Guía de la lista de medicamentos en 2018 (Lista de medicamentos con receta cubiertos)

Transcripción

1 Guía de la lista de medicamentos en 2018 (Lista de medicamentos con receta cubiertos)

2 Administración de beneficios de farmacia Índice de materias Resumen... iii Centro de Atención al Cliente de True Health New Mexico... iii Para entender la cobertura y los costos compartidos... iii Lista de medicamentos... iii Niveles... iii Para entender nuestros símbolos... vi Terapia escalonada... vi Límites que rigen las cantidades... vii Sobre los medicamento genéricos... vii Medicamentos de corto plazo... viii Medicamentos de largo plazo... viii Medicamentos especializados... viii Cómo se surten sus medicamentos con receta... ix Para surtir su medicamento con receta cuando esté de viaje... ix Suministros de medicamentos que no cubre el plan de seguro médico... ix Lista de abreviaturas... x ii

3 Administración de beneficios de farmacia Resumen Esta guía le proporciona un resumen de sus beneficios de farmacia. Explica los niveles de cobertura de los medicamentos, el proceso para conseguir ciertos medicamentos cubiertos, las opciones a su disposición para surtir sus medicamentos con receta, los números de teléfono importantes y mucho más. Centro de Atención al Cliente de True Health New Mexico: Horas hábiles: las 24 horas del día, los siete días de la semana. Para entender la cobertura y los costos compartidos Lista de medicamentos La lista de medicamentos que favorece el plan, formulary en inglés, es una lista de medicamentos con receta que se cubren conforme a su plan. La inclusión de medicamentos específicos en la lista de medicamentos del seguro médico se basa en la efectividad, la seguridad y el valor del medicamento. La lista de medicamentos ofrece una amplia selección de medicamentos con receta genéricos y de marca sugerida por el Comité de Farmacia y Terapias [Pharmacy and Therapeutics (P&T) Committee], un grupo de médicos y farmacéuticos quienes investigan y evalúan los medicamentos. Se revisa periódicamente la lista de medicamentos y se actualiza a lo largo del año a fin de asegurar que el conjunto de beneficios que ofrecemos cumpla sus necesidades consistente y adecuadamente. Si necesita un medicamento con receta, usted y su médico pueden elegir de cinco niveles diferentes que se encuentran en la lista de medicamentos. Dichos niveles son: Medicamentos genéricos que favorece el plan Nivel 1; Medicamentos genéricos - Nivel 2; Medicamentos de marca que favorece el plan Nivel 3; Medicamentos de marca que no favorece el plan Nivel 4; Medicamentos especializados que favorece el plan Nivel 5; y Medicamentos especializados que no favorece el plan Nivel 6. A cada nivel corresponde un copago diferente. Eso les ofrece, tanto a usted mismo como a su médico, la libertad de elegir un medicamento que sea apropiado para usted. Al mismo tiempo, eso le ayudará a asignar su dinero, con mayor efectividad, para los servicios médicos. Niveles Los medicamentos genéricos que favorece el plan Nivel 1 tienen el copago/coseguro más bajo. Los medicamentos genéricos ofrecen el mismo nivel de seguridad y calidad que los medicamentos de marca equivalentes. Tienen la misma cantidad de ingredientes activos que iii

4 Administración de beneficios de farmacia los medicamentos de marca. Se exige que usted use una versión genérica del medicamento si está disponible. Consulte la sección de medicamentos genéricos del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Los medicamentos genéricos Nivel 2 tienen el mismo copago/coseguro que los medicamentos del Nivel 1. Los medicamentos genéricos ofrecen el mismo nivel de seguridad y calidad que los medicamentos de marca equivalentes. Tienen la misma cantidad de ingredientes activos que los medicamentos de marca. Se exige que usted use una versión genérica del medicamento si está disponible. Consulte la sección de medicamentos genéricos del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Los medicamentos de marca que favorece el plan Nivel 3 tienen un nivel moderado de copago/coseguro. Estos medicamentos son medicamentos de marca y que favorece el plan debido a su precio y su efectividad. Consulte la sección de medicamentos de marca que favorece el plan del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Los medicamentos de marca que no favorece el plan Nivel 4 tienen un nivel de copago/coseguro más alto. Estos son medicamentos de marca que son más caros y que tienen una efectividad parecida a los medicamentos del Nivel 3. Además este nivel puede incluir medicamentos genéricos de costo más alto. Consulte la sección de medicamentos de marca que no favorece el plan del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Los medicamentos especializados que favorece el plan Nivel 5 tienen un nivel de copago/coseguro más alto. Además estos incluyen los medicamentos especializados que, por lo general, tratan problemas médicos complejos y raros. Dichos medicamentos pueden ser sustancias biológicas y medicamentos de costo elevado independientemente de cómo se administren (inyectables, orales, transdérmicos o inhalantes). Planes que entran en vigor a partir del 1/1/2018 o posteriormente: Consulte la sección de medicamentos especializados que favorece el plan del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Planes vigentes antes del 1/1/2018: Consulte la sección de medicamentos especializados del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. iv

5 Administración de beneficios de farmacia Los medicamentos especializados que no favorece el plan Nivel 6 tienen el nivel de copago/coseguro más alto. Además estos incluyen los medicamentos especializados que, por lo general, tratan problemas médicos complejos y raros. Dichos medicamentos pueden ser sustancias biológicas y medicamentos de costo elevado independientemente de cómo se administren (inyectables, orales, transdérmicos o inhalantes) y su efectividad es parecida a los medicamentos del Nivel 5. Planes que entran en vigor a partir del 1/1/2018 o posteriormente: Consulte la sección de medicamentos especializados que no favorece el plan del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Planes vigentes antes del 1/1/2018: Consulte la sección de medicamentos especializados del Resumen de Beneficios y Cobertura para informarse sobre la cantidad de costos compartidos de su plan. Medicamentos anticancerosos que se administran por vía oral La cobertura de estos medicamentos está sujeta a los mismos requisitos de autorización previa como los medicamentos anticancerosos inyectables que se administran por vía intravenosa cubiertos por el plan de seguro médico. Los medicamentos que se administran por vía oral no pueden costar más que los medicamentos equivalentes inyectables por vía intravenosa. Los medicamentos inyectables por vía intravenosa no pueden costar más que los medicamentos se administran por vía oral. Varios medicamentos genéricos para problemas médicos crónicos que le cuestan $0 El plan cubre, sin costarle nada a usted, los medicamentos genéricos para asma, trastorno bipolar, enfermedad pulmonar obstructiva crónica, insuficiencia cardíaca congestiva, enfermedad de las arterias coronarias, depresión, diabetes, hipercolesterolemia e hipertensión. No se ofrece este beneficio conforme a todos los planes; favor de consultar el Resumen de Beneficios y Cobertura para informarse sobre beneficios específicos que ofrece su plan. A lo mejor se cubran los medicamentos que no se encuentran en la lista de medicamentos con tal que los medicamentos de la lista de medicamentos no funcionen para usted. Si usted necesita un medicamento que no se encuentra en la lista de medicamentos, su médico pudiera solicitar la cobertura con el copago del Nivel 4 (medicamentos de marca que no favorece el plan) o del Nivel 6 (medicamentos especializados que no favorece el plan) con tal que solicite una exención de cobertura. v

6 Administración de beneficios de farmacia Medicamentos preventivos que le cuestan $0 La cobertura de los servicios preventivos sin requisitos de costos compartidos por la aspirina, el ácido fólico, los productos para dejar el tabaco, los anticonceptivos y otros tratamientos según se definen en la Ley de Cuidado de Salud a Bajo Precio [Affordable Care Act]. Para entender nuestros símbolos Autorización previa Usted verá el símbolo PA (autorización previa). La autorización previa ayuda a asegurar que usted esté utilizando los mejores medicamentos de la manera más segura. Si usted está tomando uno de estos medicamentos actualmente o si se le ha recetado uno de ellos hace poco, favor de hablar con su médico acerca de otras opciones o pídale a su médico que llame al para solicitar una autorización. Por lo general, los medicamentos que necesitan autorización previa son: Medicamentos más nuevos de los cuales el plan seguro médico quiere estar al tanto de cómo se están utilizando. Medicamentos que no se encuentran en la lista de medicamentos para los cuales se exige que se usen primero medicamentos de la lista de medicamentos antes de que los cubra el plan. Estos medicamentos no se utilizan como la primera opción estándar para tratar un problema médico. Medicamentos con efectos secundarios potenciales que el plan seguro médico quiere supervisar por la seguridad del paciente. Medicamentos que se clasifican como medicamentos especializados. Terapia escalonada Usted verá el símbolo ST (terapia escalonada) al lado de algunos medicamentos en las tablas de la lista de medicamentos de este folleto. La terapia escalonada asegura que usted esté tomando el medicamento más efectivo al mejor precio. Eso quiere decir que deberá probar primero los medicamentos menos caros, por lo general, los medicamentos genéricos o los medicamentos que se consideran el tratamiento estándar de primera elección. Cómo funciona la terapia escalonada Primer paso: Si la terapia escalonada afecta al medicamento que se le ha recetado, se le pedirá que pruebe primero un medicamento genérico o medicamentos de tratamiento de primera elección. El medicamento que se recomiende será aprobado por la vi

7 Administración de beneficios de farmacia Administración de Medicamentos y Alimentos [FDA por sus siglas en inglés] para proporcionar el mismo beneficio a la salud a un costo muy reducido. Segundo paso: Si no funcionara para usted el medicamento genérico del primer paso, entonces se cubrirá el medicamento de marca. Si desea conseguir información más detallada sobre la terapia escalonada, llame al Límites que rigen las cantidades El símbolo QL al lado de los medicamentos en este folleto de la lista de medicamentos representa los límites que rigen las cantidades. A fin de asegurarse de que usted reciba la dosis más rentable de su medicamento, se pueden imponer a algunos medicamentos límites que rigen las cantidades o la duración de las dosis. Dichos límites se basan en las directrices de la Administración de Medicamentos y Alimentos [FDA por sus siglas en inglés], la literatura clínica y las instrucciones del fabricante. Los límites que rigen las cantidades fomentan el uso debido del medicamento, previenen desperdicios y ayudan a controlar los costos. Para algunos medicamentos, las directrices de las dosis a lo mejor recomienden que los pacientes tomen una dosis más alta del medicamento una vez al día en vez de dosis más pequeñas varias veces al día. Los límites que rigen las cantidades cumplen las directrices y cubren una dosis más alta al día. Se limitan las recetas para los medicamentos especializados a un suministro de 30 días. Si desea conseguir información más detallada sobre los límites que rigen las cantidades o la duración de las dosis, llame al Sobre los medicamento genéricos Los medicamentos genéricos tienen los mismos ingredientes activos que los medicamentos de marca equivalentes, pero cuestan considerablemente menos. No todos los medicamentos tienen un equivalente genérico. Por lo general, los medicamentos nuevos reciben la protección de patente por veinte (20) años. Una vez que caduque el patente, otras compañías farmacéuticas pueden producir el mismo medicamento con una formulación genérica. Las compañías que producen los medicamentos genéricos no tienen que invertir grandes cantidades de dinero en investigaciones, porque la compañía que produce el medicamento equivalente de marca ya lo ha hecho. Además las compañías que producen los medicamentos genéricos no tienen que hacer publicidad para sus medicamentos. Por consiguiente, los productores de medicamentos genéricos pueden compartir los ahorros con usted. Los medicamentos genéricos tienen los mismos ingredientes activos que los medicamentos de marca, pero pueden variar sus ingredientes inactivos. Por eso a lo mejor el medicamento vii

8 Administración de beneficios de farmacia genérico luzca diferente que el medicamento de marca. Los ingredientes inactivos pueden incluir los tintes que se utilizan para colorear el medicamento o los polvos que se utilizan para formar las pastillas. Los ingredientes inactivos no afectan cómo funciona el medicamento genérico. La Administración de Medicamentos y Alimentos [FDA por sus siglas en inglés] regula los fabricantes de medicamentos genéricos así cómo regula los fabricantes de medicamentos de marca. El medicamento genérico tiene que cumplir las medidas estrictas de la FDA a fin de asegurar que proporcione la misma cantidad del ingrediente activo en el mismo periodo de tiempo que su equivalente de marca. El fabricante del medicamento genérico tiene que probar que produce su producto conforme a las mismas directrices estrictas del medicamento de marca. Medicamentos de corto plazo Estos son medicamentos que usted necesita enseguida. Dichos medicamentos se utilizan para tratar infecciones a corto plazo o para aliviar el dolor temporalmente. Si llama al le pueden ayudar a localizar la farmacia de venta al por menor de la red que esté más cerca. Para surtir su medicamento con receta, presente su tarjeta de identificación de asegurado y la receta médica escrita y pague el coseguro/copago de su seguro según se describe más arriba. Medicamentos de largo plazo Estos son medicamentos que usted toma de ordinario. Pueden ser medicamentos para tratar el asma, la presión arterial alta, la diabetes, etc. Se le puede enviar por correo a su casa un suministro máximo de 90 días de estos medicamentos. Favor de llamar al para informarse más a fondo sobre sus opciones de encargo por correo. Medicamentos especializados Los medicamentos especializados tratan problemas médicos específicos como cáncer, hemofilia, hepatitis, esclerosis múltiple, psoriasis, hipertensión arterial pulmonar, virus respiratorio sincitial y artritis reumatoide entre otros. Le pueden surtir los medicamentos especializados en CVS Specialty Pharmacy. CVS Specialty Pharmacy es una farmacia que provee medicamentos especializados. Favor de llamar al de las 6:30 de la mañana a las 8:00 de la noche (hora de la zona central) de lunes a viernes para informarse más a fondo sobre cómo surtir sus medicamentos especializados. viii

9 Administración de beneficios de farmacia Cómo se surten sus medicamentos con receta Para surtir su medicamento con receta cuando esté de viaje Si usted viaja fuera de su zona local, miles de farmacias por todo el país aceptan la tarjeta de identificación de asegurado de su plan de seguro médico. Si desea localizar una farmacia que participa en la red, llame al Centro de Atención al Cliente al Para que le surtan un medicamento con receta en una farmacia que participa en la red pero que está fuera de la zona, presente la tarjeta de identificación de asegurado de su plan de seguro médico. Algunas farmacias tal vez le pidan que usted pague el precio del medicamento en su totalidad. Si sucediera eso: Entregue un formulario de demanda de seguro para reembolso directo [Direct Reimbursement Claim] al plan de seguro médico al: CVS Caremark RxClaim P.O Box Phoenix, AZ O usted puede llamar al para recibir ayuda. Si se aprueba su demanda de seguro, se le reembolsará la cantidad que usted pagó por el medicamento, menos la cantidad del copago debido. Si usted estará fuera de su casa por un plazo de tiempo extendido, o si va a viajar fuera del país, a lo mejor deberá utilizar nuestro servicio de encargo por correo a fin de recibir un suministro de 90 días antes de irse de casa. Suministros de medicamentos que no cubre el plan de seguro médico No se proporcionará ninguna autorización para los medicamentos si el asegurado, el proveedor de servicios médicos o la farmacia han avisado que se perdieron, extraviaron, robaron, destruyeron o dañaron. No se cubrirán los medicamentos que el asegurado reciba sin cobro alguno (de indemnización laboral, los medicamentos que se compran con un cupón del fabricante, etc.). No se cubrirán las recetas médicas que se hayan escrito hace más de un año. Su médico tendrá que escribir una nueva receta médica. ix

10 Administración de beneficios de farmacia Lista de abreviaturas ACA: Ley de Cuidado de Salud a Bajo Precio [Affordable Care Act]. LA: Se limita la disponibilidad. Tal vez este medicamento con receta solo esté disponible en ciertas farmacias. Para informarse más afondo, favor de llamar al Centro de Atención al Cliente al OTC: Medicamento de venta libre. Un medicamento de venta libre es un medicamento sin receta médica. PA: Autorización previa. El plan de seguro médico exige que usted mismo o su médico consigan la autorización previa para ciertos medicamentos. Eso quiere decir que usted tendrá que recibir la aprobación antes de surtir sus medicamentos con receta. Si usted no recibiera la aprobación, a lo mejor no cubramos el medicamento. QL: Límites que rigen las cantidades. Para ciertos medicamentos, el plan de seguro médico limita las cantidades de los medicamentos que cubrimos. ST: Terapia escalonada. En algunos casos, el plan de seguro médico exige que primero pruebe ciertos medicamentos para tratar su problema médico antes de que cubramos otro medicamento para dicho problema médico. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su problema médico, no cubriremos el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no funciona para usted, entonces cubriremos el Medicamento B. x

11 Formulary Listing Effective 04/01/2018 Drug Name ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg 2 ST celecoxib cap 100 mg 2 ST; QL celecoxib cap 200 mg 2 ST; QL celecoxib cap 400 mg 2 ST; QL GOUT allopurinol tab 100 mg 1 allopurinol tab 300 mg 2 COLCRYS TAB 0.6MG 3 ULORIC TAB 40MG 3 ST; QL ULORIC TAB 80MG 3 ST LOCAL ANESTHETICS bupivacaine 0.75% in dextrose inj 8.25% 2 MARCAINE INJ SPINAL 4 MISCELLANEOUS clonidine hcl inj (for epidural infusion) mcg/ml clonidine hcl inj (for epidural infusion) mcg/ml DURACLON INJ 4 PRIALT INJ 25MCG/ML 5 PRIALT INJ 100MCG 5 PRIALT INJ 500MCG 5 NON-OPIOID ANALGESICS butalbital-acetaminophen tab mg 2 butalbital-acetaminophen-caffeine cap mg butalbital-acetaminophen-caffeine tab mg butalbital-aspirin-caffeine cap mg NSAIDS choline & magnesium salicylates liq mg/5ml diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 2 mg diclofenac sodium tab delayed release 50 2 mg diclofenac sodium tab delayed release 75 2 mg diclofenac sodium tab er 24hr 100 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 1

12 diflunisal tab 500 mg 2 etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 etodolac tab er 24hr 400 mg 2 etodolac tab er 24hr 500 mg 2 etodolac tab er 24hr 600 mg 2 fenoprofen calcium tab 600 mg 2 flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibuprofen susp 100 mg/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 indomethacin cap 25 mg 2 indomethacin cap 50 mg 2 indomethacin cap er 75 mg 2 ketoprofen cap 50 mg 2 ketoprofen cap 75 mg 2 ketoprofen cap er 24hr 200 mg 2 ketorolac tromethamine tab 10 mg 2 QL meclofenamate sodium cap 50 mg 2 meclofenamate sodium cap 100 mg 2 mefenamic acid cap 250 mg 2 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen sodium tab 275 mg 2 naproxen sodium tab 550 mg 2 naproxen susp 125 mg/5ml 2 naproxen tab 250 mg 2 naproxen tab 375 mg 1 naproxen tab 500 mg 1 naproxen tab ec 375 mg 2 naproxen tab ec 500 mg 2 oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 salsalate tab 500 mg 2 salsalate tab 750 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 2

13 tolmetin sodium tab 600 mg 2 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed release mg diclofenac w/ misoprostol tab delayed release mg NSAIDS, TOPICAL diclofenac sodium gel 1% 2 QL VOLTAREN GEL 1% 4 QL OPIOID ANALGESICS ABSTRAL SUB 100MCG 4 PA; QL ABSTRAL SUB 200MCG 4 PA; QL ABSTRAL SUB 300MCG 4 PA; QL ABSTRAL SUB 400MCG 4 PA; QL ABSTRAL SUB 600MCG 4 PA; QL ABSTRAL SUB 800MCG 4 PA; QL acetaminophen w/ codeine soln mg/5ml 2 acetaminophen w/ codeine tab mg 2 acetaminophen w/ codeine tab mg 2 acetaminophen w/ codeine tab mg 2 butalbital-acetaminophen-caff w/ cod cap mg butalbital-aspirin-caff w/ codeine cap mg butorphanol tartrate nasal soln 10 mg/ml 2 QL BUTRANS DIS 5MCG/HR 4 PA BUTRANS DIS 7.5/HR 4 PA BUTRANS DIS 10MCG/HR 4 PA BUTRANS DIS 15MCG/HR 4 PA BUTRANS DIS 20MCG/HR 4 PA codeine sulfate tab 15 mg 2 codeine sulfate tab 30 mg 2 codeine sulfate tab 60 mg 2 fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle 800 mcg 2 QL fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl td patch 72hr 12 mcg/hr 2 QL fentanyl td patch 72hr 25 mcg/hr 2 QL fentanyl td patch 72hr 50 mcg/hr 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 3 2 2

14 fentanyl td patch 72hr 75 mcg/hr 2 QL fentanyl td patch 72hr 100 mcg/hr 2 QL FENTORA TAB 100MCG 4 PA; QL FENTORA TAB 200MCG 4 PA; QL FENTORA TAB 400MCG 4 PA; QL FENTORA TAB 600MCG 4 PA; QL FENTORA TAB 800MCG 4 PA; QL hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg2 hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-ibuprofen tab mg 2 QL hydrocodone-ibuprofen tab mg 2 QL hydrocodone-ibuprofen tab mg 2 QL HYDROMORPHON SUP 3MG 2 hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 LAZANDA SPR 100MCG 4 PA; QL LAZANDA SPR 300MCG 4 PA; QL LAZANDA SPR 400MCG 4 PA; QL meperidine hcl oral soln 50 mg/5ml 2 methadone hcl soln 5 mg/5ml 2 methadone hcl soln 10 mg/5ml 2 methadone hcl tab 5 mg 2 methadone hcl tab 10 mg 2 methadone hcl tab for oral susp 40 mg 2 MORPHINE SUL SUP 30MG 2 morphine sulfate oral soln 10 mg/5ml 2 morphine sulfate oral soln 20 mg/5ml 2 morphine sulfate oral soln 100 mg/5ml (20 2 mg/ml) morphine sulfate suppos 5 mg 2 morphine sulfate suppos 10 mg 2 morphine sulfate suppos 20 mg 2 morphine sulfate tab 15 mg 2 QL morphine sulfate tab 30 mg 2 QL morphine sulfate tab er 15 mg 2 QL morphine sulfate tab er 30 mg 2 QL morphine sulfate tab er 60 mg 2 QL morphine sulfate tab er 100 mg 2 QL morphine sulfate tab er 200 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 4

15 OPANA ER TAB 5MG 3 QL OPANA ER TAB 7.5MG 3 QL OPANA ER TAB 10MG 3 QL OPANA ER TAB 15MG 3 QL OPANA ER TAB 20MG 3 QL OPANA ER TAB 30MG 3 QL OPANA ER TAB 40MG 3 QL oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml (20 2 mg/ml) oxycodone hcl soln 5 mg/5ml 2 oxycodone hcl tab 5 mg 2 oxycodone hcl tab 10 mg 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab er 12hr deter 10 mg 4 PA; QL oxycodone hcl tab er 12hr deter 15 mg 4 PA; QL oxycodone hcl tab er 12hr deter 20 mg 4 PA; QL oxycodone hcl tab er 12hr deter 30 mg 4 PA; QL oxycodone hcl tab er 12hr deter 40 mg 4 PA; QL oxycodone hcl tab er 12hr deter 60 mg 4 PA; QL oxycodone hcl tab er 12hr deter 80 mg 4 PA; QL oxycodone w/ acetaminophen soln mg/5ml 2 oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone-ibuprofen tab mg 2 QL OXYCONTIN TAB 10MG CR 5 PA; QL OXYCONTIN TAB 15MG CR 5 PA; QL OXYCONTIN TAB 20MG CR 5 PA; QL OXYCONTIN TAB 30MG CR 5 PA; QL OXYCONTIN TAB 40MG CR 5 PA; QL OXYCONTIN TAB 60MG CR 5 PA; QL OXYCONTIN TAB 80MG CR 5 PA; QL oxymorphone hcl tab 5 mg 4 oxymorphone hcl tab 10 mg 4 oxymorphone hcl tab er 12hr 5 mg 4 QL oxymorphone hcl tab er 12hr 7.5 mg 4 QL oxymorphone hcl tab er 12hr 10 mg 4 QL oxymorphone hcl tab er 12hr 15 mg 4 QL oxymorphone hcl tab er 12hr 20 mg 4 QL oxymorphone hcl tab er 12hr 30 mg 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 5

16 oxymorphone hcl tab er 12hr 40 mg 4 QL SUBSYS SPR 100MCG 5 PA; QL SUBSYS SPR 200MCG 5 PA; QL SUBSYS SPR 400MCG 5 PA; QL SUBSYS SPR 600MCG 5 PA; QL SUBSYS SPR 800MCG 5 PA; QL SUBSYS SPR 1200MCG 5 PA; QL SUBSYS SPR 1600MCG 5 PA; QL tramadol hcl tab 50 mg 2 QL tramadol hcl tab er 24hr 100 mg 2 QL tramadol hcl tab er 24hr 200 mg 2 QL tramadol hcl tab er 24hr 300 mg 2 QL tramadol-acetaminophen tab mg 2 VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 5 PA; QL ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 1 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 cefuroxime axetil tab 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 6

17 CEDAX CAP 400MG 4 CEDAX SUS 180/5ML 4 cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 SUPRAX CAP 400MG 4 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 SUPRAX SUS 100/5ML 4 SUPRAX SUS 200/5ML 4 SUPRAX SUS 500/5ML 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab er 24hr 500 mg 2 DIFICID TAB 200MG 5 ST; QL E.E.S. GRAN SUS 200/5ML 4 ERYPED SUS 400/5ML 5 erythromycin ethylsuccinate for susp mg/5ml erythromycin ethylsuccinate tab 400 mg 2 erythromycin stearate tab 250 mg 2 erythromycin tab 250 mg 2 erythromycin tab 500 mg 2 erythromycin tab delayed release 250 mg 3 erythromycin tab delayed release 333 mg 3 erythromycin tab delayed release 500 mg 3 erythromycin w/ delayed release particles 2 cap 250 mg PCE TAB 333MG EC 3 PCE TAB 500MG EC 3 ZMAX SUS 2GM 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 7

18 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX TAB 400MG 4 CIPRO (5%) SUS 250MG/5 4 CIPRO (10%) SUS 500MG/5 4 ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 1000 mg(base eq) levofloxacin oral soln 25 mg/ml 2 moxifloxacin hcl tab 400 mg (base equiv) 2 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab er 12hr mg amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 500 mg 2 dicloxacillin sodium cap 250 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 8

19 dicloxacillin sodium cap 500 mg 2 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 2 ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 2 sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 50 2 mg doxycycline hyclate tab delayed release 75 2 mg doxycycline hyclate tab delayed release mg doxycycline hyclate tab delayed release mg doxycycline hyclate tab delayed release mg doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 100 mg 2 doxycycline monohydrate tab 150 mg 2 MINOCIN CAP 50MG 4 MINOCIN CAP 100MG 4 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 9

20 VIBRAMYCIN SYP 50MG/5ML 4 ANTIFUNGALS clotrimazole troche 10 mg 2 CRESEMBA CAP 186 MG 4 QL fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole tab 50 mg 2 QL fluconazole tab 100 mg 2 QL fluconazole tab 150 mg 1 QL fluconazole tab 200 mg 2 QL griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 itraconazole cap 100 mg 2 PA; QL NOXAFIL SUS 40MG/ML 5 PA NOXAFIL TAB 100MG 5 PA; QL nystatin susp unit/ml 2 nystatin tab unit 2 ONMEL TAB 200MG 4 PA; QL SPORANOX SOL 10MG/ML 4 PA; QL terbinafine hcl tab 250 mg 2 QL voriconazole for susp 40 mg/ml 2 QL voriconazole tab 50 mg 2 QL voriconazole tab 200 mg 2 QL ANTIMALARIALS COARTEM TAB MG 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab mg abacavir sulfate-lamivudine-zidovudine tab 2 QL mg ATRIPLA TAB 3 QL COMPLERA TAB 3 QL DESCOVY TAB 200/25 3 QL EPZICOM TAB QL EVOTAZ TAB QL GENVOYA TAB 3 QL lamivudine-zidovudine tab mg 2 QL PREZCOBIX TAB QL STRIBILD TAB 3 QL TRIUMEQ TAB 3 QL TRIZIVIR TAB 3 QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 10

21 TRUVADA TAB QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 3 PA; QL SELZENTRY TAB 150MG 3 PA; QL SELZENTRY TAB 300MG 3 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 3 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 3 QL ISENTRESS CHW 100MG 3 QL ISENTRESS HD TAB 600MG 3 QL ISENTRESS POW 100MG 3 QL ISENTRESS TAB 400MG 3 QL TIVICAY TAB 10MG 3 QL TIVICAY TAB 25MG 3 QL TIVICAY TAB 50MG 3 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 3 QL APTIVUS SOL 3 QL CRIXIVAN CAP 200MG 3 QL CRIXIVAN CAP 400MG 3 QL INVIRASE CAP 200MG 3 QL INVIRASE TAB 500MG 3 QL KALETRA SOL 3 PA; QL KALETRA TAB MG 3 QL KALETRA TAB MG 3 QL LEXIVA SUS 50MG/ML 3 QL LEXIVA TAB 700MG 3 QL lopinavir-ritonavir soln mg/5ml 2 QL (80-20 mg/ml) NORVIR CAP 100MG 3 QL NORVIR SOL 80MG/ML 3 QL NORVIR TAB 100MG 3 QL PREZISTA SUS 100MG/ML 3 QL PREZISTA TAB 75MG 3 QL PREZISTA TAB 150MG 3 QL PREZISTA TAB 600MG 3 QL PREZISTA TAB 800MG 3 QL REYATAZ CAP 150MG 3 QL REYATAZ CAP 200MG 3 QL REYATAZ CAP 300MG 3 QL REYATAZ POW 50MG 3 QL VIRACEPT TAB 250MG 3 QL VIRACEPT TAB 625MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-NUCLEOSIDE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 11

22 EDURANT TAB 25MG 3 QL INTELENCE TAB 25MG 3 PA; QL INTELENCE TAB 100MG 3 PA; QL INTELENCE TAB 200MG 3 PA; QL nevirapine tab 200 mg 2 QL nevirapine tab er 24hr 100 mg 2 QL nevirapine tab er 24hr 400 mg 2 QL RESCRIPTOR TAB 100 MG 3 QL RESCRIPTOR TAB 200MG 3 QL SUSTIVA CAP 50MG 3 QL SUSTIVA CAP 200MG 3 QL SUSTIVA TAB 600MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOSIDE abacavir sulfate tab 300 mg (base equiv) 2 QL didanosine delayed release capsule 200 mg2 QL didanosine delayed release capsule 250 mg2 QL didanosine delayed release capsule 400 mg2 QL EMTRIVA CAP 200MG 3 QL EMTRIVA SOL 10MG/ML 3 QL EPIVIR SOL 10MG/ML 3 lamivudine oral soln 10 mg/ml 2 lamivudine tab 150 mg 2 lamivudine tab 300 mg 2 RETROVIR INJ 10MG/ML 3 stavudine cap 15 mg 2 QL stavudine cap 20 mg 2 QL stavudine cap 30 mg 2 QL stavudine cap 40 mg 2 QL VIDEX SOL 2GM 3 QL VIDEX SOL 4GM 3 QL zidovudine cap 100 mg 2 QL zidovudine syrup 10 mg/ml 2 QL zidovudine tab 300 mg 2 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE VIREAD POW 40MG/GM 3 VIREAD TAB 150MG 3 QL VIREAD TAB 200MG 3 QL VIREAD TAB 250MG 3 QL VIREAD TAB 300MG 3 QL ANTITUBERCULAR AGENTS cycloserine cap 250 mg 3 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid syrup 50 mg/5ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 12

23 isoniazid tab 100 mg 2 isoniazid tab 300 mg 1 PASER GRA 4GM 3 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg 2 RIFAMATE CAP 4 rifampin cap 150 mg 2 rifampin cap 300 mg 2 RIFATER TAB 3 SIRTURO TAB 100MG 4 PA TRECATOR TAB 250MG 3 ANTIVIRALS, CMV AGENTS VALCYTE SOL 50MG/ML 5 QL VALCYTE TAB 450MG 5 valganciclovir hcl tab 450 mg (base equivalent) 4 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B BARACLUDE SOL.05MG/ML 5 PA BARACLUDE TAB 0.5MG 5 PA BARACLUDE TAB 1MG 5 PA entecavir tab 0.5 mg 5 PA entecavir tab 1 mg 5 PA EPIVIR HBV SOL 5MG/ML 3 PA EPIVIR HBV TAB 100MG 4 PA lamivudine tab 100 mg (hbv) 2 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB PA; QL HARVONI TAB MG 5 PA; QL MAVYRET TAB MG 5 PA; QL REBETOL SOL 40MG/ML 5 QL ribavirin cap 200 mg 5 QL ribavirin tab 200 mg 5 QL ribavirin tab 400 mg 5 QL ribavirin tab 600 mg 5 QL VOSEVI TAB 5 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 1 acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 famciclovir tab 125 mg 2 QL famciclovir tab 250 mg 2 QL famciclovir tab 500 mg 2 QL valacyclovir hcl tab 1 gm 2 QL valacyclovir hcl tab 500 mg 2 QL ANTIVIRALS, INFLUENZA AGENTS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 13

24 oseltamivir phosphate cap 30 mg (base 2 QL equiv) oseltamivir phosphate cap 45 mg (base 2 QL equiv) oseltamivir phosphate cap 75 mg (base 2 QL equiv) oseltamivir phosphate for susp 6 mg/ml 2 QL (base equiv) RELENZA MIS DISKHALE 4 QL rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 4 QL TAMIFLU CAP 45MG 4 QL TAMIFLU CAP 75MG 4 QL TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml 2 BILTRICIDE TAB 600MG 3 CLEOCIN CAP 75MG 4 CLEOCIN CAP 150MG 4 CLEOCIN CAP 300MG 4 clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) dapsone tab 25 mg 3 dapsone tab 100 mg 3 ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 4 QL linezolid tab 600 mg 2 QL MEPRON SUS 4 metronidazole cap 375 mg 2 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 MYCOBUTIN CAP 150MG 4 NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin macrocrystalline cap 100 mg 2 nitrofurantoin monohydrate 2 macrocrystalline cap 100 mg PRIMSOL SOL 50MG/5ML 3 rifabutin cap 150 mg 2 SIVEXTRO INJ 200MG 5 SIVEXTRO TAB 200MG 5 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 14

25 STROMECTOL TAB 3MG 4 trimethoprim tab 100 mg 2 vancomycin hcl cap 125 mg 2 vancomycin hcl cap 250 mg 2 VANCOMYCIN INJ 500MG 4 VANCOMYCIN INJ 750MG 4 XIFAXAN TAB 200MG 4 QL XIFAXAN TAB 550MG 5 PA; QL ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG 5 ALKERAN TAB 2MG 5 BENDEKA INJ 100/4ML 5 BICNU INJ 100MG 5 busulfan inj 6 mg/ml 5 BUSULFEX INJ 6MG/ML 5 carboplatin iv soln 50 mg/5ml 5 carboplatin iv soln 150 mg/15ml 5 carboplatin iv soln 450 mg/45ml 5 carboplatin iv soln 600 mg/60ml 5 cisplatin inj 50 mg/50ml (1 mg/ml) 5 cisplatin inj 100 mg/100ml (1 mg/ml) 5 cisplatin inj 200 mg/200ml (1 mg/ml) 5 CYCLOPHOSPH CAP 25MG 5 CYCLOPHOSPH CAP 50MG 5 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 5 cyclophosphamide for inj 500 mg 5 dacarbazine for inj 100 mg 5 dacarbazine for inj 200 mg 5 EMCYT CAP 140MG 5 PA GLEOSTINE CAP 5MG 5 PA GLEOSTINE CAP 10MG 5 PA GLEOSTINE CAP 40MG 5 PA GLEOSTINE CAP 100MG 5 PA HEXALEN CAP 50MG 5 IFEX INJ 1GM 5 ifosfamide for inj 1 gm 5 IFOSFAMIDE INJ 3GM 5 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 5 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 5 LEUKERAN TAB 2MG 3 melphalan hcl for inj 50 mg (base equiv) 5 MUSTARGEN INJ 10MG 5 MYLERAN TAB 2MG 3 oxaliplatin for iv inj 50 mg 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 15

