2017 Healthy Premier Formulary

Transcription

1 2017 Healthy Premier Formulary

2 PRODUCT SELECTION CRITERIA When a new drug is considered for Formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on Formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion or non-formulary (NF) status of drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents. A central factor in successful management of the Formulary is the review and evaluation of the drug products available in the consumer market and a means to make changes to the Formulary in response to changing therapies and economic factors. The P&T Committee utilizes the following criterion in the evaluation of product selection for the Formulary: a) The drug product must demonstrate unequivocal safety for medical use. b) The drug product must be efficacious and be medically necessary for the treatment, maintenance, or prophylaxis of a medical condition. c) The drug product does not have alternative/similar agents on the Formulary that could be substituted. d) The drug product must demonstrate a therapeutic outcome. e) The medical community must accept the drug product for use. f ) The drug product must have an equitable cost ratio for the treatment of the medical condition. FOUR-TIER FORMULARY CO-PAYMENT STRUCTURE This Formulary is divided into four tiers and the tier is easily identified in the second column on the Formulary. Generic drugs offer an excellent value to the consumer because they are chemically identical to brand drugs but are priced at a fraction of the cost of the corresponding brand drug. The U.S. Food and Drug Administration (FDA) requires that generic drugs provide the same effectiveness and safety as their brand name counterparts. The FDA requires drug manufacturers to show that the generic version enters the bloodstream the same way, contains the same amount of active ingredient, comes in the same dosage form and is taken the same way as the brand name drug. Members will pay the lowest co-payment for 1st tier medications. These agents can be easily identified in the Formulary as the agents with a "1" in the second column. The P&T Committee has reviewed these medications and found them to be therapeutically equivalent to their brand counterparts. Refer to your benefit materials, or call the PTI/NPS Help Desk telephone number on your ID card, to determine what level of coverage you have for your prescription drugs. PREVENTIVE DRUGS Certain medications are recommended to prevent certain disease states and are covered at a different benefit than other drugs. These drugs are listed below. Coverage of these drugs may be limited based on age, quantity dispensed or other limitations. ADACEL AFLURIA AFLURIA PF AFLURIA QUADRIVALENT AFTERA ALTAVERA ALYACEN 1/35 ALYACEN 7/7/7 AMETHIA AMETHIA LO APRI ARANELLE ASHLYNA ASPIRIN CHW81MG ASPIRIN TAB81MG ASPIRIN TAB81MG EC AUBRA AVIANE AZURETTE BALZIVA BEKYREE BEXSERO BLISOVI 24 FE BLISOVI FE 1.5/30 BLISOVI FE 1/20 BOOSTRIX BRIELLYN BUPROPION HCL TAB CAMILA CAMRESE CAMRESE LO CERVARIX CHATEAL CYCLAFEM 1/35 CYCLAFEM 7/7/7 CYRED DAPTACEL DASETTA 1/35 DASETTA 7/7/7 DAYSEE DEBLITANE DELYLA DESO/ETHINYLTABEST-28 DROSPIRENONE/ETHINYL ESTR EMOQUETTE ENGERIX-B ENSKYCE ERRIN ESTARYLLA FA-8 FALMINA FEMYNOR FLUAD FLUARIX QUADRIVALENT FLUBLOK FLUCELVAX FLULAVAL QUADRIVALENT FLUORABON FLUOR-A-DAY FLUORIDE CHW0.5MG FLUORIDE CHW1MG FLUORITAB FLURA-DROPS FLUVIRIN FLUZONE HIGH-DOSE FLUZONE QUADRIVALENT FOLIC ACID TAB400MCG FOLIC ACID TAB800MCG GARDASIL GARDASIL 9 GAVILYTE-C GAVILYTE-G GAVILYTE-N/FLAVOR PACK GIANVI GILDAGIA HAVRIX HEATHER HIBTITER INFANRIX INTROVALE IPOL INACTIVATED IPV JENCYCLA JOLESSA JULEBER JUNEL 1.5/30 JUNEL 1.5/30TAB 2 JUNEL 1/20 JUNEL FE 1.5/30 JUNEL FE 1/20 JUNEL FE 24 KAITLIB FE KARIDIUM KARIVA KIMIDESS KINRIX KURVELO LARIN 1.5/30 LARIN 1/20 LARIN 24 FE LARIN FE 1.5/30 LARIN FE 1/20 LARISSIA LAYOLIS FE LEENA LESSINA LESSINA-28 TAB LEVONORGESTREL LEVONORGESTREL AND ETHINY LEVONORGESTREL/ETHINYL ES LEVORA-28 TAB0.15/30 LOMEDIA 24 FE LORYNA LUDENT LUTERA LYZA MARLISSA MEDROXYPR ACINJ150MG/ML MENACTRA MENOMUNE-A/C/Y/W-135 MENVEO MICROGESTIN 1.5/30 MICROGESTIN 1/20 MICROGESTIN 24 FE MICROGESTIN FE MICROGESTIN FE 1.5/30 MIRCETTE M-M-R II MONO-LINYAH MY WAY NAFRINSE NAFRINSE DROPS NECON TAB0.5/35 NECON 1/35 NELOVA TAB.5/35-28 NELOVA TAB1/35-21 NELOVA TAB1/35-28 NEXT CHOICE NIKKI NORETHINDRONE 0.35MG NORGESTIMATE/ETHINYL ESTR NORLYROC NORTREL (28) TAB1/35 NORTREL 0.5/35 (28) NORTREL 1/35 NORTREL 7/7/7 NUVARING OCELLA OPCICON ONE-STEP ORSYTHIA PEDIARIX PEDVAX HIB PEDVAX HIB INJ PEG 3350/ELECTROLYTES PEG-PREP PENTACEL PHILITH PIMTREA PIRMELLA 1/35 PIRMELLA 7/7/7 PNEUMOVAX 23 PORTIA-28 PREVIFEM PREVNAR 13 PROQUAD QUADRACEL QUASENSE RALOXIFENE HYDROCHLORIDE REACT RECLIPSEN RECOMBIVAX HB ROTARIX ROTATEQ

3 SETLAKIN SHAROBEL SOD FLOURIDEDRO0.5MG/ML SOD FLOURIDEDRO1.1MG/ML SOD FLUORIDECHW0.25MG SOD FLUORIDECHW0.5MG SOD FLUORIDECHW1.1MG SOD FLUORIDECHW1MG SOD FLUORIDECHW2.2MG SPRINTEC 28 SRONYX SYEDA TAKE ACTION TAMOXIFEN CITRATE TARINA FE 1/20 TENIVAC TGT ASPIRIN TGT CHILDRENS ASPIRIN TRI-ESTARYLLA TRI-LINYAH TRI-LO-ESTARYLLA TRI-LO-MARZIA TRI-LO-SPRINTEC TRILYTE TRINESSA TRINESSA LO TRI-PREVIFEM TRI-SPRINTEC TRUMENBA TWINRIX VAQTA VARIVAX VESTURA VIENVA VIORELE VYFEMLA WERA WYMZYA FE XULANE ZARAH ZENCHENT ZENCHENT FE ZOSTAVAX OFF-LABEL USE OF MEDICATIONS The Food and Drug Administration (FDA) has required that drugs used in the United States be both safe and effective. The label information or the package insert of a medication indicates drug use only in certain "approved" doses and routes of administration for a particular condition or disease state. The use of a drug for a disease state or condition not listed on the label, or in a dose or by a route not listed on the label, is considered to be a "non-approved" or "un-labeled" or "off-label" use of the drug. A prior authorization is required when a medication is used outside of its FDA approved route of administration, dosage, or indication. Coverage will be determined in the same manner and subject to the same conditions and limitations as any other prescription drug. Prior authorizations for unlabeled uses of medications may be granted provided that: a) the medication is approved by the FDA; and b) two or more peer-reviewed professional medical journals have recognized, based on scientific medical criteria, the safety and effectiveness of the medication or combination of medications, for treatment of the indication for which the medication has been prescribed unless two articles from major peer-reviewed professional medical journals have concluded, based on scientific or medical criteria, that the drug or combination of drugs is unsafe or ineffective or the safety and effectiveness of the drug or combination of drugs cannot be determined for the treatment of the indication for which the drug or combination of drugs has been prescribed. EXPERIMENTAL MEDICATIONS Any medication or drug that has not been approved by the FDA to be both safe and effective for use in the United States will not be covered. This includes both FDA approved and non-approved medications that are in experimental or investigational trials to determine new indications, new routes of administration, or new dosage forms. PRIOR AUTHORIZATION To promote appropriate utilization, selected high-risk or high-cost medications may require prior authorization to be eligible for coverage under the member s prescription drug benefit. The P&T Committee has established prior authorization criteria. In order for a member to receive coverage for a medication requiring prior authorization, the member s physician should contact the customer service center at to obtain a prior authorization request form. Your physician may then be required to document the reason why a Formulary medication is not acceptable for treatment of your disease state or medical condition. Your physician will want to include in his/her letter your diagnosis and previous therapies that have failed. NEW DRUGS INTRODUCED INTO THE CONSUMER MARKET As the U.S. Food and Drug Administration (FDA) approves new drugs and therapies available to the consumer market after the Plan Summary Documents have been distributed, the Drug Benefit Plan reserves the right to extend or deny coverage to these medications after the printing of this document. The Drug Benefit Plan also reserves the right to assign a unique co-pay or coinsurance to these medications and/or limit the quantities of these medications. Members will receive notices regarding any Drug Benefit Plan modifications concerning drugs or therapies at such time that they present a prescription that is impacted by modifications to the Formulary. Network pharmacies are charged to communicate these updates or changes to the program which may impact a member. The P&T Committee will review new drugs approved by the FDA on a monthly basis. New products with an FDA designation of 1P (FDA priority review therapeutic advance over currently-marketed drugs) will automatically be considered for addition to the Formulary, even if not requested by a plan. New products with an FDA designation of 1S (FDA standard review no therapeutic gain over currently marketed drugs) will not generally be considered for addition to the Formulary, unless requested by a plan, or the drug class is currently under review by the P&T Committee. Members wanting to have newly approved therapies considered by the plan may write and/or call the company servicing the plan or may contact the plan administrator. STEP THERAPY Step Therapy is a program especially designed for people who take prescription drugs regularly to treat an ongoing medical condition. The program helps you get the prescription drugs you need, with safety, cost and most importantly your health in mind. In Step Therapy, the covered drugs you take are organized in a series of steps, with your doctor approving and writing your prescriptions. The program usually starts with generic drugs in the first step. These generics rigorously tested and approved by the U.S. Food & Drug Administration (FDA) allow you to begin or continue treatment with safe, effective drugs that are also affordable: Your co-payment is usually the lowest with a first-step drug. More expensive brand-name drugs are usually covered in the second step, even though the generics covered have been proven to be effective in treating medical conditions. Your doctor is consulted for approval and writes your prescriptions based on the list of Step Therapy drugs covered by the formulary. Step Therapy is developed under the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. They review the most current research on thousands of drugs tested and approved by the Food and Drug Administration for safety and effectiveness. Then they recommend appropriate prescription drugs for the Step Therapy program. The first time you submit a prescription that isn t for a first-step drug, your pharmacist will tell you there s a note on the computer system indicating that our plan uses Step Therapy. This simply means that if you d rather not pay full price for your 3

4 prescription drug, your doctor needs to write you a new prescription for a first-step drug. With Step Therapy, more expensive brand-name drugs are usually covered in a later step in the program if you ve already tried the first-step, generic drugs covered in the program, you can t take the first-step drug (because of an allergy, for instance), or your doctor decides you need a brand-name drug, for medical reasons. If any one of these applies to you, your doctor can ask for a prior authorization for you to take a second-step prescription drug. Once the prior authorization is approved, you pay the appropriate co-payment for this formulary-approved drug. If the prior authorization is not approved, you will need to pay the full price for the drug. SPECIALTY PHARMACY The following list contains drugs that are deemed specialty drugs that treat medical conditions that are more complex, require more intensive patient monitoring and are limited to dispensing at specialty pharmacies. Healthy Premier requires the drugs noted as specialty to be filled primarily at University of Utah network of specialty pharmacies. In cases where drugs are available through a limited distribution from the manufacturer, these drugs may be filled at Walgreens Specialty Pharmacy or for certain drugs, other specialty pharmacies. PAPER CLAIMS FILING LIMITS Point-of-sale claims are generally submitted electronically at the time of dispensing. However, there may be mitigating reasons that require a claim to be submitted via a paper claim after being dispensed. The timely filing limit for paper claims is 90 days from the date of service for all original claims. DISPENSING LIMITATION LIST The following list represents the P&T Committee recommendations for dispensing or quantity limitations per a specific amount of time. Quantity limit programming has become an acceptable pharmacy plan practice that may be appropriate to place on some medications. The intentions are to safeguard members health and save plan benefit dollars. This program ensures members do not receive a prescription for a quantity that exceeds recommended plan limits. Limits are set because some medications have the potential to be abused, misused, shared, or have a manufacturer s limit on the maximum dose. These limits have been reviewed by our clinical and medical staff, and the Pharmacy and Therapeutics Committee. The quantity limits are based on FDA approved dosing schedules, current medical practices, evidence based clinical guidelines, and peer-reviewed medical literature related to that particular drug. The inclusion of a medication on this list does not imply coverage under all plans, nor does the inclusion of a dispensing limitation imply that your specific benefit plan also has the same limitation. Plans may elect their own limitations. Members should consult their prescription drug benefit manual or contact a customer service representative to determine specific coverage and/or inclusion of a medication in the dispensing limitations list, as the list is subject to change. A separate listing of all drugs subject to quantity limits is noted below. DRUG NAME ABACA/LAMIVUTAB ABACAV/LAMIVTAB/ZIDOVUD ABACAVIR TAB300MG ARIPIPRAZOLE SOL1MG/ML ABSTRAL SUB100MCG ABSTRAL SUB200MCG ABSTRAL SUB300MCG ABSTRAL SUB400MCG ABSTRAL SUB600MCG ABSTRAL SUB800MCG ACARBOSE TAB100MG ACARBOSE TAB25MG ACARBOSE TAB50MG ACYCLOVIR OIN5% ADCIRCA TAB20MG ADEMPAS TAB0.5MG ADEMPAS TAB1.5MG ADEMPAS TAB1MG ADEMPAS TAB2.5MG ADEMPAS TAB2MG ADRENACLICK INJ0.15MG ADVAIR DISKUAER100/50 ADVAIR DISKUAER250/50 ADVAIR DISKUAER500/50 ADVAIR HFA AER115/21 ADVAIR HFA AER230/21 ADVAIR HFA AER45/21 AFINITOR TAB10MG AFINITOR TAB2.5MG AFINITOR TAB5MG AFINITOR TAB7.5MG AFINITOR DISTAB2MG AFINITOR DISTAB3MG AFINITOR DISTAB5MG AGGRENOX CAP25-200MG ALBUTEROL NEB0.083% ALBUTEROL NEB0.5% ALBUTEROL NEB0.63MG/3 LIMITATION 900 per 30 days 2 per 30 days 12 per 30 days 12 per 30 days 12 per 30 days 150 per 30 days 3 3 DRUG NAME ALBUTEROL NEB1.25MG/3 ALENDRONATE TAB10MG ALENDRONATE TAB35MG ALENDRONATE TAB40MG ALENDRONATE TAB5MG ALENDRONATE TAB70MG ALFUZOSIN TAB10MG ALINIA SUS100/5ML ALORA DIS0.025MG ALORA DIS0.05MG ALORA DIS0.075MG ALORA DIS0.1MG ALOSETRON 0.5 MG TAB ALOSETRON 1 MG TAB AMLODIPINE TAB10MG AMLODIPINE TAB2.5MG AMLODIPINE TAB5MG ALMOTRIPTAN TAB AMPHETAMINE CAP10MG ER AMPHETAMINE CAP15MG ER AMPHETAMINE CAP20MG ER AMPHETAMINE CAP25MG ER AMPHETAMINE CAP30MG ER AMPHETAMINE CAP5MG ER AMPHETAMINE TAB10MG AMPHETAMINE TAB12.5MG AMPHETAMINE TAB15MG AMPHETAMINE TAB20MG AMPHETAMINE TAB30MG AMPHETAMINE TAB5MG ANASTROZOLE TAB1MG ANDRODERM DIS2MG/24HR ANDRODERM DIS4MG/24HR ANZEMET TAB100MG ANZEMET TAB50MG APLENZIN TAB174MG APLENZIN TAB348MG APLENZIN TAB522MG APRISO CAP0.375GM LIMITATION 3 5 per 30 days 240 per 30 days 5 per 30 days 180 per 3 days 8 per 28 days 8 per 28 days 8 per 28 days 8 per 28 days 12 per 30 days DRUG NAME APTIOM TAB200MG APTIOM TAB400MG APTIOM TAB600MG APTIOM TAB800MG APTIVUS CAP250MG APTIVUS SOL ARCAPTA CAP75MCG ASACOL HD TAB800MG ASMANEX 120 AER220MCG ASMANEX 14 AER220MCG ASMANEX 30 AER110MCG ASMANEX 30 AER220MCG ASMANEX 60 AER220MCG ASMANEX 7 AER110MCG ATORVASTATINTAB10MG ATORVASTATINTAB20MG ATORVASTATINTAB40MG ATORVASTATINTAB80MG AVANDIA TAB2MG AVANDIA TAB4MG AVANDIA TAB4MG AVANDIA TAB8MG AVONEX KIT30MCG AVONEX PREFLKIT30MCG AZELASTINE SPR0.1% AZELASTINE SPR0.15% AZITHROMYCINSUS100/5ML AZITHROMYCINSUS200/5ML AZITHROMYCINTAB250MG AZITHROMYCINTAB500MG AZITHROMYCINTAB600MG BANZEL SUS40MG/ML BANZEL TAB200MG BANZEL TAB400MG BENICAR TAB20MG BENICAR TAB40MG BENICAR TAB5MG BETASERON INJ0.3MG BICALUTAMIDETAB50MG LIMITATION 45 per 30 days 300 per 30 days 2 per 30 days 2 per 30 days 2 per 30 days 2 per 30 days 2 per 30 days 2 per 30 days 4 per 28 days 4 per 28 days 30 per 5 days 90 per 5 days 6 per 5 days 6 per 5 days 6 per 5 days 2400 per 30 days 240 per 30 days 240 per 30 days 15 per 30 days DRUG NAME BREO ELLIPTA BREO ELLIPTAINH BRILINTA TAB90MG BUDEPRION TAB100MG SR BUDEPRION TAB150MG SR BUDESONIDE SUS0.25MG/2 BUDESONIDE SUS0.5MG/2 BUPRENORPHINSUB2MG BUPRENORPHINSUB8MG BUPREN/NALOXONE SUB BUPROBAN TAB150MG BUPROPION TAB100MG BUPROPION TAB100MG BUPROPION TAB100MG SR BUPROPION TAB150MG SR BUPROPION TAB200MG SR BUPROPION TAB75MG BUPROPN HCL TAB150MG XL BUPROPN HCL TAB300MG XL BUT/APAP/CAFCAPCODEINE BUTORPHANOL SOL10MG/ML BUTRANS DIS BUTRANS DIS10MCG/HR BUTRANS DIS15MCG/HR BUTRANS DIS20MCG/HR BUTRANS DIS5MCG/HR BYDUREON INJ BYETTA INJ10MCG BYETTA INJ5MCG CALCIPOTRIENCRE0.005% CALCIPOTRIENSOL0.005% CANDESARTAN TAB16MG CANDESARTAN TAB32MG CANDESARTAN TAB8MG CANDESARTAN TAB4MG CAPRELSA TAB100MG CAPRELSA TAB300MG CARISOPRODOLTAB250MG CARISOPRODOLTAB350MG LIMITATION 45 per 30 days 10 per 30 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 2 per 30 days 2 per 30 days

