*ALL BRAND NAME PRODUCTS WITH GENERIC EQUIVALENTS ARE DISPENSED AT FULL RETAIL PRICE UNLESS OTHERWISE NOTED

Transcription

1 ACCU-CHEK AVIVA METER & STRIPS ACCU-CHEK BRAND ONLY DIABETES ONE METER/YEAR $4/$12 ACCU-CHEK FASTCLIX LANCETS ACCU-CHEK BRAND ONLY DIABETES $4/$12 ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) VENTOLIN HFA LUNG FUNCTION (COPD AND ASTHMA) $4/$12 ALENDRONATE SODIUM FOSAMAX* OSTEOPOROSIS $4/$12 AMLODIPINE BESYLATE NORVASC* HYPERTENSION $4/$12 ASPIRIN TAB 81 MG VARIOUS OTC FORMULATIONS/ 81MG STRENGTH ONLY ASPIRIN QTY LIMIT OF ONE TABLET/DAY $0/$0 ATENOLOL TENORMIN* HYPERTENSION $4/$12 ATORVASTATIN CALCIUM LIPITOR* CHOLESTEROL $4/$12 B-D INSULIN SYRINGES (ALL) BECTON-DICKSON BRAND ONLY DIABETES $4/$12 B-D PEN TIP NEEDLES BECTON-DICKSON BRAND ONLY DIABETES $4/$12 BENAZEPRIL/ BENAZEPRIL HCTZ LOTENSIN* LOTENSIN HCTZ* HYPERTENSION $4/$12 BISACODYL TAB & PEG 3350-KCL-SOD BICARB-NACL FOR SOLN KIT PEG PREP KIT, GAVILYTE H KIT BOWEL PREP ADULTS YR; LIMIT 1 KIT/YR $0/$0 BRIMONIDINE TARTRATE OPHTH SOLN ALPHAGAN* GLAUCOMA $4/$12 BUDESONIDE INHAL AERO POWD 90 AND 180 MG/ACT(BREATH ACTIVATED) PULMICORT FLEXHALER LUNG FUNCTION (COPD AND ASTHMA) $4/$12 BUDESONIDE INHALATION SUSP 0.25 MG/2ML PULMICORT RESPULES LUNG FUNCTION (COPD AND ASTHMA) $4/$12 BUDESONIDE INHALATION SUSP 0.5 MG/2ML PULMICORT RESPULES LUNG FUNCTION (COPD AND ASTHMA) $4/$12 BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG ZYBAN* SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 CANDESARTAN/CANDESARTAN HCTZ ATACAND*/ATACAND HCTZ HYPERTENSION $4/$12 CARBAMAZEPINE SUSP 100 MG/5ML TEGRETOL SUSPENSION* GRAND MAL SEIZURES $4/$12 CARBAMAZEPINE TAB, CHEW TAB, XR & ER TEGRETOL* GRAND MAL SEIZURES $4/$12 CARVEDILOL COREG* HYPERTENSION $4/$12 CERVICAL CAP FEMCAP, PRENTIF CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 CITALOPRAM HYDROBROMIDE CELEXA* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML CELEXA* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 CLOPIDOGREL BISULFATE PLAVIX* STROKE PREVENTION $4/$12 CONDOMS - FEMALE FC2 CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DESOGEST-ETH ESTRAD & ETH ESTRAD TAB /0.01 MG(21/5) AZURETTE, KARIVA, KIMIDESS, MIRCETTE, PIMTREA, VIORELE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DESOGEST-ETHIN EST TAB / / MG-MG CAZIANT, CESIA, CYCLESSA, VELIVET CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG RECLIPSEN, SOLIA, APRI, ENSKYCE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DIAPHRAGMS ORTHO COIL SPRING, WIDE-SEAL, FLAT SPRING CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DILTIAZEM HCL CARDIZEM*/ CARDIZEM CD & LA HYPERTENSION $4/$12 DIPH, ACELLULAR PERT & TET TOX INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 DIPH, ACELLULAR PERT & TET TOX INJ 15 LF-10 MCG-5 LF/0.5ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 DIPH-AC PER-TET TOX AD-POLIOV-HAEMOPH B POLY VAC FOR IM SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B-POLIO IPV VAC INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 DIPHTHERIA-TETANUS TOX ADSORBED (DT) IM INJ 25-5 UNIT/0.5ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 DROSPIRENONE-ETHINYL ESTRADIOL TAB YAZ, YASMIN CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB MG BEYAZ CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB