/ml levocarnitine oral tablet 330 mg (Carnitor) 2 LEVOLEUCOVORIN INTRAVENOUS 4 RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 (Fusilev) 5 NDS mg mesna intravenous solution 100 mg/ml (Mesnex) 2 MESNEX ORAL TABLET 400 MG 5 NDS MESTINON ORAL SYRUP 60 MG/5 5 NDS ML methylergonovine injection solution 0.2 2 mg/ml (1 ml) methylergonovine oral tablet 0.2 mg (Methergine) 2 MYOBLOC INTRAMUSCULAR 4 PA; QL (2 per 90 days) SOLUTION 10,000 UNIT/2 ML MYOBLOC INTRAMUSCULAR 4 PA; QL (0.5 per 90 days) SOLUTION 2,500 UNIT/0.5 ML MYOBLOC INTRAMUSCULAR 4 PA; QL (1 per 90 days) SOLUTION 5,000 UNIT/ML NPLATE SUBCUTANEOUS RECON 5 PA; NDS; QL (8 per 28 SOLN 250 MCG, 500 MCG days) ORENCIA CLICKJECT 5 PA; NDS SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML PROCYSBI ORAL CAPSULE, 5 NDS DELAYED REL SPRINKLE 25 MG, 75 MG pyridostigmine bromide oral tablet 60 mg (Mestinon) 2 pyridostigmine bromide oral tablet (Mestinon Timespan) 2 extended release 180 mg REMICADE INTRAVENOUS RECON 5 PA; NDS SOLN 100 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 116

Drug Name Drug Tier Requirements/Limits SENSIPAR ORAL TABLET 30 MG 3 SENSIPAR ORAL TABLET 60 MG, 90 5 NDS MG SIGNIFOR SUBCUTANEOUS 5 NDS; QL (60 per 30 SOLUTION 0.3 MG/ML (1 ML), 0.6 days) MG/ML (1 ML), 0.9 MG/ML (1 ML) SYNAREL NASAL SPRAY,NON- 5 NDS AEROSOL 2 MG/ML THALOMID ORAL CAPSULE 100 MG, 5 PA NSO; NDS; QL (60 150 MG, 200 MG, 50 MG per 30 days) THIOLA ORAL TABLET 100 MG 5 NDS TYBOST ORAL TABLET 150 MG 3 QL (30 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended (Diamox Sequels) 2 release 500 mg acetazolamide oral tablet 125 mg, 250 mg 2 acetazolamide sodium injection recon soln 2 500 mg ALPHAGAN P OPHTHALMIC DROPS 3 0.1 % AZOPT OPHTHALMIC 3 DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % 2 BETOPTIC S OPHTHALMIC 4 DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic drops 0.03 % 2 brimonidine ophthalmic drops 0.15 % (Alphagan P) 2 brimonidine ophthalmic drops 0.2 % 2 COMBIGAN OPHTHALMIC DROPS 3 0.2-0.5 % dorzolamide ophthalmic drops 2 % (Trusopt) 2 dorzolamide-timolol ophthalmic drops (Cosopt) 2 22.3-6.8 mg/ml latanoprost ophthalmic drops 0.005 % (Xalatan) 2 levobunolol ophthalmic drops 0.5 % (Betagan) 2 LUMIGAN OPHTHALMIC DROPS 0.01 3 QL (2.5 per 25 days) % methazolamide oral tablet 25 mg, 50 mg (Neptazane) 2 metipranolol ophthalmic drops 0.3 % 2 PHOSPHOLINE IODIDE 3 OPHTHALMIC DROPS 0.125 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 117

Drug Name Drug Tier Requirements/Limits pilocarpine hcl ophthalmic drops 1 %, 2 (Isopto Carpine) 2 %, 4 % SIMBRINZA OPHTHALMIC 3 DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic drops 0.25 %, (Timoptic) 1 0.5 % timolol maleate ophthalmic gel forming (Timoptic-XE) 2 solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS 3 QL (2.5 per 25 days) 0.004 % travoprost (benzalkonium) ophthalmic 2 QL (2.5 per 25 days) drops 0.004 % ZIOPTAN (PF) OPHTHALMIC 3 QL (30 per 30 days) DROPPERETTE 0.0015 % Replacement Preparations Replacement Preparations calcium chloride intravenous syringe 100 2 mg/ml (10 %) d10 %-0.45 % sodium chloride 2 intravenous parenteral solution d2.5 %-0.45 % sodium chloride 2 intravenous parenteral solution d5 % and 0.9 % sodium chloride 2 intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous 2 parenteral solution dextrose 10 % and 0.2 % nacl intravenous 2 parenteral solution dextrose 5 %-lactated ringers intravenous 2 parenteral solution dextrose 5%-0.2 % sod chloride 2 intravenous parenteral solution dextrose 5%-0.3 % sod.chloride 2 intravenous parenteral solution dextrose with sodium chloride intravenous 2 parenteral solution 5-0.2 % dextrose-kcl-nacl intravenous solution 5- 2 0.224-0.225 % effer-k oral tablet, effervescent 25 meq 2 electrolyte-48 in d5w intravenous 2 parenteral solution IONOSOL-B IN D5W INTRAVENOUS 4 PARENTERAL SOLUTION 5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 118

Drug Name Drug Tier Requirements/Limits IONOSOL-MB IN D5W 4 INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS 4 PARENTERAL SOLUTION KLOR-CON 10 ORAL TABLET 2 EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er 2 particles/crystals 10 meq klor-con m15 oral tablet,er 2 particles/crystals 15 meq klor-con m20 oral tablet,er 2 particles/crystals 20 meq klor-con sprinkle oral capsule, extended 2 release 10 meq, 8 meq magnesium sulfate in d5w intravenous 2 piggyback 1 gram/100 ml magnesium sulfate in water intravenous 2 parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous 2 piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 2 meq/ml (50 %) magnesium sulfate injection syringe 4 2 meq/ml NORMOSOL-M IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION 4 12'S,LATEX-FREE NORMOSOL-R PH 7.4 INTRAVENOUS 4 PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS 4 PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS 4 PARENTERAL SOLUTION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 119

Drug Name Drug Tier Requirements/Limits PLASMA-LYTE-56 IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 2 meq/ml potassium chlorid-d5-0.45%nacl 2 intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl 2 intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous 2 parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous 2 parenteral solution 20 meq/l potassium chloride intravenous piggyback 2 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 2 meq/ml potassium chloride oral capsule, extended (Klor-Con Sprinkle) 2 release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 2 ml, 40 meq/15 ml potassium chloride oral packet 20 meq (Klor-Con) 2 potassium chloride oral tablet extended (K-Tab) 2 release 10 meq, 8 meq potassium chloride oral tablet extended (K-Tab) 2 release 20 meq potassium chloride oral tablet,er (Klor-Con M10) 2 particles/crystals 10 meq potassium chloride-0.45 % nacl 2 intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl 2 intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl 2 intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl 2 intravenous parenteral solution 20 meq/l, 40 meq/l You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 120

Drug Name Drug Tier Requirements/Limits potassium citrate oral tablet extended (Urocit-K 10) 2 release 10 meq (1,080 mg) potassium citrate oral tablet extended (Urocit-K 15) 2 release 15 meq potassium citrate oral tablet extended (Urocit-K 5) 2 release 5 meq (540 mg) potassium citrate-citric acid oral packet (Cytra K Crystals) 2 3,300-1,002 mg potassium cl 10 meq/50 ml sol 10 meq/50 2 ml potassium cl 20 meq/50 ml sol 20 meq/50 2 ml potassium cl er 20 meq tablet (Klor-Con M20) 2 microencapsulated 20 meq ringers intravenous parenteral solution 2 sodium acetate intravenous solution 2 2 meq/ml sodium bicarbonate intravenous syringe 2 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous 2 parenteral solution 0.45 % sodium chloride 0.9 % intravenous 2 parenteral solution 0.9 % sodium chloride 3 % intravenous 2 parenteral solution 3 % sodium chloride 5 % intravenous 2 parenteral solution 5 % sodium chloride intravenous parenteral 2 solution 2.5 meq/ml sodium lactate intravenous solution 5 2 meq/ml sodium phosphate intravenous solution 3 2 mmol/ml TPN ELECTROLYTES II IV SOLN 4 25'S,20ML/50ML FTV 18-18-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS 4 SOLUTION 35-20-5 MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 121

Drug Name Drug Tier Requirements/Limits ADVAIR DISKUS INHALATION 3 QL (60 per 30 days) BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500- 50 MCG/DOSE ADVAIR HFA INHALATION HFA 3 QL (12 per 28 days) AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION ARNUITY ELLIPTA INHALATION 3 QL (30 per 30 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION 3 QL (60 per 30 days) BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE budesonide inhalation suspension for (Pulmicort) 2 PA BvD nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml DULERA INHALATION HFA 3 QL (13 per 28 days) AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION FLOVENT DISKUS INHALATION 3 QL (60 per 30 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION 3 QL (120 per 30 days) BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (12 per 28 days) AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (24 per 28 days) AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (21.2 per 28 days) AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 3 QL (17.4 per 25 days) MCG/ACTUATION, 80 MCG/ACTUATION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 122

Drug Name Drug Tier Requirements/Limits SYMBICORT 160-4.5 MCG INHALER 3 QL (12 per 25 days) 60 INHALATIONS 160-4.5 MCG/ACTUATION SYMBICORT INHALATION HFA 3 QL (11 per 25 days) AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) 2 montelukast oral tablet 10 mg (Singulair) 1 montelukast oral tablet,chewable 4 mg, 5 (Singulair) 1 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) 2 Bronchodilators albuterol sulfate inhalation solution for 2 PA BvD nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml 2 albuterol sulfate oral tablet 2 mg, 4 mg 2 albuterol sulfate oral tablet extended 2 release 12 hr 4 mg, 8 mg ANORO ELLIPTA INHALATION 3 QL (60 per 30 days) BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION ATROVENT HFA INHALATION HFA 3 QL (25.8 per 28 days) AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT 3 QL (8 per 30 days) INHALATION MIST 20-100 MCG/ACTUATION elixophyllin oral elixir 80 mg/15 ml 2 FORADIL AEROLIZER INHALATION 3 QL (60 per 30 days) CAPSULE, W/INHALATION DEVICE 12 MCG INCRUSE ELLIPTA INHALATION 3 QL (30 per 30 days) BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 2 PA BvD 0.02 % metaproterenol oral syrup 10 mg/5 ml 2 metaproterenol oral tablet 10 mg, 20 mg 2 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 123