5 DRUG NAME LIMITATION CARDURA XL TAB4MG CARDURA XL TAB8MG CARVEDILOL TAB12.5MG CARVEDILOL TAB25MG CARVEDILOL TAB3.125MG CARVEDILOL TAB6.25MG CELECOXIB 400MG CESAMET CAP1MG 30 per 5 days CHANTIX PAK0.5& 1MG 1 kit per 365 days CHANTIX PAK1MG CHANTIX TAB0.5MG CHANTIX TAB1MG CHLORPROPAM TAB100MG CHLORPROPAM TAB250MG CIMZIA KIT 6 per 28 days CIMZIA PREFLKIT200MG/ML 6 per 28 days CITALOPRAM SOL10MG/5ML 600 per 30 days CITALOPRAM TAB10MG CITALOPRAM TAB20MG CITALOPRAM TAB40MG CLARITHROMYCTAB500MG 28 per 14 days CLARITHROMYCTAB500MG ER 28 per 14 days CLONAZEP ODTTAB0.125MG CLONAZEP ODTTAB0.25MG CLONAZEP ODTTAB0.5MG CLONAZEPAM TAB0.5MG CLONAZEPAM TAB1MG CLONAZEPAM TAB2MG CLOZAPINE TAB100MG CLOZAPINE TAB200MG CLOZAPINE TAB25MG CLOZAPINE TAB25MG ODT 1080 per 30 days CLOZAPINE TAB50MG COMPRO SUP25MG CONCERTA TAB18MG CONCERTA TAB27MG CONCERTA TAB36MG CONCERTA TAB54MG CORDRAN 80X3TAP4MCG/CM 900 per 30 days COREG CR CAP10MG COREG CR CAP20MG COREG CR CAP40MG COREG CR CAP80MG CRIXIVAN CAP200MG 3 CRIXIVAN CAP400MG CROMOLYN SODNEB20MG/2ML 240 per 30 days DALIRESP TAB500MCG DESVENLAFAX TAB100MG ER DESVENLAFAX TAB50MG ER 240 per 30 days DEXMETHYLPH CAP15MG ER DEXMETHYLPH CAP30MG ER DEXMETHYLPH CAP40MG ER DEXMETHYLPH TAB10MG DEXMETHYLPH TAB2.5MG DEXMETHYLPH TAB5MG DEXTROAMPHETCAP10MG ER DEXTROAMPHETCAP15MG ER DEXTROAMPHETCAP5MG ER DEXTROAMPHETTAB10MG DEXTROAMPHETTAB5MG DIDANOSINE CAP125MG DIDANOSINE CAP200MG DIDANOSINE CAP250MG DIDANOSINE CAP400MG DIPHEN/ATROPINE 2.5MGTAB 80 per 10 days DIVIGEL GEL1MG/GM DONEPEZIL TAB10MG DONEPEZIL TAB10MG ODT DONEPEZIL TAB5MG DRUG NAME DONEPEZIL TAB5MG ODT DOVONEX CRE0.005% DOXAZOSIN TAB1MG DOXAZOSIN TAB2MG DOXAZOSIN TAB4MG DOXAZOSIN TAB8MG DRONABINOL CAP10MG DRONABINOL CAP2.5MG DRONABINOL CAP5MG DULERA AER100-5MCG DULERA AER200-5MCG DULOXETINE CAP20MG DULOXETINE CAP30MG DULOXETINE CAP60MG EDURANT TAB25MG EFFIENT TAB10MG EFFIENT TAB5MG ELIDEL CRE1% ELIQUIS TAB2.5MG ELIQUIS TAB5MG EMEND CAP125MG EMEND CAP40MG EMEND CAP80MG EMEND PAK80 & 125 EMSAM DIS12MG/24H EMSAM DIS6MG/24HR EMSAM DIS9MG/24HR EMTRIVA CAP200MG EMTRIVA SOL10MG/ML ENBREL INJ25/0.5ML ENBREL INJ25MG ENBREL INJ50MG/ML ENBREL SURECLICK ENOXAPARIN INJ100MG/ML ENOXAPARIN INJ120/0.8 ENOXAPARIN INJ150MG/ML ENOXAPARIN INJ30/0.3ML ENOXAPARIN INJ300/3ML ENOXAPARIN INJ40/0.4ML ENOXAPARIN INJ60/0.6ML ENOXAPARIN INJ80/0.8ML ENTACAPONE TAB200MG ENTECAVIR TAB0.5MG ENTECAVIR TAB1MG EPINEPHRINE INJ0.15MG EPINEPHRINE INJ0.3MG EPROSART MESTAB600MG EPZICOM TAB EQUETRO CAP100MG EQUETRO CAP200MG EQUETRO CAP300MG ERIVEDGE CAP150MG ESOMEPRA MAGCAP20MG DR ESCITALOPRAMSOL5MG/5ML ESCITALOPRAMTAB10MG ESCITALOPRAMTAB20MG ESCITALOPRAMTAB5MG ESTRADIOL DIS0.025MG ESTRADIOL DIS0.0375MG ESTRADIOL DIS0.05MG ESTRADIOL DIS0.06MG ESTRADIOL DIS0.075MG ESTRADIOL DIS0.1MG ESTRING MIS2MG EVAMIST SPR1.53MG EXEMESTANE TAB25MG EXTAVIA INJ0.3MG EZETIM/SIMVATAB10-10MG EZETIM/SIMVATAB10-20MG LIMITATION 120 per 1 days 13 per 30 days 13 per 30 days 850 per 30 days 8 per 28 days 16 per 28 days 8 per 28 days 8 per 28 days 28 per 30 days 22 per 30 days 28 per 30 days 8 per 30 days 84 per 30 days 11 per 30 days 16 per 30 days 22 per 30 days 270 per 30 days 2 per 30 days 2 per 30 days 480 per 30 days 240 per 30 days 620 per 30 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 4 per 28 days 1 per 90 days 16 per 30 days 15 per 30 days DRUG NAME EZETIM/SIMVATAB10-40MG EZETIM/SIMVATAB10-80MG FAMCICLOVIR TAB125MG FAMCICLOVIR TAB250MG FAMCICLOVIR TAB500MG FANAPT PAK FANAPT TAB10MG FANAPT TAB12MG FANAPT TAB1MG FANAPT TAB2MG FANAPT TAB4MG FANAPT TAB6MG FANAPT TAB8MG FARESTON TAB60MG FAZACLO TAB12.5/ODT FAZACLO TAB150MG FAZACLO TAB200MG FENOFIBRATE CAP130MG FENOFIBRATE CAP134MG FENOFIBRATE CAP200MG FENOFIBRATE CAP43MG FENOFIBRATE CAP67MG FENOFIBRATE TAB145MG FENOFIBRATE TAB160MG FENOFIBRATE TAB48MG FENOFIBRATE TAB54MG FENTANYL DIS100MCG/H FENTANYL DIS12MCG/HR FENTANYL DIS25MCG/HR FENTANYL DIS50MCG/HR FENTANYL DIS75MCG/HR FENTANYL OT LOZ1200MCG FENTANYL OT LOZ1600MCG FENTANYL OT LOZ200MCG FENTANYL OT LOZ400MCG FENTANYL OT LOZ600MCG FENTANYL OT LOZ800MCG FENTORA TAB400MCG FINASTERIDE TAB5MG FLOVENT DISKAER100MCG FLOVENT DISKAER250MCG FLOVENT DISKAER50MCG FLOVENT HFA AER110MCG FLOVENT HFA AER220MCG FLOVENT HFA AER44MCG FLUCONAZOLE TAB150MG FLUNISOLIDE SPR0.025% FLUOXETINE CAP10MG FLUOXETINE CAP20MG FLUOXETINE CAP40MG FLUOXETINE CAP90MG DR FLUOXETINE SOL20MG/5ML FLUOXETINE TAB10MG FLUOXETINE TAB20MG FLUOXETINE TAB20MG FLUOXETINE 60MG FLUTICASONE SPR50MCG FLUVASTATIN CAP20MG FLUVASTATIN CAP40MG FLUVASTATIN ER TAB FLUVOXAMINE TAB100MG FLUVOXAMINE TAB25MG FLUVOXAMINE TAB50MG FONDAPARINUXSOL10/0.8 FONDAPARINUXSOL2.5/0.5 FONDAPARINUXSOL5.0/0.4 FONDAPARINUXSOL7.5/0.6 FORADIL CAPAEROLIZE FORFIVO XL TAB450MG LIMITATION 720 per 30 days per 28 days 24 per 30 days 24 per 30 days 21 per 30 days 50 per 30 days 5 per 30 days 600 per 30 days 240 per 30 days 16 per 30 days 3 20 per 30 days 15 per 30 days 20 per 30 days 20 per 30 days DRUG NAME LIMITATION FORTEO SOL600/2.4 3 per 28 days FOSAMAX + D TAB per 28 days FOSAMAX + D TAB per 28 days FREESTYLE LANCETS 150 per 30 days FREESTYLE TEST STRIPS 150 per 30 days FYCOMPA TAB10MG FYCOMPA TAB12MG FYCOMPA TAB2MG FYCOMPA TAB4MG FYCOMPA TAB6MG FYCOMPA TAB8MG GABAPENTIN CAP100MG 3 GABAPENTIN CAP300MG 3 GABAPENTIN CAP400MG 270 per 30 days GABAPENTIN SOL250/5ML 21 GABAPENTIN TAB600MG GABAPENTIN TAB800MG GALANTAMINE CAP16MG ER GALANTAMINE CAP24MG ER GALANTAMINE CAP8MG ER GALANTAMINE SOL4MG/ML GALANTAMINE TAB12MG GALANTAMINE TAB4MG GALANTAMINE TAB8MG GELNIQUE GEL10% GILENYA CAP0.5MG GILOTRIF TAB20MG GILOTRIF TAB30MG GILOTRIF TAB40MG GLIMEPIRIDE TAB1MG GLIMEPIRIDE TAB2MG GLIMEPIRIDE TAB4MG GLIPIZIDE TAB10MG GLIPIZIDE TAB5MG 240 per 30 days GLIPIZIDE ERTAB10MG GLIPIZIDE ERTAB2.5MG 240 per 30 days GLIPIZIDE ERTAB5MG GLIPIZIDE ERTAB5MG GLUCAGEN INJHYPOKIT GLUCAGON KIT1MG 2 per 30 days GLYBURID MCRTAB1.5MG GLYBURID MCRTAB3MG GLYBURID MCRTAB6MG GLYBURIDE TAB1.25MG 480 per 30 days GLYBURIDE TAB2.5MG 240 per 30 days GLYBURIDE TAB5MG GRANISETRON TAB1MG HUMALOG INJ100/ML HUMALOG KWIKPEN HUMALOG MIX INJ50/50 HUMALOG MIX INJ50/50KWP HUMALOG MIX INJ75/25KWP HUMALOG MIX SUS75/25 HUMIRA INJ10MG/0.2 6 per 28 days HUMIRA INJ40MG/0.8 8 per 28 days HUMIRA KIT20MG/0.4 8 per 28 days HUMIRA PEDIATRIC CROHNS D 8 per 28 days HUMIRA PEN INJCROHNS 8 per 28 days HUMULIN INJ70/30 HUMULIN N INJU-100 HUMULIN R INJU-100 HUMULIN R INJU-500 HYDROCO/APAP MG HYDROCO/APAP TAB MG HYDROCO/APAP TAB MG HYDROCO/APAP TAB 5-325MG HYDROMORPHONTAB32MG ER HYDROMORPHONTAB4MG HYDROMORPHONTAB8MG 5

6 DRUG NAME HYDROMORPHONTAB8MG ER IBANDRONATE TAB150MG ICLUSIG TAB15MG IMBRUVICA CAP140MG INDOMETHACINCAP25MG INTELENCE TAB100MG INTELENCE TAB200MG INTELENCE TAB25MG INVIRASE CAP200MG INVIRASE TAB500MG IPRATROPIUM SPR0.03% IPRATROPIUM SPR0.06% IRBESARTAN TAB150MG IRBESARTAN TAB300MG IRBESARTAN TAB75MG ISENTRESS CHW100MG ISENTRESS CHW25MG ISENTRESS POW100MG ISENTRESS TAB400MG JAKAFI TAB10MG JAKAFI TAB15MG JAKAFI TAB20MG JAKAFI TAB25MG JAKAFI TAB5MG JANUVIA TAB100MG JANUVIA TAB25MG JANUVIA TAB50MG JARDIANCE TAB10MG JARDIANCE TAB25MG KALYDECO TAB150MG KETOROLAC TAB10MG KINERET INJ LAMIVUD/ZIDOTAB LAMIVUDINE TAB150MG LAMIVUDINE TAB300MG LANSOPRAZOLECAP30MG DR LANTUS INJ100/ML LANTUS INJSOLOSTAR LATANOPROST SOL0.005% LATUDA TAB120MG LATUDA TAB20MG LATUDA TAB40MG LATUDA TAB60MG LATUDA TAB80MG LAZANDA SPR100MCG LAZANDA SPR400MCG LEFLUNOMIDE TAB10MG LEFLUNOMIDE TAB20MG LETAIRIS TAB10MG LETAIRIS TAB5MG LETROZOLE TAB2.5MG LEVALBUTEROLNEB0.31MG LEVALBUTEROLNEB0.63MG LEVALBUTEROLNEB1.25/0.5 LEVEMIR INJ LEVEMIR INJFLEXPEN LEVETIRACETATAB500MG ER LEVETIRACETATAB750MG ER LEVOCETIRIZITAB5MG LEVOFLOXACINTAB250MG LEVOFLOXACINTAB500MG LEVOFLOXACINTAB750MG LEXIVA SUS50MG/ML LEXIVA TAB700MG LIDOCAINE PAD5% LORCET TAB5-325MG LORCET HD TAB10-325MG LORCET PLUS TAB LORTAB TAB10-325MG LIMITATION 1 per 28 days 480 per 30 days 300 per 30 days 720 per 30 days 300 per 30 days 20 per 30 days 28 per 28 days 5 per 30 days 270 per 30 days 540 per 30 days 270 per 30 days 14 per 14 days 14 per 14 days 14 per 14 days 1800 per 30 days DRUG NAME LORTAB TAB5-325MG LORTAB TAB LOSARTAN POTTAB100MG LOSARTAN POTTAB25MG LOSARTAN POTTAB50MG LOVASTATIN TAB10MG LOVASTATIN TAB20MG LOVASTATIN TAB40MG LUMIGAN SOL0.01% LUMIGAN SOL0.03% LYRICA CAP100MG LYRICA CAP150MG LYRICA CAP200MG LYRICA CAP225MG LYRICA CAP25MG LYRICA CAP300MG LYRICA CAP50MG LYRICA CAP75MG LYRICA SOL20MG/ML MAPROTILINE TAB25MG MAPROTILINE TAB50MG MEKINIST TAB0.5MG MEKINIST TAB2MG MELOXICAM TAB15MG MELOXICAM TAB7.5MG MENOSTAR DIS14MCG METADATE TAB20MG ER METFORMIN TAB1000MG METFORMIN TAB500MG METFORMIN TAB500MG ER METFORMIN TAB500MG ER METFORMIN TAB750MG ER METFORMIN TAB850MG METHADONE SOL10MG/5ML METHADONE SOL5MG/5ML METHADONE TAB10MG METHADONE TAB5MG METHYLPHENIDCAP20MG ER METHYLPHENIDCAP30MG ER METHYLPHENIDCAP40MG ER METHYLPHENIDCAP40MG ER METHYLPHENIDTAB10MG METHYLPHENIDTAB10MG ER METHYLPHENIDTAB18MG ER METHYLPHENIDTAB20MG METHYLPHENIDTAB20MG ER METHYLPHENIDTAB27MG ER METHYLPHENIDTAB36MG ER METHYLPHENIDTAB54MG ER METHYLPHENIDTAB5MG METOPROLOL TAB100MG ER METOPROLOL TAB200MG ER METOPROLOL TAB25MG ER METOPROLOL TAB50MG ER MIGRANAL SPR4MG/ML MINITRAN DIS0.1MG/HR MINITRAN DIS0.2MG/HR MINITRAN DIS0.4MG/HR MINITRAN DIS0.6MG/HR MINIVELLE DIS0.025 MG MINIVELLE DIS0.0375MG MINIVELLE DIS0.05MG MINIVELLE DIS0.075MG MINIVELLE DIS0.1MG MIRTAZAPINE TAB15MG MIRTAZAPINE TAB15MG ODT MIRTAZAPINE TAB30MG MIRTAZAPINE TAB30MG ODT MIRTAZAPINE TAB45MG LIMITATION 7 per 30 days 7 per 30 days 900 per 30 days 270 per 30 days 135 per 30 days 4 per 28 days 150 per 30 days 150 per 30 days 600 per 30 days 1200 per 30 days 16 per 30 days 8 per 28 days 8 per 28 days 8 per 28 days 8 per 28 days 8 per 28 days DRUG NAME MIRTAZAPINE TAB45MG ODT MIRTAZAPINE TAB7.5MG MODAFINIL TAB100MG MODAFINIL TAB200MG MONTELUKAST CHW4MG MONTELUKAST CHW5MG MONTELUKAST GRA4MG MONTELUKAST TAB10MG MORPHINE SULCAP100MG ER MORPHINE SULCAP10MG ER MORPHINE SULCAP120MG ER MORPHINE SULCAP20MG ER MORPHINE SULCAP30MG ER MORPHINE SULCAP45MG ER MORPHINE SULCAP50MG ER MORPHINE SULCAP60MG ER MORPHINE SULCAP75MG ER MORPHINE SULCAP80MG ER MORPHINE SULCAP90MG ER MORPHINE SULSOL10MG/5ML MORPHINE SULSOL20MG/5ML MORPHINE SULSOL20MG/ML MORPHINE SULTAB100MG ER MORPHINE SULTAB15MG MORPHINE SULTAB15MG ER MORPHINE SULTAB200MG ER MORPHINE SULTAB30MG MORPHINE SULTAB30MG ER MORPHINE SULTAB60MG ER MULTAQ TAB400MG MYRBETRIQ TAB25MG MYRBETRIQ TAB50MG NAMENDA XR CAP14MG NAMENDA XR CAP21MG NAMENDA XR CAP28MG NAMENDA XR CAP7MG NAMENDA XR CAPTITRATIO NARATRIPTAN TAB1MG NARATRIPTAN TAB2.5MG NATEGLINIDE TAB120MG NATEGLINIDE TAB60MG NEFAZODONE TAB100MG NEFAZODONE TAB150MG NEFAZODONE TAB200MG NEFAZODONE TAB250MG NEFAZODONE TAB50MG NEVIRAPINE SUS50MG/5ML NEVIRAPINE TAB200MG NEVIRAPINE TAB400MG ER NEXAVAR TAB200MG NIACIN ER 1000MG NICOTINE POLGUM2MG NICOTINE POLGUM4MG NICOTINE DIS21MG/24 NICOTINE DIS14MG/24 NICOTINE DIS7MG/24 NICOTINE LOZ2MG NICOTINE LOZ4MG NITROGLYCER DIS0.4MG/HR NITROGLYCERIDIS0.6MG/HR NORTHERA CAP100MG NORTHERA CAP200MG NORTHERA CAP300MG NORVIR CAP100MG NORVIR SOL80MG/ML NORVIR TAB100MG NOVOLIN INJ70/30 NOVOLIN N INJU-100 NOVOLIN R INJU-100 LIMITATION 1800 per 30 days 900 per 30 days 28 per 365 days 9 per 30 days 9 per 30 days 72 per 30 days per 30 days 720 per 30 days 720 per 30 days 720 per 30 days 720 per 30 days 14 per 1 days 14 per 1 days 14 per 1 days per 30 days 3 DRUG NAME NOVOLOG INJ100/ML NOVOLOG FLEXPEN NOVOLOG MIX INJ70/30 NOVOLOG MIX INJFLEXPEN NUCYNTA TAB100MG NUCYNTA TAB50MG NUCYNTA TAB75MG NUCYNTA ER TAB100MG NUCYNTA ER TAB150MG NUCYNTA ER TAB200MG NUCYNTA ER TAB250MG NUCYNTA ER TAB50MG OLANZAPINE TAB10MG OLANZAPINE TAB10MG ODT OLANZAPINE TAB15MG OLANZAPINE TAB15MG ODT OLANZAPINE TAB2.5MG OLANZAPINE TAB20MG OLANZAPINE TAB20MG ODT OLANZAPINE TAB5MG OLANZAPINE TAB5MG ODT OLANZAPINE TAB7.5MG OLMESA MEDOXTAB20MG OLMESA MEDOXTAB40MG OLMESA MEDOXTAB5MG OMEPRAZOLE CAP10MG OMEPRAZOLE CAP20MG OMEPRAZOLE CAP40MG ONDANSETRON SOL4MG/5ML ONDANSETRON TAB24MG ONDANSETRON TAB4MG ONDANSETRON TAB4MG ODT ONDANSETRON TAB8MG ONDANSETRON TAB8MG ODT ONFI SUS2.5MG/ML ONGLYZA TAB2.5MG ONGLYZA TAB5MG OPANA ER TAB10MG OPANA ER TAB20MG OPANA ER TAB30MG OPANA ER TAB40MG OPANA ER TAB5MG OPSUMIT TAB10MG OTEZLA OTEZLA TAB10/20/30 OTEZLA TAB30MG OXANDROLONE TAB10MG OXANDROLONE TAB2.5MG OXYBUTYNIN SYP5MG/5ML OXYBUTYNIN TAB5MG OXYCOD/IBU TAB5-400MG OXYCOD/APAP TAB MG OXYCOD/APAP TAB MG OXYCOD/APAP TAB 5-325MG OXYCOD/APAP TAB MG OXYCODONE TAB20MG OXYCODONE TAB30MG OXYCODONE TAB5MG OXYCONTIN TAB10MG CR OXYCONTIN TAB15MG CR OXYCONTIN TAB20MG CR OXYCONTIN TAB30MG CR OXYCONTIN TAB40MG CR OXYCONTIN TAB60MG CR OXYCONTIN TAB80MG CR OXYTROL DIS3.9MG/24 PALIPERIDONE 1.5MG ER PALIPERIDONE 3MG ER PALIPERIDONE 6MG ER LIMITATION 240 per 30 days 150 per 5 days 12 per 5 days 12 per 5 days 12 per 5 days 12 per 5 days 480 per 30 days 600 per 30 days per 28 days 240 per 30 days 6

7 DRUG NAME PALIPERIDONE 9MG ER PANTOPRAZOLETAB20MG PANTOPRAZOLETAB40MG PAROXETIN ERTAB12.5MG PAROXETIN ERTAB37.5MG PAROXETINE TAB10MG PAROXETINE TAB20MG PAROXETINE TAB25MG ER PAROXETINE TAB30MG PAROXETINE TAB40MG PAXIL SUS10MG/5ML PEGASYS INJ PEGASYS PROCLICK PEXEVA TAB10MG PEXEVA TAB20MG PEXEVA TAB30MG PEXEVA TAB40MG PIOGLITAZONETAB15MG PIOGLITAZONETAB30MG PIOGLITAZONETAB45MG POMALYST CAP1MG POMALYST CAP2MG POMALYST CAP3MG POMALYST CAP4MG POTIGA TAB200MG POTIGA TAB300MG POTIGA TAB400MG POTIGA TAB50MG PRADAXA CAP150MG PRADAXA CAP75MG PRAMIPEXOLE TAB0.125MG PRAMIPEXOLE TAB0.25MG PRAMIPEXOLE TAB0.5MG PRAMIPEXOLE TAB0.75MG PRAMIPEXOLE TAB1.5MG PRAMIPEXOLE TAB1MG PRAVASTATIN TAB10MG PRAVASTATIN TAB20MG PRAVASTATIN TAB40MG PRAVASTATIN TAB80MG PRECISION TEST STRIPS PREZISTA SUS100MG/ML PREZISTA TAB150MG PREZISTA TAB600MG PREZISTA TAB75MG PRISTIQ TAB100MG PRISTIQ TAB50MG PROAIR HFA AER PROCHLORPER SUP25MG PROMACTA TAB12.5MG PROMACTA TAB25MG PROMACTA TAB50MG PROMACTA TAB75MG PROVENTIL AERHFA PULMICORT INH180MCG PULMICORT INH90MCG QUETIAPINE TAB100MG QUETIAPINE TAB200MG QUETIAPINE TAB25MG QUETIAPINE TAB300MG QUETIAPINE TAB400MG QUETIAPINE TAB50MG QUETIAPINE TAB400MG ER QVAR AER40MCG QVAR AER80MCG RABEPRAZOLE TAB20MG RALOXIFENE TAB60MG RAMIPRIL CAP1.25MG RAMIPRIL CAP10MG LIMITATION 150 per 30 days 45 per 30 days 900 per 30 days 2 per 28 days 2 per 28 days 720 per 30 days 150 per 30 days 400 per 30 days 300 per 30 days 240 per 30 days 13.4 per 30 days 17 per 30 days 2 per 30 days 2 per 30 days 240 per 30 days per 30 days 34.8 per 30 days 18 per 30 days DRUG NAME RAMIPRIL CAP2.5MG RAMIPRIL CAP5MG RANEXA TAB1000MG RANEXA TAB500MG REBIF INJ22/0.5 REBIF INJ44/0.5 REBIF TITRTNSOLPACK RELENZA MISDISKHALE RENVELA PAK0.8GM RENVELA PAK2.4GM RESCRIPTOR TAB100 MG RESCRIPTOR TAB200MG REVLIMID CAP10MG REVLIMID CAP15MG REVLIMID CAP2.5MG REVLIMID CAP20MG REVLIMID CAP25MG REVLIMID CAP5MG REYATAZ CAP150MG REYATAZ CAP200MG REYATAZ CAP300MG RISPERIDONE SOL1MG/ML RISPERIDONE TAB0.25 ODT RISPERIDONE TAB0.25MG RISPERIDONE TAB0.5MG RISPERIDONE TAB0.5MG OD RISPERIDONE TAB1MG RISPERIDONE TAB1MG ODT RISPERIDONE TAB2MG RISPERIDONE TAB2MG ODT RISPERIDONE TAB3MG RISPERIDONE TAB3MG ODT RISPERIDONE TAB4MG RISPERIDONE TAB4MG ODT RITALIN LA CAP10MG RIVASTIGMINECAP1.5MG RIVASTIGMINECAP3MG RIVASTIGMINECAP4.5MG RIVASTIGMINECAP6MG RIZATRIPTAN TAB10MG RIZATRIPTAN TAB10MG ODT RIZATRIPTAN TAB5MG SABRIL POW500MG SABRIL TAB500MG SAMSCA TAB15MG SAMSCA TAB30MG SANCUSO DIS3.1MG SANTYL OIN250/GM SAPHRIS SUB10MG SAPHRIS SUB5MG SARAFEM TAB10MG SARAFEM TAB20MG SEREVENT DISAER50MCG SEROQUEL XR TAB150MG SEROQUEL XR TAB200MG SEROQUEL XR TAB300MG SEROQUEL XR TAB400MG SEROQUEL XR TAB50MG SERTRALINE CON20MG/ML SERTRALINE TAB100MG SERTRALINE TAB25MG SERTRALINE TAB50MG SILDENAFIL TAB20MG SIMPONI INJ100MG/ML SIMPONI INJ50/0.5ML SIMVASTATIN TAB10MG SIMVASTATIN TAB20MG SIMVASTATIN TAB40MG SIMVASTATIN TAB5MG LIMITATION 12 per 30 days 12 per 30 days 6 per 30 days 60 per 180 days per 30 days 480 per 30 days 1920 per 30 days 1920 per 30 days per 30 days 480 per 30 days 240 per 30 days 240 per 30 days 12 per 30 days 12 per 30 days 12 per 30 days 1 per 7 days 35 per 14 days 140 per 14 days 300 per 30 days 240 per 30 days 1 per 28 days 1 per 28 days DRUG NAME LIMITATION SIMVASTATIN TAB80MG SPIRIVA CAPHANDIHLR SPIRIVA SPRRESPIMAT 4 per 30 days SPRYCEL TAB100MG SPRYCEL TAB140MG SPRYCEL TAB20MG SPRYCEL TAB50MG SPRYCEL TAB70MG SPRYCEL TAB80MG STAVUDINE CAP15MG STAVUDINE CAP20MG STAVUDINE CAP30MG STAVUDINE CAP40MG STAVUDINE SOL1MG/ML 2400 per 30 days STIVARGA TAB40MG 84 per 28 days STRATTERA CAP100MG STRATTERA CAP10MG STRATTERA CAP18MG STRATTERA CAP25MG STRATTERA CAP40MG STRATTERA CAP60MG STRATTERA CAP80MG STRIBILD TAB SUBSYS SPR100MCG SUBSYS SPR200MCG SUBSYS SPR400MCG SUBSYS SPR600MCG SUBSYS SPR800MCG SUMATRIPTAN INJ6MG/0.5 6 per 30 days SUMATRIPTAN INJ6MG/0.5 8 per 28 days SUMATRIPTAN SPR20MG/ACT 18 per 28 days SUMATRIPTAN SUCCINATE REF 8 per 28 days SUMATRIPTAN TAB100MG 9 per 30 days SUMATRIPTAN TAB25MG 9 per 30 days SUMATRIPTAN TAB50MG 9 per 30 days SUSTIVA CAP200MG SUSTIVA CAP50MG 3 SUSTIVA TAB600MG SUTENT CAP12.5MG SUTENT CAP25MG SUTENT CAP37.5MG SUTENT CAP50MG SYMLINPEN 60INJ1000MCG 10 per 30 days SYMLNPEN 120INJ1000MCG 10 per 30 days TAFINLAR CAP50MG TAFINLAR CAP75MG TAMIFLU CAP30MG 84 per 180 days TAMIFLU CAP45MG 42 per 180 days TAMIFLU CAP75MG 42 per 180 days TAMIFLU SUS6MG/ML 900 per 180 days TAMSULOSIN CAP0.4MG TARCEVA TAB100MG TARCEVA TAB150MG TARCEVA TAB25MG TASIGNA CAP150MG TASIGNA CAP200MG TEKTURNA TAB150MG TEKTURNA TAB300MG TERAZOSIN CAP10MG TERAZOSIN CAP1MG TERAZOSIN CAP2MG TERAZOSIN CAP5MG TERBINAFINE TAB250MG TERCONAZOLE SUP80MG 3 per 3 days THALOMID CAP100MG THALOMID CAP150MG THALOMID CAP200MG THALOMID CAP50MG TICLOPIDINE TAB250MG DRUG NAME TIVICAY TAB50MG TOLTERODINE CAP2MG ER TOLTERODINE CAP4MG ER TOLTERODINE TAB1MG TOLTERODINE TAB2MG TOPIRAMATE TAB100MG TOPIRAMATE TAB200MG TOPIRAMATE TAB25MG TOPIRAMATE TAB50MG TOUJEO SOLO INJ300IU/ML TOVIAZ TAB4MG TOVIAZ TAB8MG TRACLEER TAB125MG TRACLEER TAB62.5MG TRAMADOL HCLTAB50MG TRANDOLAPRILTAB1MG TRANDOLAPRILTAB2MG TRANDOLAPRILTAB4MG TRANSDERM-SCDIS1.5MG TRAVATAN Z DRO0.004% TRETINOIN TRETINOIN CRE0.025% TRETINOIN CRE0.05% TRETINOIN CRE0.1% TRETINOIN GEL0.01% TRETINOIN GEL0.025% TRETIN-X CRE0.0375% TRETIN-X CRE0.075% TRIAMCINOLONAER55MCG/AC TRIUMEQ TAB TRUVADA TAB TYKERB TAB250MG ULORIC TAB40MG ULORIC TAB80MG VALACYCLOVIRTAB1GM VALACYCLOVIRTAB500MG VALSARTAN TAB160MG VALSARTAN TAB320MG VALSARTAN TAB40MG VALSARTAN TAB80MG VANCOMYCIN CAP125MG VANCOMYCIN CAP250MG VANDETANIB TAB100MG VANDETANIB TAB300MG VENLAFAXINE CAP150MG ER VENLAFAXINE CAP37.5 ER VENLAFAXINE CAP75MG ER VENLAFAXINE TAB100MG VENLAFAXINE TAB150MG ER VENLAFAXINE TAB225MG ER VENLAFAXINE TAB25MG VENLAFAXINE TAB37.5 ER VENLAFAXINE TAB37.5MG VENLAFAXINE TAB50MG VENLAFAXINE TAB75MG VENLAFAXINE TAB75MG ER VENTOLIN HFAAER VERAMYST SPR27.5MCG VESICARE TAB10MG VESICARE TAB5MG VICTOZA INJ18MG/3ML VIDEX SOL2GM VIIBRYD TAB10MG VIIBRYD TAB20MG VIIBRYD TAB40MG VIMPAT SOL10MG/ML VIMPAT TAB100MG VIMPAT TAB150MG VIMPAT TAB200MG LIMITATION 480 per 30 days 240 per 30 days 1920 per 30 days 9 21 per 30 days 240 per 30 days 24 per 30 days 5 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 45 per 30 days 33 per 30 days 30 per 1 days 30 per 1 days 40 per 30 days 80 per 30 days 270 per 30 days 150 per 30 days 150 per 30 days 36 per 30 days 20 per 30 days 9 per 30 days 1200 per 30 days 1200 per 30 days 7

