PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 Excellus BlueCross BlueShield Medicare Employer Group Plans A nonprofit independent licensee of the Blue Cross Blue Shield Association 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN This formulary was updated on 11/1/2017. For more recent information or other questions, please contact Excellus BlueCross BlueShield at or, for TTY users, , Monday Friday, 8:00 a.m. 8:00 p.m.; From October 1 to February 14, representatives are available to assist you seven days a week from 8:00 a.m. 8:00 p.m., or visit ExcellusMedicare.com. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. H3351 Formulary ID Ver. 19 M-112CY Group

2

3 When this drug list (formulary) refers to we, us, or our, it means Excellus BlueCross BlueShield. When it refers to plan or our plan, it means Excellus BlueCross BlueShield. This document includes a list of the drugs (formulary) for our plan which is current as of 11/1/2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. What is the Excellus BlueCross BlueShield Medicare Employer Group Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 11/1/2017. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance changes to our formulary, we will update the formulary with any CMS approved changes. We will notify you of any non-maintenance changes to your printed formulary 60 days prior to the effective date of the changes. A printed copy of the updated formulary can be requested by calling us. See the contact information that appears on the front and back cover pages. M-112C Y17 I

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 90. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for XARELTO. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Excellus BlueCross BlueShield Medicare Employer Group Formulary? on page III for information about how to request an exception. II M-112C Y17

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by our plan. When you You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Excellus BlueCross BlueShield Medicare Employer Group Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When you request a formulary, tier or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as M-112C Y17 III

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Any member experiencing a level of care change, such as a change in their treatment setting, will be provided a one time, up to 31-day supply of medication. This includes emergency supplies of non-formulary drugs and most Part D drugs which require prior authorization or step therapy, or that have an approved quantity limit lower than the beneficiary s current dose. For more information For more detailed information about your Excellus BlueCross BlueShield prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit IV M-112C Y17

7 Excellus BlueCross BlueShield s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 90. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., XARELTO) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Explanation of Requirements/Limits PRIOR AUTHORIZATION (PA) Certain medications require prior authorization. This means that you need to get approval before you fill your prescription. If you don t get approval, the drug may not be covered. STEP THERAPY (ST) QUANTITY LIMITS (QL) VERIFICATION FOR PART B OR PART D (B/D PA) In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 tablets per prescription for XARELTO. These medications require prior authorization only to determine whether they qualify for payment under Part B or Part D. M-112C Y17 V

8 Explanation of Tiers 1 Preferred Generic: Select generic drugs that are used for maintenance of health for chronic conditions and offer clinical and cost savings advantages. 2 Generic: Most other generic drugs on our formulary. 3 4 Preferred Brand: Preferred brand-name drugs that have unique significant clinical advantages and offer overall greater value over the other products in the same drug class. Certain generic drugs may appear in Tier 3 due to the high cost of the drug or the potential safety concerns for our Part D members. Non-Preferred Drug: All other brand-name drugs on our formulary. Certain generic drugs may appear in Tier 4 due to the high cost of the drug or the potential safety concerns for our Part D members. 5 Specialty: High cost specialty generic and brand-name drugs that exceed $670 per month. For drugs in Tier 5, you pay a percentage of the cost through coinsurance. VI M-112C Y17

9 ANALGESICS OPIOID ANALGESICS, LONG-ACTING BELBUCA 4 buprenorphine 4 BUTRANS 4 DURAGESIC (12 PATCH, 25 PATCH, 50 4 ST PATCH) DURAGESIC (75 PATCH, 100 PATCH) 5 ST EMBEDA 4 fentanyl (12 patch, 25 patch, 50 patch, 75 2 ST patch, 100 patch) fentanyl (62.5 patch, 87.5 patch) 5 ST fentanyl 37.5 mcg/hr patch 4 ST hydromorphone er 3 HYSINGLA ER (ER 20 MG TABLET, ER 4 30 MG TABLET, ER 40 MG TABLET, ER 60 MG TABLET) HYSINGLA ER (ER 80 MG TABLET, ER MG TABLET, ER 120 MG TABLET) morphine sulfate er (er 10 mg cap, er 20 mg 3 cap, er 30 mg cap, er 45 mg cap, er 50 mg cap, er 60 mg cap, er 75 mg cap, er 80 mg cap, er 90 mg cap, er 100 mg cap, er 120 mg cap) morphine sulfate er (er 15 mg tablet, er 30 mg 2 tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg tablet) NUCYNTA ER 4 oxycodone hcl er 4 OXYCONTIN 4 oxymorphone hcl er 3 tramadol hcl er (er 100 mg tablet, er 200 mg 3 tablet, er 300 mg tablet, hcl er 100 mg capsule, hcl er 100 mg tablet, hcl er 200 mg tablet, hcl er 200 mg capsule, hcl er 300 mg capsule, hcl er 300 mg tablet) XARTEMIS XR 4 XTAMPZA ER 4 ZOHYDRO ER 4 PA OPIOID ANALGESICS, SHORT-ACTING ABSTRAL 5 PA acetaminophen-codeine (acetamin-codein mg/12.5, acetaminop-codeine mg/5, acetaminophen-cod #2 tablet, acetaminophencod #3 tablet, acetaminophen-cod #4 tablet) ACTIQ 5 PA 1

10 ANALGESICS (CONTINUED) asa-butalb-caffeine-codeine 4 ASCOMP WITH CODEINE 4 aspirin-caffeine-dihydrocodein 2 BUPRENEX 4 buprenorphine hcl (0.3 mg/ml syring, mg/ml vial, 2 mg tablet sl, 8 mg tablet sl) butalb-acetaminoph-caff-codein 4 butalb-caff-acetaminoph-codein 4 butalbital compound-codeine 4 butalbital-acetaminophen (50-325, ) 4 butalbital-acetaminophen-caffe (butalbacetamin-caff , butalb-acetamin-caff , butalbit-acetaminophen-caff cp) butalbital-aspirin-caffeine 4 butorphanol tartrate 4 CAPACET 4 codeine sulfate 2 DISKETS 2 DURAMORPH 2 ENDOCET 2 fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, 5 PA citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) fentanyl citrate otfc 200 mcg 4 PA FENTORA 5 PA hydrocodone-acetaminophen (hydrocodoneacetamin , hydrocodone-acetamin /5, hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamin 5-217/10, hydrocodoneacetamin 5-163/7.5, hydrocodone-acetamin , hydrocodone-acetamin , hydrocodone-acetamin /15, hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamn /15) hydrocodone-ibuprofen 2 hydromorphone hcl (0.5 mg/0.5 ml, hcl 1 mg/ml amp, 1 mg/ml carpujct, 1 mg/ml syringe, 1 mg/ml solution, 2 mg/ml carpujct, 2 mg/ml vial, hcl 2 mg/ml amp, 2 mg tablet, 2 mg/ml isecure, hcl 4 mg/ml amp, 4 mg/ml carpujct, 4 mg tablet, 5 mg/5 ml soln, 8 mg tablet, hcl 10 mg/ml vl, 10 mg/ml vial, hcl 10 mg/ml amp, 50 mg/5 ml vial, 500 mg/50 ml via) 2 2

11 ANALGESICS (CONTINUED) INFUMORPH 4 LAZANDA 5 PA levorphanol tartrate 3 LORCET 2 LORCET HD 2 LORCET PLUS 2 MARGESIC 4 MARTEN-TAB 4 methadone hcl (5 mg/5 ml solution, hcl 5 mg 2 tablet, hcl 10 mg/ml vial, 10 mg/ml oral conc, 10 mg/5 ml solution, hcl 10 mg tablet, 40 mg tablet dispr) METHADONE INTENSOL 2 METHADOSE (10 MG/ML ORAL CONC, 2 40 MG TABLET DISPR) morphine sulfate (0.5 mg/ml vial, 1 mg/ml vial 3 p-f, sulfate 1 mg/ml vial, 2 mg/ml isecure syr, 2 mg/ml carpuject, 4 mg/ml carpuject, 4 mg/ml isecure syr, sulfate 4 mg/ml vial, 5 mg/ml vial, 8 mg/ml syringe, sulfate 8 mg/ml vial, 8 mg/ml isecure syrng, sulfate 10 mg/ml vial, 10 mg/ml isecure syrg, 10 mg/ml carpuject) morphine sulfate (sulf 10 mg/5 ml soln, sulf 20 2 mg/5 ml soln, sulf 100 mg/5 ml soln, sulfate ir 15 mg tab, sulfate ir 30 mg tab) nalbuphine hcl 2 NUCYNTA 4 oxycodone hcl (oxycodon 10 mg/0.5 ml oral 2 syr, oxycodone hcl 5 mg/5 ml soln, oxycodone hcl 5 mg capsule, oxycodone hcl 5 mg tablet, oxycodone hcl 10 mg tablet, oxycodone hcl 15 mg tablet, oxycodone hcl 20 mg tablet, oxycodone hcl 30 mg tablet, oxycodone hcl 100 mg/5 ml soln) oxycodone hcl-aspirin 2 oxycodone hcl-ibuprofen 2 oxycodone-acetaminophen (oxycodonacetaminophen , oxycodon- acetaminophen , oxycodoneacetaminophen 5-325, oxycodoneacetaminophen , oxycodoneacetaminophn 5-325/5) oxymorphone hcl 3 pentazocine-naloxone hcl 3 SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCG SPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY) 5 PA 3

12 ANALGESICS (CONTINUED) TALWIN 4 TENCON 4 tramadol hcl 2 tramadol hcl-acetaminophen 2 VANATOL LQ 4 VICODIN 2 VICODIN ES 2 VICODIN HP 2 ZEBUTAL 4 ANESTHETICS LOCAL ANESTHETICS lidocaine 5% ointment 3 lidocaine 5% patch 3 PA, QL (90 per 30 days) lidocaine hcl (0.5% vial, 1% 50 mg/5 ml vl, 1% 2 ampul, 1% vial, 1% 20 mg/2 ml vl, 1% 300 mg/30 ml, 1% 20 mg/2 ml, 1% 50 mg/5 ml, 1.5% ampul, 2% 40 mg/2 ml vl, 2% ampul, 2% jelly, 2% 40 mg/2 ml, 2% vial, 2% 100 mg/5 ml, 4% solution, 4% ampul) lidocaine hcl viscous 2 lidocaine-prilocaine 2 LIDODERM 4 PA, QL (90 per 30 days) PLIAGLIS 4 RELADOR PAK 2 RELADOR PAK PLUS 2 SYNERA 4 XYLOCAINE (0.5% VIAL, 1% VIAL) 4 XYLOCAINE-MPF (0.5% VIAL, 1% VIAL, 1% AMPUL, 1.5% AMPUL, 2% VIAL, 2% AMPUL) 4 ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS ALCOHOL DETERRENTS, ANTI-CRAVING acamprosate calcium 3 disulfiram 3 VIVITROL 5 OPIOID ANTAGONISTS buprenorphine-naloxone 2 EVZIO 0.4 MG AUTO-INJECTOR 4 QL (1 per 30 days) EVZIO 2 MG AUTO-INJECTOR 5 QL (1 per 30 days) naloxone hcl 2 naltrexone hcl 2 NARCAN 4 MG NASAL SPRAY 3 QL (2 per 30 days) 4

13 ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS (CONTINUED) SUBOXONE 4 SMOKING CESSATION AGENTS BUPROBAN 2 bupropion hcl sr 150 mg tablet 2 CHANTIX 3 QL (336 per 365 days) NICOTROL 4 NICOTROL NS 4 ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY S CAMBIA 4 ST celecoxib 2 QL (60 per 30 days) diclofenac 1.5% topical soln 3 diclofenac potassium 2 diclofenac sodium (sod dr 25 mg tab, sod dr 50 2 mg tab, sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sod ec 75 mg tab, sodium 1% gel) diclofenac sodium er 2 diclofenac sodium-misoprostol 2 diflunisal 2 etodolac 2 etodolac er 2 fenoprofen 600 mg tablet 2 FLECTOR 4 PA, QL (60 per 30 days) flurbiprofen 2 ibuprofen (100 mg/5 ml susp, 400 mg tablet, mg tablet, 800 mg tablet) indomethacin (25 mg capsule, 50 mg capsule) 2 indomethacin er 2 ketoprofen (50 mg capsule, 75 mg capsule) 2 ketoprofen er 200 mg capsule 2 QL (30 per 30 days) ketorolac 10 mg tablet 2 QL (20 per 30 days) KLOFENSAID II 3 meclofenamate sodium 2 meloxicam 15 mg tablet 2 QL (30 per 30 days) meloxicam 7.5 mg tablet 2 QL (60 per 30 days) meloxicam 7.5 mg/5 ml susp 4 QL (300 per 30 days) nabumetone 2 naproxen (125 mg/5 ml suspen, 250 mg tablet, mg tablet, dr 375 mg tablet, dr 500 mg tablet, 500 mg kit, 500 mg tablet) naproxen sodium (275 mg tab, 550 mg tab) 2 5

14 ANTI-INFLAMMATORY AGENTS (CONTINUED) naproxen sodium ds 2 oxaprozin 2 piroxicam 2 sulindac 2 tolmetin sodium 2 VIMOVO 5 QL (60 per 30 days) ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate 2 BETHKIS 5 B/D PA GENTAK 2 gentamicin sulfate (0.1% cream, 0.1% 2 ointment, 0.3% eye drops, 3 mg/ml eye drops, 10 mg/ml vial, 20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) gentamicin sulfate in ns 2 KITABIS PAK 5 neomycin sulfate 2 paromomycin sulfate 2 streptomycin sulfate 2 TOBI 5 B/D PA TOBI PODHALER 5 tobramycin 0.3% eye drops 2 tobramycin 300 mg/5 ml ampule 5 B/D PA tobramycin sulfate (1.2 gram/30 ml vial, gm vial, 10 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30 ml vial) TOBREX 0.3% EYE OINTMENT 4 ANTIBACTERIALS, OTHER acetic acid 0.25% irrig soln 4 AK-POLY-BAC 2 BACIIM 2 bacitracin (500 unit/gm ophth, 50,000 unit 2 vial) bacitracin-polymyxin eye oint 2 chloramphenicol sod succinate 2 CLEOCIN 100 MG VAGINAL OVULE 4 CLINDACIN ETZ 1% PLEDGET 4 CLINDACIN P 4 CLINDACIN PAC 4 CLINDAGEL 5 6

15 ANTIBACTERIALS (CONTINUED) clindamycin hcl 2 clindamycin palmitate hcl 2 clindamycin pediatric 2 clindamycin phosphate (ph 1% solution, ph 1% 2 gel, ph 9 g/60 ml vial, 150 mg/ml addvan, 300 mg/2 ml addvan, ph 300 mg/2 ml vl, ph 600 mg/4 ml vl, 600 mg/4 ml addvan, ph 900 mg/6 ml vl, phos 1% pledget, phosp 1% lotion, 2% vaginal cream, 900 mg/6 ml addvan) clindamycin phosphate 1% foam 4 clindamycin phosphate-d5w 2 CLINDESSE 4 colistimethate 4 CORTISPORIN CREAM 4 CUBICIN 5 CUBICIN RF 5 DALVANCE 5 daptomycin 5 lansoprazol-amoxicil-clarithro 4 QL (112 per 30 days) LINCOCIN 4 lincomycin hcl 3 linezolid (100 mg/5 ml susp, 600 mg tablet, mg/300 ml iv sol) linezolid-0.9% nacl 5 PA methenamine hippurate 2 METRO IV 2 metronidazole (0.75% lotion, top 1% gel pump, 2 topical 0.75% gl, 0.75% cream, topical 1% gel, vaginal 0.75% gl, 250 mg tablet, 375 mg capsule, 500 mg tablet, 500 mg/100 ml) MONUROL 4 mupirocin 2 NEO-POLYCIN 2 NEO-POLYCIN HC 2 NEO-SYNALAR 4 neomycin-bacitracin-poly-hc 2 neomycin-bacitracin-polymyxin 2 neomycin-poly-hc eye drops 2 neomycin-polymyxin b 2 neomycin-polymyxin-gramicidin 2 nitrofurantoin (25 mg cap, 50 mg cap, 100 mg 2 cap) nitrofurantoin 25 mg/5 ml susp 3 7

16 ANTIBACTERIALS (CONTINUED) nitrofurantoin mono-macro 2 NORITATE 5 NUVESSA 4 POLYCIN 2 polymyxin b sulfate 2 PRIMSOL 4 ROSADAN (0.75% CREAM, 0.75% GEL) 2 silver sulfadiazine 2 SIVEXTRO 5 PA, QL (6 per 6 days) SSD 2 SULFAMYLON 8.5% CREAM 4 SYNERCID 5 THERMAZENE 2 tigecycline 5 trimethoprim 2 TYGACIL 5 VANCOCIN HCL 5 vancomycin 4 vancomycin hcl (1 gm vial, 1 gm add-van vial, 2 hcl 5 gm vial, hcl 10 gm vial, hcl 750 mg vial) vancomycin hcl (125 mg capsule, 250 mg 3 capsule) vancomycin hcl (hcl 1g/200 ml bag, hcl 100 gm 4 smartpak, 500 mg vial, 500 mg a-v vial) vancomycin hcl-0.9% nacl (vanco 500 mg/100 4 ml-0.9%, vanco 750 mg/150 ml-0.9%, vancomycin 1 g/200ml-0.9%) vancomycin-d5w 500 mg/100 ml 4 XIFAXAN 200 MG TABLET 4 XIFAXAN 550 MG TABLET 5 ZYVOX (100 MG/5 ML SUSPENSION, PA MG/100 ML IV SOLN, 600 MG/300 ML IV SOLN, 600 MG TABLET) BETA-LACTAM, CEPHALOSPORINS cefaclor (125 mg/5 ml susp, 250 mg capsule, mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) cefaclor er 2 cefadroxil (1 gm tablet, 250 mg/5 ml susp, mg/5 ml susp, 500 mg capsule) cefazolin sodium 2 cefazolin sodium-dextrose (1 g/50, 2 g/100, 2 g/50) 2 8

17 ANTIBACTERIALS (CONTINUED) cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) cefepime 4 cefepime hcl 4 cefepime-dextrose 4 cefixime 2 CEFOTAN 2 GM VIAL 2 cefotaxime sodium 2 cefotetan & dextrose 2 cefotetan (1 gm vial, 2 gm vial, 10 gm vial) 2 cefoxitin 2 cefoxitin sodium 2 cefpodoxime proxetil (50 mg/5 ml susp, mg/5 ml susp, 100 mg tablet, 200 mg tablet) cefprozil (125 mg/5 ml susp, 250 mg tablet, mg/5 ml susp, 500 mg tablet) ceftazidime (1 gm vial, 1 gm piggyback, 2 gm 2 piggyback, 2 gm vial, 6 gm vial) ceftibuten (180 mg/5 ml susp, 400 mg capsule) 2 CEFTIN (125 MG/5 ML ORAL SUSP, MG/5 ML ORAL SUSP) ceftriaxone (1 gm-d5w bag, 1 gm vial, 1 gm 4 piggyback, 2 gm-d5w bag, 2 gm vial, 2 gm piggyback, 2 gm add vial) ceftriaxone (10 gm vial, 100 gram bulk bag, mg vial, 500 mg vial) cefuroxime 2 cefuroxime sodium 2 cephalexin (125 mg/5 ml susp, 250 mg/5 ml 2 susp, 250 mg capsule, 250 mg tablet, 500 mg tablet, 500 mg capsule, 750 mg capsule) DAXBIA 4 SUPRAX (100 MG/5 ML SUSPENSION, MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) TAZICEF (1 GRAM VIAL, 1 GM ADD- VANTAGE VIAL, 2 GM ADD- VANTAGE, 2 GRAM VIAL, 6 GRAM VIAL) TEFLARO 4 ZERBAXA 5 BETA-LACTAM, OTHER AZACTAM 2 GM VIAL

18 ANTIBACTERIALS (CONTINUED) AZACTAM-ISO-OSMOTIC DEXTROSE 4 aztreonam (1 gm vial, 2 gm vial) 2 CAYSTON 5 DORIBAX 4 doripenem 4 imipenem-cilastatin sodium 2 INVANZ 4 meropenem 3 meropenem-0.9% nacl 3 VABOMERE 5 BETA-LACTAM, PENICILLINS amoxicillin (125 mg/5 ml susp, 125 mg tab chew, 200 mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin-clavulanate pot er 2 amoxicillin-clavulanate potass ( mg/5 2 ml sus, mg tab chew, mg/5 ml sus, mg tablet, mg/5 ml susp, mg tab chew, mg tablet, mg/5 ml sus, mg tablet) ampicillin sodium 2 ampicillin trihydrate (125 mg/5 ml susp, mg capsule, 250 mg/5 ml susp, 500 mg capsule) ampicillin-sulbactam (1.5 gm vl, 3 gm vial, 15 4 gm vl) AUGMENTIN MG/5 ML 4 BICILLIN C-R 4 BICILLIN L-A 4 dicloxacillin sodium 2 nafcillin 4 nafcillin sodium 4 oxacillin 4 oxacillin sodium 4 penicillin g potassium 2 penicillin g procaine 2 penicillin g sodium 2 penicillin gk-iso-osm dextrose 4 penicillin v potassium (125 mg/5 ml soln, mg tablet, 250 mg/5 ml soln, 500 mg tablet) PFIZERPEN

19 ANTIBACTERIALS (CONTINUED) piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl, piperacil-tazobact 2.25 gm vl, piperacil-tazobact gm vl, piperaciltazobact 4.5 gm vial, piperacil-tazobact 13.5 gm vl, piperacil-tazobact 40.5 gram) ZOSYN (2.25 GRAM VIAL, 2.25 GM/50 ML GALAXY BAG, GRAM VIAL, GM/50 ML GALAXY, 4.5 GM/100 ML GALAXY BAG) MACROLIDES AZASITE 4 azithromycin (1 gm pwd packet, 100 mg/5 ml 2 susp, 200 mg/5 ml susp, 250 mg tablet, 500 mg tablet, 600 mg tablet, i.v. 500 mg vial) 2 4 clarithromycin (125 mg/5 ml sus, 250 mg 2 tablet, 250 mg/5 ml sus, 500 mg tablet) clarithromycin er 2 DIFICID 5 QL (20 per 10 days) E.E.S E.E.S ERY 2% PADS 2 ERY-TAB 3 ERYPED ERYPED ERYTHROCIN LACTOBIONATE (500 4 MG VIAL, 500 MG ADDVNT VL) ERYTHROCIN STEARATE 4 erythromycin (0.5% eye ointment, 2% 2 solution, 2% pledgets, 2% gel) erythromycin (250 mg filmtab, dr 250 mg cap, 3 ec 250 mg cap, 500 mg filmtab) erythromycin 200 mg/5 ml gran 4 erythromycin es 400 mg tab 3 KETEK 4 PCE 4 ZMAX 4 QUINOLONES AVELOX IV 4 BAXDELA 5 QL (28 per 14 over time) BESIVANCE 4 CILOXAN 0.3% OINTMENT 4 ciprofloxacin 2 ciprofloxacin er 2 QL (30 per 30 days) 11

20 ANTIBACTERIALS (CONTINUED) ciprofloxacin hcl (0.2% otic soln, 0.3% eye drop, hcl 250 mg tab, hcl 500 mg tab, hcl 750 mg tab) 2 ciprofloxacin hcl 100 mg tab 4 ciprofloxacin-d5w 2 FLOXIN 2 gatifloxacin 2 QL (5 per 25 days) levofloxacin (0.5% eye drops, 25 mg/ml solution, 250 mg/10 ml soln, 250 mg tablet, 500 mg tablet, 500 mg/20 ml vial, 500 mg/20 ml soln, 750 mg/30 ml vial, 750 mg tablet) levofloxacin-d5w (250 mg/50 ml-d5w, mg/100 ml-d5w) MOXEZA 4 moxifloxacin 0.5% eye drops 3 moxifloxacin 400 mg/250 ml bag 4 moxifloxacin hcl 400 mg tablet 2 ofloxacin (0.3% ear drops, 0.3% eye drops, mg tablet, 400 mg tablet) VIGAMOX 4 SULFONAMIDES polymyxin b sul-trimethoprim 2 sulfacetamide 10% eye drops 2 sulfadiazine 2 sulfamethoxazole-trimethoprim (ds tablet, inj 2 vial, ss tablet, susp) SULFATRIM 2 TETRACYCLINES demeclocycline hcl 2 DOXY doxycycline hyclate (75 mg tab, 150 mg tab) 5 QL (30 per 30 days) doxycycline hyclate (dr 50 mg tab, dr 75 mg tab, dr 100 mg tab, dr 150 mg tab, dr 200 mg tab) doxycycline hyclate (hyc 100 mg vial, hyclate 20 mg tab, hyclate 50 mg cap, hyclate 100 mg tab, hyclate 100 mg cap) doxycycline ir-dr 4 doxycycline mono 75 mg capsule 4 doxycycline monohydrate (25 mg/5 ml susp, 2 mono 50 mg cap, mono 50 mg tablet, mono 75 mg tablet, mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet)

21 ANTIBACTERIALS (CONTINUED) minocycline hcl (50 mg capsule, 75 mg capsule, 100 mg capsule) minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg tablet) 2 3 minocycline hcl er 4 MONDOXYNE NL (NL 50 MG 2 CAPSULE, NL 100 MG CAPSULE) MONDOXYNE NL 75 MG CAPSULE 4 MORGIDOX (50 MG CAPSULE, 100 MG 2 CAPSULE) ORACEA 4 SOLODYN (ER 105 MG TABLET, ER QL (30 per 30 days) MG TABLET) SOLODYN (ER 55 MG TABLET, ER 65 5 MG TABLET, ER 80 MG TABLET) tetracycline hcl 2 VIBRAMYCIN 50 MG/5 ML SYRUP 4 ANTICONVULSANTS ANTICONVULSANTS, OTHER BANZEL 200 MG TABLET 4 QL (480 per 30 days) BANZEL 40 MG/ML SUSPENSION 5 QL (2400 per 30 days) BANZEL 400 MG TABLET 5 QL (240 per 30 days) BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET) 5 QL (60 per 30 days) BRIVIACT 10 MG/ML ORAL SOLN 4 QL (600 per 30 days) BRIVIACT 50 MG/5 ML VIAL 4 KEPPRA 500 MG/5 ML VIAL 4 levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg/5 ml soln, 500 mg/5 ml vial, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) levetiracetam er 500 mg tablet 2 QL (180 per 30 days) levetiracetam er 750 mg tablet 2 QL (120 per 30 days) levetiracetam-nacl 4 phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml soln, 20 mg/5 ml elix, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) 2 2 PA POTIGA 4 QL (90 per 30 days) ROWEEPRA 2 SPRITAM (250 MG TABLET, 500 MG 4 PA, QL (60 per 30 days) TABLET, 1,000 MG TABLET) SPRITAM 750 MG TABLET 4 PA, QL (120 per 30 days) 13

22 ANTICONVULSANTS (CONTINUED) VIMPAT (10 MG/ML SOLUTION, 200 MG/20 ML VIAL) VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) BENZODIAZEPINES clonazepam 2 clorazepate dipotassium QL (60 per 30 days) ONFI (2.5 MG/ML SUSPENSION, 10 MG 4 TABLET, 20 MG TABLET) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN 4 ethosuximide (250 mg capsule, 250 mg/5 ml 2 soln) LYRICA 20 MG/ML ORAL SOLUTION 3 ZARONTIN (250 MG/5 ML SOLUTION, MG CAPSULE) zonisamide 2 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DEPACON 4 DEPAKENE (250 MG CAPSULE, MG/5 ML SOLUTION) DEPAKOTE 4 DEPAKOTE ER 4 DEPAKOTE SPRINKLE 4 DIASTAT 4 DIASTAT ACUDIAL 4 diazepam (2.5 mg rectal gel sys, 10 mg rectal 4 gel syst, 20 mg rectal gel syst) divalproex sodium 2 divalproex sodium er 2 gabapentin (100 mg capsule, 250 mg/5 ml soln, mg capsule, 300 mg/6 ml soln, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG 4 TABLET) primidone 2 SABRIL (500 MG POWDER PACKET, PA, QL (180 per 30 days) MG TABLET) tiagabine hcl 2 valproate sodium 2 valproic acid (250 mg/5 ml soln, 250 mg capsule, 500 mg/10 ml sol) 2 14