26 oxaliplatin for iv inj 100 mg 5 oxaliplatin iv soln 50 mg/10ml 5 oxaliplatin iv soln 100 mg/20ml 5 TEMODAR CAP 5MG 5 PA TEMODAR CAP 20MG 5 PA TEMODAR CAP 100MG 5 PA TEMODAR CAP 140MG 5 PA TEMODAR CAP 180MG 5 PA TEMODAR CAP 250MG 5 PA TEMODAR INJ 100MG 5 PA temozolomide cap 5 mg 5 PA temozolomide cap 20 mg 5 PA temozolomide cap 100 mg 5 PA temozolomide cap 140 mg 5 PA temozolomide cap 180 mg 5 PA temozolomide cap 250 mg 5 PA TREANDA INJ 25MG 5 TREANDA INJ 100MG 5 VALCHLOR GEL 0.016% 5 PA ZANOSAR INJ 1GM 5 ANTIMETABOLITES ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 azacitidine for inj 100 mg 5 capecitabine tab 150 mg 5 PA capecitabine tab 500 mg 5 PA cladribine iv soln 10 mg/10ml (1 mg/ml) 2 clofarabine iv soln 1 mg/ml 5 CLOLAR INJ 1MG/ML 5 cytarabine inj 20 mg/ml 2 cytarabine inj pf 20 mg/ml 4 cytarabine inj pf 100 mg/ml 2 DACOGEN INJ 50MG 5 decitabine for inj 50 mg 2 floxuridine for inj 0.5 gm 5 fludarabine phosphate for inj 50 mg 5 fludarabine phosphate inj 25 mg/ml 5 fluorouracil inj 1 gm/20ml (50 mg/ml) 5 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 5 fluorouracil inj 5 gm/100ml (50 mg/ml) 5 fluorouracil inj 500 mg/10ml (50 mg/ml) 5 gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj 200 mg 2 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 16

27 gemcitabine hcl inj 2 gm/52.6ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 2 mg/ml) (base equiv) GEMZAR INJ 1GM 5 GEMZAR INJ 200MG 5 mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 mg/2ml (25 5 mg/ml) methotrexate sodium inj 250 mg/10ml (25 5 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj pf 100 mg/4ml 2 (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml 2 (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml 2 (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml 2 (25 mg/ml) methotrexate sodium tab 2.5 mg (base 2 equiv) TABLOID TAB 40MG 5 PA VIDAZA INJ 100MG 5 XELODA TAB 150MG 5 PA XELODA TAB 500MG 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 2 flutamide cap 125 mg 2 NILANDRON TAB 150MG 4 PA XTANDI CAP 40MG 5 PA; QL ZYTIGA TAB 250MG 5 PA; QL ZYTIGA TAB 500MG 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA FASLODEX INJ 250/5ML 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 2 exemestane tab 25 mg 2 letrozole tab 2.5 mg 2 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS FIRMAGON INJ 80MG 5 PA; QL FIRMAGON INJ 120MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 17

28 HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG 5 PA; QL ELIGARD INJ 22.5MG 5 PA; QL ELIGARD INJ 30MG 5 PA; QL ELIGARD INJ 45MG 5 PA; QL leuprolide acetate inj kit 5 mg/ml 5 PA; QL LUPRON DEPOT INJ 3.75MG 5 PA; QL LUPRON DEPOT INJ 7.5MG 5 PA; QL LUPRON DEPOT INJ 11.25MG 5 PA; QL LUPRON DEPOT INJ 22.5MG 5 PA; QL LUPRON DEPOT INJ 30MG 5 PA; QL LUPRON DEPOT INJ 45MG 5 PA; QL TRELSTAR MIX INJ 3.75MG 5 PA; QL TRELSTAR MIX INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 22.5MG 5 PA; QL VANTAS KIT 50MG 5 PA; QL ZOLADEX IMP 3.6MG 5 PA; QL ZOLADEX IMP 10.8MG 5 PA; QL HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 4 QL megestrol acetate susp 40 mg/ml 2 megestrol acetate tab 20 mg 2 megestrol acetate tab 40 mg 2 IMMUNOMODULATORS POMALYST CAP 1MG 5 PA; QL POMALYST CAP 2MG 5 PA; QL POMALYST CAP 3MG 5 PA; QL POMALYST CAP 4MG 5 PA; QL REVLIMID CAP 2.5MG 5 PA; QL REVLIMID CAP 5MG 5 PA; QL REVLIMID CAP 10MG 5 PA; QL REVLIMID CAP 15MG 5 PA; QL REVLIMID CAP 20MG 5 PA; QL REVLIMID CAP 25MG 5 PA; QL THALOMID CAP 50MG 5 PA; QL THALOMID CAP 100MG 5 PA; QL THALOMID CAP 150MG 5 PA; QL THALOMID CAP 200MG 5 PA; QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 PA; QL AFINITOR DIS TAB 3MG 5 PA; QL AFINITOR DIS TAB 5MG 5 PA; QL AFINITOR TAB 2.5MG 5 PA; QL AFINITOR TAB 5MG 5 PA; QL AFINITOR TAB 7.5MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 18

29 AFINITOR TAB 10MG 5 PA; QL ALECENSA CAP 150MG 5 PA; QL ALUNBRIG PAK 5 PA; QL ALUNBRIG TAB 30MG 5 PA; QL ALUNBRIG TAB 90MG 5 PA; QL ALUNBRIG TAB 180MG 5 PA; QL BOSULIF TAB 100MG 5 PA; QL BOSULIF TAB 500MG 5 PA; QL CABOMETYX TAB 20MG 5 PA; QL CABOMETYX TAB 40MG 5 PA; QL CABOMETYX TAB 60MG 5 PA; QL CALQUENCE CAP 100MG 5 PA; QL CAPRELSA TAB 100MG 5 PA; QL CAPRELSA TAB 300MG 5 PA; QL COMETRIQ KIT 60MG 5 PA; QL COMETRIQ KIT 100MG 5 PA; QL COMETRIQ KIT 140MG 5 PA; QL COTELLIC TAB 20MG 5 PA; QL GILOTRIF TAB 20MG 5 PA; QL GILOTRIF TAB 30MG 5 PA; QL GILOTRIF TAB 40MG 5 PA; QL IBRANCE CAP 75MG 5 PA; QL IBRANCE CAP 100MG 5 PA; QL IBRANCE CAP 125MG 5 PA; QL ICLUSIG TAB 15MG 5 PA; QL ICLUSIG TAB 45MG 5 PA; QL imatinib mesylate tab 100 mg (base 5 PA; QL equivalent) imatinib mesylate tab 400 mg (base 5 PA; QL equivalent) IMBRUVICA CAP 140MG 5 PA; QL INLYTA TAB 1MG 5 PA; QL INLYTA TAB 5MG 5 PA; QL IRESSA TAB 250MG 5 PA; QL JAKAFI TAB 5MG 5 PA; QL JAKAFI TAB 10MG 5 PA; QL JAKAFI TAB 15MG 5 PA; QL JAKAFI TAB 20MG 5 PA; QL JAKAFI TAB 25MG 5 PA; QL KISQALI 200 PAK FEMARA 5 PA; QL KISQALI 400 PAK FEMARA 5 PA; QL KISQALI 600 PAK FEMARA 5 PA; QL KISQALI TAB 200DOSE 5 PA; QL KISQALI TAB 400DOSE 5 PA; QL KISQALI TAB 600DOSE 5 PA; QL LENVIMA CAP 8 MG 5 PA; QL LENVIMA CAP 10 MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 19

30 LENVIMA CAP 14 MG 5 PA; QL LENVIMA CAP 18 MG 5 PA; QL LENVIMA CAP 20 MG 5 PA; QL LENVIMA CAP 24 MG 5 PA; QL MEKINIST TAB 0.5MG 5 PA; QL MEKINIST TAB 2MG 5 PA; QL NERLYNX TAB 40MG 5 PA; QL NEXAVAR TAB 200MG 5 PA; QL RYDAPT CAP 25MG 5 PA; QL SPRYCEL TAB 20MG 5 PA; QL SPRYCEL TAB 50MG 5 PA; QL SPRYCEL TAB 70MG 5 PA; QL SPRYCEL TAB 80MG 5 PA; QL SPRYCEL TAB 100MG 5 PA; QL SPRYCEL TAB 140MG 5 PA; QL STIVARGA TAB 40MG 5 PA; QL SUTENT CAP 12.5MG 5 PA; QL SUTENT CAP 25MG 5 PA; QL SUTENT CAP 37.5MG 5 PA; QL SUTENT CAP 50MG 5 PA; QL TAFINLAR CAP 50MG 5 PA; QL TAFINLAR CAP 75MG 5 PA; QL TAGRISSO TAB 40MG 5 PA; QL TAGRISSO TAB 80MG 5 PA; QL TARCEVA TAB 25MG 5 PA TARCEVA TAB 100MG 5 PA; QL TARCEVA TAB 150MG 5 PA; QL TASIGNA CAP 150MG 5 PA; QL TASIGNA CAP 200MG 5 PA; QL TORISEL SOL 25MG/ML 5 QL TYKERB TAB 250MG 5 PA; QL VERZENIO TAB 50MG 5 PA; QL VERZENIO TAB 100MG 5 PA; QL VERZENIO TAB 150MG 5 PA; QL VERZENIO TAB 200MG 5 PA; QL VOTRIENT TAB 200MG 5 QL XALKORI CAP 200MG 5 PA; QL XALKORI CAP 250MG 5 PA; QL ZELBORAF TAB 240MG 5 PA; QL ZYDELIG TAB 100MG 5 PA; QL ZYDELIG TAB 150MG 5 PA; QL ZYKADIA CAP 150MG 5 PA; QL MISCELLANEOUS ABRAXANE INJ 100MG 5 ADCETRIS INJ 50MG 5 ARRANON INJ 5MG/ML 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 20

31 AVASTIN INJ 5 AVASTIN INJ 400/16ML 5 bleomycin sulfate for inj 15 unit 5 bleomycin sulfate for inj 30 unit 5 daunorubicin hcl inj 5 mg/ml (base equiv) 5 dexrazoxane for inj 250 mg 2 dexrazoxane for inj 500 mg 2 docetaxel for inj conc 20 mg/ml 2 docetaxel for inj conc 80 mg/4ml (20 2 mg/ml) DOCETAXEL INJ 20MG/ML 5 DOCETAXEL INJ 80MG/4ML 5 DOXIL INJ 2MG/ML 5 doxorubicin hcl for inj 10 mg 5 doxorubicin hcl for inj 50 mg 5 doxorubicin hcl inj 2 mg/ml 5 doxorubicin hcl liposomal inj (for iv 2 infusion) 2 mg/ml ELITEK INJ 1.5MG 5 ELITEK INJ 7.5MG 5 ELLENCE INJ 2MG/ML 5 epirubicin hcl iv soln 50 mg/25ml (2 2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 5 mg/ml) ERBITUX INJ 100MG 5 ERBITUX INJ 200MG 5 ERIVEDGE CAP 150MG 5 PA; QL ETOPOPHOS INJ 100MG 5 etoposide cap 50 mg 4 PA etoposide inj 1 gm/50ml (20 mg/ml) 2 PA etoposide inj 100 mg/5ml (20 mg/ml) 2 PA etoposide inj 500 mg/25ml (20 mg/ml) 2 PA FARYDAK CAP 10MG 5 PA; QL FARYDAK CAP 15MG 5 PA; QL FARYDAK CAP 20MG 5 PA; QL HERCEPTIN INJ 150MG 5 HERCEPTIN INJ 440MG 5 hydroxyurea cap 500 mg 2 IDAMYCIN PFS INJ 5MG/5ML 5 IDAMYCIN PFS INJ 10/10ML 5 IDAMYCIN PFS INJ 20/20ML 5 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 2 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5 IDHIFA TAB 50MG 5 PA; QL IDHIFA TAB 100MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 21

32 IXEMPRA KIT INJ 15MG 5 IXEMPRA KIT INJ 45MG 5 JEVTANA INJ 60/1.5ML 5 KYPROLIS SOL 30MG 5 KYPROLIS SOL 60MG 5 leucovorin calcium for inj 500 mg 5 leucovorin calcium tab 5 mg 5 leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 5 leucovorin calcium tab 25 mg 5 LONSURF TAB PA LONSURF TAB PA LYNPARZA CAP 50MG 5 PA; QL LYSODREN TAB 500MG 5 PA MATULANE CAP 50MG 5 mesna inj 100 mg/ml 5 MESNEX INJ 1GM 5 MESNEX TAB 400MG 5 mitomycin for iv soln 5 mg 5 mitomycin for iv soln 20 mg 5 mitomycin for iv soln 40 mg 5 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 5 mitoxantrone hcl inj conc 25 mg/12.5ml (2 5 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 5 mg/ml) NAVELBINE INJ 10MG/ML 5 NAVELBINE INJ 50MG/5ML 5 NINLARO CAP 2.3MG 5 PA; QL NINLARO CAP 3MG 5 PA; QL NINLARO CAP 4MG 5 PA; QL NIPENT INJ 10MG 5 ODOMZO CAP 200MG 5 PA; QL paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 2 paclitaxel iv conc 150 mg/25ml (6 mg/ml) 2 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2 PERJETA INJ 420/14ML 5 PHOTOFRIN INJ 75MG 5 PROLEUKIN INJ 22MU 5 RITUXAN INJ 100MG 5 PA RITUXAN INJ 500MG 5 PA RUBRACA TAB 200MG 5 PA; QL RUBRACA TAB 250MG 5 PA; QL RUBRACA TAB 300MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 22

33 SYNRIBO INJ 3.5MG 5 PA TARGRETIN CAP 75MG 5 PA TARGRETIN GEL 1% 5 PA TAXOTERE INJ 20MG/ML 5 TAXOTERE INJ 80MG/4ML 5 TENIPOSIDE INJ 50MG/5ML 5 THERACYS INJ 5 TICE BCG INJ 5 tretinoin cap 10 mg 5 VECTIBIX INJ 100MG 5 VECTIBIX INJ 400MG 5 VELCADE INJ 3.5MG 5 VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL VENCLEXTA TAB START PK 5 PA; QL vinblastine sulfate inj 1 mg/ml 2 vincristine sulfate iv soln 1 mg/ml 2 vinorelbine tartrate inj 10 mg/ml (base 2 equiv) vinorelbine tartrate inj 50 mg/5ml (10 2 mg/ml) (base equiv) YERVOY INJ 50MG 5 YERVOY INJ 200MG 5 ZALTRAP INJ 100/4ML 5 ZALTRAP INJ 200/8ML 5 ZEJULA CAP 100MG 5 PA; QL ZEVALIN KIT Y-90 5 ZINECARD INJ 250MG 5 ZINECARD INJ 500MG 5 ZOLINZA CAP 100MG 5 PA; QL TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 40MG/2ML 5 CAMPTOSAR INJ 100/5ML 5 CAMPTOSAR INJ 300/15ML 5 HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA HYCAMTIN INJ 4MG 5 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 5 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 5 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 5 topotecan hcl for inj 4 mg 2 TOPOTECAN INJ 4MG/4ML 5 CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 23

34 amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg TARKA TAB CR 4 TARKA TAB CR 4 TARKA TAB CR 4 TARKA TAB CR 4 trandolapril-verapamil hcl tab er mg 2 trandolapril-verapamil hcl tab er mg 2 trandolapril-verapamil hcl tab er mg 2 trandolapril-verapamil hcl tab er mg 2 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 24

35 lisinopril & hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg2 ACE INHIBITORS benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 2 captopril tab 25 mg 2 captopril tab 50 mg 2 captopril tab 100 mg 2 enalapril maleate tab 2.5 mg 2 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1 enalaprilat iv inj 1.25 mg/ml 2 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2 fosinopril sodium tab 40 mg 2 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 moexipril hcl tab 7.5 mg 2 moexipril hcl tab 15 mg 2 perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 quinapril hcl tab 5 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2 quinapril hcl tab 40 mg 2 ramipril cap 1.25 mg 2 ramipril cap 2.5 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 25

36 ramipril cap 5 mg 2 ramipril cap 10 mg 2 trandolapril tab 1 mg 2 trandolapril tab 2 mg 2 trandolapril tab 4 mg 2 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr 2 clonidine hcl td patch weekly 0.2 mg/24hr 2 clonidine hcl td patch weekly 0.3 mg/24hr 2 guanfacine hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 4 PA DIBENZYLINE CAP 10MG 4 PA phenoxybenzamine hcl cap 10 mg 4 PA ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg 2 eplerenone tab 50 mg 2 spironolactone tab 25 mg 1 spironolactone tab 50 mg 2 spironolactone tab 100 mg 2 ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS telmisartan-amlodipine tab 40-5 mg 2 telmisartan-amlodipine tab mg 2 telmisartan-amlodipine tab 80-5 mg 2 telmisartan-amlodipine tab mg 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 26

37 candesartan cilexetil-hydrochlorothiazide 2 tab mg candesartan cilexetil-hydrochlorothiazide 2 tab mg candesartan cilexetil-hydrochlorothiazide 2 tab mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide 2 tab mg losartan potassium & hydrochlorothiazide 2 tab mg losartan potassium & hydrochlorothiazide 2 tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg 2 candesartan cilexetil tab 8 mg 2 candesartan cilexetil tab 16 mg 2 candesartan cilexetil tab 32 mg 2 eprosartan mesylate tab 600 mg 2 irbesartan tab 75 mg 2 irbesartan tab 150 mg 2 irbesartan tab 300 mg 2 losartan potassium tab 25 mg 2 losartan potassium tab 50 mg 2 losartan potassium tab 100 mg 2 telmisartan tab 20 mg 2 telmisartan tab 40 mg 2 telmisartan tab 80 mg 2 valsartan tab 40 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 27

38 valsartan tab 80 mg 2 valsartan tab 160 mg 2 valsartan tab 320 mg 2 ANTIARRHYTHMICS adenosine iv soln 6 mg/2ml 2 adenosine iv soln 12 mg/4ml 2 amiodarone hcl tab 100 mg 4 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 CORVERT INJ 1MG/10ML 4 disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 ibutilide fumarate inj 1 mg/10ml 2 lidocaine hcl iv inj 10 mg/ml 2 lidocaine hcl iv inj 20 mg/ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ TAB 400MG 3 NEXTERONE INJ 4 NORPACE CAP 100MG CR 4 NORPACE CAP 150MG CR 4 PROCAINAMIDE HCL INJ 500 MG/ML 2 propafenone hcl cap er 12hr 225 mg 2 propafenone hcl cap er 12hr 325 mg 2 propafenone hcl cap er 12hr 425 mg 2 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 quinidine sulfate tab 200 mg 2 quinidine sulfate tab 300 mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl (afib/afl) tab 160 mg 2 sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 TIKOSYN CAP 125MCG 3 TIKOSYN CAP 250MCG 3 TIKOSYN CAP 500MCG 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 28

39 XYLOCAINE INJ 2% 4 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 COLESTID GRA 5GM 4 COLESTID POW 5GM 4 COLESTID TAB 1GM 4 colestipol hcl granule packets 5 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 2 ZETIA TAB 10MG 3 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg (fenofibric2 PA, ST acid equiv) choline fenofibrate cap dr 135 mg 2 PA, ST (fenofibric acid equiv) fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2 fenofibrate micronized cap 134 mg 2 fenofibrate micronized cap 200 mg 2 fenofibrate tab 48 mg 2 fenofibrate tab 54 mg 2 fenofibrate tab 145 mg 2 fenofibrate tab 160 mg 2 fenofibric acid tab 35 mg 2 fenofibric acid tab 105 mg 2 gemfibrozil tab 600 mg 2 LOPID TAB 600MG 4 TRILIPIX CAP 45MG 4 PA, ST TRILIPIX CAP 135MG 4 PA, ST ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base 2 equivalent) atorvastatin calcium tab 20 mg (base 2 equivalent) atorvastatin calcium tab 40 mg (base 2 equivalent) atorvastatin calcium tab 80 mg (base 2 equivalent) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 29

40 CRESTOR TAB 5MG 4 PA CRESTOR TAB 10MG 4 PA CRESTOR TAB 20MG 4 PA CRESTOR TAB 40MG 4 PA ezetimibe-simvastatin tab mg 4 QL ezetimibe-simvastatin tab mg 4 QL ezetimibe-simvastatin tab mg 4 QL ezetimibe-simvastatin tab mg 4 QL fluvastatin sodium cap 20 mg 2 fluvastatin sodium cap 40 mg 2 lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 pravastatin sodium tab 10 mg 2 pravastatin sodium tab 20 mg 2 pravastatin sodium tab 40 mg 2 pravastatin sodium tab 80 mg 2 rosuvastatin calcium tab 5 mg 2 rosuvastatin calcium tab 10 mg 2 rosuvastatin calcium tab 20 mg 2 rosuvastatin calcium tab 40 mg 2 simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 VYTORIN TAB 10-10MG 4 ST; QL VYTORIN TAB 10-20MG 4 ST; QL VYTORIN TAB 10-40MG 4 ST; QL VYTORIN TAB 10-80MG 4 ST; QL ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS JUXTAPID CAP 5MG 5 PA; QL JUXTAPID CAP 10MG 5 PA; QL JUXTAPID CAP 20MG 5 PA; QL JUXTAPID CAP 30MG 5 PA; QL JUXTAPID CAP 40MG 5 PA; QL JUXTAPID CAP 60MG 5 PA; QL ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 5 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 mg (antihyperlipidemic) 4 niacin tab er 750 mg (antihyperlipidemic) 4 niacin tab er 1000 mg (antihyperlipidemic) 4 ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 30

41 omega-3-acid ethyl esters cap 1 gm 4 VASCEPA CAP 1GM 3 ANTILIPEMICS, PCSK9 INHIBITORS REPATHA INJ 140MG/ML 5 PA; QL REPATHA PUSH INJ 420/3.5 5 PA; QL REPATHA SURE INJ 140MG/ML 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab mg 2 atenolol & chlorthalidone tab mg 2 bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg nadolol & bendroflumethiazide tab 40-5 mg2 nadolol & bendroflumethiazide tab 80-5 mg2 propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg BETA-BLOCKERS acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 25 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 BYSTOLIC TAB 2.5MG 4 PA, ST BYSTOLIC TAB 5MG 4 PA, ST BYSTOLIC TAB 10MG 4 PA, ST BYSTOLIC TAB 20MG 4 PA, ST carvedilol tab mg 1 carvedilol tab 6.25 mg 1 carvedilol tab 12.5 mg 1 carvedilol tab 25 mg 1 INNOPRAN XL CAP 80MG 4 ST INNOPRAN XL CAP 120MG 4 ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 31

42 labetalol hcl iv soln 5 mg/ml 2 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 metoprolol succinate tab er 24hr 25 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 200 mg 2 (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml 2 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap er 24hr 60 mg 2 propranolol hcl cap er 24hr 80 mg 2 propranolol hcl cap er 24hr 120 mg 2 propranolol hcl cap er 24hr 160 mg 2 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 2 propranolol hcl tab 40 mg 2 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 2 timolol maleate tab 5 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 CLEVIPREX EMU 50/100ML 4 felodipine tab er 24hr 2.5 mg 2 felodipine tab er 24hr 5 mg 2 felodipine tab er 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 32

43 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedipine cap 20 mg 2 nifedipine tab er 24hr 30 mg 2 nifedipine tab er 24hr 60 mg 2 nifedipine tab er 24hr 90 mg 2 nifedipine tab er 24hr osmotic release 90 2 mg nimodipine cap 30 mg 2 nisoldipine tab er 24hr 8.5 mg 2 nisoldipine tab er 24hr 17 mg 2 nisoldipine tab er 24hr 20 mg 2 nisoldipine tab er 24hr 25.5 mg 2 nisoldipine tab er 24hr 30 mg 2 nisoldipine tab er 24hr 34 mg 2 nisoldipine tab er 24hr 40 mg 2 NORVASC TAB 2.5MG 4 NORVASC TAB 5MG 4 NORVASC TAB 10MG 4 SULAR TAB 8.5MG 4 SULAR TAB 17MG 4 SULAR TAB 34MG 4 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CARDIZEM LA TAB 120MG 4 diltiazem hcl cap er 12hr 60 mg 2 diltiazem hcl cap er 12hr 90 mg 2 diltiazem hcl cap er 12hr 120 mg 2 diltiazem hcl cap er 24hr 120 mg 2 diltiazem hcl cap er 24hr 180 mg 2 diltiazem hcl cap er 24hr 240 mg 2 diltiazem hcl coated beads cap er 24hr mg diltiazem hcl coated beads cap er 24hr mg diltiazem hcl coated beads cap er 24hr mg diltiazem hcl coated beads cap er 24hr mg diltiazem hcl coated beads cap er 24hr mg diltiazem hcl coated beads tab er 24hr mg diltiazem hcl coated beads tab er 24hr mg diltiazem hcl coated beads tab er 24hr mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 33

44 diltiazem hcl coated beads tab er 24hr mg diltiazem hcl coated beads tab er 24hr mg diltiazem hcl extended release beads cap 2 er 24hr 120 mg diltiazem hcl extended release beads cap 2 er 24hr 180 mg diltiazem hcl extended release beads cap 2 er 24hr 240 mg diltiazem hcl extended release beads cap 2 er 24hr 300 mg diltiazem hcl extended release beads cap 2 er 24hr 360 mg diltiazem hcl extended release beads cap 2 er 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2 diltiazem hcl iv soln 50 mg/10ml (5 2 mg/ml) diltiazem hcl iv soln 125 mg/25ml (5 2 mg/ml) diltiazem hcl tab 30 mg 2 diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 DILTIAZEM INJ 100MG 2 verapamil hcl cap er 24hr 100 mg 2 verapamil hcl cap er 24hr 120 mg 2 verapamil hcl cap er 24hr 180 mg 2 verapamil hcl cap er 24hr 200 mg 2 verapamil hcl cap er 24hr 240 mg 2 verapamil hcl cap er 24hr 300 mg 2 verapamil hcl cap er 24hr 360 mg 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab er 120 mg 2 verapamil hcl tab er 180 mg 2 verapamil hcl tab er 240 mg 2 DIGITALIS GLYCOSIDES digoxin inj 0.25 mg/ml 2 digoxin oral soln 0.05 mg/ml 2 digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 LANOXIN INJ 0.25MG/1 4 LANOXIN PED INJ 0.1MG/ML 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 34

45 LANOXIN TAB 0.25MG 4 LANOXIN TAB 0.125MG 4 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB ST TEKTURNA HCT TAB MG 3 ST TEKTURNA HCT TAB ST TEKTURNA HCT TAB MG 3 ST TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST DIURETICS acetazolamide cap er 12hr 500 mg 2 acetazolamide sodium for inj 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 ALDACTAZIDE TAB 50/50 4 amiloride & hydrochlorothiazide tab mg amiloride hcl tab 5 mg 2 bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 DIURIL SUS 250/5ML 3 DYRENIUM CAP 50MG 4 DYRENIUM CAP 100MG 4 furosemide inj 10 mg/ml 2 furosemide oral soln 8 mg/ml 2 furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 2 indapamide tab 2.5 mg 2 KEVEYIS TAB 50MG 5 PA; QL methazolamide tab 25 mg 2 methazolamide tab 50 mg 2 methyclothiazide tab 5 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 35

46 metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2 spironolactone & hydrochlorothiazide tab mg torsemide tab 5 mg 2 torsemide tab 10 mg 2 torsemide tab 20 mg 2 torsemide tab 100 mg 2 triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg HEART FAILURE CORLANOR TAB 5MG 4 PA; QL CORLANOR TAB 7.5MG 4 PA; QL ENTRESTO TAB 24-26MG 3 PA; QL ENTRESTO TAB 49-51MG 3 PA; QL ENTRESTO TAB MG 3 PA; QL MISCELLANEOUS alprostadil inj 500 mcg/ml 2 atropine sulfate inj 0.4 mg/ml 2 atropine sulfate inj 1 mg/ml 2 atropine sulfate soln prefill syr 0.5 mg/5ml 2 (0.1 mg/ml) atropine sulfate soln prefill syr mg/5ml (0.05 mg/ml) clonidine & chlorthalidone tab mg 2 clonidine & chlorthalidone tab mg 2 clonidine & chlorthalidone tab mg 2 ETHAMOLIN INJ 5% 4 hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 1 methyldopa & hydrochlorothiazide tab mg methyldopa & hydrochlorothiazide tab mg methyldopa tab 250 mg 2 methyldopa tab 500 mg 2 methyldopate hcl inj 250 mg/5ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 36

47 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 milrinone lactate in dextrose 5% iv soln 20 2 mg/100ml milrinone lactate in dextrose 5% iv soln 40 2 mg/200ml milrinone lactate iv soln 10 mg/10ml (base 2 equivalent) milrinone lactate iv soln 20 mg/20ml (base 2 equivalent) milrinone lactate iv soln 50 mg/50ml (base 2 equivalent) minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 NATRECOR INJ 1.5MG 4 NEOPROFEN SOL 10MG/ML 4 NORTHERA CAP 200MG 5 PA; QL NORTHERA CAP 300MG 5 PA; QL papaverine hcl inj 30 mg/ml 2 PROSTIN VR INJ 500MCG 4 RANEXA TAB 500MG 3 RANEXA TAB 1000MG 3 NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML 2 NITRATES, ORAL ISORDIL TAB 40MG 4 isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab er 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab er 24hr 30 mg 2 isosorbide mononitrate tab er 24hr 60 mg 2 isosorbide mononitrate tab er 24hr 120 mg 2 nitroglycerin cap er 2.5 mg 2 nitroglycerin cap er 6.5 mg 2 nitroglycerin cap er 9 mg 2 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray2 nitroglycerin sl tab 0.3 mg 2 nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 37

48 NITROLINGUAL SPR PUMPSPRA 4 NITROSTAT SUB 0.3MG 4 NITROSTAT SUB 0.4MG 4 NITROSTAT SUB 0.6MG 4 NITRATES, TRANSDERMAL NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.1MG/HR 4 NITRO-DUR DIS 0.2MG/HR 4 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.4MG/HR 4 NITRO-DUR DIS 0.6MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS TAB 5MG 5 PA; QL LETAIRIS TAB 10MG 5 PA; QL TRACLEER TAB 62.5MG 5 PA; QL TRACLEER TAB 125MG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR REVATIO TAB 20MG 5 PA; QL sildenafil citrate tab 20 mg 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI TAB 200/800 4 PA; QL UPTRAVI TAB 200MCG 5 PA; QL UPTRAVI TAB 400MCG 5 PA; QL UPTRAVI TAB 600MCG 5 PA; QL UPTRAVI TAB 800MCG 5 PA; QL UPTRAVI TAB 1000MCG 5 PA; QL UPTRAVI TAB 1200MCG 5 PA; QL UPTRAVI TAB 1400MCG 5 PA; QL UPTRAVI TAB 1600MCG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 mg 5 PA FLOLAN INJ 0.5MG 5 PA FLOLAN INJ 1.5MG 5 PA ORENITRAM TAB 0.25MG 5 PA ORENITRAM TAB 0.125MG 5 PA ORENITRAM TAB 1MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 38

49 ORENITRAM TAB 2.5MG 5 PA ORENITRAM TAB 5MG 5 PA REMODULIN INJ 1MG/ML 5 PA REMODULIN INJ 2.5MG/ML 5 PA REMODULIN INJ 5MG/ML 5 PA REMODULIN INJ 10MG/ML 5 PA TYVASO START SOL 0.6MG/ML 5 PA VELETRI INJ 0.5MG 5 PA VENTAVIS SOL 10MCG/ML 5 PA VENTAVIS SOL 20MCG/ML 5 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 5 PA; QL ADEMPAS TAB 1.5MG 5 PA; QL ADEMPAS TAB 1MG 5 PA; QL ADEMPAS TAB 2.5MG 5 PA; QL ADEMPAS TAB 2MG 5 PA; QL VASOPRESSORS dobutamine hcl inj 12.5 mg/ml 2 dobutamine inj 1 mg/ml in d5w 2 dobutamine inj 2 mg/ml in d5w 2 dobutamine inj 4 mg/ml in d5w 2 dopamine hcl inj 40 mg/ml 2 dopamine hcl inj 80 mg/ml 2 dopamine hcl inj 160 mg/ml 2 ephedrine sulfate inj 50 mg/ml 2 EPINEPHRINE INJ 1MG/ML 4 phenylephrine hcl inj 10 mg/ml 2 CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 2 alprazolam orally disintegrating tab 0.5 mg 2 ST alprazolam orally disintegrating tab ST mg alprazolam orally disintegrating tab 1 mg 2 ST alprazolam orally disintegrating tab 2 mg 2 ST alprazolam tab 0.5 mg 2 alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 2 mg 2 alprazolam tab er 24hr 0.5 mg 2 alprazolam tab er 24hr 1 mg 2 alprazolam tab er 24hr 2 mg 2 alprazolam tab er 24hr 3 mg 2 chlordiazepoxide hcl cap 5 mg 2 chlordiazepoxide hcl cap 10 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 39

50 chlordiazepoxide hcl cap 25 mg 2 clonazepam orally disintegrating tab ST mg clonazepam orally disintegrating tab 0.25 mg 2 ST clonazepam orally disintegrating tab ST mg clonazepam orally disintegrating tab 1 mg 2 ST clonazepam orally disintegrating tab 2 mg 2 ST clonazepam tab 0.5 mg 2 clonazepam tab 1 mg 2 clonazepam tab 2 mg 2 clorazepate dipotassium tab 3.75 mg 2 clorazepate dipotassium tab 7.5 mg 2 clorazepate dipotassium tab 15 mg 2 diazepam conc 5 mg/ml 2 diazepam inj 5 mg/ml 2 DIAZEPAM INJ 10MG/2ML 2 diazepam oral soln 1 mg/ml 2 diazepam tab 2 mg 2 diazepam tab 5 mg 2 diazepam tab 10 mg 2 lorazepam conc 2 mg/ml 2 lorazepam inj 2 mg/ml 2 lorazepam inj 4 mg/ml 2 lorazepam tab 0.5 mg 2 lorazepam tab 1 mg 2 lorazepam tab 2 mg 2 oxazepam cap 10 mg 2 oxazepam cap 15 mg 2 oxazepam cap 30 mg 2 ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 2 clomipramine hcl cap 25 mg 4 ST clomipramine hcl cap 50 mg 4 ST clomipramine hcl cap 75 mg 4 ST fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 meprobamate tab 200 mg 2 meprobamate tab 400 mg 2 ANTICONVULSANTS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 40

51 APTIOM TAB 200MG 4 PA; QL APTIOM TAB 400MG 4 PA; QL APTIOM TAB 600MG 4 PA; QL APTIOM TAB 800MG 4 PA; QL BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 4 PA BRIVIACT INJ 50MG/5ML 4 PA; QL BRIVIACT SOL 10MG/ML 4 PA; QL BRIVIACT TAB 10MG 4 PA; QL BRIVIACT TAB 25MG 4 PA; QL BRIVIACT TAB 50MG 4 PA; QL BRIVIACT TAB 75MG 4 PA; QL BRIVIACT TAB 100MG 4 PA; QL carbamazepine cap er 12hr 100 mg 2 carbamazepine cap er 12hr 200 mg 2 carbamazepine cap er 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 1 carbamazepine tab er 12hr 100 mg 2 carbamazepine tab er 12hr 200 mg 2 carbamazepine tab er 12hr 400 mg 2 CARBATROL CAP 100MG 4 CARBATROL CAP 200MG 4 CARBATROL CAP 300MG 4 CELONTIN CAP 300MG 3 CEREBYX INJ 100/2ML 4 CEREBYX INJ 500/10ML 4 DEPAKOTE ER TAB 500MG 4 DIASTAT ACDL GEL 5-10MG 4 DIASTAT ACDL GEL DIASTAT PED GEL 2.5M GEL 3 DILANTIN CAP 30MG 3 DILANTIN CAP 100MG 3 DILANTIN CHW 50MG 3 DILANTIN-125 SUS 125/5ML 3 divalproex sodium cap delayed release sprinkle 125 mg 2 divalproex sodium tab delayed release mg divalproex sodium tab delayed release mg divalproex sodium tab delayed release mg divalproex sodium tab er 24 hr 250 mg 2 divalproex sodium tab er 24 hr 500 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 41

52 ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 fosphenytoin sodium inj 100 mg/2ml 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml 2 (phenytoin equiv) FYCOMPA SUS 0.5MG/ML 4 QL FYCOMPA TAB 2MG 4 PA; QL FYCOMPA TAB 4MG 4 PA; QL FYCOMPA TAB 6MG 4 PA; QL FYCOMPA TAB 8MG 4 PA; QL FYCOMPA TAB 10MG 4 PA; QL FYCOMPA TAB 12MG 4 PA; QL gabapentin cap 100 mg 1 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 KEPPRA INJ 500/5ML 4 KEPPRA SOL 100MG/ML 4 KEPPRA TAB 250MG 4 KEPPRA TAB 500MG 4 KEPPRA TAB 750MG 4 KEPPRA TAB 1000MG 4 KEPPRA XR TAB 500MG 4 QL KEPPRA XR TAB 750MG 4 QL lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg2 levetiracetam inj 500 mg/5ml (100 mg/ml)2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab er 24hr 500 mg 2 QL levetiracetam tab er 24hr 750 mg 2 QL ONFI SUS 2.5MG/ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 42