Drug Name Drug Tier Requirements/Limits PROAIR HFA INHALATION HFA 3 AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION 3 AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION 3 QL (60 per 30 days) BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION 3 MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER 3 INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION 3 QL (4 per 28 days) MIST 2.5-2.5 MCG/ACTUATION STRIVERDI RESPIMAT INHALATION 3 QL (4 per 28 days) MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg 2 terbutaline subcutaneous solution 1 mg/ml 5 NDS theophylline in dextrose 5 % intravenous 2 parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml 2 theophylline oral tablet extended release (Theochron) 2 12 hr 100 mg, 200 mg, 300 mg theophylline oral tablet extended release 2 12 hr 450 mg theophylline oral tablet extended release 2 24 hr 400 mg, 600 mg VENTOLIN HFA INHALATION HFA 3 AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 (Acetadote) 2 PA BvD mg/ml (20 %) acetylcysteine solution 100 mg/ml (10 %), 2 PA BvD 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 5 PA; NDS 10 MG/ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 124

Drug Name Drug Tier Requirements/Limits cromolyn inhalation solution for 2 PA BvD nebulization 20 mg/2 ml DALIRESP ORAL TABLET 500 MCG 3 QL (30 per 30 days) ESBRIET ORAL CAPSULE 267 MG 5 PA; NDS; QL (270 per 30 days) KALYDECO ORAL GRANULES IN 5 PA; NDS; QL (60 per 30 PACKET 50 MG, 75 MG days) KALYDECO ORAL TABLET 150 MG 5 PA; NDS; QL (60 per 30 days) NUCALA SUBCUTANEOUS RECON 5 PA; LA; NDS; QL (1 per SOLN 100 MG 28 days) OFEV ORAL CAPSULE 100 MG, 150 5 PA; NDS; QL (60 per 30 MG days) ORKAMBI ORAL TABLET 100-125 5 PA; NDS; QL (120 per MG, 200-125 MG 30 days) PROLASTIN-C INTRAVENOUS 5 NDS RECON SOLN 1,000 MG XOLAIR SUBCUTANEOUS RECON 5 PA; NDS SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg 2 carisoprodol oral tablet 250 mg, 350 mg (Soma) 2 QL (120 per 30 days) chlorzoxazone oral tablet 500 mg (Parafon Forte DSC) 2 cyclobenzaprine oral tablet 10 mg, 5 mg 2 cyclobenzaprine oral tablet 7.5 mg (Fexmid) 2 dantrolene oral capsule 100 mg 2 dantrolene oral capsule 25 mg, 50 mg (Dantrium) 2 metaxall oral tablet 800 mg 2 metaxalone oral tablet 400 mg 2 metaxalone oral tablet 800 mg (Skelaxin) 2 methocarbamol oral tablet 500 mg (Robaxin) 2 methocarbamol oral tablet 750 mg (Robaxin-750) 2 revonto intravenous recon soln 20 mg 2 tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) 2 tizanidine oral tablet 2 mg 2 tizanidine oral tablet 4 mg (Zanaflex) 2 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, (Nuvigil) 2 PA 250 mg, 50 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 125

Drug Name Drug Tier Requirements/Limits BELSOMRA ORAL TABLET 10 MG, 15 3 QL (30 per 30 days) MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) 2 QL (30 per 30 days) HETLIOZ ORAL CAPSULE 20 MG 5 PA; NDS; QL (30 per 30 days) ROZEREM ORAL TABLET 8 MG 3 SILENOR ORAL TABLET 3 MG, 6 MG 3 QL (30 per 30 days) XYREM ORAL SOLUTION 500 MG/ML 5 LA; NDS zaleplon oral capsule 10 mg, 5 mg (Sonata) 2 QL (60 per 30 days) zolpidem oral tablet 10 mg, 5 mg (Ambien) 2 QL (30 per 30 days) zolpidem oral tablet,ext release multiphase (Ambien CR) 2 QL (30 per 30 days) 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG 5 PA; NDS; QL (60 per 30 days) ADEMPAS ORAL TABLET 0.5 MG, 1 5 PA; NDS; QL (90 per 30 MG, 1.5 MG, 2 MG, 2.5 MG days) CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; QL (30 per 30 days) epoprostenol (glycine) intravenous recon (Flolan) 2 soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) 5 NDS soln 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 5 PA; NDS; QL (30 per 30 MG days) OPSUMIT ORAL TABLET 10 MG 5 PA; NDS; QL (30 per 30 days) ORENITRAM ORAL TABLET 3 PA EXTENDED RELEASE 0.125 MG ORENITRAM ORAL TABLET 5 PA; NDS EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 5 PA; NDS 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 (Revatio) 5 PA; NDS; QL (37.5 per ml 1 day) sildenafil oral tablet 20 mg (Revatio) 2 PA; QL (90 per 30 days) TRACLEER ORAL TABLET 125 MG, 5 PA; LA; NDS; QL (60 62.5 MG per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 126

Drug Name Drug Tier Requirements/Limits TYVASO INHALATION SOLUTION 5 PA; NDS FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 5 PA; NDS; QL (60 per 30 1,200 MCG, 1,400 MCG, 1,600 MCG, days) 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG 5 PA; NDS; QL (240 per 30 days) UPTRAVI ORAL TABLETS,DOSE 5 PA; NDS; QL (400 per PACK 200 MCG (140)- 800 MCG (60) 365 days) Vitamins And Minerals Vitamins And Minerals multivit-fluor 0.25 mg/ml drop 0.25 mg/ml 2 pnv prenatal plus multivit tab s/f, gluten- 3 (All Rx Prenatal free 27 mg iron- 1 mg Vitamins Covered) prenatal vitamin plus low iron oral tablet 3 (All Rx Prenatal 27 mg iron- 1 mg Vitamins Covered) sodium fluoride oral tablet 1 mg fluoride 2 (2.2 mg) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. 127

INDEX 8 AFINITOR............................. 20 amethia lo ............................... 76 8-MOP .................................... 82 AFINITOR DISPERZ ........... 20 amifostine crystalline ........... 115 A a-hydrocort ........................... 101 amiloride ................................ 69 abacavir .................................. 51 AKTEN (PF).......................... 90 amiloride-hydrochlorothiazide abacavir-lamivudine ............... 51 AKYNZEO ............................ 44 ............................................ 70 abacavir-lamivudine-zidovudine ala-cort ................................... 85 AMINO ACIDS 15 % ............ 59 ............................................ 51 ala-scalp ................................. 85 AMINOSYN 10 % ................. 59 ABELCET .............................. 40 ALBENZA............................. 45 AMINOSYN 7 % WITH ABILIFY MAINTENA .......... 47 albuterol sulfate ................... 123 ELECTROLYTES ............. 59 ABRAXANE .......................... 20 alcaine .................................... 90 AMINOSYN 8.5 % ................ 59 acamprosate .............................. 9 alclometasone ........................ 85 AMINOSYN 8.5 %- acarbose .................................. 36 ALCOHOL PADS ................. 82 ELECTROLYTES ............. 59 acebutolol ............................... 65 ALCOHOL PREP PADS ...... 82 AMINOSYN II 10 % ............. 59 acetaminophen-codeine ............ 3 ALDURAZYME ................... 88 AMINOSYN II 15 % ............. 59 acetasol hc .............................. 91 ALECENSA .......................... 20 AMINOSYN II 7 % ............... 59 acetazolamide ....................... 117 alendronate ........................... 113 AMINOSYN II 8.5 % ............ 59 acetazolamide sodium .......... 117 alfuzosin................................. 98 AMINOSYN II 8.5 %- acetic acid ....................... 91, 113 ALIMTA ................................ 20 ELECTROLYTES ............. 59 acetylcysteine ....................... 124 ALINIA ................................. 45 AMINOSYN M 3.5 % ........... 59 acitretin ................................... 82 allopurinol .............................. 42 AMINOSYN-HBC 7% .......... 59 ACTEMRA .......................... 105 ALLZITAL .............................. 3 AMINOSYN-PF 10 % ........... 59 ACTHIB (PF) ....................... 109 almotriptan malate ................. 43 AMINOSYN-PF 7 % ACTIMMUNE ..................... 115 alogliptin ................................ 36 (SULFITE-FREE) .............. 59 acyclovir ........................... 55, 82 alogliptin-metformin .............. 36 AMINOSYN-RF 5.2 % ......... 59 acyclovir sodium .................... 55 alogliptin-pioglitazone ........... 36 amiodarone ............................. 64 ADACEL(TDAP alosetron............................... 112 AMITIZA ............................... 95 ADOLESN/ADULT)(PF) 109 ALPHAGAN P .................... 117 amitriptyline ........................... 33 ADAGEN ............................... 88 alprazolam ............................. 10 amlodipine.............................. 69 adapalene ................................ 87 ALREX .................................. 93 amlodipine-atorvastatin.......... 71 ADCETRIS ............................ 20 altacaine ................................. 90 amlodipine-benazepril............ 69 ADCIRCA ............................ 126 altavera (28) ........................... 76 amlodipine-olmesartan ........... 69 adefovir................................... 55 ALTOPREV .......................... 70 amlodipine-valsartan .............. 69 ADEMPAS ........................... 126 alyacen 1/35 (28) ................... 76 amlodipine-valsartan-hcthiazid adriamycin .............................. 20 alyacen 7/7/7 (28) .................. 76 ............................................ 69 adrucil ..................................... 20 amabelz .................................. 99 ammonium lactate .................. 83 ADVAIR DISKUS ............... 122 amantadine hcl ....................... 46 amoxapine .............................. 33 ADVAIR HFA ..................... 122 AMBISOME .......................... 40 amoxicil-clarithromy-lansopraz afeditab cr ............................... 69 amethia................................... 76 ............................................ 94 I-1