8 DRUG NAME VIMPAT TAB50MG VIREAD POW40MG/GM VIREAD TAB150MG VIREAD TAB200MG VIREAD TAB250MG VIREAD TAB300MG VORICONAZOLETAB200MG VORICONAZOLETAB50MG VOTRIENT TAB200MG XALKORI CAP200MG XALKORI CAP250MG XARELTO TAB10MG XARELTO TAB15MG LIMITATION 240 per 30 days 51 per 30 days DRUG NAME XARELTO TAB20MG XARELTO STARTAB15/20MG XIFAXAN TAB550MG XOPENEX HFA AER ZAFIRLUKAST TAB10MG ZAFIRLUKAST TAB20MG ZALEPLON CAP10MG ZALEPLON CAP5MG ZETIA TAB10MG ZIAGEN SOL20MG/ML ZIDOVUDINE CAP100MG ZIDOVUDINE SYP50MG/5ML ZIDOVUDINE TAB300MG LIMITATION 51 per 30 days per 30 days DRUG NAME ZIPRASIDONE CAP20MG ZIPRASIDONE CAP40MG ZIPRASIDONE CAP40MG ZIPRASIDONE CAP60MG ZIPRASIDONE CAP80MG ZMAX SUS2GM ZOLINZA CAP100MG ZOLPIDEM TAB10MG ZOLPIDEM TAB5MG ZOLPIDEM ER TAB12.5MG ZOLPIDEM ER TAB6.25MG ZOMIG TAB2.5MG ZOMIG TAB5MG LIMITATION 240 per 30 days 6 per 30 days 6 per 30 days DRUG NAME ZOMIG NASAL SPR5MG ZOMIG ZMT TAB2.5 MG ZOMIG ZMT TAB5MG ZORTRESS TAB0.25MG ZORTRESS TAB0.5MG ZORTRESS TAB0.75MG ZYDELIG TAB100MG ZYDELIG TAB150MG ZYKADIA CAP150MG ZYTIGA TAB250MG LIMITATION 6 per 30 days 6 per 30 days 6 per 30 days 150 per 30 days 8

9 DRUG LISTING Tier 1 - Preferred Generics Tier 2 - Non-Preferred Generics and Preferred Brands Tier 3 - Non-Preferred Brands Tier 4 - Preferred Specialty Products The cost of your prescription depends on: Which tier your drug is on Whether you fill your prescription at a network pharmacy Your current drug payment stage - please read your Evidence of Coverage (EOC) for more information If the product has a limitation on the medication, this is noted in the LIMITS section. The following abbreviations apply to the LIMITS section: QL: Quantity Limitation. This medication is subject to limits on the amount of medication per prescription. PA: Prior Authorization. This medication requires you or your physician to get prior authorization prior to the medication being dispensed form a pharmacy. ST: Step Therapy. This medication 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 treat your medical condition, we would require drug A be tried before Drug B can be utilized. SP: Specialty Pharmacy. This medication is required to be dispensed in a specialty pharmacy as the medication requires more intensive patient monitoring and are limited to dispensing at specialty pharmacies. Healthy Premier requires the drugs noted as specialty to be filled primarily at University of Utah network of specialty pharmacies. In cases where drugs are available through a limited distribution from the manufacturer, these drugs may be filled at Walgreens Specialty Pharmacy or for certain drugs, other specialty pharmacies. ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINE CAP10MG ER 2 QL AMPHETAMINE CAP15MG ER 2 QL AMPHETAMINE CAP20MG ER 2 QL AMPHETAMINE CAP25MG ER 2 QL AMPHETAMINE CAP30MG ER 2 QL AMPHETAMINE CAP5MG ER 2 QL AMPHETAMINE TAB10MG 2 QL AMPHETAMINE TAB12.5MG 2 QL AMPHETAMINE TAB15MG 2 QL AMPHETAMINE TAB20MG 2 QL AMPHETAMINE TAB30MG 2 QL AMPHETAMINE TAB5MG 2 QL ARMODAFINIL TAB150MG 2 PA ARMODAFINIL TAB250MG 2 PA ARMODAFINIL TAB50MG 2 PA CONCERTA TAB18MG 3 QL CONCERTA TAB27MG 3 QL CONCERTA TAB36MG 3 QL CONCERTA TAB54MG 3 QL DAYTRANA DIS10MG/9HR 3 DAYTRANA DIS15MG/9HR 3 DAYTRANA DIS20MG/9HR 3 DAYTRANA DIS30MG/9HR 3 DEXMETHYLPH CAP15MG ER 2 QL DEXMETHYLPH CAP30MG ER 2 QL DEXMETHYLPH CAP40MG ER 2 QL DEXMETHYLPH TAB10MG 2 QL DEXMETHYLPH TAB2.5MG 2 QL DEXMETHYLPH TAB5MG 2 QL DEXTROAMPHETCAP10MG ER 2 QL DEXTROAMPHETCAP15MG ER 2 QL DEXTROAMPHETCAP5MG ER 2 QL DEXTROAMPHETTAB10MG 2 QL DEXTROAMPHETTAB5MG 2 QL GUANFACINE TAB1MG ER 2 GUANFACINE TAB2MG ER 2 GUANFACINE TAB3MG ER 2 GUANFACINE TAB4MG ER 2 METADATE TAB20MG ER 2 QL METHYLIN CHW10MG 3 METHYLIN CHW2.5MG 3 METHYLIN CHW5MG 3 METHYLPHENIDCAP10MG 2 METHYLPHENIDCAP20MG ER 2 QL METHYLPHENIDCAP30MG ER 2 QL METHYLPHENIDCAP40MG ER 2 QL METHYLPHENIDCAP40MG ER 2 QL METHYLPHENIDCAP50MG 2 METHYLPHENIDCAP60MG 2 METHYLPHENIDSOL10MG/5ML 2 METHYLPHENIDSOL5MG/5ML 2 METHYLPHENIDTAB10MG 2 QL METHYLPHENIDTAB10MG ER 2 QL 9 METHYLPHENIDTAB18MG ER 3 QL METHYLPHENIDTAB20MG 2 QL METHYLPHENIDTAB20MG ER 2 QL METHYLPHENIDTAB27MG ER 3 QL METHYLPHENIDTAB36MG ER 3 QL METHYLPHENIDTAB54MG ER 3 QL METHYLPHENIDTAB5MG 2 QL MODAFINIL TAB100MG 1 QL MODAFINIL TAB200MG 1 QL QUILLIVANT SUSXR 3 RITALIN LA CAP10MG 3 QL STRATTERA CAP100MG 2 QL STRATTERA CAP10MG 2 QL STRATTERA CAP18MG 2 QL STRATTERA CAP25MG 2 QL STRATTERA CAP40MG 2 QL STRATTERA CAP60MG 2 QL STRATTERA CAP80MG 2 QL VYVANSE CAP20MG 3 VYVANSE CAP30MG 3 VYVANSE CAP40MG 3 VYVANSE CAP50MG 3 VYVANSE CAP60MG 3 VYVANSE CAP70MG 3 AMINOGLYCOSIDES NEOMYCIN TAB500MG 1 PAROMOMYCIN CAP250MG 2 TOBRAMYCIN NEB300/5ML 4 PA SP ANALGESICS - ANTI-INFLAMMATORY ACTEMRA INJ162/0.9 4 PA SP CELECOXIB 50 MG 1 CELECOXIB 100 MG 1 CELECOXIB 200 MG 1 CELECOXIB 400 MG 1 QL DICLOFEN POTTAB50MG 1 DICLOFENAC TAB100MG ER 1 DICLOFENAC TAB25MG DR 1 DICLOFENAC TAB50MG DR 1 DICLOFENAC TAB75MG DR 1 ENBREL INJ25/0.5ML 4 QL PA SP ENBREL INJ25MG 4 QL PA SP ENBREL INJ50MG/ML 4 QL PA SP ENBREL SURECLICK 4 QL PA SP ETODOLAC CAP200MG 1 ETODOLAC CAP300MG 1 ETODOLAC TAB400MG 1 ETODOLAC TAB500MG 1 ETODOLAC ER TAB400MG 1 ETODOLAC ER TAB500MG 1 ETODOLAC ER TAB600MG 1 FENOPROFEN TAB600MG 2 FENOPROFEN CALCIUM 3 FLURBIPROFENTAB100MG 1 FLURBIPROFENTAB50MG 1

10 HUMIRA INJ10MG/0.2 4 QL PA SP HUMIRA INJ40MG/0.8 4 QL PA SP HUMIRA KIT20MG/0.4 4 QL PA SP HUMIRA PEDIATRIC CROHNS D 4 QL PA SP HUMIRA PEN INJCROHNS 4 QL PA SP IBUPROFEN TAB400MG 1 IBUPROFEN TAB600MG 1 IBUPROFEN TAB800MG 1 INDOCIN SUS25MG/5ML 3 INDOMETHACINCAP25MG 1 INDOMETHACINCAP50MG 1 INDOMETHACINCAP75MG ER 1 KETOPROFEN CAP50MG 1 KETOPROFEN CAP75MG 1 KETOROLAC TAB10MG 1 QL KINERET INJ 4 QL PA SP LEFLUNOMIDE TAB10MG 1 QL LEFLUNOMIDE TAB20MG 1 QL MECLOFEN SODCAP100MG 2 MECLOFEN SODCAP50MG 2 MEFENAM ACIDCAP250MG 2 MELOXICAM TAB15MG 1 QL MELOXICAM TAB7.5MG 1 QL NABUMETONE TAB500MG 1 NABUMETONE TAB750MG 1 NALFON CAP200MG 3 NALFON CAP400MG 3 NAPROXEN SUS125/5ML 1 NAPROXEN TAB250MG 1 NAPROXEN TAB375MG 1 NAPROXEN TAB500MG 1 NAPROXEN DR TAB375MG 1 NAPROXEN DR TAB500MG 1 NAPROXEN SODIUM CR 2 NAPROXEN SODTAB275MG 1 NAPROXEN SODTAB500MG CR 2 NAPROXEN SODTAB550MG 1 ORENCIA 4 PA SP OTEZLA 4 QL PA SP OTEZLA TAB10/20/30 4 QL PA SP OTEZLA TAB30MG 4 QL PA SP OXAPROZIN TAB600MG 2 PIROXICAM CAP10MG 1 PIROXICAM CAP20MG 1 RHEUMATREX 3 PA RHEUMATREX TAB2.5MG 3 PA RIDAURA CAP3MG 4 PA SP SIMPONI INJ100MG/ML 4 QL PA SP SIMPONI INJ50/0.5ML 4 QL PA SP SPRIX SPR15.75MG 3 PA SULINDAC TAB150MG 1 SULINDAC TAB200MG 1 TOLMETIN SODCAP400MG 2 TOLMETIN SODTAB200MG 2 TOLMETIN SODTAB600MG 2 XELJANZ TAB5MG 4 PA SP XELJANZ XR TAB11MG 4 PA SP ZIPSOR CAP25MG 3 ANALGESICS - NonNarcotic DIFLUNISAL TAB500MG 1 TENCON TAB50-325MG 1 ZEBUTAL CAP 1 ANALGESICS - OPIOID ABSTRAL SUB100MCG 4 QL PA SP ABSTRAL SUB200MCG 4 QL PA SP ABSTRAL SUB300MCG 4 QL PA SP ABSTRAL SUB400MCG 4 QL PA SP ABSTRAL SUB600MCG 4 QL PA SP ABSTRAL SUB800MCG 4 QL PA SP BUNAVAIL MIS PA BUNAVAIL MIS PA BUNAVAIL MIS6.3-1MG 3 PA BUPRENORPHINSUB2MG 1 QL BUPRENORPHINSUB8MG 1 QL BUPRENOR/NALOXONE SUB 1 QL BUT/APAP/CAFCAPCODEINE 2 QL BUTORPHANOL SOL10MG/ML 2 QL BUTRANS DIS G 2 QL PA BUTRANS DIS10MCG/HR 2 QL PA BUTRANS DIS15MCG/HR 2 QL PA 10 BUTRANS DIS20MCG/HR 2 QL PA BUTRANS DIS5MCG/HR 2 QL PA CODEINE SULFTAB30MG 2 CODEINE SULFTAB60MG 2 EMBEDA CAP100-4MG 3 PA EMBEDA CAP20-0.8MG 3 PA EMBEDA CAP30-1.2MG 3 PA EMBEDA CAP50-2MG 3 PA EMBEDA CAP60-2.4MG 3 PA EMBEDA CAP80-3.2MG 3 PA ENDOCET TAB FENTANYL DIS100MCG/H 2 QL PA FENTANYL DIS12MCG/HR 2 QL PA FENTANYL DIS25MCG/HR 2 QL PA FENTANYL DIS50MCG/HR 2 QL PA FENTANYL DIS75MCG/HR 2 QL PA FENTANYL OT LOZ1200MCG 4 QL PA SP FENTANYL OT LOZ1600MCG 4 QL PA SP FENTANYL OT LOZ200MCG 4 QL PA SP FENTANYL OT LOZ400MCG 4 QL PA SP FENTANYL OT LOZ600MCG 4 QL PA SP FENTANYL OT LOZ800MCG 4 QL PA SP FENTORA TAB400MCG 4 QL PA SP HYDROCO/APAP TAB MG 1 QL HYDROCO/APAP TAB MG 1 QL HYDROCO/APAP TAB 5-325MG 1 QL HYDROMORPHONLIQ1MG/ML 2 HYDROMORPHONTAB12MG ER 2 PA HYDROMORPHONTAB16MG ER 2 PA HYDROMORPHONTAB2MG 2 QL HYDROMORPHONTAB32MG ER 2 QL PA HYDROMORPHONTAB4MG 2 QL HYDROMORPHONTAB8MG 2 QL HYDROMORPHONTAB8MG ER 2 QL PA LAZANDA SPR100MCG 4 QL PA SP LAZANDA SPR400MCG 4 QL PA SP LORCET TAB5-325MG 1 QL LORCET HD TAB10-325MG 1 QL LORCET PLUS TAB QL LORTAB ELX10-300MG 2 LORTAB TAB10-325MG 1 QL LORTAB TAB5-325MG 1 QL LORTAB TAB QL METHADONE CON10MG/ML 1 PA METHADONE SOL10MG/5ML 1 QL PA METHADONE SOL5MG/5ML 1 QL PA METHADONE TAB10MG 1 QL PA METHADONE TAB5MG 1 QL PA MORPHINE SULCAP100MG ER 2 QL PA MORPHINE SULCAP10MG ER 2 QL PA MORPHINE SULCAP120MG ER 2 QL PA MORPHINE SULCAP20MG ER 2 QL PA MORPHINE SULCAP30MG ER 2 QL PA MORPHINE SULCAP45MG ER 2 QL PA MORPHINE SULCAP50MG ER 2 QL PA MORPHINE SULCAP60MG ER 2 QL PA MORPHINE SULCAP75MG ER 2 QL PA MORPHINE SULCAP80MG ER 2 QL PA MORPHINE SULCAP90MG ER 2 QL PA MORPHINE SULSOL10MG/5ML 2 QL MORPHINE SULSOL20MG/5ML 2 QL MORPHINE SULSOL20MG/ML 2 QL MORPHINE SULTAB100MG ER 2 QL PA MORPHINE SULTAB15MG 2 QL MORPHINE SULTAB15MG ER 2 QL PA MORPHINE SULTAB200MG ER 2 QL PA MORPHINE SULTAB30MG 2 QL MORPHINE SULTAB30MG ER 2 QL PA MORPHINE SULTAB60MG ER 2 QL PA NALTREXONE TAB50MG 2 NUCYNTA TAB100MG 3 QL NUCYNTA TAB50MG 3 QL NUCYNTA TAB75MG 3 QL NUCYNTA ER TAB100MG 2 QL PA NUCYNTA ER TAB150MG 2 QL PA NUCYNTA ER TAB200MG 2 QL PA NUCYNTA ER TAB250MG 2 QL PA NUCYNTA ER TAB50MG 2 QL PA OXECTA TAB5MG 3 OXECTA TAB7.5MG 3

11 OXYCOD/APAP TAB MG 1 QL OXYCOD/APAP TAB MG 1 QL OXYCOD/APAP TAB 5-325MG 1 QL OXYCOD/APAP TAB MG 1 QL OXYCOD/IBU TAB5-400MG 2 QL OXYCODONE TAB10MG 2 QL OXYCODONE TAB10MG 2 QL OXYCODONE TAB15MG 2 QL OXYCODONE TAB20MG 2 QL OXYCODONE TAB20MG 2 QL OXYCODONE TAB30MG 2 QL OXYCODONE TAB5MG 2 QL OXYCONTIN TAB10MG CR 2 QL PA OXYCONTIN TAB15MG CR 2 QL PA OXYCONTIN TAB20MG CR 2 QL PA OXYCONTIN TAB30MG CR 2 QL PA OXYCONTIN TAB40MG CR 2 QL PA OXYCONTIN TAB60MG CR 2 QL PA OXYCONTIN TAB80MG CR 2 QL PA OXYMORPHONE TAB10MG ER 2 PA OXYMORPHONE TAB15MG ER 2 PA OXYMORPHONE TAB20MG ER 2 PA OXYMORPHONE TAB30MG ER 2 PA OXYMORPHONE TAB40MG ER 2 PA OXYMORPHONE TAB5MG ER 2 PA OXYMORPHONE TAB7.5MG ER 2 PA OXYMORPHONE TABHCL 10MG 2 OXYMORPHONE TABHCL 5MG 2 SUBSYS SPR100MCG 4 QL PA SP SUBSYS SPR200MCG 4 QL PA SP SUBSYS SPR400MCG 4 QL PA SP SUBSYS SPR600MCG 4 QL PA SP SUBSYS SPR800MCG 4 QL PA SP TRAMADOL HCLTAB50MG 2 QL XYLON TAB10-200MG 2 ANDROGENS-ANABOLIC ANADROL-50 TAB50MG 3 ANDRODERM DIS2MG/24HR 2 QL ANDRODERM DIS4MG/24HR 2 QL ANDROGEL 3 ANDROGEL PUMP 3 ANDROID CAP10MG 3 PA ANDROXY TAB10MG 3 AXIRON 3 DANAZOL CAP100MG 2 DANAZOL CAP200MG 2 DANAZOL CAP50MG 2 DEPO-TESTOSTINJ100MG/ML 2 DEPO-TESTOSTINJ200MG/ML 2 FORTESTA 3 METHITEST TAB10MG 2 OXANDROLONE TAB10MG 2 QL OXANDROLONE TAB2.5MG 2 QL STRIANT MIS30MG 3 TESTIM 3 TESTOST CYP INJ100MG/ML 2 TESTOST CYP INJ200MG/ML 2 TESTOST ENANINJ200MG/ML 2 TESTOSTERONE 3 TESTOSTERONE PUMP 3 TESTRED CAP10MG 3 PA VOGELXO 3 VOGELXO PUMP 3 ANORECTAL AGENTS COLOCORT ENE100MG 2 HYDROCORT CRE2.5% 1 HYDROCORT ENE100MG 2 PROCTOCREAM CREHC 2.5% 1 PROCTO-KIT CRE2.5% 1 PROCTO-PAK CRE1% 1 PROCTOSOL HCCRE2.5% 1 PROCTOZONE CRE-HC 2.5% 1 RECTIV OIN0.4% 3 ANTHELMINTICS ALBENZA TAB200MG 3 BILTRICIDE TAB600MG 3 MEBENDAZOLE CHW100MG 1 ANTIANGINAL AGENTS IMDUR TAB60MG ER 1 ISOCHRON TAB40MG CR 1 11 ISODITRATE TAB40MG ER 1 ISOSORB DIN SUB2.5MG 1 ISOSORB DIN SUB5MG 1 ISOSORB DIN TAB10MG 1 ISOSORB DIN TAB20MG 1 ISOSORB DIN TAB30MG 1 ISOSORB DIN TAB40MG ER 1 ISOSORB DIN TAB5MG 1 ISOSORB MONOTAB10MG 1 ISOSORB MONOTAB120MG ER 1 ISOSORB MONOTAB20MG 1 ISOSORB MONOTAB30MG ER 1 ISOSORB MONOTAB60MG ER 1 MINITRAN DIS0.1MG/HR 1 QL MINITRAN DIS0.2MG/HR 1 QL MINITRAN DIS0.4MG/HR 1 QL MINITRAN DIS0.6MG/HR 1 QL NITRO-BID OIN2% 1 NITROGLYCER DIS0.1MG/HR 1 QL NITROGLYCER DIS0.2MG/HR 1 QL NITROGLYCER DIS0.4MG/HR 1 QL NITROGLYCERIDIS0.6MG/HR 1 QL NITROGLYCRN SPR0.4MG 3 NITROLINGUALSPRPUMPSPRA 3 NITROMIST AER400MCG 3 NITROSTAT SUB0.3MG 2 NITROSTAT SUB0.4MG 2 NITROSTAT SUB0.6MG 2 RANEXA TAB1000MG 2 QL RANEXA TAB500MG 2 QL ANTIANXIETY AGENTS ALPRAZOLAM 2 ALPRAZOLAM ODT 2 ALPRAZOLAM XR 2 BUSPIRONE TAB10MG 1 BUSPIRONE TAB15MG 1 BUSPIRONE TAB30MG 1 BUSPIRONE TAB5MG 1 BUSPIRONE TAB7.5MG 1 CLONAZEP ODTTAB0.125MG 1 QL CLONAZEP ODTTAB0.25MG 1 QL CLONAZEP ODTTAB0.5MG 1 QL CLONAZEPAM TAB0.5MG 1 QL CLONAZEPAM TAB1MG 1 QL CLONAZEPAM TAB2MG 1 QL DIAZEPAM 2 DIAZEPAM INTENSOL 2 HYDROXYZ HCLSOL10MG/5ML 1 HYDROXYZ HCLTAB10MG 1 HYDROXYZ HCLTAB25MG 1 HYDROXYZ HCLTAB50MG 1 HYDROXYZ PAMCAP100MG 1 HYDROXYZ PAMCAP25MG 1 HYDROXYZ PAMCAP50MG 1 LORAZEPAM 2 LORAZEPAM INTENSOL 2 MEPROBAMATE TAB200MG 2 MEPROBAMATE TAB400MG 2 ANTIARRHYTHMICS AMIODARONE TAB100MG 1 AMIODARONE TAB200MG 1 AMIODARONE TAB400MG 2 DISOPYRAMIDECAP100MG 2 DISOPYRAMIDECAP150MG 2 FLECAINIDE TAB100MG 2 FLECAINIDE TAB150MG 2 FLECAINIDE TAB50MG 2 MEXILETINE CAP150MG 2 MEXILETINE CAP200MG 2 MEXILETINE CAP250MG 2 MULTAQ TAB400MG 3 QL NORPACE CAP100MG CR 3 NORPACE CAP150MG CR 3 PACERONE TAB100MG 1 PACERONE TAB200MG 1 PACERONE TAB400MG 1 PROPAFENONE CAP225MG ER 1 PROPAFENONE CAP325MG ER 1 PROPAFENONE CAP425MG SR 1 PROPAFENONE TAB150MG 1