53 ONFI TAB 10MG 5 PA; QL ONFI TAB 20MG 5 PA; QL oxcarbazepine susp 300 mg/5ml (60 2 mg/ml) oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 PHENOBARB INJ 65MG/ML 2 phenobarbital elixir 20 mg/5ml 2 phenobarbital sodium inj 130 mg/ml 2 phenobarbital tab 15 mg 2 phenobarbital tab 16.2 mg 2 phenobarbital tab 30 mg 2 phenobarbital tab 32.4 mg 2 phenobarbital tab 60 mg 2 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 phenobarbital tab 100 mg 2 PHENYTEK CAP 200MG 3 PHENYTEK CAP 300MG 3 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 primidone tab 50 mg 2 primidone tab 250 mg 2 SABRIL POW 500MG 5 PA; QL SABRIL TAB 500MG 5 PA; QL TEGRETOL SUS 100/5ML 4 TEGRETOL-XR TAB 100MG 4 TEGRETOL-XR TAB 200MG 4 TEGRETOL-XR TAB 400MG 4 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 topiramate sprinkle cap 15 mg 2 QL topiramate sprinkle cap 25 mg 2 QL topiramate tab 25 mg 2 topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 valproate sodium inj 100 mg/ml 2 valproate sodium oral soln 250 mg/5ml 2 (base equiv) valproic acid cap 250 mg 2 VIMPAT INJ 200MG/20 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 43

54 VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2 ANTIDEMENTIA donepezil hydrochloride orally 2 disintegrating tab 5 mg donepezil hydrochloride orally 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 2 donepezil hydrochloride tab 10 mg 2 galantamine hydrobromide cap er 24hr 8 mg 2 PA galantamine hydrobromide cap er 24hr 16 2 PA mg galantamine hydrobromide cap er 24hr 24 2 PA mg galantamine hydrobromide oral soln 4 2 PA mg/ml galantamine hydrobromide tab 4 mg 2 PA galantamine hydrobromide tab 8 mg 2 PA galantamine hydrobromide tab 12 mg 2 PA memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 5 mg 2 memantine hcl tab 5 mg (28) & 10 mg 2 (21) titration pak memantine hcl tab 10 mg 2 rivastigmine tartrate cap 1.5 mg 2 PA rivastigmine tartrate cap 3 mg 2 PA rivastigmine tartrate cap 4.5 mg 2 PA rivastigmine tartrate cap 6 mg 2 PA rivastigmine td patch 24hr 4.6 mg/24hr 2 PA rivastigmine td patch 24hr 9.5 mg/24hr 2 PA rivastigmine td patch 24hr 13.3 mg/24hr 2 PA ANTIDEPRESSANTS, MAOIS MARPLAN TAB 10MG 3 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg 2 bupropion hcl tab 100 mg 2 bupropion hcl tab er 12hr 100 mg 2 bupropion hcl tab er 12hr 150 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 44

55 bupropion hcl tab er 12hr 200 mg 2 bupropion hcl tab er 24hr 150 mg 2 bupropion hcl tab er 24hr 300 mg 2 chlordiazepoxide-amitriptyline tab mg chlordiazepoxide-amitriptyline tab mg maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 2 ANTIDEPRESSANTS, SNRIS DESVENLAFAX TAB 50MG ER 4 ST; QL desvenlafaxine succinate tab er 24hr 25 4 ST; QL mg (base equiv) desvenlafaxine succinate tab er 24hr 50 4 ST; QL mg (base equiv) desvenlafaxine succinate tab er 24hr ST; QL mg (base equiv) desvenlafaxine tab er 24hr 50 mg 4 ST; QL desvenlafaxine tab er 24hr 100 mg 4 ST; QL duloxetine hcl enteric coated pellets cap 202 QL mg (base eq) duloxetine hcl enteric coated pellets cap 302 QL mg (base eq) duloxetine hcl enteric coated pellets cap 602 QL mg (base eq) FETZIMA CAP 20MG 4 PA; QL FETZIMA CAP 40MG 4 PA; QL FETZIMA CAP 80MG 4 PA; QL FETZIMA CAP 120MG 4 PA; QL FETZIMA CAP TITRATIO 4 PA; QL KHEDEZLA TAB 50MG ER 4 ST; QL KHEDEZLA TAB 100MG ER 4 ST; QL PRISTIQ TAB 25MG 4 ST; QL PRISTIQ TAB 50MG 4 ST; QL PRISTIQ TAB 100MG 4 ST; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 45

56 venlafaxine hcl cap er 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl cap er 24hr 75 mg (base 2 equivalent) venlafaxine hcl cap er 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 venlafaxine hcl tab er 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl tab er 24hr 75 mg (base 2 equivalent) venlafaxine hcl tab er 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab er 24hr 225 mg (base 2 equivalent) ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10 2 mg/5ml citalopram hydrobromide tab 10 mg (base 1 QL equiv) citalopram hydrobromide tab 20 mg (base 1 QL equiv) citalopram hydrobromide tab 40 mg (base 1 QL equiv) escitalopram oxalate soln 5 mg/5ml (base 2 QL equiv) escitalopram oxalate tab 5 mg (base 2 QL equiv) escitalopram oxalate tab 10 mg (base 2 QL equiv) escitalopram oxalate tab 20 mg (base 2 QL equiv) fluoxetine hcl (pmdd) cap 10 mg 1 fluoxetine hcl (pmdd) cap 20 mg 1 fluoxetine hcl (pmdd) tab 10 mg 1 fluoxetine hcl (pmdd) tab 20 mg 1 fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 1 fluoxetine hcl cap delayed release 90 mg 2 QL fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 paroxetine hcl tab 10 mg 1 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 46

57 paroxetine hcl tab 20 mg 1 QL paroxetine hcl tab 30 mg 2 QL paroxetine hcl tab 40 mg 2 QL paroxetine hcl tab er 24hr 12.5 mg 2 QL paroxetine hcl tab er 24hr 25 mg 2 QL paroxetine hcl tab er 24hr 37.5 mg 2 QL PAXIL SUS 10MG/5ML 3 QL sertraline hcl oral conc 20 mg/ml 2 sertraline hcl tab 25 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 TRINTELLIX TAB 5MG 4 PA; QL TRINTELLIX TAB 10MG 4 PA; QL TRINTELLIX TAB 20MG 4 PA; QL VIIBRYD KIT STARTER 4 PA; QL VIIBRYD TAB 10MG 4 PA; QL VIIBRYD TAB 20MG 4 PA; QL VIIBRYD TAB 40MG 4 PA; QL ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 2 amitriptyline hcl tab 75 mg 2 amitriptyline hcl tab 100 mg 2 amitriptyline hcl tab 150 mg 2 amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 desipramine hcl tab 10 mg 2 desipramine hcl tab 25 mg 2 desipramine hcl tab 50 mg 2 desipramine hcl tab 75 mg 2 desipramine hcl tab 100 mg 2 desipramine hcl tab 150 mg 2 doxepin hcl cap 10 mg 2 doxepin hcl cap 25 mg 2 doxepin hcl cap 50 mg 2 doxepin hcl cap 75 mg 2 doxepin hcl cap 100 mg 2 doxepin hcl cap 150 mg 2 doxepin hcl conc 10 mg/ml 2 imipramine hcl tab 10 mg 2 imipramine hcl tab 25 mg 2 imipramine hcl tab 50 mg 2 imipramine pamoate cap 75 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 47

58 imipramine pamoate cap 100 mg 2 imipramine pamoate cap 125 mg 2 imipramine pamoate cap 150 mg 2 nortriptyline hcl cap 10 mg 1 nortriptyline hcl cap 25 mg 1 nortriptyline hcl cap 50 mg 1 nortriptyline hcl cap 75 mg 2 nortriptyline hcl soln 10 mg/5ml 2 protriptyline hcl tab 5 mg 2 protriptyline hcl tab 10 mg 2 SURMONTIL CAP 25MG 4 SURMONTIL CAP 50MG 4 SURMONTIL CAP 100MG 4 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 2 amantadine hcl syrup 50 mg/5ml 2 amantadine hcl tab 100 mg 2 APOKYN INJ 10MG/ML 5 PA; QL AZILECT TAB 0.5MG 3 AZILECT TAB 1MG 3 benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 bromocriptine mesylate cap 5 mg (base 2 equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) 2 carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa tab mg 2 carbidopa & levodopa tab mg 2 carbidopa & levodopa tab mg 2 carbidopa & levodopa tab er mg 2 carbidopa & levodopa tab er mg 2 carbidopa tab 25 mg 2 carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 48

59 carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg DUOPA SUS PA entacapone tab 200 mg 2 NEUPRO DIS 1MG/24HR 4 NEUPRO DIS 2MG/24HR 4 NEUPRO DIS 3MG/24HR 4 NEUPRO DIS 4MG/24HR 4 NEUPRO DIS 6MG/24HR 4 NEUPRO DIS 8MG/24HR 4 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr 3 2 mg pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr mg rasagiline mesylate tab 0.5 mg (base 2 equiv) rasagiline mesylate tab 1 mg (base equiv) 2 ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 ropinirole hydrochloride tab er 24hr 2 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) 2 ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 49

60 ropinirole hydrochloride tab er 24hr 6 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) 2 ST ropinirole hydrochloride tab er 24hr 12 mg 2 ST (base equivalent) selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 trihexyphenidyl hcl elixir 0.4 mg/ml 2 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 2 ZELAPAR TAB 1.25MG 4 ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 4 PA; QL ABILIFY MAIN INJ 400MG 4 PA; QL aripiprazole oral solution 1 mg/ml 4 PA; QL aripiprazole orally disintegrating tab 10 mg 4 PA; QL aripiprazole orally disintegrating tab 15 mg 4 PA; QL aripiprazole tab 2 mg 4 PA; QL aripiprazole tab 5 mg 4 PA; QL aripiprazole tab 10 mg 4 PA; QL aripiprazole tab 15 mg 4 PA; QL aripiprazole tab 20 mg 4 PA; QL aripiprazole tab 30 mg 4 PA; QL ARISTADA INJ 441MG/1. 5 QL ARISTADA INJ 662MG/2 5 QL ARISTADA INJ 882MG/3 5 QL ARISTADA INJ 1064MG 5 PA; QL clozapine orally disintegrating tab 12.5 mg 2 PA; QL clozapine orally disintegrating tab 25 mg 2 PA; QL clozapine orally disintegrating tab 100 mg 2 PA; QL clozapine orally disintegrating tab 150 mg 2 PA; QL clozapine orally disintegrating tab 200 mg 2 PA; QL clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 FANAPT PAK 4 PA; QL FANAPT TAB 1MG 4 PA; QL FANAPT TAB 2MG 4 PA; QL FANAPT TAB 4MG 4 PA; QL FANAPT TAB 6MG 4 PA; QL FANAPT TAB 8MG 4 PA; QL FANAPT TAB 10MG 4 PA; QL FANAPT TAB 12MG 4 PA; QL GEODON INJ 20MG 4 INVEGA SUST INJ 39/ PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 50

61 INVEGA SUST INJ 78/0.5ML 5 PA; QL INVEGA SUST INJ 117/ PA; QL INVEGA SUST INJ 156MG/ML 5 PA; QL INVEGA SUST INJ 234/1.5 5 PA; QL INVEGA TRINZ INJ 273MG 5 PA; QL INVEGA TRINZ INJ 410MG 5 PA; QL INVEGA TRINZ INJ 546MG 5 PA; QL INVEGA TRINZ INJ 819MG 5 PA; QL LATUDA TAB 20MG 4 ST; QL LATUDA TAB 40MG 4 ST; QL LATUDA TAB 60MG 4 ST; QL LATUDA TAB 80MG 4 ST; QL LATUDA TAB 120MG 4 ST; QL loxapine succinate cap 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 50 mg 2 NUPLAZID TAB 17MG 5 PA; QL olanzapine for im inj 10 mg 2 olanzapine orally disintegrating tab 5 mg 2 QL olanzapine orally disintegrating tab 10 mg 2 QL olanzapine orally disintegrating tab 15 mg 2 QL olanzapine orally disintegrating tab 20 mg 2 QL olanzapine tab 2.5 mg 2 QL olanzapine tab 5 mg 2 QL olanzapine tab 7.5 mg 2 QL olanzapine tab 10 mg 2 QL olanzapine tab 15 mg 2 QL olanzapine tab 20 mg 2 QL paliperidone tab er 24hr 1.5 mg 4 PA; QL paliperidone tab er 24hr 3 mg 4 PA; QL paliperidone tab er 24hr 6 mg 4 PA; QL paliperidone tab er 24hr 9 mg 4 PA; QL quetiapine fumarate tab 25 mg 2 QL quetiapine fumarate tab 50 mg 2 QL quetiapine fumarate tab 100 mg 2 QL quetiapine fumarate tab 200 mg 2 QL quetiapine fumarate tab 300 mg 2 QL quetiapine fumarate tab 400 mg 2 QL RISPERDAL INJ 12.5MG 4 QL RISPERDAL INJ 25MG 4 QL RISPERDAL INJ 37.5MG 5 QL RISPERDAL INJ 50MG 4 QL risperidone orally disintegrating tab 0.5 mg 2 QL risperidone orally disintegrating tab 0.25 mg 2 QL risperidone orally disintegrating tab 1 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 51

62 risperidone orally disintegrating tab 2 mg 2 QL risperidone soln 1 mg/ml 2 QL risperidone tab 0.5 mg 2 QL risperidone tab 0.25 mg 2 QL risperidone tab 1 mg 2 QL risperidone tab 2 mg 2 QL risperidone tab 3 mg 2 QL risperidone tab 4 mg 2 QL SAPHRIS SUB 2.5MG 4 ST; QL SAPHRIS SUB 5MG 4 ST; QL SAPHRIS SUB 10MG 4 ST; QL SEROQUEL XR TAB 50MG 4 QL SEROQUEL XR TAB 150MG 4 QL SEROQUEL XR TAB 200MG 4 QL SEROQUEL XR TAB 300MG 4 QL SEROQUEL XR TAB 400MG 4 QL ziprasidone hcl cap 20 mg 2 QL ziprasidone hcl cap 40 mg 2 QL ziprasidone hcl cap 60 mg 2 QL ziprasidone hcl cap 80 mg 2 QL ZYPREXA RELP INJ 210MG 4 PA; QL ZYPREXA RELP INJ 300MG 4 PA; QL ZYPREXA RELP INJ 405MG 4 PA; QL ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML 2 CHLORPROMAZ INJ 50MG/2ML 2 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 fluphenazine hcl tab 10 mg 2 HALDOL DECAN INJ 50MG/ML 4 HALDOL DECAN INJ 100MG/ML 4 HALDOL INJ 5MG/ML 4 haloperidol decanoate im soln 50 mg/ml 2 haloperidol decanoate im soln 100 mg/ml 2 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 52

63 haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 2 haloperidol tab 5 mg 2 haloperidol tab 10 mg 2 haloperidol tab 20 mg 2 perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 perphenazine tab 16 mg 2 perphenazine-amitriptyline tab 2-10 mg 2 perphenazine-amitriptyline tab 2-25 mg 2 perphenazine-amitriptyline tab 4-10 mg 2 perphenazine-amitriptyline tab 4-25 mg 2 perphenazine-amitriptyline tab 4-50 mg 2 pimozide tab 1 mg 2 pimozide tab 2 mg 2 thioridazine hcl tab 10 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thioridazine hcl tab 100 mg 2 thiothixene cap 1 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 thiothixene cap 10 mg 2 trifluoperazine hcl tab 1 mg (base 2 equivalent) trifluoperazine hcl tab 2 mg (base 2 equivalent) trifluoperazine hcl tab 5 mg (base 2 equivalent) trifluoperazine hcl tab 10 mg (base 2 equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 4 QL ADDERALL TAB 7.5MG 4 QL ADDERALL TAB 10MG 4 QL ADDERALL TAB 12.5MG 4 QL ADDERALL TAB 15MG 4 QL ADDERALL TAB 20MG 4 QL ADDERALL TAB 30MG 4 QL amphetamine-dextroamphetamine cap er 2 QL 24hr 5 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 10 mg amphetamine-dextroamphetamine cap er 24hr 15 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 53

64 amphetamine-dextroamphetamine cap er 2 QL 24hr 20 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 25 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg 2 QL amphetamine-dextroamphetamine tab QL mg amphetamine-dextroamphetamine tab 10 2 QL mg amphetamine-dextroamphetamine tab 12.5 mg 2 QL amphetamine-dextroamphetamine tab 15 2 QL mg amphetamine-dextroamphetamine tab 20 2 QL mg amphetamine-dextroamphetamine tab 30 2 QL mg atomoxetine hcl cap 10 mg (base equiv) 2 QL atomoxetine hcl cap 18 mg (base equiv) 2 QL atomoxetine hcl cap 25 mg (base equiv) 2 QL atomoxetine hcl cap 40 mg (base equiv) 2 QL atomoxetine hcl cap 60 mg (base equiv) 2 QL atomoxetine hcl cap 80 mg (base equiv) 2 QL atomoxetine hcl cap 100 mg (base equiv) 2 QL clonidine hcl tab er 12hr 0.1 mg 2 QL DESOXYN TAB 5MG 4 QL DEXEDRINE CAP 5MG CR 4 QL DEXEDRINE CAP 10MG CR 4 QL DEXEDRINE CAP 15MG CR 4 QL dexmethylphenidate hcl cap er 24 hr 5 mg 2 QL dexmethylphenidate hcl cap er 24 hr 10 2 QL mg dexmethylphenidate hcl cap er 24 hr 15 2 QL mg dexmethylphenidate hcl cap er 24 hr 20 2 QL mg dexmethylphenidate hcl cap er 24 hr 25 2 QL mg dexmethylphenidate hcl cap er 24 hr 30 2 QL mg dexmethylphenidate hcl cap er 24 hr 35 2 QL mg dexmethylphenidate hcl cap er 24 hr 40 2 QL mg dexmethylphenidate hcl tab 2.5 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 54

65 dexmethylphenidate hcl tab 5 mg 2 QL dexmethylphenidate hcl tab 10 mg 2 QL dextroamphetamine sulfate cap er 24hr 5 mg 2 QL dextroamphetamine sulfate cap er 24hr 10 2 QL mg dextroamphetamine sulfate cap er 24hr 15 2 QL mg dextroamphetamine sulfate tab 5 mg 2 QL dextroamphetamine sulfate tab 10 mg 2 QL FOCALIN XR CAP 25MG 4 QL FOCALIN XR CAP 35MG 4 QL guanfacine hcl tab er 24hr 1 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 2 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 3 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 4 mg (base 2 QL equiv) methamphetamine hcl tab 5 mg 2 QL methylphenidate hcl cap er 10 mg (cd) 2 QL methylphenidate hcl cap er 20 mg (cd) 2 QL methylphenidate hcl cap er 24hr 20 mg 2 QL (la) methylphenidate hcl cap er 24hr 30 mg 2 QL (la) methylphenidate hcl cap er 24hr 40 mg 2 QL (la) methylphenidate hcl cap er 30 mg (cd) 2 QL methylphenidate hcl cap er 40 mg (cd) 2 QL methylphenidate hcl cap er 50 mg (cd) 2 QL methylphenidate hcl cap er 60 mg (cd) 2 QL methylphenidate hcl chew tab 2.5 mg 2 QL methylphenidate hcl chew tab 5 mg 2 QL methylphenidate hcl chew tab 10 mg 2 QL methylphenidate hcl soln 5 mg/5ml 2 QL methylphenidate hcl soln 10 mg/5ml 2 QL methylphenidate hcl tab 5 mg 2 QL methylphenidate hcl tab 10 mg 2 QL methylphenidate hcl tab 20 mg 2 QL methylphenidate hcl tab er 10 mg 2 QL methylphenidate hcl tab er 24hr 18 mg 2 QL methylphenidate hcl tab er 24hr 27 mg 2 QL methylphenidate hcl tab er 24hr 36 mg 2 QL methylphenidate hcl tab er 24hr 54 mg 2 QL methylphenidate hcl tab er osmotic release 2 QL (osm) 18 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 55

66 methylphenidate hcl tab er osmotic release 2 QL (osm) 27 mg methylphenidate hcl tab er osmotic release 2 QL (osm) 36 mg methylphenidate hcl tab er osmotic release 2 QL (osm) 54 mg STRATTERA CAP 10MG 4 QL STRATTERA CAP 18MG 4 QL STRATTERA CAP 25MG 4 QL STRATTERA CAP 40MG 4 QL STRATTERA CAP 60MG 4 QL STRATTERA CAP 80MG 4 QL STRATTERA CAP 100MG 4 QL VYVANSE CAP 10MG 4 PA; QL VYVANSE CAP 20MG 4 PA; QL VYVANSE CAP 30MG 4 PA; QL VYVANSE CAP 40MG 4 PA; QL VYVANSE CAP 50MG 4 PA; QL VYVANSE CAP 60MG 4 PA; QL VYVANSE CAP 70MG 4 PA; QL FIBROMYALGIA LYRICA CAP 25MG 4 PA; QL LYRICA CAP 50MG 4 PA; QL LYRICA CAP 75MG 4 PA; QL LYRICA CAP 100MG 4 PA; QL LYRICA CAP 150MG 4 PA; QL LYRICA CAP 200MG 4 PA; QL LYRICA CAP 225MG 4 PA; QL LYRICA CAP 300MG 4 PA; QL LYRICA SOL 20MG/ML 4 PA; QL SAVELLA MIS TITR PAK 4 PA; QL SAVELLA TAB 12.5MG 4 PA; QL SAVELLA TAB 25MG 4 PA; QL SAVELLA TAB 50MG 4 PA; QL SAVELLA TAB 100MG 4 PA; QL HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg 5 PA; QL tetrabenazine tab 25 mg 4 PA; QL XENAZINE TAB 12.5MG 5 PA; QL XENAZINE TAB 25MG 5 PA; QL HYPNOTICS, BENZODIAZEPINES estazolam tab 1 mg 2 estazolam tab 2 mg 2 flurazepam hcl cap 15 mg 2 flurazepam hcl cap 30 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 56

67 midazolam hcl inj 2 mg/2ml (base 2 equivalent) midazolam hcl inj 5 mg/5ml (base 2 equivalent) midazolam hcl inj 5 mg/ml (base 2 equivalent) midazolam hcl inj 10 mg/2ml (base 2 equivalent) midazolam hcl inj 10 mg/10ml (base 2 equivalent) midazolam hcl inj 25 mg/5ml (base 2 equivalent) midazolam hcl inj 50 mg/10ml (base 2 equivalent) midazolam hcl syrup 2 mg/ml (base 2 equivalent) temazepam cap 7.5 mg 2 temazepam cap 15 mg 2 temazepam cap 22.5 mg 2 temazepam cap 30 mg 2 triazolam tab 0.25 mg 2 triazolam tab mg 2 HYPNOTICS, NON-BENZODIAZEPINES AMYTAL SOD INJ 500MG 4 eszopiclone tab 1 mg 2 QL eszopiclone tab 2 mg 2 QL eszopiclone tab 3 mg 2 QL HETLIOZ CAP 20MG 5 PA; QL zaleplon cap 5 mg 2 QL zaleplon cap 10 mg 2 QL zolpidem tartrate tab 5 mg 2 QL zolpidem tartrate tab 10 mg 2 QL MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal spray 4 2 mg/ml MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 2 ST; QL almotriptan malate tab 12.5 mg 2 ST; QL AXERT TAB 6.25MG 4 ST; QL AXERT TAB 12.5MG 4 ST; QL FROVA TAB 2.5MG 4 ST; QL naratriptan hcl tab 1 mg (base equiv) 2 QL naratriptan hcl tab 2.5 mg (base equiv) 2 QL RELPAX TAB 20MG 4 ST; QL RELPAX TAB 40MG 4 ST; QL rizatriptan benzoate oral disintegrating tab 2 QL 5 mg (base eq) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 57

68 rizatriptan benzoate oral disintegrating tab 2 QL 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 QL equivalent) rizatriptan benzoate tab 10 mg (base 2 QL equivalent) sumatriptan nasal spray 5 mg/act 4 QL sumatriptan nasal spray 20 mg/act 4 QL sumatriptan succinate inj 6 mg/0.5ml 4 QL sumatriptan succinate solution 4 QL auto-injector 4 mg/0.5ml sumatriptan succinate solution auto-injector 6 mg/0.5ml 4 QL sumatriptan succinate solution cartridge 4 4 QL mg/0.5ml sumatriptan succinate solution cartridge 6 4 QL mg/0.5ml sumatriptan succinate tab 25 mg 4 QL sumatriptan succinate tab 50 mg 4 QL sumatriptan succinate tab 100 mg 4 QL zolmitriptan orally disintegrating tab 2.5 mg 2 QL zolmitriptan orally disintegrating tab 5 mg 2 QL zolmitriptan tab 2.5 mg 2 QL zolmitriptan tab 5 mg 2 QL ZOMIG SPR 2.5MG 4 QL ZOMIG SPR 5MG 4 QL MISCELLANEOUS BLOXIVERZ INJ 5MG/10ML 4 BLOXIVERZ INJ 10/10ML 4 BOTOX INJ 100UNIT 5 PA; QL BOTOX INJ 200UNIT 5 PA; QL caffeine & sodium benzoate inj mg/ml (500 mg/2ml) DYSPORT INJ 300UNIT 5 PA; QL DYSPORT INJ 500UNIT 5 PA; QL GUANIDINE TAB 125MG 2 neostigmine methylsulfate iv soln 5 mg/10 4 ml (0.5 mg/ml) neostigmine methylsulfate iv soln 10 4 mg/10 ml (1 mg/ml) REGONOL INJ 5MG/ML 4 riluzole tab 50 mg 5 PA; QL XEOMIN INJ 50 UNIT 5 PA; QL XEOMIN INJ 100UNIT 5 PA; QL XEOMIN INJ 200UNIT 5 PA; QL MOOD STABILIZERS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 58

69 lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 2 lithium carbonate tab 300 mg 2 lithium carbonate tab er 300 mg 2 lithium carbonate tab er 450 mg 2 LITHIUM SOL 8MEQ/5ML 2 MULTIPLE SCLEROSIS AMPYRA TAB 10MG 5 PA; QL AUBAGIO TAB 7MG 5 PA; QL AUBAGIO TAB 14MG 5 PA; QL BETASERON INJ 0.3MG 5 ST; QL COPAXONE INJ 20MG/ML 5 QL COPAXONE INJ 40MG/ML 5 QL GILENYA CAP 0.5MG 5 PA; QL LEMTRADA INJ 12/1.2ML 5 PA REBIF INJ 22/0.5 5 PA, ST; QL REBIF INJ 44/0.5 5 PA, ST; QL REBIF REBIDO INJ 22/0.5 5 PA, ST; QL REBIF REBIDO INJ 44/0.5 5 PA, ST; QL REBIF REBIDO INJ TITRATN 5 PA, ST; QL REBIF TITRTN INJ PACK 5 PA, ST; QL TECFIDERA CAP 120MG 5 PA; QL TECFIDERA CAP 240MG 5 PA; QL TECFIDERA MIS STARTER 5 PA; QL TYSABRI INJ 300/15ML 5 PA; QL ZINBRYTA INJ 150MG/ML 5 PA; QL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg 2 baclofen tab 20 mg 2 carisoprodol tab 250 mg 2 QL carisoprodol tab 350 mg 2 QL carisoprodol w/ aspirin & codeine tab mg carisoprodol w/ aspirin tab mg 2 chlorzoxazone tab 500 mg 2 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 10 mg 1 dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 dantrolene sodium cap 100 mg 2 dantrolene sodium for iv soln 20 mg 2 GABLOFEN INJ 10000/20 4 GABLOFEN INJ 20000/20 4 GABLOFEN INJ 40000/20 4 LIORESAL INT INJ 0.05MG/1 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 59

70 LIORESAL INT INJ 10MG/5ML 4 LIORESAL INT INJ 10MG/20 4 LIORESAL INT INJ 40MG/20 4 metaxalone tab 800 mg 2 methocarbamol inj 1000 mg/10ml 2 methocarbamol tab 500 mg 2 methocarbamol tab 750 mg 2 orphenadrine citrate inj 30 mg/ml 2 orphenadrine citrate tab er 12hr 100 mg 2 tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2 MYASTHENIA GRAVIS ENLON INJ 150/15ML 4 MESTINON SYP 60MG/5ML 3 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab er 180 mg 5 NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 4 PA; QL armodafinil tab 150 mg 4 PA; QL armodafinil tab 200 mg 4 PA; QL armodafinil tab 250 mg 4 PA; QL modafinil tab 100 mg 4 PA; QL modafinil tab 200 mg 4 PA; QL NUVIGIL TAB 50MG 4 PA; QL NUVIGIL TAB 150MG 4 PA; QL NUVIGIL TAB 200MG 4 PA; QL NUVIGIL TAB 250MG 4 PA; QL PROVIGIL TAB 100MG 4 PA; QL PROVIGIL TAB 200MG 4 PA; QL XYREM SOL 500MG/ML 5 PA; QL NONDEPOLARIZING MUSCLE RELAXANTS ANECTINE INJ 20MG/ML 2 POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 4 PA; QL GRALISE TAB 300MG 4 PA; QL GRALISE TAB 600MG 4 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release mg disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 VIVITROL INJ 380MG 5 PA PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST EVZIO INJ 4 PA; QL naloxone hcl inj 0.4 mg/ml 2 naloxone hcl inj 4 mg/10ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 60

71 naloxone hcl soln cartridge 0.4 mg/ml 2 naloxone hcl soln prefilled syringe 2 2 mg/2ml naltrexone hcl tab 50 mg 2 NARCAN SPR 3 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS BUNAVAIL MIS QL BUNAVAIL MIS QL BUNAVAIL MIS 6.3-1MG 4 QL buprenorphine hcl-naloxone hcl sl tab mg (base equiv) 2 QL buprenorphine hcl-naloxone hcl sl tab QL mg (base equiv) SUBOXONE MIS 2-0.5MG 3 QL SUBOXONE MIS 4-1MG 3 QL SUBOXONE MIS 8-2MG 3 QL SUBOXONE MIS 12-3MG 3 QL ZUBSOLV SUB QL ZUBSOLV SUB QL ZUBSOLV SUB QL ZUBSOLV SUB QL ZUBSOLV SUB QL ZUBSOLV SUB QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) 2 QL buprenorphine hcl sl tab 8 mg (base equiv) 2 QL PROBUPHINE IMP KIT PA; QL PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 5 PA; QL PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 2 12hr 150 mg NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR 4 PA ANDRODERM DIS 4MG/24HR 4 PA ANDROGEL GEL 1%(25MG) 3 PA ANDROGEL GEL 1.62% 3 PA ANDROGEL GEL PUMP 1% 3 PA AVEED INJ 750/3ML 4 PA FORTESTA GEL 10MG/ACT 4 PA methyltestosterone cap 10 mg 5 PA STRIANT MIS 30MG 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 61

72 TESTIM GEL 1%(50MG) 4 PA TESTOPEL MIS PELLETS 4 PA testosterone cypionate im inj in oil PA mg/ml testosterone cypionate im inj in oil PA mg/ml testosterone enanthate im inj in oil PA mg/ml testosterone td gel 10mg/act (2%) 4 PA testosterone td gel 12.5 mg/act (1%) 4 PA testosterone td gel 25 mg/2.5gm (1%) 4 PA testosterone td gel 50 mg/5gm (1%) 4 PA TESTRED CAP 10MG 4 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 2 acarbose tab 50 mg 2 acarbose tab 100 mg 2 GLYSET TAB 25MG 4 GLYSET TAB 50MG 4 GLYSET TAB 100MG 4 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 ST; QL SYMLNPEN 120 INJ 1000MCG 3 ST; QL ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab mg 2 glipizide-metformin hcl tab mg 2 glipizide-metformin hcl tab mg 2 glyburide-metformin tab mg 2 glyburide-metformin tab mg 2 glyburide-metformin tab mg 2 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 2 metformin hcl tab er 24hr 750 mg 2 RIOMET SOL 4 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB MG 3 JANUMET TAB JANUMET XR TAB MG 3 JANUMET XR TAB JANUMET XR TAB JENTADUETO TAB JENTADUETO TAB PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 62

73 JENTADUETO TAB JENTADUETO TAB XR 3 QL ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 TRADJENTA TAB 5MG 3 QL ANTIDIABETICS, INCRETIN MIMETIC AGENTS TANZEUM INJ 30MG 4 ST; QL TANZEUM INJ 50MG 4 ST; QL TRULICITY INJ 0.75/0.5 3 QL TRULICITY INJ 1.5/0.5 3 QL VICTOZA INJ 18MG/3ML 3 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab mg pioglitazone hcl-metformin hcl tab mg ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 mg 2 pioglitazone hcl-glimepiride tab 30-4 mg 2 ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 mg (base equiv) 2 pioglitazone hcl tab 30 mg (base equiv) 2 pioglitazone hcl tab 45 mg (base equiv) 2 ANTIDIABETICS, INSULINS HUMULIN R INJ U QL LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML 3 QL NOVOLOG INJ FLEXPEN 3 QL NOVOLOG INJ PENFILL 3 QL NOVOLOG MIX INJ 70/30 3 QL NOVOLOG MIX INJ FLEXPEN 3 QL TOUJEO SOLO INJ 300IU/ML 3 TRESIBA FLEX INJ 100UNIT 3 QL TRESIBA FLEX INJ 200UNIT 3 QL ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 2 nateglinide tab 120 mg 2 repaglinide tab 0.5 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 63

74 repaglinide tab 1 mg 2 repaglinide tab 2 mg 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab mg 2 repaglinide-metformin hcl tab mg 2 ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB MG 3 QL INVOKAMET TAB QL INVOKAMET TAB QL INVOKAMET TAB QL SYNJARDY TAB 3 SYNJARDY TAB 5-500MG 3 SYNJARDY TAB MG 3 SYNJARDY TAB SYNJARDY XR TAB 3 SYNJARDY XR TAB MG 3 SYNJARDY XR TAB SYNJARDY XR TAB ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG 3 QL INVOKANA TAB 300MG 3 QL JARDIANCE TAB 10MG 3 QL JARDIANCE TAB 25MG 3 QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG 3 QL GLYXAMBI TAB 25-5 MG 3 QL ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 2 chlorpropamide tab 250 mg 2 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab er 24hr 2.5 mg 2 glipizide tab er 24hr 5 mg 2 glipizide tab er 24hr 10 mg 2 glyburide micronized tab 1.5 mg 2 glyburide micronized tab 3 mg 1 glyburide micronized tab 6 mg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 64

75 glyburide tab 1.25 mg 1 glyburide tab 2.5 mg 1 glyburide tab 5 mg 2 tolbutamide tab 500 mg 2 ANTIDIABETICS, SUPPLIES AUTOPEN MIS 1 UNIT 3 AUTOPEN MIS 1-21UNIT 3 AUTOPEN MIS 2 UNIT 3 AUTOPEN MIS 2-32UNIT 3 AUTOPEN MIS 2-42UNIT 3 AUTOSHIELD MIS 29X3/16" 3 BD PEN MINI MIS 3 BD PEN NEEDL MIS 29GX1/2" 3 BD PEN NEEDL MIS 31GX3/16 3 BD PEN NEEDL MIS 31GX5/16 3 BD PEN NEEDL MIS 32GX4MM 3 CONTROL KIT MONITOR 3 EASY TOUCH MIS 32GX5MM 3 INSULIN PEN MIS 29GX12MM 3 INSULIN SYRG MIS 0.3/29G 3 INSULIN SYRG MIS 0.3/29G 3 INSULIN SYRG MIS 0.3/30G 3 INSULIN SYRG MIS 0.3/30G 3 INSULIN SYRG MIS 0.3/31G 3 INSULIN SYRG MIS 0.5/27G 3 INSULIN SYRG MIS 0.5/28G 3 INSULIN SYRG MIS 0.5/29G 3 INSULIN SYRG MIS 0.5/29G 3 INSULIN SYRG MIS 0.5/30G 3 INSULIN SYRG MIS 0.5/30G 3 INSULIN SYRG MIS 0.5/31G 3 INSULIN SYRG MIS 1ML 3 INSULIN SYRG MIS 1ML/28G 3 INSULIN SYRG MIS 1ML/29G 3 INSULIN SYRG MIS 1ML/29G 3 INSULIN SYRG MIS 1ML/30G 3 INSULIN SYRG MIS 1ML/31G 3 INSULIN SYRG MIS 28GX1/2" 3 INSUPEN SENS MIS 32GX6MM 3 INSUPEN SENS MIS 32GX8MM 3 LANCET CARRY MIS CASE 3 QL LANCETS MIS 3 QL LANCING DEVI MIS 3 MULTI-LANCET KIT DEVICE 3 NOVOFINE MIS 30GX8MM 3 NOVOTWIST MIS 32GX5MM 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 65