amoxicillin ........................ 16, 17 ATROVENT HFA ............... 123 BENICAR .............................. 62 amoxicillin-pot clavulanate .... 17 AUBAGIO ............................. 74 BENICAR HCT ..................... 62 amphotericin b ........................ 40 aubra ...................................... 76 BENLYSTA ......................... 115 ampicillin ................................ 17 AURYXIA ............................. 97 benztropine ............................. 46 ampicillin sodium ................... 17 AVASTIN .............................. 20 BEPREVE .............................. 90 ampicillin-sulbactam .............. 17 AVC VAGINAL.................... 42 betamethasone acet,sod phos 101 AMPYRA ............................... 74 aviane ..................................... 76 betamethasone dipropionate... 85 ANACAINE ........................... 83 AVONEX .............................. 74 betamethasone valerate .......... 85 ANADROL-50 ....................... 99 AVONEX (WITH ALBUMIN) betamethasone, augmented .... 85 anagrelide ............................... 58 ........................................... 74 BETASERON ........................ 74 anastrozole .............................. 20 AXIRON ................................ 99 betaxolol ......................... 65, 117 ANDRODERM ...................... 99 azacitidine .............................. 20 bethanechol chloride .............. 98 ANDROGEL .......................... 99 azathioprine ......................... 105 BETHKIS ............................... 11 androxy ................................... 99 azathioprine sodium ............. 105 BETOPTIC S ....................... 117 ANORO ELLIPTA .............. 123 azelastine ............................... 90 bexarotene .............................. 21 APOKYN ............................... 46 AZILECT............................... 46 BEXSERO ........................... 109 apraclonidine .......................... 90 azithromycin .......................... 15 bicalutamide ........................... 21 aprepitant ................................ 44 AZOPT ................................ 117 BICILLIN C-R ....................... 17 apri .......................................... 76 AZOR .................................... 69 BICILLIN L-A ....................... 17 APRISO ................................ 112 aztreonam ............................... 16 BIDIL ..................................... 73 APTIOM................................. 29 azurette (28) ........................... 77 bimatoprost .......................... 117 APTIVUS ............................... 51 B bisoprolol fumarate ................ 65 aranelle (28)............................ 76 baciim .................................... 12 bisoprolol-hydrochlorothiazide ARCALYST ......................... 105 bacitracin ......................... 12, 91 ............................................ 65 aripiprazole ............................. 47 bacitracin-polymyxin b .......... 91 bleomycin ............................... 21 ARISTADA ...................... 47, 48 baclofen ............................... 125 bleph-10 ................................. 91 armodafinil ........................... 125 balsalazide ........................... 112 BLINCYTO ........................... 21 ARNUITY ELLIPTA ........... 122 balziva (28) ............................ 77 blisovi 24 fe............................ 77 ASACOL HD ....................... 112 BANZEL ............................... 29 blisovi fe 1.5/30 (28) .............. 77 ascomp with codeine ................ 3 BCG VACCINE, LIVE (PF) 109 blisovi fe 1/20 (28) ................. 77 ashlyna .................................... 76 BD INSULIN PEN NEEDLE BOOSTRIX TDAP .............. 109 aspirin-dipyridamole .............. 58 UF SHORT ........................ 88 BOSULIF ............................... 21 ASSURE ID INSULIN BD INSULIN SYRINGE BOTOX ................................ 115 SAFETY ............................. 88 ULTRA-FINE .................... 88 BREO ELLIPTA .................. 122 ASTAGRAF XL .................. 105 bekyree (28) ........................... 77 briellyn ................................... 77 atenolol ................................... 65 BELBUCA............................... 3 BRILINTA ............................. 58 atenolol-chlorthalidone........... 65 BELEODAQ .......................... 20 brimonidine .......................... 117 atorvastatin ............................. 71 BELSOMRA ....................... 126 BRINTELLIX ........................ 33 atovaquone ............................. 45 benazepril ............................... 63 BRIVIACT ............................. 29 atovaquone-proguanil ............. 45 benazepril-hydrochlorothiazide bromfenac .............................. 93 ATRIPLA ............................... 51 ........................................... 63 bromocriptine ......................... 46 atropine ............................. 29, 90 BENDEKA ............................ 20 budesonide ................... 112, 122 I-2

bumetanide ............................. 70 CARAFATE .......................... 94 CELLCEPT INTRAVENOUS BUNAVAIL ............................. 9 CARBAGLU ......................... 95 .......................................... 105 BUPHENYL........................... 95 carbamazepine ....................... 29 CELONTIN............................ 29 buprenorphine hcl ................. 3, 9 carbidopa ............................... 46 cephalexin .............................. 15 buprenorphine-naloxone......... 10 carbidopa-levodopa ............... 46 CEPROTIN (BLUE BAR) ..... 56 buproban ................................. 10 carbidopa-levodopa-entacapone CERDELGA ........................ 115 bupropion hcl.......................... 33 ..................................... 46, 47 CEREZYME .......................... 88 bupropion hcl (smoking deter) carbinoxamine maleate .......... 42 CERVARIX VACCINE (PF) ............................................ 10 carboplatin ............................. 21 .......................................... 109 buspirone .............................. 115 CARIMUNE NF CETYLEV ........................... 115 butalbital compound w/codeine 3 NANOFILTERED ........... 105 cevimeline .............................. 82 butalbital-acetaminop-caf-cod .. 3 carisoprodol ......................... 125 CHANTIX.............................. 10 butalbital-acetaminophen ......... 3 carteolol ................................. 90 CHANTIX CONTINUING butalbital-acetaminophen-caff .. 3 cartia xt .................................. 66 MONTH BOX ................... 10 butalbital-aspirin-caffeine ........ 3 carvedilol ............................... 65 CHANTIX STARTING butorphanol tartrate .................. 3 CAYSTON ............................ 16 MONTH BOX ................... 10 BUTRANS ............................... 3 caziant (28) ............................ 77 chloramphenicol sod succinate BYSTOLIC ............................ 65 cefaclor .................................. 13 ............................................ 12 BYVALSON .......................... 65 cefadroxil ............................... 14 chlordiazepoxide hcl .............. 10 C cefazolin ................................. 14 chlorhexidine gluconate ......... 82 cabergoline ............................. 46 cefazolin in dextrose (iso-os) . 14 chloroquine phosphate ........... 45 CABOMETYX....................... 21 cefdinir ................................... 14 chlorothiazide ......................... 70 caffeine citrate ........................ 74 cefditoren pivoxil ................... 14 chlorothiazide sodium ............ 70 calcipotriene ........................... 83 cefepime ................................. 14 chlorpromazine ...................... 48 calcitonin (salmon) ............... 113 CEFEPIME ............................ 14 chlorthalidone ........................ 70 calcitrene ................................ 83 CEFEPIME IN DEXTROSE 5 chlorzoxazone ...................... 125 calcitriol .......................... 83, 113 % ........................................ 14 cholestyramine (with sugar) ... 71 calcium acetate ....................... 97 CEFEPIME IN cholestyramine light ............... 71 calcium chloride ................... 118 DEXTROSE,ISO-OSM ..... 14 CIALIS ................................. 126 CALDOLOR ............................ 7 cefixime ................................. 14 ciclopirox ............................... 40 camila ..................................... 77 cefotaxime ............................. 14 cidofovir ................................. 55 camrese ................................... 77 cefoxitin ................................. 14 cilostazol ................................ 58 camrese lo ............................... 77 cefoxitin in dextrose, iso-osm 14 CILOXAN.............................. 91 CANCIDAS ........................... 40 cefpodoxime .......................... 14 cimetidine ............................... 94 candesartan ............................. 62 cefprozil ................................. 14 cimetidine hcl ......................... 94 candesartan-hydrochlorothiazid ceftazidime ............................. 14 CIMZIA ............................... 105 ............................................ 63 ceftibuten ......................... 14, 15 CIMZIA POWDER FOR capacet ...................................... 3 ceftriaxone ............................. 15 RECONST ....................... 105 CAPASTAT ........................... 43 ceftriaxone in dextrose,iso-os 15 CINQAIR ............................. 124 CAPRELSA ........................... 21 cefuroxime axetil ................... 15 CINRYZE .............................. 57 captopril .................................. 63 cefuroxime sodium ................ 15 CIPRODEX............................ 91 captopril-hydrochlorothiazide 64 celecoxib .................................. 7 ciprofloxacin .......................... 18 I-3