23 ANTICONVULSANTS (CONTINUED) vigabatrin 5 PA, QL (180 per 30 days) GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet) 4 felbamate 600 mg/5 ml susp 5 FELBATOL (400 MG TABLET, 600 MG/5 5 ML SUSP, 600 MG TABLET) FYCOMPA (0.5 MG/ML ORAL SUSP, 2 4 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) lamotrigine (25 mg tablet, 25 mg tb start kit, mg tablet, 150 mg tablet, 200 mg tablet) lamotrigine (5 mg disper tablet, 25 mg disper 3 tab) lamotrigine (green) 2 lamotrigine (orange) 2 lamotrigine er 3 lamotrigine odt 3 lamotrigine odt (blue) 3 lamotrigine odt (green) 3 lamotrigine odt (orange) 3 QUDEXY XR (150 MG CAPSULE, PA, QL (60 per 30 days) MG CAPSULE) QUDEXY XR (50 MG CAPSULE, 100 MG 4 PA, QL (30 per 30 days) CAPSULE) QUDEXY XR 25 MG CAPSULE 4 PA topiramate 2 topiramate er (er 150 mg capsule, er 200 mg 4 PA, QL (60 per 30 days) capsule) topiramate er (er 25 mg capsule, er 50 mg 4 PA, QL (30 per 30 days) capsule, er 100 mg capsule) TROKENDI XR (25 MG CAPSULE, 50 4 PA, QL (90 per 30 days) MG CAPSULE, 100 MG CAPSULE) TROKENDI XR 200 MG CAPSULE 5 PA, QL (90 per 30 days) SODIUM CHANNEL AGENTS APTIOM (400 MG TABLET, 800 MG 5 QL (30 per 30 days) TABLET) APTIOM 200 MG TABLET 4 QL (30 per 30 days) APTIOM 600 MG TABLET 5 QL (60 per 30 days) carbamazepine (100 mg/5 ml susp, 100 mg tab 2 chew, 200 mg tablet) carbamazepine er (er 100 mg cap, er 100 mg tablet, er 200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mg tablet) 2 15

24 ANTICONVULSANTS (CONTINUED) DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 4 DILANTIN EPITOL 2 fosphenytoin sodium 2 GRALISE 30-DAY STARTER PACK 4 PA GRALISE ER 300 MG TABLET 4 PA, QL (60 per 30 days) GRALISE ER 600 MG TABLET 4 PA, QL (90 per 30 days) HORIZANT ER 300 MG TABLET 4 PA, QL (90 per 30 days) HORIZANT ER 600 MG TABLET 4 PA, QL (60 per 30 days) oxcarbazepine (150 mg tablet, 300 mg tablet, mg/5 ml susp, 600 mg tablet) OXTELLAR XR 4 PA PEGANONE 4 PHENYTEK 4 phenytoin (50 mg infatab, 50 mg tablet chew, mg/4 ml susp, 125 mg/5 ml susp) phenytoin sodium 2 phenytoin sodium extended 2 TEGRETOL (100 MG/5 ML SUSP, 200 MG 4 TABLET) TEGRETOL XR 4 TRILEPTAL 300 MG/5 ML SUSP 4 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates 3 CHOLINESTERASE INHIBITORS donepezil hcl (5 mg tablet, 10 mg tablet) 2 donepezil hcl 23 mg tablet 3 QL (30 per 30 days) donepezil hcl odt 2 galantamine 4 mg/ml oral soln 2 galantamine er 2 QL (30 per 30 days) galantamine hbr 2 QL (60 per 30 days) rivastigmine (1.5 mg capsule, 3 mg capsule, 2 QL (60 per 30 days) 4.5 mg capsule, 6 mg capsule) rivastigmine (9.5 mg/24hr patch, 13.3 mg/24hr 3 ptch) rivastigmine 4.6 mg/24hr patch 3 QL (30 per 30 days) N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine 5-10 mg titration pk 2 QL (49 per 28 days) memantine hcl (5 mg tablet, 10 mg tablet) 2 QL (60 per 30 days) memantine hcl 2 mg/ml solution 2 QL (300 per 30 days) 16

25 ANTIDEMENTIA AGENTS (CONTINUED) NAMENDA XR 4 QL (30 per 30 days) NAMZARIC (7 MG-10 MG CAPSULE, 14 4 PA, QL (30 per 30 days) MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE) NAMZARIC TITRATION PACK 4 PA, QL (28 per 28 days) ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN 4 QL (30 per 30 days) bupropion hcl 2 bupropion hcl sr (100 mg tablet, 200 mg 2 tablet) bupropion xl 2 maprotiline hcl 2 mirtazapine 2 nefazodone hcl 2 trazodone hcl 2 MONOAMINE OXIDASE INHIBITORS EMSAM 5 QL (30 per 30 days) MARPLAN 4 phenelzine sulfate 2 tranylcypromine sulfate 2 SEROTONIN/ NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hbr (10 mg tablet, 20 mg tablet, 40 1 mg tablet) citalopram hbr 10 mg/5 ml soln 2 desvenlafaxine er (er 50 mg tab, er 100 mg 4 QL (30 per 30 days) tab) desvenlafaxine er 50 mg tablet 4 QL (30 per 30 days) desvenlafaxine fumarate er 4 QL (30 per 30 days) desvenlafaxine succinate er 2 QL (30 per 30 days) duloxetine hcl (dr 20 mg cap, dr 40 mg cap, dr 2 QL (60 per 30 days) 60 mg cap) duloxetine hcl dr 30 mg cap 2 QL (90 per 30 days) escitalopram oxalate (5 mg tablet, 10 mg 1 tablet, 20 mg tablet) escitalopram oxalate 5 mg/5 ml 4 FETZIMA (ER 20 MG CAPSULE, ER 40 4 QL (30 per 30 days) MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) FETZIMA MG TITRATION PAK 4 QL (28 per 28 days) fluoxetine 20 mg/5 ml solution 2 fluoxetine dr 3 QL (8 per 28 days) fluoxetine hcl (10 mg capsule, 20 mg capsule, 40 mg capsule) 1 17

26 ANTIDEPRESSANTS (CONTINUED) fluoxetine hcl (10 mg tablet, 20 mg tablet, 60 mg tablet) 3 fluvoxamine maleate 2 fluvoxamine maleate er 2 paroxetine cr 3 paroxetine er 3 paroxetine hcl 1 PAXIL 10 MG/5 ML SUSPENSION 4 PEXEVA 4 PRISTIQ 4 QL (30 per 30 days) SARAFEM 4 sertraline 20 mg/ml oral conc 2 sertraline hcl (25 mg tablet, 50 mg tablet, mg tablet) TRINTELLIX 4 PA, QL (30 per 30 days) venlafaxine hcl 2 venlafaxine hcl er (er 37.5 mg cap, er 75 mg 2 QL (90 per 30 days) cap, er 150 mg cap) VIIBRYD (10 MG TABLET, MG STARTER PACK, 20 MG TABLET, 40 MG TABLET) 4 QL (30 per 30 days) VIIBRYD MG STARTER PK 4 QL (30 per 30 days) TRICYCLICS amitriptyline hcl 3 amoxapine 2 clomipramine hcl 3 desipramine hcl 3 doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl 3 imipramine pamoate 4 nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg 2 cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) protriptyline hcl 3 trimipramine maleate

27 ANTIEMETICS ANTIEMETICS, OTHER COMPRO 2 meclizine hcl (12.5 mg tablet, 25 mg tablet) 2 metoclopramide hcl (5 mg tablet, 5 mg/5 ml 2 soln, 10 mg/2 ml vial, 10 mg/10 ml sol, 10 mg/2 ml syr, 10 mg tablet) metoclopramide hcl odt 4 PHENADOZ 4 PHENERGAN (12.5 MG, 25 MG, 50 MG) 4 prochlorperazine 2 prochlorperazine maleate 2 promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg 4 tablet, 12.5 mg suppos, 25 mg tablet, 25 mg/ml ampul, 25 mg/ml vial, 25 mg suppository, 50 mg/ml ampul, 50 mg/ml vial, 50 mg tablet, 50 mg suppository) PROMETHEGAN 4 scopolamine 3 TRANSDERM-SCOP 4 trimethobenzamide hcl 3 B/D PA EMETOGENIC THERAPY ADJUNCTS AKYNZEO 4 B/D PA, QL (2 per 28 days) ALOXI 4 ANZEMET (50 MG TABLET, 100 MG 4 B/D PA, QL (4 per 28 days) TABLET) aprepitant (40 mg capsule, 80 mg capsule) 3 B/D PA, QL (4 per 30 days) aprepitant 125 mg capsule 3 B/D PA, QL (2 per 30 days) aprepitant mg pack 3 B/D PA, QL (6 per 30 days) CESAMET 5 PA, QL (120 per 30 days) dronabinol 4 PA EMEND (125 MG POWDER PACKET, 4 B/D PA, QL (6 per 30 days) TRIPACK) EMEND (40 MG CAPSULE, 80 MG 4 B/D PA, QL (4 per 30 days) CAPSULE) EMEND 125 MG CAPSULE 4 B/D PA, QL (2 per 30 days) granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 2 QL (60 per 30 days) mg/4 ml vial) granisetron hcl 1 mg tablet 2 B/D PA, QL (60 per 30 days) ondansetron 4 mg/5 ml solution 3 B/D PA ondansetron hcl (4 mg tablet, 8 mg tablet) 2 B/D PA, QL (90 per 30 days) ondansetron hcl (hcl 4 mg/2 ml amp, hcl 4 2 mg/2 ml vial, 40 mg/20 ml vial) ondansetron hcl 24 mg tablet 2 B/D PA, QL (30 per 30 days) 19

28 ANTIEMETICS (CONTINUED) ondansetron odt 2 B/D PA, QL (90 per 30 days) SANCUSO 5 ST, QL (4 per 28 days) SYNDROS 5 PA VARUBI 4 B/D PA, QL (4 per 28 days) ZUPLENZ 4 B/D PA, ST, QL (90 per 30 days) ANTIFUNGALS ANTIFUNGALS ABELCET 5 B/D PA AMBISOME 4 B/D PA amphotericin b 2 B/D PA CANCIDAS 5 caspofungin acetate 5 CICLODAN (0.77% CREAM, 8% 4 ST SOLUTION) ciclopirox (0.77% topical susp, 0.77% cream, % gel, 1% shampoo, 8% solution) clotrimazole (1% cream, 1% solution, 10 mg 2 troche) clotrimazole-betamethasone (crm, lot) 2 CRESEMBA 5 econazole nitrate 2 ERAXIS (WATER DILUENT) 4 ERTACZO 4 ST EXELDERM (1% SOLUTION, 1% 4 ST CREAM) fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 2 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) fluconazole in dextrose 2 fluconazole in saline (200 mg/100 ml, mg/200 ml) fluconazole-nacl 2 flucytosine 5 griseofulvin (125 mg/5 ml susp, micro 500 mg 3 tab) griseofulvin ultramicrosize 3 itraconazole 3 JUBLIA 4 PA KERYDIN 4 PA ketoconazole (2% cream, 2% shampoo, mg tablet) ketoconazole 2% foam 4 KETODAN 2% FOAM 4 ST 20

29 ANTIFUNGALS (CONTINUED) LAMISIL 125 MG GRANULES PACKET 4 QL (60 per 30 days) LAMISIL MG GRANULES PACK 4 QL (30 per 30 days) LUZU 4 ST MENTAX 4 ST miconazole mg vag supp 2 MYCAMINE 5 naftifine hcl (1% cream, 2% cream) 4 NAFTIN (1% GEL, 1% CREAM, 2% GEL) 4 ST NATACYN 4 NOXAFIL (40 MG/ML SUSPENSION, DR MG TABLET, 300 MG/16.7 ML VIAL) NYAMYC 2 NYATA 100,000 UNIT/GM POWDER 2 nystatin (100,000 units/gm oint, 100,000 2 unit/gm powd, 100,000 unit/gm cream, 100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus) nystatin-triamcinolone 2 NYSTOP 2 ONMEL 5 ST oxiconazole nitrate 4 OXISTAT 1% LOTION 4 ST SPORANOX (10 MG/ML SOLUTION, ST MG CAPSULE) terbinafine hcl 2 terconazole (0.4% cream, 0.8% cream, 80 mg 2 suppository) VFEND (40 MG/ML SUSPENSION, 50 5 ST MG TABLET, 200 MG TABLET) voriconazole (40 mg/ml susp, 50 mg tablet, mg tablet) voriconazole 200 mg vial 4 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol 1 colchicine 0.6 mg capsule 4 QL (60 per 30 days) colchicine 0.6 mg tablet 4 QL (120 per 30 days) COLCRYS 3 QL (120 per 30 days) MITIGARE 4 QL (60 per 30 days) probenecid 2 probenecid-colchicine 2 ULORIC 3 ST, QL (30 per 30 days) 21

30 ANTIGOUT AGENTS (CONTINUED) ZURAMPIC 4 PA, QL (30 per 30 days) ANTIMIGRAINE AGENTS ERGOT ALKALOIDS CAFERGOT 3 QL (40 per 30 days) D.H.E.45 5 dihydroergotamine 4 mg/ml spry 5 QL (8 per 28 days) dihydroergotamine mesylate (1 mg/ml vl, 1 5 mg/ml am) ERGOMAR 4 QL (20 per 28 days) ergotamine-caffeine 2 QL (40 per 30 days) MIGERGOT 4 QL (20 per 28 days) MIGRANAL 5 QL (8 per 28 days) PROPHYLACTIC INNOPRAN XL 4 propranolol hcl er 2 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 2 SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate 2 QL (12 per 30 days) eletriptan hbr 2 QL (12 per 30 over time) frovatriptan succinate 2 QL (18 per 30 days) naratriptan 2 QL (18 per 30 days) naratriptan hcl 2 QL (18 per 30 days) ONZETRA XSAIL 4 QL (16 per 30 days) RELPAX 4 ST, QL (12 per 30 days) rizatriptan 2 QL (24 per 30 days) sumatriptan 20 mg nasal spray 3 QL (12 per 30 days) sumatriptan 5 mg nasal spray 3 QL (18 per 30 days) sumatriptan succ 100 mg tablet 2 QL (9 per 30 days) sumatriptan succinate (25 mg tablet, 50 mg 2 QL (18 per 30 days) tablet) sumatriptan succinate (4 mg/0.5 ml inject, 4 3 QL (10 per 30 days) mg/0.5 ml cart, 6 mg/0.5 ml refill, 6 mg/0.5 ml syrng, 6 mg/0.5 ml vial, 6 mg/0.5 ml inject) SUMAVEL DOSEPRO 4 MG/0.5 ML 4 ST, QL (5 per 30 days) SUMAVEL DOSEPRO 6 MG/0.5 ML 5 ST, QL (5 per 30 days) TREXIMET MG TABLET 4 ST, QL (16 per 30 days) TREXIMET MG TABLET 4 ST, QL (10 per 30 days) ZEMBRACE SYMTOUCH 4 ST, QL (5 per 30 days) zolmitriptan 2 QL (12 per 30 days) zolmitriptan odt 2 QL (12 per 30 days) 22

31 ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl 4 MESTINON 60 MG/5 ML SYRUP 4 pyridostigmine bromide 2 pyridostigmine bromide er 2 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone (25 mg tablet, 100 mg tablet) 2 rifabutin 4 ANTITUBERCULARS CAPASTAT SULFATE 4 cycloserine 5 ethambutol hcl 2 isoniazid (50 mg/5 ml solution, 100 mg tablet, mg/ml vial, 300 mg tablet) PASER 4 PRIFTIN 4 pyrazinamide 2 RIFAMATE 4 rifampin 2 RIFATER 4 SIRTURO 5 QL (68 per 28 days) TRECATOR 4 ANTINEOPLASTICS ALKYLATING AGENTS ALKERAN 2 MG TABLET 4 B/D PA ALKERAN 50 MG VIAL 4 BENDEKA 5 PA cyclophosphamide (1 gm vial, 2 gm vial, mg vial) cyclophosphamide (25 mg capsule, 50 mg 4 B/D PA capsule) dacarbazine 2 EVOMELA 5 GLEOSTINE 4 HEXALEN 5 ifosfamide (1 gm/20 ml vial, 1 gm vial, 3 gm 2 vial, 3 gm/ 60 ml vial) LEUKERAN 3 MATULANE 5 melphalan 2 B/D PA melphalan hcl 5 23

32 ANTINEOPLASTICS (CONTINUED) MUSTARGEN 5 thiotepa 2 TREANDA (25 MG VIAL, 45 MG/0.5 ML 5 PA VIAL, 180 MG/2 ML VIAL) TREANDA 100 MG VIAL 5 PA VALCHLOR 5 PA, QL (60 per 30 days) YONDELIS 5 PA ZANOSAR 4 ANTIANDROGENS bicalutamide 2 flutamide 2 NILANDRON 5 nilutamide 5 XTANDI 5 PA, QL (120 per 30 days) ANTIANGIOGENIC AGENTS POMALYST 5 PA, QL (21 per 28 days) REVLIMID 5 QL (30 per 30 days) THALOMID (50 MG CAPSULE, 100 MG 5 PA, QL (30 per 30 days) CAPSULE, 150 MG CAPSULE) THALOMID 200 MG CAPSULE 5 PA, QL (60 per 30 days) VOTRIENT 5 PA, QL (120 per 30 days) ANTIESTROGENS/MODIFIERS EMCYT 4 FARESTON 5 FASLODEX 5 SOLTAMOX 4 tamoxifen citrate 2 ANTIMETABOLITES cladribine 5 B/D PA clofarabine 5 CLOLAR 5 cytarabine 2 B/D PA DROXIA 4 ELITEK 5 fludarabine phosphate (50 mg vial, 50 mg/2 ml 2 vial) gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram 5 vial, 2 gram/52.6 ml vl, hcl 2 gram vial, 200 mg/5.26 ml vl, hcl 200 mg vial) GEMZAR 1 GRAM VIAL 4 GEMZAR 200 MG VIAL 5 hydroxyurea 2 24

33 ANTINEOPLASTICS (CONTINUED) mercaptopurine 2 NIPENT 5 PURIXAN 4 TABLOID 4 ANTINEOPLASTICS, OTHER ABRAXANE 5 ADRIAMYCIN 2 ADRUCIL 2 B/D PA ALIMTA 5 ALIQOPA 5 PA ALUNBRIG 5 PA, QL (180 per 30 days) ARRANON 5 BESPONSA 5 PA BICNU 4 BLEO 15K 2 bleomycin sulfate (15 vial, 30 vial) 2 B/D PA BLINCYTO 35MCG VIAL+STABILIZER 5 PA busulfan 5 BUSULFEX 5 CAPRELSA 100 MG TABLET 5 PA, QL (60 per 30 days) CAPRELSA 300 MG TABLET 5 PA, QL (30 per 30 days) carboplatin (50 mg/5 ml vial, 150 mg/15 ml 2 vial, 450 mg/45 ml vial, 600 mg/60 ml vial) cisplatin 2 COSMEGEN 5 DACOGEN 5 daunorubicin 20 mg/4 ml vial 2 DAUNOXOME 4 decitabine 2 dexrazoxane 5 DOCEFREZ 20 MG VIAL 5 docetaxel (20 mg/2 ml vial, 20 mg/ml vial, 80 5 mg/4 ml vial, 80 mg/8 ml vial, 140 mg/7 ml vial, 160 mg/8 ml vial, 160 mg/16 ml vial, 200 mg/10 ml vial, 200 mg/20 ml vial) DOXIL 5 doxorubicin hcl (10 mg/5 ml vial, 10 mg vial, 2 20 mg/10 ml vial, 50 mg/25 ml vial, 50 mg vial, 150 mg/75 ml vial, 200 mg/100 ml vial) doxorubicin hcl liposome 2 ELLENCE 5 ELOXATIN 5 25

34 ANTINEOPLASTICS (CONTINUED) epirubicin hcl (50 mg/25 ml vial, 200 mg/100 ml vial) 2 ERIVEDGE 5 PA, QL (30 per 30 days) ERWINAZE 5 PA FIRMAGON 2 X 120 MG KIT 5 FIRMAGON 80 MG KIT 4 fluorouracil (2.5 gm/50 ml btl, 2.5 gm/50 ml vial, 5 gm/100 ml vial, 5 gm/100 ml btl, 500 mg/10 ml vial, 1,000 mg/20 ml vl, 2,500 mg/50 ml vl, 5,000 mg/100 ml) 2 B/D PA FOLOTYN 20 MG/ML VIAL 5 PA FOLOTYN 40 MG/2 ML VIAL 5 PA FUSILEV 5 HALAVEN 5 PA IDAMYCIN PFS 5 idarubicin hcl 5 IDHIFA 5 PA, QL (30 per 30 days) irinotecan hcl 2 ISTODAX 5 PA IXEMPRA 5 PA JAKAFI 5 PA KADCYLA 100 MG VIAL 5 PA KADCYLA 160 MG VIAL 5 PA KEYTRUDA 50 MG VIAL 5 PA KISQALI 5 PA, QL (63 per 28 days) KISQALI FEMARA 200 MG CO-PACK 5 PA, QL (49 per 28 days) KISQALI FEMARA 400 MG CO-PACK 5 PA, QL (70 per 28 days) KISQALI FEMARA 600 MG CO-PACK 5 PA, QL (91 per 28 days) KYPROLIS 5 PA leucovorin calcium 2 levoleucovorin calcium (175 mg/17.5 ml, mg/25 ml vl) levoleucovorin calcium (50 mg vial, 175 mg 4 vial) LONSURF 15 MG-6.14 MG TABLET 5 PA, QL (100 per 28 days) LONSURF 20 MG-8.19 MG TABLET 5 PA, QL (80 per 28 days) LYNPARZA (100 MG TABLET, 150 MG 5 PA, QL (120 per 30 days) TABLET) MARQIBO 5 PA MEKINIST 0.5 MG TABLET 5 PA, QL (90 per 30 days) MEKINIST 2 MG TABLET 5 PA, QL (30 per 30 days) mesna 2 26

35 ANTINEOPLASTICS (CONTINUED) MESNEX 400 MG TABLET 5 mitomycin (5 mg vial, 20 mg vial) 4 mitomycin 40 mg vial 5 mitoxantrone hcl 2 NINLARO 5 PA, QL (3 per 28 days) OPDIVO 100 MG/10 ML VIAL 5 PA OPDIVO 40 MG/4 ML VIAL 5 PA oxaliplatin (50 mg vial, 50 mg/10 ml vial, mg vial) oxaliplatin 100 mg/20 ml vial 4 paclitaxel 2 PROLEUKIN 5 RUBRACA (200 MG TABLET, 300 MG 5 PA, QL (120 per 30 days) TABLET) RUBRACA 250 MG TABLET 5 PA, QL (120 per 30 days) SYLATRON 5 PA SYLVANT 100 MG VIAL 5 PA SYLVANT 400 MG VIAL 5 PA SYNRIBO 5 PA TAFINLAR 5 PA, QL (120 per 30 days) TAXOTERE 5 TORISEL 5 PA TRISENOX 4 UNITUXIN 5 VELCADE 5 PA VERZENIO (50 MG TABLET, 100 MG 5 PA, QL (60 per 30 days) TABLET, 150 MG TABLET, 200 MG TABLET) vinblastine sulfate 2 B/D PA VINCASAR PFS 2 B/D PA vincristine sulfate 2 B/D PA vinorelbine tartrate 2 VYXEOS 5 PA XALKORI 5 PA YERVOY 200 MG/40 ML VIAL 5 PA YERVOY 50 MG/10 ML VIAL 5 PA ZEJULA 5 PA, QL (90 per 30 days) ZELBORAF 5 PA ZINECARD 5 ZOLINZA 5 PA, QL (120 per 30 days) ZYTIGA 250 MG TABLET 5 QL (120 per 30 days) ZYTIGA 500 MG TABLET 5 QL (60 per 30 days) 27

36 ANTINEOPLASTICS (CONTINUED) AROMATASE INHIBITORS, 3RD GENERATION anastrozole 2 exemestane 3 letrozole 2 ENYZME INHIBITORS ETOPOPHOS 4 etoposide (100 mg/5 ml vial, 500 mg/25 ml 2 vial, 1,000 mg/50 ml vial) HYCAMTIN 4 MG VIAL 5 TOPOSAR 2 topotecan hcl (4 mg/4 ml vial, 4 mg vial) 5 MOLECULAR TARGET INHIBITORS AFINITOR (2.5 MG TABLET, 5 MG TABLET) 5 PA, QL (30 per 30 days) AFINITOR (7.5 MG TABLET, 10 MG 5 PA, QL (60 per 30 days) TABLET) AFINITOR DISPERZ (2 MG TABLET, 3 5 PA MG TABLET) AFINITOR DISPERZ 5 MG TABLET 5 PA, QL (112 per 28 days) ALECENSA 5 PA, QL (240 per 30 days) BELEODAQ 5 PA BOSULIF 100 MG TABLET 5 PA, QL (120 per 30 days) BOSULIF 500 MG TABLET 5 PA, QL (30 per 30 days) CABOMETYX 5 PA, QL (30 per 30 days) COMETRIQ 5 PA COTELLIC 5 PA, QL (63 per 28 days) CYRAMZA 5 PA FARYDAK 5 PA, QL (6 per 21 days) GILOTRIF 5 PA, QL (30 per 30 days) GLEEVEC 100 MG TABLET 5 PA, QL (120 per 30 days) GLEEVEC 400 MG TABLET 5 PA, QL (60 per 30 days) IBRANCE 5 PA, QL (21 per 28 days) ICLUSIG 5 PA imatinib mesylate 100 mg tab 5 PA, QL (120 per 30 days) imatinib mesylate 400 mg tab 5 PA, QL (60 per 30 days) IMBRUVICA 5 PA, QL (120 per 30 days) INLYTA 1 MG TABLET 5 PA, QL (180 per 30 days) INLYTA 5 MG TABLET 5 PA, QL (120 per 30 days) IRESSA 5 PA, QL (30 per 30 days) JEVTANA 5 PA LENVIMA (18 MG DAILY, 24 MG DAILY) 5 PA, QL (90 per 30 days) 28

37 ANTINEOPLASTICS (CONTINUED) LENVIMA (8 MG DAILY, 14 MG DAILY, 20 MG DAILY) 5 PA, QL (60 per 30 days) LENVIMA 10 MG DAILY DOSE 5 PA, QL (30 per 30 days) LYNPARZA 50 MG CAPSULE 5 PA, QL (480 per 30 days) NERLYNX 5 PA, QL (180 per 30 days) NEXAVAR 5 PA, QL (120 per 30 days) ODOMZO 5 PA, QL (30 per 30 days) RYDAPT 5 PA, QL (240 per 30 days) SPRYCEL (20 MG TABLET, 50 MG 5 PA, QL (60 per 30 days) TABLET, 70 MG TABLET) SPRYCEL (80 MG TABLET, 100 MG 5 PA, QL (30 per 30 days) TABLET, 140 MG TABLET) STIVARGA 5 PA SUTENT 5 PA, QL (30 per 30 days) TAGRISSO 5 PA, QL (30 per 30 days) TARCEVA 5 QL (30 per 30 days) TASIGNA 5 PA, QL (120 per 30 days) TYKERB 5 PA, QL (150 per 30 days) VECTIBIX 5 VENCLEXTA 10 MG TABLET 4 PA, QL (42 per 28 days) VENCLEXTA 100 MG TABLET 5 PA, QL (112 per 28 days) VENCLEXTA 50 MG TABLET 4 PA, QL (224 per 28 days) VENCLEXTA STARTING PACK 5 PA, QL (42 per 28 days) ZALTRAP 100 MG/4 ML VIAL 5 PA ZALTRAP 200 MG/8 ML VIAL 5 PA ZYDELIG 5 PA, QL (60 per 30 days) ZYKADIA 5 PA MONOCLONAL ANTIBODIES ARZERRA 5 PA AVASTIN 5 PA BAVENCIO 5 PA DARZALEX 5 PA EMPLICITI 5 PA ERBITUX 100 MG/50 ML VIAL 5 PA ERBITUX 200 MG/100 ML VIAL 5 PA GAZYVA 5 PA HERCEPTIN 5 IMFINZI 5 PA LARTRUVO 5 PA PERJETA 5 PA PORTRAZZA 5 PA RITUXAN 5 PA 29