76 ONETOUCH KIT ULT MINI 3 ONETOUCH KIT ULTRA 2 3 ONETOUCH KIT ULTRALNK 3 ONETOUCH KIT VERIO 3 ONETOUCH KIT VERIO FL 3 ONETOUCH KIT VERIO IQ 3 ONETOUCH TES ULTRA BL 3 QL ONETOUCH TES VERIO 3 QL PEN NEEDLES MIS 31GX6MM 3 SURESTEP PRO TES HIGH CON 3 SURESTEP PRO TES NORM CON 4 1ST TIER UNI MIS 29GX12MM 3 ULTRAFLEX II MIS 31"/8MM 4 ULTRAFLEX MIS 24"/10MM 4 V-GO 20 KIT 4 PA V-GO 30 KIT 4 PA V-GO 40 KIT 4 PA ANTIDOTES acetylcysteine inj 200 mg/ml 2 CETYLEV TAB 2.5GM 4 PA CETYLEV TAB 500MG 4 PA DIGIFAB INJ 40MG 4 flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) 2 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) 2 fomepizole inj 1 gm/ml (for iv infusion) 2 PHYSOS SALIC INJ 1MG/ML 2 PROTOPAM CHL INJ 1GM 4 sodium thiosulfate inj 25% 2 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 3 SENSIPAR TAB 60MG 3 SENSIPAR TAB 90MG 3 CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml 2 QL alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 2 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 1 BONIVA INJ 3MG/3ML 5 ST; QL BONIVA TAB 150MG 4 QL etidronate disodium tab 400 mg 2 ibandronate sodium iv soln 3 mg/3ml 5 ST; QL (base equivalent) ibandronate sodium tab 150 mg (base equivalent) 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 66

77 pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 2 risedronate sodium tab 5 mg 2 ST; QL risedronate sodium tab 30 mg 2 ST; QL risedronate sodium tab 35 mg 2 ST; QL risedronate sodium tab 150 mg 2 ST; QL risedronate sodium tab delayed release 35 2 ST; QL mg zoledronic acid inj conc for iv infusion 4 5 QL mg/5ml zoledronic acid iv soln 5 mg/100ml 5 ST; QL ZOMETA INJ 4MG/100 5 ST; QL CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 2 MIACALCIN INJ 200/ML 4 CALCIUM REGULATORS, MISCELLANEOUS PROLIA SOL 60MG/ML 5 PA; QL XGEVA INJ 5 PA; QL CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 5 ST; QL NATPARA INJ 25MCG 5 PA; QL NATPARA INJ 50MCG 5 PA; QL NATPARA INJ 75MCG 5 PA; QL NATPARA INJ 100MCG 5 PA; QL CONTRACEPTIVES, BIPHASIC MIRCETTE TAB 28 DAY 4 CONTRACEPTIVES, EXTENDED CYCLE LOSEASONIQUE TAB 4 SEASONIQUE TAB 4 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA INJ 150MG/ML 4 QL CONTRACEPTIVES, MONOPHASIC BEYAZ TAB 4 LO LOESTRIN TAB 3 ENDOMETRIOSIS danazol cap 50 mg 2 PA danazol cap 100 mg 2 PA danazol cap 200 mg 2 PA LUPANETA KIT PA; QL LUPANETA KIT PA; QL SYNAREL SOL 2MG/ML 5 PA; QL ESTROGEN/PROGESTIN, ORAL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 67

78 ANGELIQ TAB 0.5-1MG 4 estradiol & norethindrone acetate tab mg estradiol & norethindrone acetate tab mg norethindrone acetate-ethinyl estradiol tab mg-2.5 mcg norethindrone acetate-ethinyl estradiol tab 2 1 mg-5 mcg PREFEST TAB 4 PREMPHASE TAB 3 PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO DIS WEEKLY 4 QL COMBIPATCH DIS.05/.14 4 QL COMBIPATCH DIS.05/.25 4 QL ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE TAB ESTROGENS, INJECTABLE DEPO-ESTRADI INJ 5MG/ML 4 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 PREMARIN INJ 25MG 4 ESTROGENS, ORAL estradiol tab 0.5 mg 1 estradiol tab 1 mg 1 estradiol tab 2 mg 1 estropipate tab 0.75 mg 2 estropipate tab 1.5 mg 2 estropipate tab 3 mg 2 MENEST TAB 0.3MG 4 MENEST TAB 0.625MG 4 MENEST TAB 1.25MG 4 PREMARIN TAB 0.3MG 3 PREMARIN TAB 0.9MG 3 PREMARIN TAB 0.45MG 3 PREMARIN TAB 0.625MG 3 PREMARIN TAB 1.25MG 3 ESTROGENS, TRANSDERMAL ALORA DIS 0.1MG 4 QL ALORA DIS 0.05MG 4 QL ALORA DIS 0.025MG 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 68

79 ALORA DIS 0.075MG 4 QL DIVIGEL GEL 0.5MG 4 DIVIGEL GEL 0.25MG 4 DIVIGEL GEL 1MG/GM 4 estradiol td patch twice weekly QL mg/24hr estradiol td patch twice weekly QL mg/24hr estradiol td patch twice weekly QL mg/24hr estradiol td patch twice weekly QL mg/24hr estradiol td patch twice weekly QL mg/24hr estradiol td patch weekly 0.1 mg/24hr 2 QL estradiol td patch weekly 0.05 mg/24hr 2 QL estradiol td patch weekly 0.06 mg/24hr 2 QL estradiol td patch weekly mg/24hr 2 QL estradiol td patch weekly mg/24hr 2 QL estradiol td patch weekly mg/24hr 2 QL (37.5 mcg/24hr) ESTROGEL GEL 4 QL EVAMIST SPR 1.53MG 4 MENOSTAR DIS 14MCG 4 QL MINIVELLE DIS 0.1MG 4 QL MINIVELLE DIS 0.05MG 4 QL MINIVELLE DIS 0.025MG 4 QL MINIVELLE DIS 0.075MG 4 QL MINIVELLE DIS MG 4 QL ESTROGENS, VAGINAL ESTRACE VAG CRE 0.01% 4 estradiol vaginal tab 10 mcg 2 ESTRING MIS 2MG 4 FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 PREMARIN VAG CRE 0.625MG 3 VAGIFEM TAB 10MCG 4 GLUCOCORTICOID COMBINATIONS CELESTONE INJ SOLUSPAN 4 GLUCOCORTICOIDS CORTEF TAB 5MG 4 CORTEF TAB 10MG 4 CORTEF TAB 20MG 4 cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEPO-MEDROL INJ 40MG/ML 4 DEPO-MEDROL INJ 80MG/ML 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 69

80 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sod phosphate 2 preservative free inj 10 mg/ml dexamethasone sodium phosphate inj 4 2 mg/ml dexamethasone sodium phosphate inj 10 2 mg/ml dexamethasone sodium phosphate inj 20 2 mg/5ml dexamethasone sodium phosphate inj mg/10ml dexamethasone sodium phosphate inj mg/30ml dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 3 DEXPAK PAK 10 DAY 3 DEXPAK PAK 13 DAY 3 fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 KENALOG-10 INJ 10MG/ML 4 KENALOG-40 INJ 40MG/ML 4 METHYLPRD PF INJ 80MG/ML 4 methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 2 mg/ml methylprednisolone sod succ for inj 40 mg 2 (base equiv) methylprednisolone sod succ for inj mg (base equiv) methylprednisolone sod succ for inj mg (base equiv) methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 70

81 MILLIPRED DP PAK 5MG 2 prednisolone sod phosph oral soln mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 10 2 mg/5ml (base equiv) prednisolone sod phosphate oral soln 15 2 mg/5ml (base equiv) prednisolone sod phosphate oral soln 20 2 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 2 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 2 solution equivalent) prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab 50 mg 2 SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 1GM 4 SOLU-MEDROL INJ 2GM 4 SOLU-MEDROL INJ 40MG 4 SOLU-MEDROL INJ 125MG 4 SOLU-MEDROL INJ 500MG 4 GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG 3 QL GLUCAGEN INJ HYPOKIT 3 QL GLUCAGON KIT 1MG 3 QL PROGLYCEM SUS 50MG/ML 3 HUMAN GROWTH HORMONES HUMATROPE INJ 5MG 5 PA HUMATROPE INJ 6MG 5 PA HUMATROPE INJ 12MG 5 PA HUMATROPE INJ 24MG 5 PA SEROSTIM INJ 4MG 5 PA SEROSTIM INJ 5MG 5 PA SEROSTIM INJ 6MG 5 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 71

82 doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 2 HECTOROL CAP 0.5MCG 4 HECTOROL CAP 1MCG 4 HECTOROL CAP 2.5MCG 4 HECTOROL INJ 2MCG/ML 3 HECTOROL INJ 4MCG/2ML 4 paricalcitol cap 1 mcg 2 paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 paricalcitol iv soln 2 mcg/ml 4 paricalcitol iv soln 5 mcg/ml 4 ROCALTROL CAP 0.5MCG 4 ROCALTROL CAP 0.25MCG 4 ROCALTROL SOL 1MCG/ML 4 ZEMPLAR CAP 1MCG 4 ZEMPLAR CAP 2MCG 4 ZEMPLAR INJ 2MCG/ML 4 ZEMPLAR INJ 5MCG/ML 4 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 5 PA LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 5 PA CEREZYME INJ 400UNIT 5 PA ELAPRASE INJ 6MG/3ML 5 PA ELELYSO INJ 200UNIT 5 PA FABRAZYME INJ 5MG 5 PA FABRAZYME INJ 35MG 5 PA NAGLAZYME INJ 1MG/ML 5 PA VIMIZIM INJ 5MG/5ML 5 PA VPRIV INJ 400UNIT 5 PA ZAVESCA CAP 100MG 5 PA MISCELLANEOUS ADAGEN INJ 250/ML 5 PA AMMONUL INJ 10% 4 cabergoline tab 0.5 mg 2 CARBAGLU TAB 200MG 5 PA CERVIDIL VAG MIS 10MG INS 3 CYSTADANE POW 5 PA H.P. ACTHAR INJ 80UNIT 5 PA; QL HEMABATE INJ 250MCG 4 KANUMA INJ 20/10ML 5 KORLYM TAB 300MG 5 PA; QL levocarnitine oral soln 1 gm/10ml (10%) 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 72

83 levocarnitine tab 330 mg 2 LUPR DEP-PED INJ 3M 30MG 5 PA; QL LUPR DEP-PED INJ 7.5MG 5 PA; QL LUPR DEP-PED INJ 11.25MG 5 PA; QL LUPR DEP-PED INJ 15MG 5 PA; QL methylergonovine maleate inj 0.2 mg/ml 4 MYALEPT INJ 11.3MG 5 PA; QL octreotide acetate inj 50 mcg/ml ( mg/ml) octreotide acetate inj 100 mcg/ml (0.1 5 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 5 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 5 mg/ml) ORFADIN CAP 2MG 5 PA ORFADIN CAP 5MG 5 PA ORFADIN CAP 10MG 5 PA ORFADIN SUS 4MG/ML 5 PA oxytocin inj 10 unit/ml 2 PITOCIN INJ 10UNT/ML 4 PREPIDIL GEL 0.5MG/3G 3 PROSTIN E2 SUP 20MG 3 RAVICTI LIQ 1.1GM/ML 5 PA; QL SANDOSTATIN INJ 50MCG/ML 5 SANDOSTATIN INJ 100MCG 5 SANDOSTATIN INJ 200MCG 5 SANDOSTATIN INJ 500MCG 5 SANDOSTATIN INJ 1000MCG 5 SANDOSTATIN KIT LAR 10MG 5 PA; QL SANDOSTATIN KIT LAR 20MG 5 PA; QL SANDOSTATIN KIT LAR 30MG 5 PA; QL SIGNIFOR INJ 0.3MG/ML 5 PA; QL SIGNIFOR INJ 0.6MG/ML 5 PA; QL SIGNIFOR INJ 0.9MG/ML 5 PA; QL SIGNIFOR LAR INJ 20MG 5 PA; QL SIGNIFOR LAR INJ 40MG 5 PA; QL SIGNIFOR LAR INJ 60MG 5 PA; QL SOMATULINE INJ 60/0.2ML 5 PA; QL SOMATULINE INJ 90/0.3ML 5 PA; QL SOMATULINE INJ 120/.5ML 5 PA; QL SOMAVERT INJ 10MG 5 PA; QL SOMAVERT INJ 15MG 5 PA; QL SOMAVERT INJ 20MG 5 PA; QL SOMAVERT INJ 25MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 73

84 SOMAVERT INJ 30MG 5 PA; QL STRENSIQ INJ 18/ PA STRENSIQ INJ 28/0.7ML 5 PA STRENSIQ INJ 40MG/ML 5 PA STRENSIQ INJ 80/0.8ML 5 PA SUPPRELIN LA KIT 50MG 5 PA; QL SYPRINE CAP 250MG 5 PA THYROGEN INJ 1.1MG 5 PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG 5 PA KUVAN POW 500MG 5 PA KUVAN TAB 100MG 5 PA PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG 3 calcium acetate (phosphate binder) cap mg (169 mg ca) calcium acetate (phosphate binder) tab mg RENAGEL TAB 400MG 5 RENAGEL TAB 800MG 5 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 5 PA PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg 1 medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 mg 1 norethindrone acetate tab 5 mg 2 progesterone micronized cap 100 mg 2 progesterone micronized cap 200 mg 2 PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 ENDOMETRIN SUP 100MG 4 THYROID AGENTS, ANTITHYROID AGENTS iodine solution strong 5% (lugol's) 2 methimazole tab 5 mg 2 methimazole tab 10 mg 2 propylthiouracil tab 50 mg 2 SSKI SOL 1GM/ML 2 THYROID SUPPLEMENTS CYTOMEL TAB 5MCG 4 CYTOMEL TAB 25MCG 4 CYTOMEL TAB 50MCG 4 LEVOTHYROXIN INJ 200MCG 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 74

85 levothyroxine sodium for iv inj 100 mcg 2 levothyroxine sodium for iv inj 500 mcg 2 levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 4 NATURE-THROI TAB 32.5MG 2 NATURE-THROI TAB 48.75MG 4 NATURE-THROI TAB 81.25MG 4 NATURE-THROI TAB 97.5MG 2 NATURE-THROI TAB MG 4 NATURE-THROI TAB 130MG 2 NATURE-THROI TAB MG 4 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 NATURE-THROI TAB 325MG 2 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 75

86 THYROLAR-3 TAB 180MG 3 TIROSINT CAP 13MCG 4 TIROSINT CAP 25MCG 4 TIROSINT CAP 50MCG 4 TIROSINT CAP 75MCG 4 TIROSINT CAP 88MCG 4 TIROSINT CAP 100MCG 4 TIROSINT CAP 112MCG 4 TIROSINT CAP 125MCG 4 TIROSINT CAP 137MCG 4 TIROSINT CAP 150MCG 4 TRIOSTAT INJ 10MCG/ML 4 WESTHROID TAB 32.5MG 2 WESTHROID TAB 97.5MG 2 WESTHROID TAB 130MG 2 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 5 PA; QL SAMSCA TAB 30MG 5 PA; QL VASOPRESSINS desmopressin acetate inj 4 mcg/ml 5 desmopressin acetate nasal soln 0.01% 5 (refrigerated) desmopressin acetate nasal spray soln % desmopressin acetate nasal spray soln % (refrigerated) desmopressin acetate tab 0.1 mg 2 desmopressin acetate tab 0.2 mg 2 STIMATE SOL 1.5MG/ML 5 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq mg/5ml diphenoxylate w/ atropine tab mg loperamide hcl cap 2 mg 2 ANTIEMETICS AKYNZEO CAP QL ALOXI INJ 0.25MG/5 4 ST aprepitant capsule 40 mg 3 QL aprepitant capsule 80 mg 3 QL aprepitant capsule 125 mg 3 QL aprepitant capsule therapy pack 80 & QL mg CESAMET CAP 1MG 3 DIMENHYDRIN INJ 50MG/ML 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 76

87 dronabinol cap 2.5 mg 2 dronabinol cap 5 mg 2 dronabinol cap 10 mg 2 droperidol inj 2.5 mg/ml 2 EMEND CAP 40MG 3 QL EMEND CAP 80MG 3 QL EMEND CAP 125MG 3 QL EMEND SOL 150MG 4 QL EMEND TRIPAC PAK 80 & QL granisetron hcl inj 0.1 mg/ml 2 ST; QL granisetron hcl inj 1 mg/ml 2 ST; QL granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 ST; QL granisetron hcl tab 1 mg 2 ST; QL meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 metoclopramide hcl inj 5 mg/ml 2 metoclopramide hcl soln 5 mg/5ml (10 1 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 ondansetron hcl oral soln 4 mg/5ml 2 ondansetron hcl tab 4 mg 2 QL ondansetron hcl tab 8 mg 2 QL ondansetron hcl tab 24 mg 2 QL ondansetron orally disintegrating tab 4 mg 2 QL ondansetron orally disintegrating tab 8 mg 2 QL prochlorperazine edisylate inj 5 mg/ml 2 prochlorperazine maleate tab 5 mg (base 1 equivalent) prochlorperazine maleate tab 10 mg (base 1 equivalent) prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl suppos 50 mg 2 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 2 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 2 SANCUSO DIS 3.1MG 4 ST; QL TIGAN INJ 100MG/ML 4 TRANSDERM-SC DIS 1.5MG 4 trimethobenzamide hcl cap 300 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 77

88 ANTISPASMODICS BELLA/OPIUM SUP chlordiazepoxide hcl-clidinium bromide cap mg CUVPOSA SOL 1MG/5ML 4 PA dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 1 GLYCOPYRROLA INJ 1MG/5ML 2 glycopyrrolate inj 0.2 mg/ml 2 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 2 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 2 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 2 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 hyoscyamine sulfate elixir mg/5ml 2 hyoscyamine sulfate soln mg/ml 2 hyoscyamine sulfate tab mg 2 hyoscyamine sulfate tab disint mg 2 hyoscyamine sulfate tab er 12hr mg 2 hyoscyamine sulfate tab sl mg 2 LEVSIN INJ 0.5MG/ML 4 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 propantheline bromide tab 15 mg 2 SYMAX DUOTAB TAB 4 CHOLELITHOLYTICS ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2 INFLAMMATORY BOWEL DISEASE, INJECTABLE AGENTS ENTYVIO INJ 300MG 5 PA; QL INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 3 ASACOL HD TAB 800MG 3 balsalazide disodium cap 750 mg 2 budesonide delayed release particles cap 3 2 mg DELZICOL CAP 400MG 3 DIPENTUM CAP 250MG 4 ST GIAZO TAB 1.1GM 4 LIALDA TAB 1.2GM 4 ST PENTASA CAP 250MG CR 4 PENTASA CAP 500MG CR 4 sulfasalazine tab 500 mg 2 sulfasalazine tab delayed release 500 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 78

89 UCERIS TAB 9MG 5 PA INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 5 CORTIFOAM AER 90MG 4 hydrocortisone enema 100 mg/60ml 2 mesalamine enema 4 gm 2 UCERIS AER 2MG/ACT 5 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 4 QL AMITIZA CAP 24MCG 4 QL LINZESS CAP 72MCG 3 QL LINZESS CAP 145MCG 3 QL LINZESS CAP 290MCG 3 QL IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 4 PA; QL alosetron hcl tab 1 mg (base equiv) 4 PA; QL LOTRONEX TAB 0.5MG 4 PA; QL LOTRONEX TAB 1MG 4 PA; QL VIBERZI TAB 75MG 5 PA; QL VIBERZI TAB 100MG 5 PA; QL LAXATIVES/STOOL SOFTENERS GOLYTELY SOL 3 lactulose solution 10 gm/15ml 2 NULYTELY SOL FLAV PKS 3 OSMOPREP TAB 1.5GM 4 peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln gm polyethylene glycol 3350 oral powder 2 polyethylene glycol 3350 oral powder 2 MISCELLANEOUS BUPHENYL POW 4 PA BUPHENYL TAB 500MG 4 PA CARAFATE SUS 1GM/10ML 3 cromolyn sodium oral conc 100 mg/5ml 2 GASTROCROM CON 100/5ML 3 GATTEX KIT 5MG 5 PA; QL KEPIVANCE INJ 6.25MG 5 lactulose (encephalopathy) solution 10 2 gm/15ml OCALIVA TAB 5MG 5 PA OCALIVA TAB 10MG 5 PA RECTIV OIN 0.4% 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 79

90 sodium phenylbutyrate oral powder 3 4 PA gm/teaspoonful SUCRAID SOL 8500/ML 5 PA sucralfate tab 1 gm 2 OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 3 QL MOVANTIK TAB 25MG 3 QL PANCREATIC ENZYMES CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 PANCREAZE CAP 4200UNIT 4 ST PANCREAZE CAP 10500UNT 4 ST PANCREAZE CAP 16800UNT 4 ST PANCREAZE CAP 21000UNT 4 ST PERTZYE CAP 4 ST VIOKACE TAB 4 ST VIOKACE TAB ST ZENPEP CAP 3000UNIT 4 ST ZENPEP CAP 5000UNIT 4 ST ZENPEP CAP 10000UNT 4 ST ZENPEP CAP 15000UNT 4 ST ZENPEP CAP 20000UNT 4 ST ZENPEP CAP 25000UNT 4 ST ZENPEP CAP 40000UNT 4 ST PROSTAGLANDINS misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 SALIVA STIMULANTS cevimeline hcl cap 30 mg 2 pilocarpine hcl tab 5 mg 2 pilocarpine hcl tab 7.5 mg 2 STEROIDS, RECTAL EPIFOAM AER 1% 4 hydrocortisone acetate suppos 25 mg 2 hydrocortisone acetate suppos 30 mg 2 hydrocortisone acetate w/ pramoxine rectal2 cream 1-1% hydrocortisone acetate w/ pramoxine rectal2 cream 2.5-1% hydrocortisone rectal cream 1% 2 hydrocortisone rectal cream 2.5% 2 lidocaine-hydrocortisone acetate rectal 2 cream 3-0.5% PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 80

91 lidocaine-hydrocortisone acetate rectal 2 cream kit 2-2% lidocaine-hydrocortisone acetate rectal 2 cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal 2 cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel 2 kit 3-2.5% PROCTOFOAM AER HC 1% 4 ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap 2 dr therapy pack OMECLAMOX- MIS PAK 4 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 2 CARDURA XL TAB 4MG 4 QL CARDURA XL TAB 8MG 4 QL dutasteride cap 0.5 mg 2 dutasteride-tamsulosin hcl cap mg 2 finasteride tab 5 mg 2 RAPAFLO CAP 4MG 4 ST RAPAFLO CAP 8MG 4 ST tamsulosin hcl cap 0.4 mg 2 UROXATRAL TAB 10MG 4 GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 2 glycine irrigation soln 1.5% 2 neomycin-polymyxin b gu irrigation soln 2 NEOSPORIN GU SOL 40/ML IR 4 RESECTISOL SOL 5% 3 sodium chloride irrigation soln 0.9% 2 MISCELLANEOUS acetic acid-oxyquinoline vaginal gel % bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 CYSTAGON CAP 50MG 5 PA CYSTAGON CAP 150MG 5 PA ELMIRON CAP 100MG 3 FEM PH GEL 2 mannitol iv soln 25% 2 methenamine hippurate tab 1 gm 2 methenamine-hyosc-meth blue-benz 2 acid-phenyl sal tab 81.6mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 81

92 ORACIT SOL 3 phenazopyridine hcl tab 100 mg 2 phenazopyridine hcl tab 200 mg 2 pot & sod citrates w/ cit ac soln mg/5ml potassium citrate & citric acid powder pack mg potassium citrate & citric acid soln mg/5ml potassium citrate tab er 5 meq (540 mg) 2 potassium citrate tab er 10 meq (1080 mg)2 potassium citrate tab er 15 meq (1620 mg)2 PROCYSBI CAP 25MG 5 PA; QL PROCYSBI CAP 75MG 5 PA; QL RIMSO-50 SOL 50% 3 SHOHLS SOL MODIFIED 3 sodium citrate & citric acid soln mg/5ml THIOLA TAB 100MG 5 PERITONEAL DIALYSIS SOLUTION DELFLEX-LC/ SOL 2.5% DEX 4 URINARY ANTISPASMODICS MYRBETRIQ TAB 25MG 3 QL MYRBETRIQ TAB 50MG 3 QL oxybutynin chloride syrup 5 mg/5ml 2 oxybutynin chloride tab 5 mg 2 oxybutynin chloride tab er 24hr 5 mg 2 oxybutynin chloride tab er 24hr 10 mg 2 oxybutynin chloride tab er 24hr 15 mg 2 tolterodine tartrate cap er 24hr 2 mg 2 tolterodine tartrate cap er 24hr 4 mg 2 tolterodine tartrate tab 1 mg 2 tolterodine tartrate tab 2 mg 2 trospium chloride cap er 24hr 60 mg 2 trospium chloride tab 20 mg 2 VESICARE TAB 5MG 3 VESICARE TAB 10MG 3 VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 METROGEL-VAG GEL 0.75% 3 metronidazole vaginal gel 0.75% 2 terconazole vaginal suppos 80 mg 2 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 82

93 ANGIOMAX INJ 250MG 4 ARGATROBAN INJ 50MG/50M 4 argatroban inj 250 mg/2.5ml (concentrate 4 for iv infusion) ARGATROBAN INJ 250/250 4 bivalirudin for iv soln 250 mg 2 enoxaparin sodium inj 30 mg/0.3ml 2 enoxaparin sodium inj 40 mg/0.4ml 2 enoxaparin sodium inj 60 mg/0.6ml 2 enoxaparin sodium inj 80 mg/0.8ml 2 enoxaparin sodium inj 100 mg/ml 2 enoxaparin sodium inj 120 mg/0.8ml 2 enoxaparin sodium inj 150 mg/ml 2 enoxaparin sodium inj 300 mg/3ml 2 fondaparinux sodium subcutaneous inj QL mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL fondaparinux sodium subcutaneous inj QL mg/0.6ml fondaparinux sodium subcutaneous inj 10 5 QL mg/0.8ml FRAGMIN INJ 2500/0.2 5 QL FRAGMIN INJ 5000/0.2 5 QL FRAGMIN INJ 7500/0.3 5 QL FRAGMIN INJ 10000/ML 5 QL FRAGMIN INJ 12500UNT 5 QL FRAGMIN INJ 15000UNT 5 QL FRAGMIN INJ 18000UNT 5 QL FRAGMIN INJ 95000UNT 5 QL heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj unit/ml2 heparin sodium (porcine) inj unit/ml2 heparin sodium (porcine) pf inj unit/0.5ml ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG 3 QL ELIQUIS TAB 5MG 3 QL warfarin sodium tab 1 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 83

94 warfarin sodium tab 10 mg 1 XARELTO STAR TAB 15/20MG 3 QL XARELTO TAB 10MG 3 QL XARELTO TAB 15MG 3 QL XARELTO TAB 20MG 3 QL ANTIHEMOPHILIC AGENTS OBIZUR INJ 500 UNIT 4 HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 5 PA ARANESP INJ 25MCG 5 PA ARANESP INJ 40MCG 5 PA ARANESP INJ 60MCG 5 PA ARANESP INJ 100MCG 5 PA ARANESP INJ 150MCG 5 PA ARANESP INJ 200MCG 5 PA ARANESP INJ 300MCG 5 PA ARANESP INJ 500MCG 5 PA EPOGEN INJ 2000/ML 5 PA EPOGEN INJ 3000/ML 5 PA EPOGEN INJ 4000/ML 5 PA EPOGEN INJ 10000/ML 5 PA EPOGEN INJ 20000/ML 5 PA GRANIX INJ 300/0.5 5 PA GRANIX INJ 480/0.8 5 PA LEUKINE INJ 250MCG 5 PA NEULASTA INJ 6MG/0.6M 5 PA NEUPOGEN INJ 300/0.5 5 PA NEUPOGEN INJ 300MCG 5 PA NEUPOGEN INJ 480/0.8 5 PA NEUPOGEN INJ 480MCG 5 PA PROCRIT INJ 40000/ML 5 PA ZARXIO INJ 300/0.5 5 PA ZARXIO INJ 480/0.8 5 PA HEMOSTATICS, SYSTEMIC aminocaproic acid inj 250 mg/ml 2 tranexamic acid iv soln 1000 mg/10ml 2 (100 mg/ml) tranexamic acid tab 650 mg 2 QL HEMOSTATICS, TOPICAL AVITENE PAD 35X35MM 4 AVITENE POW FLOUR 4 AVITENE SYRG MIS 1GM 4 ENDO AVITENE MIS 5MM DIA 4 ENDO AVITENE MIS 10MM DIA 4 GELFOAM MIS DENTAL 4 4 GELFOAM MIS SPON COM 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 84

95 GELFOAM POW 4 MONSELS FERR SOL SUBSULF 4 THROMBIN-JMI KIT 20000UNT 4 HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 5 PA; QL CINRYZE SOL 500 UNIT 5 PA; QL FIRAZYR INJ 30MG/3ML 5 PA; QL KALBITOR INJ 10MG/ML 5 PA RUCONEST INJ 2100UNIT 5 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA NPLATE INJ 250MCG 5 PA NPLATE INJ 500MCG 5 PA PROMACTA TAB 12.5MG 5 PA; QL PROMACTA TAB 25MG 5 PA; QL PROMACTA TAB 50MG 5 PA; QL PROMACTA TAB 75MG 5 PA; QL MISCELLANEOUS ACD FORMULA SOL A 4 ACTIVASE INJ 50MG 4 ACTIVASE INJ 100MG 4 ANTICOAG CIT SOL DEX SOL 4 ANTICOAG CPD SOL 3 CATHFLO ACTI INJ VASE 4 CEPROTIN INJ 1000UNIT 4 CHEMET CAP 100MG 4 PA cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 deferoxamine mesylate for inj 2 gm 2 deferoxamine mesylate for inj 500 mg 2 DESFERAL INJ 500MG 5 EXJADE TAB 125MG 5 PA EXJADE TAB 250MG 5 PA EXJADE TAB 500MG 5 PA FERRIPROX SOL 100MG/ML 4 PA FERRIPROX TAB 500MG 5 PA JADENU TAB 90MG 5 PA JADENU TAB 180MG 5 PA JADENU TAB 360MG 5 PA NOCLOT-50 SOL ACD-A 4 pentoxifylline tab er 400 mg 2 protamine sulfate inj 10 mg/ml 2 THROMBAT III INJ 500UNIT 4 TRICITRASOL CON 4 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 5 PA PLATELET AGGREGATION INHIBITORS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 85

96 AGGRENOX CAP MG 4 aspirin-dipyridamole cap er 12hr mg BRILINTA TAB 60MG 3 QL BRILINTA TAB 90MG 3 QL clopidogrel bisulfate tab 75 mg (base 1 equiv) clopidogrel bisulfate tab 300 mg (base 2 equiv) dipyridamole tab 25 mg 2 dipyridamole tab 50 mg 2 dipyridamole tab 75 mg 2 EFFIENT TAB 5MG 3 QL EFFIENT TAB 10MG 3 QL prasugrel hcl tab 5 mg (base equiv) 2 prasugrel hcl tab 10 mg (base equiv) 2 REOPRO INJ 2MG/ML 4 ZONTIVITY TAB 2.08MG 4 PA; QL PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 STEM CELL MOBILIZERS MOZOBIL INJ 5 PA; QL IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS ACTEMRA INJ 80MG/4ML 5 PA; QL ACTEMRA INJ 162/0.9 5 PA; QL ACTEMRA INJ 200/10ML 5 PA; QL ACTEMRA INJ 400/20ML 5 PA; QL CIMZIA KIT 5 PA; QL CIMZIA KIT STARTER 5 PA; QL CIMZIA PREFL KIT 200MG/ML 5 PA; QL COSENTYX INJ 150MG/ML 5 PA; QL COSENTYX PEN INJ 300DOSE 5 PA; QL ENBREL INJ 25/0.5ML 5 PA; QL ENBREL INJ 25MG 5 PA; QL ENBREL INJ 50MG/ML 5 PA; QL ENBREL SRCLK INJ 50MG/ML 5 PA; QL HUMIRA INJ 10MG/0.2 5 PA; QL HUMIRA KIT 20MG/0.4 5 PA; QL HUMIRA KIT 40MG/0.8 5 PA; QL HUMIRA PEN INJ 40MG/0.8 5 PA; QL KINERET INJ 5 PA; QL ORENCIA INJ 50/0.4 5 PA; QL ORENCIA INJ 87.5/0.7 5 PA; QL ORENCIA INJ 125MG/ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 86

97 ORENCIA INJ 250MG 5 PA REMICADE INJ 100MG 5 PA SIMPONI ARIA SOL 50MG/4ML 5 PA; QL SIMPONI INJ 50/0.5ML 5 PA; QL SIMPONI INJ 100MG/ML 5 PA; QL STELARA INJ 5MG/ML 5 PA; QL STELARA INJ 45MG/0.5 5 PA; QL STELARA INJ 90MG/ML 5 PA; QL TALTZ INJ 80MG/ML 5 PA; QL XELJANZ TAB 5MG 5 PA; QL XELJANZ XR TAB 11MG 5 PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) DEPEN TITRA TAB 250MG 5 PA hydroxychloroquine sulfate tab 200 mg 2 leflunomide tab 10 mg 2 leflunomide tab 20 mg 2 OTREXUP INJ 10MG 5 PA; QL OTREXUP INJ 12.5/0.4 5 QL OTREXUP INJ 15MG 5 PA; QL OTREXUP INJ 17.5/0.4 5 QL OTREXUP INJ 20MG 5 PA; QL OTREXUP INJ 22.5/0.4 5 QL OTREXUP INJ 25MG 5 PA; QL RASUVO INJ 7.5MG 5 PA; QL RASUVO INJ 10MG 5 PA; QL RASUVO INJ 12.5MG 5 PA; QL RASUVO INJ 15MG 5 PA; QL RASUVO INJ 17.5MG 5 PA; QL RASUVO INJ 20MG 5 PA; QL RASUVO INJ 22.5MG 5 PA; QL RASUVO INJ 25MG 5 PA; QL RASUVO INJ 30MG 5 PA; QL IMMUNE GLOBULINS ATGAM INJ 250MG 5 CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA FLEBOGAMMA INJ 20/400ML 5 PA FLEBOGAMMA INJ DIF 5% 5 PA GAMASTAN S/D INJ 5 PA GAMMAGARD INJ 1GM/10ML 5 PA GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA GAMMAGARD INJ 30GM/300 5 PA GAMMAGARD SD INJ 5GM HU 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 87

98 GAMMAGARD SD INJ 10GM HU 5 PA GAMUNEX-C INJ 40/400ML 5 PA HIZENTRA INJ 1GM/5ML 5 PA HIZENTRA INJ 2GM/10ML 5 PA HIZENTRA INJ 4GM/20ML 5 PA HIZENTRA INJ 10/50ML 5 PA HYQVIA INJ PA HYQVIA INJ PA HYQVIA INJ PA HYQVIA INJ PA HYQVIA INJ PA OCTAGAM INJ 1GM 5 PA OCTAGAM INJ 2.5GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA OCTAGAM INJ 5GM 5 PA OCTAGAM INJ 10GM 5 PA OCTAGAM INJ 25GM 5 PA PRIVIGEN INJ 5 GRAMS 5 PA PRIVIGEN INJ 10GRAMS 5 PA PRIVIGEN INJ 20GRAMS 5 PA PRIVIGEN INJ 40GRAMS 5 PA THYMOGLOBULN INJ 25MG 5 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 5 PA ALFERON N INJ 5MU/ML 5 PA INTRON A INJ 18MU 5 PA INTRON A INJ 25MU 5 PA PEG-INTRON KIT 50MCG 5 PA; QL PEG-INTRON KIT 80MCG 5 PA; QL PEG-INTRON KIT 120MCG 5 PA; QL PEG-INTRON KIT 150MCG 5 PA; QL PEGASYS INJ 180MCG/M 5 PA; QL PEGASYS INJ PROCLICK 5 PA; QL SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 5 PA; QL ILARIS (150) INJ 180MG 5 PA; QL ILARIS INJ 150MG/ML 5 PA; QL OTEZLA TAB 10/20/30 5 PA; QL OTEZLA TAB 30MG 5 PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES azathioprine tab 50 mg 2 CELLCEPT CAP 250MG 4 CELLCEPT IV INJ 500MG 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 88