MG SAFYRAL CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 DULOXETINE HCL CYMBALTA* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 ENALAPRIL/ ENALAPRIL HCTZ VASOTEC*/VASERETIC* HYPERTENSION $4/$12 EPROSARTAN/ EPROSARTAN HCTZ TEVENTEN*/TEVETEN HCTZ* HYPERTENSION $4/$12 ESCITALOPRAM OXALATE ORAL SOLN 5 MG/5ML (BASE EQUIV) LEXAPRO* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 ESCITALOPRAM OXALATE TAB 5 MG LEXAPRO* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 ESTRADIOL VALERATE-DIENOGEST TAB 3 MG /2-2 MG/2-3 MG/1 MG NATAZIA CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 Page 1

2 ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB ZOVIA, KELNOR, CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG ZOVIA, KELNOR, CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 ETONOGESTREL-ETHINYL ESTRADIOL VA RING MG/24HR NUVARING CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 FELODIPINE ER PLENDIL* HYPERTENSION $4/$12 FENOFIBRATE ANTARA* CHOLESTEROL/TRIGLYCERIDES $4/$12 FERROUS SULFATE VARIOUS OTC FORMULATIONS IRON CHILDREN UP TO 1 YEAR OF AGE $0/$0 FLUOXETINE HCL PROZAC* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 FLUOXETINE HCL SOLUTION 20 MG/5ML PROZAC* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 FLUVASTATIN SODIUM CAP 20 MG LESCOL* CHOLESTEROL $4/$12 FOLIC ACID FOLIC ACID FEMALES UP TO AGE 50; QTY LIMIT 1/DAY $0/$0 FORMOTEROL/BUDESONIDE SYMBICORT HFA LUNG FUNCTION (COPD AND ASTHMA) $4/$12 FOSINOPRIL/FOSINOPRIL HCTZ MONOPRIL* HYPERTENSION $4/$12 GEMFIBROZIL TAB 600 MG LOPID* CHOLESTEROL/TRIGLYCERIDES $4/$12 GLIMEPIRIDE AMARYL* DIABETES $4/$12 GLIPIZIDE GLUCOTROL* DIABETES $4/$12 GLIPIZIDE/GLIPIZIDE XL & ER GLUCOTROL* GLUCOTROL XL*, GLUCOTROL ER* DIABETES $4/$12 GLIPIZIDE-METFORMIN HCL METAGLIP* DIABETES $4/$12 GLYBURIDE/ GLYBURIDE MICRO DIABETA/GLYNASE* DIABETES $4/$12 GLYBURIDE-METFORMIN GLUCOVANCE* DIABETES $4/$12 HAEMOPHILUS B POLYSAC CONJ-HEPATITIS B (RECOMB) VAC IM SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HAEMOPHILUS B POLYSACCHARIDE CONJ VAC IM SUSP 7.5 MCG/0.5 ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HAEMOPHILUS B POLYSACCHARIDE CONJUGATE VAC FOR INJ 10 MCG IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HAEMOPHILUS B POLYSACCHARIDE CONJUGATE VACCINE FOR INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HEPATITIS A (INACT)-HEP B (RECOMB) VAC INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HEPATITIS A VACCINE INJ SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HEPATITIS B VACCINE (RECOMBINANT) 10 MCG/0.5ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HEPATITIS B VACCINE (RECOMBINANT) 20 MCG/ML IMMUNIZATIONS $0/$0 HEPATITIS B VACCINE (RECOMBINANT) SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HEPATITIS B VACCINE (RECOMBINANT) SUSP 40 MCG/ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC IM SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC SUSP PREF SYR IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HUMAN PAPILLOMAVIRUS (HPV) BIVAL (TYPE 16, 18) RECMB VAC INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HUMAN PAPILLOMAVIRUS (HPV) QUADRIVALENT RECOMBINANT VAC INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 HYDROCHLOROTHIAZIDE MICROZIDE* HYPERTENSION $4/$12 IBANDRONATE SODIUM BONIVA* OSTEOPOROSIS $4/$12 INFLUENZA VIRUS VAC TYPES A & B PF PREF SYRINGE KIT 0.5 ML IMMUNIZATIONS $0/$0 INFLUENZA VIRUS VACCINE VARIOUS FLU VACCINE FORMULATIONS IMMUNIZATIONS $0/$0 INSULIN LEVEMIR (VIALS ONLY) DIABETES $4/$12 INSULIN NOVOLIN R,N, 70/30 (VIALS ONLY) DIABETES $4/$12 INSULIN NOVOLOG, NOVOLOG 70/30 (VIALS ONLY) DIABETES $4/$12 IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT ATROVENT HFA* LUNG FUNCTION (COPD AND ASTHMA) $4/$12 IRBESARTAN/ IRBESARTAN HCTZ AVAPRO*/ AVALIDE* HYPERTENSION $4/$12 ISRADIPINE DYNACIRC* HYPERTENSION $4/$12 LATANOPROST OPHTH SOLN 0.005% XALATAN* GLAUCOMA $4/$12 LEVONOR-ETH EST TAB /0.025/0.03 MG &ETH EST 0.01 MG QUARTETTE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 Page 2

3 LEVONORGEST-ETH ESTRAD TAB 0.1 MG-20 MCG & FA TAB 1 MG KIT FALESSA KIT* CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB MG INTROVALE, JOLESSA, QUASENSE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORGESTREL & ETHINYL ESTRADIOL TAB AUBRA, AVIANE, DELYLA, FALMINA, LESSINA, ORSYTHIA, SRONYX CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORGESTREL TAB 1.5 MG MY WAY TAB, NEXT CHOICE TAB CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORGESTREL-ETH ESTRA TAB / / MG-MCG EMPRESSE, LEVONEST, MYZILRA, TRIVORA CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB MCG AMYTHYST CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORG-ETH EST TAB MG(84) & ETH EST TAB 0.01MG(7) AMETHIA LO, CAMRESE LO, (LO-SEASONIQUE) CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVONORG-ETH EST TAB MG(84) & ETH EST TAB 0.01MG(7) (SEASONIQUE), AMETHIA, ASHLYNA, CAMRESE, DAYSE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 LEVOTHYROXINE SODIUM (ALL STRENGTHS) SYNTHROID*, LEVOTHROID*, LEVOXYL* THYROID $4/$12 LISINOPRIL & LISINOPRIL HYDROCHLOROTHIAZIDE PRINIVIL*, ZESTRIL*, ZESTORETIC* HYPERTENSION $4/$12 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB MG HYZAR* HYPERTENSION $4/$12 LOSARTAN POTASSIUM TAB COZAAR* HYPERTENSION $4/$12 LOVASTATIN TAB 10 MG MEVACOR* CHOLESTEROL $4/$12 MEASLES, MUMPS & RUBELLA VIRUS VACCINES FOR INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS VACCINES FOR INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML DEPO PROVERA**(COVERED UNDER MEDICAL BENEFIT) CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 MEDROXYPROGESTERONE ACETATE SUBCUTANEOUS SUSP 104 MG/0.65ML DEPO SUBQ PROVERA**(COVERED UNDER MEDICAL BENEFIT) CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 MENINGOCOCCAL (A, C, Y, AND W-135) CONJUGATE VACCINE INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC FOR INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MENINGOCOCCAL (C & Y)-HAEMOPHILUS B TET TOX CONJ VAC FOR INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MENINGOCOCCAL GROUP B VACCINE IM SUSP PREFILLED SYRINGE IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MENINGOCOCCAL VAC B (RECOMB ADSORBED) INJ PREFILLED SYRINGE IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 MENINGOCOCCAL VACCINE IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 METFORMIN HCL; METFORMIN XR & SL GLUCOPHAGE*, GLUCOPHAGE XR* DIABETES $4/$12 METHIMAZOLE TAPAZOLE* THYROID $4/$12 METOPROLOL TARTRATE LOPRESSOR* HYPERTENSION $4/$12 MOEXIPRIL HCL UNIVASC*/UNIRETIC* HYPERTENSION $4/$12 NICOTINE INHALER SYSTEM 10 MG (4 