38 ANTINEOPLASTICS (CONTINUED) RITUXAN HYCELA 5 PA TECENTRIQ 5 PA RETINOIDS bexarotene 5 PANRETIN 5 TARGRETIN (1% GEL, 75 MG 5 CAPSULE) tretinoin 10 mg capsule 5 ANTIPARASITICS ANTHELMINTICS ALBENZA 4 BILTRICIDE 4 EMVERM 4 ivermectin 2 SOOLANTRA 4 ST ANTIPROTOZOALS ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) atovaquone 5 atovaquone-proguanil hcl 4 chloroquine phosphate 2 COARTEM 4 DARAPRIM 5 hydroxychloroquine sulfate 2 mefloquine hcl 2 MEPRON 5 NEBUPENT 4 B/D PA PENTAM primaquine 4 QUALAQUIN 4 PA quinine sulfate 3 PA TINDAMAX 250 MG TABLET 4 tinidazole (250 mg tablet, 500 mg tablet) 2 PEDICULICIDES/ SCABICIDES EURAX 4 lindane 1% shampoo 3 malathion 3 permethrin 5% cream

39 ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate (mes 0.5 mg tab, mes 1 mg tablet, 2 mg/2 ml ampule, mes 2 mg tablet, 2 mg/2 ml vial) trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml 2 2 elx, 5 mg tablet) ANTIPARKINSON AGENTS, OTHER entacapone 2 QL (240 per 30 days) GOCOVRI ER 137 MG CAPSULE 5 PA, QL (60 per 30 days) GOCOVRI ER 68.5 MG CAPSULE 5 PA, QL (30 per 30 days) TASMAR 5 tolcapone 5 DOPAMINE AGONISTS APOKYN 5 NEUPRO 4 QL (30 per 30 days) pramipexole mg tablet 2 pramipexole dihydrochloride (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 2 QL (90 per 30 days) pramipexole er 3 QL (30 per 30 days) ropinirole er 3 QL (60 per 30 days) ropinirole hcl 2 DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa 5 carbidopa-levodopa ( mg odt, mg odt, mg odt) carbidopa-levodopa ( tab, tab, tab) carbidopa-levodopa er 2 carbidopa-levodopa-entacapone 2 SINEMET SINEMET SINEMET SINEMET CR 4 MONOAMINE OXIDASE B (MAO-B) INHIBITORS AZILECT 3 QL (30 per 30 days) rasagiline mesylate 2 QL (30 per 30 days) selegiline hcl 2 XADAGO 100 MG TABLET 5 ST, QL (30 per 30 days) XADAGO 50 MG TABLET 5 ST, QL (46 per 30 days) ZELAPAR 4 ST 31

40 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL ADASUVE 4 chlorpromazine hcl (10 mg tablet, 25 mg/ml amp, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) fluphenazine decanoate 2 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, mg/5 ml elix, 2.5 mg/ml vial, 5 mg/ml conc, 5 mg tablet, 10 mg tablet) haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 5 mg/ml ampul, 10 mg tablet, 20 mg tablet) haloperidol decanoate 2 haloperidol decanoate haloperidol lactate 2 loxapine 2 molindone hcl 4 perphenazine 2 perphenazine-amitriptyline 3 pimozide 3 prochlorperazine 10 mg/2 ml vl 2 thioridazine hcl 2 thiothixene 2 trifluoperazine hcl 2 2ND GENERATION/ATYPICAL ABILIFY 5 ABILIFY DISCMELT 5 ABILIFY MAINTENA 5 aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) aripiprazole 1 mg/ml solution 3 aripiprazole odt (odt 10 mg tablet, odt 15 mg 3 tablet) ARISTADA 5 FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, TITRATION PACK) 4 PA, QL (60 per 30 days) FANAPT (6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) GEODON 20 MG/ML VIAL 4 INVEGA SUSTENNA (78 MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML) 5 ST 5 PA, QL (60 per 30 days) 32

41 ANTIPSYCHOTICS (CONTINUED) INVEGA SUSTENNA 39 MG/0.25 ML 4 ST INVEGA TRINZA 5 ST LATUDA 5 PA, QL (30 per 30 days) NUPLAZID 5 PA, QL (60 per 30 days) olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg 2 tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) olanzapine 10 mg vial 4 olanzapine odt 3 olanzapine-fluoxetine hcl 4 paliperidone er (er 1.5 mg tablet, er 3 mg 4 QL (30 per 30 days) tablet, er 9 mg tablet) paliperidone er 6 mg tablet 4 QL (60 per 30 days) quetiapine fumarate 2 quetiapine fumarate er (er 300 mg tablet, er 3 QL (60 per 30 days) 400 mg tablet) quetiapine fumarate er (er 50 mg tablet, er QL (30 per 30 days) mg tablet, er 200 mg tablet) REXULTI (0.25 MG TABLET, 2 MG 5 PA, QL (30 per 30 days) TABLET, 3 MG TABLET, 4 MG TABLET) REXULTI (0.5 MG TABLET, 1 MG 5 PA, QL (120 per 30 days) TABLET) RISPERDAL CONSTA (12.5 MG SYR, 25 4 MG SYR) RISPERDAL CONSTA (37.5 MG SYR, 50 5 MG SYR) risperidone (0.25 mg tablet, 0.5 mg tablet, 1 2 mg tablet, 1 mg/ml solution, 2 mg tablet, 3 mg tablet, 4 mg tablet) risperidone odt 3 SAPHRIS (2.5 MG TAB SL CHRY, 5 MG 4 PA, QL (60 per 30 days) TAB SL CHERRY) SAPHRIS 10 MG TAB SL BLK CHERY 5 PA, QL (60 per 30 days) SEROQUEL XR (300 MG TABLET, QL (60 per 30 days) MG TABLET) SEROQUEL XR (50 MG TABLET, QL (30 per 30 days) MG TABLET, 200 MG TABLET) VRAYLAR (1.5 MG CAPSULE, 3 MG 5 PA, QL (30 per 30 days) CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) VRAYLAR 1.5 MG-3 MG PACK 4 PA ziprasidone hcl 2 ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT, 300 MG VL KIT, 405 MG VL KIT) 4 33

42 ANTIPSYCHOTICS (CONTINUED) ATYPICALS clozapine odt 2 TREATMENT-RESISTANT clozapine 2 FAZACLO 4 VERSACLOZ 4 QL (540 per 30 days) ANTISPASTICITY AGENTS ANTISPASTICITY AGENTS baclofen 2 dantrolene sodium 2 tizanidine hcl 2 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS cidofovir 5 foscarnet sodium 2 B/D PA ganciclovir sodium 3 B/D PA VALCYTE (50 MG/ML SOLUTION, MG TABLET) valganciclovir hcl (hcl 50 mg/ml, 450 mg 5 tablet) VISTIDE 5 ZIRGAN 4 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA 5 QL (30 per 30 days) COMPLERA 5 EDURANT 5 INTELENCE (100 MG TABLET, 200 MG 5 QL (120 per 30 days) TABLET) INTELENCE 25 MG TABLET 4 QL (120 per 30 days) nevirapine (50 mg/5 ml susp, 200 mg tablet) 2 nevirapine er 2 QL (30 per 30 days) ODEFSEY 5 QL (30 per 30 days) RESCRIPTOR 4 SUSTIVA (50 MG CAPSULE, 200 MG 4 CAPSULE) SUSTIVA 600 MG TABLET 5 VIRAMUNE 200 MG TABLET 5 VIRAMUNE 50 MG/5 ML SUSP 4 VIRAMUNE XR 100 MG TABLET 4 QL (30 per 30 days) VIRAMUNE XR 400 MG TABLET 5 QL (30 per 30 days) ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir (20 mg/ml solution, 300 mg tablet) 2 34

43 ANTIVIRALS (CONTINUED) abacavir-lamivudine 5 abacavir-lamivudine-zidovudine 5 COMBIVIR 5 DESCOVY 5 QL (30 per 30 days) didanosine 2 EMTRIVA (10 MG/ML SOLUTION, MG CAPSULE) EPIVIR 10 MG/ML ORAL SOLN 4 EPZICOM 5 lamivudine (10 mg/ml oral soln, 150 mg tablet, mg tablet) lamivudine-zidovudine 4 RETROVIR 200 MG/20 ML VIAL 4 stavudine (1 mg/ml solution, 15 mg capsule, 20 2 mg capsule, 30 mg capsule, 40 mg capsule) TRIUMEQ 5 QL (30 per 30 days) TRIZIVIR 5 TRUVADA 5 VIDEX 2 GM PEDIATRIC SOLN 4 VIDEX 4 GM PEDIATRIC SOLN 4 VIREAD (150 MG TABLET, 200 MG 5 TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZERIT 1 MG/ML SOLUTION 4 ZIAGEN (20 MG/ML SOLUTION, MG TABLET) zidovudine (50 mg/5 ml syrup, 100 mg capsule, mg tablet) ANTI-HIV AGENTS, OTHER FUZEON 5 SELZENTRY 150 MG TABLET 5 QL (60 per 30 days) SELZENTRY 20 MG/ML ORAL SOLN 4 SELZENTRY 25 MG TABLET 4 QL (240 per 30 days) SELZENTRY 300 MG TABLET 5 QL (120 per 30 days) SELZENTRY 75 MG TABLET 5 QL (60 per 30 days) TYBOST 3 ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) CRIXIVAN 4 EVOTAZ 5 QL (30 per 30 days) fosamprenavir calcium

44 ANTIVIRALS (CONTINUED) INVIRASE 5 KALETRA (80 MG-20 MG/ML SOLN, MG TABLET) KALETRA MG TABLET 4 LEXIVA 50 MG/ML SUSPENSION 4 LEXIVA 700 MG TABLET 5 lopinavir-ritonavir 4 NORVIR (80 MG/ML SOLUTION, MG SOFTGEL CAP, 100 MG TABLET) PREZCOBIX 5 QL (30 per 30 days) PREZISTA (75 MG TABLET, 100 MG/ML 5 SUSPENSION, 150 MG TABLET, 600 MG TABLET, 800 MG TABLET) REYATAZ 5 VIRACEPT 5 ANTI-HIV, INTEGRASE INHIBITORS GENVOYA 5 QL (30 per 30 days) ISENTRESS (100 MG TABLET CHEW, 5 QL (60 per 30 days) 400 MG TABLET) ISENTRESS 100 MG POWDER PACKET 4 ISENTRESS 25 MG TABLET CHEW 3 ISENTRESS HD 5 QL (60 per 30 days) STRIBILD 5 TIVICAY (10 MG TABLET, 25 MG 4 QL (30 per 30 days) TABLET) TIVICAY 50 MG TABLET 5 VITEKTA 5 QL (30 per 30 days) ANTI-INFLUENZA AGENTS amantadine (50 mg/5 ml solution, 100 mg 2 capsule, 100 mg tablet, 100 mg/10 ml soln) oseltamivir phosphate 2 QL (20 per 30 days) RELENZA 4 QL (56 per 30 days) rimantadine hcl 2 TAMIFLU (6 MG/ML SUSPENSION, 30 4 MG CAPSULE, 45 MG CAPSULE) TAMIFLU 75 MG CAPSULE 4 QL (20 per 30 days) ANTIHEPATITIS AGENTS adefovir dipivoxil 2 QL (30 per 30 days) BARACLUDE (0.5 MG TABLET, 1 MG 5 QL (30 per 30 days) TABLET) BARACLUDE 0.05 MG/ML SOLUTION 4 QL (600 per 30 days) COPEGUS 4 PA DAKLINZA 5 PA, QL (30 per 30 days) 36

45 ANTIVIRALS (CONTINUED) entecavir 5 QL (30 per 30 days) EPCLUSA 5 PA, QL (30 per 30 days) EPIVIR HBV 25 MG/5 ML SOLN 4 HARVONI 5 PA, QL (30 per 30 days) HEPSERA 5 QL (30 per 30 days) INTRON A (10 MILLION UNITS VIL, 18 5 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL) lamivudine 100 mg tablet 2 lamivudine hbv 2 MODERIBA ( MG DOSEPACK, 5 PA MG DOSEPACK, MG DOSEPACK, MG DOSEPACK) MODERIBA 200 MG TABLET 4 PA OLYSIO 5 PA, QL (30 per 30 days) PEGASYS 180 MCG/0.5 ML SYRINGE 5 PA, QL (2 per 28 days) PEGASYS 180 MCG/ML VIAL 5 PA PEGASYS PROCLICK 135 MCG/0.5 5 PA PEGASYS PROCLICK 180 MCG/0.5 5 PA, QL (2 per 28 days) PEGINTRON 5 PA, QL (4 per 28 days) PEGINTRON REDIPEN 5 PA, QL (4 per 28 days) REBETOL 40 MG/ML SOLUTION 5 PA RIBASPHERE (200 MG TABLET, 200 MG 2 PA CAPSULE, 400 MG TABLET) RIBASPHERE 600 MG TABLET 5 PA RIBASPHERE RIBAPAK 5 PA ribavirin (200 mg capsule, 200 mg tablet) 2 PA ribavirin 6 gm inhalation vial 5 SOVALDI 5 PA, QL (30 per 30 days) TECHNIVIE 5 PA, QL (60 per 30 days) TYZEKA 5 QL (30 per 30 days) VEMLIDY 5 VIEKIRA PAK 5 PA, QL (112 per 28 days) VIEKIRA XR 5 PA, QL (90 per 30 days) VIRAZOLE 5 VOSEVI 5 PA, QL (30 per 30 days) ZEPA 5 PA, QL (28 per 28 days) ANTIHERPETIC AGENTS acyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) acyclovir 200 mg/5 ml susp

46 ANTIVIRALS (CONTINUED) acyclovir 5% ointment 4 QL (30 per 30 days) acyclovir sodium (sodium 500 mg vial, B/D PA mg/10 ml vial, 1,000 mg/20 ml vial) DENAVIR 5 QL (5 per 30 days) famciclovir 2 QL (90 per 30 days) trifluridine 2 valacyclovir 2 ZOVIRAX 5% CREAM 5 QL (15 per 30 days) ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl 2 chlordiazepoxide-amitriptyline 4 hydroxyzine pamoate 3 BENZODIAZEPINES alprazolam 2 alprazolam er 2 alprazolam odt 2 alprazolam xr 2 chlordiazepoxide hcl 2 diazepam (2 mg tablet, 5 mg/ml vial, 5 mg 2 tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 10 mg/2 ml carpuject, 10 mg tablet, 50 mg/10 ml vial) lorazepam (0.5 mg tablet, 1 mg tablet, 2 2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 2 mg tablet, 4 mg/ml vial, 4 mg/ml carpuject, 20 mg/10 ml vial, 40 mg/10 ml vial) oxazepam 2 BIPOLAR AGENTS MOOD STABILIZERS EQUETRO 4 lithium 2 lithium carbonate (150 mg cap, 300 mg cap) 2 lithium carbonate (300 mg tab, 600 mg cap) 4 lithium carbonate er 2 38

47 BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose 2 alogliptin 4 ST, QL (30 per 30 days) alogliptin-metformin 4 ST, QL (60 per 30 days) alogliptin-pioglitazone 4 ST, QL (30 per 30 days) AVANDIA (2 MG TABLET, 4 MG 4 QL (60 per 30 days) TABLET) AVANDIA 8 MG TABLET 4 QL (30 per 30 days) BYDUREON 4 QL (4 per 28 days) BYDUREON PEN 4 QL (4 per 28 days) BYETTA 10 MCG DOSE PEN INJ 4 QL (2.4 per 30 days) BYETTA 5 MCG DOSE PEN INJ 4 QL (1.2 per 30 days) chlorpropamide 3 PA, QL (90 per 30 days) CYCLOSET 4 DIABETA 1.25 MG TABLET 4 PA, QL (60 per 30 days) DIABETA 2.5 MG TABLET 4 PA, QL (90 per 30 days) DIABETA 5 MG TABLET 4 PA, QL (120 per 30 days) glimepiride 1 mg tablet 1 QL (180 per 30 days) glimepiride 2 mg tablet 1 QL (90 per 30 days) glimepiride 4 mg tablet 1 QL (60 per 30 days) glipizide 1 QL (120 per 30 days) glipizide er (er 2.5 mg tablet, er 5 mg tablet) 1 QL (90 per 30 days) glipizide er 10 mg tablet 1 QL (60 per 30 days) glipizide xl (2.5 mg tablet, 5 mg tablet) 1 QL (90 per 30 days) glipizide xl 10 mg tablet 1 QL (60 per 30 days) glipizide-metformin ( mg, mg) 2 QL (120 per 30 days) glipizide-metformin mg 2 QL (240 per 30 days) GLUCOVANCE 4 PA, QL (120 per 30 days) GLUMETZA ER 1,000 MG TABLET 5 PA, QL (60 per 30 days) GLUMETZA ER 500 MG TABLET 5 PA, QL (120 per 30 days) glyburid-metformin mg 3 PA, QL (60 per 30 days) glyburide 1.25 mg tablet 3 PA, QL (60 per 30 days) glyburide 2.5 mg tablet 3 PA, QL (90 per 30 days) glyburide 5 mg tablet 3 PA, QL (120 per 30 days) glyburide micronized 3 PA, QL (60 per 30 days) glyburide-metformin hcl ( mg, PA, QL (120 per 30 days) mg) GLYNASE 4 PA, QL (60 per 30 days) GLYSET 4 INVOKAMET 3 QL (60 per 30 days) INVOKAMET XR 3 QL (60 per 30 days) INVOKANA 100 MG TABLET 3 QL (60 per 30 days) 39

48 BLOOD GLUCOSE REGULATORS (CONTINUED) INVOKANA 300 MG TABLET 3 QL (30 per 30 days) JANUMET 3 QL (60 per 30 days) JANUMET XR ( MG TABLET, QL (30 per 30 days) 1,000 MG TABLET) JANUMET XR 50-1,000 MG TABLET 3 QL (60 per 30 days) JANUVIA 3 QL (30 per 30 days) JARDIANCE 3 QL (30 per 30 days) JENTADUETO 4 QL (60 per 30 days) JENTADUETO XR 2.5 MG-1,000 MG 4 QL (60 per 30 days) JENTADUETO XR 5 MG-1,000 MG TB 4 QL (30 per 30 days) KAZANO 4 ST, QL (60 per 30 days) KOMBIGLYZE XR (5-500 MG TABLET, 3 QL (30 per 30 days) 5-1,000 MG TAB) KOMBIGLYZE XR 2.5-1,000 MG TAB 3 QL (60 per 30 days) metformin er 1000 mg osmotic tablet (generic 2 for fortamet) metformin er 500 mg osmotic tablet (generic 2 for fortamet) metformin hcl 1000mg tablet (immediaterelease) 1 QL (60 per 30 days) metformin hcl 500 mg tablet (immediaterelease) 1 QL (150 per 30 days) metformin hcl 850 mg tablet (immediaterelease) 1 QL (90 per 30 days) metformin hcl er 1000 mg tablet (generic for 2 glumetza) metformin hcl er 500mg (generic for 2 glucophage xr) metformin hcl er 500mg (generic for 2 glumetza) metformin hcl er 750 mg (generic for 2 glucophage xr) miglitol 2 nateglinide 2 NESINA 4 ST, QL (30 per 30 days) ONGLYZA 3 QL (30 per 30 days) OSENI 4 ST, QL (30 per 30 days) pioglitazone hcl 1 QL (30 per 30 days) pioglitazone-glimepiride 2 QL (30 per 30 days) pioglitazone-metformin 3 QL (90 per 30 days) repaglinide 2 QL (240 per 30 days) repaglinide-metformin hcl 3 QL (150 per 30 days) RIOMET 4 QL (765 per 30 days) 40

49 BLOOD GLUCOSE REGULATORS (CONTINUED) SYMLINPEN QL (12 per 28 days) SYMLINPEN 60 3 QL (12 per 28 days) SYNJARDY 3 QL (60 per 30 days) SYNJARDY XR (10-1,000 MG TABLET, 3 QL (30 per 30 days) 25-1,000 MG TABLET) SYNJARDY XR (5-1,000 MG TABLET, 3 QL (60 per 30 days) ,000 MG TAB) tolazamide 2 QL (60 per 30 days) tolbutamide 2 QL (180 per 30 days) TRADJENTA 4 QL (30 per 30 days) TRULICITY 3 QL (2 per 28 days) VICTOZA 2-PAK 3 QL (9 per 30 days) VICTOZA 3-PAK 3 QL (9 per 30 days) GLYCEMIC AGENTS GLUCAGEN 1 MG HYPOKIT 3 GLUCAGON EMERGENCY KIT 3 PROGLYCEM 4 INSULINS HUMALOG 3 HUMALOG JUNIOR KWIKPEN 3 HUMALOG KWIKPEN U HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 3 HUMALOG MIX HUMALOG MIX KWIKPEN 3 HUMULIN HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U HUMULIN R U-500 KWIKPEN 3 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 TOUJEO SOLOSTAR 3 41

50 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ARIXTRA (5 MG/0.4 ML SYRINGE, MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) BRILINTA 3 QL (60 per 30 days) COUMADIN 4 ELIQUIS 2.5 MG TABLET 3 QL (60 per 30 days) ELIQUIS 5 MG TABLET 3 QL (74 per 30 days) enoxaparin sodium 3 fondaparinux sodium (2.5 mg/0.5 ml syr, 5 4 mg/0.4 ml syr, 7.5 mg/0.6 ml syr, 10 mg/0.8 ml syr) FRAGMIN (7,500 UNITS/0.3 ML SYR, 5 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 ML VL) heparin sodium 2 heparin sodium in 0.45% nacl (heparin-1/2ns 2 25,000 units/500, heparin-1/2ns 12,500 units/250, heparin 25,000 unit/250-1/2 ns) heparin sodium-0.9% nacl (heparin-ns 1,000 2 units/500 ml, heparin-ns 2,000 unit/1,000 ml) heparin sodium-d5w (heparin 20,000 unit/500 2 ml-d5w, heparin 25,000 unit/500 ml-d5w, heparin 25,000 unit/250 ml-d5w, heparin-d5w 12,500 unit/250 ml, heparin-d5w 25,000 unit/250 ml, heparin-d5w 25,000 unit/500 ml) JANTOVEN 1 warfarin sodium 1 XARELTO (10 MG TABLET, 20 MG 3 QL (30 per 30 days) TABLET) XARELTO 15 MG TABLET 3 QL (60 per 30 days) XARELTO STARTER PACK 3 QL (51 per 30 days) ZONTIVITY 4 PA, QL (30 per 30 days) BLOOD FORMATION MODIFIERS anagrelide hcl 2 ARANESP (10 MCG/0.4 ML SYRINGE, 25 4 MCG/ML VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL) ARANESP (100 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/ML VIAL, 200 MCG/0.4 ML SYRINGE, 300 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 500 MCG/1 ML 5 You SYRINGE) can find information on what the symbols and abbreviations on this table mean by going to page V. 42

51 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (CONTINUED) azacitidine 2 EPOGEN (2,000 UNITS/ML VIAL, 3,000 4 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL) EPOGEN 20,000 UNITS/ML VIAL 5 GRANIX 5 LEUKINE 5 MIRCERA (30 MCG/0.3 ML SYRINGE, 50 4 MCG/0.3 ML SYRINGE, 75 MCG/0.3 ML SYRINGE, 100 MCG/0.3 ML SYRINGE, 150 MCG/0.3 ML SYRINGE) MIRCERA 200 MCG/0.3 ML SYRINGE 5 MOZOBIL 5 PA NEULASTA 6 MG/0.6 ML SYRINGE 5 QL (2 per 30 days) NEULASTA ONPRO 6 MG/0.6 ML KIT 5 QL (2 per 30 days) NEUPOGEN 5 PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 4 VIAL, 10,000 VIAL) PROCRIT (20,000 VIAL, 40,000 VIAL) 5 PROMACTA (12.5 MG TABLET, 50 MG 5 PA, QL (30 per 30 days) TABLET, 75 MG TABLET) PROMACTA 25 MG TABLET 5 PA, QL (90 per 30 days) protamine sulfate 4 VIDAZA 5 ZARXIO 5 COAGULANTS CYKLOKAPRON 4 tranexamic acid (650 mg tablet, 1,000 mg/10 2 ml) PLATELET MODIFYING AGENTS AGGRENOX 4 QL (60 per 30 days) aspirin-dipyridamole er 4 QL (60 per 30 days) cilostazol 2 clopidogrel 300 mg tablet 2 QL (1 per 30 days) clopidogrel 75 mg tablet 2 QL (60 per 30 days) dipyridamole (25 mg tablet, 50 mg tablet, 75 2 mg tablet) EFFIENT 3 QL (30 per 30 days) PRADAXA 4 QL (60 per 30 days) prasugrel hcl 2 QL (30 per 30 days) ticlopidine hcl 2 43

52 CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 2 clonidine patch 3 QL (8 per 28 days) CLORPRES 4 guanfacine hcl 2 PA methyldopa 2 PA methyldopa-hydrochlorothiazide 2 PA methyldopate hcl 2 midodrine hcl 2 NORTHERA 5 PA, QL (180 per 30 days) ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA XL 4 DIBENZYLINE 5 phenoxybenzamine hcl 5 prazosin hcl 2 reserpine 2 terazosin hcl 2 ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 4 BENICAR HCT 4 candesartan cilexetil 2 QL (30 per 30 days) candesartan-hydrochlorothiazid 2 QL (30 per 30 days) EDARBI 4 ST, QL (30 per 30 days) EDARBYCLOR 4 ST, QL (30 per 30 days) eprosartan mesylate 2 QL (30 per 30 days) irbesartan (75 mg tablet, 150 mg tablet) 1 QL (60 per 30 days) irbesartan 300 mg tablet 1 QL (30 per 30 days) irbesartan-hydrochlorothiazide 2 QL (30 per 30 days) losartan potassium (50 mg tab, 100 mg tab) 1 QL (60 per 30 days) losartan potassium 25 mg tab 1 QL (120 per 30 days) losartan-hctz mg tab 1 QL (60 per 30 days) losartan-hydrochlorothiazide ( mg 1 QL (30 per 30 days) tab, mg tab) olmesartan medoxomil 2 olmesartan-amlodipine-hctz 2 QL (30 per 30 days) olmesartan-hydrochlorothiazide 2 telmisartan 2 QL (30 per 30 days) telmisartan-amlodipine 3 QL (30 per 30 days) telmisartan-hydrochlorothiazid 3 QL (30 per 30 days) valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL (60 per 30 days) 44

53 CARDIOVASCULAR AGENTS (CONTINUED) valsartan 320 mg tablet 1 QL (30 per 30 days) valsartan-hydrochlorothiazide 1 QL (30 per 30 days) ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl 1 benazepril-hydrochlorothiazide 2 captopril 2 captopril-hydrochlorothiazide 2 enalapril maleate 1 enalapril-hydrochlorothiazide 1 fosinopril sodium 1 fosinopril-hydrochlorothiazide 2 lisinopril 1 lisinopril-hydrochlorothiazide 1 moexipril hcl 2 moexipril-hydrochlorothiazide 2 perindopril erbumine 2 quinapril hcl 1 quinapril-hydrochlorothiazide 2 ramipril 1 trandolapril 2 trandolapril-verapamil er 3 QL (30 per 30 days) ANTIARRHYTHMICS amiodarone hcl (hcl 100 mg tablet, 150 mg/3 2 ml vial, 150 mg/3 ml syringe, hcl 200 mg tablet, hcl 400 mg tablet, 450 mg/9 ml vial, 900 mg/18 ml vial) dofetilide 2 flecainide acetate 2 lidocaine hcl (1% syringe, 1% abboject, 2% 2 luer-jet, 2% syringe, 2% abboject) mexiletine hcl 2 MULTAQ 3 QL (60 per 30 days) PACERONE 2 procainamide hcl 2 propafenone hcl 2 propafenone hcl er 2 quinidine gluc 80 mg/ml vial 2 quinidine gluc er 324 mg tab 3 quinidine sulfate (200 mg tab, 300 mg tab) 2 SORINE 2 sotalol 2 sotalol af 2 45