99 CELLCEPT SUS 200MG/ML 4 CELLCEPT TAB 500MG 4 mycophenolate mofetil cap 250 mg 2 mycophenolate mofetil for oral susp mg/ml mycophenolate mofetil tab 500 mg 2 mycophenolate sodium tab dr 180 mg 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 2 (mycophenolic acid equiv) IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 mg 2 cyclosporine cap 100 mg 2 cyclosporine iv soln 50 mg/ml 2 cyclosporine modified cap 50 mg 2 cyclosporine modified oral soln 100 mg/ml 2 NEORAL CAP 25MG 4 NEORAL CAP 100MG 4 NEORAL SOL 100MG/ML 4 PROGRAF CAP 0.5MG 4 PROGRAF CAP 1MG 4 PROGRAF CAP 5MG 4 PROGRAF INJ 5MG/ML 5 SANDIMMUNE CAP 25MG 4 SANDIMMUNE CAP 100MG 4 SANDIMMUNE INJ 50MG/ML 5 SANDIMMUNE SOL 100MG/ML 3 tacrolimus cap 0.5 mg 2 tacrolimus cap 1 mg 2 tacrolimus cap 5 mg 2 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 400MG 5 PA NULOJIX INJ 250MG 5 PA SIMULECT INJ 10MG 5 SIMULECT INJ 20MG 5 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 3 PA RAPAMUNE TAB 0.5MG 4 PA RAPAMUNE TAB 1MG 5 PA RAPAMUNE TAB 2MG 4 PA sirolimus tab 0.5 mg 2 PA sirolimus tab 1 mg 2 PA sirolimus tab 2 mg 2 PA ZORTRESS TAB 0.5MG 4 PA ZORTRESS TAB 0.25MG 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 89

100 ZORTRESS TAB 0.75MG 4 PA MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 5 PA; QL SYNAGIS INJ 100MG/ML 5 PA; QL VACCINES BCG VACCINE INJ 5 NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS CARDIOTEK-RX TAB 4 FOLTANX TAB 2 METAFOLBIC TAB PLUS 2 PHENYLADE POW GMP 4 ELECTROLYTES, MISCELLANEOUS K-PHOS TAB 4 K-PHOS TAB NEUTRAL 2 K-PHOS TAB NO 2 4 pot phos monobasic w/sod phos di & 2 monobas tab mg ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 EFFER-K TAB 20MEQ 3 KLOR-CON M15 TAB 15MEQ ER 2 pot bicarbonate & chloride effer tab 25 2 meq potassium bicarbonate effer tab 25 meq 2 potassium chloride cap er 8 meq 2 potassium chloride cap er 10 meq 2 potassium chloride microencapsulated crys 2 er tab 10 meq potassium chloride microencapsulated crys 2 er tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride powder packet 20 meq 2 potassium chloride tab er 8 meq (600 mg) 2 potassium chloride tab er 10 meq 2 potassium chloride tab er 20 meq ( mg) ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15 2 gm/60ml sodium polystyrene sulfonate powder 2 sodium polystyrene sulfonate powder 4 VELTASSA POW 8.4GM 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 90

101 VELTASSA POW 16.8GM 5 PA; QL VELTASSA POW 25.2GM 5 PA; QL VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS ANIMI-3 CAP 4 ANIMI-3 CAP VIT D 4 BP VIT 3 CAP 4 FOLGARD RX TAB 4 folic acid tab 1 mg 1 folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg FOLTRATE TAB 3 VITAMINS AND MINERALS, MISCELLANEOUS ACTIVE FE TAB AQUASOL A INJ 50000/ML 4 b-complex w/ c & folic acid cap 1 mg 2 b-complex w/ c & folic acid tab 1 mg 2 BIFERARX TAB 4 CALCIUM-FA WAF PLUS D 2 CORVITE 150 TAB 4 CORVITE FE TAB 4 ergocalciferol cap unit 2 ESCAVITE CHW 4 ESCAVITE D CHW 4 fe asp gly-fe polysacch-succ ac-c-threon 2 ac-b12-fa cap fe asparto gly-fe fum-b12-fa-c-succinic ac 2 tab ther pack fe fumarate w/ b12-vit c-fa-ifc cap mg FERAHEME INJ 510/17ML 4 FERIVA CAP 75-1MG 4 FERRALET 90 TAB 4 FERRAPLUS 90 TAB 2 ferrex 150 cap 150mg 2 FERRLECIT INJ 12.5MG/M 4 FLORIVA CHW 0.5MG 4 FLORIVA CHW 0.25MG 4 FLORIVA CHW 1MG 4 FLORIVA DRO 0.25MG 4 FUSION PAK SPRINKLE 4 FUSION PLUS CAP 4 GALZIN CAP 25MG 3 PA GALZIN CAP 50MG 3 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 91

102 HEMATOGEN FA CAP 2 HEMATRON-AF TAB 4 HEMETAB TAB 2 hydroxocobalamin inj 1000 mcg/ml 2 INFED INJ 50MG/ML 2 INTEGRA F CAP 4 INTEGRA PLUS CAP 4 iron combination cap 2 iron polysacch complex-vit b12-fa cap mg iron polysacch complex-vit b12-fa cap mg iron-folic acid-vit c-vit b6-vit b12-zinc tab mg IROSPAN 24/6 MIS 4 MAGNEBIND TAB MEPHYTON TAB 5MG 4 NEPHPLEX RX TAB 2 NEPHRON FA TAB 4 NEURIN-SL SUB 4 NICADAN TAB 4 pediatric multiple vitamin w/ minerals & c 4 drops 45 mg/ml pediatric multiple vitamins w/ fl-fe drops mg/ml pediatric multiple vitamins w/ fl-fe drops mg/ml pediatric multiple vitamins w/ fluoride 2 chew tab 0.5 mg pediatric multiple vitamins w/ fluoride soln mg/ml pediatric multiple vitamins w/ fluoride soln mg/ml pediatric vitamins acd fluoride & fe drops mg/ml pediatric vitamins acd w/ fluoride soln mg/ml pediatric vitamins acd w/ fluoride soln mg/ml POLY-VI-FLOR CHW 0.5MG 4 POLY-VI-FLOR CHW 0.25MG 4 POLY-VI-FLOR CHW 1MG 4 POLY-VI-FLOR SUS 0.25/ML 4 POLY-VI-FLOR SUS /IRON 4 PROFERRIN- TAB FORTE 4 PUREFE CAP PLUS 4 pyridoxine hcl inj 100 mg/ml 2 QUFLORA PED CHW 0.5MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 92

103 QUFLORA PED CHW 0.25MG 4 QUFLORA PED CHW 1MG 4 sod ferric gluc cmplx in sucrose iv soln mg/ml (fe eq) sodium fluoride chew tab 1 mg f (from mg naf) sodium fluoride tab 1 mg f (from 2.2 mg 2 naf) TANDEM PLUS CAP 4 TARON FORTE CAP 2 TEXAVITE LQ LIQ 4 thiamine hcl inj 100 mg/ml 2 TRI-VI-FLOR SUS 0.5MG/ML 4 TRI-VI-FLOR SUS 0.25/ML 4 VENOFER INJ 20MG/ML 4 VITAMINS AND MINERALS, PRENATAL VITAMINS ATABEX EC TAB 29-1MG 4 C-NATE DHA CAP CITRANATAL CAP HARMONY 4 CITRANATAL MIS 90 DHA 4 CITRANATAL MIS B-CALM 4 CITRANATAL PAK ASSURE 4 CITRANATAL PAK DHA 4 CITRANATAL TAB RX 4 COMPLETE NAT PAK DHA 2 COMPLETENATE CHW 2 CONCEPT DHA CAP 4 CONCEPT OB CAP 4 DOTHELLE DHA CAP 2 DUET DHA 400 MIS DUET DHA MIS BALANCED 4 ENBRACE HR CAP 4 FOLET DHA PAK 4 FOLET ONE CAP FOLIVANE-OB CAP 2 HEMENATAL OB TAB MG 2 LEVOMEFOLATE CAP DHA 2 M-VIT TAB 27-1MG 3 MARNATAL-F CAP 4 MYNATAL CAP 2 MYNATAL TAB 2 MYNATAL TAB ADVANCE 2 MYNATAL-Z TAB 2 MYNATE 90 TAB PLUS 2 NATACHEW CHW 4 NATELLE ONE CAP 4 NEEVO DHA CAP PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 93

104 NESTABS ABC MIS 4 NESTABS DHA PAK 4 NEWGEN TAB 32-1MG 2 NIVA-PLUS TAB 4 O-CAL FA TAB 3 O-CAL TAB PRENATAL 3 OB COMPLETE CAP ONE 4 OB COMPLETE CAP PETITE 4 OB COMPLETE TAB 3 OB COMPLETE TAB PREMIER 4 OBSTETRIX EC TAB 3 OBSTETRIX PAK DHA 4 PNV OB+DHA PAK 2 PNV PRENATAL TAB PLUS 2 PNV PRENATAL TAB PLUS 2 PNV TABS TAB 29-1MG 2 PNV-DHA CAP DOCUSATE 2 PR NATAL 400 PAK 2 PR NATAL 430 PAK 2 PR NATAL 430 PAK EC 2 PREFERAOB MIS +DHA 4 PRENAISSANCE CAP PLUS 2 PRENAISSANCE TAB NEXT 2 PRENAT PLUS TAB 27-1MG 2 prenat w/o a w/fefum-methfol-fa-dha cap mg PRENATA CHW 29-1MG 4 PRENATAL TAB 27-1MG 2 PRENATAL TAB PLUS 2 PRENATAL VIT TAB LOW IRON 2 prenatal vit w/ dss-fe fumarate-fa tab mg prenatal vit w/ dss-iron carbonyl-fa tab mg prenatal vit w/ fe fum-methylfolate-fa tab mg prenatal vit w/ fe fumarate-fa chew tab mg prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 prenatal vit w/ fe fumarate-fa tab 28-1 mg 2 PRENATAL+FE TAB 29-1MG 2 PRENATAL-U CAP PRENATE AM TAB 1MG 4 PRENATE CAP ENHANCE 4 PRENATE CAP ESSENTIA 4 PRENATE CAP PIXIE 4 PRENATE CAP RESTORE 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 94

105 PRENATE CHW PRENATE DHA CAP 4 PRENATE MINI CAP 4 PRENATE TAB ELITE 4 PREPLUS TAB 27-1MG 2 PRETAB TAB 29-1MG 2 PROVIDA DHA CAP 4 PROVIDA OB CAP 4 PUREFE OB CAP PLUS 4 REDICHEW RX CHW 4 RELNATE DHA CAP 2 SE-NATAL 19 TAB 2 SELECT-OB CHW 4 SELECT-OB+ PAK DHA 4 TARON-C DHA CAP 2 TARON-PREX CAP 2 TL-SELECT CAP 2 TRI-TABS DHA MIS 2 TRICARE PRE CAP TRICARE TAB PRENATAL 4 TRISTART DHA CAP 4 VEMAVITE- CAP PRX 2 2 VENA-BAL MIS DHA 2 VINATE II TAB 2 VINATE M TAB 2 VINATE ONE TAB 2 VIRT NATE TAB 2 VIRT NATE TAB 28-1MG 2 VIRT-C DHA CAP 2 VIRT-NATE CAP DHA 2 VIRT-PN PLUS CAP 2 VIRT-PN TAB 2 VITAFOL CAP ULTRA 4 VITAFOL FE+ CAP 4 VITAFOL-NANO TAB 4 VITAFOL-OB PAK +DHA 4 VITAFOL-ONE CAP 4 VITAMEDMD CAP ONE RX 4 VITAPEARL CAP 4 VITATRUE MIS 4 VIVA DHA CAP 4 VOL-PLUS TAB 2 VOL-TAB RX TAB 4 VP-HEME OB TAB 2 VP-HEME ONE CAP 2 VP-HEME-OB TAB MG 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 95

106 VP-PNV-DHA CAP 4 ZATEAN-PN CAP DHA 2 ZATEAN-PN CAP PLUS 2 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 4 ADRENALIN INJ 30/30ML 4 epinephrine hcl inj 1 mg/ml 2 epinephrine hcl soln prefilled syringe mg/ml epinephrine solution auto-injector mg/0.3ml (1:1000) epinephrine solution auto-injector mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 4 EPIPEN-JR INJ 2-PAK 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER STIOLTO AER UTIBRON CAP NEOHALER 4 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER ipratropium-albuterol nebu soln (3) 2 mg/3ml ANTICHOLINERGICS ATROVENT HFA AER 17MCG 4 ipratropium bromide inhal soln 0.02% 2 SEEBRI NEOHA CAP 15.6MCG 4 SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR RESPIMAT 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine syrup mg/5ml ANTIHISTAMINES, LOW-SEDATING levocetirizine dihydrochloride soln PA mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2 ANTIHISTAMINES, SEDATING carbinoxamine maleate soln 4 mg/5ml 2 carbinoxamine maleate tab 4 mg 2 clemastine fumarate tab 2.68 mg 2 cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 diphenhydramine hcl cap 50 mg 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 96

107 diphenhydramine hcl elixir 12.5 mg/5ml 5 diphenhydramine hcl inj 50 mg/ml 5 hydroxyzine hcl im soln 25 mg/ml 2 hydroxyzine hcl im soln 50 mg/ml 2 hydroxyzine hcl syrup 10 mg/5ml 2 hydroxyzine hcl tab 10 mg 2 hydroxyzine hcl tab 25 mg 2 hydroxyzine hcl tab 50 mg 2 hydroxyzine pamoate cap 25 mg 2 hydroxyzine pamoate cap 50 mg 2 hydroxyzine pamoate cap 100 mg 2 ANTITUSSIVE COMBINATIONS, NON-OPIOID promethazine-dm syrup mg/5ml 1 pseudoephed-bromphen-dm syrup mg/5ml ANTITUSSIVE COMBINATIONS, OPIOID CAPCOF SYP MG 4 guaifenesin-codeine soln mg/5ml 2 guaifenesin-codeine soln mg/5ml 2 hydrocod polst-chlorphen polst er susp mg/5ml hydrocodone w/ homatropine syrup mg/5ml M-END PE LIQ 4 promethazine w/ codeine syrup mg/5ml TUSSICAPS CAP 5-4MG 4 TUSSICAPS CAP 10-8MG 4 TUSSIONEX SUS 10-8/5ML 3 Z-TUSS AC LIQ 2-9/5ML 4 ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 200 mg 2 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active Inhalation ARCAPTA CAP 75MCG 4 ST SEREVENT DIS AER 50MCG 3 STRIVERDI AER 2.5MCG 4 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive Inhalation BROVANA NEB 15MCG 4 PERFOROMIST NEB 20MCG 4 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml)2 albuterol sulfate soln nebu 0.63 mg/3ml 2 (base equiv) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 97

108 albuterol sulfate soln nebu 0.083% (2.5 1 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 0.31 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu conc mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 4 mcg/act (base equiv) metaproterenol sulfate syrup 10 mg/5ml 2 metaproterenol sulfate tab 10 mg 2 metaproterenol sulfate tab 20 mg 2 PROVENTIL AER HFA 4 PA; QL VENTOLIN HFA AER 3 QL XOPENEX HFA AER 4 ST; QL BETA AGONISTS, INJECTABLE ISUPREL INJ 0.2MG/ML 4 terbutaline sulfate inj 1 mg/ml 2 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 2 albuterol sulfate tab er 12hr 4 mg 2 albuterol sulfate tab er 12hr 8 mg 2 terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2 CYSTIC FIBROSIS BETHKIS NEB 300/4ML 5 QL CAYSTON INH 75MG 5 QL KALYDECO PAK 50MG 5 PA; QL KALYDECO PAK 75MG 5 PA; QL KALYDECO TAB 150MG 5 PA; QL ORKAMBI TAB PA; QL PULMOZYME SOL 1MG/ML 5 PA; QL TOBI PODHALR CAP 28MG 5 QL tobramycin nebu soln 300 mg/5ml 5 QL LEUKOTRIENE MODIFIERS montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) 2 QL 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 98

109 montelukast sodium oral granules packet 4 2 QL mg (base equiv) montelukast sodium tab 10 mg (base 2 QL equiv) zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 2 MEDICAL SUPPLIES AEROCHAMBER MIS PLUS 4 MISCELLANEOUS acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 ARALAST NP INJ 500MG 5 PA CINQAIR INJ 5 PA GLASSIA INJ 5 PA HYPER-SAL NEB 7% 4 HYPERSAL NEB 3.5% 4 ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) NEBUSAL NEB 6% 4 NUCALA INJ 100MG 5 PA; QL PROLASTIN-C INJ 1000MG 5 PA sodium chloride soln nebu 0.9% 2 sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2 XOLAIR SOL 150MG 5 PA; QL ZEMAIRA INJ 1000MG 5 PA NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 2 mcg/spray) azelastine hcl nasal spray 0.15% ( mcg/spray) olopatadine hcl nasal soln 0.6% 2 PATANASE SPR 0.6% 4 PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 4 PA PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 5 PA ESBRIET TAB 267MG 5 PA ESBRIET TAB 801MG 5 PA OFEV CAP 100MG 5 PA OFEV CAP 150MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 99

110 STEROID INHALANTS ARNUITY ELPT INH 100MCG 3 ARNUITY ELPT INH 200MCG 3 ASMANEX 30 AER 110MCG 3 ASMANEX 120 AER 220MCG 3 ASMANEX HFA AER 100 MCG 3 ASMANEX HFA AER 200 MCG 3 budesonide inhalation susp 0.5 mg/2ml 2 budesonide inhalation susp 0.25 mg/2ml 2 budesonide inhalation susp 1 mg/2ml 2 FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG 3 FLOVENT DISK AER 250MCG 3 FLOVENT HFA AER 44MCG 3 FLOVENT HFA AER 110MCG 3 FLOVENT HFA AER 220MCG 3 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 QVAR AER 40MCG 3 QVAR AER 80MCG 3 QVAR REDIHA AER 80MCG 3 QVAR REDIHAL AER 40MCG 3 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 BREO ELLIPTA INH BREO ELLIPTA INH SYMBICORT AER SYMBICORT AER TOPICAL DECONGESTANTS ADRENALIN SOL 1: XANTHINES ELIXOPHYLLIN ELX 80/15ML 4 THEO-24 CAP 100MG CR 4 THEO-24 CAP 200MG CR 4 THEO-24 CAP 300MG CR 4 THEO-24 CAP 400MG ER 4 theophylline soln 80 mg/15ml 2 theophylline tab er 12hr 100 mg 2 theophylline tab er 12hr 200 mg 2 theophylline tab er 12hr 300 mg 2 theophylline tab er 12hr 450 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 100

111 theophylline tab er 24hr 400 mg 2 theophylline tab er 24hr 600 mg 2 TOPICAL DERMATOLOGY, ACNE: ORAL isotretinoin cap 10 mg 2 isotretinoin cap 20 mg 2 isotretinoin cap 30 mg 2 isotretinoin cap 40 mg 2 DERMATOLOGY, ACNE: TOPICAL ACZONE GEL 5% 4 PA ACZONE GEL 7.5% 4 PA adapalene cream 0.1% 2 adapalene gel 0.1% 2 adapalene gel 0.3% 2 AZELEX CRE 20% 4 PA benzoyl peroxide-erythromycin gel 5-3% 2 clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 creamy face liq wash 4% 2 erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 oscion clnsr lot 6% 2 sulfacetamide sodium w/ sulfur emulsion % sulfacetamide sodium w/ sulfur wash % tazarotene cream 0.1% 2 TAZORAC CRE 0.1% 4 PA TAZORAC CRE 0.05% 4 PA TAZORAC GEL 0.1% 4 PA TAZORAC GEL 0.05% 4 PA tretinoin cream 0.1% 2 tretinoin cream 0.05% 2 tretinoin cream 0.025% 2 tretinoin gel 0.01% 2 tretinoin gel 0.025% 2 DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% 4 fluorouracil soln 2% 4 fluorouracil soln 5% 5 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 101

112 CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 4 BACTROBAN OIN NASAL 2% 4 gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin oint 2% 2 silver sulfadiazine cream 1% 2 DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base 2 equiv) ciclopirox solution 8% 2 clotrimazole cream 1% 2 clotrimazole w/ betamethasone lotion % econazole nitrate cream 1% 2 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 EXODERM LOT 25-1% 4 ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 nystatin cream unit/gm 2 nystatin oint unit/gm 2 nystatin topical powder unit/gm 2 nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% oxiconazole nitrate cream 1% 2 PENLAC SOL 8% 4 DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 4 acitretin cap 17.5 mg 4 methoxsalen rapid cap 10 mg 5 PA OXSORALEN-UL CAP 10MG 5 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 2 calcipotriene oint 0.005% 2 calcipotriene soln 0.005% (50 mcg/ml) 2 calcitriol oint 3 mcg/gm 2 DRITHO-CREME CRE HP 1% 3 DERMATOLOGY, ANTISEBORRHEICS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 102

113 selenium sulfide-pyrithione zinc in urea 2 shampoo 2.25% DERMATOLOGY, ANTISEPTICS/DISINFECTANTS formaldehyde solution 20% 4 PHENOL LIQ 89% 2 DERMATOLOGY, ATOPIC DERMATITIS ELIDEL CRE 1% 4 PA tacrolimus oint 0.1% 2 PA; QL tacrolimus oint 0.03% 2 PA; QL DERMATOLOGY, CORTICOSTEROID COMBINATIONS pramoxine-hc cream 1-2.5% 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% 2 amcinonide lotion 0.1% 2 AMCINONIDE OIN 0.1% 2 betamethasone dipropionate augmented 2 cream 0.05% betamethasone dipropionate augmented 2 lotion 0.05% betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.25% 2 diflorasone diacetate cream 0.05% 2 fluocinonide cream 0.05% 2 fluocinonide emulsified base cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 2 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide oil 0.01% (body oil) 2 fluocinolone acetonide oil 0.01% (scalp oil) 2 fluocinolone acetonide soln 0.01% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 103

114 betamethasone valerate cream 0.1% (base 2 equivalent) betamethasone valerate lotion 0.1% (base 2 equivalent) betamethasone valerate oint 0.1% (base 2 equivalent) desoximetasone cream 0.05% 2 desoximetasone oint 0.05% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate oint 0.005% 2 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion)2 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented 2 gel 0.05% betamethasone dipropionate augmented 2 oint 0.05% clobetasol propionate cream 0.05% 2 clobetasol propionate emollient base cream % clobetasol propionate gel 0.05% 2 clobetasol propionate oint 0.05% 2 clobetasol propionate soln 0.05% 2 diflorasone diacetate oint 0.05% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 UREA NAIL MIS 50% 2 DERMATOLOGY, LOCAL ANALGESIC PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 104

115 lidocaine patch 5% 4 PA; QL LIDODERM DIS 5% 4 PA; QL DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 CETACAINE AER 4 cocaine hcl soln 4% 2 lidocaine hcl cream 3% 2 lidocaine hcl gel 2% 2 LIDOCAINE HCL LOTION 3% 2 lidocaine hcl soln 4% 2 lidocaine oint 5% 2 lidocaine-prilocaine cream % 2 lidocaine-prilocaine cream kit % 2 QUTENZA KIT 8% 1-PCH 5 PA; QL DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 4 ARZOL SILVER MIS NITR APP 3 BUCALSEP SOL 3 BUCALSEP SPR 3 CONDYLOX GEL 0.5% 4 DENAVIR CRE 1% 4 DRYSOL SOL 20% 4 GEBAUERS SPR AER /STRETCH 4 GORDOFILM SOL 3 imiquimod cream 5% 2 PANRETIN GEL 0.1% 5 PA PODOCON SOL 25% 3 podofilox soln 0.5% 2 PR CREAM KIT 2 salicylic acid cream 6% 2 salicylic acid film forming liquid 27.5% 2 salicylic acid lotion 6% 2 salicylic acid shampoo 6% 2 SALICYLIC ACID SOLN 26% 2 salisol fort sol 26% 2 SANTYL OIN 250/GM 3 SILVER NITRA OIN 10% 2 SILVER NITRA SOL 0.5% 2 SILVER NITRA SOL 10% 2 SILVER NITRA SOL 25% 2 SILVER NITRA SOL 50% 2 SULFAMYLON CRE 85MG/GM 3 TRI-CHLOR LIQ 80% 3 DERMATOLOGY, ROSACEA FINACEA GEL 15% 4 metronidazole cream 0.75% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 105

116 metronidazole gel 0.75% 2 metronidazole lotion 0.75% 2 MIRVASO GEL 0.33% 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% 3 EURAX LOT 10% 3 lindane shampoo 1% 3 malathion lotion 0.5% 2 permethrin cream 5% 2 ULESFIA LOT 5% 4 DERMATOLOGY, WOUND CARE PRODUCTS AVO CREAM EMU 2 BIAFINE EMU 4 PRUTECT EMU 2 REGENECARE GEL 3 SILVRSTAT GEL DRESSING 4 SONAFINE EMU 4 IRRIGATION SOLUTIONS irrigation solution, physiological 4 lactated ringer's for irrigation 2 ringer's solution for irrigation 2 water for irrigation, sterile irrigation soln 2 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS AQUORAL SPR 4 BIOTENE DRY SPR MOIST 3 BIOTENE SPR MOUTH 3 CAPHOSOL SOL 3 chlorhexidine gluconate soln 0.12% 1 DEBACTEROL SOL 30-50% 3 fluorid sens pst 1.1-5% 4 GELCLAIR GEL 4 lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 1 MOI-STIR SOL 3 MOUTHKOTE SOL 3 NUMOISYN LOZ 4 PREVDNT 5000 PST 1.1% 4 PREVDNT 5000 PST 1.1-5% 4 PREVIDENT CRE 5000 PLS 4 PREVIDENT GEL 1.1% 4 PREVIDENT GEL 1.1% BER 4 PREVIDENT GEL 1.1% CHR 4 PREVIDENT GEL 1.1% MIN 4 PREVIDENT PST 5000 BST 4 sodium fluoride cream 1.1% 2 sodium fluoride gel 1.1% (0.5% f) 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 106

117 sodium fluoride paste 1.1% 4 sodium fluoride rinse 0.2% 2 sodium fluoride rinse 0.2% 2 triamcinolone acetonide dental paste 0.1% 2 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS ORAMAGICRX SUS 4 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth 2 oint 1% BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 PRED-G S.O.P OIN OP 3 PRED-G SUS OP 3 sulfacetamide sodium-prednisolone ophth 2 soln (0.25)% TOBRADEX OIN % 4 TOBRADEX ST SUS tobramycin-dexamethasone ophth susp % ZYLET SUS % 4 OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% 4 bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BESIVANCE SUS 0.6% 4 BETADINE SOL 5% OP 3 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 mg/gm 1 gatifloxacin ophth soln 0.5% 2 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 3 moxifloxacin hcl ophth soln 0.5% (base 2 equiv) neomycin-bacitrac zn-polymyx 2 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 107

118 polymyxin b-trimethoprim ophth soln unit/ml-0.1% sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 4 TOBREX SOL 0.3% OP 3 VIGAMOX DRO 0.5% 3 ZYMAXID SOL 0.5% 3 OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL SOL 0.45% 4 QL bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 2 ketorolac tromethamine ophth soln 0.4% 2 QL ketorolac tromethamine ophth soln 0.5% 2 QL NEVANAC SUS 0.1% 4 PROLENSA SOL 0.07% 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% 4 dexamethasone sodium phosphate ophth 2 soln 0.1% DUREZOL EMU 0.05% 3 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 FML FORTE SUS 0.25% OP 4 FML LIQUIFLM SUS 0.1% OP 4 FML OIN 0.1% OP 3 ILUVIEN IMP 0.19MG 5 PA; QL LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 OMNIPRED SUS 1% OP 4 PRED MILD SUS 0.12% OP 4 prednisolone acetate ophth susp 1% 2 TRIESENCE INJ 40MG/ML 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 BEPREVE DRO 1.5% 4 cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 108

119 olopatadine hcl ophth soln 0.1% (base 2 equivalent) olopatadine hcl ophth soln 0.2% (base 2 equivalent) PATADAY SOL 0.2% 3 PAZEO DRO 0.7% 3 OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 3 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 2 ZIRGAN GEL 0.15% 3 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 carteolol hcl ophth soln 1% 2 ISTALOL SOL 0.5% OP 4 levobunolol hcl ophth soln 0.5% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 2 0.5% timolol maleate ophth gel forming soln % timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.25% 2 TIMOPTIC OCU SOL 0.5% OP 4 TIMOPTIC OCU SOL 0.25% OP 4 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% 2 BETOPTIC-S SUS 0.25% OP 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS COSOPT PF SOL 4 dorzolamide hcl-timolol maleate ophth soln mg/ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA SUS 1-0.2% 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP 3 dorzolamide hcl ophth soln 2% 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS fluorescein sodium ophth strips 1 mg 4 fluorescein w/ benoxinate ophth soln % OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 109

120 OPHTHALMIC, MISCELLANEOUS AMVISC INJ 12MG/ML 4 AMVISC PLUS INJ 16MG/ML 4 CYSTARAN SOL 0.44% 5 PA; QL EYLEA INJ 2/0.05ML 5 PA LACRISERT MIS 5MG OP 4 LUCENTIS SOL 0.3MG 5 PA LUCENTIS SOL 0.5MG 5 PA MACUGEN INJ 5 MEMBRANEBLUE SOL 0.15% 4 ophthalmic irrigation solution - intraocular 2 phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 PROVISC INJ 1% 4 tetracaine hcl ophth soln 0.5% 2 tetracaine hcl ophth soln 0.5% 4 VISUDYNE INJ 15MG 5 OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 2 atropine sulfate ophth soln 1% 2 CYCLOMYDRIL SOL OP 3 cyclopentolate hcl ophth soln 0.5% 2 cyclopentolate hcl ophth soln 1% 2 cyclopentolate hcl ophth soln 2% 2 homatropine hbr ophth soln 5% 2 tropicamide ophth soln 0.5% 2 tropicamide ophth soln 1% 2 OPHTHALMIC, PARASYMPATHOMIMETICS MIOSTAT INJ 0.01% OP 4 pilocarpine hcl ophth soln 1% 2 pilocarpine hcl ophth soln 4% 2 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 2 ST latanoprost ophth soln 0.005% 2 LUMIGAN SOL 0.01% 3 TRAVATAN Z DRO 0.004% 4 ST ZIOPTAN DRO % 4 ST OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 3 brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 PHOSPHOLINE SOL 0.125%OP 4 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 110

121 CIPRO HC SUS OTIC 3 CIPRODEX SUS % 3 hydrocortisone w/ acetic acid otic soln 2 1-2% neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp mg/ml unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid otic soln 2% 2 CETRAXAL SOL 0.2% 4 ciprofloxacin hcl otic soln 0.2% (base 2 equivalent) ofloxacin otic soln 0.3% 2 OTIC, MISCELLANEOUS DERMOTIC OIL 0.01% 4 fluocinolone acetonide (otic) oil 0.01% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 111

122 Index 1 1ST TIER UNI MIS 29GX12MM A abacavir sulfate tab 300 mg (base equiv) abacavir sulfate-lamivudine tab mg abacavir sulfate-lamivudine-zidovudine tab mg ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABRAXANE INJ 100MG ABSTRAL SUB 100MCG... 3 ABSTRAL SUB 200MCG... 3 ABSTRAL SUB 300MCG... 3 ABSTRAL SUB 400MCG... 3 ABSTRAL SUB 600MCG... 3 ABSTRAL SUB 800MCG... 3 acamprosate calcium tab delayed release 333 mg acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg ACD FORMULA SOL A acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg acetaminophen w/ codeine soln mg/5ml... 3 acetaminophen w/ codeine tab mg... 3 acetaminophen w/ codeine tab mg... 3 acetaminophen w/ codeine tab mg... 3 acetazolamide cap er 12hr 500 mg acetazolamide sodium for inj 500 mg.. 35 acetazolamide tab 125 mg acetazolamide tab 250 mg acetic acid irrigation soln 0.25% acetic acid otic soln 2% acetic acid-oxyquinoline vaginal gel % acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% acetylcysteine inj 200 mg/ml acitretin cap 10 mg acitretin cap 17.5 mg ACTEMRA INJ 162/ ACTEMRA INJ 200/10ML ACTEMRA INJ 400/20ML ACTEMRA INJ 80MG/4ML ACTIMMUNE INJ 2MU/ ACTIVASE INJ 100MG ACTIVASE INJ 50MG ACTIVE FE TAB ACUVAIL SOL 0.45% acyclovir cap 200 mg acyclovir oint 5% acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg ACZONE GEL 5% ACZONE GEL 7.5% ADAGEN INJ 250/ML adapalene cream 0.1% adapalene gel 0.1% adapalene gel 0.3% ADCETRIS INJ 50MG ADDERALL TAB 10MG ADDERALL TAB 12.5MG ADDERALL TAB 15MG ADDERALL TAB 20MG ADDERALL TAB 30MG ADDERALL TAB 5MG ADDERALL TAB 7.5MG ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG adenosine iv soln 12 mg/4ml adenosine iv soln 6 mg/2ml ADRENALIN INJ 1MG/ML ADRENALIN INJ 30/30ML ADRENALIN SOL 1: ADVAIR DISKU AER 100/ ADVAIR DISKU AER 250/ ADVAIR DISKU AER 500/ ADVAIR HFA AER 115/ ADVAIR HFA AER 230/ ADVAIR HFA AER 45/ AEROCHAMBER MIS PLUS AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG

123 AFINITOR DIS TAB 5MG AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AGGRENOX CAP MG AKYNZEO CAP ALBENZA TAB 200MG albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% ALDACTAZIDE TAB 50/ ALDURAZYME INJ 2.9MG/5M ALECENSA CAP 150MG alendronate sodium oral soln 70 mg/75ml alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg ALFERON N INJ 5MU/ML alfuzosin hcl tab er 24hr 10 mg ALIMTA INJ 100MG ALIMTA INJ 500MG ALINIA SUS 100/5ML ALINIA TAB 500MG ALKERAN INJ 50MG ALKERAN TAB 2MG allopurinol tab 100 mg... 1 allopurinol tab 300 mg... 1 almotriptan malate tab 12.5 mg almotriptan malate tab 6.25 mg ALOCRIL SOL 2% ALOMIDE SOL 0.1% OP ALORA DIS 0.025MG ALORA DIS 0.05MG ALORA DIS 0.075MG ALORA DIS 0.1MG alosetron hcl tab 0.5 mg (base equiv). 79 alosetron hcl tab 1 mg (base equiv) ALOXI INJ 0.25MG/ ALPHAGAN P SOL 0.1% ALPRAZOLAM CON 1 MG/ML alprazolam orally disintegrating tab 0.25 mg alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab er 24hr 0.5 mg alprazolam tab er 24hr 1 mg alprazolam tab er 24hr 2 mg alprazolam tab er 24hr 3 mg alprostadil inj 500 mcg/ml ALREX SUS 0.2% ALTABAX OIN 1% ALUNBRIG PAK ALUNBRIG TAB 180MG ALUNBRIG TAB 30MG ALUNBRIG TAB 90MG amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg aminocaproic acid inj 250 mg/ml amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg AMITIZA CAP 24MCG AMITIZA CAP 8MCG