12 PROPAFENONE TAB225MG 1 PROPAFENONE TAB300MG 1 QUINIDINE GLTAB324MG CR 2 QUINIDINE SUTAB200MG 2 QUINIDINE SUTAB300MG 2 QUINIDINE SUTAB300MG ER 2 TIKOSYN CAP125MCG 4 PA SP TIKOSYN CAP250MCG 4 PA SP TIKOSYN CAP500MCG 4 PA SP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ADVAIR DISKUAER100/50 2 QL ADVAIR DISKUAER250/50 2 QL ADVAIR DISKUAER500/50 2 QL ADVAIR HFA AER115/21 2 QL ADVAIR HFA AER230/21 2 QL ADVAIR HFA AER45/21 2 QL ALBUTEROL NEB0.083% 1 QL ALBUTEROL NEB0.5% 1 QL ALBUTEROL NEB0.63MG/3 1 QL ALBUTEROL NEB1.25MG/3 1 QL ALBUTEROL SYP2MG/5ML 1 ALBUTEROL TAB2MG 1 ALBUTEROL TAB4MG 1 ALBUTEROL TAB8MG ER 1 ANORO ELLIPTAER ARCAPTA CAP75MCG 3 QL ASMANEX 120 AER220MCG 3 QL ASMANEX 14 AER220MCG 3 QL ASMANEX 30 AER110MCG 3 QL ASMANEX 30 AER220MCG 3 QL ASMANEX 60 AER220MCG 3 QL ASMANEX 7 AER110MCG 3 QL ASMANEX HFA AER100 MCG 3 ASMANEX HFA AER200 MCG 3 BREO ELLIPTAINH QL BREO ELLIPTAINH QL BROVANA NEB15MCG 3 BUDESONIDE SUS0.25MG/2 2 QL BUDESONIDE SUS0.5MG/2 2 QL CROMOLYN SODNEB20MG/2ML 2 QL DALIRESP TAB500MCG 3 QL DULERA AER100-5MCG 2 QL DULERA AER200-5MCG 2 QL ELIXOPHYLLINELX80/15ML 2 EPINEPHRINE INJ0.1MG/ML 2 FLOVENT DISKAER100MCG 2 QL FLOVENT DISKAER250MCG 2 QL FLOVENT DISKAER50MCG 2 QL FLOVENT HFA AER110MCG 2 QL FLOVENT HFA AER220MCG 2 QL FLOVENT HFA AER44MCG 2 QL FORADIL CAPAEROLIZE 2 QL IPRATROPIUM SOL0.02%INH 2 LEVALBUTEROLNEB0.31MG 1 QL LEVALBUTEROLNEB0.63MG 1 QL LEVALBUTEROLNEB1.25/0.5 1 QL LUFYLLIN TAB200MG 2 LUFYLLIN TAB400MG 2 METAPROTERENSYP10MG/5ML 1 METAPROTERENTAB10MG 1 METAPROTERENTAB20MG 1 MONTELUKAST CHW4MG 1 QL MONTELUKAST CHW5MG 1 QL MONTELUKAST GRA4MG 1 QL MONTELUKAST TAB10MG 1 QL PERFOROMIST NEB20MCG 3 PROAIR HFA AER 3 QL PROAIR RESPICLICK 3 PROVENTIL AERHFA 3 QL PULMICORT INH180MCG 2 QL PULMICORT INH90MCG 2 QL QVAR AER40MCG 2 QL QVAR AER80MCG 2 QL SEREVENT DISAER50MCG 3 QL SPIRIVA CAPHANDIHLR 2 QL SPIRIVA SPRRESPIMAT 2 QL SPIRIVA RESPIMAT 2 STRIVERDI AERRESPIMAT 2 TERBUTALINE TAB2.5MG 1 TERBUTALINE TAB5MG 1 12 THEOCHRON TAB100MG CR 1 THEOCHRON TAB200MG CR 1 THEOCHRON TAB300MG CR 1 THEOPHYLLINETAB100MG CR 1 THEOPHYLLINETAB200MG CR 1 THEOPHYLLINETAB300MG ER 1 THEOPHYLLINETAB400MG ER 1 THEOPHYLLINETAB450MG ER 1 THEOPHYLLINETAB600MG ER 1 VENTOLIN HFAAER 3 QL VOSPIRE ER TAB8MG 1 XOPENEX HFA AER 3 QL ZAFIRLUKAST TAB10MG 2 QL ZAFIRLUKAST TAB20MG 2 QL ANTICOAGULANTS ELIQUIS TAB2.5MG 2 QL ELIQUIS TAB5MG 2 QL ENOXAPARIN INJ100MG/ML 2 QL ENOXAPARIN INJ120/0.8 2 QL ENOXAPARIN INJ150MG/ML 2 QL ENOXAPARIN INJ30/0.3ML 2 QL ENOXAPARIN INJ300/3ML 2 QL ENOXAPARIN INJ40/0.4ML 2 QL ENOXAPARIN INJ60/0.6ML 2 QL ENOXAPARIN INJ80/0.8ML 2 QL FONDAPARINUXSOL10/0.8 4 QL PA SP FONDAPARINUXSOL2.5/0.5 4 QL PA SP FONDAPARINUXSOL5.0/0.4 4 QL PA SP FONDAPARINUXSOL7.5/0.6 4 QL PA SP HEPARIN LOCKINJ100/ML 1 HEPARIN SOD INJ1000/ML 1 HEPARIN SOD INJ10000/ML 1 HEPARIN SOD INJ5000/ML 1 HEPARIN SODIUM 1 JANTOVEN TAB10MG 1 JANTOVEN TAB1MG 1 JANTOVEN TAB2.5MG 1 JANTOVEN TAB2MG 1 JANTOVEN TAB3MG 1 JANTOVEN TAB4MG 1 JANTOVEN TAB5MG 1 JANTOVEN TAB6MG 1 JANTOVEN TAB7.5MG 1 PRADAXA CAP110MG 3 QL PRADAXA CAP150MG 3 QL PRADAXA CAP75MG 3 QL WARFARIN TAB10MG 1 WARFARIN TAB1MG 1 WARFARIN TAB2.5MG 1 WARFARIN TAB2MG 1 WARFARIN TAB3MG 1 WARFARIN TAB4MG 1 WARFARIN TAB5MG 1 WARFARIN TAB6MG 1 WARFARIN TAB7.5MG 1 XARELTO TAB10MG 3 QL XARELTO TAB15MG 3 QL XARELTO TAB20MG 3 QL XARELTO STARTAB15/20MG 3 QL ANTICONVULSANTS APTIOM TAB200MG 3 QL APTIOM TAB400MG 3 QL APTIOM TAB600MG 3 QL APTIOM TAB800MG 3 QL BANZEL SUS40MG/ML 3 QL BANZEL TAB200MG 3 QL BANZEL TAB400MG 3 QL CARBAMAZEPINCAP100MG ER 1 CARBAMAZEPINCAP200MG ER 1 CARBAMAZEPINCAP300MG ER 1 CARBAMAZEPINCHW100MG 1 CARBAMAZEPINSUS100/5ML 1 CARBAMAZEPINTAB200MG 1 CARBAMAZEPINTAB200MG ER 1 CARBAMAZEPINTAB400MG ER 1 CELONTIN CAP300MG 2 DILANTIN CAP30MG 3 DIVALPROEX CAP125MG 2 DIVALPROEX TAB125MG DR 2 DIVALPROEX TAB250MG DR 2

13 DIVALPROEX TAB250MG ER 2 DIVALPROEX TAB500MG DR 2 DIVALPROEX TAB500MG ER 2 EPITOL TAB200MG 1 ETHOSUXIMIDECAP250MG 2 ETHOSUXIMIDESOL250/5ML 2 FELBAMATE SUS600/5ML 2 FELBAMATE TAB400MG 2 FELBAMATE TAB600MG 2 FYCOMPA TAB10MG 3 QL FYCOMPA TAB12MG 3 QL FYCOMPA TAB2MG 3 QL FYCOMPA TAB4MG 3 QL FYCOMPA TAB6MG 3 QL FYCOMPA TAB8MG 3 QL GABAPENTIN CAP100MG 2 QL GABAPENTIN CAP300MG 2 QL GABAPENTIN CAP400MG 2 QL GABAPENTIN SOL250/5ML 2 QL GABAPENTIN TAB600MG 2 QL GABAPENTIN TAB800MG 2 QL GABITRIL TAB12MG 3 GABITRIL TAB16MG 3 LAMOTRIGINE CHW25MG 2 LAMOTRIGINE CHW5MG 2 LAMOTRIGINE ER 2 LAMOTRIGINE TAB100MG 2 LAMOTRIGINE TAB150MG 2 LAMOTRIGINE TAB200MG 2 LAMOTRIGINE TAB25MG 2 LEVETIRACETASOL100MG/ML 2 LEVETIRACETATAB1000MG 2 LEVETIRACETATAB250MG 2 LEVETIRACETATAB500MG 2 LEVETIRACETATAB500MG ER 2 QL LEVETIRACETATAB750MG 2 LEVETIRACETATAB750MG ER 2 QL LYRICA CAP100MG 2 QL LYRICA CAP150MG 2 QL LYRICA CAP200MG 2 QL LYRICA CAP225MG 2 QL LYRICA CAP25MG 2 QL LYRICA CAP300MG 2 QL LYRICA CAP50MG 2 QL LYRICA CAP75MG 2 QL LYRICA SOL20MG/ML 2 QL ONFI SUS2.5MG/ML 3 QL PA OXCARBAZEPINSUS300MG/5M 2 OXCARBAZEPINTAB150MG 2 OXCARBAZEPINTAB300MG 2 OXCARBAZEPINTAB600MG 2 PEGANONE TAB250MG 3 PHENYTEK CAP200MG 1 PHENYTEK CAP200MG 2 PHENYTEK CAP300MG 1 PHENYTEK CAP300MG 2 PHENYTOIN CHW50MG 1 PHENYTOIN SUS125/5ML 1 PHENYTOIN EXCAP100MG 1 PHENYTOIN EXCAP200MG 1 PHENYTOIN EXCAP300MG 1 PIMOZIDE TAB1MG 1 PIMOZIDE TAB2MG 1 POTIGA TAB200MG 3 QL POTIGA TAB300MG 3 QL POTIGA TAB400MG 3 QL POTIGA TAB50MG 3 QL PRIMIDONE TAB250MG 1 PRIMIDONE TAB50MG 1 QUDEXY XR CAP100/24HR 3 QUDEXY XR CAP150/24HR 3 QUDEXY XR CAP200/24HR 3 QUDEXY XR CAP25/24HR 3 QUDEXY XR CAP50/24HR 3 SABRIL POW500MG 4 PA QL SP SABRIL TAB500MG 4 PA QL SP SPRITAM TAB 250MG 3 SPRITAM TAB 500MG 3 SPRITAM TAB 1000MG 3 SPRITAM TAB 750MG 3 13 TIAGABINE TAB2MG 2 TIAGABINE TAB4MG 2 TOPIRAMATE CAPER 100MG 3 TOPIRAMATE CAPER 150MG 3 TOPIRAMATE CAPER 200MG 3 TOPIRAMATE CAPER 25MG 3 TOPIRAMATE CAPER 50MG 3 TOPIRAMATE TAB100MG 1 QL TOPIRAMATE TAB200MG 1 QL TOPIRAMATE TAB25MG 1 QL TOPIRAMATE TAB50MG 1 QL VALPROIC ACDCAP250MG 1 VALPROIC ACDSYP250/5ML 1 VIMPAT SOL10MG/ML 2 QL ST VIMPAT TAB100MG 2 QL ST VIMPAT TAB150MG 2 QL ST VIMPAT TAB200MG 2 QL ST VIMPAT TAB50MG 2 QL ST ZONISAMIDE CAP100MG 2 ZONISAMIDE CAP25MG 2 ZONISAMIDE CAP50MG 2 ANTIDEPRESSANTS AMITRIPTYLINTAB100MG 2 AMITRIPTYLINTAB10MG 2 AMITRIPTYLINTAB150MG 2 AMITRIPTYLINTAB25MG 2 AMITRIPTYLINTAB50MG 2 AMITRIPTYLINTAB75MG 2 AMOXAPINE TAB100MG 2 AMOXAPINE TAB150MG 2 AMOXAPINE TAB25MG 2 AMOXAPINE TAB50MG 2 APLENZIN TAB174MG 3 QL ST APLENZIN TAB348MG 3 QL ST APLENZIN TAB522MG 3 QL ST BUDEPRION TAB100MG SR 1 QL BUDEPRION TAB150MG SR 1 QL BUPROPION TAB100MG 1 QL BUPROPION TAB100MG 1 QL BUPROPION TAB100MG SR 1 QL BUPROPION TAB150MG SR 1 QL BUPROPION TAB200MG SR 1 QL BUPROPION TAB75MG 1 QL BUPROPN HCL TAB150MG XL 1 QL BUPROPN HCL TAB300MG XL 1 QL CITALOPRAM SOL10MG/5ML 1 QL CITALOPRAM TAB10MG 1 QL CITALOPRAM TAB20MG 1 QL CITALOPRAM TAB40MG 1 QL CLOMIPRAMINECAP25MG 1 CLOMIPRAMINECAP50MG 1 CLOMIPRAMINECAP75MG 1 DESIPRAMINE TAB100MG 1 DESIPRAMINE TAB10MG 1 DESIPRAMINE TAB150MG 1 DESIPRAMINE TAB25MG 1 DESIPRAMINE TAB50MG 1 DESIPRAMINE TAB75MG 1 DESVENLAFAX TAB100MG ER 2 QL DESVENLAFAX TAB50MG ER 2 QL DOXEPIN HCL CAP100MG 1 DOXEPIN HCL CAP10MG 1 DOXEPIN HCL CAP150MG 1 DOXEPIN HCL CAP25MG 1 DOXEPIN HCL CAP50MG 1 DOXEPIN HCL CAP75MG 1 DOXEPIN HCL CON10MG/ML 1 DULOXETINE CAP20MG 2 QL DULOXETINE CAP30MG 2 QL DULOXETINE CAP60MG 2 QL EMSAM DIS12MG/24H 4 QL PA SP EMSAM DIS6MG/24HR 4 QL PA SP EMSAM DIS9MG/24HR 4 QL PA SP ESCITALOPRAMSOL5MG/5ML 2 QL ESCITALOPRAMTAB10MG 2 QL ESCITALOPRAMTAB20MG 2 QL ESCITALOPRAMTAB5MG 2 QL FLUOXETINE CAP10MG 1 QL FLUOXETINE CAP20MG 1 QL FLUOXETINE CAP40MG 1 QL

14 FLUOXETINE CAP90MG DR 1 QL FLUOXETINE SOL20MG/5ML 1 QL FLUOXETINE TAB10MG 1 QL FLUOXETINE TAB20MG 1 QL FLUOXETINE TAB20MG 1 QL FLUOXETINE TAB60MG 2 QL FLUVOXAMINE TAB100MG 2 QL FLUVOXAMINE TAB25MG 2 QL FLUVOXAMINE TAB50MG 2 QL FLUVOXAMINE CAP 100 MG ER 2 FLUVOXAMINE CAP 150 MG ER 2 FORFIVO XL TAB450MG 3 QL ST IMIPRAM HCL TAB10MG 2 IMIPRAM HCL TAB25MG 2 IMIPRAM HCL TAB50MG 2 IMIPRAM PAM CAP100MG 1 IMIPRAM PAM CAP125MG 3 IMIPRAM PAM CAP150MG 1 IMIPRAM PAM CAP75MG 1 MAPROTILINE TAB25MG 2 QL MAPROTILINE TAB50MG 2 QL MAPROTILINE TAB75MG 2 MARPLAN TAB10MG 3 MIRTAZAPINE TAB15MG 2 QL MIRTAZAPINE TAB15MG ODT 2 QL MIRTAZAPINE TAB30MG 2 QL MIRTAZAPINE TAB30MG ODT 2 QL MIRTAZAPINE TAB45MG 2 QL MIRTAZAPINE TAB45MG ODT 2 QL MIRTAZAPINE TAB7.5MG 2 QL NEFAZODONE TAB100MG 2 QL NEFAZODONE TAB150MG 2 QL NEFAZODONE TAB200MG 2 QL NEFAZODONE TAB250MG 2 QL NEFAZODONE TAB50MG 2 QL NORTRIPTYLINCAP10MG 2 NORTRIPTYLINCAP25MG 2 NORTRIPTYLINCAP50MG 2 NORTRIPTYLINCAP75MG 2 NORTRIPTYLINSOL10MG/5ML 2 OLEPTRO TAB24HR150 3 OLEPTRO TAB24HR300 3 PAROXETIN ERTAB12.5MG 2 QL PAROXETIN ERTAB37.5MG 2 QL PAROXETINE SUS10MG/5ML 2 PAROXETINE TAB10MG 2 QL PAROXETINE TAB20MG 2 QL PAROXETINE TAB25MG ER 2 QL PAROXETINE TAB30MG 2 QL PAROXETINE TAB40MG 2 QL PAXIL SUS10MG/5ML 3 QL PEXEVA TAB10MG 3 QL PEXEVA TAB20MG 3 QL PEXEVA TAB30MG 3 QL PEXEVA TAB40MG 3 QL PHENELZINE TAB15MG 2 PRISTIQ TAB100MG 3 PA QL PRISTIQ TAB50MG 3 PA QL PROTRIPTYLINTAB10MG 2 PROTRIPTYLINTAB5MG 2 SERTRALINE CON20MG/ML 1 QL SERTRALINE TAB100MG 1 QL SERTRALINE TAB25MG 1 QL SERTRALINE TAB50MG 1 QL TRANYLCYPROMTAB10MG 2 TRAZODONE TAB100MG 2 TRAZODONE TAB150MG 2 TRAZODONE TAB300MG 2 TRAZODONE TAB50MG 2 TRIMIPRAMINECAP100MG 2 TRIMIPRAMINECAP25MG 2 TRIMIPRAMINECAP50MG 2 VENLAFAXINE CAP150MG ER 2 QL VENLAFAXINE CAP37.5 ER 2 QL VENLAFAXINE CAP75MG ER 2 QL VENLAFAXINE TAB100MG 2 QL VENLAFAXINE TAB150MG ER 2 QL VENLAFAXINE TAB225MG ER 2 QL ST VENLAFAXINE TAB25MG 2 QL VENLAFAXINE TAB37.5 ER 2 QL 14 VENLAFAXINE TAB37.5MG 2 QL VENLAFAXINE TAB50MG 2 QL VENLAFAXINE TAB75MG 2 QL VENLAFAXINE TAB75MG ER 2 QL VIIBRYD KIT 3 ST VIIBRYD TAB10MG 3 QL ST VIIBRYD TAB20MG 3 QL ST VIIBRYD TAB40MG 3 QL ST ANTIDIABETICS ACARBOSE TAB100MG 1 QL ACARBOSE TAB25MG 1 QL ACARBOSE TAB50MG 1 QL AVANDIA TAB2MG 3 QL AVANDIA TAB4MG 3 QL AVANDIA TAB8MG 3 QL BASAGLAR INJ100UNIT 2 BYDUREON INJ 2 QL ST BYDUREON INJ 2 QL ST BYETTA INJ10MCG 2 QL PA ST BYETTA INJ5MCG 2 QL PA ST CHLORPROPAM TAB100MG 1 QL CHLORPROPAM TAB250MG 1 QL FARXIGA TAB10MG 2 ST FARXIGA TAB5MG 2 ST GLIMEPIRIDE TAB1MG 1 QL GLIMEPIRIDE TAB2MG 1 QL GLIMEPIRIDE TAB4MG 1 QL GLIPIZIDE TAB10MG 1 QL GLIPIZIDE TAB5MG 1 QL GLIPIZIDE ERTAB10MG 1 QL GLIPIZIDE ERTAB2.5MG 1 QL GLIPIZIDE ERTAB5MG 1 QL GLIPIZIDE ERTAB5MG 1 QL GLUCAGEN INJHYPOKIT 2 QL GLUCAGON KIT1MG 2 QL GLYBURID MCRTAB1.5MG 1 QL GLYBURID MCRTAB3MG 1 QL GLYBURID MCRTAB6MG 1 QL GLYBURIDE TAB1.25MG 1 QL GLYBURIDE TAB2.5MG 1 QL GLYBURIDE TAB5MG 1 QL HUMALOG INJ100/ML 2 QL HUMALOG KWIKPEN 2 QL HUMALOG MIX INJ50/50 2 QL HUMALOG MIX INJ50/50KWP 2 QL HUMALOG MIX INJ75/25KWP 2 QL HUMALOG MIX SUS75/25 2 QL HUMULIN INJ70/30 2 QL HUMULIN N INJU QL HUMULIN R INJU QL HUMULIN R INJU PA QL INVOKAMET TAB ST INVOKAMET TAB ST INVOKAMET TAB ST INVOKAMET TAB50-500MG 3 ST INVOKANA TAB100MG 3 ST INVOKANA TAB300MG 3 ST JANUVIA TAB100MG 2 QL JANUVIA TAB25MG 2 QL JANUVIA TAB50MG 2 QL JARDIANCE TAB10MG 3 QL ST JARDIANCE TAB25MG 3 QL ST LANTUS INJ100/ML 2 QL LANTUS INJSOLOSTAR 2 QL LEVEMIR INJ 2 QL LEVEMIR INJFLEXPEN 2 QL METFORMIN TAB1000MG 1 QL METFORMIN TAB500MG 1 QL METFORMIN TAB500MG ER 1 QL METFORMIN TAB500MG ER 1 QL METFORMIN TAB750MG ER 1 QL METFORMIN TAB850MG 1 QL MIGLITOL TAB100MG 2 QL MIGLITOL TAB50MG 2 QL MIGLITOL TAB25MG 2 QL NATEGLINIDE TAB120MG 2 QL NATEGLINIDE TAB60MG 2 QL NOVOLIN INJ70/30 2 QL NOVOLIN N INJU QL NOVOLIN R INJU QL