ciprofloxacin (mixture) .......... 18 CLINIMIX E 4.25%/D5W cortisone ............................... 101 ciprofloxacin hcl ............... 18, 91 SULF FREE ....................... 60 COSENTYX .......................... 83 ciprofloxacin in 5 % dextrose. 18 CLINIMIX E 5%/D15W COSENTYX (2 SYRINGES) 83 ciprofloxacin lactate ............... 18 SULFIT FREE ................... 60 COSENTYX PEN .................. 83 citalopram ............................... 33 CLINIMIX E 5%/D20W COSENTYX PEN (2 PENS) . 83 cladribine ................................ 21 SULFIT FREE ................... 61 COTELLIC ............................ 21 clarithromycin ........................ 16 CLINIMIX E 5%/D25W CREON .................................. 88 clemastine ............................... 42 SULFIT FREE ................... 61 CRIXIVAN ............................ 51 CLEVIPREX .......................... 69 CLINISOL SF 15 % .............. 61 cromolyn .................. 90, 95, 125 clindamycin hcl ...................... 12 clobetasol ......................... 85, 86 cryselle (28) ........................... 77 clindamycin in 5 % dextrose .. 12 clobetasol-emollient ............... 86 CUBICIN ............................... 13 clindamycin palmitate hcl ...... 12 clocortolone pivalate .............. 86 CUPRIMINE.......................... 98 clindamycin pediatric ............. 12 clomipramine ......................... 33 cyclafem 1/35 (28) ................. 77 clindamycin phosphate .... 12, 42, clonazepam ...................... 10, 11 cyclafem 7/7/7 (28) ................ 77 84 clonidine ................................ 62 cyclobenzaprine ................... 125 clindamycin-benzoyl peroxide clonidine hcl .................... 62, 74 cyclopentolate ........................ 90 ............................................ 84 clopidogrel ....................... 58, 59 cyclophosphamide.................. 21 CLINIMIX 5%/D15W clorazepate dipotassium ......... 11 CYCLOPHOSPHAMIDE...... 21 SULFITE FREE ................. 60 clorpres .................................. 62 CYCLOSET ........................... 36 CLINIMIX 5%/D25W clotrimazole ........................... 40 cyclosporine ......................... 105 SULFITE-FREE ................. 60 clotrimazole-betamethasone .. 40 cyclosporine modified .......... 105 CLINIMIX 2.75%/D5W clozapine ................................ 48 cyproheptadine ....................... 42 SULFIT FREE.................... 60 COARTEM ............................ 45 CYRAMZA............................ 21 CLINIMIX 4.25%/D10W SULF codeine sulfate ......................... 3 cyred ....................................... 77 FREE .................................. 60 COGENTIN ........................... 47 CYSTADANE ..................... 115 CLINIMIX 4.25%/D5W COLCRYS ............................. 42 CYSTARAN .......................... 90 SULFIT FREE.................... 60 colestipol ................................ 71 D CLINIMIX 4.25%-D20W colistin (colistimethate na)..... 13 d10 %-0.45 % sodium chloride SULF-FREE ....................... 60 colocort ................................ 113 .......................................... 118 CLINIMIX 4.25%-D25W COLY-MYCIN S .................. 91 d2.5 %-0.45 % sodium chloride SULF-FREE ....................... 60 COMBIGAN ....................... 117 .......................................... 118 CLINIMIX 5%- COMBIPATCH ..................... 99 d5 % and 0.9 % sodium chloride D20W(SULFITE-FREE) ... 60 COMBIVENT RESPIMAT . 123 .......................................... 118 CLINIMIX E 2.75%/D10W COMETRIQ .......................... 21 d5 %-0.45 % sodium chloride SUL FREE.......................... 60 COMPLERA ......................... 51 .......................................... 118 CLINIMIX E 2.75%/D5W compro ................................... 44 DAKLINZA ........................... 54 SULF FREE ....................... 60 COMVAX (PF) ................... 109 DALIRESP .......................... 125 CLINIMIX E 4.25%/D10W CONDYLOX ......................... 83 danazol ................................... 99 SUL FREE.......................... 60 constulose .............................. 95 dantrolene ............................. 125 CLINIMIX E 4.25%/D25W COPAXONE ......................... 74 dapsone .................................. 43 SUL FREE.......................... 60 CORLANOR ......................... 67 DAPTACEL (DTAP cormax ................................... 86 PEDIATRIC) (PF) ........... 109 I-4

daptomycin ............................. 13 dextrose 40 % in water (d40w) divalproex ........................ 29, 30 DARAPRIM ........................... 45 ........................................... 61 dobutamine ............................. 68 DARZALEX .......................... 21 dextrose 5 % in ringers .......... 61 dobutamine in d5w ................. 68 dasetta 1/35 (28) ..................... 77 dextrose 5 % in water (d5w) .. 61 docetaxel .......................... 21, 22 dasetta 7/7/7 (28) .................... 77 dextrose 5 %-lactated ringers dofetilide ................................ 64 daysee ..................................... 77 ......................................... 118 donepezil ................................ 32 deblitane ................................. 77 dextrose 5%-0.2 % sod chloride dopamine ................................ 68 decitabine ............................... 21 ......................................... 118 dopamine in 5 % dextrose ...... 68 deferoxamine .......................... 98 dextrose 5%-0.3 % sod.chloride dorzolamide.......................... 117 delyla (28) .............................. 77 ......................................... 118 dorzolamide-timolol ............. 117 DELZICOL .......................... 113 dextrose 50 % in water (d50w) doxazosin ............................... 62 demeclocycline ....................... 19 ........................................... 61 doxepin ................................... 34 DEMSER ................................ 67 dextrose 70 % in water (d70w) doxercalciferol ..................... 113 DENAVIR .............................. 83 ........................................... 61 doxorubicin ............................ 22 DEPEN TITRATABS ............ 98 dextrose with sodium chloride doxorubicin, peg-liposomal ... 22 DEPO-PROVERA ............... 104 ......................................... 118 doxy-100 ................................ 19 DESCOVY ............................. 51 dextrose-kcl-nacl ................. 118 doxycycline hyclate ............... 19 desipramine ............................ 33 diazepam ................................ 11 doxycycline monohydrate ...... 19 desmopressin ........................ 102 diazepam intensol .................. 11 dronabinol .............................. 44 desog-e.estradiol/e.estradiol ... 77 diclofenac potassium ............... 7 droperidol ............................. 115 desogestrel-ethinyl estradiol ... 77 diclofenac sodium ........ 7, 83, 93 drospirenone-ethinyl estradiol 77 desonide .................................. 86 diclofenac-misoprostol ............ 8 DROXIA ................................ 22 desoximetasone ...................... 86 dicloxacillin ........................... 17 DUAVEE ............................... 99 desvenlafaxine succinate ........ 34 dicyclomine ........................... 95 DULERA ............................. 122 dexamethasone ..................... 101 didanosine .............................. 52 duloxetine ............................... 34 dexamethasone sodium DIFICID................................. 16 DUREZOL ............................. 93 phosphate .................... 93, 101 diflorasone ............................. 86 dutasteride .............................. 98 DEXILANT ............................ 94 diflunisal .................................. 8 dutasteride-tamsulosin ........... 98 dexmethylphenidate ............... 74 digitek .................................... 67 DYRENIUM .......................... 70 dexrazoxane hcl .................... 115 digoxin ............................. 67, 68 E dextroamphetamine ................ 74 DIGOXIN .............................. 68 e.e.s. 400 ................................ 16 dextroamphetamine- dihydroergotamine ................. 43 e.e.s. granules ......................... 16 amphetamine ...................... 74 DILANTIN ............................ 29 econazole................................ 40 dextrose 10 % and 0.2 % nacl diltiazem hcl .................... 66, 67 EDARBI ................................. 63 .......................................... 118 dilt-xr ..................................... 67 EDARBYCLOR .................... 63 dextrose 10 % in water (d10w) dimenhydrinate ...................... 44 EDURANT ............................ 52 ............................................ 61 DIPENTUM......................... 113 effer-k ................................... 118 dextrose 20 % in water (d20w) diphenhydramine hcl ............. 42 EFFIENT................................ 59 ............................................ 61 diphenoxylate-atropine .......... 95 ELAPRASE ........................... 88 dextrose 25 % in water (d25w) dipyridamole .......................... 59 electrolyte-48 in d5w ........... 118 ............................................ 61 disopyramide phosphate ........ 64 ELIDEL.................................. 86 disulfiram ............................... 10 ELIGARD .............................. 22 I-5

ELIGARD (3 MONTH) ......... 22 EPIPEN JR 2-PAK ................ 68 EUCRISA .............................. 86 ELIGARD (4 MONTH) ......... 22 epitol ...................................... 30 EVOTAZ................................ 52 ELIGARD (6 MONTH) ......... 22 EPIVIR HBV ......................... 52 EXELDERM .................... 40, 41 elinest ..................................... 77 eplerenone .............................. 72 exemestane ............................. 22 eliphos .................................... 97 EPOGEN ............................... 57 EXJADE ................................ 98 ELIQUIS ................................ 56 epoprostenol (glycine) ......... 126 EXONDYS 51 ..................... 115 ELITEK .................................. 89 eprosartan ............................... 63 EXTAVIA .............................. 74 elixophyllin........................... 123 EPZICOM .............................. 52 F ELLA ...................................... 77 ergoloid ................................ 115 FABRAZYME ....................... 89 ELMIRON ............................ 115 ERGOMAR ........................... 43 falmina (28) ............................ 78 EMBEDA ................................. 4 ERIVEDGE ........................... 22 famciclovir ............................. 56 EMCYT .................................. 22 errin ........................................ 78 famotidine .............................. 94 EMEND .................................. 44 ery pads .................................. 84 famotidine (pf) ....................... 94 EMFLAZA ........................... 101 ery-tab .................................... 16 famotidine (pf)-nacl (iso-os) . 94 emoquette ............................... 78 ERY-TAB .............................. 16 FANAPT ................................ 48 EMPLICITI ............................ 22 ERYTHROCIN ..................... 16 FARESTON ........................... 22 EMSAM ................................. 34 erythrocin (as stearate) ........... 16 FARYDAK ............................ 22 EMTRIVA .............................. 52 erythromycin .................... 16, 91 FASLODEX ........................... 22 enalapril maleate .................... 64 erythromycin ethylsuccinate .. 16 felbamate ................................ 30 enalaprilat ............................... 64 erythromycin with ethanol ..... 84 felodipine ............................... 69 enalapril-hydrochlorothiazide 64 erythromycin-benzoyl peroxide FEMRING............................ 100 ENBREL .............................. 105 ........................................... 84 femynor .................................. 78 ENBREL SURECLICK ....... 106 ESBRIET ............................. 125 fenofibrate .............................. 71 endocet ..................................... 4 escitalopram oxalate .............. 34 fenofibrate micronized ........... 71 endodan .................................... 4 esmolol................................... 65 fenofibrate nanocrystallized ... 71 ENGERIX-B (PF) ................ 109 esomeprazole sodium ............ 94 fenofibric acid ........................ 71 ENGERIX-B PEDIATRIC (PF) estarylla .................................. 78 fenofibric acid (choline) ......... 71 .......................................... 109 estazolam ............................... 11 fenoprofen ................................ 8 enoxaparin .............................. 56 ESTRACE ........................... 100 fentanyl .................................... 4 enpresse .................................. 78 estradiol ............................... 100 fentanyl citrate ......................... 4 enskyce ................................... 78 estradiol valerate .................. 100 FERRIPROX.......................... 99 entacapone .............................. 47 estradiol-norethindrone acet 100 FETZIMA .............................. 34 entecavir ................................. 55 ESTRING ............................ 100 finasteride ............................... 98 ENTRESTO ........................... 63 estropipate ............................ 100 FIRAZYR .............................. 68 enulose .................................... 95 eszopiclone .......................... 126 flavoxate ................................. 98 ENVARSUS XR .................. 106 ethambutol ............................. 43 FLEBOGAMMA DIF .......... 106 EPCLUSA .............................. 54 ethosuximide .......................... 30 flecainide ................................ 65 epinastine ................................ 90 ethynodiol diac-eth estradiol . 78 FLECTOR ................................ 8 epinephrine ............................. 68 etidronate disodium ............. 113 FLOVENT DISKUS ............ 122 epinephrine hcl (pf) ................ 68 etodolac .................................... 8 FLOVENT HFA .................. 122 EPIPEN .................................. 68 ETOPOPHOS ........................ 22 floxuridine .............................. 22 EPIPEN 2-PAK ...................... 68 etoposide ................................ 22 flucaine ................................... 90 I-6