124 amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amlodipine besylate tab 10 mg amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg AMMONUL INJ 10% amoxapine tab 100 mg amoxapine tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxicillin & k clavulanate chew tab mg... 8 amoxicillin & k clavulanate chew tab mg... 8 amoxicillin & k clavulanate for susp mg/5ml... 8 amoxicillin & k clavulanate for susp mg/5ml... 8 amoxicillin & k clavulanate for susp mg/5ml... 8 amoxicillin & k clavulanate for susp mg/5ml... 8 amoxicillin & k clavulanate tab mg... 8 amoxicillin & k clavulanate tab mg... 8 amoxicillin & k clavulanate tab mg... 8 amoxicillin & k clavulanate tab er 12hr mg... 8 amoxicillin (trihydrate) cap 250 mg... 8 amoxicillin (trihydrate) cap 500 mg... 8 amoxicillin (trihydrate) chew tab 125 mg... 8 amoxicillin (trihydrate) chew tab 250 mg... 8 amoxicillin (trihydrate) for susp 125 mg/5ml... 8 amoxicillin (trihydrate) for susp 200 mg/5ml... 8 amoxicillin (trihydrate) for susp 250 mg/5ml... 8 amoxicillin (trihydrate) for susp 400 mg/5ml... 8 amoxicillin (trihydrate) tab 500 mg... 8 amoxicillin (trihydrate) tab 875 mg... 8 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack amphetamine-dextroamphetamine cap er 24hr 10 mg amphetamine-dextroamphetamine cap er 24hr 15 mg amphetamine-dextroamphetamine cap er 24hr 20 mg amphetamine-dextroamphetamine cap er 24hr 25 mg amphetamine-dextroamphetamine cap er 24hr 30 mg amphetamine-dextroamphetamine cap er 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg ampicillin cap 500 mg... 8 AMPYRA TAB 10MG AMVISC INJ 12MG/ML AMVISC PLUS INJ 16MG/ML AMYTAL SOD INJ 500MG ANACAINE OIN

125 anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg anastrozole tab 1 mg ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR ANDROGEL GEL 1%(25MG) ANDROGEL GEL 1.62% ANDROGEL GEL PUMP 1% ANECTINE INJ 20MG/ML ANGELIQ TAB 0.5-1MG ANGIOMAX INJ 250MG ANIMI-3 CAP ANIMI-3 CAP VIT D ANORO ELLIPT AER ANTICOAG CIT SOL DEX SOL ANTICOAG CPD SOL APOKYN INJ 10MG/ML aprepitant capsule 125 mg aprepitant capsule 40 mg aprepitant capsule 80 mg aprepitant capsule therapy pack 80 & 125 mg APRISO CAP 0.375GM APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG APTIVUS CAP 250MG APTIVUS SOL AQUASOL A INJ 50000/ML AQUORAL SPR ARALAST NP INJ 500MG ARANESP INJ 100MCG ARANESP INJ 10MCG ARANESP INJ 150MCG ARANESP INJ 200MCG ARANESP INJ 25MCG ARANESP INJ 300MCG ARANESP INJ 40MCG ARANESP INJ 500MCG ARANESP INJ 60MCG ARCALYST INJ 220MG ARCAPTA CAP 75MCG argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ARGATROBAN INJ 250/ ARGATROBAN INJ 50MG/50M aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 2 mg aripiprazole tab 20 mg aripiprazole tab 30 mg aripiprazole tab 5 mg ARISTADA INJ 1064MG ARISTADA INJ 441MG/ ARISTADA INJ 662MG/ ARISTADA INJ 882MG/ armodafinil tab 150 mg armodafinil tab 200 mg armodafinil tab 250 mg armodafinil tab 50 mg ARNUITY ELPT INH 100MCG ARNUITY ELPT INH 200MCG ARRANON INJ 5MG/ML ARZOL SILVER MIS NITR APP ASACOL HD TAB 800MG ASMANEX 120 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX HFA AER 100 MCG ASMANEX HFA AER 200 MCG aspirin-dipyridamole cap er 12hr mg ATABEX EC TAB 29-1MG atenolol & chlorthalidone tab mg atenolol & chlorthalidone tab mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg ATGAM INJ 250MG atomoxetine hcl cap 10 mg (base equiv) atomoxetine hcl cap 100 mg (base equiv) atomoxetine hcl cap 18 mg (base equiv) atomoxetine hcl cap 25 mg (base equiv) atomoxetine hcl cap 40 mg (base equiv)

126 atomoxetine hcl cap 60 mg (base equiv) atomoxetine hcl cap 80 mg (base equiv) atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) atovaquone susp 750 mg/5ml ATRIPLA TAB ATROPINE SUL OIN 1% OP atropine sulfate inj 0.4 mg/ml atropine sulfate inj 1 mg/ml atropine sulfate ophth soln 1% atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) atropine sulfate soln prefill syr 0.5 mg/5ml (0.1 mg/ml) ATROVENT HFA AER 17MCG AUBAGIO TAB 14MG AUBAGIO TAB 7MG AURYXIA TAB 210MG AUTOPEN MIS 1 UNIT AUTOPEN MIS 1-21UNIT AUTOPEN MIS 2 UNIT AUTOPEN MIS 2-32UNIT AUTOPEN MIS 2-42UNIT AUTOSHIELD MIS 29X3/16" AVASTIN INJ AVASTIN INJ 400/16ML AVEED INJ 750/3ML AVELOX TAB 400MG... 8 AVITENE PAD 35X35MM AVITENE POW FLOUR AVITENE SYRG MIS 1GM AVO CREAM EMU AXERT TAB 12.5MG AXERT TAB 6.25MG azacitidine for inj 100 mg AZASITE SOL 1% azathioprine tab 50 mg azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) azelastine hcl ophth soln 0.05% AZELEX CRE 20% AZILECT TAB 0.5MG AZILECT TAB 1MG azithromycin for susp 100 mg/5ml... 7 azithromycin for susp 200 mg/5ml... 7 azithromycin tab 250 mg... 7 azithromycin tab 500 mg... 7 azithromycin tab 600 mg... 7 AZOPT SUS 1% OP B bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% baclofen tab 10 mg baclofen tab 20 mg BACTROBAN OIN NASAL 2% balsalazide disodium cap 750 mg BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE SOL.05MG/ML BARACLUDE TAB 0.5MG BARACLUDE TAB 1MG BCG VACCINE INJ b-complex w/ c & folic acid cap 1 mg.. 91 b-complex w/ c & folic acid tab 1 mg.. 91 BD PEN MINI MIS BD PEN NEEDL MIS 29GX1/2" BD PEN NEEDL MIS 31GX3/ BD PEN NEEDL MIS 31GX5/ BD PEN NEEDL MIS 32GX4MM BELLA/OPIUM SUP benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg benazepril hcl tab 5 mg BENDEKA INJ 100/4ML

127 BENLYSTA INJ 120MG BENLYSTA INJ 400MG benzonatate cap 100 mg benzonatate cap 200 mg benzoyl peroxide-erythromycin gel 5-3% benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg BEPREVE DRO 1.5% BERINERT INJ 500UNIT BESIVANCE SUS 0.6% BETADINE SOL 5% OP betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone valerate cream 0.1% (base equivalent) betamethasone valerate lotion 0.1% (base equivalent) betamethasone valerate oint 0.1% (base equivalent) BETASERON INJ 0.3MG betaxolol hcl ophth soln 0.5% betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg BETHKIS NEB 300/4ML BETIMOL SOL 0.25% BETIMOL SOL 0.5% BETOPTIC-S SUS 0.25% OP BEYAZ TAB BIAFINE EMU bicalutamide tab 50 mg BICNU INJ 100MG BIFERARX TAB BILTRICIDE TAB 600MG bimatoprost ophth soln 0.03% BIOTENE DRY SPR MOIST BIOTENE SPR MOUTH bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg bivalirudin for iv soln 250 mg bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit BLEPHAMIDE OIN S.O.P BLEPHAMIDE SUS OP BLOXIVERZ INJ 10/10ML BLOXIVERZ INJ 5MG/10ML BONIVA INJ 3MG/3ML BONIVA TAB 150MG BOSULIF TAB 100MG BOSULIF TAB 500MG BOTOX INJ 100UNIT BOTOX INJ 200UNIT BP VIT 3 CAP BREO ELLIPTA INH BREO ELLIPTA INH BRILINTA TAB 60MG BRILINTA TAB 90MG brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2% 110 BRIVIACT INJ 50MG/5ML BRIVIACT SOL 10MG/ML BRIVIACT TAB 100MG BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) bromocriptine mesylate cap 5 mg (base equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) BROVANA NEB 15MCG

128 BUCALSEP SOL BUCALSEP SPR budesonide delayed release particles cap 3 mg budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 0.5 mg/2ml budesonide inhalation susp 1 mg/2ml 100 bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg BUNAVAIL MIS BUNAVAIL MIS BUNAVAIL MIS 6.3-1MG BUPHENYL POW BUPHENYL TAB 500MG bupivacaine 0.75% in dextrose inj 8.25%... 1 buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) bupropion hcl (smoking deterrent) tab er 12hr 150 mg bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg bupropion hcl tab er 24hr 150 mg bupropion hcl tab er 24hr 300 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg busulfan inj 6 mg/ml BUSULFEX INJ 6MG/ML butalbital-acetaminophen tab mg... 1 butalbital-acetaminophen-caff w/ cod cap mg... 3 butalbital-acetaminophen-caffeine cap mg... 1 butalbital-acetaminophen-caffeine tab mg... 1 butalbital-aspirin-caff w/ codeine cap mg... 3 butalbital-aspirin-caffeine cap mg... 1 butorphanol tartrate nasal soln 10 mg/ml... 3 BUTRANS DIS 10MCG/HR... 3 BUTRANS DIS 15MCG/HR... 3 BUTRANS DIS 20MCG/HR... 3 BUTRANS DIS 5MCG/HR... 3 BUTRANS DIS 7.5/HR... 3 BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG C cabergoline tab 0.5 mg CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG caffeine & sodium benzoate inj mg/ml (500 mg/2ml) calcipotriene cream 0.005% calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oint 3 mcg/gm calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) cap 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 667 mg CALCIUM-FA WAF PLUS D CALQUENCE CAP 100MG CAMPTOSAR INJ 100/5ML CAMPTOSAR INJ 300/15ML CAMPTOSAR INJ 40MG/2ML CANASA SUP 1000MG candesartan cilexetil tab 16 mg

129 candesartan cilexetil tab 32 mg candesartan cilexetil tab 4 mg candesartan cilexetil tab 8 mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg CAPCOF SYP MG capecitabine tab 150 mg capecitabine tab 500 mg CAPHOSOL SOL CAPRELSA TAB 100MG CAPRELSA TAB 300MG captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril tab 100 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg CARAFATE SUS 1GM/10ML CARBAGLU TAB 200MG carbamazepine cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg CARBATROL CAP 100MG CARBATROL CAP 200MG CARBATROL CAP 300MG carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa tab mg.. 48 carbidopa & levodopa tab mg.. 48 carbidopa & levodopa tab mg.. 48 carbidopa & levodopa tab er mg carbidopa & levodopa tab er mg carbidopa tab 25 mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbinoxamine maleate soln 4 mg/5ml 96 carbinoxamine maleate tab 4 mg carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml carboplatin iv soln 50 mg/5ml carboplatin iv soln 600 mg/60ml CARDIOTEK-RX TAB CARDIZEM LA TAB 120MG CARDURA XL TAB 4MG CARDURA XL TAB 8MG CARIMUNE NF INJ 12GM CARIMUNE NF INJ 6GM carisoprodol tab 250 mg carisoprodol tab 350 mg carisoprodol w/ aspirin & codeine tab mg carisoprodol w/ aspirin tab mg carteolol hcl ophth soln 1% carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab mg carvedilol tab 6.25 mg CATHFLO ACTI INJ VASE CAYSTON INH 75MG CEDAX CAP 400MG... 7 CEDAX SUS 180/5ML... 7 cefaclor cap 250 mg... 6 cefaclor cap 500 mg

130 CEFACLOR ER TAB 500MG... 6 cefaclor for susp 125 mg/5ml... 6 cefaclor for susp 250 mg/5ml... 6 cefaclor for susp 375 mg/5ml... 6 cefadroxil cap 500 mg... 6 cefadroxil for susp 250 mg/5ml... 6 cefadroxil for susp 500 mg/5ml... 6 cefadroxil tab 1 gm... 6 cefdinir cap 300 mg... 7 cefdinir for susp 125 mg/5ml... 7 cefdinir for susp 250 mg/5ml... 7 cefixime for susp 100 mg/5ml... 7 cefixime for susp 200 mg/5ml... 7 cefpodoxime proxetil for susp 100 mg/5ml... 7 cefpodoxime proxetil for susp 50 mg/5ml... 7 cefpodoxime proxetil tab 100 mg... 7 cefpodoxime proxetil tab 200 mg... 7 cefprozil for susp 125 mg/5ml... 6 cefprozil for susp 250 mg/5ml... 6 cefprozil tab 250 mg... 6 cefprozil tab 500 mg... 6 ceftibuten cap 400 mg... 7 ceftibuten for susp 180 mg/5ml... 7 CEFTIN SUS 125/5ML... 6 CEFTIN SUS 250/5ML... 6 cefuroxime axetil tab 500 mg... 6 celecoxib cap 100 mg... 1 celecoxib cap 200 mg... 1 celecoxib cap 400 mg... 1 celecoxib cap 50 mg... 1 CELESTONE INJ SOLUSPAN CELLCEPT CAP 250MG CELLCEPT IV INJ 500MG CELLCEPT SUS 200MG/ML CELLCEPT TAB 500MG CELONTIN CAP 300MG cephalexin cap 250 mg... 6 cephalexin cap 500 mg... 6 cephalexin cap 750 mg... 6 cephalexin for susp 125 mg/5ml... 6 cephalexin for susp 250 mg/5ml... 6 cephalexin tab 250 mg... 6 cephalexin tab 500 mg... 6 CEPROTIN INJ 1000UNIT CEREBYX INJ 100/2ML CEREBYX INJ 500/10ML CEREZYME INJ 400UNIT CERVIDIL VAG MIS 10MG INS CESAMET CAP 1MG CETACAINE AER CETRAXAL SOL 0.2% CETYLEV TAB 2.5GM CETYLEV TAB 500MG cevimeline hcl cap 30 mg CHEMET CAP 100MG chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl-clidinium bromide cap mg chlordiazepoxide-amitriptyline tab mg chlordiazepoxide-amitriptyline tab mg chlorhexidine gluconate soln 0.12% chlorothiazide sodium for inj 500 mg.. 35 chlorothiazide tab 250 mg chlorothiazide tab 500 mg CHLORPROMAZ INJ 25MG/ML CHLORPROMAZ INJ 50MG/2ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpropamide tab 100 mg chlorpropamide tab 250 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg chlorzoxazone tab 500 mg cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm. 29 choline & magnesium salicylates liq 500 mg/5ml... 1 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base 120

131 equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox solution 8% cilostazol tab 100 mg cilostazol tab 50 mg CILOXAN OIN 0.3% OP CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML CINQAIR INJ CINRYZE SOL 500 UNIT CIPRO (10%) SUS 500MG/ CIPRO (5%) SUS 250MG/ CIPRO HC SUS OTIC CIPRODEX SUS % ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl otic soln 0.2% (base equivalent) ciprofloxacin hcl tab 100 mg (base equiv)... 8 ciprofloxacin hcl tab 250 mg (base equiv)... 8 ciprofloxacin hcl tab 500 mg (base equiv)... 8 ciprofloxacin hcl tab 750 mg (base equiv)... 8 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)... 8 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)... 8 cisplatin inj 100 mg/100ml (1 mg/ml). 15 cisplatin inj 200 mg/200ml (1 mg/ml). 15 cisplatin inj 50 mg/50ml (1 mg/ml) citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) CITRANATAL CAP HARMONY CITRANATAL MIS 90 DHA CITRANATAL MIS B-CALM CITRANATAL PAK ASSURE CITRANATAL PAK DHA CITRANATAL TAB RX cladribine iv soln 10 mg/10ml (1 mg/ml) clarithromycin for susp 125 mg/5ml... 7 clarithromycin for susp 250 mg/5ml... 7 clarithromycin tab 250 mg... 7 clarithromycin tab 500 mg... 7 clarithromycin tab er 24hr 500 mg... 7 clemastine fumarate tab 2.68 mg CLEOCIN CAP 150MG CLEOCIN CAP 300MG CLEOCIN CAP 75MG CLEOCIN SUP 100MG CLEVIPREX EMU 50/100ML CLIMARA PRO DIS WEEKLY clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin hcl cap 75 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate vaginal cream 2% clobetasol propionate cream 0.05% clobetasol propionate emollient base cream 0.05% clobetasol propionate gel 0.05% clobetasol propionate oint 0.05% clobetasol propionate soln 0.05% clofarabine iv soln 1 mg/ml CLOLAR INJ 1MG/ML clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg

132 clonazepam tab 1 mg clonazepam tab 2 mg clonidine & chlorthalidone tab mg clonidine & chlorthalidone tab mg clonidine & chlorthalidone tab mg clonidine hcl inj (for epidural infusion) 100 mcg/ml... 1 clonidine hcl inj (for epidural infusion) 500 mcg/ml... 1 clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine hcl tab er 12hr 0.1 mg clonidine hcl td patch weekly 0.1 mg/24hr clonidine hcl td patch weekly 0.2 mg/24hr clonidine hcl td patch weekly 0.3 mg/24hr clopidogrel bisulfate tab 300 mg (base equiv) clopidogrel bisulfate tab 75 mg (base equiv) clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg.. 40 clorazepate dipotassium tab 7.5 mg clotrimazole cream 1% clotrimazole troche 10 mg clotrimazole w/ betamethasone lotion % clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine orally disintegrating tab 25 mg clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg C-NATE DHA CAP COARTEM TAB MG cocaine hcl soln 4% codeine sulfate tab 15 mg... 3 codeine sulfate tab 30 mg... 3 codeine sulfate tab 60 mg... 3 COLCRYS TAB 0.6MG... 1 COLESTID GRA 5GM COLESTID POW 5GM COLESTID TAB 1GM colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm COMBIGAN SOL 0.2/0.5% COMBIPATCH DIS.05/ COMBIPATCH DIS.05/ COMBIVENT AER COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG COMPLERA TAB COMPLETE NAT PAK DHA COMPLETENATE CHW CONCEPT DHA CAP CONCEPT OB CAP CONDYLOX GEL 0.5% CONTROL KIT MONITOR COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML CORLANOR TAB 5MG CORLANOR TAB 7.5MG CORTEF TAB 10MG CORTEF TAB 20MG CORTEF TAB 5MG CORTIFOAM AER 90MG cortisone acetate tab 25 mg CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% CORVERT INJ 1MG/10ML CORVITE 150 TAB CORVITE FE TAB COSENTYX INJ 150MG/ML COSENTYX PEN INJ 300DOSE COSOPT PF SOL COTELLIC TAB 20MG creamy face liq wash 4% CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT

133 CREON CAP 36000UNT CREON CAP 6000UNIT CRESEMBA CAP 186 MG CRESTOR TAB 10MG CRESTOR TAB 20MG CRESTOR TAB 40MG CRESTOR TAB 5MG CRINONE GEL 4% VAG CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG cromolyn sodium ophth soln 4% cromolyn sodium oral conc 100 mg/5ml cromolyn sodium soln nebu 20 mg/2ml CUVPOSA SOL 1MG/5ML cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg CYCLOMYDRIL SOL OP cyclopentolate hcl ophth soln 0.5% cyclopentolate hcl ophth soln 1% cyclopentolate hcl ophth soln 2% CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 mg cycloserine cap 250 mg CYCLOSET TAB 0.8MG cyclosporine cap 100 mg cyclosporine cap 25 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 50 mg cyclosporine modified oral soln 100 mg/ml cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg CYSTADANE POW CYSTAGON CAP 150MG CYSTAGON CAP 50MG CYSTARAN SOL 0.44% cytarabine inj 20 mg/ml cytarabine inj pf 100 mg/ml cytarabine inj pf 20 mg/ml CYTOMEL TAB 25MCG CYTOMEL TAB 50MCG CYTOMEL TAB 5MCG D dacarbazine for inj 100 mg dacarbazine for inj 200 mg DACOGEN INJ 50MG DALIRESP TAB 500MCG danazol cap 100 mg danazol cap 200 mg danazol cap 50 mg dantrolene sodium cap 100 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium for iv soln 20 mg dapsone tab 100 mg dapsone tab 25 mg daunorubicin hcl inj 5 mg/ml (base equiv) DEBACTEROL SOL 30-50% decitabine for inj 50 mg deferoxamine mesylate for inj 2 gm deferoxamine mesylate for inj 500 mg 85 DELFLEX-LC/ SOL 2.5% DEX DELZICOL CAP 400MG demeclocycline hcl tab 150 mg... 9 demeclocycline hcl tab 300 mg... 9 DEMSER CAP 250MG DENAVIR CRE 1% DEPAKOTE ER TAB 500MG DEPEN TITRA TAB 250MG DEPO-ESTRADI INJ 5MG/ML DEPO-MEDROL INJ 20MG/ML DEPO-MEDROL INJ 40MG/ML DEPO-MEDROL INJ 80MG/ML DEPO-PROVERA INJ 150MG/ML DEPO-PROVERA INJ 400/ML DERMOTIC OIL 0.01% DESCOVY TAB 200/ DESFERAL INJ 500MG desipramine hcl tab 10 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desmopressin acetate inj 4 mcg/ml desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01%

134 desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg desonide cream 0.05% desonide lotion 0.05% desonide oint 0.05% desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05% desoximetasone oint 0.25% DESOXYN TAB 5MG DESVENLAFAX TAB 50MG ER desvenlafaxine succinate tab er 24hr 100 mg (base equiv) desvenlafaxine succinate tab er 24hr 25 mg (base equiv) desvenlafaxine succinate tab er 24hr 50 mg (base equiv) desvenlafaxine tab er 24hr 100 mg desvenlafaxine tab er 24hr 50 mg DEXAMETHASON CON 1MG/ML dexamethasone elixir 0.5 mg/5ml dexamethasone sod phosphate preservative free inj 10 mg/ml dexamethasone sodium phosphate inj 10 mg/ml dexamethasone sodium phosphate inj 100 mg/10ml dexamethasone sodium phosphate inj 120 mg/30ml dexamethasone sodium phosphate inj 20 mg/5ml dexamethasone sodium phosphate inj 4 mg/ml dexamethasone sodium phosphate ophth soln 0.1% dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg DEXEDRINE CAP 10MG CR DEXEDRINE CAP 15MG CR DEXEDRINE CAP 5MG CR dexmethylphenidate hcl cap er 24 hr 10 mg dexmethylphenidate hcl cap er 24 hr 15 mg dexmethylphenidate hcl cap er 24 hr 20 mg dexmethylphenidate hcl cap er 24 hr 25 mg dexmethylphenidate hcl cap er 24 hr 30 mg dexmethylphenidate hcl cap er 24 hr 35 mg dexmethylphenidate hcl cap er 24 hr 40 mg dexmethylphenidate hcl cap er 24 hr 5 mg dexmethylphenidate hcl tab 10 mg dexmethylphenidate hcl tab 2.5 mg dexmethylphenidate hcl tab 5 mg DEXPAK PAK 10 DAY DEXPAK PAK 13 DAY DEXPAK PAK 6 DAY dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg dextroamphetamine sulfate cap er 24hr 10 mg dextroamphetamine sulfate cap er 24hr 15 mg dextroamphetamine sulfate cap er 24hr 5 mg dextroamphetamine sulfate tab 10 mg 55 dextroamphetamine sulfate tab 5 mg.. 55 DIASTAT ACDL GEL DIASTAT ACDL GEL 5-10MG DIASTAT PED GEL 2.5M GEL diazepam conc 5 mg/ml DIAZEPAM INJ 10MG/2ML diazepam inj 5 mg/ml diazepam oral soln 1 mg/ml diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg DIBENZYLINE CAP 10MG diclofenac potassium tab 50 mg... 1 diclofenac sodium gel 1%... 3 diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release

135 mg... 1 diclofenac sodium tab delayed release 50 mg... 1 diclofenac sodium tab delayed release 75 mg... 1 diclofenac sodium tab er 24hr 100 mg.. 1 diclofenac w/ misoprostol tab delayed release mg... 3 diclofenac w/ misoprostol tab delayed release mg... 3 dicloxacillin sodium cap 250 mg... 8 dicloxacillin sodium cap 500 mg... 9 dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg DIFICID TAB 200MG... 7 diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% diflunisal tab 500 mg... 2 DIGIFAB INJ 40MG digoxin inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) dihydroergotamine mesylate nasal spray 4 mg/ml DILANTIN CAP 100MG DILANTIN CAP 30MG DILANTIN CHW 50MG DILANTIN-125 SUS 125/5ML diltiazem hcl cap er 12hr 120 mg diltiazem hcl cap er 12hr 60 mg diltiazem hcl cap er 12hr 90 mg diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 120 mg diltiazem hcl coated beads cap er 24hr 180 mg diltiazem hcl coated beads cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 300 mg diltiazem hcl coated beads cap er 24hr 360 mg diltiazem hcl coated beads tab er 24hr 180 mg diltiazem hcl coated beads tab er 24hr 240 mg diltiazem hcl coated beads tab er 24hr 300 mg diltiazem hcl coated beads tab er 24hr 360 mg diltiazem hcl coated beads tab er 24hr 420 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) diltiazem hcl tab 120 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg DILTIAZEM INJ 100MG DIMENHYDRIN INJ 50MG/ML DIPENTUM CAP 250MG diphenhydramine hcl cap 50 mg diphenhydramine hcl elixir 12.5 mg/5ml diphenhydramine hcl inj 50 mg/ml diphenoxylate w/ atropine liq mg/5ml diphenoxylate w/ atropine tab mg dipyridamole tab 25 mg

136 dipyridamole tab 50 mg dipyridamole tab 75 mg disopyramide phosphate cap 100 mg.. 28 disopyramide phosphate cap 150 mg.. 28 disulfiram tab 250 mg disulfiram tab 500 mg DIURIL SUS 250/5ML divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg DIVIGEL GEL 0.25MG DIVIGEL GEL 0.5MG DIVIGEL GEL 1MG/GM dobutamine hcl inj 12.5 mg/ml dobutamine inj 1 mg/ml in d5w dobutamine inj 2 mg/ml in d5w dobutamine inj 4 mg/ml in d5w docetaxel for inj conc 20 mg/ml docetaxel for inj conc 80 mg/4ml (20 mg/ml) DOCETAXEL INJ 20MG/ML DOCETAXEL INJ 80MG/4ML donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 5 mg dopamine hcl inj 160 mg/ml dopamine hcl inj 40 mg/ml dopamine hcl inj 80 mg/ml dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln mg/ml DOTHELLE DHA CAP doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl conc 10 mg/ml doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg doxercalciferol inj 4 mcg/2ml (2 mcg/ml) DOXIL INJ 2MG/ML doxorubicin hcl for inj 10 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj 2 mg/ml doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml doxycycline hyclate tab 100 mg... 9 doxycycline hyclate tab 20 mg... 9 doxycycline hyclate tab delayed release 100 mg... 9 doxycycline hyclate tab delayed release 150 mg... 9 doxycycline hyclate tab delayed release 200 mg... 9 doxycycline hyclate tab delayed release 50 mg... 9 doxycycline hyclate tab delayed release 75 mg... 9 doxycycline monohydrate cap 100 mg.. 9 doxycycline monohydrate cap 150 mg.. 9 doxycycline monohydrate cap 75 mg... 9 doxycycline monohydrate for susp 25 mg/5ml... 9 doxycycline monohydrate tab 100 mg... 9 doxycycline monohydrate tab 150 mg... 9 doxycycline monohydrate tab 50 mg... 9 doxycycline monohydrate tab 75 mg... 9 DRITHO-CREME CRE HP 1% dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg droperidol inj 2.5 mg/ml DRYSOL SOL 20% DUAVEE TAB DUET DHA 400 MIS DUET DHA MIS BALANCED

137 duloxetine hcl enteric coated pellets cap 20 mg (base eq) duloxetine hcl enteric coated pellets cap 30 mg (base eq) duloxetine hcl enteric coated pellets cap 60 mg (base eq) DUOPA SUS DURACLON INJ... 1 DUREZOL EMU 0.05% dutasteride cap 0.5 mg dutasteride-tamsulosin hcl cap mg DYRENIUM CAP 100MG DYRENIUM CAP 50MG DYSPORT INJ 300UNIT DYSPORT INJ 500UNIT E E.E.S. GRAN SUS 200/5ML... 7 EASY TOUCH MIS 32GX5MM econazole nitrate cream 1% EDURANT TAB 25MG EFFER-K TAB 10MEQ EFFER-K TAB 20MEQ EFFIENT TAB 10MG EFFIENT TAB 5MG ELAPRASE INJ 6MG/3ML ELELYSO INJ 200UNIT ELIDEL CRE 1% ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG ELIGARD INJ 7.5MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG ELITEK INJ 1.5MG ELITEK INJ 7.5MG ELIXOPHYLLIN ELX 80/15ML ELLENCE INJ 2MG/ML ELMIRON CAP 100MG EMADINE SOL 0.05% OP EMCYT CAP 140MG EMEND CAP 125MG EMEND CAP 40MG EMEND CAP 80MG EMEND SOL 150MG EMEND TRIPAC PAK 80 & EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate tab 10 mg enalapril maleate tab 2.5 mg enalapril maleate tab 20 mg enalapril maleate tab 5 mg enalaprilat iv inj 1.25 mg/ml ENBRACE HR CAP ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML ENBREL SRCLK INJ 50MG/ML ENDO AVITENE MIS 10MM DIA ENDO AVITENE MIS 5MM DIA ENDOMETRIN SUP 100MG ENLON INJ 150/15ML enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml.. 83 enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 300 mg/3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml entacapone tab 200 mg entecavir tab 0.5 mg entecavir tab 1 mg ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB MG ENTYVIO INJ 300MG EPCLUSA TAB ephedrine sulfate inj 50 mg/ml EPIFOAM AER 1% epinastine hcl ophth soln 0.05% epinephrine hcl inj 1 mg/ml epinephrine hcl soln prefilled syringe 0.1 mg/ml EPINEPHRINE INJ 1MG/ML epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK epirubicin hcl iv soln 200 mg/100ml (2 127

138 mg/ml) epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) EPIVIR HBV SOL 5MG/ML EPIVIR HBV TAB 100MG EPIVIR SOL 10MG/ML eplerenone tab 25 mg eplerenone tab 50 mg EPOGEN INJ 10000/ML EPOGEN INJ 2000/ML EPOGEN INJ 20000/ML EPOGEN INJ 3000/ML EPOGEN INJ 4000/ML epoprostenol sodium for inj 0.5 mg eprosartan mesylate tab 600 mg EPZICOM TAB ERBITUX INJ 100MG ERBITUX INJ 200MG ergocalciferol cap unit ERIVEDGE CAP 150MG ERYPED SUS 400/5ML... 7 erythromycin ethylsuccinate for susp 200 mg/5ml... 7 erythromycin ethylsuccinate tab 400 mg... 7 erythromycin gel 2% erythromycin ophth oint 5 mg/gm erythromycin pads 2% erythromycin soln 2% erythromycin stearate tab 250 mg... 7 erythromycin tab 250 mg... 7 erythromycin tab 500 mg... 7 erythromycin tab delayed release 250 mg... 7 erythromycin tab delayed release 333 mg... 7 erythromycin tab delayed release 500 mg... 7 erythromycin w/ delayed release particles cap 250 mg... 7 ESBRIET CAP 267MG ESBRIET TAB 267MG ESBRIET TAB 801MG ESCAVITE CHW ESCAVITE D CHW escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate tab 5 mg (base equiv) estazolam tab 1 mg estazolam tab 2 mg ESTRACE VAG CRE 0.01% estradiol & norethindrone acetate tab mg estradiol & norethindrone acetate tab mg estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly 0.05 mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly 0.1 mg/24hr estradiol td patch weekly mg/24hr estradiol td patch weekly mg/24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 mg/24hr estradiol td patch weekly 0.06 mg/24hr estradiol td patch weekly mg/24hr estradiol td patch weekly 0.1 mg/24hr 69 estradiol vaginal tab 10 mcg estradiol valerate im in oil 20 mg/ml estradiol valerate im in oil 40 mg/ml ESTRING MIS 2MG ESTROGEL GEL estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 mg ethambutol hcl tab 100 mg

139 ethambutol hcl tab 400 mg ETHAMOLIN INJ 5% ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml etidronate disodium tab 400 mg etodolac cap 200 mg... 2 etodolac cap 300 mg... 2 etodolac tab 400 mg... 2 etodolac tab 500 mg... 2 etodolac tab er 24hr 400 mg... 2 etodolac tab er 24hr 500 mg... 2 etodolac tab er 24hr 600 mg... 2 ETOPOPHOS INJ 100MG etoposide cap 50 mg etoposide inj 1 gm/50ml (20 mg/ml).. 21 etoposide inj 100 mg/5ml (20 mg/ml) 21 etoposide inj 500 mg/25ml (20 mg/ml) EUFLEXXA INJ 10MG/ML... 6 EURAX CRE 10% EURAX LOT 10% EVAMIST SPR 1.53MG EVOTAZ TAB EVZIO INJ EXELDERM CRE 1% EXELDERM SOL 1% exemestane tab 25 mg EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG EXODERM LOT 25-1% EYLEA INJ 2/0.05ML ezetimibe tab 10 mg ezetimibe-simvastatin tab mg ezetimibe-simvastatin tab mg ezetimibe-simvastatin tab mg ezetimibe-simvastatin tab mg F FABRAZYME INJ 35MG FABRAZYME INJ 5MG famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg FANAPT PAK FANAPT TAB 10MG FANAPT TAB 12MG FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG FANAPT TAB 8MG FARESTON TAB 60MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FASLODEX INJ 250/5ML fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack fe fumarate w/ b12-vit c-fa-ifc cap mg felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg felodipine tab er 24hr 10 mg felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg FEM PH GEL FEMRING MIS 0.05/24H FEMRING MIS 0.1MG/ fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 43 mg fenofibrate micronized cap 67 mg fenofibrate tab 145 mg fenofibrate tab 160 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibric acid tab 105 mg fenofibric acid tab 35 mg fenoprofen calcium tab 600 mg... 2 fentanyl citrate lozenge on a handle 1200 mcg... 3 fentanyl citrate lozenge on a handle 1600 mcg... 3 fentanyl citrate lozenge on a handle 200 mcg... 3 fentanyl citrate lozenge on a handle 600 mcg... 3 fentanyl citrate lozenge on a handle 800 mcg... 3 fentanyl td patch 72hr 100 mcg/hr... 4 fentanyl td patch 72hr 12 mcg/hr... 3 fentanyl td patch 72hr 25 mcg/hr... 3 fentanyl td patch 72hr 50 mcg/hr

140 fentanyl td patch 72hr 75 mcg/hr... 4 FENTORA TAB 100MCG... 4 FENTORA TAB 200MCG... 4 FENTORA TAB 400MCG... 4 FENTORA TAB 600MCG... 4 FENTORA TAB 800MCG... 4 FERAHEME INJ 510/17ML FERIVA CAP 75-1MG FERRALET 90 TAB FERRAPLUS 90 TAB ferrex 150 cap 150mg FERRIPROX SOL 100MG/ML FERRIPROX TAB 500MG FERRLECIT INJ 12.5MG/M FETZIMA CAP 120MG FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP TITRATIO FINACEA GEL 15% finasteride tab 5 mg FIRAZYR INJ 30MG/3ML FIRMAGON INJ 120MG FIRMAGON INJ 80MG FLAREX SUS 0.1% OP FLEBOGAMMA INJ 20/400ML FLEBOGAMMA INJ DIF 5% flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg FLOLAN INJ 0.5MG FLOLAN INJ 1.5MG FLORIVA CHW 0.25MG FLORIVA CHW 0.5MG FLORIVA CHW 1MG FLORIVA DRO 0.25MG FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT DISK AER 50MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG FLOVENT HFA AER 44MCG floxuridine for inj 0.5 gm fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg fludarabine phosphate for inj 50 mg fludarabine phosphate inj 25 mg/ml fludrocortisone acetate tab 0.1 mg flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) flumazenil iv soln 1 mg/10ml (0.1 mg/ml) fluocinolone acetonide (otic) oil 0.01% fluocinolone acetonide cream 0.01%. 103 fluocinolone acetonide cream 0.025% 104 fluocinolone acetonide oil 0.01% (body oil) fluocinolone acetonide oil 0.01% (scalp oil) fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% fluorescein sodium ophth strips 1 mg 109 fluorescein w/ benoxinate ophth soln % fluorid sens pst 1.1-5% fluorometholone ophth susp 0.1% fluorouracil cream 5% fluorouracil inj 1 gm/20ml (50 mg/ml) 16 fluorouracil inj 2.5 gm/50ml (50 mg/ml) fluorouracil inj 5 gm/100ml (50 mg/ml) fluorouracil inj 500 mg/10ml (50 mg/ml) fluorouracil soln 2% fluorouracil soln 5% fluoxetine hcl (pmdd) cap 10 mg fluoxetine hcl (pmdd) cap 20 mg fluoxetine hcl (pmdd) tab 10 mg fluoxetine hcl (pmdd) tab 20 mg fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl cap delayed release 90 mg