15 NOVOLOG INJ100/ML 2 QL NOVOLOG FLEXPEN 2 QL NOVOLOG MIX INJ70/30 2 QL NOVOLOG MIX INJFLEXPEN 2 QL ONGLYZA TAB2.5MG 2 QL ONGLYZA TAB5MG 2 QL PIOGLITAZONETAB15MG 2 QL PIOGLITAZONETAB30MG 2 QL PIOGLITAZONETAB45MG 2 QL REPAGLINIDE TAB0.5MG 1 REPAGLINIDE TAB1MG 1 REPAGLINIDE TAB2MG 1 RIOMET SOL 3 SYMLINPEN 60INJ1000MCG 3 QL PA SYMLNPEN 120INJ1000MCG 3 QL PA TANZEUM INJ30MG 2 ST TANZEUM INJ50MG 2 ST TOLAZAMIDE TAB250MG 1 TOLAZAMIDE TAB500MG 1 TOLBUTAMIDE TAB500MG 1 TOUJEO SOLO INJ300IU/ML 2 QL PA TRADJENTA TAB5MG 2 TRULICITY INJ0.75/0.5 3 ST TRULICITY INJ1.5/0.5 3 ST VICTOZA INJ18MG/3ML 3 QL ST ANTIDOTES CHEMET CAP100MG 3 JADENU TAB180MG 4 PA SP JADENU TAB360MG 4 PA SP JADENU TAB90MG 4 PA SP FERRIPROX TAB500MG 4 PA SP NALOXONE INJ0.4MG/ML 1 NARCAN SPRAY 2 NALTREXONE TAB50MG 2 ANTIEMETICS ANZEMET TAB100MG 3 QL ANZEMET TAB100MG 3 QL SP ANZEMET TAB50MG 3 QL CESAMET CAP1MG 3 QL DRONABINOL CAP10MG 2 QL DRONABINOL CAP2.5MG 2 QL DRONABINOL CAP5MG 2 QL EMEND CAP125MG 3 QL EMEND CAP40MG 3 QL EMEND CAP80MG 3 QL EMEND PAK80 & QL GRANISETRON TAB1MG 2 QL GRANISOL SOL2MG/10ML 2 MECLIZINE TAB12.5MG 2 MECLIZINE TAB25MG 2 ONDANSETRON INJ4MG/2ML 2 ONDANSETRON SOL4MG/5ML 2 QL ONDANSETRON TAB24MG 2 QL ONDANSETRON TAB4MG 1 QL ONDANSETRON TAB4MG ODT 1 QL ONDANSETRON TAB8MG 1 QL ONDANSETRON TAB8MG ODT 1 QL SANCUSO DIS3.1MG 3 QL PA TRANSDERM-SCDIS1.5MG 3 QL TRIMETHOBENZCAP300MG 1 ANTIFUNGALS FLUCONAZOLE SUS10MG/ML 2 FLUCONAZOLE SUS40MG/ML 2 FLUCONAZOLE TAB100MG 2 FLUCONAZOLE TAB150MG 2 QL FLUCONAZOLE TAB200MG 2 FLUCONAZOLE TAB50MG 2 FLUCYTOSINE CAP250MG 2 FLUCYTOSINE CAP500MG 2 GRISEOFULVINSUS125/5ML 2 GRISEOFULVINTABMICR GRISEOFULVINTABULTR GRISEOFULVINTABULTR ITRACONAZOLECAP100MG 2 PA KETOCONAZOLETAB200MG 2 LAMISIL GRA125MG 3 LAMISIL GRA187.5MG 3 NYSTATIN SUS NYSTATIN TAB SPORANOX CAP PULSEPAK 3 PA 15 SPORANOX SOL10MG/ML 3 PA TERBINAFINE TAB250MG 2 QL VORICONAZOLETAB200MG 2 QL PA VORICONAZOLETAB50MG 2 QL PA ANTIHISTAMINES ARBINOXA SOL4MG/5ML 1 ARBINOXA TAB4MG 1 CARBINOXAMINSOL4MG/5ML 1 CARBINOXAMINTAB4MG 1 CLEMASTINE SYP0.5/5ML 2 CLEMASTINE TAB2.68MG 2 CYPROHEPTAD SYP2MG/5ML 2 CYPROHEPTAD TAB4MG 2 DESLORATADINTAB2.5 ODT 2 DESLORATADINTAB5MG 2 DESLORATADINTAB5MG ODT 2 DEXCHLORPHENSYP2MG/5ML 2 LEVOCETIRIZISOL2.5/5ML 2 LEVOCETIRIZITAB5MG 2 QL PALGIC SOL4MG/5ML 1 PHENADOZ SUP12.5MG 1 PHENADOZ SUP25MG 1 PHENERGAN SUP12.5MG 1 PHENERGAN SUP25MG 1 PROMETHAZINESUP12.5MG 1 PROMETHAZINESUP25MG 1 PROMETHAZINESUP50MG 1 PROMETHAZINESYP6.25/5ML 2 PROMETHAZINETAB12.5MG 2 PROMETHAZINETAB25MG 2 PROMETHAZINETAB50MG 1 PROMETHAZINETAB50MG 2 PROMETHEGAN SUP12.5MG 1 PROMETHEGAN SUP25MG 1 PROMETHEGAN SUP50MG 1 ANTIHYPERLIPIDEMICS ANTARA CAP30MG 3 ANTARA CAP90MG 3 ATORVASTATINTAB10MG 1 QL ATORVASTATINTAB20MG 1 QL ATORVASTATINTAB40MG 1 QL ATORVASTATINTAB80MG 1 QL CHOLESTYRAM POW4GM LITE 1 COLESTIPOL GRA5GM 2 COLESTIPOL TAB1GM 2 EZETIM/SIMVATAB10-10MG 2 QL EZETIM/SIMVATAB10-20MG 2 QL EZETIM/SIMVATAB10-40MG 2 QL EZETIM/SIMVATAB10-80MG 2 QL FENOFIBRATE CAP130MG 1 QL FENOFIBRATE CAP134MG 1 QL FENOFIBRATE CAP200MG 1 QL FENOFIBRATE CAP43MG 1 QL FENOFIBRATE CAP67MG 1 QL FENOFIBRATE TAB145MG 1 QL FENOFIBRATE TAB160MG 1 QL FENOFIBRATE TAB48MG 1 QL FENOFIBRATE TAB54MG 1 QL FENOFIBRIC TAB105MG 3 FENOFIBRIC TAB35MG 3 FENOFIBRIC CAP135MG DR 2 FENOFIBRIC CAP45MG DR 2 FENOGLIDE TAB120MG 3 FENOGLIDE TAB40MG 3 FIBRICOR TAB105MG 3 FIBRICOR TAB35MG 3 FLUVASTATIN CAP20MG 1 QL FLUVASTATIN CAP40MG 1 QL FLUVASTATIN ER TAB 2 QL GEMFIBROZIL TAB600MG 1 LIPOFEN CAP150MG 3 LIPOFEN CAP50MG 3 LOVASTATIN TAB10MG 1 QL LOVASTATIN TAB20MG 1 QL LOVASTATIN TAB40MG 1 QL NIACIN ER TAB1000MG 2 QL NIACIN ER TAB500MG 2 NIACIN ER TAB750MG 2 NIACOR TAB500MG 1 OMEGA-3 ACID CAP 1 GM 2

16 PRAVASTATIN TAB10MG 1 QL PRAVASTATIN TAB20MG 1 QL PRAVASTATIN TAB40MG 1 QL PRAVASTATIN TAB80MG 1 QL PREVALITE POW4GM 1 QUESTRAN POW4GM 1 ROSUVASTATINTAB10MG 1 QL ROSUVASTATINTAB20MG 1 QL ROSUVASTATINTAB40MG 1 QL ROSUVASTATINTAB5MG 1 QL SIMVASTATIN TAB10MG 1 QL SIMVASTATIN TAB20MG 1 QL SIMVASTATIN TAB40MG 1 QL SIMVASTATIN TAB5MG 1 QL SIMVASTATIN TAB80MG 1 QL TRIGLIDE TAB160MG 3 VASCEPA CAP1GM 3 ZETIA TAB10MG 2 QL ANTIHYPERTENSIVES BENAZEP/HCTZTAB BENAZEP/HCTZTAB BENAZEP/HCTZTAB20-25MG 2 BENAZEP/HCTZTAB BENAZEPRIL TAB10MG 1 BENAZEPRIL TAB20MG 1 BENAZEPRIL TAB40MG 1 BENAZEPRIL TAB5MG 1 BENICAR TAB20MG 3 QL BENICAR TAB40MG 3 QL BENICAR TAB5MG 3 QL CANDESARTAN 4 MG 1 QL CANDESARTAN 8 MG 1 QL CANDESARTAN TAB16MG 1 QL CANDESARTAN TAB32MG 1 QL CAPTOPRIL TAB100MG 1 CAPTOPRIL TAB12.5MG 1 CAPTOPRIL TAB25MG 1 CAPTOPRIL TAB50MG 1 CLONIDINE DIS0.1/24HR 2 QL CLONIDINE DIS0.2/24HR 2 QL CLONIDINE DIS0.3/24HR 2 QL CLONIDINE TAB0.1MG 1 CLONIDINE TAB0.2MG 1 CLONIDINE TAB0.3MG 1 DIBENZYLINE CAP10MG 4 PA SP DOXAZOSIN TAB1MG 1 QL DOXAZOSIN TAB2MG 1 QL DOXAZOSIN TAB4MG 1 QL DOXAZOSIN TAB8MG 1 QL EDARBI TAB40MG 3 EDARBI TAB80MG 3 ENALAPRIL TAB10MG 1 ENALAPRIL TAB2.5MG 1 ENALAPRIL TAB20MG 1 ENALAPRIL TAB5MG 1 EPLERENONE TAB25MG 2 EPLERENONE TAB50MG 2 EPROSART MESTAB600MG 1 QL FOSINOPRIL TAB10MG 1 FOSINOPRIL TAB20MG 1 FOSINOPRIL TAB40MG 1 GUANFACINE TAB1MG 1 GUANFACINE TAB2MG 1 HYDRALAZINE TAB100MG 1 HYDRALAZINE TAB10MG 1 HYDRALAZINE TAB25MG 1 HYDRALAZINE TAB50MG 1 IRBESARTAN TAB150MG 1 QL IRBESARTAN TAB300MG 1 QL IRBESARTAN TAB75MG 1 QL LISINOP/HCTZTAB LISINOP/HCTZTAB LISINOP/HCTZTAB20-25MG 1 LISINOPRIL TAB10MG 1 LISINOPRIL TAB2.5MG 1 LISINOPRIL TAB20MG 1 LISINOPRIL TAB30MG 1 LISINOPRIL TAB40MG 1 LISINOPRIL TAB5MG 1 16 LOSARTAN POTTAB100MG 1 QL LOSARTAN POTTAB25MG 1 QL LOSARTAN POTTAB50MG 1 QL LOSARTAN/HCTTAB LOSARTAN/HCTTAB LOSARTAN/HCTTAB METHYLDOPA TAB250MG 1 METHYLDOPA TAB500MG 1 MINOXIDIL TAB10MG 1 MINOXIDIL TAB2.5MG 1 MOEXIPRIL TAB15MG 1 MOEXIPRIL TAB7.5MG 1 OLMESA MEDOXTAB20MG 2 QL OLMESA MEDOXTAB40MG 2 QL OLMESA MEDOXTAB5MG 2 QL PERINDOPRIL TAB2MG 1 PERINDOPRIL TAB4MG 1 PERINDOPRIL TAB8MG 1 PRAZOSIN HCLCAP1MG 1 PRAZOSIN HCLCAP2MG 1 PRAZOSIN HCLCAP5MG 1 QUINAPRIL TAB10MG 1 QUINAPRIL TAB20MG 1 QUINAPRIL TAB40MG 1 QUINAPRIL TAB5MG 1 RAMIPRIL CAP1.25MG 1 QL RAMIPRIL CAP10MG 1 QL RAMIPRIL CAP2.5MG 1 QL RAMIPRIL CAP5MG 1 QL TEKTURNA TAB150MG 3 QL TEKTURNA TAB300MG 3 QL TELMISARTAN TAB20MG 2 TELMISARTAN TAB40MG 2 TELMISARTAN/HCTZ 40/12.5MG 2 TELMISARTAN/HCTZ 80/12.5MG 2 TELMISARTAN/HCTZ 80/25MG 2 TELMISARTAN TAB80MG 2 TERAZOSIN CAP10MG 1 QL TERAZOSIN CAP1MG 1 QL TERAZOSIN CAP2MG 1 QL TERAZOSIN CAP5MG 1 QL TEVETEN TAB400MG 3 TRANDOLAPRILTAB1MG 1 QL TRANDOLAPRILTAB2MG 1 QL TRANDOLAPRILTAB4MG 1 QL VALSARTAN TAB160MG 1 QL VALSARTAN TAB320MG 1 QL VALSARTAN TAB40MG 1 QL VALSARTAN TAB80MG 1 QL VALSART/HCTZTAB VALSART/HCTZTAB160-25MG 1 VALSART/HCTZTAB VALSART/HCTZTAB320-25MG 1 VALSART/HCTZTAB ANTI-INFECTIVE AGENTS - MISC ALINIA SUS100/5ML 3 QL ALINIA TAB500MG 3 ATOVAQUONE SUS750/5ML 2 CAYSTON INH75MG 4 PA SP CLINDAMYCIN CAP150MG 2 CLINDAMYCIN CAP300MG 2 CLINDAMYCIN CAP75MG 2 CLINDAMYCIN SOL75MG/5ML 1 DAPSONE TAB100MG 1 DAPSONE TAB25MG 1 KETEK TAB300MG 3 KETEK TAB400MG 3 LINEZOLID INJ2MG/ML 4 PA SP LINEZOLID SUSP100/5ML 2 LINEZOLID TAB600MG 2 METRONIDAZOLCAP375MG 2 METRONIDAZOLTAB250MG 2 METRONIDAZOLTAB500MG 2 PRIMSOL SOL50MG/5ML 2 SIVEXTRO TAB200MG 4 PA SP SMZ/TMP DS TAB SMZ-TMP SUS200-40/5 1 SMZ-TMP TAB400-80MG 1 SULFATRIM PDSUS200-40/5 1 SYANGIS INJ 4 PA SP

17 TRIMETHOPRIMTAB100MG 1 VANCOMYCIN CAP125MG 2 QL PA VANCOMYCIN CAP250MG 2 QL PA XIFAXAN TAB200MG 3 PA XIFAXAN TAB550MG 3 QL PA ANTIMALARIALS ATOVAQ/PROGUTAB ATOVAQ/PROGUTAB CHLOROQUINE TAB250MG 1 CHLOROQUINE TAB500MG 1 COARTEM TAB20-120MG 2 DARAPRIM TAB25MG 4 PA SP HYDROXYCHLORTAB200MG 1 MEFLOQUINE TAB250MG 2 PRIMAQUINE TAB26.3MG 3 QUININE SULFCAP324MG 2 ANTIMYASTHENIC AGENTS GUANIDINE TAB125MG 2 MESTINON SYP60MG/5ML 3 MYTELASE TAB10MG 3 PYRIDOSTIGM TAB60MG 2 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE CAP250MG 2 ETHAMBUTOL TAB100MG 2 ETHAMBUTOL TAB400MG 2 ISONIAZID SYP50MG/5ML 2 ISONIAZID TAB100MG 2 ISONIAZID TAB300MG 2 PASER GRA4GM 2 PRIFTIN TAB150MG 3 PYRAZINAMIDETAB500MG 2 RIFABUTIN CAP150MG 2 RIFAMATE CAP 3 RIFAMPIN CAP150MG 2 RIFAMPIN CAP300MG 2 RIFATER TAB 3 RIMACTANE CAP300MG 2 SEROMYCIN CAP250MG 2 SIRTURO TAB100MG 4 PA SP TRECATOR TAB250MG 3 ANTINEOPLASTICS AFINITOR TAB10MG 4 QL PA SP AFINITOR TAB2.5MG 4 QL PA SP AFINITOR TAB5MG 4 QL PA SP AFINITOR TAB7.5MG 4 QL PA SP AFINITOR DISTAB2MG 4 QL PA SP AFINITOR DISTAB3MG 4 QL PA SP AFINITOR DISTAB5MG 4 QL PA SP ANASTROZOLE TAB1MG 1 QL BEXAROTENE CAP75MG 4 PA SP BICALUTAMIDETAB50MG 1 QL CABOMETYX TAB 20MG 4 PA SP CABOMETYX TAB 40MG 4 PA SP CABOMETYX TAB 60MG 4 PA SP CAPECITABINETAB150MG 4 PA SP CAPECITABINETAB500MG 4 PA SP CAPRELSA TAB100MG 4 QL PA SP CAPRELSA TAB300MG 4 QL PA SP COMETRIQ KIT 4 PA SP CYCLOPHOSPH TAB25MG 4 PA SP CYCLOPHOSPH TAB50MG 4 PA SP EMCYT CAP140MG 4 PA SP ERIVEDGE CAP150MG 4 QL PA SP EXEMESTANE TAB25MG 2 QL FARESTON TAB60MG 3 QL FLUTAMIDE CAP125MG 2 GILOTRIF TAB20MG 4 QL PA SP GILOTRIF TAB30MG 4 QL PA SP GILOTRIF TAB40MG 4 QL PA SP GLEOSTINE CAP100MG 4 PA SP GLEOSTINE CAP10MG 4 PA SP GLEOSTINE CAP40MG 4 PA SP HEXALEN 4 PA SP HYDROXY CAPRINJ1.25/5ML 4 PA SP HYDROXYUREA CAP500MG 2 ICLUSIG TAB15MG 4 QL PA SP IMATINIB MESTAB100MG 4 QL PA SP IMATINIB MESTAB400MG 4 QL PA SP IMBRUVICA CAP140MG 4 QL PA SP INTRON A INJ18MU 4 PA SP 17 INTRON A INJ50MU 4 PA SP INTRON-A INJ10MU 4 PA SP INTRON-A INJ18MU 4 PA SP JAKAFI TAB10MG 4 QL PA SP JAKAFI TAB15MG 4 QL PA SP JAKAFI TAB20MG 4 QL PA SP JAKAFI TAB25MG 4 QL PA SP JAKAFI TAB5MG 4 QL PA SP LENVIMA 8MG CAP 4 PA SP LENVIMA 18MG CAP 4 PA SP LETROZOLE TAB2.5MG 1 QL LEUCOVOR CA TAB10MG 2 LEUCOVOR CA TAB15MG 2 LEUCOVOR CA TAB25MG 2 LEUCOVOR CA TAB5MG 2 LEUKERAN TAB2MG 2 LEUPROLIDE INJ1MG/0.2 4 PA SP LONSURF TAB PA SP LONSURF TAB PA SP LYSODREN 4 PA SP MATULANE 4 PA SP MEGESTROL ACSUS40MG/ML 2 MEGESTROL ACSUS625MG/5ML 2 MEGESTROL ACTAB20MG 2 MEGESTROL ACTAB40MG 2 MEKINIST TAB0.5MG 4 QL PA SP MEKINIST TAB2MG 4 QL PA SP MERCAPTOPUR TAB50MG 1 METHOTREXATE SODIUM INJ PF 1000MG/40ML 1 METHOTREXATEINJ1GM 1 METHOTREXATETAB2.5MG 1 NEXAVAR TAB200MG 4 QL PA SP NILANDRON TAB150MG 4 QL PA SP POMALYST CAP1MG 4 QL PA SP POMALYST CAP2MG 4 QL PA SP POMALYST CAP3MG 4 QL PA SP POMALYST CAP4MG 4 QL PA SP PURIXAN SUS20MG/ML 4 PA SP SPRYCEL TAB100MG 4 QL PA SP SPRYCEL TAB140MG 4 QL PA SP SPRYCEL TAB20MG 4 QL PA SP SPRYCEL TAB50MG 4 QL PA SP SPRYCEL TAB70MG 4 QL PA SP SPRYCEL TAB80MG 4 QL PA SP STIVARGA TAB40MG 4 QL PA SP SUTENT CAP12.5MG 4 QL PA SP SUTENT CAP25MG 4 QL PA SP SUTENT CAP37.5MG 4 QL PA SP SUTENT CAP50MG 4 QL PA SP TABLOID TAB40MG 3 TAFINLAR CAP50MG 4 QL PA SP TAFINLAR CAP75MG 4 QL PA SP TARCEVA TAB100MG 4 QL PA SP TARCEVA TAB150MG 4 QL PA SP TARCEVA TAB25MG 4 QL PA SP TASIGNA CAP150MG 4 QL PA SP TASIGNA CAP200MG 4 QL PA SP TEMOZOLOMIDECAP100MG 4 PA SP TEMOZOLOMIDECAP140MG 4 PA SP TEMOZOLOMIDECAP180MG 4 PA SP TEMOZOLOMIDECAP20MG 4 PA SP TEMOZOLOMIDECAP250MG 4 PA SP TEMOZOLOMIDECAP5MG 4 PA SP TRETINOIN CAP10MG 4 PA SP TREXALL TAB10MG 2 TREXALL TAB15MG 2 TREXALL TAB5MG 2 TREXALL TAB7.5MG 2 TYKERB TAB250MG 4 QL PA SP VANDETANIB TAB100MG 4 QL PA SP VANDETANIB TAB300MG 4 QL PA SP VOTRIENT TAB200MG 4 QL PA SP XALKORI CAP200MG 4 QL PA SP XALKORI CAP250MG 4 QL PA SP ZOLINZA CAP100MG 4 QL PA SP ZYDELIG TAB100MG 4 QL PA SP ZYDELIG TAB150MG 4 QL PA SP ZYKADIA CAP150MG 4 QL PA SP ZYTIGA TAB250MG 4 QL PA SP ANTIPARKINSON AGENTS