fluconazole ............................. 41 GABITRIL............................. 30 GILOTRIF ............................. 23 fluconazole in nacl (iso-osm) . 41 galantamine ............................ 32 GLEOSTINE.......................... 23 flucytosine .............................. 41 GAMASTAN S/D ............... 106 glimepiride ............................. 39 fludrocortisone ..................... 101 GAMMAGARD LIQUID ... 106 glipizide............................ 39, 40 flumazenil ............................... 74 GAMMAGARD S-D (IGA < 1 glipizide-metformin ............... 40 flunisolide ............................... 93 MCG/ML) ........................ 106 GLUCAGEN HYPOKIT ..... 115 fluocinolone acetonide oil ...... 93 GAMMAPLEX (WITH GLUCAGON EMERGENCY fluocinonide ............................ 86 SORBITOL) .................... 106 KIT (HUMAN) ................ 115 fluocinonide-e......................... 86 GAMUNEX-C ..................... 106 glyburide ................................ 40 fluorometholone ..................... 93 ganciclovir sodium ................ 56 glyburide micronized ............. 40 fluorouracil ....................... 22, 83 GARDASIL (PF) ......... 109, 110 glyburide-metformin .............. 40 fluoxetine ................................ 34 GARDASIL 9 (PF) .............. 110 glycopyrrolate ........................ 95 FLUOXETINE ....................... 34 gatifloxacin ............................ 91 glydo ........................................ 9 fluphenazine decanoate .......... 48 GATTEX 30-VIAL ............... 95 GLYXAMBI .......................... 36 fluphenazine hcl ..................... 48 GATTEX ONE-VIAL ........... 95 GRALISE ............................... 30 flurazepam .............................. 11 GAUZE PAD ......................... 88 GRALISE 30-DAY STARTER flurbiprofen............................... 8 gavilyte-c ............................... 96 PACK ................................. 30 flurbiprofen sodium ................ 93 gavilyte-g ............................... 96 granisetron (pf)....................... 44 flutamide................................. 22 gavilyte-n ............................... 97 granisetron hcl ........................ 44 fluticasone ........................ 86, 93 GAZYVA .............................. 22 GRANIX ................................ 57 fluvastatin ............................... 71 gemcitabine ............................ 23 griseofulvin microsize ............ 41 fluvoxamine ............................ 34 gemfibrozil............................. 71 griseofulvin ultramicrosize .... 41 fomepizole ............................ 115 generlac .................................. 95 guanfacine ........................ 62, 74 fondaparinux..................... 56, 57 gengraf ................................. 106 guanidine .............................. 115 FORADIL AEROLIZER ..... 123 GENOTROPIN .................... 102 H FORTEO .............................. 114 GENOTROPIN MINIQUICK halobetasol propionate ........... 86 FORTICAL .......................... 114 ......................................... 102 haloperidol ............................. 49 foscarnet ................................. 54 gentak..................................... 91 haloperidol decanoate ............ 48 fosinopril ................................ 64 gentamicin ................. 12, 84, 91 haloperidol lactate .................. 48 fosinopril-hydrochlorothiazide gentamicin in nacl (iso-osm) . 12 HARVONI ............................. 54 ............................................ 64 gentamicin sulfate (ped) (pf) . 12 HAVRIX (PF) ...................... 110 fosphenytoin ........................... 30 gentamicin sulfate (pf) ........... 12 heather .................................... 78 FOSRENOL ........................... 97 GENVOYA ........................... 52 heparin (porcine) .................... 57 FREAMINE HBC 6.9 % ........ 61 GEODON .............................. 48 heparin (porcine) in 5 % dex .. 57 FREAMINE III 10 % ............. 61 gianvi (28).............................. 78 heparin(porcine) in 0.45% nacl furosemide .............................. 70 gildagia .................................. 78 ............................................ 57 FUSILEV ............................. 115 gildess 1.5/30 (21) ................. 78 heparin, porcine (pf)............... 57 FUZEON ................................ 52 gildess 1/20 (21) .................... 78 HEPATAMINE 8% ............... 61 fyavolv .................................. 100 gildess 24 fe ........................... 78 HERCEPTIN.......................... 23 FYCOMPA ............................ 30 gildess fe 1.5/30 (28) ............. 78 HETLIOZ ............................. 126 G gildess fe 1/20 (28) ................ 78 HEXALEN ............................. 23 gabapentin .............................. 30 GILENYA ............................. 74 HIBERIX (PF) ..................... 110 I-7

homatropaire........................... 90 hydroxyprogesterone caproate INTRON A............................. 55 homatropine hbr ..................... 90 ......................................... 104 introvale ................................. 78 HUMALOG ........................... 38 hydroxyurea ........................... 23 INVANZ ................................ 16 HUMALOG KWIKPEN ........ 38 hydroxyzine hcl ..................... 42 INVEGA SUSTENNA .......... 49 HUMALOG MIX 50-50 ........ 38 hydroxyzine pamoate ........... 115 INVEGA TRINZA................. 49 HUMALOG MIX 50-50 HYPERRAB S/D (PF)......... 107 INVIRASE ............................. 52 KWIKPEN ......................... 38 HYQVIA ............................. 107 INVOKAMET ....................... 36 HUMALOG MIX 75-25 ........ 38 HYQVIA IG COMPONENT INVOKAMET XR ................. 36 HUMALOG MIX 75-25 ......................................... 107 INVOKANA .......................... 36 KWIKPEN ......................... 38 HYSINGLA ER ....................... 5 IONOSOL-B IN D5W ......... 118 HUMATROPE ..................... 102 I IONOSOL-MB IN D5W...... 119 HUMIRA .............................. 106 ibandronate .......................... 114 IPOL ..................................... 110 HUMIRA PEDIATRIC IBRANCE .............................. 23 ipratropium bromide ...... 90, 123 CROHN'S START ........... 106 ibuprofen .................................. 8 IPRIVASK ............................. 57 HUMIRA PEN ..................... 106 ICLUSIG ............................... 23 irbesartan ................................ 63 HUMIRA PEN CROHN'S-UC- ifosfamide .............................. 23 irbesartan-hydrochlorothiazide HS START ....................... 106 ifosfamide-mesna ................... 23 ............................................ 63 HUMIRA PEN PSORIASIS- ILARIS (PF) ........................ 107 IRESSA .................................. 23 UVEITIS .......................... 106 ILEVRO................................. 93 irinotecan.......................... 23, 24 HUMULIN 70/30 ................... 38 imatinib .................................. 23 ISENTRESS ........................... 52 HUMULIN 70/30 KWIKPEN 38 IMBRUVICA ........................ 23 ISOLYTE-P IN 5 % HUMULIN N ......................... 38 imipenem-cilastatin ............... 16 DEXTROSE ..................... 119 HUMULIN N KWIKPEN ...... 38 imipramine hcl ....................... 34 ISOLYTE-S ......................... 119 HUMULIN R U-100 .............. 39 imipramine pamoate .............. 34 isoniazid ................................. 43 HUMULIN R U-500 (CONC) imiquimod .............................. 83 isosorbide dinitrate ................. 73 KWIKPEN ......................... 39 IMLYGIC .............................. 23 isosorbide mononitrate ........... 73 HUMULIN R U-500 IMOGAM RABIES-HT (PF) isradipine ................................ 69 (CONCENTRATED) ......... 39 ......................................... 107 itraconazole ............................ 41 hydralazine ............................. 68 IMOVAX RABIES VACCINE ivermectin .............................. 45 hydrochlorothiazide ................ 70 (PF) .................................. 110 IXEMPRA.............................. 24 hydrocodone-acetaminophen ... 4 INCRELEX ......................... 102 IXIARO (PF) ....................... 110 hydrocodone-ibuprofen ............ 4 INCRUSE ELLIPTA ........... 123 J hydrocortisone ........ 86, 101, 113 indapamide............................. 70 JAKAFI .................................. 24 hydrocortisone butyrate .......... 86 indomethacin ........................... 8 jantoven .................................. 57 hydrocortisone butyr-emollient indomethacin sodium ............... 8 JANUMET ............................. 36 ............................................ 86 INFANRIX (DTAP) (PF) .... 110 JANUMET XR ...................... 36 hydrocortisone valerate .... 86, 87 INFLECTRA ....................... 115 JANUVIA .............................. 36 hydrocortisone-acetic acid...... 91 INLYTA ................................ 23 JARDIANCE ......................... 36 hydromorphone ........................ 5 INSULIN SYRINGE-NEEDLE jencycla .................................. 78 hydromorphone (pf) ................. 5 U-100 ................................. 88 JENTADUETO ...................... 37 hydroxychloroquine ............... 45 INTELENCE ......................... 52 JENTADUETO XR ............... 37 INTRALIPID ......................... 61 jinteli .................................... 100 I-8