141 fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluphenazine decanoate inj 25 mg/ml.. 52 fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg flurazepam hcl cap 15 mg flurazepam hcl cap 30 mg flurbiprofen sodium ophth soln 0.03% flurbiprofen tab 100 mg... 2 flurbiprofen tab 50 mg... 2 flutamide cap 125 mg fluticasone propionate cream 0.05%. 104 fluticasone propionate oint 0.005% fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg FML FORTE SUS 0.25% OP FML LIQUIFLM SUS 0.1% OP FML OIN 0.1% OP FOCALIN XR CAP 25MG FOCALIN XR CAP 35MG FOLET DHA PAK FOLET ONE CAP FOLGARD RX TAB folic acid tab 1 mg folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg FOLIVANE-OB CAP FOLTANX TAB FOLTRATE TAB fomepizole inj 1 gm/ml (for iv infusion) fondaparinux sodium subcutaneous inj 10 mg/0.8ml fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml formaldehyde solution 20% FORTEO SOL 600/ FORTESTA GEL 10MG/ACT fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) FRAGMIN INJ 10000/ML FRAGMIN INJ 12500UNT FRAGMIN INJ 15000UNT FRAGMIN INJ 18000UNT FRAGMIN INJ 2500/ FRAGMIN INJ 5000/ FRAGMIN INJ 7500/ FRAGMIN INJ 95000UNT FROVA TAB 2.5MG furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide oral soln 8 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg FUSION PAK SPRINKLE FUSION PLUS CAP FUZEON INJ 90MG FYCOMPA SUS 0.5MG/ML FYCOMPA TAB 10MG FYCOMPA TAB 12MG FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG FYCOMPA TAB 8MG G gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg

142 gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg GABITRIL TAB 12MG GABITRIL TAB 16MG GABLOFEN INJ 10000/ GABLOFEN INJ 20000/ GABLOFEN INJ 40000/ galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 12 mg. 44 galantamine hydrobromide tab 4 mg.. 44 galantamine hydrobromide tab 8 mg.. 44 GALZIN CAP 25MG GALZIN CAP 50MG GAMASTAN S/D INJ GAMMAGARD INJ 10GM/ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/ GAMMAGARD INJ 20GM/ GAMMAGARD INJ 30GM/ GAMMAGARD INJ 5GM/50ML GAMMAGARD SD INJ 10GM HU GAMMAGARD SD INJ 5GM HU GAMUNEX-C INJ 40/400ML GASTROCROM CON 100/5ML gatifloxacin ophth soln 0.5% GATTEX KIT 5MG GEBAUERS SPR AER /STRETCH GELCLAIR GEL GELFOAM MIS DENTAL GELFOAM MIS SPON COM GELFOAM POW gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj 200 mg gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) gemfibrozil tab 600 mg GEMZAR INJ 1GM GEMZAR INJ 200MG gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% GENVOYA TAB GEODON INJ 20MG GIAZO TAB 1.1GM GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLASSIA INJ GLEOSTINE CAP 100MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 5MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab er 24hr 10 mg glipizide tab er 24hr 2.5 mg glipizide tab er 24hr 5 mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg. 62 GLUCAGEN INJ 1MG GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab mg 62 glyburide-metformin tab mg.. 62 glyburide-metformin tab mg glycine irrigation soln 1.5% GLYCOPYRROLA INJ 1MG/5ML glycopyrrolate inj 0.2 mg/ml glycopyrrolate inj 0.4 mg/2ml (

143 mg/ml) glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg GLYSET TAB 100MG GLYSET TAB 25MG GLYSET TAB 50MG GLYXAMBI TAB 10-5 MG GLYXAMBI TAB 25-5 MG GOLYTELY SOL GORDOFILM SOL GRALISE STAR MIS 300/ GRALISE TAB 300MG GRALISE TAB 600MG granisetron hcl inj 0.1 mg/ml granisetron hcl inj 1 mg/ml granisetron hcl inj 4 mg/4ml (1 mg/ml) granisetron hcl tab 1 mg GRANIX INJ 300/ GRANIX INJ 480/ griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg guaifenesin-codeine soln mg/5ml guaifenesin-codeine soln mg/5ml guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg guanfacine hcl tab er 24hr 1 mg (base equiv) guanfacine hcl tab er 24hr 2 mg (base equiv) guanfacine hcl tab er 24hr 3 mg (base equiv) guanfacine hcl tab er 24hr 4 mg (base equiv) GUANIDINE TAB 125MG GYNAZOLE-1 CRE 2% H H.P. ACTHAR INJ 80UNIT HALDOL DECAN INJ 100MG/ML HALDOL DECAN INJ 50MG/ML HALDOL INJ 5MG/ML halobetasol propionate cream 0.05% 104 halobetasol propionate oint 0.05% haloperidol decanoate im soln 100 mg/ml haloperidol decanoate im soln 50 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml. 52 haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg HARVONI TAB MG HECTOROL CAP 0.5MCG HECTOROL CAP 1MCG HECTOROL CAP 2.5MCG HECTOROL INJ 2MCG/ML HECTOROL INJ 4MCG/2ML HEMABATE INJ 250MCG HEMATOGEN FA CAP HEMATRON-AF TAB HEMENATAL OB TAB MG HEMETAB TAB heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml HERCEPTIN INJ 150MG HERCEPTIN INJ 440MG HETLIOZ CAP 20MG HEXALEN CAP 50MG HIZENTRA INJ 10/50ML HIZENTRA INJ 1GM/5ML HIZENTRA INJ 2GM/10ML HIZENTRA INJ 4GM/20ML homatropine hbr ophth soln 5% HUMATROPE INJ 12MG HUMATROPE INJ 24MG HUMATROPE INJ 5MG HUMATROPE INJ 6MG

144 HUMIRA INJ 10MG/ HUMIRA KIT 20MG/ HUMIRA KIT 40MG/ HUMIRA PEN INJ 40MG/ HUMULIN R INJ U HYCAMTIN CAP 0.25MG HYCAMTIN CAP 1MG HYCAMTIN INJ 4MG hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg hydrocod polst-chlorphen polst er susp 10-8 mg/5ml hydrocodone w/ homatropine syrup mg/5ml hydrocodone-acetaminophen soln mg/15ml... 4 hydrocodone-acetaminophen tab mg... 4 hydrocodone-acetaminophen tab mg... 4 hydrocodone-acetaminophen tab mg... 4 hydrocodone-acetaminophen tab mg... 4 hydrocodone-ibuprofen tab mg. 4 hydrocodone-ibuprofen tab mg... 4 hydrocodone-ibuprofen tab mg 4 hydrocortisone acetate suppos 25 mg. 80 hydrocortisone acetate suppos 30 mg. 80 hydrocortisone acetate w/ pramoxine rectal cream 1-1% hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% hydrocortisone butyrate cream 0.1% 104 hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/60ml hydrocortisone lotion 2.5% hydrocortisone oint 1% hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5% hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg hydrocortisone valerate cream 0.2% 104 hydrocortisone valerate oint 0.2% hydrocortisone w/ acetic acid otic soln 1-2% HYDROMORPHON SUP 3MG... 4 hydromorphone hcl tab 2 mg... 4 hydromorphone hcl tab 4 mg... 4 hydromorphone hcl tab 8 mg... 4 hydroxocobalamin inj 1000 mcg/ml hydroxychloroquine sulfate tab 200 mg hydroxyurea cap 500 mg hydroxyzine hcl im soln 25 mg/ml hydroxyzine hcl im soln 50 mg/ml hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 100 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg hyoscyamine sulfate elixir mg/5ml hyoscyamine sulfate soln mg/ml 78 hyoscyamine sulfate tab mg hyoscyamine sulfate tab disint mg hyoscyamine sulfate tab er 12hr mg hyoscyamine sulfate tab sl mg.. 78 HYPERSAL NEB 3.5% HYPER-SAL NEB 7% HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ I ibandronate sodium iv soln 3 mg/3ml (base equivalent) ibandronate sodium tab 150 mg (base equivalent) IBRANCE CAP 100MG IBRANCE CAP 125MG

145 IBRANCE CAP 75MG ibuprofen susp 100 mg/5ml... 2 ibuprofen tab 400 mg... 2 ibuprofen tab 600 mg... 2 ibuprofen tab 800 mg... 2 ibutilide fumarate inj 1 mg/10ml ICLUSIG TAB 15MG ICLUSIG TAB 45MG IDAMYCIN PFS INJ 10/10ML IDAMYCIN PFS INJ 20/20ML IDAMYCIN PFS INJ 5MG/5ML idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) IDHIFA TAB 100MG IDHIFA TAB 50MG IFEX INJ 1GM ifosfamide for inj 1 gm IFOSFAMIDE INJ 3GM ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) ILARIS (150) INJ 180MG ILARIS INJ 150MG/ML ILUVIEN IMP 0.19MG imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg imipramine pamoate cap 75 mg imiquimod cream 5% INCRELEX INJ 40MG/4ML indapamide tab 1.25 mg indapamide tab 2.5 mg indomethacin cap 25 mg... 2 indomethacin cap 50 mg... 2 indomethacin cap er 75 mg... 2 INFED INJ 50MG/ML INLYTA TAB 1MG INLYTA TAB 5MG INNOPRAN XL CAP 120MG INNOPRAN XL CAP 80MG INSULIN PEN MIS 29GX12MM INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/31G INSULIN SYRG MIS 0.5/27G INSULIN SYRG MIS 0.5/28G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/31G INSULIN SYRG MIS 1ML INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/29G INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/31G INSULIN SYRG MIS 28GX1/2" INSUPEN SENS MIS 32GX6MM INSUPEN SENS MIS 32GX8MM INTEGRA F CAP INTEGRA PLUS CAP INTELENCE TAB 100MG INTELENCE TAB 200MG INTELENCE TAB 25MG INTRON A INJ 18MU INTRON A INJ 25MU INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/ INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG INVIRASE CAP 200MG INVIRASE TAB 500MG INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG INVOKANA TAB 100MG INVOKANA TAB 300MG iodine solution strong 5% (lugol's) ipratropium bromide inhal soln 0.02%

146 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) ipratropium-albuterol nebu soln (3) mg/3ml irbesartan tab 150 mg irbesartan tab 300 mg irbesartan tab 75 mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg IRESSA TAB 250MG irinotecan hcl inj 100 mg/5ml (20 mg/ml) irinotecan hcl inj 40 mg/2ml (20 mg/ml) irinotecan hcl inj 500 mg/25ml (20 mg/ml) iron combination cap iron polysacch complex-vit b12-fa cap mg iron-folic acid-vit c-vit b6-vit b12-zinc tab mg IROSPAN 24/6 MIS irrigation solution, physiological ISENTRESS CHW 100MG ISENTRESS CHW 25MG ISENTRESS HD TAB 600MG ISENTRESS POW 100MG ISENTRESS TAB 400MG isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg ISORDIL TAB 40MG isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab 5 mg isosorbide dinitrate tab er 40 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab er 24hr 120 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isotretinoin cap 10 mg isotretinoin cap 20 mg isotretinoin cap 30 mg isotretinoin cap 40 mg isradipine cap 2.5 mg isradipine cap 5 mg ISTALOL SOL 0.5% OP ISUPREL INJ 0.2MG/ML itraconazole cap 100 mg ivermectin tab 3 mg IXEMPRA KIT INJ 15MG IXEMPRA KIT INJ 45MG J JADENU TAB 180MG JADENU TAB 360MG JADENU TAB 90MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG JANUMET TAB JANUMET TAB MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA TAB 100MG JANUVIA TAB 25MG JANUVIA TAB 50MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR JEVTANA INJ 60/1.5ML JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG JUXTAPID CAP 60MG K KALBITOR INJ 10MG/ML KALETRA SOL KALETRA TAB MG KALETRA TAB MG

147 KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG KANUMA INJ 20/10ML KENALOG-10 INJ 10MG/ML KENALOG-40 INJ 40MG/ML KEPIVANCE INJ 6.25MG KEPPRA INJ 500/5ML KEPPRA SOL 100MG/ML KEPPRA TAB 1000MG KEPPRA TAB 250MG KEPPRA TAB 500MG KEPPRA TAB 750MG KEPPRA XR TAB 500MG KEPPRA XR TAB 750MG ketoconazole cream 2% ketoconazole shampoo 2% ketoprofen cap 50 mg... 2 ketoprofen cap 75 mg... 2 ketoprofen cap er 24hr 200 mg... 2 ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% ketorolac tromethamine tab 10 mg... 2 KEVEYIS TAB 50MG KHEDEZLA TAB 100MG ER KHEDEZLA TAB 50MG ER KINERET INJ KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200DOSE KISQALI TAB 400DOSE KISQALI TAB 600DOSE KLOR-CON M15 TAB 15MEQ ER KORLYM TAB 300MG K-PHOS TAB K-PHOS TAB NEUTRAL K-PHOS TAB NO KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG KYNAMRO INJ 200MG/ML KYPROLIS SOL 30MG KYPROLIS SOL 60MG L labetalol hcl iv soln 5 mg/ml labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg LACRISERT MIS 5MG OP lactated ringer's for irrigation lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 10% lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml lamivudine oral soln 10 mg/ml lamivudine tab 100 mg (hbv) lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg LANCET CARRY MIS CASE LANCETS MIS LANCING DEVI MIS LANOXIN INJ 0.25MG/ LANOXIN PED INJ 0.1MG/ML LANOXIN TAB 0.125MG LANOXIN TAB 0.25MG LANTUS INJ 100/ML LANTUS INJ SOLOSTAR latanoprost ophth soln 0.005% LATUDA TAB 120MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LAZANDA SPR 100MCG... 4 LAZANDA SPR 300MCG... 4 LAZANDA SPR 400MCG... 4 leflunomide tab 10 mg leflunomide tab 20 mg LEMTRADA INJ 12/1.2ML LENVIMA CAP 10 MG

148 LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 8 MG LETAIRIS TAB 10MG LETAIRIS TAB 5MG letrozole tab 2.5 mg leucovorin calcium for inj 500 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg LEUKERAN TAB 2MG LEUKINE INJ 250MCG leuprolide acetate inj kit 5 mg/ml levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) LEVEMIR INJ LEVEMIR INJ FLEXTOUC levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 1000 mg levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg levobunolol hcl ophth soln 0.5% levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 96 levofloxacin ophth soln 0.5% levofloxacin oral soln 25 mg/ml... 8 LEVOMEFOLATE CAP DHA LEVOTHYROXIN INJ 200MCG levothyroxine sodium for iv inj 100 mcg levothyroxine sodium for iv inj 500 mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg LEVSIN INJ 0.5MG/ML LEXIVA SUS 50MG/ML LEXIVA TAB 700MG LIALDA TAB 1.2GM lidocaine hcl cream 3% lidocaine hcl gel 2% lidocaine hcl iv inj 10 mg/ml lidocaine hcl iv inj 20 mg/ml lidocaine hcl laryngotracheal soln 4% 106 LIDOCAINE HCL LOTION 3% lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine iv infusion in d5w inj 4 mg/ml lidocaine iv infusion in d5w inj 8 mg/ml lidocaine oint 5% lidocaine patch 5% lidocaine-hydrocortisone acetate rectal cream 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 2-2% lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% lidocaine-prilocaine cream %. 105 lidocaine-prilocaine cream kit % LIDODERM DIS 5%

149 lindane shampoo 1% linezolid for susp 100 mg/5ml linezolid tab 600 mg LINZESS CAP 145MCG LINZESS CAP 290MCG LINZESS CAP 72MCG LIORESAL INT INJ 0.05MG/ LIORESAL INT INJ 10MG/ LIORESAL INT INJ 10MG/5ML LIORESAL INT INJ 40MG/ liothyronine sodium iv soln 10 mcg/ml 75 liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril tab 10 mg lisinopril tab 2.5 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg lisinopril tab 5 mg lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab er 300 mg lithium carbonate tab er 450 mg LITHIUM SOL 8MEQ/5ML LO LOESTRIN TAB LONSURF TAB LONSURF TAB loperamide hcl cap 2 mg LOPID TAB 600MG lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) lorazepam conc 2 mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium tab 100 mg losartan potassium tab 25 mg losartan potassium tab 50 mg LOSEASONIQUE TAB LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% LOTRONEX TAB 0.5MG LOTRONEX TAB 1MG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg LOVAZA CAP 1GM loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg LUCENTIS SOL 0.3MG LUCENTIS SOL 0.5MG LUMIGAN SOL 0.01% LUPANETA KIT LUPANETA KIT LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 3M 30MG LUPR DEP-PED INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 30MG LUPRON DEPOT INJ 45MG LUPRON DEPOT INJ 7.5MG LYNPARZA CAP 50MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 25MG LYRICA CAP 300MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA SOL 20MG/ML LYSODREN TAB 500MG

150 M MACUGEN INJ MAGNEBIND TAB MAKENA INJ 250MG/ML malathion lotion 0.5% mannitol iv soln 25% maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg MARCAINE INJ SPINAL... 1 MARNATAL-F CAP MARPLAN TAB 10MG MATULANE CAP 50MG MAVYRET TAB MG MAXIDEX SUS 0.1% OP meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclofenamate sodium cap 100 mg... 2 meclofenamate sodium cap 50 mg... 2 medroxyprogesterone acetate tab 10 mg medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg mefenamic acid cap 250 mg... 2 megestrol acetate susp 40 mg/ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg MEKINIST TAB 0.5MG MEKINIST TAB 2MG meloxicam tab 15 mg... 2 meloxicam tab 7.5 mg... 2 melphalan hcl for inj 50 mg (base equiv) memantine hcl oral solution 2 mg/ml.. 44 memantine hcl tab 10 mg memantine hcl tab 5 mg memantine hcl tab 5 mg (28) & 10 mg (21) titration pak MEMBRANEBLUE SOL 0.15% M-END PE LIQ MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENOSTAR DIS 14MCG meperidine hcl oral soln 50 mg/5ml... 4 MEPHYTON TAB 5MG meprobamate tab 200 mg meprobamate tab 400 mg MEPRON SUS mercaptopurine tab 50 mg mesalamine enema 4 gm mesna inj 100 mg/ml MESNEX INJ 1GM MESNEX TAB 400MG MESTINON SYP 60MG/5ML METAFOLBIC TAB PLUS metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg metaxalone tab 800 mg metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab er 24hr 500 mg metformin hcl tab er 24hr 750 mg methadone hcl soln 10 mg/5ml... 4 methadone hcl soln 5 mg/5ml... 4 methadone hcl tab 10 mg... 4 methadone hcl tab 5 mg... 4 methadone hcl tab for oral susp 40 mg. 4 methamphetamine hcl tab 5 mg methazolamide tab 25 mg methazolamide tab 50 mg methenamine hippurate tab 1 gm methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg methimazole tab 10 mg methimazole tab 5 mg methocarbamol inj 1000 mg/10ml methocarbamol tab 500 mg methocarbamol tab 750 mg methotrexate sodium for inj 1 gm methotrexate sodium inj 250 mg/10ml (25 mg/ml) methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml 140

151 (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) methoxsalen rapid cap 10 mg methscopolamine bromide tab 2.5 mg 78 methscopolamine bromide tab 5 mg methyclothiazide tab 5 mg methyldopa & hydrochlorothiazide tab mg methyldopa & hydrochlorothiazide tab mg methyldopa tab 250 mg methyldopa tab 500 mg methyldopate hcl inj 250 mg/5ml methylergonovine maleate inj 0.2 mg/ml methylphenidate hcl cap er 10 mg (cd)55 methylphenidate hcl cap er 20 mg (cd)55 methylphenidate hcl cap er 24hr 20 mg (la) methylphenidate hcl cap er 24hr 30 mg (la) methylphenidate hcl cap er 24hr 40 mg (la) methylphenidate hcl cap er 30 mg (cd)55 methylphenidate hcl cap er 40 mg (cd)55 methylphenidate hcl cap er 50 mg (cd)55 methylphenidate hcl cap er 60 mg (cd)55 methylphenidate hcl chew tab 10 mg.. 55 methylphenidate hcl chew tab 2.5 mg. 55 methylphenidate hcl chew tab 5 mg methylphenidate hcl soln 10 mg/5ml.. 55 methylphenidate hcl soln 5 mg/5ml methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab 5 mg methylphenidate hcl tab er 10 mg methylphenidate hcl tab er 24hr 18 mg methylphenidate hcl tab er 24hr 27 mg methylphenidate hcl tab er 24hr 36 mg methylphenidate hcl tab er 24hr 54 mg methylphenidate hcl tab er osmotic release (osm) 18 mg methylphenidate hcl tab er osmotic release (osm) 27 mg methylphenidate hcl tab er osmotic release (osm) 36 mg methylphenidate hcl tab er osmotic release (osm) 54 mg METHYLPRD PF INJ 80MG/ML methylprednisolone acetate inj susp 40 mg/ml methylprednisolone acetate inj susp 80 mg/ml methylprednisolone sod succ for inj 1000 mg (base equiv) methylprednisolone sod succ for inj 125 mg (base equiv) methylprednisolone sod succ for inj 40 mg (base equiv) methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab therapy pack 4 mg (21) methyltestosterone cap 10 mg metipranolol ophth soln 0.3% metoclopramide hcl inj 5 mg/ml metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 10 mg metoclopramide hcl tab 5 mg metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol succinate tab er 24hr 100 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol succinate tab er 24hr 25 mg (tartrate equiv) metoprolol succinate tab er 24hr 50 mg (tartrate equiv)

152 metoprolol tartrate iv soln 5 mg/5ml.. 32 metoprolol tartrate tab 100 mg metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg METROGEL-VAG GEL 0.75% metronidazole cap 375 mg metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% metronidazole tab 250 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg MIACALCIN INJ 200/ML midazolam hcl inj 10 mg/10ml (base equivalent) midazolam hcl inj 10 mg/2ml (base equivalent) midazolam hcl inj 2 mg/2ml (base equivalent) midazolam hcl inj 25 mg/5ml (base equivalent) midazolam hcl inj 5 mg/5ml (base equivalent) midazolam hcl inj 5 mg/ml (base equivalent) midazolam hcl inj 50 mg/10ml (base equivalent) midazolam hcl syrup 2 mg/ml (base equivalent) midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg MILLIPRED DP PAK 5MG milrinone lactate in dextrose 5% iv soln 20 mg/100ml milrinone lactate in dextrose 5% iv soln 40 mg/200ml milrinone lactate iv soln 10 mg/10ml (base equivalent) milrinone lactate iv soln 20 mg/20ml (base equivalent) milrinone lactate iv soln 50 mg/50ml (base equivalent) MINIVELLE DIS 0.025MG MINIVELLE DIS MG MINIVELLE DIS 0.05MG MINIVELLE DIS 0.075MG MINIVELLE DIS 0.1MG MINOCIN CAP 100MG... 9 MINOCIN CAP 50MG... 9 minocycline hcl cap 100 mg... 9 minocycline hcl cap 50 mg... 9 minocycline hcl cap 75 mg... 9 minocycline hcl tab 100 mg... 9 minocycline hcl tab 50 mg... 9 minocycline hcl tab 75 mg... 9 minoxidil tab 10 mg minoxidil tab 2.5 mg MIOSTAT INJ 0.01% OP MIRCETTE TAB 28 DAY mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg mirtazapine tab 7.5 mg MIRVASO GEL 0.33% misoprostol tab 100 mcg misoprostol tab 200 mcg mitomycin for iv soln 20 mg mitomycin for iv soln 40 mg mitomycin for iv soln 5 mg mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) modafinil tab 100 mg modafinil tab 200 mg moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg MOI-STIR SOL

153 mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) MONSELS FERR SOL SUBSULF montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) MORPHINE SUL SUP 30MG... 4 morphine sulfate oral soln 10 mg/5ml... 4 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)... 4 morphine sulfate oral soln 20 mg/5ml... 4 morphine sulfate suppos 10 mg... 4 morphine sulfate suppos 20 mg... 4 morphine sulfate suppos 5 mg... 4 morphine sulfate tab 15 mg... 4 morphine sulfate tab 30 mg... 4 morphine sulfate tab er 100 mg... 4 morphine sulfate tab er 15 mg... 4 morphine sulfate tab er 200 mg... 4 morphine sulfate tab er 30 mg... 4 morphine sulfate tab er 60 mg... 4 MOUTHKOTE SOL MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG MOXEZA SOL 0.5% moxifloxacin hcl ophth soln 0.5% (base equiv) moxifloxacin hcl tab 400 mg (base equiv)... 8 MOZOBIL INJ MULTAQ TAB 400MG MULTI-LANCET KIT DEVICE mupirocin oint 2% MUSTARGEN INJ 10MG M-VIT TAB 27-1MG MYALEPT INJ 11.3MG MYCOBUTIN CAP 150MG mycophenolate mofetil cap 250 mg mycophenolate mofetil for oral susp 200 mg/ml mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) MYLERAN TAB 2MG MYNATAL CAP MYNATAL TAB MYNATAL TAB ADVANCE MYNATAL-Z TAB MYNATE 90 TAB PLUS MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG N nabumetone tab 500 mg... 2 nabumetone tab 750 mg... 2 nadolol & bendroflumethiazide tab 40-5 mg nadolol & bendroflumethiazide tab 80-5 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg NAGLAZYME INJ 1MG/ML naloxone hcl inj 0.4 mg/ml naloxone hcl inj 4 mg/10ml naloxone hcl soln cartridge 0.4 mg/ml 61 naloxone hcl soln prefilled syringe 2 mg/2ml naltrexone hcl tab 50 mg naproxen sodium tab 275 mg... 2 naproxen sodium tab 550 mg... 2 naproxen susp 125 mg/5ml... 2 naproxen tab 250 mg... 2 naproxen tab 375 mg... 2 naproxen tab 500 mg... 2 naproxen tab ec 375 mg... 2 naproxen tab ec 500 mg... 2 naratriptan hcl tab 1 mg (base equiv). 57 naratriptan hcl tab 2.5 mg (base equiv) NARCAN SPR NATACHEW CHW NATACYN SUS 5% OP nateglinide tab 120 mg nateglinide tab 60 mg NATELLE ONE CAP NATPARA INJ 100MCG NATPARA INJ 25MCG

154 NATPARA INJ 50MCG NATPARA INJ 75MCG NATRECOR INJ 1.5MG NATURE THROI TAB 162.5MG NATURE-THROI TAB MG NATURE-THROI TAB 130MG NATURE-THROI TAB MG NATURE-THROI TAB 16.25MG NATURE-THROI TAB 195MG NATURE-THROI TAB 260MG NATURE-THROI TAB 32.5MG NATURE-THROI TAB 325MG NATURE-THROI TAB 48.75MG NATURE-THROI TAB 81.25MG NATURE-THROI TAB 97.5MG NAVELBINE INJ 10MG/ML NAVELBINE INJ 50MG/5ML NEBUPENT INH 300MG NEBUSAL NEB 6% NEEVO DHA CAP neomycin sulfate tab 500 mg... 6 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mg-unt-mg/ml neomycin-polymyxin b gu irrigation soln neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp neomycin-polymyxin-hc otic soln 1% 111 neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% NEOPROFEN SOL 10MG/ML NEORAL CAP 100MG NEORAL CAP 25MG NEORAL SOL 100MG/ML NEOSPORIN GU SOL 40/ML IR neostigmine methylsulfate iv soln 10 mg/10 ml (1 mg/ml) neostigmine methylsulfate iv soln 5 mg/10 ml (0.5 mg/ml) NEPHPLEX RX TAB NEPHRON FA TAB NERLYNX TAB 40MG NESTABS ABC MIS NESTABS DHA PAK NEULASTA INJ 6MG/0.6M NEUPOGEN INJ 300/ NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/ NEUPOGEN INJ 480MCG NEUPRO DIS 1MG/24HR NEUPRO DIS 2MG/24HR NEUPRO DIS 3MG/24HR NEUPRO DIS 4MG/24HR NEUPRO DIS 6MG/24HR NEUPRO DIS 8MG/24HR NEURIN-SL SUB NEVANAC SUS 0.1% nevirapine tab 200 mg nevirapine tab er 24hr 100 mg nevirapine tab er 24hr 400 mg NEWGEN TAB 32-1MG NEXAVAR TAB 200MG NEXTERONE INJ niacin tab er 1000 mg (antihyperlipidemic) niacin tab er 500 mg (antihyperlipidemic) niacin tab er 750 mg (antihyperlipidemic) NICADAN TAB nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nicardipine hcl iv soln 2.5 mg/ml NICOTROL INH NICOTROL NS SPR 10MG/ML nifedipine cap 20 mg nifedipine tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 90 mg NILANDRON TAB 150MG nimodipine cap 30 mg NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG NIPENT INJ 10MG nisoldipine tab er 24hr 17 mg nisoldipine tab er 24hr 20 mg nisoldipine tab er 24hr 25.5 mg nisoldipine tab er 24hr 30 mg

155 nisoldipine tab er 24hr 34 mg nisoldipine tab er 24hr 40 mg nisoldipine tab er 24hr 8.5 mg NITRO-BID OIN 2% NITRO-DUR DIS 0.1MG/HR NITRO-DUR DIS 0.2MG/HR NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.4MG/HR NITRO-DUR DIS 0.6MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg NITROGLYCER INJ 5MG/ML nitroglycerin cap er 2.5 mg nitroglycerin cap er 6.5 mg nitroglycerin cap er 9 mg nitroglycerin lingual aerosol 400 mcg/spray nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr. 38 nitroglycerin td patch 24hr 0.2 mg/hr. 38 nitroglycerin td patch 24hr 0.4 mg/hr. 38 nitroglycerin td patch 24hr 0.6 mg/hr. 38 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) NITROLINGUAL SPR PUMPSPRA NITROSTAT SUB 0.3MG NITROSTAT SUB 0.4MG NITROSTAT SUB 0.6MG NIVA-PLUS TAB NOCLOT-50 SOL ACD-A norethindrone acetate tab 5 mg norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg NORPACE CAP 100MG CR NORPACE CAP 150MG CR NORTHERA CAP 200MG NORTHERA CAP 300MG nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml NORVASC TAB 10MG NORVASC TAB 2.5MG NORVASC TAB 5MG NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG NOVOFINE MIS 30GX8MM NOVOLIN INJ 70/ NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/ NOVOLOG MIX INJ FLEXPEN NOVOTWIST MIS 32GX5MM NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG NPLATE INJ 250MCG NPLATE INJ 500MCG NUCALA INJ 100MG NUEDEXTA CAP 20-10MG NULOJIX INJ 250MG NULYTELY SOL FLAV PKS NUMOISYN LOZ NUPLAZID TAB 17MG NUVIGIL TAB 150MG NUVIGIL TAB 200MG NUVIGIL TAB 250MG NUVIGIL TAB 50MG nystatin cream unit/gm nystatin oint unit/gm nystatin susp unit/ml nystatin tab unit nystatin topical powder unit/gm nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% O OB COMPLETE CAP ONE OB COMPLETE CAP PETITE OB COMPLETE TAB OB COMPLETE TAB PREMIER

156 OBIZUR INJ 500 UNIT OBSTETRIX EC TAB OBSTETRIX PAK DHA O-CAL FA TAB O-CAL TAB PRENATAL OCALIVA TAB 10MG OCALIVA TAB 5MG OCTAGAM INJ 10GM OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 25GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ODOMZO CAP 200MG OFEV CAP 100MG OFEV CAP 150MG ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% olanzapine for im inj 10 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine orally disintegrating tab 5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 2.5 mg olanzapine tab 20 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olopatadine hcl nasal soln 0.6% olopatadine hcl ophth soln 0.1% (base equivalent) olopatadine hcl ophth soln 0.2% (base equivalent) OMECLAMOX- MIS PAK omega-3-acid ethyl esters cap 1 gm OMNIPRED SUS 1% OP ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl inj 40 mg/20ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml ondansetron hcl tab 24 mg ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg ONETOUCH KIT ULT MINI ONETOUCH KIT ULTRA ONETOUCH KIT ULTRALNK ONETOUCH KIT VERIO ONETOUCH KIT VERIO FL ONETOUCH KIT VERIO IQ ONETOUCH TES ULTRA BL ONETOUCH TES VERIO ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG ONMEL TAB 200MG OPANA ER TAB 10MG... 5 OPANA ER TAB 15MG... 5 OPANA ER TAB 20MG... 5 OPANA ER TAB 30MG... 5 OPANA ER TAB 40MG... 5 OPANA ER TAB 5MG... 5 OPANA ER TAB 7.5MG... 5 ophthalmic irrigation solution - intraocular ORACIT SOL ORAMAGICRX SUS ORENCIA INJ 125MG/ML ORENCIA INJ 250MG ORENCIA INJ 50/ ORENCIA INJ 87.5/ ORENITRAM TAB 0.125MG ORENITRAM TAB 0.25MG ORENITRAM TAB 1MG ORENITRAM TAB 2.5MG ORENITRAM TAB 5MG ORFADIN CAP 10MG

157 ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN SUS 4MG/ML ORKAMBI TAB orphenadrine citrate inj 30 mg/ml orphenadrine citrate tab er 12hr 100 mg oscion clnsr lot 6% oseltamivir phosphate cap 30 mg (base equiv) oseltamivir phosphate cap 45 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) oseltamivir phosphate for susp 6 mg/ml (base equiv) OSMOPREP TAB 1.5GM OTEZLA TAB 10/20/ OTEZLA TAB 30MG OTREXUP INJ 10MG OTREXUP INJ 12.5/ OTREXUP INJ 15MG OTREXUP INJ 17.5/ OTREXUP INJ 20MG OTREXUP INJ 22.5/ OTREXUP INJ 25MG oxaliplatin for iv inj 100 mg oxaliplatin for iv inj 50 mg oxaliplatin iv soln 100 mg/20ml oxaliplatin iv soln 50 mg/10ml oxaprozin tab 600 mg... 2 oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg oxiconazole nitrate cream 1% OXSORALEN-UL CAP 10MG oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab er 24hr 10 mg 82 oxybutynin chloride tab er 24hr 15 mg 82 oxybutynin chloride tab er 24hr 5 mg. 82 oxycodone hcl cap 5 mg... 5 oxycodone hcl conc 100 mg/5ml (20 mg/ml)... 5 oxycodone hcl soln 5 mg/5ml... 5 oxycodone hcl tab 10 mg... 5 oxycodone hcl tab 15 mg... 5 oxycodone hcl tab 20 mg... 5 oxycodone hcl tab 30 mg... 5 oxycodone hcl tab 5 mg... 5 oxycodone hcl tab er 12hr deter 10 mg. 5 oxycodone hcl tab er 12hr deter 15 mg. 5 oxycodone hcl tab er 12hr deter 20 mg. 5 oxycodone hcl tab er 12hr deter 30 mg. 5 oxycodone hcl tab er 12hr deter 40 mg. 5 oxycodone hcl tab er 12hr deter 60 mg. 5 oxycodone hcl tab er 12hr deter 80 mg. 5 oxycodone w/ acetaminophen soln mg/5ml... 5 oxycodone w/ acetaminophen tab mg... 5 oxycodone w/ acetaminophen tab mg... 5 oxycodone w/ acetaminophen tab mg... 5 oxycodone-ibuprofen tab mg... 5 OXYCONTIN TAB 10MG CR... 5 OXYCONTIN TAB 15MG CR... 5 OXYCONTIN TAB 20MG CR... 5 OXYCONTIN TAB 30MG CR... 5 OXYCONTIN TAB 40MG CR... 5 OXYCONTIN TAB 60MG CR... 5 OXYCONTIN TAB 80MG CR... 5 oxymorphone hcl tab 10 mg... 5 oxymorphone hcl tab 5 mg... 5 oxymorphone hcl tab er 12hr 10 mg... 5 oxymorphone hcl tab er 12hr 15 mg... 5 oxymorphone hcl tab er 12hr 20 mg... 5 oxymorphone hcl tab er 12hr 30 mg... 5 oxymorphone hcl tab er 12hr 40 mg... 6 oxymorphone hcl tab er 12hr 5 mg... 5 oxymorphone hcl tab er 12hr 7.5 mg... 5 oxytocin inj 10 unit/ml P paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml) paclitaxel iv conc 30 mg/5ml (6 mg/ml) paclitaxel iv conc 300 mg/50ml (6 147