18 AMANTADINE CAP100MG 2 AMANTADINE SYP50MG/5ML 2 AMANTADINE TAB100MG 2 AZILECT TAB0.5MG 3 AZILECT TAB1MG 3 BENZTROPINE TAB0.5MG 1 BENZTROPINE TAB1MG 1 BENZTROPINE TAB2MG 1 BROMOCRIPTINCAP5MG 1 BROMOCRIPTINTAB2.5MG 1 CARB/LEVO TAB10-100MG 1 CARB/LEVO TAB25-100MG 1 CARB/LEVO TAB25-250MG 1 CARB/LEVO ERTAB25-100MG 1 CARB/LEVO ERTAB50-200MG 1 ENTACAPONE TAB200MG 2 QL PRAMIPEXOLE TAB0.125MG 2 QL PRAMIPEXOLE TAB0.25MG 2 QL PRAMIPEXOLE TAB0.5MG 2 QL PRAMIPEXOLE TAB0.75MG 2 QL PRAMIPEXOLE TAB1.5MG 2 QL PRAMIPEXOLE TAB1MG 2 QL PRAMIPEXOLE TAB0.375MG ER 2 PRAMIPEXOLE TAB0.75 ER 2 PRAMIPEXOLE TAB1.5MG ER 2 PRAMIPEXOLE TAB2.25MG ER 2 PRAMIPEXOLE TAB3MG ER 2 PRAMIPEXOLE TAB4.5MG ER 2 ROPINIROLE TAB0.25MG 1 ROPINIROLE TAB0.5MG 1 ROPINIROLE TAB12MG ER 2 ROPINIROLE TAB1MG 1 ROPINIROLE TAB2MG 1 ROPINIROLE TAB2MG ER 2 ROPINIROLE TAB3MG 1 ROPINIROLE TAB4MG 1 ROPINIROLE TAB4MG ER 2 ROPINIROLE TAB5MG 1 ROPINIROLE TAB6MG ER 2 ROPINIROLE TAB8MG ER 2 SELEGILINE CAP5MG 2 SELEGILINE TAB5MG 2 TOLCAPONE TAB100MG 2 TRIHEXYPHEN ELX0.4MG/ML 1 TRIHEXYPHEN TAB2MG 1 TRIHEXYPHEN TAB5MG 1 ZELAPAR TAB1.25MG 3 ANTIPSYCHOTICS ARIPIPRAZOLE SOL1MG/ML 3 QL ARIPIPRAZOLE TAB10MG 3 ARIPIPRAZOLE TAB15MG 3 ARIPIPRAZOLE TAB30MG 3 CHLORPROMAZ TAB100MG 1 CHLORPROMAZ TAB10MG 1 CHLORPROMAZ TAB200MG 1 CHLORPROMAZ TAB25MG 1 CHLORPROMAZ TAB50MG 1 CLOZAPINE TAB100/ODT 2 QL CLOZAPINE TAB100MG 2 QL CLOZAPINE TAB200MG 2 QL CLOZAPINE TAB25MG 2 QL CLOZAPINE TAB25MG ODT 2 QL CLOZAPINE TAB50MG 2 QL COMPRO SUP25MG 2 QL EQUETRO CAP100MG 3 QL EQUETRO CAP200MG 3 QL EQUETRO CAP300MG 3 QL FANAPT PAK 3 QL FANAPT TAB10MG 3 QL FANAPT TAB12MG 3 QL FANAPT TAB1MG 3 QL FANAPT TAB2MG 3 QL FANAPT TAB4MG 3 QL FANAPT TAB6MG 3 QL FANAPT TAB8MG 3 QL FAZACLO TAB12.5/ODT 3 QL FAZACLO TAB150MG 3 QL FAZACLO TAB200MG 3 QL FLUPHENAZINECON5MG/ML 1 FLUPHENAZINEELX2.5/5ML 1 18 FLUPHENAZINETAB10MG 1 FLUPHENAZINETAB1MG 1 FLUPHENAZINETAB2.5MG 1 FLUPHENAZINETAB5MG 1 HALOPERIDOL CON2MG/ML 2 HALOPERIDOL TAB0.5MG 2 HALOPERIDOL TAB10MG 2 HALOPERIDOL TAB1MG 2 HALOPERIDOL TAB20MG 2 HALOPERIDOL TAB2MG 2 HALOPERIDOL TAB5MG 2 LATUDA TAB120MG 3 QL LATUDA TAB20MG 3 QL LATUDA TAB40MG 3 QL LATUDA TAB60MG 3 QL LATUDA TAB80MG 3 QL LITHIUM SOL8MEQ/5ML 2 LITHIUM CARBCAP150MG 1 LITHIUM CARBCAP300MG 1 LITHIUM CARBTAB300MG 1 LITHIUM CARBTAB300MG ER 1 LITHIUM CARBTAB450MG ER 1 LOXAPINE CAP10MG 2 LOXAPINE CAP25MG 2 LOXAPINE CAP50MG 2 LOXAPINE CAP5MG 2 OLANZAPINE TAB10MG 2 QL OLANZAPINE TAB10MG ODT 2 QL OLANZAPINE TAB15MG 2 QL OLANZAPINE TAB15MG ODT 2 QL OLANZAPINE TAB2.5MG 2 QL OLANZAPINE TAB20MG 2 QL OLANZAPINE TAB20MG ODT 2 QL OLANZAPINE TAB5MG 2 QL OLANZAPINE TAB5MG ODT 2 QL OLANZAPINE TAB7.5MG 2 QL PALIPERIDONE 1.5 MG ER 2 QL PALIPERIDONE 3 MG ER 2 QL PALIPERIDONE 6 MG ER 2 QL PALIPERIDONE 9MG ER 2 QL PERPHENAZINETAB16MG 1 PERPHENAZINETAB2MG 1 PERPHENAZINETAB4MG 1 PERPHENAZINETAB8MG 1 PROCHLORPER SUP25MG 2 QL PROCHLORPER TAB10MG 2 PROCHLORPER TAB5MG 2 QUETIAPINE TAB100MG 2 QL QUETIAPINE TAB200MG 2 QL QUETIAPINE TAB25MG 2 QL QUETIAPINE TAB300MG 2 QL QUETIAPINE TAB400MG 2 QL QUETIAPINE TAB50MG 2 QL QUETIAPINE TAB400MG ER 2 QL RISPERIDONE SOL1MG/ML 2 QL RISPERIDONE TAB0.25 ODT 2 QL RISPERIDONE TAB0.25MG 2 QL RISPERIDONE TAB0.5MG 2 QL RISPERIDONE TAB0.5MG OD 2 QL RISPERIDONE TAB1MG 2 QL RISPERIDONE TAB1MG ODT 2 QL RISPERIDONE TAB2MG 2 QL RISPERIDONE TAB2MG ODT 2 QL RISPERIDONE TAB3MG 2 QL RISPERIDONE TAB3MG ODT 2 QL RISPERIDONE TAB4MG 2 QL RISPERIDONE TAB4MG ODT 2 QL SAPHRIS SUB10MG 3 QL SAPHRIS SUB5MG 3 QL SEROQUEL XR TAB150MG 3 QL SEROQUEL XR TAB200MG 3 QL SEROQUEL XR TAB300MG 3 QL SEROQUEL XR TAB400MG 3 QL SEROQUEL XR TAB50MG 3 QL THIORIDAZINETAB100MG 1 THIORIDAZINETAB10MG 1 THIORIDAZINETAB25MG 1 THIORIDAZINETAB50MG 1 THIOTHIXENE CAP10MG 1 THIOTHIXENE CAP1MG 1

19 THIOTHIXENE CAP2MG 1 THIOTHIXENE CAP5MG 1 TRIFLUOPERAZTAB10MG 1 TRIFLUOPERAZTAB1MG 1 TRIFLUOPERAZTAB2MG 1 TRIFLUOPERAZTAB5MG 1 VRAYLAR 3 ZIPRASIDONE CAP20MG 2 QL ZIPRASIDONE CAP40MG 2 QL ZIPRASIDONE CAP40MG 2 QL ZIPRASIDONE CAP60MG 2 QL ZIPRASIDONE CAP80MG 2 QL ANTISEPTICS & DISINFECTANTS PHISOHEX LIQ3% 3 ANTIVIRALS ABACA/LAMIVUTAB QL SP ABACAV/LAMIVTAB/ZIDOVUD 4 QL SP ABACAVIR TAB300MG 4 QL SP ACYCLOVIR CAP200MG 2 ACYCLOVIR SUS200/5ML 2 ACYCLOVIR TAB400MG 2 ACYCLOVIR TAB800MG 2 APTIVUS CAP250MG 4 QL SP APTIVUS SOL 4 QL SP ATRIPLA TAB 4 SP COMPLERA TAB 4 SP CRIXIVAN CAP200MG 4 QL SP CRIXIVAN CAP400MG 4 QL SP DESCOVY TAB200/25 4 SP DIDANOSINE CAP125MG 4 QL SP DIDANOSINE CAP200MG 4 QL SP DIDANOSINE CAP250MG 4 QL SP DIDANOSINE CAP400MG 4 QL SP EDURANT TAB25MG 4 QL SP EMTRIVA CAP200MG 4 QL SP EMTRIVA SOL10MG/ML 4 QL SP ENTECAVIR TAB0.5MG 4 QL PA SP ENTECAVIR TAB1MG 4 QL PA SP EPCLUSA TAB 4 PA SP EPZICOM TAB QL SP EVOTAZ 4 SP FAMCICLOVIR TAB125MG 2 QL FAMCICLOVIR TAB250MG 2 QL FAMCICLOVIR TAB500MG 2 QL GENVOYA TAB 4 SP INTELENCE TAB100MG 4 QL SP INTELENCE TAB200MG 4 QL SP INTELENCE TAB25MG 4 QL SP INVIRASE CAP200MG 4 QL SP INVIRASE TAB500MG 4 QL SP ISENTRESS CHW100MG 4 QL SP ISENTRESS CHW25MG 4 QL SP ISENTRESS POW100MG 4 QL SP ISENTRESS TAB400MG 4 QL SP LAMIVUD/ZIDOTAB QL SP LAMIVUDINE TAB100MG 4 QL SP LAMIVUDINE TAB150MG 4 QL SP LAMIVUDINE TAB300MG 4 QL SP LEXIVA SUS50MG/ML 4 QL SP LEXIVA TAB700MG 4 QL SP NEVIRAPINE SUS50MG/5ML 4 QL SP NEVIRAPINE TAB200MG 4 QL SP NEVIRAPINE TAB400MG ER 4 QL SP NORVIR CAP100MG 4 QL SP NORVIR SOL80MG/ML 4 QL SP NORVIR TAB100MG 4 QL SP ODEFSEY TAB 4 SP PEGASYS INJ 4 QL PA SP PEGASYS PROCLICK 4 QL PA SP PEG-INTRON KIT 4 PA SP PREZCOBIX 4 SP PREZISTA SUS100MG/ML 4 QL SP PREZISTA TAB150MG 4 QL SP PREZISTA TAB400MG 4 QL SP PREZISTA TAB600MG 4 QL SP PREZISTA TAB75MG 4 QL SP RELENZA MISDISKHALE 3 QL RESCRIPTOR TAB100 MG 4 QL SP RESCRIPTOR TAB200MG 4 QL SP REYATAZ CAP150MG 4 QL SP 19 REYATAZ CAP200MG 4 QL SP REYATAZ CAP300MG 4 QL SP RIBAPAK PAK1000/DAY 4 PA SP RIBAPAK PAK1200/DAY 4 PA SP RIBAPAK PAK800/DAY 4 PA SP RIBASPHERE CAP200MG 4 PA SP RIBASPHERE TAB200MG 4 PA SP RIBASPHERE TAB400MG 4 PA SP RIBASPHERE TAB600MG 4 PA SP RIBATAB PAK1000/DAY 4 PA SP RIBATAB TAB400MG 4 PA SP RIBATAB TAB600MG 4 PA SP RIBATAB TAB800/DAY 4 PA SP RIBAVIRIN CAP200MG 4 PA SP RIBAVIRIN TAB200MG 4 PA SP RIBAVIRIN TAB400MG 4 PA SP RIBAVIRIN TAB600MG 4 PA SP SELZENTRY TAB150MG 4 PA SP SELZENTRY TAB300MG 4 PA SP STAVUDINE CAP15MG 4 QL SP STAVUDINE CAP20MG 4 QL SP STAVUDINE CAP30MG 4 QL SP STAVUDINE CAP40MG 4 QL SP STAVUDINE SOL1MG/ML 4 QL SP STRIBILD TAB 4 QL SP SUSTIVA CAP200MG 4 QL SP SUSTIVA CAP50MG 4 QL SP SUSTIVA TAB600MG 4 QL SP TAMIFLU CAP30MG 2 QL TAMIFLU CAP45MG 2 QL TAMIFLU CAP75MG 2 QL TAMIFLU SUS6MG/ML 2 QL TIVICAY TAB50MG 4 QL SP TRIUMEQ TAB 4 QL SP TRUVADA TAB QL PA SP VALACYCLOVIRTAB1GM 2 QL VALACYCLOVIRTAB500MG 2 QL VALGANCICLOVIRTAB450MG 4 PA SP VIDEX SOL2GM 4 QL SP VIREAD POW40MG/GM 4 QL SP VIREAD TAB150MG 4 QL SP VIREAD TAB200MG 4 QL SP VIREAD TAB250MG 4 QL SP VIREAD TAB300MG 4 QL SP ZEPATIER TABLET 4 PA SP ZIDOVUDINE CAP100MG 4 QL SP ZIDOVUDINE SYP50MG/5ML 4 QL SP ZIDOVUDINE TAB300MG 4 QL SP ASSORTED CLASSES ASTAGRAF XL CAP0.5MG 4 SP ASTAGRAF XL CAP1MG 4 SP ASTAGRAF XL CAP5MG 4 SP AZASAN TAB100MG 3 AZASAN TAB75 MG 3 AZATHIOPRINETAB50MG 1 CYCLOSPORINECAP100MG 2 CYCLOSPORINECAP100MG MD 1 CYCLOSPORINECAP25MG 1 CYCLOSPORINECAP25MG MOD 1 CYCLOSPORINECAP50MG MOD 1 CYCLOSPORINESOLMODIFIED 2 DICLEGIS TAB 3 GENGRAF CAP100MG 1 GENGRAF CAP25MG 1 GENGRAF SOL100MG/ML 2 IVERMECTIN TAB3MG 1 KIONEX POW 1 MYCOPHENOLATCAP250MG 2 MYCOPHENOLATTAB500MG 2 MYCOPHENOLICTAB180MG DR 2 MYCOPHENOLICTAB360MG DR 2 NEORAL CAP100MG 4 PA SP NEORAL CAP25MG 4 PA SP NEORAL SOL100MG/ML 4 PA SP PHYSIOLYTE SOL 3 PHYSIOSOL SOLIRRIGAT 3 REVLIMID CAP10MG 4 QL PA SP REVLIMID CAP15MG 4 QL PA SP REVLIMID CAP2.5MG 4 QL PA SP REVLIMID CAP20MG 4 QL PA SP

20 REVLIMID CAP25MG 4 QL PA SP REVLIMID CAP5MG 4 QL PA SP SIROLIMUS TAB0.5MG 4 PA SP SOD POLY SULSUS15GM/60 1 SOD CHLORIDEINJ3% 1 SOD CHLORIDEINJ5% 1 SYPRINE CAP250MG 4 SP TACROLIMUS CAP0.5MG 2 TACROLIMUS CAP1MG 2 TACROLIMUS CAP5MG 2 THALOMID CAP100MG 4 QL PA SP THALOMID CAP150MG 4 QL PA SP THALOMID CAP200MG 4 QL PA SP THALOMID CAP50MG 4 QL PA SP ZORTRESS TAB0.25MG 4 QL SP ZORTRESS TAB0.5MG 4 QL SP ZORTRESS TAB0.75MG 4 QL SP BETA BLOCKERS ACEBUTOLOL CAP200MG 2 ACEBUTOLOL CAP400MG 2 ATENOLOL TAB100MG 1 ATENOLOL TAB25MG 1 ATENOLOL TAB50MG 1 BETAXOLOL TAB10MG 1 BETAXOLOL TAB20MG 1 BISOPROL FUMTAB10MG 1 BISOPROL FUMTAB5MG 1 BYSTOLIC TAB10MG 3 BYSTOLIC TAB2.5MG 3 BYSTOLIC TAB20MG 3 BYSTOLIC TAB5MG 3 CARVEDILOL TAB12.5MG 1 QL CARVEDILOL TAB25MG 1 QL CARVEDILOL TAB3.125MG 1 QL CARVEDILOL TAB6.25MG 1 QL COREG CR CAP10MG 3 QL COREG CR CAP20MG 3 QL COREG CR CAP40MG 3 QL COREG CR CAP80MG 3 QL ESTRADIOL TAB0.5MG 1 LABETALOL TAB100MG 1 LABETALOL TAB200MG 1 LABETALOL TAB300MG 1 LEVATOL TAB20MG 3 METOPROL TARTAB100MG 1 METOPROL TARTAB25MG 1 METOPROL TARTAB50MG 1 METOPROL TARTAB37.5MG 1 METOPROL TARTAB75MG 1 METOPROLOL TAB100MG ER 1 QL METOPROLOL TAB200MG ER 1 QL METOPROLOL TAB25MG ER 1 QL METOPROLOL TAB50MG ER 1 QL NADOLOL TAB20MG 1 NADOLOL TAB40MG 1 NADOLOL TAB80MG 1 PINDOLOL TAB10MG 1 PINDOLOL TAB5MG 1 PRAVASTATIN TAB40MG 1 QL PROPRANOLOL CAP120MG ER 1 PROPRANOLOL CAP160MG ER 1 PROPRANOLOL CAP60MG ER 1 PROPRANOLOL CAP80MG ER 1 PROPRANOLOL SOL20MG/5ML 1 PROPRANOLOL SOL40MG/5ML 1 PROPRANOLOL TAB10MG 1 PROPRANOLOL TAB20MG 1 PROPRANOLOL TAB40MG 1 PROPRANOLOL TAB60MG 1 PROPRANOLOL TAB80MG 1 SORINE TAB120MG 1 SORINE TAB160MG 1 SORINE TAB240MG 1 SORINE TAB80MG 1 SOTALOL AF TAB120MG 1 SOTALOL HCL TAB160MG 1 SOTALOL HCL TAB240MG 1 SOTALOL HCL TAB80MG 1 TIMOLOL MAL TAB10MG 1 TIMOLOL MAL TAB20MG 1 20 TIMOLOL MAL TAB5MG 1 CALCIUM CHANNEL BLOCKERS AFEDITAB TAB30MG CR 2 AFEDITAB TAB60MG CR 2 AMLODIPINE TAB10MG 1 QL AMLODIPINE TAB2.5MG 1 QL AMLODIPINE TAB5MG 1 QL CARTIA XT CAP120/24HR 1 CARTIA XT CAP180/24HR 1 CARTIA XT CAP240/24HR 1 CARTIA XT CAP300/24HR 1 COVERA-HS TAB180MG 3 COVERA-HS TAB240MG 3 DILT-CD CAP300MG 1 DILTIA XT CAP120MG/24 1 DILTIA XT CAP180MG/24 1 DILTIA XT CAP240MG/24 1 DILTIAZEM CAP120MG CD 1 DILTIAZEM CAP120MG ER 1 DILTIAZEM CAP180MG/24 1 DILTIAZEM CAP240MG CD 1 DILTIAZEM CAP300MG ER 1 DILTIAZEM CAP360MG/24 1 DILTIAZEM CAP420MG/24 1 DILTIAZEM CAP60MG ER 1 DILTIAZEM CAP90MG ER 1 DILTIAZEM TAB120MG 1 DILTIAZEM TAB30MG 1 DILTIAZEM TAB60MG 1 DILTIAZEM TAB90MG 1 DILT-XR CAP120MG 1 DILT-XR CAP180MG 1 DILT-XR CAP240MG 1 DYNACIRC CR TAB5MG 2 FELODIPINE TAB10MG ER 2 FELODIPINE TAB2.5MG ER 2 FELODIPINE TAB5MG ER 2 ISRADIPINE CAP2.5MG 1 ISRADIPINE CAP5MG 1 MATZIM LA TAB180MG/24 1 MATZIM LA TAB240MG/24 1 MATZIM LA TAB300MG/24 1 MATZIM LA TAB360MG/24 1 MATZIM LA TAB420MG/24 1 NICARDIPINE CAP20MG 2 NICARDIPINE CAP30MG 2 NIFEDIAC CC TAB90MG ER 1 NIFEDICAL XLTAB30MG 1 NIFEDICAL XLTAB60MG 1 NIFEDIPINE CAP10MG 2 NIFEDIPINE CAP20MG 2 NIFEDIPINE TAB30MG ER 1 NIFEDIPINE TAB60MG ER 1 NIFEDIPINE TAB90MG ER 1 NIMODIPINE CAP30MG 2 NISOLDIPINE TAB17MG ER 3 NISOLDIPINE TAB20MG 3 NISOLDIPINE TAB25.5MG 3 NISOLDIPINE TAB30MG 3 NISOLDIPINE TAB34MG ER 3 NISOLDIPINE TAB40MG 3 NISOLDIPINE TAB8.5MG ER 3 TAZTIA XT CAP120MG/24 1 TAZTIA XT CAP180MG/24 1 TAZTIA XT CAP240MG/24 1 TAZTIA XT CAP300MG/24 1 TAZTIA XT CAP360MG/24 1 VERAPAMIL CAP100MG ER 1 VERAPAMIL CAP120MG ER 1 VERAPAMIL CAP180MG ER 1 VERAPAMIL CAP200MG ER 1 VERAPAMIL CAP240MG ER 1 VERAPAMIL CAP300MG ER 1 VERAPAMIL CAP360MG SR 1 VERAPAMIL TAB120MG 1 VERAPAMIL TAB180MG ER 1 VERAPAMIL TAB240MG ER 1 VERAPAMIL TAB40MG 1 VERAPAMIL TAB80MG 1 VERAPAMIL HCL ER 1

21 CARDIOTONICS DIGOX TAB0.125MG 1 DIGOX TAB0.25MG 1 DIGOXIN SOL50MCG/ML 3 DIGOXIN TAB0.125MG 1 DIGOXIN TAB0.25MG 1 LANOXIN TAB0.0625MG 3 LANOXIN TAB 0.25MG 1 LANOXIN TAB0.1875MG 3 CARDIOVASCULAR AGENTS - MISC ADCIRCA TAB20MG 4 QL PA SP ADEMPAS TAB0.5MG 4 QL PA SP ADEMPAS TAB1.5MG 4 QL PA SP ADEMPAS TAB1MG 4 QL PA SP ADEMPAS TAB2.5MG 4 QL PA SP ADEMPAS TAB2MG 4 QL PA SP CIALIS TAB2.5MG 3 CIALIS TAB5MG 3 LETAIRIS TAB10MG 4 QL PA SP LETAIRIS TAB5MG 4 QL PA SP OPSUMIT TAB10MG 4 QL PA SP ORENITRAM TAB0.125MG 4 PA SP ORENITRAM TAB0.25MG 4 PA SP ORENITRAM TAB1MG 4 PA SP ORENITRAM TAB2.5MG 4 PA SP SILDENAFIL TAB20MG 4 QL PA TRACLEER TAB125MG 4 QL PA SP TRACLEER TAB62.5MG 4 QL PA SP VENTAVIS SOL10MCG/ML 4 PA SP CEPHALOSPORINS CEDAX CAP400MG 3 CEFACLOR CAP250MG 2 CEFACLOR CAP500MG 2 CEFACLOR SUS125/5ML 2 CEFACLOR SUS250/5ML 2 CEFACLOR SUS375/5ML 2 CEFACLOR ER TAB500MG 2 CEFADROXIL CAP500MG 2 CEFADROXIL SUS250/5ML 2 CEFADROXIL SUS500/5ML 2 CEFADROXIL TAB1GM 2 CEFDINIR CAP300MG 1 CEFDINIR SUS125/5ML 1 CEFDINIR SUS250/5ML 1 CEFDITOREN TAB200MG 2 CEFIXIME SUS100/5ML 2 CEFIXIME SUS200/5ML 2 CEFPODO PROXSUS100/5ML 2 CEFPODO PROXSUS50MG/5ML 2 CEFPODOXIME TAB100MG 2 CEFPODOXIME TAB200MG 2 CEFPROZIL SUS125/5ML 2 CEFPROZIL SUS250/5ML 2 CEFPROZIL TAB250MG 2 CEFPROZIL TAB500MG 2 CEFTIN SUS125/5ML 3 CEFTIN SUS250/5ML 3 CEFUROXIME SUS125/5ML 2 CEFUROXIME TAB250MG 1 CEFUROXIME TAB500MG 1 CEPHALEXIN CAP250MG 1 CEPHALEXIN CAP500MG 1 CEPHALEXIN SUS125/5ML 1 CEPHALEXIN SUS250/5ML 1 CEPHALEXIN TAB250MG 1 CEPHALEXIN TAB500MG 1 CHLORZOXAZONTAB500MG 2 SUPRAX TAB400MG 3 CONTRACEPTIVES ELLA TAB30MG 3 MIBELAS 24 CHWFE 1 NORETH/ETHINCHWFE 1/20 1 TAYTULLA 3 CORTICOSTEROIDS BAYCADRON ELX0.5/5ML 1 BUDESONIDE CAP3MG/24HR 2 CORTISONE ACTAB25MG 1 DEXAMETHASONCON1MG/ML 1 DEXAMETHASONELX0.5/5ML 1 21 DEXAMETHASONTAB0.5MG 1 DEXAMETHASONTAB0.75MG 1 DEXAMETHASONTAB1.5MG 1 DEXAMETHASONTAB1MG 1 DEXAMETHASONTAB2MG 1 DEXAMETHASONTAB4MG 1 DEXAMETHASONTAB6MG 1 DEXPAK PAK13 DAY 3 DEXPAK PAK6 DAY 3 FLUDROCORT TAB0.1MG 2 HYDROCORT TAB10MG 1 HYDROCORT TAB20MG 1 HYDROCORT TAB5MG 1 METHYLPRED PAK4MG 1 METHYLPRED TAB16MG 1 METHYLPRED TAB32MG 1 METHYLPRED TAB4MG 1 METHYLPRED TAB8MG 1 MILLIPRED SOL10MG/5ML 2 MILLIPRED TAB5MG 2 MILLIPRED DPPAK5MG 2 ORAPRED ODT TAB10MG 3 ORAPRED ODT TAB15MG 3 ORAPRED ODT TAB30MG 3 PRED SOD PHOSOL5MG/5ML 2 PREDNISOLONESOL15MG/5ML 2 PREDNISOLONESOL25MG/5ML 2 PREDNISOLONE ODT TAB10MG 2 PREDNISOLONE ODT TAB15MG 2 PREDNISOLONE ODT TAB30MG 2 PREDNISONE CON5MG/ML 1 PREDNISONE PAK10MG 1 PREDNISONE PAK5MG 1 PREDNISONE SOL5MG/5ML 1 PREDNISONE TAB10MG 1 PREDNISONE TAB1MG 1 PREDNISONE TAB2.5MG 1 PREDNISONE TAB20MG 1 PREDNISONE TAB50MG 1 PREDNISONE TAB5MG 1 RAYOS TAB1MG 3 RAYOS TAB2MG 3 RAYOS TAB5MG 3 VERIPRED 20 SOL20MG/5ML 2 COUGH/COLD/ALLERGY ACETYLCYST SOL10% 2 ACETYLCYST SOL20% 2 DERMATOLOGICALS 8-MOP CAP10MG 4 PA SP ACANYA GEL % 3 ACITRETIN CAP10MG 2 ACITRETIN CAP17.5MG 2 ACITRETIN CAP25MG 2 ACTICIN CRE5% 1 ACYCLOVIR OIN5% 2 QL ADAPALENE CRE0.1% 2 ADAPALENE GEL0.1% 2 ADAPALENE GEL0.3% 2 AKNE-MYCIN OIN2% 3 ALCLOMETASONCRE0.05% 2 ALCLOMETASONOIN0.05% 2 ALTABAX OIN1% 3 AMCINONIDE CRE0.1% 2 AMCINONIDE LOT0.1% 2 AMCINONIDE OIN0.1% 2 AMNESTEEM CAP10MG 2 AMNESTEEM CAP20MG 2 AMNESTEEM CAP40MG 2 APEXICON OIN0.05% 2 APEXICON E CRE0.05% 2 AUG BETAMET CRE0.05% 2 AUG BETAMET GEL0.05% 2 AUG BETAMET LOT0.05% 2 AUG BETAMET OIN0.05% 2 AZELEX CRE20% 3 BETAMETH DIPCRE0.05% 2 BETAMETH DIPLOT0.05% 2 BETAMETH DIPOIN0.05% 2 BETAMETH VALAER 0.12% 2 BETAMETH VALCRE0.1% 2