54 CARDIOVASCULAR AGENTS (CONTINUED) SOTYLIZE 4 TIKOSYN 4 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl 2 atenolol 1 atenolol-chlorthalidone 1 betaxolol hcl (10 mg tablet, 20 mg tablet) 2 bisoprolol fumarate 2 bisoprolol-hydrochlorothiazide 2 BYSTOLIC (2.5 MG TABLET, 5 MG 3 QL (30 per 30 days) TABLET, 10 MG TABLET) BYSTOLIC 20 MG TABLET 3 QL (60 per 30 days) BYVALSON 3 QL (120 per 30 days) carvedilol 1 COREG CR 4 ST, QL (30 per 30 days) labetalol hcl (100 mg tablet, 100 mg/20 ml vl, mg/40 ml vl, 200 mg tablet, 300 mg tablet) LOPRESSOR 50 MG TABLET 4 metoprolol succinate er 2 metoprolol tartrate (1 mg/ml carpuject, tart 5 2 mg/5 ml amp, tart 5 mg/5 ml vial) metoprolol tartrate (25 mg tab, 37.5 mg tb, 50 1 mg tab, 75 mg tab, 100 mg tab) metoprolol-hydrochlorothiazide 2 nadolol 2 nadolol-bendroflumethiazide 2 pindolol 2 propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 2 mg tablet, 20 mg/5 ml soln, 40 mg/5 ml soln, 40 mg tablet, 60 mg tablet, 80 mg tablet) propranolol-hydrochlorothiazid 2 CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR 2 amlodipine besylate 1 amlodipine besylate-benazepril 2 amlodipine-atorvastatin 4 QL (30 per 30 days) amlodipine-olmesartan 2 QL (30 per 30 days) amlodipine-valsartan 3 QL (30 per 30 days) amlodipine-valsartan-hctz 3 QL (30 per 30 days) AZOR 4 QL (30 per 30 days) CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN, CARDENE-DEX 40 MG/200 ML IV, CARDENE-NACL 20 MG/200 ML SOLN, CARDENE-NACL 40 MG/200 ML IV) 4 46

55 CARDIOVASCULAR AGENTS (CONTINUED) CARTIA XT 2 CLEVIPREX 4 DILT-XR 2 diltiazem 12hr er 2 diltiazem 24hr cd (24hr 360 mg cap, 24hr mg cap, 24hr 240 mg cap, 24hr 180 mg cap, 24hr 120 mg cap) diltiazem 24hr er (24hr er 240 mg tab, 24hr er mg cap, 24hr er 420 mg cap, 24hr er 420 mg tab, 24hr er 360 mg tab, 24hr er 240 mg cap, 24hr er 180 mg tab, 24hr er 360 mg cap, 24hr er 300 mg tab, 24hr er 180 mg cap, 24hr er 120 mg cap) diltiazem er 2 diltiazem hcl (25 mg/5 ml vial, 30 mg tablet, 2 50 mg/10 ml vial, 60 mg tablet, 90 mg tablet, hcl 100 mg vial, 120 mg tablet, 125 mg/25 ml vial) felodipine er 2 isradipine 2 MATZIM LA 2 nicardipine hcl (20 mg capsule, 25 mg/10 ml 2 vial, 25 mg/10 ml ampule, 30 mg capsule) NIFEDICAL XL 2 nifedipine er (er 30 mg tablet, er 60 mg tablet, 2 er 90 mg tablet) nimodipine 2 nisoldipine 2 TAZTIA XT 2 verapamil er (er 120 mg capsule, er 180 mg 2 capsule, er 240 mg capsule) verapamil er (er 120 mg tablet, er 180 mg 1 tablet, er 240 mg tablet) verapamil er pm 2 verapamil hcl (2.5 mg/ml vial, 2.5 mg/ml 2 ampul, 5 mg/2 ml vial, 360 mg cap pellet) verapamil hcl (40 mg tablet, 80 mg tablet, mg tablet) verapamil sr 2 CARDIOVASCULAR AGENTS, OTHER CORLANOR 4 QL (60 per 30 days) DEMSER 5 DIGITEK 2 DIGOX 2 47

56 CARDIOVASCULAR AGENTS (CONTINUED) digoxin (0.125 mg tablet, 0.25 mg tablet, mcg tablet, 250 mcg tablet, 500 mcg/2 ml ampule) digoxin 0.05 mg/ml solution 4 ENTRESTO 3 QL (60 per 30 days) LANOXIN (62.5 MCG TABLET, 125 MCG 4 TABLET, MCG TABLET, 250 MCG TABLET, 500 MCG/2 ML AMPULE) LANOXIN PEDIATRIC 4 pentoxifylline 2 RANEXA ER 1,000 MG TABLET 3 QL (60 per 30 days) RANEXA ER 500 MG TABLET 3 QL (120 per 30 days) SAMSCA 5 PA TEKTURNA 3 QL (30 per 30 days) TEKTURNA HCT 3 QL (30 per 30 days) VECAMYL 5 DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide sodium 2 methazolamide 2 DIURETICS, LOOP bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 2 mg/4 ml vial, 1 mg tablet, 2 mg tablet, 2.5 mg/10 ml vial) EDECRIN 4 ethacrynate sodium 5 ethacrynic acid 3 furosemide (10 mg/ml solution, 20 mg/2 ml 2 vial, 40 mg/4 ml syringe, 40 mg/5 ml soln, 40 mg/4 ml vial, 100 mg/10 ml vial, 100 mg/10 ml syring) furosemide (20 mg tablet, 40 mg tablet, 80 mg 1 tablet) SODIUM EDECRIN 5 torsemide 2 DIURETICS, POTASSIUM-SPARING amiloride hcl 2 amiloride-hydrochlorothiazide 2 DYRENIUM 4 eplerenone 2 spironolactone 1 spironolactone-hctz 2 triamterene-hydrochlorothiazid 2 DIURETICS, THIAZIDE chlorothiazide 1 48

57 CARDIOVASCULAR AGENTS (CONTINUED) chlorothiazide sodium 2 chlorthalidone 1 hydrochlorothiazide 1 indapamide 1 methyclothiazide 2 metolazone 2 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate (43 mg capsule, 48 mg tablet, 54 2 QL (30 per 30 days) mg tablet, 67 mg capsule, 130 mg capsule, 134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mg capsule) fenofibrate 120 mg tablet 5 QL (30 per 30 days) fenofibrate 40 mg tablet 4 QL (30 per 30 days) fenofibric acid 2 QL (30 per 30 days) FENOGLIDE 4 gemfibrozil 2 TRIGLIDE 4 QL (30 per 30 days) DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS ALTOPREV 4 ST, QL (30 per 30 days) atorvastatin calcium 1 CRESTOR (5 MG TABLET, 10 MG 4 QL (45 per 30 days) TABLET, 20 MG TABLET) CRESTOR 40 MG TABLET 4 QL (30 per 30 days) ezetimibe-simvastatin 2 QL (30 per 30 days) fluvastatin er 2 QL (30 per 30 days) fluvastatin sodium 20 mg cap 2 QL (30 per 30 days) fluvastatin sodium 40 mg cap 2 QL (60 per 30 days) LIVALO 4 QL (30 per 30 days) lovastatin 1 pravastatin sodium 1 rosuvastatin calcium (5 mg tab, 10 mg tab, 20 2 QL (45 per 30 days) mg tab) rosuvastatin calcium 40 mg tab 2 QL (30 per 30 days) simvastatin 1 VYTORIN 4 ST, QL (30 per 30 days) DYSLIPIDEMICS, OTHER cholestyramine (packet, powder) 2 cholestyramine light (packet, powder) 2 colestipol hcl (hcl 1 gm tablet, hcl granules, hcl 2 granules packet, micronized 1 gm tab) ezetimibe 2 QL (30 per 30 days) JUXTAPID 5 PA, QL (30 per 30 days) 49

58 CARDIOVASCULAR AGENTS (CONTINUED) KYNAMRO 5 PA, QL (4 per 28 days) niacin er (er 750 mg tablet, er 1,000 mg 2 QL (60 per 30 days) tablet) niacin er 500 mg tablet 2 QL (90 per 30 days) NIACOR 2 omega-3 acid ethyl esters 2 QL (120 per 30 days) PRALUENT PEN 5 PA, QL (2 per 28 days) PRALUENT SYRINGE 5 PA, QL (2 per 28 days) PREVALITE (PACKET, POWDER) 2 REPATHA PUSHTRONEX 5 PA, QL (4 per 30 days) REPATHA SURECLICK 5 PA, QL (3 per 28 days) REPATHA SYRINGE 5 PA, QL (3 per 28 days) VASCEPA 3 QL (120 per 30 days) WELCHOL 4 ZETIA 3 QL (30 per 30 days) VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl (10 mg tablet, 20 mg/ml vial, 2 25 mg tablet, 50 mg tablet, 100 mg tablet) minoxidil (2.5 mg tablet, 10 mg tablet) 2 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS BIDIL 4 QL (180 per 30 days) DILATRATE-SR 4 GONITRO 4 isosorbide dinitrate 2 isosorbide mononitrate 2 isosorbide mononitrate er 2 MINITRAN 2 NITRO-BID 4 NITRO-DUR (0.1 PATCH, 0.2 PATCH, PATCH, 0.4 PATCH, 0.6 PATCH, 0.8 PATCH) nitroglycerin (0.3 mg tablet sl, 0.4 mg tablet sl, mg tablet sl) nitroglycerin (5 mg/ml vial, 400 mcg spray) 4 nitroglycerin 400 mcg lingual spray 4 nitroglycerin patch 2 NITROLINGUAL 4 NITROMIST 4 NITROSTAT 3 50

59 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES dextroamp-amphet er 30 mg cap 3 QL (60 per 30 days) dextroamphetamine sulfate (5 mg tab, 5 mg/5 4 ml, 10 mg tab) dextroamphetamine sulfate er 4 dextroamphetamine-amphet er (er 5 mg cap, 3 QL (90 per 30 days) er 10 mg cap, er 15 mg cap, er 20 mg cap, er 25 mg cap) dextroamphetamine-amphetamine 3 methamphetamine hcl 4 PA ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON- AMPHETAMINES atomoxetine hcl 3 clonidine hcl er 3 QL (120 per 30 days) DAYTRANA 4 QL (30 per 30 days) dexmethylphenidate hcl 3 dexmethylphenidate hcl er (er 15 mg cp, er 20 3 QL (30 per 30 days) mg cp, er 30 mg cp, er 40 mg cp) dexmethylphenidate hcl er (er 25 mg cp, er 35 3 QL (30 per 30 day) mg cp) dexmethylphenidate hcl er (er 5 mg cap, er 10 3 QL (60 per 30 days) mg cp) guanfacine hcl er (er 1 mg tablet, er 2 mg 3 QL (60 per 30 days) tablet) guanfacine hcl er (er 3 mg tablet, er 4 mg 3 QL (30 per 30 days) tablet) METADATE ER 2 METHYLIN (2.5 MG TAB, 5 MG 4 TABLET, 10 MG TABLET) methylphenidate cd 10 mg cap 3 QL (90 per 30 days) methylphenidate cd 20 mg cap 3 QL (90 per 30 days) methylphenidate cd 30 mg cap 3 QL (60 per 30 days) methylphenidate cd 40 mg cap 3 QL (30 per 30 days) methylphenidate er (er 10 mg tab, er 20 mg 3 tab) methylphenidate er (er 18 mg tab, er 27 mg 3 QL (90 per 30 days) tab) methylphenidate er (er 30 mg cap, er 36 mg 3 QL (60 per 30 days) tab, er 54 mg tab) methylphenidate er 10 mg cap 3 QL (90 per 30 days) methylphenidate er 20 mg cap 3 QL (90 per 30 days) methylphenidate er 40 mg cap 3 QL (30 per 30 days) methylphenidate hcl (2.5 mg chew tb, 5 mg tablet, 5 mg chew tab, 10 mg chew tab, 10 mg tablet, 20 mg tablet) 3 51

60 CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) methylphenidate hcl cd (50 mg cap, 60 mg 3 QL (30 per 30 days) cap) methylphenidate hcl er (er 50 mg cap, er 60 mg 3 QL (30 per 30 days) cap) methylphenidate la 20 mg cap 3 QL (90 per 30 days) methylphenidate la 30 mg cap 3 QL (60 per 30 days) methylphenidate la 40 mg cap 3 QL (30 per 30 days) methylphenidate la 60 mg cap 3 QL (30 per 30 days) RITALIN LA (10 MG CAPSULE, 60 MG 4 QL (30 per 30 days) CAPSULE) STRATTERA 4 QL (60 per 30 days) CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO (9 MG TABLET, 12 MG 5 PA, QL (120 per 30 days) TABLET) AUSTEDO 6 MG TABLET 5 PA, QL (60 per 30 days) INGREZZA 40 MG CAPSULE 5 PA, QL (60 per 30 days) NUEDEXTA 4 PA, QL (60 per 30 days) RILUTEK 5 riluzole 2 tetrabenazine 12.5 mg tablet 5 PA, QL (240 per 30 days) tetrabenazine 25 mg tablet 5 PA, QL (120 per 30 days) XENAZINE 12.5 MG TABLET 5 PA, QL (240 per 30 days) XENAZINE 25 MG TABLET 5 PA, QL (120 per 30 days) FIBROMYALGIA AGENTS LYRICA (200 MG CAPSULE, 225 MG 3 QL (90 per 30 days) CAPSULE) LYRICA 100 MG CAPSULE 3 QL (180 per 30 days) LYRICA 150 MG CAPSULE 3 QL (120 per 30 days) LYRICA 25 MG CAPSULE 3 QL (720 per 30 days) LYRICA 300 MG CAPSULE 3 QL (60 per 30 days) LYRICA 50 MG CAPSULE 3 QL (360 per 30 days) LYRICA 75 MG CAPSULE 3 QL (240 per 30 days) SAVELLA (12.5 MG TABLET, 25 MG 4 ST, QL (60 per 30 days) TABLET, 50 MG TABLET, 100 MG TABLET) SAVELLA TITRATION PACK 4 ST MULTIPLE SCLEROSIS AGENTS AMPYRA 5 PA, QL (60 per 30 days) AUBAGIO 5 QL (30 per 30 days) AVONEX (30 MCG VIAL KIT, 5 QL (4 per 30 days) PREFILLED SYR 30 MCG KT) AVONEX PEN 30 MCG/0.5 ML KIT 5 QL (4 per 30 days) 52

61 CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) BETASERON 0.3 MG KIT 5 PA, QL (14 per 28 days) COPAXONE 20 MG/ML SYRINGE 5 PA, QL (30 per 30 days) COPAXONE 40 MG/ML SYRINGE 5 QL (12 per 28 days) EXTAVIA 0.3 MG KIT 5 PA, QL (15 per 30 days) EXTAVIA 0.3 MG VIAL 5 PA, QL (15 per 30 days) GILENYA 5 QL (30 per 30 days) GLATOPA 5 QL (30 per 30 days) LEMTRADA 5 PA OCREVUS 5 PA PLEGRIDY 125 MCG/0.5 ML SYRING 5 QL (1 per 28 days) PLEGRIDY PEN 5 QL (1 per 28 days) PLEGRIDY SYRINGE STARTER PACK 5 QL (1 per 30 days) REBIF 5 QL (12 per 28 days) REBIF REBIDOSE 5 QL (12 per 28 days) TECFIDERA 5 QL (60 per 30 days) TYSABRI 5 PA DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS cevimeline hcl 3 chlorhexidine 0.12% rinse 2 DENTA 5000 PLUS 2 DENTAGEL 2 FLUORIDEX DAILY DEFENSE 2 KEPIVANCE 5 ORALONE 2 PAROEX 2 PERIOGARD 2 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 3 PREVIDENT % DRY MOUTH 4 PREVIDENT 5000 ENAMEL PROTECT 4 PREVIDENT 5000 SENSITIVE 4 SF 1.1% GEL 2 SF 5000 PLUS 2 triamcinolone 0.1% paste 2 53

62 DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS 8-MOP 4 ABSORICA 5 ACANYA 4 acitretin 4 ACZONE (5% GEL, 7.5% GEL PUMP) 4 PA adapalene (0.1% cream, 0.1% gel, 0.3% gel, 4 PA 0.3% gel pump) adapalene-benzoyl peroxide 3 ammonium lactate 2 AMNESTEEM 3 ATRALIN 4 PA AVITA 4 PA AZELEX 4 calcipotriene (0.005% solution, 0.005% 3 ointment, 0.005% cream) calcipotriene-betamethasone dp 4 CALCITRENE 2 calcitriol 3 mcg/g ointment 4 CARAC 5 CLARAVIS 3 clind ph-benzoyl perox 1.2-5% 3 clinda-benzoyl perox 1-5% pump 3 clindamycin phos-tretinoin 4 clindamycin-benzoyl perox 1-5% 3 CONDYLOX (0.5% TOPICAL SOLN, 0.5% 4 GEL) COSENTYX (2 SYRINGES) 5 PA, QL (1 per 28 days) COSENTYX PEN 5 PA, QL (10 per 28 days) COSENTYX PEN (2 PENS) 5 PA, QL (1 per 28 days) COSENTYX SYRINGE 5 PA, QL (10 per 28 days) diclofenac sodium 3% gel 5 DIFFERIN (0.1% CREAM, 0.1% LOTION, 4 PA 0.1% GEL, 0.3% GEL PUMP, 0.3% GEL) doxepin 5% cream 4 ELIDEL 4 QL (100 per 30 days) ENSTILAR 5 ST EPIDUO ( % GEL, % GEL 4 PUMP) EPIDUO FORTE 4 erythromycin-benzoyl peroxide 3 FABIOR 4 PA 54

63 DERMATOLOGICAL AGENTS (CONTINUED) FINACEA 4 fluorouracil (2% topical soln, 5% cream, 5% 2 topical soln) fluorouracil 0.5% cream 5 imiquimod 3 methoxsalen 5 MYORISAN 3 ONEXTON GEL PUMP 4 PICATO 5 podofilox 2 PRUDOXIN 4 REGRANEX 5 RETIN-A 4 PA RETIN-A MICRO 4 PA RETIN-A MICRO PUMP (PUMP 0.04% 4 PA GEL, PUMP 0.08% GEL, PUMP 0.1% GEL) SANTYL 4 selenium sulfide 2.5% lotion 2 sodium sulfacetamide 10% lot 2 SORIATANE 5 SORILUX 4 sulfacetamide sodium (sod 10% top susp, 2 sodium 10% lotn) TACLONEX (0.005%-0.064% SUSPENS, 5 ST OINTMENT) tacrolimus (0.03% ointment, 0.1% ointment) 2 QL (100 per 30 days) tazarotene 3 PA TAZORAC (0.05% CREAM, 0.05% GEL, 4 PA 0.1% CREAM, 0.1% GEL) TOLAK 4 TRETIN-X (0.0375% CREAM, 0.075% 4 PA CREAM) tretinoin (0.01% gel, 0.025% gel, 0.025% 3 PA cream, 0.05% cream, 0.05% gel, 0.1% cream) tretinoin microsphere 4 PA UVADEX 4 VEREGEN 5 XERESE 4 ZENATANE 3 ZONALON 4 ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM PUMP, 3.75% CREAM) 5 55

64 ENZYME REPLACEMENTS/ MODIFIERS ENZYME REPLACEMENTS/ MODIFIERS ADAGEN 5 ALDURAZYME 5 PA BUPHENYL (500 MG TABLET, 5 POWDER) CARBAGLU 5 PA CERDELGA 5 PA, QL (56 per 28 days) CEREZYME 5 PA CREON 3 CYSTADANE 5 CYSTAGON 4 ELAPRASE 5 PA ELELYSO 5 PA FABRAZYME (5 MG VIAL, 35 MG VIAL) 5 PA KANUMA 5 PA KRYSTEXXA 5 PA KUVAN 5 PA LUMIZYME 5 NAGLAZYME 5 PA ORFADIN (2 MG CAPSULE, 4 MG/ML 5 PA SUSPENSION, 5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) PANCREAZE 3 PROCYSBI 5 PA RAVICTI 5 PA sodium phenylbutyrate (500mg tb, powder) 5 STRENSIQ (18 MG/0.45 ML VIAL, 28 5 PA MG/0.7 ML VIAL, 40 MG/ML VIAL) STRENSIQ 80 MG/0.8 ML VIAL 5 PA, QL (38.4 per 28 days) SUCRAID 5 VIMIZIM 5 PA VPRIV 5 PA ZAVESCA 5 PA ZENPEP 4 GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml syringe, 0.1 mg/ml abboject) BENTYL 10 MG/ML AMPUL 4 CANTIL 4 dicyclomine 10 mg/5 ml soln 3 dicyclomine hcl (10 mg capsule, 20 mg tablet)

65 GASTROINTESTINAL AGENTS (CONTINUED) glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 2 1 mg/5 ml vial, 1 mg tablet, 2 mg tablet, 4 mg/20 ml vial) glycopyrrolate 1.5 mg tablet 5 methscopolamine bromide 2 GASTROINTESTINAL AGENTS, OTHER chlordiazepoxide/clidinium (oceanside 4 manufacturer only) CHOLBAM 5 PA diphenoxylate-atropine (diphenoxylat-atrop /5, diphenoxylate-atrop ) FULYZAQ 4 PA GASTROCROM 5 GATTEX 5 PA loperamide 2 mg capsule 2 MOVANTIK 3 QL (30 per 30 days) MYTESI 4 PA OCALIVA 5 PA, QL (30 per 30 days) OSMOPREP 4 peg 3350-electrolyte solution 2 PYLERA 3 RELISTOR (8 MG/0.4 ML SYRINGE, 12 5 PA, QL (30 per 30 days) MG/0.6 ML VIAL, 12 MG/0.6 ML SYRINGE) RELISTOR 150 MG TABLET 5 PA, QL (90 per 30 days) SUPREP 4 SYMPROIC 4 PA, QL (30 per 30 days) TRILYTE WITH FLAVOR PACKETS 2 ursodiol 2 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine (200 mg tablet, 300 mg/5 ml soln, mg tablet, 400 mg tablet, 800 mg tablet) famotidine (20 mg tablet, 20 mg/2 ml vial, 20 2 mg piggyback, 40 mg/4 ml vial, 40 mg tablet, 200 mg/20 ml vial) nizatidine (15 mg/ml solution, 150 mg capsule, mg capsule) ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 ml 3 vial, 150 mg/10 ml syrup, 150 mg capsule, hcl 150 mg/6 ml vl, 300 mg capsule) ranitidine hcl (150 mg tablet, 300 mg tablet) 2 IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl 5 QL (60 per 30 days) 57

66 GASTROINTESTINAL AGENTS (CONTINUED) LINZESS (145 MCG CAPSULE, 290 MCG 3 QL (30 per 30 days) CAPSULE) LINZESS 72 MCG CAPSULE 3 QL (30 per 30 days) LOTRONEX 5 QL (60 per 30 days) VIBERZI 5 QL (60 per 30 days) LAXATIVES CONSTULOSE 2 ENULOSE 2 GAVILYTE-C 2 GAVILYTE-G 2 GAVILYTE-H AND BISACODYL 2 GAVILYTE-N 2 GENERLAC 2 KRISTALOSE 4 lactulose 2 MOVIPREP 4 peg 3350 electrolyte soln 2 peg-3350 and electrolytes 2 polyethylene glycol PROTECTANTS CARAFATE (1 GM/10 ML SUSP, 1 GM 4 TABLET) misoprostol 2 sucralfate 2 PROTON PUMP INHIBITORS DEXILANT 4 esomeprazole magnesium 2 QL (60 per 30 days) esomeprazole sodium (20 mg vial, 40 mg vial) 3 lansoprazole (dr 15 mg capsule, dr 30 mg 2 QL (60 per 30 days) capsule) NEXIUM (DR 2.5 MG PACKET, DR 5 4 QL (60 per 30 days) MG PACKET, DR 10 MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET) NEXIUM I.V. 4 omeprazole (dr 10 mg capsule, dr 40 mg 2 QL (60 per 30 days) capsule) omeprazole dr 20 mg capsule 2 QL (120 per 30 days) omeprazole-sodium bicarbonate (20-1,680 pkt, 4 QL (60 per 30 days) 20-1,100 cap, 40-1,100 cap, 40-1,680 pkt) pantoprazole sodium (dr 20 mg tab, dr 40 mg 2 QL (60 per 30 days) tab) pantoprazole sodium 40 mg vial 3 58

67 GASTROINTESTINAL AGENTS (CONTINUED) PRILOSEC DR SUSPENSION 4 rabeprazole sodium 2 QL (60 per 30 days) GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin er 2 QL (30 per 30 days) flavoxate hcl 2 GELNIQUE 10% GEL PUMP 4 QL (30 per 30 days) GELNIQUE 10% GEL SACHETS 4 QL (30 per 30 days) GELNIQUE 3% GEL 4 QL (276 per 30 days) MYRBETRIQ 3 QL (30 per 30 days) oxybutynin chloride (5 mg tablet, 5 mg/5 ml 2 syrup) oxybutynin chloride er 2 QL (60 per 30 days) tolterodine tartrate 2 tolterodine tartrate er 2 QL (30 per 30 days) TOVIAZ 4 QL (30 per 30 days) trospium chloride 2 trospium chloride er 2 QL (30 per 30 days) VESICARE 3 QL (30 per 30 days) BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er 2 QL (60 per 30 days) doxazosin mesylate 2 dutasteride 2 QL (30 per 30 days) dutasteride-tamsulosin 2 QL (30 per 30 days) finasteride 5 mg tablet 2 RAPAFLO 3 tamsulosin hcl 1 QL (60 per 30 days) GENITOURINARY AGENTS, OTHER bethanechol chloride 2 CIALIS 2.5 MG TABLET 3 PA, QL (30 per 30 days) CIALIS 5 MG TABLET 3 PA, QL (30 per 30 days) ELMIRON 4 LITHOSTAT 5 THIOLA 4 PHOSPHATE BINDERS AURYXIA 5 ST calcium acetate (667 mg capsule, 667 mg 2 tablet, 667 mg gelcap) ELIPHOS 2 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER PACK, 1,000 MG TABLET CHEW) 4 ST 59

68 GENITOURINARY AGENTS (CONTINUED) lanthanum carbonate 4 PHOSLYRA 4 RENVELA (0.8 GM POWDER PACKET, GM POWDER PACKET) RENVELA 800 MG TABLET 3 QL (270 per 30 days) sevelamer 0.8 gm powder packet 5 QL (180 per 30 days) sevelamer 2.4 gm powder packet 5 sevelamer carbonate 800 mg tab 3 QL (270 per 30 days) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/ MINERALOCORTICOIDS A-HYDROCORT 2 B/D PA ALA-CORT 2 ALA-SCALP 4 ST alclometasone dipropionate 2 amcinonide (0.1% ointment, 0.1% lotion, 0.1% 3 cream) ANALPRAM HC (1% CREAM, 2.5%-1% 2 LOTION) APEXICON E 4 ARISTOSPAN 4 B/D PA betamethasone dipropionate (aug 0.05% lot, 2 aug 0.05% oin, 0.05% oint, aug 0.05% crm, aug 0.05% gel, 0.05% crm, 0.05% lot) betamethasone valer 0.12% foam 3 betamethasone valerate (va 0.1% cream, va 2 0.1% lotion, valer 0.1% ointm) CAPEX SHAMPOO 4 ST CELESTONE 4 clobetasol emollient 0.05% crm 2 clobetasol emollnt 0.05% foam 4 clobetasol emulsion 4 clobetasol propionate (0.05% ointment, 0.05% 2 cream, 0.05% topical lotn, 0.05% solution) clobetasol propionate (prop 0.05% foam, prop % spray, 0.05% gel, 0.05% shampoo) clocortolone pivalate 2 CORDRAN (4 CM TAPE LARGE, 4 CM 4 ST TAPE SMALL) CORTIFOAM 4 cortisone acetate 2 B/D PA DELTASONE 2 B/D PA DEPO-MEDROL 20 MG/ML VIAL 4 B/D PA DESONATE 4 ST 60