jolessa ..................................... 78 labetalol ........................... 65, 66 levonest (28)........................... 79 jolivette ................................... 78 LACRISERT ......................... 90 levonorgestrel-ethinyl estrad .. 79 juleber ..................................... 78 LACTATED RINGERS ...... 113 levonorg-eth estrad triphasic .. 79 junel 1.5/30 (21) ..................... 78 lactulose ................................. 95 levora-28 ................................ 79 junel 1/20 (21) ........................ 78 lamivudine ............................. 52 levothyroxine ....................... 104 junel fe 1.5/30 (28) ................. 78 lamivudine-zidovudine .......... 52 LEXIVA ................................. 52 junel fe 1/20 (28) .................... 78 lamotrigine ............................. 30 LIALDA ............................... 113 junel fe 24 ............................... 78 LANOXIN ............................. 68 lidocaine ................................... 9 JUXTAPID ............................. 71 lansoprazole ........................... 94 lidocaine (pf) ...................... 9, 65 K LANTUS ............................... 39 lidocaine hcl ............................. 9 KABIVEN .............................. 61 LANTUS SOLOSTAR .......... 39 lidocaine in 5 % dextrose (pf) 65 KALETRA ............................. 52 larin 1.5/30 (21) ..................... 79 lidocaine viscous ...................... 9 KALYDECO ........................ 125 larin 1/20 (21) ........................ 79 lidocaine-prilocaine.................. 9 KANUMA .............................. 89 larin 24 fe ............................... 79 linezolid.................................. 13 kariva (28) .............................. 78 larin fe 1.5/30 (28) ................. 79 LINZESS................................ 95 KAZANO ............................... 37 larin fe 1/20 (28) .................... 79 liothyronine .................. 104, 105 kelnor 1/35 (28) ...................... 78 larissia .................................... 79 lisinopril ................................. 64 ketoconazole ........................... 41 LARTRUVO ......................... 24 lisinopril-hydrochlorothiazide 64 ketoprofen................................. 8 latanoprost ........................... 117 lithium carbonate ................... 75 ketorolac ............................. 8, 93 LATUDA ............................... 49 lithium citrate ......................... 75 KEVEYIS ............................. 116 LAZANDA .............................. 5 LIVALO ................................. 71 KEYTRUDA .......................... 24 leena 28 .................................. 79 lomedia 24 fe.......................... 79 kimidess (28) .......................... 79 leflunomide .......................... 107 LONSURF ............................. 24 KINERET ............................. 107 LEMTRADA ......................... 75 loperamide.............................. 96 KINRIX (PF) ........................ 110 LENVIMA ............................. 24 lopinavir-ritonavir .................. 52 kionex ..................................... 95 lessina .................................... 79 lorazepam ............................... 11 kionex (with sorbitol) ............. 95 LETAIRIS ........................... 126 lorazepam intensol ................. 11 KISQALI ................................ 24 letrozole ................................. 24 lorcet (hydrocodone) ................ 5 KLOR-CON 10 .................... 119 leucovorin calcium .............. 116 lorcet hd ................................... 5 klor-con m10 ........................ 119 LEUKERAN .......................... 24 lorcet plus ................................. 5 klor-con m15 ........................ 119 LEUKINE .............................. 58 loryna (28) .............................. 79 klor-con m20 ........................ 119 leuprolide ............................... 24 losartan ................................... 63 klor-con sprinkle .................. 119 levetiracetam .......................... 31 losartan-hydrochlorothiazide . 63 KOMBIGLYZE XR ............... 37 levetiracetam in nacl (iso-os) . 31 LOTEMAX ............................ 93 KORLYM............................... 37 levobunolol .......................... 117 lovastatin ................................ 71 KRYSTEXXA ........................ 89 levocarnitine ........................ 116 low-ogestrel (28) .................... 79 kurvelo .................................... 79 levocarnitine (with sugar) .... 116 loxapine succinate .................. 49 KUVAN ................................. 89 levocetirizine ......................... 42 LUMIGAN ........................... 117 KYNAMRO ........................... 71 levofloxacin ............... 18, 19, 91 LUPRON DEPOT .................. 25 KYPROLIS ............................ 24 levofloxacin in d5w ............... 18 LUPRON DEPOT (3 MONTH) L levoleucovorin ..................... 116 ............................................ 24 l norgest/e.estradiol-e.estrad ... 79 LEVOLEUCOVORIN......... 116 I-9

LUPRON DEPOT (4 MONTH) MENOMUNE - A/C/Y/W-135 miconazole-3 .......................... 41 ............................................ 24 (PF) .................................. 110 microgestin 1.5/30 (21) .......... 79 LUPRON DEPOT (6 MONTH) MENVEO A-C-Y-W-135-DIP microgestin 1/20 (21) ............. 80 ............................................ 24 (PF) .................................. 111 microgestin fe 1.5/30 (28) ...... 80 LUPRON DEPOT-PED ....... 102 mercaptopurine ...................... 25 microgestin fe 1/20 (28) ......... 80 LUPRON DEPOT-PED (3 meropenem ............................ 16 midazolam .............................. 11 MONTH) .......................... 102 mesalamine .......................... 113 midodrine ............................... 62 lutera (28) ............................... 79 mesna ................................... 116 miglitol ................................... 37 LYNPARZA........................... 25 MESNEX ............................. 116 milrinone ................................ 69 LYRICA ................................. 31 MESTINON......................... 116 milrinone in 5 % dextrose ...... 69 LYSODREN........................... 25 metaproterenol ..................... 123 mimvey ................................ 100 lyza ......................................... 79 metaxall ............................... 125 mimvey lo ............................ 100 M metaxalone ........................... 125 minitran .................................. 73 magnebind 400 ....................... 97 metformin .............................. 37 MINOCIN .............................. 20 magnesium sulfate ................ 119 methadone ................................ 5 minocycline ............................ 20 magnesium sulfate in d5w .... 119 methadose ................................ 5 minoxidil ................................ 73 magnesium sulfate in water .. 119 methazolamide ..................... 117 MIRCERA ............................. 58 malathion ................................ 88 methenamine hippurate .......... 13 mirtazapine ............................. 35 maprotiline ............................. 34 methimazole ......................... 105 misoprostol ............................. 94 margesic ................................... 5 methocarbamol .................... 125 mitoxantrone .......................... 25 marlissa................................... 79 methotrexate sodium.............. 25 M-M-R II (PF) ..................... 111 MARPLAN ............................ 35 methotrexate sodium (pf) ....... 25 moexipril ................................ 64 MARQIBO ............................. 25 methoxsalen ........................... 83 moexipril-hydrochlorothiazide MATULANE ......................... 25 methscopolamine ................... 96 ............................................ 64 matzim la ................................ 67 methyclothiazide .................... 70 molindone .............................. 49 meclizine ................................ 44 methylergonovine ................ 116 mometasone ........................... 87 medroxyprogesterone ........... 104 methylphenidate..................... 75 mono-linyah ........................... 80 mefenamic acid ........................ 8 methylprednisolone ............. 101 mononessa (28) ...................... 80 mefloquine .............................. 46 methylprednisolone acetate . 101 montelukast .......................... 123 MEFOXIN IN DEXTROSE methylprednisolone sodium succ morphine .............................. 5, 6 (ISO-OSM) ......................... 15 ......................................... 101 MORPHINE ............................. 6 megestrol ........................ 25, 104 metipranolol ......................... 117 morphine concentrate ............... 5 MEKINIST ............................. 25 metoclopramide hcl ............... 96 MOVANTIK .......................... 96 meloxicam ................................ 8 metolazone ............................. 70 MOVIPREP ........................... 97 melphalan hcl ......................... 25 metoprolol succinate .............. 66 MOXEZA .............................. 91 memantine .............................. 33 metoprolol ta-hydrochlorothiaz moxifloxacin .......................... 19 MENACTRA (PF) ............... 110 ........................................... 66 MOZOBIL ............................. 58 MENEST .............................. 100 metoprolol tartrate ................. 66 MULTAQ .............................. 65 MENHIBRIX (PF) ............... 110 metronidazole ............ 13, 42, 84 multi-vitamin with fluoride .. 127 MENOMUNE - A/C/Y/W-135 metronidazole in nacl (iso-os) 13 mupirocin ............................... 84 .......................................... 110 mexiletine .............................. 65 mupirocin calcium ................. 84 MIACALCIN....................... 114 mycophenolate mofetil......... 107 I-10