22 BETAMETH VALLOT0.1% 2 BETAMETH VALOIN0.1% 2 BP CLEANSINGEMU10-4% 1 CALCIPOTRIENCRE0.005% 2 QL CALCIPOTRIENOINBETAMETH 2 CALCIPOTRIENSOL0.005% 2 QL CALCITRIOL OIN3MCG/GM 2 CAPEX SHA0.01% 3 CICLODAN CRE0.77% 2 CICLODAN SOL8% 2 CICLOPIROX CRE0.77% 2 CICLOPIROX GEL0.77% 2 CICLOPIROX SHA1% 2 CICLOPIROX SOL8% 2 CICLOPIROX SUS0.77% 2 CLARAVIS CAP10MG 2 CLARAVIS CAP20MG 2 CLARAVIS CAP30MG 2 CLARAVIS CAP40MG 2 CLINDACIN KITPAC 1% 2 CLINDAGEL 3 CLINDAMAX GEL1% 2 CLINDAMAX LOT10MG/ML 2 CLINDAMY/BENGEL1-5% 2 CLINDAMYCIN AER1% 2 CLINDAMYCIN GEL1% 2 CLINDAMYCIN LOT1% 2 CLINDAMYCIN PAD1% 1 CLINDAMYCIN SOL1% 1 CLINDETS PAD1% 1 CLOBETASOL AER0.05% 2 CLOBETASOL GEL0.05% 2 CLOBETASOL LOT0.05% 2 CLOBETASOL OIN0.05% 2 CLOBETASOL SHA0.05% 2 CLOBETASOL SOL0.05% 2 CLOBETASOL ECRE0.05% 2 CLOCORTOLONECREPIV 0.1% 3 CLODAN SHA0.05% 2 CLODERM CRE0.1% PMP 3 CLOTRIM/BETACREDIPROP 2 CLOTRIM/BETALOTDIPROP 2 CONDYLOX GEL0.5% 3 CORDRAN LOT0.05% 3 CORDRAN 80X3TAP4MCG/CM 3 QL CORMAX OIN0.05% 2 CORTISPORIN CRE0.5% 3 CORTISPORIN OIN1% 3 COSENTYX INJ150MG/ML 4 PA SP DESONATE GEL0.05% 3 DESONIDE CRE0.05% 2 DESONIDE LOT0.05% 2 DESONIDE OIN0.05% 2 DESOXIMETAS CRE0.25% 2 DESOXIMETAS GEL0.05% 2 DESOXIMETAS OIN0.25% 2 DICLOFENAC SOL1.5% 1 DICLOFENAC GEL 3% 2 DIFLORASONE CRE0.05% 2 DIFLORASONE OIN0.05% 2 DOVONEX CRE0.005% 3 QL ECONAZOLE CRE1% 2 ELIDEL CRE1% 3 QL EPIDUO GEL % 3 ERTACZO CRE2% 3 ST ERY PAD2% 1 ERYTHROMYCINGEL/BENZOYL 2 ERYTHROMYCINGEL2% 2 ERYTHROMYCINPAD2% 1 ERYTHROMYCINSOL2% 1 EURAX CRE10% 2 EURAX LOT10% 2 EXELDERM CRE1% 3 ST EXELDERM SOL1% 3 ST FABIOR AER0.1% 3 FINACEA GEL15% 3 FLUOCIN ACETCRE0.01% 2 FLUOCIN ACETCRE0.025% 2 FLUOCIN ACETOILBODY 2 FLUOCIN ACETOIN0.025% 2 FLUOCIN ACETSOL0.01% 2 FLUOCINONIDECRE0.1% 2 FLUOCINONIDECRE-E 0.05% 2 FLUOCINONIDEGEL0.05% 2 FLUOCINONIDEOIN0.05% 2 FLUOCINONIDESOL0.05% 2 FLUOROPLEX CRE1% 2 FLUOROURACILCRE5% 2 FLUOROURACILSOL2% 2 FLUOROURACILSOL5% 2 FLUTICASONE CRE0.05% 2 FLUTICASONE LOT0.05% 2 FLUTICASONE OIN0.005% 2 GENTAMICIN CRE0.1% 1 GENTAMICIN OIN0.1% 1 GLYDO GEL2% 2 HALOBETASOL CRE0.05% 2 HALOBETASOL OIN0.05% 2 ST HALOG CRE0.1% 3 HALOG OIN0.1% 3 HC BUTYRATE CRE0.1% 2 HC BUTYRATE OIN0.1% 2 HC BUTYRATE SOL0.1% 2 HC VALERATE CRE0.2% 2 HC VALERATE OIN0.2% 2 HYDROCORT CRE2.5% 1 HYDROCORT LOT2.5% 2 HYDROCORT OIN2.5% 1 IMIQUIMOD CRE5% 1 JUBLIA SOL10% 3 ST KENALOG AERSPRAY 3 KERYDIN SOL5% 3 ST KETOCONAZOLEAER2% 2 KETOCONAZOLECRE2% 2 KETOCONAZOLESHA2% 2 KETODAN KIT2% 2 KURIC CRE2% 2 LIDOCAINE GEL2% JELLY 2 LIDOCAINE OIN5% 2 LIDOCAINE PAD5% 2 QL LIDOCAINE SOL4% 2 LIDO/PRILOCNCRE % 1 LINDANE LOT1% 2 LINDANE SHA1% 2 LOCOID LOT0.1% 3 LOKARA LOT0.05% 2 MENTAX CRE1% 3 ST METRONIDAZOLCRE0.75% 2 METRONIDAZOLGEL0.75% 2 METRONIDAZOLGEL1% 2 METRONIDAZOLLOT0.75% 2 MOMETASONE CRE0.1% 2 MOMETASONE OIN0.1% 2 MOMETASONE SOL0.1% 2 MUPIROCIN OIN2% 2 MYORISAN 2 MYORISAN CAP10MG 2 MYORISAN CAP20MG 2 MYORISAN CAP40MG 2 NAFTIFINE 1%CRE 3 ST NAFTIFINE 2%CRE 3 NORITATE CRE1% 3 NYAMYC POW NYSTAT/TRIAMCRE 2 NYSTAT/TRIAMOIN 1 NYSTATIN CRE NYSTATIN OIN NYSTATIN POW NYSTOP POW ORACEA CAP40MG 3 METHOXSALEN CAP10MG 2 PANDEL CRE0.1% 2 PEDI-DRI POW PENNSAID SOL2% 3 PERMETHRIN CRE5% 1 PICATO GEL0.015% 2 PICATO GEL0.05% 2 PODOFILOX SOL0.5% 2 PREDNICARBATCRE0.1% 2 PREDNICARBATOIN0.1% 2 22

23 PRUDOXIN CRE5% 3 REFISSA CRE0.05% 2 REGRANEX GEL0.01% 2 RETIN-A MICRGEL0.08% 3 ROSADAN CRE0.75% 2 ROSADAN GEL0.75% 2 SANTYL OIN250/GM 3 QL SCALACORT 2% 1 SELENIUM SULLOT2.5% 2 SELENIUM SULSHA2.25% 1 SILVER SULFACRE1% 1 SKLICE LOT0.5% 3 SOTRET CAP10MG 2 SOTRET CAP20MG 2 SOTRET CAP40MG 2 SSD CRE1% 1 STELARA INJ45MG/0.5 4 PA SP STELARA INJ90MG/ML 4 PA SP SULFACETAMIDSUS10% 2 SULFAMYLON CRE85MG/GM 3 SYNERA DIS70-70MG 3 TACLONEX OIN 3 TACLONEX SUS 3 TACROLIMUS OIN0.03% 2 TACROLIMUS OIN0.1% 2 TAZORAC CRE0.05% 3 TAZORAC CRE0.1% 3 TAZORAC GEL0.05% 3 TAZORAC GEL0.1% 3 TOPICORT OIN0.05% 3 TOPICORT SPR0.25% 3 TRETINOIN 2 QL TRETINOIN CRE0.025% 2 QL TRETINOIN CRE0.05% 2 QL TRETINOIN CRE0.1% 2 QL TRETINOIN GEL0.01% 2 QL TRETINOIN GEL0.025% 2 QL TRETINOIN GEL0.1% 2 QL TRETIN-X CRE0.0375% 2 QL TRETIN-X CRE0.075% 2 QL TRETIN-X CREKIT0.025% 2 TRETIN-X CREKIT0.05% 2 TRETIN-X CREKIT0.1% 2 TRIAMCINOLONCRE0.025% 2 TRIAMCINOLONCRE0.1% 2 TRIAMCINOLONCRE0.5% 2 TRIAMCINOLONLOT0.025% 2 TRIAMCINOLONLOT0.1% 2 TRIAMCINOLONOIN0.025% 2 TRIAMCINOLONOIN0.1% 2 TRIAMCINOLONOIN0.5% 2 TRIDERM CRE0.1% 2 U-CORT CRE1% 1 ULESFIA LOT5% 3 VECTICAL OIN3MCG/GM 2 VELTIN GEL 3 VERDESO AER0.05% 3 VEREGEN OIN15% 3 XOLEGEL GEL2% 3 ST ZENATANE 2 ZENATANE CAP10MG 2 ZENATANE CAP20MG 2 ZENATANE CAP40MG 2 ZIANA GEL 3 ZONALON CRE5% 3 ZYCLARA CRE3.75% 3 ZYCLARA PUMPCRE2.5% 3 DIAGNOSTIC PRODUCTS FREESTYLE LANCETS 2 QL FREESTYLE TEST STRIPS 2 QL PRECISION TEST STRIPS 2 QL GLUCAGEN INJHYPOKIT 2 QL DIGESTIVE AIDS CREON CAP12000UNT 2 PA CREON CAP24000UNT 2 PA CREON CAP3000UNIT 2 PA CREON CAP36000UNT 2 PA CREON CAP6000UNIT 2 PA PANCREAZE CAP10500UNT 3 PA PANCREAZE CAP16800UNT 3 PA 23 PANCREAZE CAP21000UNT 3 PA PANCREAZE CAP4200UNIT 3 PA PERTZYE CAP 3 PA ZENPEP CAP10000UNT 3 PA ZENPEP CAP15000UNT 3 PA ZENPEP CAP20000UNT 3 PA ZENPEP CAP25000UNT 3 PA ZENPEP CAP3000UNIT 3 PA ZENPEP CAP40000UNT 3 PA ZENPEP CAP5000UNIT 3 PA DIURETICS ACETAZOLAMIDCAP500MG ER 2 ACETAZOLAMIDTAB125MG 2 ACETAZOLAMIDTAB250MG 2 AMILORIDE TAB5MG 1 BUMETANIDE INJ0.25/ML 1 BUMETANIDE TAB0.5MG 1 BUMETANIDE TAB1MG 1 BUMETANIDE TAB2MG 1 CHLOROTHIAZ TAB250MG 1 CHLOROTHIAZ TAB500MG 1 CHLORTHALID TAB100MG 1 CHLORTHALID TAB25MG 1 CHLORTHALID TAB50MG 1 DIURIL SUS250/5ML 3 DYRENIUM CAP100MG 3 DYRENIUM CAP50MG 3 EDECRIN TAB25MG 3 FUROSEMIDE SOL10MG/ML 1 FUROSEMIDE SOL8MG/ML 1 FUROSEMIDE TAB20MG 1 FUROSEMIDE TAB40MG 1 FUROSEMIDE TAB80MG 1 HYDROCHLOROTCAP12.5MG 1 HYDROCHLOROTTAB12.5MG 1 HYDROCHLOROTTAB25MG 1 INDAPAMIDE TAB1.25MG 1 INDAPAMIDE TAB2.5MG 1 METHAZOLAMIDTAB25MG 1 METHAZOLAMIDTAB50MG 1 METHYCLOTHIATAB5MG 2 METOLAZONE TAB10MG 1 METOLAZONE TAB2.5MG 1 METOLAZONE TAB5MG 1 SPIRONOLACT TAB100MG 1 SPIRONOLACT TAB25MG 1 SPIRONOLACT TAB50MG 1 THALITONE TAB15MG 3 TORSEMIDE TAB100MG 1 TORSEMIDE TAB10MG 1 TORSEMIDE TAB20MG 1 TORSEMIDE TAB5MG 1 ENDOCRINE AND METABOLIC AGENTS - MISC ALENDRONATE TAB10MG 1 QL ALENDRONATE TAB35MG 1 QL ALENDRONATE TAB40MG 1 QL ALENDRONATE TAB5MG 1 QL ALENDRONATE TAB70MG 1 QL CABERGOLINE TAB0.5MG 2 CALCITONIN SPR200/ACT 2 CALCITRIOL CAP0.25MCG 1 CALCITRIOL CAP0.5MCG 1 CALCITRIOL SOL1MCG/ML 1 CARBAGLU TAB200MG 4 PA SP DESMOPRESSINSOL0.01% 2 DESMOPRESSINSPR0.01% 2 DESMOPRESSINTAB0.1MG 2 DESMOPRESSINTAB0.2MG 2 DOXERCALCIF CAP0.5MCG 2 DOXERCALCIF CAP1MCG 2 DOXERCALCIF CAP2.5MCG 2 ETIDRON DISDTAB200MG 2 ETIDRON DISDTAB400MG 2 FORTEO SOL600/2.4 4 QL PA SP FORTICAL SPR200/ACT 4 PA SP FOSAMAX + D TAB QL FOSAMAX + D TAB QL GENOTROPIN INJ0.2MG 4 PA SP GENOTROPIN INJ0.4MG 4 PA SP GENOTROPIN INJ0.6MG 4 PA SP

24 GENOTROPIN INJ0.8MG 4 PA SP GENOTROPIN INJ1.2MG 4 PA SP GENOTROPIN INJ1.4MG 4 PA SP GENOTROPIN INJ1.6MG 4 PA SP GENOTROPIN INJ1.8MG 4 PA SP GENOTROPIN INJ12MG 4 PA SP GENOTROPIN INJ1MG 4 PA SP GENOTROPIN INJ2MG 4 PA SP GENOTROPIN INJ5MG 4 PA SP HUMATROPE INJ12MG 4 PA SP HUMATROPE INJ24MG 4 PA SP HUMATROPE INJ5MG 4 PA SP HUMATROPE INJ6MG 4 PA SP IBANDRONATE TAB150MG 1 QL INCRELEX INJ40MG/4ML 4 PA SP MIACALCIN INJ200/ML 4 PA SP NORDITROPIN INJ10/1.5ML 4 PA SP NORDITROPIN INJ15/1.5ML 4 PA SP NORDITROPIN INJ30/3ML 4 PA SP NORDITROPIN INJ5/1.5ML 4 PA SP NUTROPIN AQ INJ10MG/2ML 4 PA SP NUTROPIN AQ INJ20MG/2ML 4 PA SP NUTROPIN AQ INJNUSPIN 5 4 PA SP PROLIA 4 PA SP RISEDRONATE TAB150MG 2 SAMSCA TAB15MG 4 QL PA SP SAMSCA TAB30MG 4 QL PA SP SEROSTIM INJ4MG 4 PA SP SEROSTIM INJ5MG 4 PA SP SEROSTIM INJ6MG 4 PA SP SEROSTIM INJ8.8MG 4 PA SP SIGNIFOR INJ0.3MG/ML 4 PA SP SIGNIFOR INJ0.6MG/ML 4 PA SP SIGNIFOR INJ0.9MG/ML 4 PA SP SOMAVERT INJ10MG 4 PA SP SOMAVERT INJ15MG 4 PA SP SOMAVERT INJ20MG 4 PA SP ZORBTIVE INJ8.8MG 4 PA SP ESTROGENS ALORA DIS0.025MG 2 QL ALORA DIS0.05MG 2 QL ALORA DIS0.075MG 2 QL ALORA DIS0.1MG 2 QL CENESTIN TAB0.3MG 3 CENESTIN TAB0.45MG 3 CENESTIN TAB0.625MG 3 CENESTIN TAB0.9MG 3 CENESTIN TAB1.25MG 3 DELESTROGEN INJ10MG/ML 3 DEPO-ESTRADIINJ5MG/ML 3 DIVIGEL GEL1MG/GM 3 QL ELESTRIN GEL0.06% 3 ENJUVIA TAB0.3MG 3 ENJUVIA TAB0.45MG 3 ENJUVIA TAB0.625MG 3 ENJUVIA TAB0.9MG 3 ENJUVIA TAB1.25MG 3 ESTRAD VAL INJ10MG/ML 2 ESTRAD VAL INJ20MG/ML 2 ESTRAD VAL INJ40MG/ML 2 ESTRADIOL DIS0.025MG 1 QL ESTRADIOL DIS0.0375MG 1 QL ESTRADIOL DIS0.05MG 1 QL ESTRADIOL DIS0.06MG 1 QL ESTRADIOL DIS0.075MG 1 QL ESTRADIOL DIS0.1MG 1 QL ESTRADIOL TAB0.5MG 1 ESTRADIOL TAB1MG 1 ESTRADIOL TAB2MG 1 ESTROPIPATE TAB0.75MG 1 ESTROPIPATE TAB1.5MG 1 ESTROPIPATE TAB3MG 2 EVAMIST SPR1.53MG 3 QL MENEST TAB0.3MG 2 MENEST TAB0.625MG 2 MENEST TAB1.25MG 2 MENEST TAB2.5MG 2 MENOSTAR DIS14MCG 3 QL MIMVEY LO TAB MINIVELLE DIS0.025 MG 2 QL 24 MINIVELLE DIS0.0375MG 2 QL MINIVELLE DIS0.05MG 2 QL MINIVELLE DIS0.075MG 2 QL MINIVELLE DIS0.1MG 2 QL PREMARIN TAB0.3MG 2 PREMARIN TAB0.45MG 2 PREMARIN TAB0.625MG 2 PREMARIN TAB0.9MG 2 PREMARIN TAB1.25MG 2 PREMPRO 3 FLUOROQUINOLONES CIPROFLOXACNSUS250MG/5 2 CIPROFLOXACNSUS500MG/5 2 CIPROFLOXACNTAB1000MG 1 CIPROFLOXACNTAB100MG 1 CIPROFLOXACNTAB250MG 1 CIPROFLOXACNTAB500MG 1 CIPROFLOXACNTAB500MG ER 1 CIPROFLOXACNTAB750MG 1 FACTIVE TAB320MG 3 LEVAQUIN TABLEVA-PAK 3 LEVOFLOXACINSOL25MG/ML 2 LEVOFLOXACINTAB250MG 2 QL LEVOFLOXACINTAB500MG 2 QL LEVOFLOXACINTAB750MG 2 QL MOXIFLOXACINTAB400MG 2 OFLOXACIN TAB200MG 2 OFLOXACIN TAB300MG 2 OFLOXACIN TAB400MG 2 GASTROINTESTINAL AGENTS - MISC ALOSETRON 0.5 MG TAB 2 QL ALOSETRON 1 MG TAB 2 QL APRISO CAP0.375GM 3 QL ASACOL TAB400MG DR 2 ASACOL HD TAB800MG 2 QL BALSALAZIDE CAP750MG 2 CALC ACETATECAP667MG 2 CALC ACETATETAB667MG 2 CANASA SUP1000MG 3 CIMZIA KIT 4 QL PA SP CIMZIA PREFLKIT200MG/ML 4 QL PA SP CROMOLYN SODCON100/5ML 1 DELZICOL CAP400MG 2 DIPENTUM CAP250MG 3 DIPHEN/ATROPINE 2.5MGTAB 1 QL ELIPHOS TAB667MG 2 FOSRENOL CHW1000MG 3 FOSRENOL CHW500MG 3 FOSRENOL CHW750MG 3 GENERLAC SOL10GM/15 2 GIAZO TAB1.1GM 3 LACTULOSE SOL10GM/15 1 MESALAMINE KIT4GM 2 METOCLOPRAM SOL5MG/5ML 1 METOCLOPRAM TAB10MG 1 METOCLOPRAM TAB5MG ODT 2 METOCLOPRAM TAB5MG 1 METOZOLV ODTTAB10MG 3 PARICALCITOLCAP1 MCG 2 PARICALCITOLCAP2 MCG 2 PARICALCITOLCAP4 MCG 2 PENTASA CAP250MG CR 2 PENTASA CAP500MG CR 2 PHOSLYRA SOL 3 RENAGEL TAB400MG 3 RENAGEL TAB800MG 3 RENVELA PAK0.8GM 3 QL RENVELA PAK2.4GM 3 QL SFROWASA ENE4GM 3 SULFASALAZINTAB500MG 2 SULFAZINE TAB500MG 2 SULFAZINE ECTAB500MG 2 URSODIOL CAP300MG 2 URSODIOL TAB250MG 2 URSODIOL TAB500MG 2 GENITOURINARY AGENTS - MISCELLANEOUS ALFUZOSIN TAB10MG 2 QL AVODART CAP0.5MG 1 CARDURA XL TAB4MG 3 QL CARDURA XL TAB8MG 3 QL