69 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) desonide (0.05% ointment, 0.05% lotion, % cream) desoximetasone 3 dexamethasone (0.5 mg/5 ml elx, 0.5 mg/5 ml 2 B/D PA liq, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) DEXAMETHASONE INTENSOL 2 dexamethasone sodium phosphate (4 mg/ml 2 B/D PA vial, 4 mg/ml syringe, 10 mg/ml vial, 20 mg/5 ml vial, 100 mg/10 ml vl, 120 mg/30 ml vl) diflorasone diacetate 4 EMFLAZA (22.75 MG/ML ORAL SUSP, 5 PA 30 MG TABLET, 36 MG TABLET) EMFLAZA 18 MG TABLET 5 PA, QL (30 per 30 days) EMFLAZA 6 MG TABLET 5 PA, QL (60 per 30 days) fludrocortisone acetate 2 fluocinolone acetonide (0.01% solution, 0.01% 2 scalp oil, 0.01% body oil, 0.01% cream, 0.025% ointment, 0.025% cream) fluocinonide (0.05% solution, 0.05% gel, % cream, 0.05% ointment) fluocinonide 0.1% cream 3 fluocinonide-e 2 flurandrenolide (0.05% lotion, 0.05% cream, % ointment) fluticasone prop 0.05% lotion 3 fluticasone propionate (0.005% oint, 0.05% 2 cream) H.P. ACTHAR 5 PA halobetasol propionate 2 HALOG 4 ST hydrocortisone (1% ointment, 1% cream, 1% 2 absorbase, 2.5% ointment, 2.5% lotion, 2.5% cream) hydrocortisone (5 mg tablet, 10 mg tablet, 20 2 B/D PA mg tablet) hydrocortisone butyrate (hydrocort buty 0.1% 2 lipid crm, hydrocort buty 0.1% lipo cream, hydrocortisone buty 0.1% cream, hydrocortisone butyr 0.1% oint, hydrocortisone butyr 0.1% soln) hydrocortisone valerate 2 61

70 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) KENALOG MG/GRAM SPRAY 4 ST KENALOG-10 4 B/D PA KENALOG-40 4 B/D PA LOCOID 0.1% LOTION 4 ST LOCORT 4 B/D PA MEDROL 2 MG TABLET 4 B/D PA methylprednisolone (4 mg dosepk, 8 mg tab, 2 B/D PA 16 mg tab, 32 mg tab) methylprednisolone acetate 2 B/D PA methylprednisolone sodium succ (1 gm vl, 40 2 B/D PA mg vl, 125 mg) MICORT-HC 4 mometasone furoate (0.1% soln, 0.1% oint, 2 0.1% cream) NOLIX 3 PANDEL 4 ST PRAMOSONE (1% LOTION, 1%-1% 2 CREAM, 2.5%-1% LOTION) prednicarbate 2 prednisolone 2 B/D PA prednisolone sodium phos odt 2 prednisolone sodium phosphate (10 mg/5 ml 4 B/D PA soln, 20 mg/5 ml soln) prednisolone sodium phosphate (5 mg/5 ml 2 B/D PA soln, 15 mg/5 ml soln, sod ph 25 mg/5 ml) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg/5 2 B/D PA ml solution, 5 mg tablet, 5 mg tab dose pack, 10 mg tab dose pack, 10 mg tablet, 20 mg tablet, 50 mg tablet) PREDNISONE INTENSOL 2 B/D PA PROCTO-MED HC 2 PROCTO-PAK 2 PROCTOFOAM-HC 4 PROCTOSOL-HC 2 PROCTOZONE-HC 2 SERNIVO 5 ST SOLU-CORTEF 4 B/D PA SOLU-MEDROL (1 GM VIAL, 40 MG 4 B/D PA VIAL, 125 MG VIAL, 500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) TOPICORT 0.25% SPRAY 4 ST triamcinolone mg/g topical spray 3 62

71 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) triamcinolone acetonide (0.025% oint, 0.025% 2 cream, 0.025% lotion, 0.1% cream, 0.1% ointment, 0.1% lotion, 0.5% ointment, 0.5% cream) triamcinolone acetonide (40mg/ml vl, 2 B/D PA 50mg/5ml vl) TRIANEX 2 TRIDERM 2 U-CORT 2 ZODEX 4 B/D PA ZONACORT 4 B/D PA HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) chorionic gonadotropin 4 PA DDAVP (4 MCG/ML AMPUL, 4 MCG/ML 5 VIAL) desmopressin acetate (0.01% spray, 0.01% 3 solution, 0.1 mg/ml sol, ac 4 mcg/ml ampul, ac 4 mcg/ml vial, 10 mcg/0.1 ml spr, 40 mcg/10 ml vial) desmopressin acetate (0.1 mg tb, 0.2 mg tb) 2 EGRIFTA 5 PA GENOTROPIN (MINIQUICK 0.4 MG, 5 PA MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE) GENOTROPIN MINIQUICK 0.2 MG 3 PA HUMATROPE 5 PA INCRELEX 5 PA NORDITROPIN FLEXPRO 5 PA NORDITROPIN NORDIFLEX 5 PA NOVAREL (5,000 UNIT VIAL, 10,000 4 PA UNITS VIAL) NUTROPIN AQ 5 PA NUTROPIN AQ NUSPIN 5 PA OMNITROPE (5 MG/1.5 ML CRTG, PA MG VIAL, 10 MG/1.5 ML CRTG) PREGNYL 4 PA SAIZEN 5 PA SAIZEN-SAIZENPREP 5 PA 63

72 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) (CONTINUED) SEROSTIM 5 PA STIMATE 4 ZOMACTON 10 MG VIAL 5 PA ZOMACTON 5 MG VIAL 4 PA ZORBTIVE 5 PA HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 5 oxandrolone 10 mg tablet 5 oxandrolone 2.5 mg tablet 3 ANDROGENS ANDRODERM 3 PA, QL (30 per 30 days) ANDROGEL (1%(2.5G) GEL PACKET, 3 PA, QL (300 per 30 days) 1%(5G) GEL PACKET) ANDROGEL (1.62% GEL PUMP, 3 PA, QL (150 per 30 days) 1.62%(2.5G) GEL PCKT) ANDROGEL 1.62%(1.25G) GEL PCKT 3 PA, QL (38 per 30 days) ANDROXY 2 AXIRON 4 PA, QL (180 per 30 days) danazol 2 FORTESTA 4 PA, QL (120 per 30 days) METHITEST 4 methyltestosterone 3 NATESTO 4 PA STRIANT 4 PA, QL (60 per 30 days) TESTIM 4 PA, QL (300 per 30 days) testosterone (12.5 mg/1.25 gram, 25 mg/2.5 4 PA, QL (300 per 30 days) gm pkt, 50 mg/5 gram pkt) testosterone 10 mg gel pump 4 PA, QL (120 per 30 days) testosterone 30 mg/1.5 ml pump 4 PA, QL (180 per 30 days) testosterone 50 mg/5 gram gel 4 PA, QL (300 per 30 days) testosterone cypionate 2 testosterone enanthate 2 VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 4 PA, QL (300 per 30 days) GEL) VOGELXO 50 MG/5 GRAM GEL PACKT 4 PA, QL (300 per 30 days) ESTROGENS ALORA 4 QL (8 per 28 days) ALTAVERA 2 ALYACEN 2 64

73 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) AMABELZ 2 AMETHIA 2 AMETHIA LO 2 AMETHYST 2 ANGELIQ 4 APRI 2 ARANELLE 2 ASHLYNA 2 AUBRA 2 AVIANE 2 AZURETTE 2 BALZIVA 2 BEKYREE 2 BEYAZ 4 BLISOVI 24 FE 2 BLISOVI FE (1-20 TABLET, TABLET) BRIELLYN 2 CAMRESE 2 CAMRESE LO 2 CAZIANT 2 CHATEAL 2 CLIMARA 4 QL (4 per 28 days) CLIMARA PRO 4 QL (4 per 28 days) COMBIPATCH 4 QL (8 per 28 days) CRYSELLE 2 CYCLAFEM 2 CYRED 2 DASETTA 2 DAYSEE 2 DELESTROGEN 10 MG/ML VIAL 4 DELYLA 2 DEPO-ESTRADIOL 4 desogestr-eth estrad eth estra 2 desogestrel-ethinyl estrad tab 2 DIVIGEL (0.25 MG GEL PACKET, MG GEL PACKET, 1 MG GEL PACKET) drospirenone-eth estra-levomef 4 drospirenone-ethinyl estradiol 2 DUAVEE 4 ELESTRIN 4 65

74 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) ELINEST 2 EMOQUETTE 2 ENJUVIA (0.3 MG TABLET, 0.45 MG 4 TABLET, 0.9 MG TABLET) ENPRESSE 2 ENSKYCE 2 ESTARYLLA 2 ESTRACE 0.01% CREAM 4 estradiol (0.5 mg tablet, 1 mg tablet, 2 mg 2 tablet, 10 mcg vaginal insrt) estradiol twice weekly 2 QL (8 per 28 days) estradiol valerate 2 estradiol weekly 2 QL (4 per 28 days) estradiol-norethindrone acetat 2 ESTRING 4 QL (1 per 90 days) estropipate 2 ethynodiol-ethinyl estradiol 2 EVAMIST 4 FALMINA 2 FAYOSIM 4 FEMHRT 4 FEMRING 4 QL (1 per 90 days) FEMYNOR 2 FYAVOLV 2 GENERESS FE 4 GIANVI 2 GILDAGIA 2 GILDESS (1 MG-20 MCG TABLET, MG-30 MCG TABLET) GILDESS 24 FE 2 GILDESS FE (1-20 TABLET, TABLET) INTROVALE 2 JEVANTIQUE LO 2 JINTELI 2 JOLESSA 2 JULEBER 2 JUNEL (1 MG-20 MCG TABLET, 1.5 MG MCG TABLET) JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET) 2 66

75 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) JUNEL FE 24 2 KAITLIB FE 2 KARIVA 2 KELNOR KIMIDESS 2 KURVELO 2 LARIN (1.5 MG-30 MCG TABLET, TABLET) LARIN 24 FE 2 LARIN FE (1-20 TABLET, TABLET) LARISSIA 2 LEENA 2 LESSINA 2 LEVONEST 2 levonorg 0.15mg-ee mcg 4 levonorg-eth estrad eth estrad ( , ) levonorgestrel-eth estradiol (estra mg, estrad mg, estrad ) LEVORA-28 2 LO LOESTRIN FE 4 LOMEDIA 24 FE 2 LOPREEZA 4 LORYNA 2 LOW-OGESTREL 2 LUTERA 2 MARLISSA 2 MENEST 4 MIBELAS 24 FE 2 MICROGESTIN ( TABLET, TAB) MICROGESTIN FE (1-20 TABLET, TAB) MIMVEY LO 2 MINASTRIN 24 FE 4 MONO-LINYAH 2 MONONESSA 2 MYZILRA 2 NATAZIA 4 NECON 2 67

76 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) NIKKI 2 noreth-estrad-fe (24)-75 2 norethin-eth estra-ferrous fum 2 norethindron-ethinyl estradiol 2 norgestimate-ethinyl estradiol 2 NORINYL NORINYL NORTREL 2 NUVARING 4 OCELLA 2 OGESTREL 2 ORSYTHIA 2 ORTHO TRI-CYCLEN LO 4 PHILITH 2 PIMTREA 2 PIRMELLA 2 PORTIA 2 PREFEST 4 PREMARIN (0.3 MG TABLET, 0.45 MG 3 TABLET, MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, 25 MG VIAL, VAGINAL CREAM-APPL) PREMPHASE 3 PREMPRO 3 PREVIFEM 2 QUARTETTE 4 QUASENSE 2 RAJANI 2 RECLIPSEN 2 RIVELSA 4 SAFYRAL 4 SETLAKIN 2 SPRINTEC 2 SRONYX 2 SYEDA 4 TARINA FE 2 TAYTULLA 4 TILIA FE 2 TRI-ESTARYLLA 2 TRI-LEGEST FE 2 TRI-LINYAH 2 68

77 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) TRI-LO-ESTARYLLA 2 TRI-LO-MARZIA 2 TRI-LO-SPRINTEC 2 TRI-PREVIFEM 2 TRI-SPRINTEC 2 TRINESSA 2 TRIVORA-28 2 VAGIFEM 4 VELIVET 2 VESTURA 2 VIENVA 2 VIORELE 2 VIVELLE-DOT 4 QL (8 per 28 days) VYFEMLA 2 WERA 2 WYMZYA FE 2 YUVAFEM 2 ZARAH 2 ZENCHENT 2 ZENCHENT FE 2 ZOVIA 1-35E 2 ZOVIA 1-50E 2 PROGESTERONE AGONISTS/ANTAGONISTS ELLA 3 PROGESTINS CAMILA 2 DEBLITANE 2 DEPO-SUBQ PROVERA ERRIN 2 HEATHER 2 hydroxyprogesterone caproate 4 JENCYCLA 2 JOLIVETTE 2 KYLEENA 4 levonorgestrel 2 LILETTA 4 medroxyprogesterone acetate (2.5 mg tab, 5 2 mg tab, 10 mg tab, 150 mg/ml) megestrol 625 mg/5 ml susp 3 megestrol acetate (20 mg tablet, 40 mg tablet, acet 40 mg/ml susp, acet 400 mg/10 ml) 2 69

78 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) MIRENA 4 NORA-BE 2 norethindrone 2 norethindrone ac (lupaneta) 2 norethindrone acetate 2 NORLYROC 2 progesterone (100 mg capsule, 200 mg 2 capsule) SHAROBEL 2 SKYLA 4 SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS raloxifene hcl 3 QL (30 per 30 days) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) CYTOMEL 4 levothyroxine 100 mcg vial 2 levothyroxine sodium (25 mcg tablet, 50 mcg 1 tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) LEVOXYL 2 liothyronine sodium (5 mcg tab, 10 mcg/ml vl, 2 25 mcg tab, 50 mcg tab) SYNTHROID 3 THYROLAR-1 4 THYROLAR-1/2 4 THYROLAR-1/4 4 THYROLAR-2 4 THYROLAR-3 4 UNITHROID 1 HORMONAL AGENTS, SUPPRESSANT (ADRENAL) HORMONAL AGENTS, SUPPRESSANT (ADRENAL) LYSODREN 3 70

79 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) SENSIPAR (60 MG TABLET, 90 MG 5 TABLET) SENSIPAR 30 MG TABLET 3 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) bromocriptine mesylate 2 cabergoline 2 ELIGARD 4 PA leuprolide acetate (2wk 1 mg/0.2 ml kit, 2wk 2 PA 14 mg/2.8 ml kt) LUPRON DEPOT 5 PA LUPRON DEPOT (LUPANETA) 5 PA LUPRON DEPOT-PED 5 PA octreotide acetate (acet 0.05 mg/ml vl, acet 50 3 mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml vl, acet 100 mcg/ml syr, acet 200 mcg/ml vl, 1,000 mcg/5 ml vial) octreotide acetate (acet 500 mcg/ml amp, acet mcg/ml syr, acet 500 mcg/ml vl, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial) SANDOSTATIN (0.1 MG/ML AMPUL, MG/ML VIAL, 0.5 MG/ML AMPUL, 1 MG/ML VIAL) SANDOSTATIN LAR 5 SANDOSTATIN LAR DEPOT 5 SIGNIFOR LAR 5 PA, QL (1 per 28 days) SOMATULINE DEPOT (60 MG/0.2 ML, 5 PA 90 MG/0.3 ML) SOMATULINE DEPOT 120 MG/0.5 ML 5 PA SOMAVERT 5 PA SYNAREL 5 TRELSTAR 5 PA TRIPTODUR 5 PA HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/ MODIFIERS) ESTROGENS XULANE 2 71

80 HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole 2 propylthiouracil 2 IMMUNOLOGICAL AGENTS ANGIOEDEMA (HAE) AGENTS BERINERT 500 UNIT KIT 5 PA CINRYZE 5 PA FIRAZYR 5 PA HAEGARDA 5 PA, QL (16 per 28 days) RUCONEST 5 PA IMMUNE SUPPRESSANTS ACTEMRA (162 MG/0.9 ML SYRINGE, 5 PA 200 MG/10 ML VIAL) ASTAGRAF XL 4 B/D PA AZASAN 4 B/D PA azathioprine 2 B/D PA azathioprine sodium 4 B/D PA BENLYSTA (120 MG VIAL, 400 MG 5 PA VIAL) BENLYSTA (200 MG/ML SYRINGE, PA, QL (4 per 28 days) MG/ML AUTOINJECT) CELLCEPT (200 MG/ML ORAL SUSP, B/D PA MG CAPSULE, 500 MG TABLET) CELLCEPT 500 MG VIAL 4 B/D PA CIMZIA (200 MG/ML SYRINGE KIT, PA, QL (6 per 28 days) MG VIAL KIT) CIMZIA 200 MG/ML STARTER KIT 5 PA, QL (6 per 28 days) cyclosporine (25 mg capsule, 50 mg/ml ampul, 2 B/D PA 100 mg capsule, 100 mg/ml soln) cyclosporine modified 2 B/D PA ENBREL (25 MG/0.5 ML SYRINGE, 50 5 PA, QL (8 per 28 days) MG/ML SYRINGE, 50 MG/ML SURECLICK SYR) ENBREL 25 MG KIT 5 PA, QL (16 per 28 days) ENVARSUS XR 4 B/D PA GENGRAF (25 MG CAPSULE, 50 MG 2 B/D PA CAPSULE, 100 MG/ML SOLUTION, 100 MG CAPSULE) HUMIRA (20 MG/0.4 ML SYRINGE, 40 5 PA, QL (6 per 28 days) MG/0.8 ML SYRINGE) HUMIRA 10 MG/0.2 ML SYRINGE 5 PA, QL (2 per 28 days) HUMIRA PEDIATRIC CROHN'S 5 PA, QL (6 per 28 days) HUMIRA PEN 5 PA, QL (6 per 28 days) 72

81 IMMUNOLOGICAL AGENTS (CONTINUED) HUMIRA PEN CROHN-UC-HS 5 PA, QL (6 per 28 days) STARTER HUMIRA PEN PSORIASIS-UVEITIS 5 PA, QL (6 per 28 days) INFLECTRA 5 PA methotrexate (1 gm vial, 50 mg/2 ml vial, B/D PA mg/10 ml vial) methotrexate 2.5 mg tablet 1 B/D PA methotrexate sodium 2 B/D PA mycophenolate 200 mg/ml susp 3 B/D PA mycophenolate 500 mg vial 4 B/D PA mycophenolate mofetil (250 mg capsule, B/D PA mg tablet) mycophenolic acid 4 B/D PA MYFORTIC 180 MG TABLET 4 B/D PA MYFORTIC 360 MG TABLET 5 B/D PA NEORAL (25 MG GELATIN CAPSULE, 4 B/D PA 100 MG/ML SOLUTION, 100 MG GELATIN CAPSULE) NULOJIX 5 PA ORENCIA (125 MG/ML SYRINGE, PA MG VIAL) ORENCIA 50 MG/0.4 ML SYRINGE 5 PA, QL (1.6 per 28 days) ORENCIA 87.5 MG/0.7 ML SYRINGE 5 PA, QL (2.8 per 28 days) ORENCIA CLICKJECT 5 PA, QL (4 per 28 days) PROGRAF (0.5 MG CAPSULE, 1 MG 4 B/D PA CAPSULE, 5 MG CAPSULE, 5 MG/ML AMPULE) PROLIA 4 PA RAPAMUNE (1 MG/ML ORAL SOLN, 1 5 B/D PA MG TABLET, 2 MG TABLET) RAPAMUNE 0.5 MG TABLET 4 B/D PA REMICADE 5 PA RENFLEXIS 5 PA SANDIMMUNE (25 MG CAPSULE, 50 4 B/D PA MG/ML AMPUL, 100 MG CAPSULE, 100 MG/ML SOLN) SIMPONI 5 PA, QL (1 per 28 days) SIMPONI ARIA 5 PA sirolimus 2 B/D PA SOLIRIS 5 PA STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE, 130 MG/26 ML VIAL) 5 PA 73

82 IMMUNOLOGICAL AGENTS (CONTINUED) tacrolimus (0.5 mg capsule, 1 mg capsule, 5 2 B/D PA mg capsule) TALTZ AUTOINJECTOR 5 PA, QL (4 per 28 days) TALTZ AUTOINJECTOR (2 PACK) 5 PA, QL (4 per 28 days) TALTZ AUTOINJECTOR (3 PACK) 5 PA, QL (4 per 28 days) TALTZ SYRINGE 5 PA, QL (4 per 28 days) TALTZ SYRINGE (2 PACK) 5 PA, QL (4 per 28 days) TALTZ SYRINGE (3 PACK) 5 PA, QL (4 per 28 days) TREMFYA 5 PA, QL (3 per 56 days) XATMEP 5 B/D PA XELJANZ 5 PA, QL (60 per 30 days) XELJANZ XR 5 PA, QL (30 per 30 days) ZORTRESS (0.5 MG TABLET, 0.75 MG 5 B/D PA TABLET) ZORTRESS 0.25 MG TABLET 4 B/D PA IMMUNIZING AGENTS, PASSIVE ATGAM 5 PA BIVIGAM 5 PA CARIMUNE NF NANOFILTERED (6 5 PA GM VIAL, 12 GM VIAL) CUVITRU 5 PA FLEBOGAMMA DIF 10% VIAL 5 PA FLEBOGAMMA DIF 5% VIAL 5 PA GAMMAGARD LIQUID 5 PA GAMMAGARD S-D 5 PA GAMMAKED (1 GRAM/10 ML VIAL, PA GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL) GAMMAPLEX 5 PA GAMUNEX-C (1 GRAM/10 ML VIAL, PA GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL) HIZENTRA 5 PA HYQVIA 5 PA OCTAGAM 5 PA PRIVIGEN 5 PA THYMOGLOBULIN 5 PA IMMUNOMODULATORS ACTIMMUNE 5 ARCALYST 5 PA 74

83 IMMUNOLOGICAL AGENTS (CONTINUED) DUPIXENT 5 PA, QL (8 per 28 days) ILARIS (150 MG/ML VIAL, 180 MG 5 VIAL) KINERET 5 PA leflunomide 2 OTEZLA (28 DAY STARTER PACK, 30 5 PA, QL (60 per 30 days) MG TABLET) OTEZLA STARTER PACK 5 PA, QL (60 per 30 days) RIDAURA 5 SIMULECT 5 VACCINES ACTHIB 4 ADACEL TDAP 4 bcg (tice strain) 4 bcg vaccine (tice strain) 4 BEXSERO 4 BOOSTRIX TDAP 4 CERVARIX 4 DAPTACEL DTAP 4 diphtheria-tetanus toxoids-ped 4 ENGERIX-B ADULT 4 B/D PA ENGERIX-B PEDIATRIC-ADOLESCENT 4 B/D PA GARDASIL 4 GARDASIL 9 4 HAVRIX 4 HIBERIX 4 IMOVAX RABIES VACCINE 4 B/D PA INFANRIX DTAP 4 IPOL 4 IXIARO 4 KINRIX 4 M-M-R II VACCINE 4 MENACTRA 4 MENHIBRIX 4 MENOMUNE-A-C-Y-W MENVEO A-C-Y-W-135-DIP 4 PEDIARIX 4 PEDVAXHIB 4 PENTACEL 4 PENTACEL ACTHIB COMPONENT 4 PROQUAD 4 QUADRACEL DTAP-IPV 4 75

84 IMMUNOLOGICAL AGENTS (CONTINUED) RABAVERT 4 B/D PA RECOMBIVAX HB 4 B/D PA ROTARIX 4 ROTATEQ 4 TENIVAC 4 tetanus diphtheria toxoids 4 THERACYS 4 TRUMENBA 4 TWINRIX 4 TYPHIM VI 4 VAQTA 4 VARIVAX VACCINE 4 VARIZIG 125 UNIT/1.2 ML VIAL 3 YF-VAX 4 ZOSTAVAX 3 PA INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES ASACOL HD 3 balsalazide disodium 2 CANASA 4 DELZICOL 3 DIPENTUM 5 GIAZO 5 LIALDA 3 QL (120 per 30 days) mesalamine (4 gm/60 ml enema, 4 gm/60 ml 2 kit) mesalamine 800 mg dr tablet 4 mesalamine dr 1.2 gm tablet 2 QL (120 per 30 days) PENTASA 3 ROWASA 5 SFROWASA 5 GLUCOCORTICOIDS budesonide ec 5 COLOCORT 2 CORTENEMA 4 ENTOCORT EC 5 hydrocortisone 100 mg/60 ml 2 methylprednisolone 4 mg tablet 2 B/D PA UCERIS 2 MG RECTAL FOAM 4 PA UCERIS 9 MG ER TABLET 5 PA, QL (30 per 30 days) SULFONAMIDES sulfasalazine 2 76

85 INFLAMMATORY BOWEL DISEASE AGENTS (CONTINUED) sulfasalazine dr 2 METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS alendronate sod 70 mg/75 ml 2 QL (300 per 28 days) alendronate sodium (35 mg tab, 70 mg tab) 1 QL (4 per 28 days) alendronate sodium (5 mg tablet, 10 mg tab, 2 QL (30 per 30 days) 40 mg tab) BONIVA 3 MG/3 ML SYRINGE 4 calcitonin-salmon 2 calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 2 mcg/ml ampul, 1 mcg/ml solution) doxercalciferol (0.5 mcg cap, 1 mcg capsule, mcg cap, 4 mcg/2 ml vl, 4 mcg/2 ml amp) etidronate disodium 2 FORTEO 5 PA, QL (3 per 28 days) FORTICAL 2 HECTOROL (0.5 MCG CAPSULE, 1 MCG 4 CAPSULE, 2 MCG/ML VIAL, 2.5 MCG CAPSULE, 4 MCG/2 ML VIAL) ibandronate sodium (3 mg/3 ml vial, 3 mg/3 ml 2 syringe, sodium 150 mg tab) MIACALCIN (200 UNIT/ML VIAL, UNIT/2 ML VIAL) NATPARA 5 PA, QL (30 per 30 days) pamidronate disodium (disod 30 mg vial, 30 2 mg/10 ml vial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90 mg vial) paricalcitol (1 mcg capsule, 2 mcg capsule, 4 2 mcg capsule) paricalcitol (2 mcg/ml vial, 5 mcg/ml vial, 10 4 mcg/2 ml vial) RAYALDEE 5 QL (60 per 30 days) risedronate sodium (5 mg tablet, 30 mg tab) 2 QL (30 per 30 days) risedronate sodium 150 mg tab 2 QL (1 per 28 days) risedronate sodium 35 mg tab 2 QL (4 per 28 days) risedronate sodium dr 2 QL (4 per 28 days) ROCALTROL (0.25 MCG CAPSULE, MCG CAPSULE, 1 MCG/ML ORAL SOLN) TYMLOS 5 PA, QL (2 per 30 days) XGEVA 5 PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE, 2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL) 4 77

86 METABOLIC BONE DISEASE AGENTS (CONTINUED) zoledronic acid (4 mg/5 ml vial, 4 mg vial, 5 4 mg/100 ml) ZOMETA (4 MG/100 ML INJECTION, 4 5 MG/5 ML VIAL) MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS alcohol pads 4 amifostine 5 aminocaproic acid (500 mg tab, 1,000 mg tab) 4 autopen 4 BOTOX 4 PA CARNITOR 1 GM/5 ML VIAL 4 CHENODAL 5 clomiphene citrate 4 PA, QL (30 per 30 days) CUROSURF 4 CYTOGAM 4 deferoxamine mesylate 2 DESFERAL 4 DESFERAL MESYLATE 4 dextrose in lactated ringers 2 dextrose in water 2 ENDARI 5 PA, QL (180 per 30 days) EXONDYS 51 5 PA fomepizole 5 gauze pads 2 x 2 4 GRASTEK 4 humapen luxura hd 4 insulin pen needle 4 insulin pen needle, safety 4 insulin syringe 4 insulin syringe (bd syringe 1 ml, syringe) 4 insulin syringe u INTRALIPID 4 B/D PA KALBITOR 5 PA KEVEYIS 5 PA, QL (120 per 30 days) KORLYM 5 PA, QL (120 per 30 days) levocarnitine (1 g/10 ml soln, 200 mg/ml vial, mg tablet) methylergonovine 0.2 mg tablet 4 METOPIRONE 5 PA MYALEPT 5 PA novopen echo 4 78