mycophenolate mofetil hcl ... 107 NEPHRAMINE 5.4 % ........... 61 NORMOSOL-R PH 7.4 ....... 119 mycophenolate sodium ......... 107 NESINA................................. 37 NORTHERA .......................... 62 MYOBLOC .......................... 116 neuac ...................................... 84 nortrel 0.5/35 (28) .................. 80 MYOZYME ........................... 89 NEULASTA .......................... 58 nortrel 1/35 (21) ..................... 80 MYRBETRIQ ........................ 98 NEUPOGEN .......................... 58 nortrel 1/35 (28) ..................... 80 myzilra .................................... 80 NEUPRO ............................... 47 nortrel 7/7/7 (28) .................... 80 N NEVANAC ............................ 93 nortriptyline............................ 35 nabumetone .............................. 8 nevirapine ........................ 52, 53 NORVIR ................................ 53 nadolol .................................... 66 NEXAVAR ............................ 25 NOVOLIN 70/30 ................... 39 nafcillin................................... 17 niacin ..................................... 71 NOVOLIN N ......................... 39 NAGLAZYME....................... 89 niacor ..................................... 71 NOVOLIN R .......................... 39 naloxone ................................. 10 nicardipine ............................. 69 NOVOLOG ............................ 39 naltrexone ............................... 10 NICOTROL ........................... 10 NOVOLOG FLEXPEN ......... 39 NAMENDA XR ..................... 33 nifedical xl ............................. 69 NOVOLOG MIX 70-30 ......... 39 NAMZARIC........................... 33 nifedipine ............................... 69 NOVOLOG MIX 70-30 naphazoline............................. 90 nikki (28) ............................... 80 FLEXPEN .......................... 39 naproxen ............................... 8, 9 NILANDRON ....................... 25 NOVOLOG PENFILL ........... 39 naproxen sodium ...................... 9 nilutamide .............................. 25 NOXAFIL .............................. 41 naratriptan............................... 43 NINLARO ............................. 25 NPLATE .............................. 116 NARCAN ............................... 10 NITRO-BID ........................... 73 NUCALA ............................. 125 NATACYN ............................ 91 nitrofurantoin ......................... 13 NUCYNTA .............................. 6 nateglinide .............................. 37 nitrofurantoin macrocrystal ... 13 NUCYNTA ER ........................ 6 NATPARA ........................... 114 nitrofurantoin monohyd/m-cryst NUEDEXTA .......................... 75 NEBUPENT ........................... 46 ........................................... 13 NULOJIX ............................. 107 necon 0.5/35 (28).................... 80 nitroglycerin........................... 73 NUPLAZID............................ 49 necon 1/35 (28)....................... 80 nitroglycerin in 5 % dextrose. 73 NUTRESTORE...................... 96 necon 1/50 (28)....................... 80 NITROSTAT ......................... 73 NUTRILIPID ......................... 61 necon 10/11 (28)..................... 80 nizatidine ............................... 94 NUTROPIN AQ................... 103 necon 7/7/7 (28) ..................... 80 nora-be ................................... 80 NUTROPIN AQ NUSPIN ... 103 nefazodone ............................. 35 NORDITROPIN FLEXPRO 103 NUVARING .......................... 81 neomycin ................................ 12 norepinephrine bitartrate ........ 69 nyamyc ................................... 41 neomycin-bacitracin-poly-hc . 91 noreth-ethinyl estradiol-iron .. 80 nyata ....................................... 41 neomycin-bacitracin-polymyxin norethindrone (contraceptive) 80 nystatin ................................... 41 ............................................ 91 norethindrone acetate ........... 104 nystatin-triamcinolone ........... 41 neomycin-polymyxin b gu ..... 84 norethindrone ac-eth estradiol nystop ..................................... 41 neomycin-polymyxin b- ................................... 80, 100 O dexameth ...................... 91, 92 norethindrone-e.estradiol-iron 80 OCALIVA.............................. 96 neomycin-polymyxin- norgestimate-ethinyl estradiol 80 ocella ...................................... 81 gramicidin........................... 92 norlyroc .................................. 80 OCTAGAM ......................... 107 neomycin-polymyxin-hc ........ 92 NORMOSOL-M IN 5 % octreotide acetate ................. 103 neo-polycin ............................. 92 DEXTROSE .................... 119 ODEFSEY.............................. 53 neo-polycin hc ........................ 92 NORMOSOL-R ................... 119 ODOMZO .............................. 25 I-11

OFEV ................................... 125 oxandrolone ........................... 99 permethrin .............................. 88 ofloxacin ........................... 19, 92 oxcarbazepine ........................ 31 perphenazine .......................... 50 ogestrel (28)............................ 81 OXTELLAR XR.................... 31 perphenazine-amitriptyline .... 35 olanzapine............................... 49 oxybutynin chloride ............... 98 PERTZYE .............................. 89 olanzapine-fluoxetine ............. 35 oxycodone ................................ 6 pfizerpen-g ............................. 18 olmesartan .............................. 63 oxycodone-acetaminophen ...... 6 phenadoz ................................ 45 olmesartan-amlodipin-hcthiazid oxycodone-aspirin ................... 6 phenelzine .............................. 35 ............................................ 63 OXYCONTIN ..................... 6, 7 phenobarbital.......................... 31 olmesartan-hydrochlorothiazide oxymorphone ........................... 7 phenylephrine hcl ............. 62, 90 ............................................ 63 P phenytoin................................ 31 olopatadine ............................. 90 pacerone ................................. 65 phenytoin sodium ................... 31 OLYSIO ................................. 54 paclitaxel ................................ 26 phenytoin sodium extended ... 31 omega-3 acid ethyl esters ....... 71 paliperidone ..................... 49, 50 philith ..................................... 81 omeprazole ............................. 94 pamidronate ......................... 114 PHOSLYRA .......................... 97 OMNITROPE....................... 103 PANRETIN ........................... 83 PHOSPHOLINE IODIDE ... 117 ONCASPAR .......................... 25 pantoprazole ........................... 95 PICATO ................................. 83 ondansetron ............................ 45 paricalcitol ........................... 114 pilocarpine hcl ................ 82, 118 ondansetron hcl ...................... 45 paromomycin ......................... 46 pimozide ................................. 50 ondansetron hcl (pf) ......... 44, 45 paroxetine hcl ........................ 35 pimtrea (28) ............................ 81 ONFI....................................... 11 PASER ................................... 43 pindolol .................................. 66 ONGLYZA............................. 37 PATADAY ............................ 90 pioglitazone ............................ 37 ONIVYDE .............................. 25 PAXIL ................................... 35 pioglitazone-glimepiride ........ 37 OPDIVO ................................. 25 PEDIARIX (PF) .................. 111 pioglitazone-metformin.......... 37 OPSUMIT ............................ 126 PEDVAX HIB (PF) ............. 111 piperacillin-tazobactam .......... 18 oralone .................................... 82 peg 3350-electrolytes ............. 97 pirmella .................................. 81 ORENCIA ............................ 107 PEGANONE .......................... 31 piroxicam ................................. 9 ORENCIA (WITH MALTOSE) PEGASYS ............................. 55 PLASMA-LYTE 148 ........... 119 .......................................... 107 PEGASYS PROCLICK ......... 55 PLASMA-LYTE A .............. 119 ORENCIA CLICKJECT ...... 116 peg-electrolyte soln ................ 97 PLASMA-LYTE-56 IN 5 % ORENITRAM ...................... 126 PEGINTRON......................... 55 DEXTROSE ..................... 120 ORFADIN .............................. 89 PEN NEEDLE, DIABETIC .. 88 PLEGRIDY ............................ 75 ORKAMBI ........................... 125 penicillin g pot in dextrose .... 18 podofilox ................................ 83 orsythia ................................... 81 penicillin g potassium ............ 18 polyethylene glycol 3350 ....... 97 oseltamivir .............................. 54 penicillin g procaine .............. 18 polymyxin b sulfate................ 13 OSENI .................................... 37 penicillin v potassium ............ 18 polymyxin b sulf-trimethoprim OTEZLA .............................. 107 PENTACEL (PF) ................. 111 ............................................ 92 OTEZLA STARTER............ 108 PENTAM ............................... 46 POMALYST .......................... 26 OTOVEL ................................ 90 pentoxifylline ......................... 59 portia ...................................... 81 OTREXUP (PF) ................... 108 PERIKABIVEN..................... 61 PORTRAZZA ........................ 26 oxacillin ............................ 17, 18 perindopril erbumine ............. 64 potassium acetate ................. 120 oxacillin in dextrose(iso-osm) 18 periogard ................................ 82 potassium chlorid-d5-0.45%nacl oxaliplatin ............................... 25 PERJETA............................... 26 .......................................... 120 I-12

potassium chloride........ 120, 121 PRIFTIN ................................ 44 PULMOZYME ...................... 89 potassium chloride in 0.9%nacl PRIMAQUINE ...................... 46 PURIXAN .............................. 26 .......................................... 120 primidone ............................... 32 pyrazinamide .......................... 44 potassium chloride in 5 % dex PRISTIQ ................................ 35 pyridostigmine bromide ....... 116 .......................................... 120 PRIVIGEN........................... 108 Q potassium chloride in lr-d5 ... 120 PROAIR HFA...................... 124 QBRELIS ............................... 64 potassium chloride-0.45 % nacl PROAIR RESPICLICK ....... 124 QUADRACEL (PF) ............. 111 .......................................... 120 probenecid ............................. 42 quasense ................................. 81 potassium chloride-d5-0.2%nacl probenecid-colchicine ............ 42 quetiapine ............................... 50 .......................................... 120 procainamide ......................... 65 quinapril ................................. 64 potassium chloride-d5-0.3%nacl PROCALAMINE 3% ............ 62 quinapril-hydrochlorothiazide 64 .......................................... 120 prochlorperazine .................... 45 quinidine gluconate ................ 65 potassium chloride-d5-0.9%nacl prochlorperazine edisylate ..... 45 quinidine sulfate ..................... 65 .......................................... 120 prochlorperazine maleate ....... 45 quinine sulfate ........................ 46 potassium citrate ................... 121 PROCRIT .............................. 58 QVAR .................................. 122 potassium citrate-citric acid . 121 procto-med hc ........................ 87 R potassium hydroxide .............. 83 procto-pak .............................. 87 RABAVERT (PF) ................ 111 POTIGA ................................. 31 proctosol hc............................ 87 raloxifene ............................. 100 PRADAXA............................. 57 proctozone-hc ........................ 87 ramipril ................................... 64 PRALUENT PEN .................. 72 PROCYSBI .......................... 116 RANEXA ............................... 69 PRALUENT SYRINGE ......... 72 progesterone in oil ............... 104 ranitidine hcl .......................... 95 pramipexole ............................ 47 progesterone micronized ...... 104 RAPAMUNE ....................... 108 pravastatin .............................. 72 PROGLYCEM....................... 73 rasagiline ................................ 47 prazosin .................................. 62 PROGRAF ........................... 108 RASUVO (PF) ..................... 108 prednicarbate .......................... 87 PROLASTIN-C ................... 125 RAVICTI ............................... 96 prednisolone acetate ............... 93 PROLENSA........................... 93 RAYALDEE ........................ 114 prednisolone sodium phosphate PROLEUKIN......................... 26 REBIF (WITH ALBUMIN) .. 75 .................................... 93, 101 PROLIA ............................... 114 REBIF REBIDOSE ................ 76 prednisone .................... 101, 102 PROMACTA ......................... 58 REBIF TITRATION PACK .. 76 PREMARIN ......................... 100 promethazine ................... 42, 45 reclipsen (28) ......................... 81 PREMASOL 10 % ................. 62 promethegan .......................... 45 RECOMBIVAX HB (PF) .... 111 PREMASOL 6 % ................... 62 propafenone ........................... 65 REGRANEX .......................... 83 PREMPHASE ...................... 100 propantheline ......................... 29 RELENZA DISKHALER ...... 54 PREMPRO ........................... 100 proparacaine ........................... 90 RELISTOR ............................ 96 prenatal plus (calcium carb) . 127 propranolol............................. 66 REMICADE ......................... 116 prenatal vitamin plus low iron propranolol-hydrochlorothiazid REMODULIN...................... 126 .......................................... 127 ........................................... 66 RENAGEL ............................. 97 PREPOPIK ............................. 97 propylthiouracil ................... 105 RENVELA ............................. 97 prevalite .................................. 72 PROQUAD (PF) .................. 111 repaglinide.............................. 37 previfem ................................. 81 PROSOL 20 %....................... 62 repaglinide-metformin ........... 37 PREZCOBIX .......................... 53 protamine ............................... 58 REPATHA PUSHTRONEX .. 72 PREZISTA ............................. 53 protriptyline ........................... 35 REPATHA SURECLICK ...... 72 I-13