158 mg/ml) paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg pamidronate disodium for inj 30 mg pamidronate disodium for inj 90 mg pamidronate disodium iv soln 3 mg/ml 67 pamidronate disodium iv soln 9 mg/ml 67 PAMIDRONATE INJ 6MG/ML PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT PANCREAZE CAP 4200UNIT PANRETIN GEL 0.1% papaverine hcl inj 30 mg/ml paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paricalcitol iv soln 2 mcg/ml paricalcitol iv soln 5 mcg/ml paromomycin sulfate cap 250 mg... 6 paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg paroxetine hcl tab er 24hr 12.5 mg paroxetine hcl tab er 24hr 25 mg paroxetine hcl tab er 24hr 37.5 mg PASER GRA 4GM PATADAY SOL 0.2% PATANASE SPR 0.6% PAXIL SUS 10MG/5ML PAZEO DRO 0.7% PCE TAB 333MG EC... 7 PCE TAB 500MG EC... 7 pediatric multiple vitamin w/ minerals & c drops 45 mg/ml pediatric multiple vitamins w/ fl-fe drops mg/ml pediatric multiple vitamins w/ fl-fe drops mg/ml pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric vitamins acd fluoride & fe drops mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEG-INTRON KIT 120MCG PEG-INTRON KIT 150MCG PEG-INTRON KIT 50MCG PEG-INTRON KIT 80MCG PEN NEEDLES MIS 31GX6MM penicillin v potassium for soln 125 mg/5ml... 9 penicillin v potassium for soln 250 mg/5ml... 9 penicillin v potassium tab 250 mg... 9 penicillin v potassium tab 500 mg... 9 PENLAC SOL 8% PENTASA CAP 250MG CR PENTASA CAP 500MG CR pentoxifylline tab er 400 mg PERFOROMIST NEB 20MCG perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg PERJETA INJ 420/14ML permethrin cream 5% perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg 148

159 PERTZYE CAP phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg phenelzine sulfate tab 15 mg PHENOBARB INJ 65MG/ML phenobarbital elixir 20 mg/5ml phenobarbital sodium inj 130 mg/ml.. 43 phenobarbital tab 100 mg phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg PHENOL LIQ 89% phenoxybenzamine hcl cap 10 mg PHENYLADE POW GMP phenylephrine hcl inj 10 mg/ml phenylephrine hcl ophth soln 10% phenylephrine hcl ophth soln 2.5% PHENYTEK CAP 200MG PHENYTEK CAP 300MG phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml PHOSPHOLINE SOL 0.125%OP PHOTOFRIN INJ 75MG PHYSOS SALIC INJ 1MG/ML pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 4% pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg pimozide tab 1 mg pimozide tab 2 mg pindolol tab 10 mg pindolol tab 5 mg pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg pioglitazone hcl-metformin hcl tab mg pioglitazone hcl-metformin hcl tab mg piroxicam cap 10 mg... 2 piroxicam cap 20 mg... 2 PITOCIN INJ 10UNT/ML PNV OB+DHA PAK PNV PRENATAL TAB PLUS PNV TABS TAB 29-1MG PNV-DHA CAP DOCUSATE PODOCON SOL 25% podofilox soln 0.5% polyethylene glycol 3350 oral powder. 79 polymyxin b-trimethoprim ophth soln unit/ml-0.1% POLY-VI-FLOR CHW 0.25MG POLY-VI-FLOR CHW 0.5MG POLY-VI-FLOR CHW 1MG POLY-VI-FLOR SUS /IRON POLY-VI-FLOR SUS 0.25/ML POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG pot & sod citrates w/ cit ac soln mg/5ml pot bicarbonate & chloride effer tab 25 meq pot phos monobasic w/sod phos di & monobas tab mg potassium bicarbonate effer tab 25 meq potassium chloride cap er 10 meq potassium chloride cap er 8 meq potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 149

160 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 mg) potassium chloride tab er 8 meq (600 mg) potassium citrate & citric acid powder pack mg potassium citrate & citric acid soln mg/5ml potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) potassium citrate tab er 5 meq (540 mg) PR CREAM KIT PR NATAL 400 PAK PR NATAL 430 PAK PR NATAL 430 PAK EC pramipexole dihydrochloride tab mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg 49 pramipexole dihydrochloride tab 1.5 mg pramipexole dihydrochloride tab er 24hr mg pramipexole dihydrochloride tab er 24hr 0.75 mg pramipexole dihydrochloride tab er 24hr 1.5 mg pramipexole dihydrochloride tab er 24hr 2.25 mg pramipexole dihydrochloride tab er 24hr 3 mg pramipexole dihydrochloride tab er 24hr 3.75 mg pramipexole dihydrochloride tab er 24hr 4.5 mg pramoxine-hc cream 1-2.5% prasugrel hcl tab 10 mg (base equiv).. 86 prasugrel hcl tab 5 mg (base equiv) pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg PRED MILD SUS 0.12% OP PRED-G S.O.P OIN OP PRED-G SUS OP prednicarbate cream 0.1% prednicarbate oint 0.1% prednisolone acetate ophth susp 1% 108 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution equivalent) prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 50 mg PREFERAOB MIS +DHA PREFEST TAB PREMARIN INJ 25MG PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG PREMARIN VAG CRE 0.625MG PREMPHASE TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB

161 PRENAISSANCE CAP PLUS PRENAISSANCE TAB NEXT PRENAT PLUS TAB 27-1MG prenat w/o a w/fefum-methfol-fa-dha cap mg PRENATA CHW 29-1MG PRENATAL TAB 27-1MG PRENATAL TAB PLUS PRENATAL VIT TAB LOW IRON prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg prenatal vit w/ fe fumarate-fa chew tab 29-1 mg prenatal vit w/ fe fumarate-fa tab 27-1 mg prenatal vit w/ fe fumarate-fa tab 28-1 mg prenatal vit w/ fe fum-methylfolate-fa tab mg PRENATAL+FE TAB 29-1MG PRENATAL-U CAP PRENATE AM TAB 1MG PRENATE CAP ENHANCE PRENATE CAP ESSENTIA PRENATE CAP PIXIE PRENATE CAP RESTORE PRENATE CHW PRENATE DHA CAP PRENATE MINI CAP PRENATE TAB ELITE PREPIDIL GEL 0.5MG/3G PREPLUS TAB 27-1MG PRETAB TAB 29-1MG PREVDNT 5000 PST 1.1% PREVDNT 5000 PST 1.1-5% PREVIDENT CRE 5000 PLS PREVIDENT GEL 1.1% PREVIDENT GEL 1.1% BER PREVIDENT GEL 1.1% CHR PREVIDENT GEL 1.1% MIN PREVIDENT PST 5000 BST PREZCOBIX TAB PREZISTA SUS 100MG/ML PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 75MG PREZISTA TAB 800MG PRIALT INJ 100MCG... 1 PRIALT INJ 25MCG/ML... 1 PRIALT INJ 500MCG... 1 PRIFTIN TAB 150MG primidone tab 250 mg primidone tab 50 mg PRIMSOL SOL 50MG/5ML PRISTIQ TAB 100MG PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRIVIGEN INJ 10GRAMS PRIVIGEN INJ 20GRAMS PRIVIGEN INJ 40GRAMS PRIVIGEN INJ 5 GRAMS PROBUPHINE IMP KIT PROCAINAMIDE HCL INJ 500 MG/ML.. 28 prochlorperazine edisylate inj 5 mg/ml 77 prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine suppos 25 mg PROCRIT INJ 40000/ML PROCTOFOAM AER HC 1% PROCYSBI CAP 25MG PROCYSBI CAP 75MG PROFERRIN- TAB FORTE progesterone micronized cap 100 mg.. 74 progesterone micronized cap 200 mg.. 74 PROGLYCEM SUS 50MG/ML PROGRAF CAP 0.5MG PROGRAF CAP 1MG PROGRAF CAP 5MG PROGRAF INJ 5MG/ML PROLASTIN-C INJ 1000MG PROLENSA SOL 0.07% PROLEUKIN INJ 22MU PROLIA SOL 60MG/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG promethazine & phenylephrine syrup mg/5ml promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl suppos 12.5 mg

162 promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml.. 77 promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg promethazine w/ codeine syrup mg/5ml promethazine-dm syrup mg/5ml propafenone hcl cap er 12hr 225 mg.. 28 propafenone hcl cap er 12hr 325 mg.. 28 propafenone hcl cap er 12hr 425 mg.. 28 propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg propantheline bromide tab 15 mg propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg propranolol hcl cap er 24hr 120 mg propranolol hcl cap er 24hr 160 mg propranolol hcl cap er 24hr 60 mg propranolol hcl cap er 24hr 80 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg propylthiouracil tab 50 mg PROSTIN E2 SUP 20MG PROSTIN VR INJ 500MCG protamine sulfate inj 10 mg/ml PROTOPAM CHL INJ 1GM protriptyline hcl tab 10 mg protriptyline hcl tab 5 mg PROVENTIL AER HFA PROVIDA DHA CAP PROVIDA OB CAP PROVIGIL TAB 100MG PROVIGIL TAB 200MG PROVISC INJ 1% PRUTECT EMU pseudoephed-bromphen-dm syrup mg/5ml PULMICORT INH 180MCG PULMICORT INH 90MCG PULMOZYME SOL 1MG/ML PUREFE CAP PLUS PUREFE OB CAP PLUS pyrazinamide tab 500 mg pyridostigmine bromide tab 60 mg pyridostigmine bromide tab er 180 mg 60 pyridoxine hcl inj 100 mg/ml Q quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab 50 mg QUFLORA PED CHW 0.25MG QUFLORA PED CHW 0.5MG QUFLORA PED CHW 1MG quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg quinapril hcl tab 5 mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg QUTENZA KIT 8% 1-PCH QVAR AER 40MCG QVAR AER 80MCG QVAR REDIHA AER 80MCG QVAR REDIHAL AER 40MCG R ramipril cap 1.25 mg ramipril cap 10 mg ramipril cap 2.5 mg ramipril cap 5 mg RANEXA TAB 1000MG RANEXA TAB 500MG RAPAFLO CAP 4MG RAPAFLO CAP 8MG RAPAMUNE SOL 1MG/ML RAPAMUNE TAB 0.5MG

163 RAPAMUNE TAB 1MG RAPAMUNE TAB 2MG rasagiline mesylate tab 0.5 mg (base equiv) rasagiline mesylate tab 1 mg (base equiv) RASUVO INJ 10MG RASUVO INJ 12.5MG RASUVO INJ 15MG RASUVO INJ 17.5MG RASUVO INJ 20MG RASUVO INJ 22.5MG RASUVO INJ 25MG RASUVO INJ 30MG RASUVO INJ 7.5MG RAVICTI LIQ 1.1GM/ML REBETOL SOL 40MG/ML REBIF INJ 22/ REBIF INJ 44/ REBIF REBIDO INJ 22/ REBIF REBIDO INJ 44/ REBIF REBIDO INJ TITRATN REBIF TITRTN INJ PACK RECTIV OIN 0.4% REDICHEW RX CHW REGENECARE GEL REGONOL INJ 5MG/ML RELENZA MIS DISKHALE RELNATE DHA CAP RELPAX TAB 20MG RELPAX TAB 40MG REMICADE INJ 100MG REMODULIN INJ 10MG/ML REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML RENAGEL TAB 400MG RENAGEL TAB 800MG RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENVELA TAB 800MG REOPRO INJ 2MG/ML repaglinide tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg repaglinide-metformin hcl tab mg repaglinide-metformin hcl tab mg REPATHA INJ 140MG/ML REPATHA PUSH INJ 420/ REPATHA SURE INJ 140MG/ML RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RESECTISOL SOL 5% RESTASIS EMU 0.05% RETROVIR INJ 10MG/ML REVATIO TAB 20MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG ribavirin cap 200 mg ribavirin tab 200 mg ribavirin tab 400 mg ribavirin tab 600 mg rifabutin cap 150 mg RIFAMATE CAP rifampin cap 150 mg rifampin cap 300 mg RIFATER TAB riluzole tab 50 mg rimantadine hydrochloride tab 100 mg 14 RIMSO-50 SOL 50% ringer's solution for irrigation RIOMET SOL risedronate sodium tab 150 mg risedronate sodium tab 30 mg risedronate sodium tab 35 mg risedronate sodium tab 5 mg risedronate sodium tab delayed release 35 mg RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg

164 risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab 2 mg risperidone soln 1 mg/ml risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg RITUXAN INJ 100MG RITUXAN INJ 500MG rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap 4.5 mg rivastigmine tartrate cap 6 mg rivastigmine td patch 24hr 13.3 mg/24hr rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rizatriptan benzoate oral disintegrating tab 10 mg (base eq) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) rizatriptan benzoate tab 10 mg (base equivalent) rizatriptan benzoate tab 5 mg (base equivalent) ROCALTROL CAP 0.25MCG ROCALTROL CAP 0.5MCG ROCALTROL SOL 1MCG/ML ropinirole hydrochloride tab 0.25 mg.. 49 ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg rosuvastatin calcium tab 5 mg RUBRACA TAB 200MG RUBRACA TAB 250MG RUBRACA TAB 300MG RUCONEST INJ 2100UNIT RYDAPT CAP 25MG S SABRIL POW 500MG SABRIL TAB 500MG salicylic acid cream 6% salicylic acid film forming liquid 27.5% salicylic acid lotion 6% salicylic acid shampoo 6% SALICYLIC ACID SOLN 26% salisol fort sol 26% salsalate tab 500 mg... 2 salsalate tab 750 mg... 2 SAMSCA TAB 15MG SAMSCA TAB 30MG SANCUSO DIS 3.1MG SANDIMMUNE CAP 100MG SANDIMMUNE CAP 25MG SANDIMMUNE INJ 50MG/ML SANDIMMUNE SOL 100MG/ML SANDOSTATIN INJ 1000MCG SANDOSTATIN INJ 100MCG SANDOSTATIN INJ 200MCG SANDOSTATIN INJ 500MCG SANDOSTATIN INJ 50MCG/ML SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SANTYL OIN 250/GM SAPHRIS SUB 10MG SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAVELLA MIS TITR PAK SAVELLA TAB 100MG SAVELLA TAB 12.5MG SAVELLA TAB 25MG SAVELLA TAB 50MG

165 SEASONIQUE TAB SEEBRI NEOHA CAP 15.6MCG SELECT-OB CHW SELECT-OB+ PAK DHA selegiline hcl cap 5 mg selegiline hcl tab 5 mg selenium sulfide-pyrithione zinc in urea shampoo 2.25% SELZENTRY SOL 20MG/ML SELZENTRY TAB 150MG SELZENTRY TAB 300MG SE-NATAL 19 TAB SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG SEREVENT DIS AER 50MCG SEROQUEL XR TAB 150MG SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG SEROQUEL XR TAB 50MG SEROSTIM INJ 4MG SEROSTIM INJ 5MG SEROSTIM INJ 6MG sertraline hcl oral conc 20 mg/ml sertraline hcl tab 100 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg SHOHLS SOL MODIFIED SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SIGNIFOR LAR INJ 20MG SIGNIFOR LAR INJ 40MG SIGNIFOR LAR INJ 60MG sildenafil citrate tab 20 mg SILVER NITRA OIN 10% SILVER NITRA SOL 0.5% SILVER NITRA SOL 10% SILVER NITRA SOL 25% SILVER NITRA SOL 50% silver sulfadiazine cream 1% SILVRSTAT GEL DRESSING SIMBRINZA SUS 1-0.2% SIMPONI ARIA SOL 50MG/4ML SIMPONI INJ 100MG/ML SIMPONI INJ 50/0.5ML SIMULECT INJ 10MG SIMULECT INJ 20MG simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg simvastatin tab 80 mg sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg SIRTURO TAB 100MG SIVEXTRO INJ 200MG SIVEXTRO TAB 200MG sod ferric gluc cmplx in sucrose iv soln 12.5 mg/ml (fe eq) sodium chloride irrigation soln 0.9% sodium chloride soln nebu 0.9% sodium chloride soln nebu 10% sodium chloride soln nebu 3% sodium chloride soln nebu 7% sodium citrate & citric acid soln mg/5ml sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride cream 1.1% sodium fluoride gel 1.1% (0.5% f) sodium fluoride paste 1.1% sodium fluoride rinse 0.2% sodium fluoride tab 1 mg f (from 2.2 mg naf) sodium phenylbutyrate oral powder 3 gm/teaspoonful sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder. 90 sodium thiosulfate inj 25% SOLIRIS INJ 10MG/ML SOLU-CORTEF INJ 1000MG SOLU-CORTEF INJ 100MG SOLU-CORTEF INJ 250MG SOLU-CORTEF INJ 500MG SOLU-MEDROL INJ 125MG SOLU-MEDROL INJ 1GM SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG SOLU-MEDROL INJ 500MG SOMATULINE INJ 120/.5ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML

166 SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG SONAFINE EMU sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg SPIRIVA AER 1.25MCG SPIRIVA CAP HANDIHLR SPIRIVA SPR RESPIMAT spironolactone & hydrochlorothiazide tab mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg SPORANOX SOL 10MG/ML SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SSKI SOL 1GM/ML stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg STELARA INJ 45MG/ STELARA INJ 5MG/ML STELARA INJ 90MG/ML STIMATE SOL 1.5MG/ML STIOLTO AER STIVARGA TAB 40MG STRATTERA CAP 100MG STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG STRENSIQ INJ 18/ STRENSIQ INJ 28/0.7ML STRENSIQ INJ 40MG/ML STRENSIQ INJ 80/0.8ML STRIANT MIS 30MG STRIBILD TAB STRIVERDI AER 2.5MCG STROMECTOL TAB 3MG SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUBSYS SPR 100MCG... 6 SUBSYS SPR 1200MCG... 6 SUBSYS SPR 1600MCG... 6 SUBSYS SPR 200MCG... 6 SUBSYS SPR 400MCG... 6 SUBSYS SPR 600MCG... 6 SUBSYS SPR 800MCG... 6 SUCRAID SOL 8500/ML sucralfate tab 1 gm SULAR TAB 17MG SULAR TAB 34MG SULAR TAB 8.5MG sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% sulfacetamide sodium w/ sulfur emulsion 10-1% sulfacetamide sodium w/ sulfur wash 9-4.5% sulfacetamide sodium-prednisolone ophth soln (0.25)% SULFADIAZINE TAB 500MG... 9 sulfamethoxazole-trimethoprim susp mg/5ml... 9 sulfamethoxazole-trimethoprim tab mg... 9 sulfamethoxazole-trimethoprim tab mg... 9 SULFAMYLON CRE 85MG/GM sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg sulindac tab 150 mg... 2 sulindac tab 200 mg... 2 sumatriptan nasal spray 20 mg/act sumatriptan nasal spray 5 mg/act sumatriptan succinate inj 6 mg/0.5ml

167 sumatriptan succinate solution auto-injector 4 mg/0.5ml sumatriptan succinate solution auto-injector 6 mg/0.5ml sumatriptan succinate solution cartridge 4 mg/0.5ml sumatriptan succinate solution cartridge 6 mg/0.5ml sumatriptan succinate tab 100 mg sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg SUPPRELIN LA KIT 50MG SUPRAX CAP 400MG... 7 SUPRAX CHW 100MG... 7 SUPRAX CHW 200MG... 7 SUPRAX SUS 100/5ML... 7 SUPRAX SUS 200/5ML... 7 SUPRAX SUS 500/5ML... 7 SURESTEP PRO TES HIGH CON SURESTEP PRO TES NORM CON SURMONTIL CAP 100MG SURMONTIL CAP 25MG SURMONTIL CAP 50MG SUSTIVA CAP 200MG SUSTIVA CAP 50MG SUSTIVA TAB 600MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYMAX DUOTAB TAB SYMBICORT AER SYMBICORT AER SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG SYNAGIS INJ 100MG/ML SYNAGIS INJ 50MG SYNAREL SOL 2MG/ML SYNJARDY TAB SYNJARDY TAB SYNJARDY TAB MG SYNJARDY TAB 5-500MG SYNJARDY XR TAB SYNJARDY XR TAB SYNJARDY XR TAB SYNJARDY XR TAB MG SYNRIBO INJ 3.5MG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 25MCG SYNTHROID TAB 300MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG SYPRINE CAP 250MG T TABLOID TAB 40MG tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg tacrolimus oint 0.03% tacrolimus oint 0.1% TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG TALTZ INJ 80MG/ML TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML tamsulosin hcl cap 0.4 mg TANDEM PLUS CAP TANZEUM INJ 30MG TANZEUM INJ 50MG TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TARGRETIN CAP 75MG TARGRETIN GEL 1% TARKA TAB CR TARKA TAB CR TARKA TAB CR TARKA TAB CR TARON FORTE CAP TARON-C DHA CAP TARON-PREX CAP TASIGNA CAP 150MG

168 TASIGNA CAP 200MG TAXOTERE INJ 20MG/ML TAXOTERE INJ 80MG/4ML tazarotene cream 0.1% TAZORAC CRE 0.05% TAZORAC CRE 0.1% TAZORAC GEL 0.05% TAZORAC GEL 0.1% TECFIDERA CAP 120MG TECFIDERA CAP 240MG TECFIDERA MIS STARTER TEGRETOL SUS 100/5ML TEGRETOL-XR TAB 100MG TEGRETOL-XR TAB 200MG TEGRETOL-XR TAB 400MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA TAB 150MG TEKTURNA TAB 300MG telmisartan tab 20 mg telmisartan tab 40 mg telmisartan tab 80 mg telmisartan-amlodipine tab mg. 26 telmisartan-amlodipine tab 40-5 mg telmisartan-amlodipine tab mg. 26 telmisartan-amlodipine tab 80-5 mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg temazepam cap 15 mg temazepam cap 22.5 mg temazepam cap 30 mg temazepam cap 7.5 mg TEMODAR CAP 100MG TEMODAR CAP 140MG TEMODAR CAP 180MG TEMODAR CAP 20MG TEMODAR CAP 250MG TEMODAR CAP 5MG TEMODAR INJ 100MG temozolomide cap 100 mg temozolomide cap 140 mg temozolomide cap 180 mg temozolomide cap 20 mg temozolomide cap 250 mg temozolomide cap 5 mg TENIPOSIDE INJ 50MG/5ML terazosin hcl cap 1 mg terazosin hcl cap 10 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terbinafine hcl tab 250 mg terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg terconazole vaginal suppos 80 mg TESTIM GEL 1%(50MG) TESTOPEL MIS PELLETS testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 10mg/act (2%) testosterone td gel 12.5 mg/act (1%). 62 testosterone td gel 25 mg/2.5gm (1%)62 testosterone td gel 50 mg/5gm (1%).. 62 TESTRED CAP 10MG tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg tetracaine hcl ophth soln 0.5% tetracycline hcl cap 250 mg... 9 tetracycline hcl cap 500 mg... 9 TEXAVITE LQ LIQ THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THALOMID CAP 50MG THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg THERACYS INJ

169 thiamine hcl inj 100 mg/ml THIOLA TAB 100MG thioridazine hcl tab 10 mg thioridazine hcl tab 100 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg thiothixene cap 5 mg THROMBAT III INJ 500UNIT THROMBIN-JMI KIT 20000UNT THYMOGLOBULN INJ 25MG THYROGEN INJ 1.1MG THYROLAR-1 TAB 60MG THYROLAR-1/2 TAB 30MG THYROLAR-1/4 TAB 15MG THYROLAR-2 TAB 120MG THYROLAR-3 TAB 180MG tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg TICE BCG INJ TIGAN INJ 100MG/ML TIKOSYN CAP 125MCG TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg TIMOPTIC OCU SOL 0.25% OP TIMOPTIC OCU SOL 0.5% OP TIROSINT CAP 100MCG TIROSINT CAP 112MCG TIROSINT CAP 125MCG TIROSINT CAP 137MCG TIROSINT CAP 13MCG TIROSINT CAP 150MCG TIROSINT CAP 25MCG TIROSINT CAP 50MCG TIROSINT CAP 75MCG TIROSINT CAP 88MCG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) TL-SELECT CAP TOBI PODHALR CAP 28MG TOBRADEX OIN % TOBRADEX ST SUS tobramycin nebu soln 300 mg/5ml tobramycin ophth soln 0.3% tobramycin-dexamethasone ophth susp % TOBREX OIN 0.3% OP TOBREX SOL 0.3% OP tolbutamide tab 500 mg tolmetin sodium cap 400 mg... 2 tolmetin sodium tab 200 mg... 2 tolmetin sodium tab 600 mg... 3 tolterodine tartrate cap er 24hr 2 mg.. 82 tolterodine tartrate cap er 24hr 4 mg.. 82 tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 100 mg topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg topotecan hcl for inj 4 mg TOPOTECAN INJ 4MG/4ML TORISEL SOL 25MG/ML torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg TOUJEO SOLO INJ 300IU/ML TRACLEER TAB 125MG TRACLEER TAB 62.5MG TRADJENTA TAB 5MG tramadol hcl tab 50 mg... 6 tramadol hcl tab er 24hr 100 mg... 6 tramadol hcl tab er 24hr 200 mg... 6 tramadol hcl tab er 24hr 300 mg... 6 tramadol-acetaminophen tab mg... 6 trandolapril tab 1 mg

170 trandolapril tab 2 mg trandolapril tab 4 mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) tranexamic acid tab 650 mg TRANSDERM-SC DIS 1.5MG tranylcypromine sulfate tab 10 mg TRAVATAN Z DRO 0.004% trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg trazodone hcl tab 50 mg TREANDA INJ 100MG TREANDA INJ 25MG TRECATOR TAB 250MG TRELSTAR MIX INJ 11.25MG TRELSTAR MIX INJ 22.5MG TRELSTAR MIX INJ 3.75MG TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT tretinoin cap 10 mg tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% 104 triamcinolone acetonide cream 0.5% 103 triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1%. 104 triamcinolone acetonide oint 0.025% 104 triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg triazolam tab mg triazolam tab 0.25 mg TRICARE PRE CAP TRICARE TAB PRENATAL TRI-CHLOR LIQ 80% TRICITRASOL CON TRIESENCE INJ 40MG/ML trifluoperazine hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluridine ophth soln 1% trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg TRILIPIX CAP 135MG TRILIPIX CAP 45MG trimethobenzamide hcl cap 300 mg trimethoprim tab 100 mg TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG TRINTELLIX TAB 5MG TRIOSTAT INJ 10MCG/ML TRISTART DHA CAP TRI-TABS DHA MIS TRIUMEQ TAB TRI-VI-FLOR SUS 0.25/ML TRI-VI-FLOR SUS 0.5MG/ML TRIZIVIR TAB tropicamide ophth soln 0.5% tropicamide ophth soln 1% trospium chloride cap er 24hr 60 mg.. 82 trospium chloride tab 20 mg TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUVADA TAB TRUVADA TAB TRUVADA TAB

171 TRUVADA TAB TUSSICAPS CAP 10-8MG TUSSICAPS CAP 5-4MG TUSSIONEX SUS 10-8/5ML TYBOST TAB 150MG TYKERB TAB 250MG TYSABRI INJ 300/15ML TYVASO START SOL 0.6MG/ML U UCERIS AER 2MG/ACT UCERIS TAB 9MG ULESFIA LOT 5% ULORIC TAB 40MG... 1 ULORIC TAB 80MG... 1 ULTRAFLEX II MIS 31"/8MM ULTRAFLEX MIS 24"/10MM UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG UPTRAVI TAB 200/ UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG UREA NAIL MIS 50% UROXATRAL TAB 10MG ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg UTIBRON CAP NEOHALER V VAGIFEM TAB 10MCG valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCHLOR GEL 0.016% VALCYTE SOL 50MG/ML VALCYTE TAB 450MG valganciclovir hcl tab 450 mg (base equivalent) valproate sodium inj 100 mg/ml valproate sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg valsartan tab 160 mg valsartan tab 320 mg valsartan tab 40 mg valsartan tab 80 mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg vancomycin hcl cap 125 mg vancomycin hcl cap 250 mg VANCOMYCIN INJ 500MG VANCOMYCIN INJ 750MG VANTAS KIT 50MG VASCEPA CAP 1GM VECTIBIX INJ 100MG VECTIBIX INJ 400MG VELCADE INJ 3.5MG VELETRI INJ 0.5MG VELTASSA POW 16.8GM VELTASSA POW 25.2GM VELTASSA POW 8.4GM VEMAVITE- CAP PRX VENA-BAL MIS DHA VENCLEXTA TAB 100MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG VENCLEXTA TAB START PK venlafaxine hcl cap er 24hr 150 mg (base equivalent) venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base equivalent) venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab er 24hr 150 mg (base equivalent) venlafaxine hcl tab er 24hr 225 mg (base equivalent) venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) venlafaxine hcl tab er 24hr 75 mg (base equivalent)

172 VENOFER INJ 20MG/ML VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VENTOLIN HFA AER verapamil hcl cap er 24hr 100 mg verapamil hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 180 mg verapamil hcl cap er 24hr 200 mg verapamil hcl cap er 24hr 240 mg verapamil hcl cap er 24hr 300 mg verapamil hcl cap er 24hr 360 mg verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 120 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg VERZENIO TAB 100MG VERZENIO TAB 150MG VERZENIO TAB 200MG VERZENIO TAB 50MG VESICARE TAB 10MG VESICARE TAB 5MG V-GO 20 KIT V-GO 30 KIT V-GO 40 KIT VIBERZI TAB 100MG VIBERZI TAB 75MG VIBRAMYCIN SYP 50MG/5ML VICTOZA INJ 18MG/3ML VIDAZA INJ 100MG VIDEX SOL 2GM VIDEX SOL 4GM VIGAMOX DRO 0.5% VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG VIMIZIM INJ 5MG/5ML VIMPAT INJ 200MG/ VIMPAT SOL 10MG/ML VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG VIMPAT TAB 50MG VINATE II TAB VINATE M TAB VINATE ONE TAB vinblastine sulfate inj 1 mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) VIOKACE TAB VIOKACE TAB VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG VIRT NATE TAB VIRT NATE TAB 28-1MG VIRT-C DHA CAP VIRT-NATE CAP DHA VIRT-PN PLUS CAP VIRT-PN TAB VISUDYNE INJ 15MG VITAFOL CAP ULTRA VITAFOL FE+ CAP VITAFOL-NANO TAB VITAFOL-OB PAK +DHA VITAFOL-ONE CAP VITAMEDMD CAP ONE RX VITAPEARL CAP VITATRUE MIS VIVA DHA CAP VIVITROL INJ 380MG VOL-PLUS TAB VOL-TAB RX TAB VOLTAREN GEL 1%... 3 voriconazole for susp 40 mg/ml voriconazole tab 200 mg voriconazole tab 50 mg VOSEVI TAB VOTRIENT TAB 200MG VP-HEME OB TAB VP-HEME ONE CAP VP-HEME-OB TAB MG VP-PNV-DHA CAP VPRIV INJ 400UNIT VYTORIN TAB 10-10MG VYTORIN TAB 10-20MG

173 VYTORIN TAB 10-40MG VYTORIN TAB 10-80MG VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG W warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg water for irrigation, sterile irrigation soln WELCHOL PAK 3.75GM WELCHOL TAB 625MG WESTHROID TAB 130MG WESTHROID TAB 32.5MG WESTHROID TAB 97.5MG X XALKORI CAP 200MG XALKORI CAP 250MG XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XELJANZ TAB 5MG XELJANZ XR TAB 11MG XELODA TAB 150MG XELODA TAB 500MG XENAZINE TAB 12.5MG XENAZINE TAB 25MG XEOMIN INJ 100UNIT XEOMIN INJ 200UNIT XEOMIN INJ 50 UNIT XGEVA INJ XIFAXAN TAB 200MG XIFAXAN TAB 550MG XOLAIR SOL 150MG XOPENEX HFA AER XTANDI CAP 40MG XYLOCAINE INJ 2% XYREM SOL 500MG/ML Y YERVOY INJ 200MG YERVOY INJ 50MG Z zafirlukast tab 10 mg zafirlukast tab 20 mg zaleplon cap 10 mg zaleplon cap 5 mg ZALTRAP INJ 100/4ML ZALTRAP INJ 200/8ML ZANOSAR INJ 1GM ZARXIO INJ 300/ ZARXIO INJ 480/ ZATEAN-PN CAP DHA ZATEAN-PN CAP PLUS ZAVESCA CAP 100MG ZEJULA CAP 100MG ZELAPAR TAB 1.25MG ZELBORAF TAB 240MG ZEMAIRA INJ 1000MG ZEMPLAR CAP 1MCG ZEMPLAR CAP 2MCG ZEMPLAR INJ 2MCG/ML ZEMPLAR INJ 5MCG/ML ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 3000UNIT ZENPEP CAP 40000UNT ZENPEP CAP 5000UNIT ZETIA TAB 10MG ZEVALIN KIT Y zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg ZINBRYTA INJ 150MG/ML ZINECARD INJ 250MG ZINECARD INJ 500MG ZIOPTAN DRO % ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZIRGAN GEL 0.15% ZMAX SUS 2GM

174 ZOLADEX IMP 10.8MG ZOLADEX IMP 3.6MG zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml ZOLINZA CAP 100MG zolmitriptan orally disintegrating tab 2.5 mg zolmitriptan orally disintegrating tab 5 mg zolmitriptan tab 2.5 mg zolmitriptan tab 5 mg zolpidem tartrate tab 10 mg zolpidem tartrate tab 5 mg ZOMETA INJ 4MG/ ZOMIG SPR 2.5MG ZOMIG SPR 5MG zonisamide cap 100 mg zonisamide cap 25 mg zonisamide cap 50 mg ZONTIVITY TAB 2.08MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG Z-TUSS AC LIQ 2-9/5ML ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG ZYLET SUS % ZYMAXID SOL 0.5% ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ZYTIGA TAB 250MG ZYTIGA TAB 500MG

175 Language Assistance Services Servicios de acceso al idioma English Spanish Navajo Vietnamese German Chinese Arabic Korean TagalogFilipino Japanese French Italian Russian Hindi Farsi Thai THNM-ID ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). é (TTY: 711.) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 注意 如果您使用繁體中文 您可以免費獲得語言援助服務 請致電 TTY 711.)711: (رقم هاتف الصم والبكم اتصل برقم. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان إذا كنت تتحدث اذكر اللغة : ملحوظة 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다 (TTY: 711) 번으로 전화해 주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 注意事項 日本語を話される場合 無料の言語支援をご利用いただけます TTY: 711 まで お 電話にてご連絡ください ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर. تماس بگیرید (TTY: 711) با. تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد اگر به زبان فارسی گفتگو می کنید : توجه เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).

176 Notice of Non-Discrimination and Accessibility Aviso de no discriminación y accesibilidad The following is a statement describing nondiscrimination for True Health New Mexico and the services it provides to its clients and members. We do not discriminate on the basis of race, color, national origin, age, disability, or gender in our health programs or activities. We provide help free of charge to people with disabilities or whose primary language is not English. To ask for a document in another format such as large print, or to get language help such as a qualified interpreter, please call True Health New Mexico Customer Service at , Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY: If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can send a complaint to: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM Phone: Fax: You also have the right to file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail: Online: Complaint forms are available at Phone: Toll-free: , TDD: Mail: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC Aviso de no discriminación y accesibilidad A continuación presentamos una declaración que resume la norma de no discriminación de True Health New Mexico y los servicios que prestamos a nuestros clientes y asegurados. No discriminamos por la raza, el color, el origen nacional, la edad, las discapacidades o el sexo en nuestras actividades o programas de salud. Ayudamos gratuitamente a las personas que tienen discapacidades o cuyo idioma nativo no es el inglés. Para pedir un documento en otro formato, como en letra grande, o para recibir la ayuda de un intérprete calificado, favor de llamar al Centro de Atención al Cliente de True Health New Mexico al , para los servicios TTY llame al , de lunes a viernes, de las 8:00 de la mañana a las 5:00 de la tarde. Si usted cree que no hemos prestado estos servicios o que le hemos discriminado de alguna otra manera por su raza, color, origen nacional, edad, discapacidad o sexo, puede enviar una queja a: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM Teléfono: Fax: Además tiene derecho a presentar una queja directamente al Departamento de Salud y Servicios Humanos de los EE. UU. [U.S. Dept. of Health and Human Services] ya sea en línea, por teléfono o por correo: En línea: Los formularios de queja están a su disposición en: Por teléfono: Línea telefónica gratis: , TDD: Por correo: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC THNM-ID