MG DELIVERED) NICOTROL INHALER* SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 NICOTINE NASAL SPRAY 10 MG/ML (0.5 MG/SPRAY) NICOTROL NASAL SPRAY SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 NICOTINE POLACRILEX GUM VARIOIOUS GENERIC NICOTINE GUM(OTC) SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 NICOTINE POLACRILEX LOZENGE VARIOUS GENERIC NICOTINE LOZENGES SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 NICOTINE TD PATCH 24HR VARIOUS GENERIC OTC NICOTINE PATCHES SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 NIFEDIPINE, NIFEDIPINE SR PROCARDIA*, PROCARDIA XL*, ADALAT CC HYPERTENSION $4/$12 NONOXYNOL-9 FOAM VARIOUS OTC FORMULATIONS CONTRACEPTIVES WOMEN < 55 YR; PRESCRIPTION REQ'D; $0/$0 NONOXYNOL-9 VAGINAL SPONGE 1000 MG TODAY SPONGE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NONOXYNOL-9 VAGINAL SUPPOS 100 MG ENCARE CONTRACEPTIVES WOMEN < 55 YR; PRESCRIPTION REQ'D; $0/$0 NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK MCG/24HR XULANE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE & ETHINYL ESTRADIOL TAB BALZIVA, BRIELLYN, GILDAGIA, OVCON, PHILITH, VYFEMLA, ZENCHENT CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG FEMCON FE, WEMZYA FE, ZENCHENT FE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG GENERESS FE, LAYOLIS FE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE & MESTRANOL TAB 1 MG-50 MCG NECON, NORINYL CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG GILDESS, JUNEL, LARIN, LOESTRIN, MICROGESTIN CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG EMOQUETTE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG LOESTRIN FE, MICROGESTIN FE, TARINA FE, GILDESS FE, JUNEL FE,LARIN FE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG JUNEL FE, LARIN FE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 Page 3

4 NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24) MINASTRIN 24 FE CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) GILDESS FE 24, JUNEL FE-24, LARIN FE-24, LOESTRIN FE 24, LOMEDIA FE 24 CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG (ESTROSTEP FE), TILIA FE, TRI-LEGEST FE, CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE TAB 0.35 MG ATHER TAB, JENCYCLA TAB, JOLIVETTE TAB, LYZA, NORA-BE, NORLYROC, SHARO CONTRACEPTIVES WOMEN < 55 YEARS OF AGE; $0/$0 NORETHINDRONE-ETH ESTRADIOL TAB / /1-35 MG-MCG ALYACEN, CYCLAFEM,DASETTA, NECON, NORTREL, ORTHO-NOVUM, PIRMELLA CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHINDRONE-ETH ESTRADIOL TAB /1-35 MG-MCG (10/11) NECON 10/11 CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORETHIN-ETH ESTRADIOL-FE TAB 1 MG-10 MCG (24)/10 MCG (2) LOESTRIN CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG MONO-LINYAH, MONONESSA, ORTHO-CYCLEN, PREVIFEM,SPRINTEC, ESTARYLLA CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORGESTIMATE-ETH ESTRAD TAB / / MG-MCG ORTHO TRICYLEN LO CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORGESTIMATE-ETH ESTRAD TAB / / MG-MCG THO TRICYCLEN, TRISTARYLL, TRI-LINYAH, TRINESSA, TRI-PREVIFEM,TRI-SPRINT CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG LOW-OGESTREL, CRYSELLE, ELINEST CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 NORGESTREL & ETHINYL ESTRADIOL TAB 0.5 MG-50 MCG OGESTREL CONTRACEPTIVES WOMEN < 55 YEARS OF AGE $0/$0 