REPATHA SYRINGE ........... 72 SAPHRIS (BLACK CHERRY) SOMATULINE DEPOT ...... 103 reprexain ................................... 7 ........................................... 50 SOMAVERT........................ 104 RESCRIPTOR ........................ 53 SAVAYSA ............................ 57 sorbitol ................................. 113 RESTASIS ............................. 93 SAVELLA ............................. 76 sorbitol-mannitol .................. 113 RESTASIS MULTIDOSE ..... 93 selegiline hcl .......................... 47 sorine ...................................... 66 RETROVIR ............................ 53 selenium sulfide ..................... 85 sotalol ..................................... 66 REVLIMID ............................ 26 SELZENTRY ........................ 53 sotalol af ................................. 66 revonto .................................. 125 SENSIPAR .......................... 117 SOVALDI .............................. 54 REXULTI ............................... 50 SEREVENT DISKUS ......... 124 spinosad.................................. 88 REYATAZ ............................. 53 SEROQUEL XR .............. 50, 51 SPIRIVA RESPIMAT ......... 124 ribasphere ............................... 56 SEROSTIM ......................... 103 SPIRIVA WITH ribasphere ribapak .................. 56 sertraline ................................ 35 HANDIHALER ............... 124 ribavirin .................................. 56 setlakin ................................... 81 spironolactone ........................ 70 RIDAURA ............................ 108 sharobel .................................. 81 spironolacton-hydrochlorothiaz rifabutin .................................. 44 SIGNIFOR ........................... 117 ............................................ 70 rifampin .................................. 44 sildenafil .............................. 126 SPORANOX .......................... 41 RIFATER ............................... 44 SILENOR ............................ 126 sprintec (28) ........................... 81 riluzole .................................... 76 SILIQ ..................................... 83 SPRITAM .............................. 32 rimantadine ............................. 54 silver nitrate ........................... 85 SPRYCEL .............................. 26 ringers ........................... 113, 121 silver sulfadiazine .................. 85 sps (with sorbitol) .................. 96 risedronate ............................ 114 SIMBRINZA ....................... 118 sronyx ..................................... 81 RISPERDAL CONSTA ......... 50 SIMPONI ............................. 108 ssd .......................................... 85 risperidone .............................. 50 SIMPONI ARIA .................. 108 stavudine ................................ 53 RITUXAN .............................. 26 simvastatin ............................. 72 STELARA............................ 108 rivastigmine ............................ 33 sirolimus .............................. 108 STERILE GAUZE PAD ........ 88 rivastigmine tartrate................ 33 SIRTURO .............................. 44 STIMATE ............................ 104 rizatriptan ............................... 43 smoflipid ................................ 62 STIOLTO RESPIMAT ........ 124 ropinirole ................................ 47 sodium acetate ..................... 121 STIVARGA ........................... 26 rosadan ................................... 84 sodium bicarbonate .............. 121 STRATTERA ........................ 76 rosuvastatin............................. 72 sodium chloride ........... 113, 121 STRENSIQ ............................ 89 ROTARIX ............................ 111 sodium chloride 0.45 % ....... 121 streptomycin ........................... 12 ROTATEQ VACCINE ........ 111 sodium chloride 0.9 % ......... 121 STRIBILD.............................. 53 ROWEEPRA .......................... 32 sodium chloride 3 % ............ 121 STRIVERDI RESPIMAT .... 124 ROZEREM ........................... 126 sodium chloride 5 % ............ 121 SUBOXONE .......................... 10 RUBRACA............................. 26 sodium fluoride .................... 127 sucralfate ................................ 95 S sodium lactate ...................... 121 sulfacetamide sodium............. 92 SABRIL .................................. 32 sodium phosphate ................ 121 sulfacetamide sodium (acne).. 85 SAIZEN ................................ 103 sodium polystyrene (sorb free) sulfacetamide-prednisolone ... 92 SAIZEN CLICK.EASY ....... 103 ........................................... 96 sulfadiazine ............................ 19 SANDOSTATIN LAR DEPOT sodium polystyrene sulfonate 96 sulfamethoxazole-trimethoprim .......................................... 103 SOLTAMOX ......................... 26 ............................................ 19 SANTYL ................................ 83 SOLU-CORTEF (PF) .......... 102 sulfasalazine ........................... 19 I-14

sulfatrim ................................. 19 TECFIDERA ......................... 76 TOBI PODHALER ................ 12 sulindac..................................... 9 TECHNIVIE .......................... 55 TOBRADEX .......................... 92 sumatriptan ............................. 43 TEFLARO ............................. 15 TOBRADEX ST .................... 92 sumatriptan succinate ............. 43 TEKAMLO ............................ 73 tobramycin ............................. 92 SUPPRELIN LA .................. 104 TEKTURNA .......................... 73 tobramycin in 0.225 % nacl ... 12 SUPRAX ................................ 15 TEKTURNA HCT ................. 73 tobramycin in 0.9 % nacl ....... 12 SUPREP BOWEL PREP KIT 97 telmisartan ............................. 63 tobramycin sulfate .................. 12 SURMONTIL......................... 35 telmisartan-hydrochlorothiazid tobramycin-dexamethasone ... 92 SUSTIVA ............................... 53 ........................................... 63 TOLAK .................................. 84 SUTENT................................. 26 temazepam ............................. 11 tolazamide .............................. 40 syeda ....................................... 81 TEMODAR ........................... 27 tolbutamide ............................ 40 SYLATRON........................... 55 tencon....................................... 7 tolmetin .................................... 9 SYLVANT ............................. 26 teniposide ............................... 27 tolterodine .............................. 98 SYMBICORT....................... 123 TENIVAC (PF).................... 111 topiramate .............................. 32 SYMLINPEN 120 .................. 38 terazosin ................................. 98 toposar .................................... 27 SYMLINPEN 60 .................... 38 terbinafine hcl ........................ 41 topotecan ................................ 27 SYNAGIS............................... 54 terbutaline ............................ 124 TORISEL ............................... 27 SYNAREL ........................... 117 terconazole ....................... 42, 43 torsemide ................................ 70 SYNERCID ............................ 13 testosterone ............................ 99 TOUJEO SOLOSTAR ........... 39 SYNJARDY ........................... 38 testosterone cypionate ............ 99 TOVIAZ ................................. 98 SYNRIBO .............................. 26 testosterone enanthate ............ 99 TPN ELECTROLYTES....... 121 SYPRINE ............................... 99 TETANUS,DIPHTHERIA TOX TPN ELECTROLYTES II ... 121 T PED(PF)........................... 111 TRACLEER ......................... 126 TABLOID .............................. 26 TETANUS-DIPHTHERIA TRADJENTA ........................ 38 tacrolimus ....................... 87, 108 TOXOIDS-TD ................. 111 tramadol ................................... 7 TAFINLAR ............................ 26 tetrabenazine .......................... 76 tramadol-acetaminophen .......... 7 TAGRISSO ............................ 26 tetracycline ............................. 20 trandolapril ............................. 64 TALTZ AUTOINJECTOR .... 83 THALOMID ........................ 117 tranexamic acid ...................... 58 TALTZ AUTOINJECTOR (3 theophylline ......................... 124 TRANSDERM-SCOP............ 45 PACK) ................................ 84 theophylline in dextrose 5 % 124 tranylcypromine ..................... 35 TALTZ SYRINGE ................. 84 THIOLA .............................. 117 TRAVASOL 10 % ................. 62 TAMIFLU .............................. 54 thioridazine ............................ 51 TRAVATAN Z .................... 118 tamoxifen ................................ 26 thiotepa .................................. 27 travoprost (benzalkonium) ... 118 tamsulosin............................... 98 thiothixene ............................. 51 trazodone ................................ 35 TARCEVA ............................. 26 tiagabine................................. 32 TREANDA ............................ 27 TARGRETIN ......................... 27 TICE BCG ........................... 112 TRECATOR .......................... 44 tarina fe 1/20 (28) ................... 81 tigecycline .............................. 20 TRELSTAR ........................... 27 TASIGNA .............................. 27 tilia fe ..................................... 81 tretinoin .................................. 87 tazicef ..................................... 15 timolol maleate .............. 66, 118 tretinoin (chemotherapy) ........ 27 TAZORAC ............................. 87 tinidazole ............................... 46 tretinoin microspheres ............ 87 taztia xt ................................... 67 TIVICAY ............................... 53 TREXALL ............................. 27 TECENTRIQ .......................... 27 tizanidine ............................. 125 I-15