87 MISCELLANEOUS THERAPEUTIC AGENTS (CONTINUED) NUTRILIPID 4 B/D PA ORALAIR (300 IR SUBLINGUAL TAB, IR ADULT SAMPLE KT, 300 IR STARTER PACK) RADICAVA 5 PA RAGWITEK 4 SIGNIFOR 5 PA SMOFLIPID 4 B/D PA sterile water for irrigation 2 SYNAGIS 5 VELTASSA 4 QL (30 per 30 days) vgo 20 4 vgo 30 4 vgo 40 4 XERMELO 5 PA, QL (90 per 30 days) OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER ALCAINE 4 atropine 1% eye drops 2 CYSTARAN 5 EYLEA 5 PA gentamicin 0.3% eye ointment 2 JETREA 1.25 MG/ML VIAL 5 PA LACRISERT 4 LUCENTIS 5 PA MACUGEN 5 PA proparacaine hcl 2 RESTASIS 3 RESTASIS MULTIDOSE 3 sulfacetamide 10% eye ointment 2 OPHTHALMIC ANTI-ALLERGY AGENTS ALOCRIL 4 ALOMIDE 4 azelastine hcl 0.05% drops 2 BEPREVE 4 cromolyn 4% eye drops 2 EMADINE 4 epinastine hcl 2 olopatadine hcl 0.1% eye drops 2 olopatadine hcl 0.2% eye drop 3 PATADAY 4 OPHTHALMIC ANTI-INFLAMMATORIES ACUVAIL 4 79

88 OPHTHALMIC AGENTS (CONTINUED) ALREX 4 BLEPHAMIDE 4 BLEPHAMIDE S.O.P. 4 bromfenac sodium 2 CORTISPORIN OINTMENT 4 dexamethasone 0.1% eye drop 2 diclofenac 0.1% eye drops 2 DUREZOL 3 FLAREX 4 fluorometholone 2 flurbiprofen sodium 2 FML FORTE 4 FML S.O.P. 4 ILEVRO 3 ketorolac tromethamine (0.4% solution, 0.5% 2 solution) LOTEMAX (0.5% OPHTHALMIC GEL, 3 0.5% EYE OINTMENT, 0.5% EYE DROPS) MAXIDEX 4 neomycin-polymyxin-dexameth (neomycpolym-dexamet 2 ointm, neomyc-polym- dexameth drop) NEVANAC 3 PRED MILD 4 PRED-G (1% DROPS, S.O.P. OINTMENT) 4 prednisolone acetate 2 prednisolone sod 1% eye drop 2 sulfacetamide-prednisolone 2 TOBRADEX EYE OINTMENT 4 TOBRADEX ST 4 tobramycin-dexamethasone 2 VEXOL 4 ZYLET 4 OPHTHALMIC ANTIGLAUCOMA AGENTS acetazolamide 2 ALPHAGAN P 0.1% DROPS 4 apraclonidine hcl 2 AZOPT 4 betaxolol hcl 0.5% eye drop 2 BETIMOL 4 BETOPTIC S 4 80

89 OPHTHALMIC AGENTS (CONTINUED) brimonidine tartrate 2 carteolol hcl 1 COMBIGAN 4 COSOPT PF 4 QL (60 per 30 days) dorzolamide hcl 2 QL (10 per 25 days) dorzolamide-timolol 2 QL (10 per 25 days) IOPIDINE 1% EYE DROPS 4 ISTALOL 4 levobunolol hcl 1 metipranolol 2 PHOSPHOLINE IODIDE 4 pilocarpine hcl (1% drops, 2% drops, 4% 2 drops) SIMBRINZA 4 timolol 0.25% eye drops 1 timolol 0.25% gel-solution 2 timolol 0.5% eye drops 1 timolol 0.5% gel-solution 2 TIMOPTIC 4 TIMOPTIC OCUDOSE 4 OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost 0.03% eye drops 2 QL (7.5 per 25 days) latanoprost 1 QL (2.5 per 25 days) LUMIGAN 3 QL (7.5 per 25 days) TRAVATAN Z 3 QL (5 per 25 days) travoprost 2 QL (5 per 25 days) ZIOPTAN 4 QL (30 per 30 days) OTIC AGENTS OTIC AGENTS ACETASOL HC 2 acetic acid 2% ear solution 2 acetic acid-aluminum 2 CIPRO HC 4 CIPRODEX 4 COLY-MYCIN S 4 fluocinolone acetonide oil 2 hydrocortisone-acetic acid 3 neomycin-polymyxin-hc ear susp 2 neomycin-polymyxin-hydrocort 2 OTOVEL 4 QL (28 per 7 days) 81

90 RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ADVAIR DISKUS 3 QL (60 per 30 days) ADVAIR HFA 3 QL (12 per 30 days) ARNUITY ELLIPTA 3 QL (30 per 30 days) ASMANEX (110 MCG #7, 220 MCG #14) 3 QL (1 per 30 days) ASMANEX (TWISTHALER 110 MCG 3 QL (1 per 30 days) #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120) ASMANEX HFA 3 QL (13 per 30 days) BREO ELLIPTA 3 QL (60 per 30 days) budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml 3 B/D PA, QL (120 per 30 days) susp, 1 mg/2 ml inh susp) budesonide 32 mcg nasal spray 2 QL (17.2 per 30 days) DULERA 3 QL (13 per 30 days) FLOVENT 250 MCG DISKUS 3 QL (240 per 30 days) FLOVENT DISKUS (50 MCG, 100 MCG) 3 QL (60 per 30 days) FLOVENT HFA 3 QL (24 per 30 days) flunisolide 2 QL (50 per 30 days) fluticasone prop 50 mcg spray 2 QL (16 per 30 days) mometasone furoate 50 mcg spry 2 QL (34 per 30 days) PULMICORT RESPULE 4 B/D PA, QL (120 per 30 days) QVAR 3 QL (17.4 per 30 days) SYMBICORT 3 QL (11 per 30 days) triamcinolone 55 mcg nasal spr 2 QL (16.5 per 25 days) ANTIHISTAMINES ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) azelastine hcl (0.1% (137 mcg) spry, 0.15% 2 QL (30 per 25 days) nasal spray) clemastine fum 2.68 mg tab 2 cyproheptadine hcl (2 mg/5 ml syrup, 4 mg 2 tablet, 4 mg/10 ml syrp) desloratadine 2 QL (30 per 30 days) diphenhydramine 12.5 mg/5 ml 2 diphenhydramine 50 mg/ml syrng 2 diphenhydramine 50 mg/ml vial 2 hydroxyzine hcl (hcl 10 mg tablet, 10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 25 mg tablet, 25 mg/ml vial, 50 mg/ml vial, hcl 50 mg tablet, 50 mg/25 ml syrup, 100 mg/2 ml vial, 500 mg/10 ml vial) levocetirizine 2.5 mg/5 ml sol 2 QL (300 per 30 days)

91 RESPIRATORY TRACT AGENTS (CONTINUED) levocetirizine 5 mg tablet 2 QL (60 per 30 days) olopatadine 665 mcg nasal spry 3 QL (31 per 30 days) promethazine vc 2 SEMPREX-D 4 ANTILEUKOTRIENES montelukast sod 4 mg granules 2 montelukast sodium (4 mg tab chew, 5 mg tab 2 QL (30 per 30 days) chew, 10 mg tablet) zafirlukast 2 QL (60 per 30 days) zileuton er 5 ST, QL (120 per 30 days) ZYFLO 5 ST, QL (120 per 30 days) ZYFLO CR 5 ST, QL (120 per 30 days) BRONCHODILATORS, ANTICHOLINERGIC ANORO ELLIPTA 3 QL (60 per 30 days) ATROVENT HFA 4 QL (25.8 per 30 days) COMBIVENT RESPIMAT 4 QL (8 per 30 days) ipratropium br 0.02% soln 2 B/D PA ipratropium bromide (0.03% spray, 0.06% 2 spray) ipratropium-albuterol 2 B/D PA SPIRIVA 3 QL (30 per 30 days) SPIRIVA RESPIMAT 3 QL (4 per 30 days) STIOLTO RESPIMAT 3 QL (4 per 30 days) TUDORZA PRESSAIR 3 QL (1 per 30 days) BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) aminophylline 2 ELIXOPHYLLIN 4 THEO-24 4 theophylline (er 400 mg tablet, er 600 mg 2 tablet) theophylline anhydrous 2 BRONCHODILATORS, SYMPATHOMIMETIC albuterol sulfate (er 4 mg tab, er 8 mg tab) 2 albuterol sulfate (sul 0.63 mg/3 ml sol, sul B/D PA mg/3 ml sol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, 5 mg/ml solution, 15 mg/3 ml solution, 20 mg/4 ml solution) albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate 4 2 mg tab, sulfate 4 mg tab) BROVANA 4 B/D PA, QL (120 per 30 days) epinephrine 0.15 mg auto-injct 3 QL (2 per 30 days) epinephrine 0.3 mg auto-inject 3 QL (2 per 30 days) 83

92 RESPIRATORY TRACT AGENTS (CONTINUED) EPIPEN 3 QL (2 per 30 days) EPIPEN 2-PAK 3 QL (2 per 30 days) EPIPEN JR 2-PAK 3 QL (2 per 30 days) FORADIL 3 QL (60 per 30 days) ISUPREL 4 levalbuterol concentrate 3 B/D PA levalbuterol hcl 3 B/D PA levalbuterol tartrate hfa 4 QL (30 per 30 days) metaproterenol sulfate (10 mg/5 ml syr, 10 mg 2 tablet, 20 mg tablet) PERFOROMIST 4 B/D PA, QL (120 per 30 days) PROAIR HFA 3 QL (17 per 30 days) PROAIR RESPICLICK 3 QL (2 per 30 days) SEREVENT DISKUS 3 QL (60 per 30 days) STRIVERDI RESPIMAT 4 QL (5 per 30 days) terbutaline sulfate (sulf 1 mg/ml vial, sulfate mg tab, sulfate 5 mg tab) UTIBRON NEOHALER 4 QL (60 per 30 days) VENTOLIN HFA 3 QL (36 per 30 days) XOPENEX 4 B/D PA XOPENEX CONCENTRATE 4 B/D PA CYSTIC FIBROSIS KALYDECO 5 PA, QL (60 per 30 days) ORKAMBI 5 PA, QL (120 per 30 days) MAST CELL STABILIZERS cromolyn 100 mg/5 ml oral conc 4 cromolyn 20 mg/2 ml neb soln 2 B/D PA PULMONARY ANTIHYPERTENSIVES ADCIRCA 5 PA, QL (60 per 30 days) ADEMPAS 5 PA, QL (90 per 30 days) epoprostenol sodium 2 PA FLOLAN 5 PA LETAIRIS 5 PA, QL (30 per 30 days) OPSUMIT 5 PA, QL (30 per 30 days) ORENITRAM ER (ER 0.25 MG TABLET, 5 PA, QL (90 per 30 days) ER 1 MG TABLET) ORENITRAM ER MG TABLET 4 PA, QL (90 per 30 days) ORENITRAM ER 2.5 MG TABLET 5 PA ORENITRAM ER 5 MG TABLET 5 PA, QL (90 per 30 days) REMODULIN 5 PA REVATIO 10 MG/12.5 ML VIAL 5 PA REVATIO 10 MG/ML ORAL SUSP 5 PA, QL (180 per 30 days) 84

93 RESPIRATORY TRACT AGENTS (CONTINUED) REVATIO 20 MG TABLET 5 PA, QL (90 per 30 days) sildenafil 10 mg/12.5 ml vial 5 PA sildenafil 20 mg tablet 2 PA, QL (90 per 30 days) TRACLEER 5 PA, QL (60 per 30 days) TYVASO 5 PA, QL (87 per 30 days) TYVASO INSTITUTIONAL START KIT 5 PA, QL (87 per 30 days) TYVASO REFILL KIT 5 PA, QL (87 per 30 days) TYVASO STARTER KIT 5 PA, QL (87 per 30 days) UPTRAVI (400 MCG TABLET, 600 MCG 5 PA, QL (60 per 30 days) TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) UPTRAVI 200 MCG TABLET 5 PA, QL (140 per 28 days) UPTRAVI TITRATION PACK 5 PA, QL (200 per 30 days) VELETRI 5 PA VENTAVIS 5 PA RESPIRATORY TRACT AGENTS, OTHER acetylcysteine 2 B/D PA ARALAST NP 5 PA CINQAIR 5 PA DALIRESP 4 QL (30 per 30 days) ESBRIET 267 MG CAPSULE 5 PA, QL (270 per 30 days) ESBRIET 267 MG TABLET 5 PA, QL (270 per 30 days) ESBRIET 801 MG TABLET 5 PA, QL (90 per 30 days) GLASSIA 5 PA NUCALA 5 PA OFEV 5 PA, QL (60 per 30 days) PROLASTIN C 5 PA PULMOZYME 5 PA XOLAIR 5 PA ZEMAIRA 5 PA SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS carisoprodol 4 QL (120 per 30 days) carisoprodol compound 4 carisoprodol compound-codeine 4 carisoprodol-aspirin 4 carisoprodol-aspirin-codeine 4 chlorzoxazone 250 mg tablet 5 chlorzoxazone 500 mg tablet 2 cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2 85

94 SKELETAL MUSCLE RELAXANTS (CONTINUED) METAXALL 4 metaxalone (400 mg tablet, 800 mg tablet) 4 methocarbamol (500 mg tablet, 750 mg tablet, 2 1,000 mg/10 ml) orphenadrine citrate (30 mg/ml vial, 60 mg/2 4 ml vial, 60 mg/2 ml ampule) orphenadrine er 100 mg tablet 2 SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS AMBIEN 4 PA, QL (30 per 30 days) AMBIEN CR 4 PA, QL (30 per 30 days) EDLUAR 4 PA, QL (30 per 30 days) eszopiclone 2 PA, QL (30 per 30 days) INTERMEZZO 4 PA, QL (30 per 30 days) LUNESTA 4 PA, QL (30 per 30 days) SONATA 4 PA, QL (30 per 30 days) zaleplon 2 PA, QL (30 per 30 days) zolpidem tartrate (1.75 mg tab sl, 3.5 mg 3 PA, QL (30 per 30 days) tablet sl) zolpidem tartrate (5 mg tablet, 10 mg tablet) 2 PA, QL (30 per 30 days) zolpidem tartrate er 2 PA, QL (30 per 30 days) ZOLPIMIST 4 PA, QL (8 per 30 days) SLEEP DISORDERS, OTHERS armodafinil 3 PA, QL (30 per 30 days) BELSOMRA 4 QL (30 per 30 days) HETLIOZ 5 PA, QL (30 per 30 days) modafinil 3 PA, QL (60 per 30 days) NUVIGIL 4 PA, QL (30 per 30 days) PROVIGIL 5 PA, QL (60 per 30 days) ROZEREM 4 SILENOR 4 temazepam (15 mg capsule, 30 mg capsule) 2 temazepam (7.5 mg capsule, 22.5 mg capsule) 3 XYREM 5 PA, QL (540 per 30 days) THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS CHEMET 4 CUPRIMINE 5 ST DEPEN 5 EXJADE 5 FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 5 86

95 THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES (CONTINUED) JADENU 5 JADENU SPRINKLE 5 KIONEX (15 GM/60 ML SUSPENSION, 2 POWDER) sodium polystyrene sulfonate (sod polystyren 2 sulf 15 g/60 ml, sodium polystyrene sulf powder, sps 15 gm/60 ml suspension, sps 30 gm/120 ml enema, sps 50 gm/200 ml enema) SPS 2 ELECTROLYTE/MINERAL REPLACEMENT AMINOSYN 4 B/D PA AMINOSYN II 4 B/D PA AMINOSYN II WITH ELECTROLYTES 4 B/D PA AMINOSYN M 4 B/D PA AMINOSYN WITH ELECTROLYTES 4 B/D PA AMINOSYN-HBC 4 B/D PA AMINOSYN-PF 4 B/D PA AMINOSYN-RF 4 B/D PA ammonium chloride 2 calcium gluconate 10% vial 2 CLINIMIX 4 B/D PA CLINIMIX E 4 B/D PA CLINISOL 4 B/D PA dextrose 10%-0.2% nacl 2 dextrose 10%-0.45% nacl 2 dextrose 2.5%-0.45% nacl 2 dextrose 5%-0.2% nacl 2 dextrose 5%-0.2% nacl-kcl 2 dextrose 5%-0.225% nacl 2 dextrose 5%-0.225% nacl-kcl 2 dextrose 5%-0.3% nacl 2 dextrose 5%-0.3% nacl-kcl 2 dextrose 5%-0.33% nacl 2 dextrose 5%-0.33% nacl-kcl 2 dextrose 5%-0.45% nacl 2 dextrose 5%-0.45% nacl-kcl 2 dextrose 5%-0.9% nacl 2 dextrose 5%-1/2ns-kcl 2 dextrose 5%-1/4ns-kcl (d5%-1/4ns-kcl 40 iv 2 sol, d5%-1/4ns-kcl 30 iv sol) dextrose 5%-electrolyte #48 2 dextrose 5%-ns-kcl 2 87

96 THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES (CONTINUED) dextrose 5%-potassium chloride 2 ESCAVITE 2 ESCAVITE LQ 2 FLORIVA (0.25 MG CHEW TABLET, MG CHEWABLE TABLET, 1 MG CHEWABLE TABLET) FREAMINE HBC 4 B/D PA FREAMINE III 4 B/D PA HEPATAMINE 2 B/D PA IONOSOL B WITH DEXTROSE 5% 4 IONOSOL MB-DEXTROSE 5% 4 ISOLYTE P WITH DEXTROSE 4 ISOLYTE S 4 KABIVEN 4 B/D PA kcl 20 meq in d5w-lact ringer 4 kcl 40 meq in d5w-lact ringer 2 kcl-ns 1,000 ml iv soln 2 KLOR-CON 10 2 KLOR-CON 8 2 KLOR-CON M10 2 KLOR-CON M15 2 KLOR-CON M20 2 KLOR-CON SPRINKLE 2 lactated ringers 2 magnesium chl 200 mg/ml vial 4 magnesium sulf 1 g/100 ml-d5w 4 magnesium sulfate (2 g/50 ml bag, 4 g/50 ml 4 bag, 4 g/100 ml bag, 20 g/500 ml bag, 40 g/1,000 ml) magnesium sulfate (50% syringe, 50% vial) 2 NEPHRAMINE 4 B/D PA NORMOSOL-M AND DEXTROSE 2 NORMOSOL-R 4 NORMOSOL-R AND DEXTROSE 2 NORMOSOL-R PH PERIKABIVEN 4 B/D PA PHYSIOLYTE 2 PHYSIOSOL 2 PLASMA-LYTE PLASMA-LYTE 56 IN DEXTROSE 4 PLASMA-LYTE A PH

97 THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES (CONTINUED) potassium citrate er 2 potassium cl 20 meq packet (qualitest and 4 virtus manufacturers only) potassium cl 20 meq-0.45% nacl 4 PREMASOL 4 B/D PA PROCALAMINE 4 B/D PA PROSOL 4 B/D PA RENACIDIN 4 ringers injection 2 ringers irrigation 2 sodium chloride (saline 0.45% soln-excel con, 2 saline 0.9% soln-excel cont, sodium chloride 0.45% soln, sodium chloride 0.45% solution, sodium chloride 0.9% 50 ml, sodium chloride 0.9% solution, sodium chloride 0.9% soln, sodium chloride 0.9% 1,000 ml, sodium chloride 0.9% irrig., sodium chloride 0.9% 100 ml, sodium chloride 0.9% 250 ml, sodium chloride 0.9% 500 ml, sodium chloride 3% iv soln, sodium chloride 4 meq/ml vl, sodium chloride 5% iv soln, sodium chloride 50 meq/20 ml, sodium chloride 100 meq/40 ml) SODIUM FLUORIDE ORAL TABLET 2 sodium lactate 2 SYPRINE 5 TIS-U-SOL PENTALYTE 2 TPN ELECTROLYTES 2 TRAVASOL 4 B/D PA TROPHAMINE 4 B/D PA VITAMINS PRENATAL VITAMIN ORAL TABLET 4 89

98 Index of Drugs 8 8-MOP 54 A A-HYDROCORT 60 abacavir 34 abacavir-lamivudine 35 abacavir-lamivudine-zidovudine 35 ABELCET 20 ABILIFY 32 ABILIFY DISCMELT 32 ABILIFY MAINTENA 32 ABRAXANE 25 ABSORICA 54 ABSTRAL 1 acamprosate calcium 4 ACANYA 54 acarbose 39 acebutolol hcl 46 acetaminophen-codeine 1 ACETASOL HC 81 acetazolamide 80 acetazolamide sodium 48 acetic acid 6,81 acetic acid-aluminum 81 acetylcysteine 85 acitretin 54 ACTEMRA 72 ACTHIB 75 ACTIMMUNE 74 ACTIQ 1 ACUVAIL 79 acyclovir 37,38 acyclovir sodium 38 ACZONE 54 ADACEL TDAP 75 ADAGEN 56 adapalene 54 adapalene-benzoyl peroxide 54 ADASUVE 32 ADCIRCA 84 adefovir dipivoxil 36 ADEMPAS 84 ADRIAMYCIN 25 ADRUCIL 25 ADVAIR DISKUS 82 ADVAIR HFA 82 AFEDITAB CR 46 AFINITOR 28 AFINITOR DISPERZ 28 AGGRENOX 43 AK-POLY-BAC 6 AKYNZEO 19 ALA-CORT 60 ALA-SCALP 60 ALBENZA 30 albuterol sulfate 83 ALCAINE 79 alclometasone dipropionate 60 alcohol pads 78 ALDURAZYME 56 ALECENSA 28 alendronate sodium 77 alfuzosin hcl er 59 ALIMTA 25 ALINIA 30 ALIQOPA 25 ALKERAN 23 allopurinol 21 almotriptan malate 22 ALOCRIL 79 alogliptin 39 alogliptin-metformin 39 alogliptin-pioglitazone 39 ALOMIDE 79 ALORA 64 alosetron hcl 57 ALOXI 19 ALPHAGAN P 80 alprazolam 38 alprazolam er alprazolam odt 38 alprazolam xr 38 ALREX 80 ALTAVERA 64 ALTOPREV 49 ALUNBRIG 25 ALYACEN 64 AMABELZ 65 amantadine 36 AMBIEN 86 AMBIEN CR 86 AMBISOME 20 amcinonide 60 AMETHIA 65 AMETHIA LO 65 AMETHYST 65 amifostine 78 amikacin sulfate 6 amiloride hcl 48 amiloride-hydrochlorothiazide 48 aminocaproic acid 78 aminophylline 83 AMINOSYN 87 AMINOSYN II 87 AMINOSYN II WITH ELECTROLYTES 87 AMINOSYN M 87 AMINOSYN WITH ELECTROLYTES 87 AMINOSYN-HBC 87 AMINOSYN-PF 87 AMINOSYN-RF 87 amiodarone hcl 45 amitriptyline hcl 18 amlodipine besylate 46 amlodipine besylate-benazepril 46 amlodipine-atorvastatin 46 amlodipine-olmesartan 46 amlodipine-valsartan 46 amlodipine-valsartan-hctz 46 ammonium chloride 87

99 ammonium lactate 54 AMNESTEEM 54 amoxapine 18 amoxicillin 10 amoxicillin-clavulanate pot er 10 amoxicillin-clavulanate potass 10 amphotericin b 20 ampicillin sodium 10 ampicillin trihydrate 10 ampicillin-sulbactam 10 AMPYRA 52 ANADROL anagrelide hcl 42 ANALPRAM HC 60 anastrozole 28 ANDRODERM 64 ANDROGEL 64 ANDROXY 64 ANGELIQ 65 ANORO ELLIPTA 83 ANZEMET 19 APEXICON E 60 APLENZIN 17 APOKYN 31 apraclonidine hcl 80 aprepitant 19 APRI 65 APTIOM 15 APTIVUS 35 ARALAST NP 85 ARANELLE 65 ARANESP 42 ARBINOXA 82 ARCALYST 74 aripiprazole 32 aripiprazole odt 32 ARISTADA 32 ARISTOSPAN 60 ARIXTRA 42 armodafinil 86 ARNUITY ELLIPTA 82 ARRANON 25 ARZERRA 29 asa-butalb-caffeine-codeine 2 ASACOL HD 76 ASCOMP WITH CODEINE 2 ASHLYNA 65 ASMANEX 82 ASMANEX HFA 82 aspirin-caffeine-dihydrocodein 2 aspirin-dipyridamole er 43 ASTAGRAF XL 72 atenolol 46 atenolol-chlorthalidone 46 ATGAM 74 atomoxetine hcl 51 atorvastatin calcium 49 atovaquone 30 atovaquone-proguanil hcl 30 ATRALIN 54 ATRIPLA 34 atropine sulfate 56,79 ATROVENT HFA 83 AUBAGIO 52 AUBRA 65 AUGMENTIN 10 AURYXIA 59 AUSTEDO 52 autopen 78 AVANDIA 39 AVASTIN 29 AVELOX IV 11 AVIANE 65 AVITA 54 AVONEX 52 AVONEX PEN 52 AXIRON 64 azacitidine 43 AZACTAM 9 AZACTAM-ISO-OSMOTIC DEXTROSE 10 AZASAN AZASITE 11 azathioprine 72 azathioprine sodium 72 azelastine hcl 79,82 AZELEX 54 AZILECT 31 azithromycin 11 AZOPT 80 AZOR 46 aztreonam 10 AZURETTE 65 B BACIIM 6 bacitracin 6 bacitracin-polymyxin 6 baclofen 34 balsalazide disodium 76 BALZIVA 65 BANZEL 13 BARACLUDE 36 BAVENCIO 29 BAXDELA 11 bcg (tice strain) 75 bcg vaccine (tice strain) 75 BEKYREE 65 BELBUCA 1 BELEODAQ 28 BELSOMRA 86 benazepril hcl 45 benazepril-hydrochlorothiazide 45 BENDEKA 23 BENICAR 44 BENICAR HCT 44 BENLYSTA 72 BENTYL 56 benztropine mesylate 31 BEPREVE 79 BERINERT 72 BESIVANCE 11 BESPONSA 25

100 betamethasone dipropionate 60 betamethasone valerate 60 BETASERON 53 betaxolol hcl 46,80 bethanechol chloride 59 BETHKIS 6 BETIMOL 80 BETOPTIC S 80 bexarotene 30 BEXSERO 75 BEYAZ 65 bicalutamide 24 BICILLIN C-R 10 BICILLIN L-A 10 BICNU 25 BIDIL 50 BILTRICIDE 30 bimatoprost 81 bisoprolol fumarate 46 bisoprolol-hydrochlorothiazide 46 BIVIGAM 74 BLEO 15K 25 bleomycin sulfate 25 BLEPHAMIDE 80 BLEPHAMIDE S.O.P. 80 BLINCYTO 25 BLISOVI 24 FE 65 BLISOVI FE 65 BONIVA 77 BOOSTRIX TDAP 75 BOSULIF 28 BOTOX 78 BREO ELLIPTA 82 BRIELLYN 65 BRILINTA 42 brimonidine tartrate 81 BRIVIACT 13 bromfenac sodium 80 bromocriptine mesylate 71 BROVANA 83 budesonide 82 budesonide ec 76 bumetanide 48 BUPHENYL 56 BUPRENEX 2 buprenorphine 1 buprenorphine hcl 2 buprenorphine-naloxone 4 BUPROBAN 5 bupropion hcl 17 bupropion hcl sr 5,17 bupropion xl 17 buspirone hcl 38 busulfan 25 BUSULFEX 25 butalb-acetaminoph-caff-codein 2 butalb-caff-acetaminoph-codein 2 butalbital compound-codeine 2 butalbital-acetaminophen 2 butalbital-acetaminophen-caffe 2 butalbital-aspirin-caffeine 2 butorphanol tartrate 2 BUTRANS 1 BYDUREON 39 BYDUREON PEN 39 BYETTA 39 BYSTOLIC 46 BYVALSON 46 C cabergoline 71 CABOMETYX 28 CAFERGOT 22 calcipotriene 54 calcipotriene-betamethasone dp 54 calcitonin-salmon 77 CALCITRENE 54 calcitriol 54,77 calcium acetate 59 calcium gluconate 87 CAMBIA 5 CAMILA CAMRESE 65 CAMRESE LO 65 CANASA 76 CANCIDAS 20 candesartan cilexetil 44 candesartanhydrochlorothiazid 44 CANTIL 56 CAPACET 2 CAPASTAT SULFATE 23 CAPEX SHAMPOO 60 CAPRELSA 25 captopril 45 captopril-hydrochlorothiazide 45 CARAC 54 CARAFATE 58 CARBAGLU 56 carbamazepine 15 carbamazepine er 15 carbidopa 31 carbidopa-levodopa 31 carbidopa-levodopa er 31 carbidopa-levodopaentacapone 31 carboplatin 25 CARDENE I.V. 46 CARDURA XL 44 CARIMUNE NF NANOFILTERED 74 carisoprodol 85 carisoprodol compound 85 carisoprodol compoundcodeine 85 carisoprodol-aspirin 85 carisoprodol-aspirin-codeine 85 CARNITOR 78 carteolol hcl 81 CARTIA XT 47 carvedilol 46 caspofungin acetate 20 CAYSTON 10