PAROXETINE HCL PAXIL* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM COLYTE, GOLYTELY, GAVILYTE-G BOWEL PREP ADULTS YR; LIMIT 1 KIT/YR $0/$0 PHENYTOIN CHEW TAB 50 MG DILANTIN INFATAB* GRAND MAL SEIZURES $4/$12 PHENYTOIN SODIUM EXTENDED CAP DILANTIN* GRAND MAL SEIZURES $4/$12 PHENYTOIN SUSP 125 MG/5ML DILANTIN* GRAND MAL SEIZURES $4/$12 PIOGLITAZONE HCL ACTOS* DIABETES $4/$12 PIOGLITAZONE HCL-METFORMIN HCL ACTOPLUS MET* DIABETES $4/$12 PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE INJ PREVNAR 13 IMMUNIZATIONS $0/$0 PNEUMOCOCCAL VACCINE POLYVALENT INJ 25 MCG/0.5ML PNEUMOVAX 23 IMMUNIZATIONS $0/$0 POLIOVIRUS VACCINE, IPV INJECTION IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 PRAVASTATIN PRAVCHOL* CHOLESTEROL $4/$12 PROPRANOLOL HCL ORAL SOLN INDERAL* INDERAL SR* HYPERTENSION $4/$12 PROPRANOLOL HCL/PROPRANOLOL XL & LA INDERAL* INDERAL XL &ER* HYPERTENSION $4/$12 QUINAPRIL/ QUNIPRIL HCTZ ACCUPRIL* ACCURETIC* HYPERTENSION $4/$12 RALOXIFENE EVISTA* ANTIESTROGENS INCREASED RISK FOR BREAST CANCER $0/$0 RAMIPRIL RAMIPRIL* HYPERTENSION $4/$12 REPAGLINIDE PRANDIN* DIABETES $4/$12 ROTAVIRUS VACCINE, LIVE FOR ORAL SUSP IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 ROTAVIRUS VACCINE, LIVE ORAL PENTAVALENT SOLN IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 SERTRALINE HCL ZOLOFT* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 SIMVASTATIN ZOCOR* CHOLESTEROL $4/$12 SODIUM FLUORIDE CHEW TAB FLUORITAB,FLUORIDE CHEWABLE, LUDENT, (LURIDE) FLUORIDE CHILDREN > 6 MOS THROUGH 5 YEARS OLD $0/$0 SODIUM FLUORIDE LOZENGE 1 MG F (FROM 2.2 MG NAF) LOZI-FLUR FLUORIDE CHILDREN > 6 MOS THROUGH 5 YEARS OLD $0/$0 SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/DROP NAF) FLURA-DROPS FLUORIDE CHILDREN > 6 MOS THROUGH 5 YEARS OLD $0/$0 SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF) (LURIDE DROPS), FLUORIDE DROPS FLUORIDE CHILDREN > 6 MOS THROUGH 5 YEARS OLD $0/$0 SODIUM FLUORIDE-XYLITOL CHEW TAB FLUOR-O-DAY FLUORIDE CHILDREN > 6 MOS THROUGH 5 YEARS OLD $0/$0 TAMOXIFEN NOLVADEX* ANTIESTROGENS INCREASED RISK FOR BREAST CANCER $0/$0 TAMSULOSIN HCL CAP 0.4 MG FLOMAX* BENIGN PROSTATIC HYPERPLASIA $4/$12 TELMISARTAN/TELMISARTAN HCTZ MICARDIS*/MICARDIS HCT HYPERTENSION $4/$12 TET TOX-DIPH-ACELL PERTUSS IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 TETANUS-DIPHTHERIA TOXOIDS (TD) INJ IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 2-2 LF/0.5ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 TIMOLOL MALEATE OPHTH GEL FORMING SOLN TIMOPTIC GFS* GLAUCOMA $4/$12 Page 4

5 TIMOLOL MALEATE OPHTH SOLN TIMOPTIC* GLAUCOMA $4/$12 TRANDOLAPRIL MAVIK* HYPERTENSION $4/$12 VALPROATE SODIUM SYRUP 250 MG/5ML (BASE EQUIV) DEPEKENE* GRAND MAL SEIZURES $4/$12 VALSARTAN/VALSARTAN HCTZ DIOVAN* DIOVAN HCTZ* HYPERTENSION $4/$12 VARENICLINE TARTRATE TAB CHANTIX SMOKING DETERRENTS LIMITED TO ADULTS(>18 YR) 30DAY SUPPLY/RX; $0/$0 VARICELLA VIRUS VAC LIVE FOR SUBCUTANEOUS INJ 1350 PFU/0.5ML IMMUNIZATIONS *COVERED UNDER MEDICAL PLAN ONLY $0/$0 VENLAFAXINE HCL; VENLAFAXINE HCL SR EFFEXOR*, EFFEXOR XR* MENTAL HEALTH Y LAW, QTY WRITTEN MUST EQUAL QTY DISPENSE $4/$12 VERAPAMIL HCL CALAN*/CALAN SR* HYPERTENSION $4/$12 WARFARIN SODIUM COUMADIN* STROKE PREVENTION $4/$12 ZOSTER VACCINE LIVE FOR INJ UNIT/0.65ML ZOSTAVAX IMMUNIZATIONS $0/$0 Page 5