25 CYPROHEPTAD TAB4MG 2 CYSTAGON CAP150MG 4 PA SP CYSTAGON CAP50MG 4 PA SP FINASTERIDE TAB5MG 1 QL POT CITRATE TAB1080MG 2 POT CITRATE TAB1620MG 2 POT CITRATE TAB540MG ER 2 RAPAFLO CAP4MG 3 RAPAFLO CAP8MG 3 TAMSULOSIN CAP0.4MG 1 QL GOUT AGENTS ALLOPURINOL TAB100MG 1 ALLOPURINOL TAB300MG 1 COLCHICINE CAP0.6MG 3 MITIGARE CAP0.6MG 3 PROBEN/COLCHTAB PROBENECID TAB500MG 1 ULORIC TAB40MG 2 QL ULORIC TAB80MG 2 QL HEMATOLOGICAL AGENTS - MISC AGGRENOX CAP25-200MG 2 QL ANAGRELIDE CAP0.5MG 1 ANAGRELIDE CAP1MG 1 BRILINTA TAB90MG 2 QL CILOSTAZOL TAB100MG 1 CILOSTAZOL TAB50MG 1 CLOPIDOGREL TAB300MG 1 QL CLOPIDOGREL TAB75MG 1 QL DIPYRIDAMOLETAB25MG 1 DIPYRIDAMOLETAB50MG 1 DIPYRIDAMOLETAB75MG 1 EFFIENT TAB10MG 3 QL EFFIENT TAB5MG 3 QL FIRAZYR 4 PA SP PENTOXIFYLLITAB400MG ER 1 PENTOXIL TAB400MG CR 1 TICLOPIDINE TAB250MG 1 QL ZONTIVITY TAB2.08MG 3 HEMATOPOIETIC AGENTS CERDELGA CAP84MG 4 PA SP DROXIA CAP200MG 3 DROXIA CAP300MG 3 DROXIA CAP400MG 3 PROMACTA TAB12.5MG 4 QL PA SP PROMACTA TAB25MG 4 QL PA SP PROMACTA TAB50MG 4 QL PA SP PROMACTA TAB75MG 4 QL PA SP ZAVESCA CAP100MG 4 PA SP HEMOSTATICS TRANEXAMIC ACID 1 HYPNOTICS ESZOPICLONE TAB1MG 2 ESZOPICLONE TAB2MG 2 ESZOPICLONE TAB3MG 2 TEMAZEPAM 2 ZALEPLON CAP10MG 2 QL ZALEPLON CAP5MG 2 QL ZOLPIDEM TAB10MG 2 QL ZOLPIDEM TAB5MG 2 QL ZOLPIDEM SUB 1.75MG 2 QL ZOLPIDEM SUB 3.5MG 2 QL ZOLPIDEM ER TAB12.5MG 2 QL ZOLPIDEM ER TAB6.25MG 2 QL LAXATIVES CONSTULOSE SOL10GM/15 2 KRISTALOSE PAK10GM 1 KRISTALOSE PAK20GM 1 LACTULOSE SOL10GM/15 1 OSMOPREP TAB1.5GM 3 VISICOL TAB1.5GM 3 MACROLIDES AZITHROMYCINPOW1GM PAK 1 AZITHROMYCINSUS100/5ML 1 QL AZITHROMYCINSUS200/5ML 1 QL AZITHROMYCINTAB250MG 1 QL AZITHROMYCINTAB500MG 1 QL AZITHROMYCINTAB600MG 1 QL CLARITHROMYCSUS125/5ML 2 CLARITHROMYCSUS250/5ML 2 25 CLARITHROMYCTAB500MG 2 QL CLARITHROMYCTAB500MG ER 2 QL DIFICID TAB200MG 4 PA SP E.E.S. 400 TAB400MG 2 E.E.S. GRAN SUS200/5ML 3 ERYPED SUS200/5ML 3 ERYPED SUS400/5ML 3 ERY-TAB TAB250MG EC 1 ERY-TAB TAB333MG EC 1 ERY-TAB TAB500MG EC 1 ERYTHROCIN TAB250MG 1 ERYTHROM ETHTAB400MG 2 ERYTHROMYCINTAB250MG BS 1 ERYTHROMYCINTAB500MG BS 1 PCE TAB333MG EC 3 PCE TAB500MG EC 3 ZITHROMAX POW1GM PAK 3 ZMAX SUS2GM 3 QL MIGRAINE PRODUCTS ALMOTRIPTAN TAB 2 QL ALSUMA INJ6MG/0.5 3 DIHYDROERGOTINJ1MG/ML 2 ERGOMAR SUB2MG 1 FROVATRIPTAN TAB 2.5MG 2 QL MIGRANAL SPR4MG/ML 2 QL NARATRIPTAN TAB1MG 2 QL NARATRIPTAN TAB2.5MG 2 QL RELPAX TAB20MG 3 RELPAX TAB40MG 3 RIZATRIPTAN TAB10MG 2 QL RIZATRIPTAN TAB10MG ODT 2 QL RIZATRIPTAN TAB5MG 2 QL SUMATRIPTAN INJ6MG/0.5 1 QL SUMATRIPTAN SPR20MG/ACT 2 SUMATRIPTAN SPR20MG/ACT 2 QL SUMATRIPTAN SPR5MG/ACT 2 SUMATRIPTAN SUCCINATE REF 2 QL SUMATRIPTAN TAB100MG 2 QL SUMATRIPTAN TAB25MG 2 QL SUMATRIPTAN TAB50MG 2 QL SUMAVEL DOSEINJ4MG/0.5 3 SUMAVEL DOSEINJ6MG/0.5 3 ZOLMITRIPTAN TAB2.5MG 1 QL ZOLMITRIPTAN TAB5MG 1 QL ZOLMITRIPTAN TAB2.5MG ODT 1 QL ZOLMITRIPTAN TAB5MG ODT 1 QL ZOMIG TAB2.5MG 3 QL ZOMIG TAB5MG 3 QL ZOMIG NASAL SPR5MG 3 QL ZOMIG ZMT TAB2.5 MG 3 QL ZOMIG ZMT TAB5MG 3 QL MINERALS & ELECTROLYTES KLOR-CON 10 TAB10MEQ ER 1 KLOR-CON 8 TAB8MEQ ER 1 KLOR-CON M15TAB 1 KLOR-CON M20TAB20MEQ ER 1 KLOR-CON SPRINKLE 1 K-TAB TAB20MEQ 1 POT CHLORIDECAP10MEQ ER 1 POT CHLORIDECAP8MEQ ER 1 POT CHLORIDETAB8MEQ ER 1 POT CL MICROTAB10MEQ ER 1 POT CL MICROTAB20MEQ ER 1 MISCELLANOUS DIABETIC PRODUCTS INSULIN SYRINGES 2 INSULIN PEN NEEDLES 2 MOUTH/THROAT/DENTAL AGENTS APHTHASOL PST5% 3 CEVIMELINE CAP30MG 3 CHLORHEX GLUSOL0.12% 1 CLOTRIMAZOLETRO10MG 2 LIDOCAINE SOL2% VISC 1 NYSTATIN SUS ORAVIG TAB50MG 3 PAROEX SOL0.12% 1 PERIOGARD SOL0.12% 1 PILOCARPINE TAB5MG 1 PILOCARPINE TAB7.5MG 1 TRIAMCIN/ORAPST0.1% 1

26 MUSCULOSKELETAL THERAPY AGENTS BACLOFEN TAB10MG 2 BACLOFEN TAB20MG 2 CARISOPRODOLTAB250MG 1 CARISOPRODOLTAB350MG 1 CHLORZOXAZONTAB500MG 1 CYCLOBENZAPRCAP15MG ER 1 CYCLOBENZAPRCAP30MG ER 1 CYCLOBENZAPRTAB10MG 1 CYCLOBENZAPRTAB5MG 1 CYCLOBENZAPRTAB7.5MG 1 DANTROLENE CAP100MG 2 DANTROLENE CAP25MG 2 DANTROLENE CAP50MG 2 LORZONE TAB375MG 1 LORZONE TAB750MG 1 METAXALONE TAB800MG 2 METHOCARBAM TAB500MG 1 METHOCARBAM TAB750MG 1 ORPHENADRINETAB100MG ER 1 TIZANIDINE CAP2MG 2 TIZANIDINE CAP4MG 2 TIZANIDINE CAP6MG 2 TIZANIDINE TAB2MG 2 TIZANIDINE TAB4MG 2 NASAL AGENTS - SYSTEMIC AND TOPICAL AZELASTINE SPR0.1% 1 QL AZELASTINE SPR0.15% 1 QL BACTROBAN OINNASAL 2% 3 BUDESONIDE SUS32MCG 2 FLUNISOLIDE SPR0.025% 1 QL FLUTICASONE SPR50MCG 1 QL IPRATROPIUM SPR0.03% 1 QL IPRATROPIUM SPR0.06% 1 QL OLOPATADINE SPR0.6% 3 TRIAMCINOLONAER55MCG/AC 2 QL TYZINE SOL0.1% 2 TYZINE PED DRO0.05% 2 VERAMYST SPR27.5MCG 3 QL ST OPHTHALMIC AGENTS ACUVAIL SOL0.45% 3 ALOCRIL SOL2% 2 ALOMIDE SOL0.1% OP 2 ALPHAGAN P SOL0.1% 2 ALREX SUS0.2% 2 APRACLONIDINSOL0.5% OP 2 AZASITE SOL1% 3 AZELASTINE DRO0.05% 2 AZOPT SUS1% OP 3 BACITRACIN OINOP 2 BEPREVE DRO1.5% 2 BESIVANCE SUS0.6% 3 BETAXOLOL SOL0.5% OP 2 BETIMOL SOL0.25% 3 BETIMOL SOL0.5% 3 BETOPTIC-S SUS0.25% OP 3 BRIMONIDINE SOL0.15% 2 BRIMONIDINE SOL0.2% OP 2 BROMDAY SOL0.09% 3 BROMFENAC SOL0.09% OP 2 CARTEOLOL SOL1% OP 2 CILOXAN OIN0.3% OP 3 CIPRO HC SUSOTIC 2 CIPROFLOXACNSOL0.3% OP 2 COMBIGAN SOL0.2/0.5% 3 CROMOLYN SODSOL4% OP 2 CYCLOPENTOLATE SOL OP 2 CYSTARAN SOL0.44% 4 PA SP DEXAMETH PHOSOL0.1% OP 1 DICLOFENAC SOL0.1% OP 2 DORZOL/TIMOLSOL2-0.5%OP 2 DORZOLAMIDE SOL2% OP 2 DUREZOL EMU0.05% 3 EMADINE SOL0.05% OP 2 EPINASTINE DRO0.05% 2 ERYTHROMYCINOINOP 1 FLAREX SUS0.1% OP 3 FLUOROMETHOLSUS0.1% OP 2 FLURBIPROFENSOL0.03% OP 2 FML OIN0.1% OP 2 26 FML FORTE SUS0.25% OP 2 GATIFLOXACINSOL0.5% 1 GENOPTIC SOL0.3% OP 1 GENTAK OIN0.3% OP 2 GENTAMICIN OIN0.3% OP 2 GENTAMICIN SOL0.3% OP 1 GENTASOL SOL0.3% OP 1 ILEVRO DRO0.3% OP 3 ILOTYCIN OINOP 1 IOPIDINE SOL1% OP 3 ISTALOL SOL0.5% OP 3 KETOROLAC SOL0.4% 2 KETOROLAC SOL0.5% 2 LACRISERT MIS5MG OP 3 PA LASTACAFT SOL0.25% 3 LATANOPROST SOL0.005% 2 QL LEVOBUNOLOL SOL0.5% OP 1 LEVOFLOXACINSOL0.5% 2 LOTEMAX GEL0.5% 2 LOTEMAX OIN0.5% 2 LOTEMAX SUS0.5% 2 LUMIGAN SOL0.01% 2 QL ST LUMIGAN SOL0.03% 2 QL ST MAXIDEX SUS0.1% OP 3 METIPRANOLOLSOL0.3% OPH 2 MOXEZA SOL0.5% 3 NAPHAZOLINE SOL0.1% OP 1 NATACYN SUS5% OP 3 NEVANAC SUS0.1% 3 OFLOXACIN DRO0.3% OP 2 OLOPATADINE HCL OPH SOL 1 PHOSPHOLINE SOL0.125%OP 2 PILOCARPINE SOL1% OP 1 PILOCARPINE SOL2% OP 1 PILOCARPINE SOL4% OP 1 PILOPINE HS GEL4% OP 3 PRED MILD SUS0.12% OP 3 PRED SOD PHOSOL1% OP 2 PREDNISOLONE ACETATE 2 PREDNISOLONESUS1% OP 1 PROPINE SOL0.1% OP 3 ROMYCIN OINOP 1 SIMBRINZA SUS1-0.2% 3 SOD SULFACETSOL10% OP 2 TIMOLOL GEL SOL0.25% OP 2 TIMOLOL GEL SOL0.5% OP 2 TIMOLOL MAL SOL0.25% OP 2 TIMOLOL MAL SOL0.5% OP 2 TIMOPTIC OCUSOL0.25% OP 3 TIMOPTIC OCUSOL0.5% OP 3 TOBRADEX OIN % 2 TOBRAMYCIN SOL0.3% OP 1 TRAVATAN Z DRO0.004% 3 QL ST TRIFLURIDINESOL1% OP 2 TROPICAMIDE SOL0.5% OP 2 VEXOL SUS1% OP 3 VIGAMOX DRO0.5% 3 XIIDRA 5% 3 ZIOPTAN DRO0.0015% 3 ST ZIRGAN GEL0.15% 3 OTIC AGENTS ACETASOL HC SOLOTIC 2 ACETIC ACID SOL2% OTIC 2 CIPRO HC SUSOTIC 2 CIPRODEX SUS % 2 COLY-MYCIN SSUSOTIC 3 CORTISPORIN SUS-TC OTIC 3 CORTOMYCIN SUS1% OTIC 1 FLUOCIN ACETOIL0.01% 2 HC/ACET ACIDSOLOTIC 2 NEO/POLY/HC SOL1% OTIC 1 NEO/POLY/HC SUS1% OTIC 1 OFLOXACIN DRO0.3%OTIC 2 PENICILLINS AMOX/K CLAV CHW200MG 2 AMOX/K CLAV CHW400MG 2 AMOX/K CLAV SUS200/5ML 2 AMOX/K CLAV SUS250/5ML 2 AMOX/K CLAV SUS400/5ML 2 AMOX/K CLAV SUS600/5ML 2

27 AMOX/K CLAV TAB250MG 2 AMOX/K CLAV TAB500MG 2 AMOX/K CLAV TAB875MG 2 AMOXICILLIN CAP250MG 1 AMOXICILLIN CAP500MG 1 AMOXICILLIN CHW125MG 1 AMOXICILLIN CHW250MG 1 AMOXICILLIN SUS125/5ML 1 AMOXICILLIN SUS200/5ML 1 AMOXICILLIN SUS250/5ML 1 AMOXICILLIN SUS400/5ML 1 AMOXICILLIN TAB500MG 1 AMOXICILLIN TAB875MG 1 AMOXIL CAP500MG 1 AMOXIL SUS125/5ML 1 AMOXIL SUS250/5ML 1 AMOX-POT CLATABER 2 AMPICILLIN CAP250MG 1 AMPICILLIN CAP500MG 1 AMPICILLIN SUS125/5ML 1 AMPICILLIN SUS250/5ML 1 AUGMENTIN SUS125/5ML 3 DICLOXACILL CAP250MG 2 DICLOXACILL CAP500MG 2 MOXATAG TAB775MG 3 PENICILLN VKSOL125/5ML 1 PENICILLN VKSOL250/5ML 1 PENICILLN VKTAB250MG 1 PENICILLN VKTAB500MG 1 PROGESTINS MEDROXYPR ACTAB10MG 1 MEDROXYPR ACTAB2.5MG 1 MEDROXYPR ACTAB5MG 1 NORETHIN ACETAB5MG 2 PROGESTERONECAP100MG 2 PROGESTERONECAP200MG 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC ACAMPROSATE 333 MG TAB 1 AMPYRA TAB10MG 4 PA SP AUBAGIO TAB14MG 4 PA SP AUBAGIO TAB7MG 4 PA SP AVONEX KIT30MCG 4 QL PA SP AVONEX PREFLKIT30MCG 4 QL PA SP BETASERON INJ0.3MG 4 QL PA SP BUPROBAN TAB150MG 1 QL BUPROPION TAB150MG SR 1 QL DISULFIRAM TAB250MG 2 DISULFIRAM TAB500MG 2 DONEPEZIL TAB10MG 1 QL DONEPEZIL TAB10MG ODT 1 QL DONEPEZIL TAB5MG 1 QL DONEPEZIL TAB5MG ODT 1 QL ERGOLOID MESTAB1MG ORAL 1 EXELON SOL2MG/ML 3 EXTAVIA INJ0.3MG 4 QL PA SP FLUOXETINE CAP10MG 1 QL FLUOXETINE CAP20MG 1 QL GALANTAMINE CAP16MG ER 2 QL GALANTAMINE CAP24MG ER 2 QL GALANTAMINE CAP8MG ER 2 QL GALANTAMINE SOL4MG/ML 2 QL GALANTAMINE TAB12MG 2 QL GALANTAMINE TAB4MG 2 QL GALANTAMINE TAB8MG 2 QL GILENYA CAP0.5MG 4 QL PA SP GLATOPA INJ 20MG/ML 4 PA SP HORIZANT TAB300MG 3 HORIZANT TAB600MG 3 MEMANTINE HCL 5 MG TAB 2 MEMANTINE HCL 10MG TAB 2 MEMANTINE HCSOL2MG/ML 2 PA NAMENDA XR CAP14MG 3 QL NAMENDA XR CAP21MG 3 QL NAMENDA XR CAP28MG 3 QL NAMENDA XR CAP7MG 3 QL NAMENDA XR CAPTITRATIO 3 QL PLEGRIDY INJ 4 PA SP PLEGRIDY PENINJSTARTER 4 PA SP REBIF INJ22/0.5 4 QL PA SP 27 REBIF INJ44/0.5 4 QL PA SP REBIF TITRTNSOLPACK 4 QL PA SP RILUZOLE TAB50MG 2 RIVASTIGMINECAP1.5MG 2 QL RIVASTIGMINECAP3MG 2 QL RIVASTIGMINECAP4.5MG 2 QL RIVASTIGMINECAP6MG 2 QL SARAFEM TAB10MG 3 QL SARAFEM TAB20MG 3 QL TECFIDERA CAP120MG 4 PA SP TECFIDERA CAP240MG 4 PA SP TECFIDERA MISSTARTER 4 PA SP TETRABENAZINETAB12.5MG 4 PA SP TETRABENAZINETAB25MG 4 PA SP RESPIRATORY AGENTS - MISC KALYDECO TAB150MG 4 QL PA SP PULMOZYME SOL 1MG/ML 4 PA SP SODIUM CHLORNEB7% 1 SMOKING CESSATION CHANTIX PAK0.5& 1MG 1 PA QL CHANTIX PAK1MG 1 PA QL CHANTIX PAK0.5MG 1 PA QL CHANTIX TAB0.5MG 1 PA QL CHANTIX TAB1MG 1 PA QL NICOTINE POLGUM2MG 1 QL NICOTINE POLGUM4MG 1 QL NICOTINE DIS21MG/24 1 QL NICOTINE DIS14MG/24 1 QL NICOTINE DIS7MG/24 1 QL NICOTINE LOZ2MG 1 QL NICOTINE LOZ4MG 1 QL SULFONAMIDES SULFADIAZINETAB500MG 1 TETRACYCLINES AVIDOXY TAB100MG 2 DEMECLOCYCL TAB150MG 2 DEMECLOCYCL TAB300MG 2 DOXYCYCL HYCTA2100MG DR 2 DOXYCYCL HYCTAB100MG DR 2 DOXYCYCL HYCTAB150MG DR 2 DOXYCYCL HYCTAB75MG DR 2 DOXYCYCLINE 2 DOXYCYCLINE CAP150MG 2 DOXYCYCLINE CAP75MG 2 DOXYCYCLINE MONOHYDRATE 2 DOXYCYCLINE TAB20MG 2 MINOCYCLINE CAP100MG 2 MINOCYCLINE CAP50MG 2 MINOCYCLINE CAP75MG 2 MINOCYCLINE TAB100MG 2 MINOCYCLINE TAB135MG ER 2 MINOCYCLINE TAB45MG ER 2 MINOCYCLINE TAB50MG 2 MINOCYCLINE TAB75MG 2 MINOCYCLINE TAB90MG ER 2 MONDOXYNE NLCAP100MG 2 MONDOXYNE NLCAP75MG 2 MORGIDOX CAP1X100MG 1 TETRACYCLINECAP250MG 2 TETRACYCLINECAP500MG 2 VIBRAMYCIN SYP50MG/5ML 3 THYROID AGENTS LEVOTHYROXINTAB100MCG 1 LEVOTHYROXINTAB112MCG 1 LEVOTHYROXINTAB125MCG 1 LEVOTHYROXINTAB137MCG 1 LEVOTHYROXINTAB150MCG 1 LEVOTHYROXINTAB175MCG 1 LEVOTHYROXINTAB200MCG 1 LEVOTHYROXINTAB25MCG 1 LEVOTHYROXINTAB300MCG 1 LEVOTHYROXINTAB50MCG 1 LEVOTHYROXINTAB75MCG 1 LEVOTHYROXINTAB88MCG 1 LIOTHYRONINETAB25MCG 1 LIOTHYRONINETAB50MCG 1 LIOTHYRONINETAB5MCG 1 METHIMAZOLE TAB10MG 2 METHIMAZOLE TAB5MG 2

28 NP THYROID TAB15MG 1 NP THYROID TAB30MG 1 NP THYROID TAB60MG 1 NP THYROID TAB90MG 1 PROPYLTHIOURTAB50MG 2 SYNTHROID TAB100MCG 3 SYNTHROID TAB112MCG 3 SYNTHROID TAB125MCG 3 SYNTHROID TAB137MCG 3 SYNTHROID TAB150MCG 3 SYNTHROID TAB175MCG 3 SYNTHROID TAB200MCG 3 SYNTHROID TAB25MCG 3 SYNTHROID TAB50MCG 3 SYNTHROID TAB75MCG 3 SYNTHROID TAB88MCG 3 THYROLAR-1 TAB60MG 1 THYROLAR-1/2TAB30MG 1 THYROLAR-1/4TAB15MG 1 THYROLAR-2 TAB120MG 1 THYROLAR-3 TAB180MG 1 UNITHROID TAB100MCG 1 UNITHROID TAB112MCG 1 UNITHROID TAB125MCG 1 UNITHROID TAB150MCG 1 UNITHROID TAB175MCG 1 UNITHROID TAB200MCG 1 UNITHROID TAB25MCG 1 UNITHROID TAB300MCG 1 UNITHROID TAB50MCG 1 UNITHROID TAB75MCG 1 UNITHROID TAB88MCG 1 ULCER DRUGS CANTIL TAB25MG 3 CARAFATE SUS1GM/10ML 3 CIMETIDINE SOL300/5ML 2 CUVPOSA SOL1MG/5ML 3 DICYCLOMINE CAP10MG 1 DICYCLOMINE SOL10MG/5ML 1 DICYCLOMINE TAB20MG 1 ESOMEPRA MAGCAP20MG DR 2 QL ESOMEPRA MAGCAP40MG DR 2 FAMOTIDINE TAB20MG 2 FAMOTIDINE TAB40MG 2 FAMOTIDINESUS40MG/5ML 2 FIRST-OMEPRASUS2MG/ML 2 GLYCATE TAB1.5MG 2 GLYCOPYRROL TAB1MG 2 GLYCOPYRROL TAB2MG 2 LANSOPRAZOLECAP30MG DR 2 QL METHSCOPOLAMTAB2.5MG 2 METHSCOPOLAMTAB5MG 2 MISOPROSTOL TAB100MCG 2 MISOPROSTOL TAB200MCG 2 OMEPRAZOLE CAP10MG 1 QL OMEPRAZOLE CAP20MG 1 QL OMEPRAZOLE CAP40MG 1 QL PANTOPRAZOLETAB20MG 1 QL PANTOPRAZOLETAB40MG 1 QL RABEPRAZOLE TAB20MG 1 QL RANITIDINE SYP15MG/ML 2 RANITIDINE CAP150MG 2 RANITIDINE CAP300MG 2 RANITIDINE TAB150MG 2 RANITIDINE TAB300MG 2 SUCRALFATE SUS1GM/10ML 3 SUCRALFATE TAB1GM 1 URINARY ANTI-INFECTIVES METHENAM HIPTAB1GM 1 METHENAM HIPTAB1GM 3 MONUROL PAKGRANULES 3 NITROFUR MACCAP50MG 1 NITROFURANTNSUS25MG/5ML 2 NITROFURANTOIN MACROCRYST 1 NITROFURANTOIN MONOHYDRAT 1 URINARY ANTISPASMODICS BETHANECHOL TAB10MG 1 BETHANECHOL TAB25MG 1 BETHANECHOL TAB50MG 1 BETHANECHOL TAB5MG 1 28 DARIFENACIN ER TAB 15MG 1 DARIFENACIN ER TAB 7.5MG 1 FLAVOXATE TAB100MG 1 GELNIQUE GEL10% 3 QL GELNIQUE GEL3% 3 MYRBETRIQ TAB25MG 3 QL MYRBETRIQ TAB50MG 3 QL OXYBUTYNIN SYP5MG/5ML 1 QL OXYBUTYNIN TAB5MG 1 QL OXYTROL DIS3.9MG/24 3 QL TOLTERODINE CAP2MG ER 1 QL TOLTERODINE CAP4MG ER 1 QL TOLTERODINE TAB1MG 1 QL TOLTERODINE TAB2MG 1 QL TOVIAZ TAB4MG 3 QL TOVIAZ TAB8MG 3 QL TROSPIUM CHLCAP60MG ER 2 VESICARE TAB10MG 2 QL VESICARE TAB5MG 2 QL VAGINAL PRODUCTS CLEOCIN CRE2% VAG 3 CLEOCIN SUP100MG 3 CLINDAMAX CRE2% VAG 1 CLINDAMYCIN CRE2% VAG 1 CRINONE GEL4% VAG 4 PA SP CRINONE GEL8% VAG 4 PA SP ENDOMETRIN SUP100MG 3 ESTRACE VAG CRE0.1MG/GM 3 ESTRING MIS2MG 2 QL FEMRING MIS0.05/24H 3 FEMRING MIS0.1MG/24 3 METRONIDAZOLGEL0.75%VAG 2 PREMARIN VAGCRE0.625MG 2 PROCHIEVE GEL4% 4 PA SP TERCONAZOLE CRE0.4% 2 TERCONAZOLE CRE0.8% 2 TERCONAZOLE SUP80MG 2 QL VAGIFEM TAB10MCG 2 ZAZOLE CRE0.4% 2 VASOPRESSORS ADRENACLICK INJ0.15MG 3 QL PA EPINEPHRINE INJ0.15MG 2 QL EPINEPHRINE INJ0.3MG 2 QL MIDODRINE TAB10MG 2 MIDODRINE TAB2.5MG 2 MIDODRINE TAB5MG 2 NORTHERA CAP100MG 4 QL PA SP NORTHERA CAP200MG 4 QL PA SP NORTHERA CAP300MG 4 QL PA SP

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