101 CAZIANT 65 cefaclor 8 cefaclor er 8 cefadroxil 8 cefazolin sodium 8 cefazolin sodium-dextrose 8 cefdinir 9 cefepime 9 cefepime hcl 9 cefepime-dextrose 9 cefixime 9 CEFOTAN 9 cefotaxime sodium 9 cefotetan 9 cefotetan & dextrose 9 cefoxitin 9 cefoxitin sodium 9 cefpodoxime proxetil 9 cefprozil 9 ceftazidime 9 ceftibuten 9 CEFTIN 9 ceftriaxone 9 cefuroxime 9 cefuroxime sodium 9 celecoxib 5 CELESTONE 60 CELLCEPT 72 CELONTIN 14 cephalexin 9 CERDELGA 56 CEREZYME 56 CERVARIX 75 CESAMET 19 cevimeline hcl 53 CHANTIX 5 CHATEAL 65 CHEMET 86 CHENODAL 78 chloramphenicol sod succinate 6 chlordiazepoxide hcl 38 chlordiazepoxide-amitriptyline 38 chlordiazepoxide/clidinium (oceanside manufacturer only) 57 chlorhexidine gluconate 53 chloroquine phosphate 30 chlorothiazide 48 chlorothiazide sodium 49 chlorpromazine hcl 32 chlorpropamide 39 chlorthalidone 49 chlorzoxazone 85 CHOLBAM 57 clindamycin phosphate 7 cholestyramine 49 clindamycin phosphate-d5w 7 cholestyramine light 49 clindamycin-benzoyl perox 1- chorionic gonadotropin 63 5% 54 CIALIS 2.5 MG TABLET 59 clindamycin-benzoyl peroxide 54 CIALIS 5 MG TABLET 59 CLINDESSE 7 CICLODAN 20 ciclopirox 20 cidofovir 34 cilostazol 43 CILOXAN 11 cimetidine 57 CIMZIA 72 CINQAIR 85 CINRYZE 72 CIPRO HC 81 CIPRODEX 81 ciprofloxacin 11 ciprofloxacin er 11 ciprofloxacin hcl 12 ciprofloxacin-d5w 12 cisplatin 25 citalopram hbr 17 cladribine 24 CLARAVIS 54 clarithromycin 11 clarithromycin er 11 clemastine fumarate 82 CLEOCIN 6 CLEVIPREX CLIMARA 65 CLIMARA PRO 65 clind ph-benzoyl perox 1.2-5% 54 CLINDACIN ETZ 6 CLINDACIN P 6 CLINDACIN PAC 6 CLINDAGEL 6 clindamycin hcl 7 clindamycin palmitate hcl 7 clindamycin pediatric 7 clindamycin phos-tretinoin 54 CLINIMIX 87 CLINIMIX E 87 CLINISOL 87 clobetasol emollient 60 clobetasol emulsion 60 clobetasol propionate 60 clocortolone pivalate 60 clofarabine 24 CLOLAR 24 clomiphene citrate 78 clomipramine hcl 18 clonazepam 14 clonidine hcl 44 clonidine hcl er 51 clonidine patch 44 clopidogrel 43 clorazepate dipotassium 14 CLORPRES 44 clotrimazole 20 clotrimazole-betamethasone 20 clozapine 34 clozapine odt 34 COARTEM 30 codeine sulfate 2

102 colchicine 21 COLCRYS 21 colestipol hcl 49 colistimethate 7 COLOCORT 76 COLY-MYCIN S 81 COMBIGAN 81 COMBIPATCH 65 COMBIVENT RESPIMAT 83 COMBIVIR 35 COMETRIQ 28 COMPLERA 34 COMPRO 19 CONDYLOX 54 CONSTULOSE 58 COPAXONE 53 COPEGUS 36 CORDRAN 60 COREG CR 46 CORLANOR 47 CORTENEMA 76 CORTIFOAM 60 cortisone acetate 60 CORTISPORIN 7,80 COSENTYX (2 SYRINGES) 54 COSENTYX PEN 54 COSENTYX PEN (2 PENS) 54 COSENTYX SYRINGE 54 COSMEGEN 25 COSOPT PF 81 COTELLIC 28 COUMADIN 42 CREON 56 CRESEMBA 20 CRESTOR 49 CRIXIVAN 35 cromolyn sodium 79,84 CRYSELLE 65 CUBICIN 7 CUBICIN RF 7 CUPRIMINE 86 CUROSURF 78 CUVITRU 74 CYCLAFEM 65 cyclobenzaprine hcl 85 cyclophosphamide 23 cycloserine 23 CYCLOSET 39 cyclosporine 72 cyclosporine modified 72 CYKLOKAPRON 43 cyproheptadine hcl 82 CYRAMZA 28 CYRED 65 CYSTADANE 56 CYSTAGON 56 CYSTARAN 79 cytarabine 24 CYTOGAM 78 CYTOMEL 70 D D.H.E dacarbazine 23 DACOGEN 25 DAKLINZA 36 DALIRESP 85 DALVANCE 7 danazol 64 dantrolene sodium 34 dapsone 23 DAPTACEL DTAP 75 daptomycin 7 DARAPRIM 30 darifenacin er 59 DARZALEX 29 DASETTA 65 daunorubicin hcl 25 DAUNOXOME 25 DAXBIA 9 DAYSEE 65 DAYTRANA DDAVP 63 DEBLITANE 69 decitabine 25 deferoxamine mesylate 78 DELESTROGEN 65 DELTASONE 60 DELYLA 65 DELZICOL 76 demeclocycline hcl 12 DEMSER 47 DENAVIR 38 DENTA 5000 PLUS 53 DENTAGEL 53 DEPACON 14 DEPAKENE 14 DEPAKOTE 14 DEPAKOTE ER 14 DEPAKOTE SPRINKLE 14 DEPEN 86 DEPO-ESTRADIOL 65 DEPO-MEDROL 60 DEPO-SUBQ PROVERA DESCOVY 35 DESFERAL 78 DESFERAL MESYLATE 78 desipramine hcl 18 desloratadine 82 desmopressin acetate 63 desogestr-eth estrad eth estra 65 desogestrel-ethinyl estradiol 65 DESONATE 60 desonide 61 desoximetasone 61 desvenlafaxine er 17 desvenlafaxine fumarate er 17 desvenlafaxine succinate er 17 dexamethasone 61 DEXAMETHASONE INTENSOL 61

103 dexamethasone sodium phosphate 61,80 DEXILANT 58 dexmethylphenidate hcl 51 dexmethylphenidate hcl er 51 dexrazoxane 25 dextroamphetamine sulfate 51 dextroamphetamine sulfate er 51 dextroamphetamine-amphet er 51 dextroamphetamineamphetamine 51 dextrose 10%-0.2% nacl 87 dextrose 10%-0.45% nacl 87 dextrose 2.5%-0.45% nacl 87 dextrose 5%-0.2% nacl 87 dextrose 5%-0.2% nacl-kcl 87 dextrose 5%-0.225% nacl 87 dextrose 5%-0.225% nacl-kcl 87 dextrose 5%-0.3% nacl 87 dextrose 5%-0.3% nacl-kcl 87 dextrose 5%-0.33% nacl 87 dextrose 5%-0.33% nacl-kcl 87 dextrose 5%-0.45% nacl 87 dextrose 5%-0.45% nacl-kcl 87 dextrose 5%-0.9% nacl 87 dextrose 5%-1/2ns-kcl 87 dextrose 5%-1/4ns-kcl 87 dextrose 5%-electrolyte #48 87 dextrose 5%-ns-kcl 87 dextrose 5%-potassium chloride88 dextrose in lactated ringers 78 dextrose in water 78 DIABETA 39 DIASTAT 14 DIASTAT ACUDIAL 14 diazepam 14,38 DIBENZYLINE 44 diclofenac potassium 5 diclofenac sodium 5,54,80 diclofenac sodium er 5 diclofenac sodium-misoprostol 5 dicloxacillin sodium 10 dicyclomine hcl 56 didanosine 35 DIFFERIN 54 DIFICID 11 diflorasone diacetate 61 diflunisal 5 DIGITEK 47 DIGOX 47 digoxin 48 dihydroergotamine mesylate 22 DILANTIN 16 DILANTIN DILATRATE-SR 50 DILT-XR 47 diltiazem 12hr er 47 diltiazem 24hr cd 47 diltiazem 24hr er 47 diltiazem er 47 diltiazem hcl 47 DIPENTUM 76 diphenhydramine 12.5 mg/5 ml 82 dutasteride 59 diphenhydramine 50 mg/ml vial 82 dutasteride-tamsulosin 59 diphenhydramine hcl 82 DYRENIUM 48 diphenoxylate-atropine 57 diphtheria-tetanus toxoids-ped 75 E dipyridamole 43 E.E.S DISKETS 2 E.E.S disulfiram 4 divalproex sodium 14 divalproex sodium er 14 DIVIGEL 65 DOCEFREZ 25 docetaxel 25 dofetilide 45 donepezil hcl 16 donepezil hcl odt 16 DORIBAX 10 doripenem 10 dorzolamide hcl 81 dorzolamide-timolol doxazosin mesylate 59 doxepin hcl 18,54 doxercalciferol 77 DOXIL 25 doxorubicin hcl 25 doxorubicin hcl liposome 25 DOXY doxycycline hyclate 12 doxycycline ir-dr 12 doxycycline monohydrate 12 dronabinol 19 drospirenone-eth estra-levomef 65 drospirenone-ethinyl estradiol 65 DROXIA 24 DUAVEE 65 DULERA 82 duloxetine hcl 17 DUPIXENT 75 DURAGESIC 1 DURAMORPH 2 DUREZOL 80 econazole nitrate 20 EDARBI 44 EDARBYCLOR 44 EDECRIN 48 EDLUAR 86 EDURANT 34 EFFIENT 43 EGRIFTA 63 ELAPRASE 56 ELELYSO 56 ELESTRIN 65 eletriptan hbr 22 ELIDEL 54

104 ELIGARD 71 ELINEST 66 ELIPHOS 59 ELIQUIS 42 ELITEK 24 ELIXOPHYLLIN 83 ELLA 69 ELLENCE 25 ELMIRON 59 ELOXATIN 25 EMADINE 79 EMBEDA 1 EMCYT 24 EMEND 19 EMFLAZA 61 EMOQUETTE 66 EMPLICITI 29 EMSAM 17 EMTRIVA 35 EMVERM 30 enalapril maleate 45 enalapril-hydrochlorothiazide 45 ENBREL 72 ENDARI 78 ENDOCET 2 ENGERIX-B ADULT 75 ENGERIX-B PEDIATRIC- ADOLESCENT 75 ENJUVIA 66 enoxaparin sodium 42 ENPRESSE 66 ENSKYCE 66 ENSTILAR 54 entacapone 31 entecavir 37 ENTOCORT EC 76 ENTRESTO 48 ENULOSE 58 ENVARSUS XR 72 EPCLUSA 37 EPIDUO 54 EPIDUO FORTE 54 epinastine hcl 79 epinephrine 83 EPIPEN 84 EPIPEN 2-PAK 84 EPIPEN JR 2-PAK 84 epirubicin hcl 26 EPITOL 16 EPIVIR 35 EPIVIR HBV 37 eplerenone 48 EPOGEN 43 epoprostenol sodium 84 eprosartan mesylate 44 EPZICOM 35 EQUETRO 38 ERAXIS (WATER DILUENT) 20 ERBITUX 29 ergoloid mesylates 16 ERGOMAR 22 ergotamine-caffeine 22 ERIVEDGE 26 ERRIN 69 ERTACZO 20 ERWINAZE 26 ERY 2% PADS 11 ERY-TAB 11 ERYPED ERYPED ERYTHROCIN LACTOBIONATE 11 ERYTHROCIN STEARATE 11 erythromycin 11 erythromycin ethylsuccinate 11 erythromycin-benzoyl peroxide 54 ESBRIET 85 ESCAVITE 88 ESCAVITE LQ 88 escitalopram oxalate 17 esomeprazole magnesium esomeprazole sodium 58 ESTARYLLA 66 ESTRACE 66 estradiol 66 estradiol twice weekly 66 estradiol valerate 66 estradiol weekly 66 estradiol-norethindrone acetat 66 ESTRING 66 estropipate 66 eszopiclone 86 ethacrynate sodium 48 ethacrynic acid 48 ethambutol hcl 23 ethosuximide 14 ethynodiol-ethinyl estradiol 66 etidronate disodium 77 etodolac 5 etodolac er 5 ETOPOPHOS 28 etoposide 28 EURAX 30 EVAMIST 66 EVOMELA 23 EVOTAZ 35 EVZIO 4 EXELDERM 20 exemestane 28 EXJADE 86 EXONDYS EXTAVIA 53 EYLEA 79 ezetimibe 49 ezetimibe-simvastatin 49 F FABIOR 54 FABRAZYME 56 FALMINA 66 famciclovir 38 famotidine 57

105 FANAPT 32 FARESTON 24 FARYDAK 28 FASLODEX 24 FAYOSIM 66 FAZACLO 34 felbamate 15 FELBATOL 15 felodipine er 47 FEMHRT 66 FEMRING 66 FEMYNOR 66 fenofibrate 49 fenofibric acid 49 FENOGLIDE 49 fenoprofen calcium 5 fentanyl 1 fentanyl citrate 2 FENTORA 2 FERRIPROX 86 FETZIMA 17 FINACEA 55 finasteride 5 mg tablet 59 FIRAZYR 72 FIRMAGON 26 FLAREX 80 flavoxate hcl 59 FLEBOGAMMA DIF 74 flecainide acetate 45 FLECTOR 5 FLOLAN 84 FLORIVA 88 FLOVENT DISKUS 82 FLOVENT HFA 82 FLOXIN 12 fluconazole 20 fluconazole in dextrose 20 fluconazole in saline 20 fluconazole-nacl 20 flucytosine 20 fludarabine phosphate 24 fludrocortisone acetate 61 flunisolide 82 fluocinolone acetonide 61 fluocinolone acetonide oil 81 fluocinonide 61 fluocinonide-e 61 FLUORIDEX DAILY DEFENSE 53 fluorometholone 80 fluorouracil 26,55 fluoxetine dr 17 fluoxetine hcl 17,18 fluphenazine decanoate 32 fluphenazine hcl 32 flurandrenolide 61 flurbiprofen 5 flurbiprofen sodium 80 flutamide 24 fluticasone propionate 61,82 fluvastatin er 49 fluvastatin sodium 49 fluvoxamine maleate 18 fluvoxamine maleate er 18 FML FORTE 80 FML S.O.P. 80 FOLOTYN 26 fomepizole 78 fondaparinux sodium 42 FORADIL 84 FORTEO 77 FORTESTA 64 FORTICAL 77 fosamprenavir calcium 35 foscarnet sodium 34 fosinopril sodium 45 fosinopril-hydrochlorothiazide 45 fosphenytoin sodium 16 FOSRENOL 59 FRAGMIN 42 FREAMINE HBC 88 FREAMINE III frovatriptan succinate 22 FULYZAQ 57 furosemide 48 FUSILEV 26 FUZEON 35 FYAVOLV 66 FYCOMPA 15 G gabapentin 14 GABITRIL 14 galantamine 4 mg/ml oral soln 16 galantamine er 16 galantamine hbr 16 GAMMAGARD LIQUID 74 GAMMAGARD S-D 74 GAMMAKED 74 GAMMAPLEX 74 GAMUNEX-C 74 ganciclovir sodium 34 GARDASIL 75 GARDASIL 9 75 GASTROCROM 57 gatifloxacin 12 GATTEX 57 gauze pads 2 x 2 78 GAVILYTE-C 58 GAVILYTE-G 58 GAVILYTE-H AND BISACODYL 58 GAVILYTE-N 58 GAZYVA 29 GELNIQUE 59 gemcitabine hcl 24 gemfibrozil 49 GEMZAR 24 GENERESS FE 66 GENERLAC 58 GENGRAF 72 GENOTROPIN 63 GENTAK 6

106 gentamicin sulfate 6,79 gentamicin sulfate in ns 6 GENVOYA 36 GEODON 32 GIANVI 66 GIAZO 76 GILDAGIA 66 GILDESS 66 GILDESS 24 FE 66 GILDESS FE 66 GILENYA 53 GILOTRIF 28 GLASSIA 85 GLATOPA 53 GLEEVEC 28 GLEOSTINE 23 glimepiride 39 glipizide 39 glipizide er 39 glipizide xl 39 glipizide-metformin 39 GLUCAGEN 41 GLUCAGON EMERGENCY KIT 41 GLUCOVANCE 39 GLUMETZA 39 glyburide 39 glyburide micronized 39 glyburide-metformin hcl 39 glycopyrrolate 57 GLYNASE 39 GLYSET 39 GOCOVRI 31 GONITRO 50 GRALISE 16 granisetron hcl 19 GRANIX 43 GRASTEK 78 griseofulvin 20 griseofulvin ultramicrosize 20 guanfacine hcl 44 guanfacine hcl er 51 guanidine hcl 23 H H.P. ACTHAR 61 HAEGARDA 72 HALAVEN 26 halobetasol propionate 61 HALOG 61 haloperidol 32 haloperidol decanoate 32 haloperidol decanoate haloperidol lactate 32 HARVONI 37 HAVRIX 75 HEATHER 69 HECTOROL 77 heparin sodium 42 heparin sodium in 0.45% nacl 42 heparin sodium-0.9% nacl 42 heparin sodium-d5w 42 HEPATAMINE 88 HEPSERA 37 HERCEPTIN 29 HETLIOZ 86 HEXALEN 23 HIBERIX 75 HIZENTRA 74 HORIZANT 16 HUMALOG 41 HUMALOG JUNIOR KWIKPEN 41 HUMALOG KWIKPEN U HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 41 HUMALOG MIX HUMALOG MIX KWIKPEN 41 humapen luxura hd 78 HUMATROPE 63 HUMIRA 72 HUMIRA PEDIATRIC CROHN'S 72 HUMIRA PEN 72 HUMIRA PEN CROHN-UC- HS STARTER 73 HUMIRA PEN PSORIASIS- UVEITIS 73 HUMULIN HUMULIN 70/30 KWIKPEN 41 HUMULIN N 41 HUMULIN N KWIKPEN 41 HUMULIN R 41 HUMULIN R U HUMULIN R U-500 KWIKPEN 41 HYCAMTIN 28 hydralazine hcl 50 hydrochlorothiazide 49 hydrocodone-acetaminophen 2 hydrocodone-ibuprofen 2 hydrocortisone 61,76 hydrocortisone butyrate 61 hydrocortisone valerate 61 hydrocortisone-acetic acid 81 hydromorphone er 1 hydromorphone hcl 2 hydroxychloroquine sulfate 30 hydroxyprogesterone caproate 69 hydroxyurea 24 hydroxyzine hcl 82 hydroxyzine pamoate 38 HYQVIA 74 HYSINGLA ER 1

107 I ibandronate sodium 77 IBRANCE 28 ibuprofen 5 ICLUSIG 28 IDAMYCIN PFS 26 idarubicin hcl 26 IDHIFA 26 ifosfamide 23 ILARIS 75 ILEVRO 80 imatinib mesylate 28 IMBRUVICA 28 IMFINZI 29 imipenem-cilastatin sodium 10 imipramine hcl 18 imipramine pamoate 18 imiquimod 55 IMOVAX RABIES VACCINE 75 INCRELEX 63 indapamide 49 indomethacin 5 indomethacin er 5 INFANRIX DTAP 75 INFLECTRA 73 INFUMORPH 3 INGREZZA 52 INLYTA 28 INNOPRAN XL 22 insulin pen needle 78 insulin pen needle, safety 78 insulin syringe 78 insulin syringe 78 insulin syringe u INTELENCE 34 INTERMEZZO 86 INTRALIPID 78 INTRON A 37 INTROVALE 66 INVANZ 10 INVEGA SUSTENNA 32,33 INVEGA TRINZA 33 INVIRASE 36 INVOKAMET 39 INVOKAMET XR 39 INVOKANA 39,40 IONOSOL B WITH DEXTROSE 5% 88 IONOSOL MB-DEXTROSE 5% 88 IOPIDINE 81 IPOL 75 ipratropium bromide 83 ipratropium-albuterol 83 irbesartan 44 irbesartan-hydrochlorothiazide 44 IRESSA 28 irinotecan hcl 26 ISENTRESS 36 ISENTRESS HD 36 ISOLYTE P WITH DEXTROSE 88 ISOLYTE S 88 isoniazid 23 isosorbide dinitrate 50 isosorbide mononitrate 50 isosorbide mononitrate er 50 isradipine 47 ISTALOL 81 ISTODAX 26 ISUPREL 84 itraconazole 20 ivermectin 30 IXEMPRA 26 IXIARO 75 J JADENU 87 JADENU SPRINKLE 87 JAKAFI JANTOVEN 42 JANUMET 40 JANUMET XR 40 JANUVIA 40 JARDIANCE 40 JENCYCLA 69 JENTADUETO 40 JENTADUETO XR 40 JETREA 79 JEVANTIQUE LO 66 JEVTANA 28 JINTELI 66 JOLESSA 66 JOLIVETTE 69 JUBLIA 20 JULEBER 66 JUNEL 66 JUNEL FE 66 JUNEL FE JUXTAPID 49 K KABIVEN 88 KADCYLA 26 KAITLIB FE 67 KALBITOR 78 KALETRA 36 KALYDECO 84 KANUMA 56 KARIVA 67 KAZANO 40 kcl 20 meq in d5w-lact ringer 88 kcl-ns 1,000 ml iv soln 88 KELNOR KENALOG MG/GRAM SPRAY 62 KENALOG KENALOG KEPIVANCE 53 KEPPRA 13 KERYDIN 20

108 KETEK 11 ketoconazole 20 KETODAN 20 ketoprofen 5 ketorolac tromethamine 5,80 KEVEYIS 78 KEYTRUDA 26 KIMIDESS 67 KINERET 75 KINRIX 75 KIONEX 87 KISQALI 26 KISQALI FEMARA CO- PACK 26 KITABIS PAK 6 KLOFENSAID II 5 KLOR-CON KLOR-CON 8 88 KLOR-CON M10 88 KLOR-CON M15 88 KLOR-CON M20 88 KLOR-CON SPRINKLE 88 KOMBIGLYZE XR 40 KORLYM 78 KRISTALOSE 58 KRYSTEXXA 56 KURVELO 67 KUVAN 56 KYLEENA 69 KYNAMRO 50 KYPROLIS 26 L labetalol hcl 46 LACRISERT 79 lactated ringers 88 lactulose 58 LAMISIL 21 lamivudine 35,37 lamivudine hbv 37 lamivudine-zidovudine 35 lamotrigine 15 lamotrigine (green) 15 lamotrigine (orange) 15 lamotrigine er 15 lamotrigine odt 15 lamotrigine odt (blue) 15 lamotrigine odt (green) 15 lamotrigine odt (orange) 15 LANOXIN 48 LANOXIN PEDIATRIC 48 lansoprazol-amoxicil-clarithro 7 lansoprazole 58 lanthanum carbonate 60 LANTUS 41 LANTUS SOLOSTAR 41 LARIN 67 LARIN 24 FE 67 LARIN FE 67 LARISSIA 67 LARTRUVO 29 latanoprost 81 LATUDA 33 LAZANDA 3 LEENA 67 leflunomide 75 LEMTRADA 53 LENVIMA 28,29 LESSINA 67 LETAIRIS 84 letrozole 28 leucovorin calcium 26 LEUKERAN 23 LEUKINE 43 leuprolide acetate 71 levalbuterol concentrate 84 levalbuterol hcl 84 levalbuterol tartrate hfa 84 LEVEMIR 41 LEVEMIR FLEXTOUCH 41 levetiracetam 13 levetiracetam er levetiracetam-nacl 13 levobunolol hcl 81 levocarnitine 78 levocetirizine dihydrochloride 82,83 levofloxacin 12 levofloxacin-d5w 12 levoleucovorin calcium 26 LEVONEST 67 levonorg-eth estrad eth estrad 67 levonorgestrel 69 levonorgestrel-eth estradiol 67 LEVORA levorphanol tartrate 3 levothyroxine sodium 70 LEVOXYL 70 LEXIVA 36 LIALDA 76 lidocaine 4 lidocaine hcl 4,45 lidocaine hcl viscous 4 lidocaine-prilocaine 4 LIDODERM 4 LILETTA 69 LINCOCIN 7 lincomycin hcl 7 lindane 30 linezolid 7 linezolid-0.9% nacl 7 LINZESS 58 liothyronine sodium 70 lisinopril 45 lisinopril-hydrochlorothiazide 45 lithium 38 lithium carbonate 38 lithium carbonate er 38 LITHOSTAT 59 LIVALO 49 LO LOESTRIN FE 67 LOCOID 62 LOCORT 62

109 LOMEDIA 24 FE 67 LONSURF 26 loperamide 57 lopinavir-ritonavir 36 LOPREEZA 67 LOPRESSOR 46 lorazepam 38 LORCET 3 LORCET HD 3 LORCET PLUS 3 LORYNA 67 losartan potassium 44 losartan-hydrochlorothiazide 44 LOTEMAX 80 LOTRONEX 58 lovastatin 49 LOW-OGESTREL 67 loxapine 32 LUCENTIS 79 LUMIGAN 81 LUMIZYME 56 LUNESTA 86 LUPRON DEPOT 71 LUPRON DEPOT (LUPANETA) 71 LUPRON DEPOT-PED 71 LUTERA 67 LUZU 21 LYNPARZA 26,29 LYRICA 14,52 LYSODREN 70 M M-M-R II VACCINE 75 MACUGEN 79 magnesium chloride 88 magnesium sulfate 88 magnesium sulfate-d5w 88 malathion 30 maprotiline hcl 17 MARGESIC 3 MARLISSA 67 MARPLAN 17 MARQIBO 26 MARTEN-TAB 3 MATULANE 23 MATZIM LA 47 MAXIDEX 80 meclizine hcl 19 meclofenamate sodium 5 MEDROL 62 medroxyprogesterone acetate 69 mefloquine hcl 30 megestrol acetate 69 MEKINIST 26 meloxicam 5 melphalan 23 melphalan hcl 23 memantine hcl 16 MENACTRA 75 MENEST 67 MENHIBRIX 75 MENOMUNE-A-C-Y-W MENTAX 21 MENVEO A-C-Y-W-135-DIP75 MEPRON 30 mercaptopurine 25 meropenem 10 meropenem-0.9% nacl 10 mesalamine 76 mesna 26 MESNEX 27 MESTINON 23 METADATE ER 51 metaproterenol sulfate 84 METAXALL 86 metaxalone 86 metformin er 1000 mg osmotic tablet (generic for fortamet) 40 metformin er 500 mg osmotic tablet (generic for fortamet) metformin hcl 1000mg tablet (immediate-release) 40 metformin hcl 500 mg tablet (immediate-release) 40 metformin hcl 850 mg tablet (immediate-release) 40 metformin hcl er 1000 mg tablet (generic for glumetza) 40 metformin hcl er 500mg (generic for glucophage xr) 40 metformin hcl er 500mg (generic for glumetza) 40 metformin hcl er 750 mg (generic for glucophage xr) 40 methadone hcl 3 METHADONE INTENSOL 3 METHADOSE 3 methamphetamine hcl 51 methazolamide 48 methenamine hippurate 7 methimazole 72 METHITEST 64 methocarbamol 86 methotrexate 73 methotrexate sodium 73 methoxsalen 55 methscopolamine bromide 57 methyclothiazide 49 methyldopa 44 methyldopahydrochlorothiazide 44 methyldopate hcl 44 methylergonovine maleate 78 METHYLIN 51 methylphenidate er 51 methylphenidate hcl 51 methylphenidate hcl cd 51,52 methylphenidate hcl er 51,52 methylphenidate la 52 methylphenidate la 20 mg cap 52 methylphenidate la 40 mg cap 52

110 methylprednisolone 62,76 methylprednisolone acetate 62 methylprednisolone sodium succ 62 methyltestosterone 64 metipranolol 81 metoclopramide hcl 19 metoclopramide hcl odt 19 metolazone 49 METOPIRONE 78 metoprolol succinate er 46 metoprolol tartrate 46 metoprolol-hydrochlorothiazide 46 METRO IV 7 metronidazole 7 mexiletine hcl 45 MIACALCIN 77 MIBELAS 24 FE 67 miconazole 3 21 MICORT-HC 62 MICROGESTIN 67 MICROGESTIN FE 67 midodrine hcl 44 MIGERGOT 22 miglitol 40 MIGRANAL 22 MIMVEY LO 67 MINASTRIN 24 FE 67 MINITRAN 50 minocycline hcl 13 minocycline hcl er 13 minoxidil 50 MIRCERA 43 MIRENA 70 mirtazapine 17 misoprostol 58 MITIGARE 21 mitomycin 27 mitoxantrone hcl 27 modafinil 86 MODERIBA 37 moexipril hcl 45 moexipril-hydrochlorothiazide 45 molindone hcl 32 mometasone furoate 62,82 MONDOXYNE NL 13 MONO-LINYAH 67 MONONESSA 67 montelukast sodium 83 MONUROL 7 MORGIDOX 13 morphine sulfate 3 morphine sulfate er 1 MOVANTIK 57 MOVIPREP 58 MOXEZA 12 moxifloxacin 12 moxifloxacin hcl 12 MOZOBIL 43 MULTAQ 45 mupirocin 7 MUSTARGEN 24 MYALEPT 78 MYCAMINE 21 mycophenolate mofetil 73 mycophenolic acid 73 MYFORTIC 73 MYORISAN 55 MYRBETRIQ 59 MYTESI 57 MYZILRA 67 N nabumetone 5 nadolol 46 nadolol-bendroflumethiazide 46 nafcillin 10 nafcillin sodium 10 naftifine hcl 21 NAFTIN 21 NAGLAZYME 56 nalbuphine hcl naloxone hcl 4 naltrexone hcl 4 NAMENDA XR 17 NAMZARIC 17 naproxen 5 naproxen sodium 5 naproxen sodium ds 6 naratriptan 22 naratriptan hcl 22 NARCAN 4 NATACYN 21 NATAZIA 67 nateglinide 40 NATESTO 64 NATPARA 77 NEBUPENT 30 NECON 67 nefazodone hcl 17 NEO-POLYCIN 7 NEO-POLYCIN HC 7 NEO-SYNALAR 7 neomycin sulfate 6 neomycin-bacitracin-poly-hc 7 neomycin-bacitracin-polymyxin 7 neomycin-polymyxin b 7 neomycin-polymyxin-dexameth80 neomycin-polymyxin-gramicidin 7 neomycin-polymyxin-hc 7,81 neomycin-polymyxin-hydrocort81 NEORAL 73 NEPHRAMINE 88 NERLYNX 29 NESINA 40 NEULASTA 43 NEUPOGEN 43 NEUPRO 31 NEVANAC 80 nevirapine 34 nevirapine er 34 NEXAVAR 29 NEXIUM 58

111 NEXIUM I.V. 58 niacin er 50 NIACOR 50 nicardipine hcl 47 NICOTROL 5 NICOTROL NS 5 NIFEDICAL XL 47 nifedipine er 47 NIKKI 68 NILANDRON 24 nilutamide 24 nimodipine 47 NINLARO 27 NIPENT 25 nisoldipine 47 NITRO-BID 50 NITRO-DUR 50 nitrofurantoin 7 nitrofurantoin mono-macro 8 nitroglycerin 50 nitroglycerin 400 mcg lingual spray 50 nitroglycerin patch 50 NITROLINGUAL 50 NITROMIST 50 NITROSTAT 50 nizatidine 57 NOLIX 62 NORA-BE 70 NORDITROPIN FLEXPRO 63 NORDITROPIN NORDIFLEX 63 noreth-estrad-fe (24) norethin-eth estra-ferrous fum 68 norethindron-ethinyl estradiol 68 norethindrone 70 norethindrone ac (lupaneta) 70 norethindrone acetate 70 norgestimate-ethinyl estradiol 68 NORINYL NORINYL NORITATE 8 NORLYROC 70 NORMOSOL-M AND DEXTROSE 88 NORMOSOL-R 88 NORMOSOL-R AND DEXTROSE 88 NORMOSOL-R PH NORTHERA 44 NORTREL 68 nortriptyline hcl 18 NORVIR 36 NOVAREL 63 novopen echo 78 NOXAFIL 21 NUCALA 85 NUCYNTA 3 NUCYNTA ER 1 NUEDEXTA 52 NULOJIX 73 NUPLAZID 33 NUTRILIPID 79 NUTROPIN AQ 63 NUTROPIN AQ NUSPIN 63 NUVARING 68 NUVESSA 8 NUVIGIL 86 NYAMYC 21 NYATA 21 nystatin 21 nystatin-triamcinolone 21 NYSTOP 21 O OCALIVA 57 OCELLA 68 OCREVUS 53 OCTAGAM 74 octreotide acetate 71 ODEFSEY 34 ODOMZO OFEV 85 ofloxacin 12 OGESTREL 68 olanzapine 33 olanzapine odt 33 olanzapine-fluoxetine hcl 33 olmesartan medoxomil 44 olmesartan-amlodipine-hctz 44 olmesartanhydrochlorothiazide 44 olopatadine hcl 79,83 OLYSIO 37 omega-3 acid ethyl esters 50 omeprazole 58 omeprazole-sodium bicarbonate 58 OMNITROPE 63 ondansetron hcl 19 ondansetron odt 20 ONEXTON 55 ONFI 14 ONGLYZA 40 ONMEL 21 ONZETRA XSAIL 22 OPDIVO 27 OPSUMIT 84 ORACEA 13 ORALAIR 79 ORALONE 53 ORENCIA 73 ORENCIA CLICKJECT 73 ORENITRAM ER 84 ORFADIN 56 ORKAMBI 84 orphenadrine citrate 86 ORSYTHIA 68 ORTHO TRI-CYCLEN LO 68 oseltamivir phosphate 36 OSENI 40 OSMOPREP 57 OTEZLA 75

112 OTOVEL 81 oxacillin 10 oxacillin sodium 10 oxaliplatin 27 oxandrolone 64 oxaprozin 6 oxazepam 38 oxcarbazepine 16 oxiconazole nitrate 21 OXISTAT 21 OXTELLAR XR 16 oxybutynin chloride 59 oxybutynin chloride er 59 oxycodone hcl 3 oxycodone hcl er 1 oxycodone hcl-aspirin 3 oxycodone hcl-ibuprofen 3 oxycodone-acetaminophen 3 OXYCONTIN 1 oxymorphone hcl 3 oxymorphone hcl er 1 P PACERONE 45 paclitaxel 27 paliperidone er 33 pamidronate disodium 77 PANCREAZE 56 PANDEL 62 PANRETIN 30 pantoprazole sodium 58 paricalcitol 77 PAROEX 53 paromomycin sulfate 6 paroxetine cr 18 paroxetine er 18 paroxetine hcl 18 PASER 23 PATADAY 79 PAXIL 18 PCE 11 PEDIARIX 75 PEDVAXHIB 75 peg 3350-electrolyte 57,58 peg-3350 and electrolytes 58 PEGANONE 16 PEGASYS 37 PEGASYS PROCLICK 37 PEGINTRON 37 PEGINTRON REDIPEN 37 penicillin g potassium 10 penicillin g procaine 10 pindolol 46 pioglitazone hcl 40 pioglitazone-glimepiride 40 penicillin g sodium 10 pioglitazone-metformin 40 penicillin gk-iso-osm dextrose 10 piperacillin-tazobactam 11 penicillin v potassium 10 PIRMELLA 68 PENTACEL 75 piroxicam 6 PENTACEL ACTHIB COMPONENT 75 PLASMA-LYTE 148 PLASMA-LYTE 56 IN 88 PENTAM DEXTROSE 88 PENTASA 76 pentazocine-naloxone hcl 3 pentoxifylline 48 PERFOROMIST 84 PERIKABIVEN 88 perindopril erbumine 45 PERIOGARD 53 PERJETA 29 permethrin 30 perphenazine 32 perphenazine-amitriptyline 32 PEXEVA 18 PFIZERPEN 10 PHENADOZ 19 phenelzine sulfate 17 PHENERGAN 19 phenobarbital 13 phenoxybenzamine hcl 44 PHENYTEK 16 phenytoin 16 phenytoin sodium 16 phenytoin sodium extended 16 PHILITH PHOSLYRA 60 PHOSPHOLINE IODIDE 81 PHYSIOLYTE 88 PHYSIOSOL 88 PICATO 55 pilocarpine hcl 53,81 pimozide 32 PIMTREA 68 PLASMA-LYTE A PH PLEGRIDY 53 PLEGRIDY PEN 53 PLIAGLIS 4 podofilox 55 POLYCIN 8 polyethylene glycol polymyxin b sul-trimethoprim 12 polymyxin b sulfate 8 POMALYST 24 PORTIA 68 PORTRAZZA 29 potassium chloride 88 potassium chloride in d5lr 88 potassium citrate er 89 potassium cl 20 meq packet (qualitest and virtus manufacturers only) 89 potassium cl 20 meq-0.45% nacl 89 POTIGA 13 PRADAXA 43 PRALUENT PEN 50

113 PRALUENT SYRINGE 50 pramipexole dihydrochloride 31 pramipexole er 31 PRAMOSONE 62 prasugrel hcl 43 pravastatin sodium 49 prazosin hcl 44 PRED MILD 80 PRED-G 80 prednicarbate 62 prednisolone 62 prednisolone acetate 80 prednisolone sodium phos odt 62 prednisolone sodium phosphate 62,80 prednisone 62 PREDNISONE INTENSOL 62 PREFEST 68 PREGNYL 63 PREMARIN 68 PREMASOL 89 PREMPHASE 68 PREMPRO 68 PRENATAL VITAMIN ORAL TABLET 89 PREVALITE 50 PREVIDENT % DRY MOUTH 53 PREVIDENT 5000 ENAMEL PROTECT 53 PREVIDENT 5000 SENSITIVE 53 PREVIFEM 68 PREZCOBIX 36 PREZISTA 36 PRIFTIN 23 PRILOSEC DR SUSPENSION 59 primaquine 30 primidone 14 PRIMSOL 8 PRISTIQ 18 PRIVIGEN 74 PROAIR HFA 84 PROAIR RESPICLICK 84 probenecid 21 probenecid-colchicine 21 procainamide hcl 45 PROCALAMINE 89 prochlorperazine 19 prochlorperazine edisylate 32 prochlorperazine maleate 19 PROCRIT 43 PROCTO-MED HC 62 PROCTO-PAK 62 PROCTOFOAM-HC 62 PROCTOSOL-HC 62 PROCTOZONE-HC 62 PROCYSBI 56 progesterone 70 PROGLYCEM 41 PROGRAF 73 PROLASTIN C 85 PROLEUKIN 27 PROLIA 73 PROMACTA 43 promethazine hcl 19 promethazine vc 83 PROMETHEGAN 19 propafenone hcl 45 propafenone hcl er 45 proparacaine hcl 79 propranolol hcl 46 propranolol hcl er 22 propranolol-hydrochlorothiazid 46 propylthiouracil 72 PROQUAD 75 PROSOL 89 protamine sulfate 43 protriptyline hcl 18 PROVIGIL 86 PRUDOXIN PULMICORT RESPULE 82 PULMOZYME 85 PURIXAN 25 PYLERA 57 pyrazinamide 23 pyridostigmine bromide 23 pyridostigmine bromide er 23 Q QUADRACEL DTAP-IPV 75 QUALAQUIN 30 QUARTETTE 68 QUASENSE 68 QUDEXY XR 15 quetiapine fumarate 33 quetiapine fumarate er 33 quinapril hcl 45 quinapril-hydrochlorothiazide 45 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 30 QVAR 82 R RABAVERT 76 rabeprazole sodium 59 RADICAVA 79 RAGWITEK 79 RAJANI 68 raloxifene hcl 70 ramipril 45 RANEXA 48 ranitidine hcl 57 RAPAFLO 59 RAPAMUNE 73 rasagiline mesylate 31 RAVICTI 56 RAYALDEE 77 REBETOL 37 REBIF 53 REBIF REBIDOSE 53

114 RECLIPSEN 68 RECOMBIVAX HB 76 REGRANEX 55 RELADOR PAK 4 RELADOR PAK PLUS 4 RELENZA 36 RELISTOR 57 RELPAX 22 REMICADE 73 REMODULIN 84 RENACIDIN 89 RENFLEXIS 73 RENVELA 60 repaglinide 40 repaglinide-metformin hcl 40 REPATHA PUSHTRONEX 50 REPATHA SURECLICK 50 REPATHA SYRINGE 50 RESCRIPTOR 34 reserpine 44 RESTASIS 79 RESTASIS MULTIDOSE 79 RETIN-A 55 RETIN-A MICRO 55 RETIN-A MICRO PUMP 55 RETROVIR 35 REVATIO 84,85 REVLIMID 24 REXULTI 33 REYATAZ 36 RIBASPHERE 37 RIBASPHERE RIBAPAK 37 ribavirin 37 RIDAURA 75 rifabutin 23 RIFAMATE 23 rifampin 23 RIFATER 23 RILUTEK 52 riluzole 52 rimantadine hcl 36 ringers injection 89 ringers irrigation 89 RIOMET 40 risedronate sodium 77 risedronate sodium dr 77 RISPERDAL CONSTA 33 risperidone 33 risperidone odt 33 RITALIN LA 52 RITUXAN 29 RITUXAN HYCELA 30 rivastigmine 16 RIVELSA 68 rizatriptan 22 ROCALTROL 77 ropinirole er 31 ropinirole hcl 31 ROSADAN 8 rosuvastatin calcium 49 ROTARIX 76 ROTATEQ 76 ROWASA 76 ROWEEPRA 13 ROZEREM 86 RUBRACA 27 RUCONEST 72 RYDAPT 29 S SABRIL 14 SAFYRAL 68 SAIZEN 63 SAIZEN-SAIZENPREP 63 SAMSCA 48 SANCUSO 20 SANDIMMUNE 73 SANDOSTATIN 71 SANDOSTATIN LAR 71 SANDOSTATIN LAR DEPOT 71 SANTYL SAPHRIS 33 SARAFEM 18 SAVELLA 52 scopolamine 19 selegiline hcl 31 selenium sulfide 55 SELZENTRY 35 SEMPREX-D 83 SENSIPAR 71 SEREVENT DISKUS 84 SERNIVO 62 SEROQUEL XR 33 SEROSTIM 64 sertraline hcl 18 SETLAKIN 68 sevelamer carbonate 60 SF 1.1% GEL 53 SF 5000 PLUS 53 SFROWASA 76 SHAROBEL 70 SIGNIFOR 79 SIGNIFOR LAR 71 sildenafil 10 mg/12.5 ml vial 85 sildenafil 20 mg tablet 85 SILENOR 86 silver sulfadiazine 8 SIMBRINZA 81 SIMPONI 73 SIMPONI ARIA 73 SIMULECT 75 simvastatin 49 SINEMET SINEMET SINEMET SINEMET CR 31 sirolimus 73 SIRTURO 23 SIVEXTRO 8 SKYLA 70 SMOFLIPID 79 sodium chloride 89

115 SODIUM EDECRIN 48 SODIUM FLUORIDE ORAL TABLET 89 sodium lactate 89 sodium phenylbutyrate 56 sodium polystyrene sulfonate 87 sodium sulfacetamide 55 SOLIRIS 73 SOLODYN 13 SOLTAMOX 24 SOLU-CORTEF 62 SOLU-MEDROL 62 SOMATULINE DEPOT 71 SOMAVERT 71 SONATA 86 SOOLANTRA 30 SORIATANE 55 SORILUX 55 SORINE 45 sotalol 45 sotalol af 45 SOTYLIZE 46 SOVALDI 37 SPIRIVA 83 SPIRIVA RESPIMAT 83 spironolactone 48 spironolactone-hctz 48 SPORANOX 21 SPRINTEC 68 SPRITAM 13 SPRYCEL 29 SPS 87 SRONYX 68 SSD 8 stavudine 35 STELARA 73 sterile water for irrigation 79 STIMATE 64 STIOLTO RESPIMAT 83 STIVARGA 29 STRATTERA 52 STRENSIQ 56 streptomycin sulfate 6 STRIANT 64 STRIBILD 36 STRIVERDI RESPIMAT 84 SUBOXONE 5 SUBSYS 3 SUCRAID 56 sucralfate 58 sulfacetamide sodium 12,55,79 sulfacetamide-prednisolone 80 sulfadiazine 12 sulfamethoxazole-trimethoprim 12 SULFAMYLON 8 sulfasalazine 76 sulfasalazine dr 77 SULFATRIM 12 sulindac 6 sumatriptan 22 sumatriptan succinate 22 SUMAVEL DOSEPRO 22 SUPRAX 9 SUPREP 57 SUSTIVA 34 SUTENT 29 SYEDA 68 SYLATRON 27 SYLVANT 27 SYMBICORT 82 SYMLINPEN SYMLINPEN SYMPROIC 57 SYNAGIS 79 SYNAREL 71 SYNDROS 20 SYNERA 4 SYNERCID 8 SYNJARDY 41 SYNJARDY XR 41 SYNRIBO 27 SYNTHROID SYPRINE 89 T TABLOID 25 TACLONEX 55 tacrolimus 55,74 TAFINLAR 27 TAGRISSO 29 TALTZ AUTOINJECTOR 74 TALTZ AUTOINJECTOR (2 PACK) 74 TALTZ AUTOINJECTOR (3 PACK) 74 TALTZ SYRINGE 74 TALTZ SYRINGE (2 PACK) 74 TALTZ SYRINGE (3 PACK) 74 TALWIN 4 TAMIFLU 36 tamoxifen citrate 24 tamsulosin hcl 59 TARCEVA 29 TARGRETIN 30 TARINA FE 68 TASIGNA 29 TASMAR 31 TAXOTERE 27 TAYTULLA 68 tazarotene 55 TAZICEF 9 TAZORAC 55 TAZTIA XT 47 TECENTRIQ 30 TECFIDERA 53 TECHNIVIE 37 TEFLARO 9 TEGRETOL 16 TEGRETOL XR 16 TEKTURNA 48 TEKTURNA HCT 48

116 telmisartan 44 telmisartan-amlodipine 44 telmisartan-hydrochlorothiazid 44 temazepam 86 TENCON 4 TENIVAC 76 terazosin hcl 44 terbinafine hcl 21 terbutaline sulfate 84 terconazole 21 TESTIM 64 testosterone 64 testosterone cypionate 64 testosterone enanthate 64 tetanus diphtheria toxoids 76 tetrabenazine 52 tetracycline hcl 13 THALOMID 24 THEO theophylline 83 theophylline anhydrous 83 THERACYS 76 THERMAZENE 8 THIOLA 59 thioridazine hcl 32 thiotepa 24 thiothixene 32 THYMOGLOBULIN 74 THYROLAR-1 70 THYROLAR-1/2 70 THYROLAR-1/4 70 THYROLAR-2 70 THYROLAR-3 70 tiagabine hcl 14 ticlopidine hcl 43 tigecycline 8 TIKOSYN 46 TILIA FE 68 timolol 0.25% eye drops 81 timolol 0.25% gel-solution 81 timolol 0.5% eye drops 81 timolol 0.5% gel-solution 81 timolol maleate 22 TIMOPTIC 81 TIMOPTIC OCUDOSE 81 TINDAMAX 30 tinidazole 30 TIS-U-SOL PENTALYTE 89 TIVICAY 36 tizanidine hcl 34 TOBI 6 TOBI PODHALER 6 TOBRADEX 80 TOBRADEX ST 80 tobramycin 6 tobramycin sulfate 6 tobramycin-dexamethasone 80 TOBREX 6 TOLAK 55 tolazamide 41 tolbutamide 41 tolcapone 31 tolmetin sodium 6 tolterodine tartrate 59 tolterodine tartrate er 59 TOPICORT 62 topiramate 15 topiramate er 15 TOPOSAR 28 topotecan hcl 28 TORISEL 27 torsemide 48 TOUJEO SOLOSTAR 41 TOVIAZ 59 TPN ELECTROLYTES 89 TRACLEER 85 TRADJENTA 41 tramadol hcl 4 tramadol hcl er 1 tranexamic acid 43 TRANSDERM-SCOP 19 tranylcypromine sulfate 17 TRAVASOL 89 TRAVATAN Z 81 travoprost 81 trazodone hcl 17 TREANDA 24 TRECATOR 23 TRELSTAR 71 TREMFYA 74 TRETIN-X 55 tretinoin 30,55 tretinoin microsphere 55 TREXIMET 22 TRI-ESTARYLLA 68 TRI-LEGEST FE 68 TRI-LINYAH 68 TRI-LO-ESTARYLLA 69 TRI-LO-MARZIA 69 TRI-LO-SPRINTEC 69 TRI-PREVIFEM 69 TRI-SPRINTEC 69 triamcinolone mg/g topical spray 62 triamcinolone acetonide 53,63,82 triamterene-hydrochlorothiazid48 TRIANEX 63 TRIDERM 63 trifluoperazine hcl 32 trifluridine 38 TRIGLIDE 49 trihexyphenidyl hcl 31 TRILEPTAL 16 TRILYTE WITH FLAVOR PACKETS 57 trimethobenzamide hcl 19 trimethoprim 8 tramadol hcl-acetaminophen 4 trimipramine maleate 18 trandolapril 45 TRINESSA 69 trandolapril-verapamil er 45 TRINTELLIX

117 TRIPTODUR 71 TRISENOX 27 TRIUMEQ 35 TRIVORA TRIZIVIR 35 TROKENDI XR 15 TROPHAMINE 89 trospium chloride 59 trospium chloride er 59 TRULICITY 41 TRUMENBA 76 TRUVADA 35 TUDORZA PRESSAIR 83 TWINRIX 76 TYBOST 35 TYGACIL 8 TYKERB 29 TYMLOS 77 TYPHIM VI 76 TYSABRI 53 TYVASO 85 TYVASO INSTITUTIONAL START KIT 85 TYVASO REFILL KIT 85 TYVASO STARTER KIT 85 TYZEKA 37 U U-CORT 63 UCERIS 76 ULORIC 21 UNITHROID 70 UNITUXIN 27 UPTRAVI 85 ursodiol 57 UTIBRON NEOHALER 84 UVADEX 55 V VABOMERE 10 VAGIFEM 69 valacyclovir 38 VALCHLOR 24 VALCYTE 34 valganciclovir hcl 34 valproate sodium 14 valproic acid 14 valsartan 44,45 valsartan-hydrochlorothiazide 45 VANATOL LQ 4 VANCOCIN HCL 8 vancomycin 8 vancomycin hcl 8 vancomycin hcl-0.9% nacl 8 vancomycin hcl-d5w 8 VAQTA 76 VARIVAX VACCINE 76 VARIZIG 76 VARUBI 20 VASCEPA 50 VECAMYL 48 VECTIBIX 29 VELCADE 27 VELETRI 85 VELIVET 69 VELTASSA 79 VEMLIDY 37 VENCLEXTA 29 VENCLEXTA STARTING PACK 29 venlafaxine hcl 18 venlafaxine hcl er 18 VENTAVIS 85 VENTOLIN HFA 84 verapamil er 47 verapamil er pm 47 verapamil hcl 47 verapamil sr 47 VEREGEN 55 VERSACLOZ 34 VERZENIO 27 VESICARE VESTURA 69 VEXOL 80 VFEND 21 vgo vgo vgo VIBERZI 58 VIBRAMYCIN 13 VICODIN 4 VICODIN ES 4 VICODIN HP 4 VICTOZA 2-PAK 41 VICTOZA 3-PAK 41 VIDAZA 43 VIDEX 2 GM PEDIATRIC SOLN 35 VIDEX 4 GM PEDIATRIC SOLN 35 VIEKIRA PAK 37 VIEKIRA XR 37 VIENVA 69 vigabatrin 15 VIGAMOX 12 VIIBRYD 18 VIMIZIM 56 VIMOVO 6 VIMPAT 14 vinblastine sulfate 27 VINCASAR PFS 27 vincristine sulfate 27 vinorelbine tartrate 27 VIORELE 69 VIRACEPT 36 VIRAMUNE 34 VIRAMUNE XR 34 VIRAZOLE 37 VIREAD 35 VISTIDE 34 VITEKTA 36 VIVELLE-DOT 69 VIVITROL 4

118 VOGELXO 64 voriconazole 21 VOSEVI 37 VOTRIENT 24 VPRIV 56 VRAYLAR 33 VYFEMLA 69 VYTORIN 49 VYXEOS 27 W warfarin sodium 42 WELCHOL 50 WERA 69 WYMZYA FE 69 X XADAGO 31 XALKORI 27 XARELTO 42 XARTEMIS XR 1 XATMEP 74 XELJANZ 74 XELJANZ XR 74 XENAZINE 52 XERESE 55 XERMELO 79 XGEVA 77 XIFAXAN 8 XOLAIR 85 XOPENEX 84 XOPENEX CONCENTRATE 84 XTAMPZA ER 1 XTANDI 24 XULANE 71 XYLOCAINE 4 XYLOCAINE-MPF 4 XYREM 86 Y YERVOY 27 YF-VAX 76 YONDELIS 24 YUVAFEM 69 Z zafirlukast 83 zaleplon 86 ZALTRAP 29 ZANOSAR 24 ZARAH 69 ZARONTIN 14 ZARXIO 43 ZAVESCA 56 ZEBUTAL 4 ZEJULA 27 ZELAPAR 31 ZELBORAF 27 ZEMAIRA 85 ZEMBRACE SYMTOUCH 22 ZEMPLAR 77 ZENATANE 55 ZENCHENT 69 ZENCHENT FE 69 ZENPEP 56 ZEPA 37 ZERBAXA 9 ZERIT 35 ZETIA 50 ZIAGEN 35 zidovudine 35 zileuton er 83 ZINECARD 27 ZIOPTAN 81 ziprasidone hcl 33 ZIRGAN 34 ZMAX 11 ZODEX 63 ZOHYDRO ER zoledronic acid 78 ZOLINZA 27 zolmitriptan 22 zolmitriptan odt 22 zolpidem tartrate 86 zolpidem tartrate er 86 ZOLPIMIST 86 ZOMACTON 64 ZOMETA 78 ZONACORT 63 ZONALON 55 zonisamide 14 ZONTIVITY 42 ZORBTIVE 64 ZORTRESS 74 ZOSTAVAX 76 ZOSYN 11 ZOVIA 1-35E 69 ZOVIA 1-50E 69 ZOVIRAX 38 ZUPLENZ 20 ZURAMPIC 22 ZYCLARA 55 ZYDELIG 29 ZYFLO 83 ZYFLO CR 83 ZYKADIA 29 ZYLET 80 ZYPREXA RELPREVV 33 ZYTIGA 27 ZYVOX 8

119 Discrimination is Against the Law Our Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Our Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Our Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact our dedicated Medicare Customer Care representatives at , (TTY: ). Monday - Friday, 8 a.m. - 8 p.m. From October 1 - February 14, 8 a.m. - 8 p.m., 7 days a week. If you believe that our Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Advocacy Department Attn: Civil Rights Coordinator PO Box 4717 Syracuse, NY Telephone Number: (TTY: ) Fax Number: You can file a grievance in person, or by mail or fax. If you need help filing a grievance, our Health Plan s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Y0028_5016_2 Accepted B-5608 (Rev. 09/2016)

120 A nonprofit independent licensee of the Blue Cross Blue Shield Association ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ) (TTY ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). :, (TTY: ). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ) (TTY: ),, (TTY: ) pod numer (TTY: ) ( ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ) (TTY: ). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ) (TTY: ). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). Y0028_2971_4 Accepted B-5606